Surgery: Fixing Disease

after 30 hours by ~shiroi-kishi on deviantART

The one central question that surgeons ask: is this surgical or not? That is to say, "Can I do something about this or not?" That one question is paramount because surgeons work in the here and now and their work is very tangible. As one of my interns on medicine said, "You will never feel as macho and more like a man than on surgery." He was right.

Surgery is a realm very much separate from medicine . . . a dark dark realm. I say this because often you will wake up in the dark, go to the hospital in the dark, and possibly leave the hospital in the dark (particularly in the winter months). Only the glaringly bright OR lights punctuate that darkness away from natural light. There are a few critical tenets of surgery:

The List: a list of patients under the care of a surgical team that must be updated at the beginning of the day and the end of the day. This duty often falls to the med students.

Vitals: surgeons are obsessed with patients' vitals over the last 12-24 hours - temperature, blood pressure, heart rate, respiratory rate. These things tell the surgeon the general condition a patient is in, they don't necessarily care how well a patient is doing so long as he/she is not in a critical condition that warrants immediate attention.

In's and Out's: also known as I/O's. Surgeons also obsess with just how much a patient is taking in and excreting out. "In's" include things such as food (whether it's clears, liquids, semi-solids, solids, etc), IV fluids and nutrition, etc. "Out's" are usually urine and stools, but also include drain output, ostomy output, etc.

Pain Control: surgeons are well aware of the damage and pain they inflict upon patients. Thus they always ask about pain control and how to better optimize it. Also, the better a patient's pain is under control, the quicker the patient can usually be discharged from the hospital.

Surgeons do with the ideal of fixing disease; this may be either definitive or not. Gallstones or any one of cholestatic diseases? Remove the gallbladder. Hernia? Choose the kind of repair you'd like, though different repairs have different recurrence rates. Non-healing ulcer on the foot or infection penetrating down to the bone (osteomyelitis) or necrotic foot? Amputate it. Colon cancer? Resect it, though it may come back elsewhere. Regardless, there is either action or no action, nothing in between. In this respect some surgeons have earned that well-known stereotype of surgeons pronouncing themselves God-like, because they have the power with their hands to do something. Indeed, some surgeons scoff at medicine because medical management fails whereas surgery produces direct, definitive, and immediate results (whether those results are good or bad depend on many things).

I've had a very love-hate relationship with my 2 months on surgery.

Love:
- Doing something tangible. As a med student that's kind of limited, but what little I was allowed to do I enjoyed. I liked dressing wounds, I liked stapling wounds closed at the end of an operation, I liked practicing suturing, I liked removing lines and drains and staples.
- Scrubbing in. I love the act of scrubbing in - that OCD ritual of scrubbing your fingers, hands, and arms with soap while being careful not to bump into anything, then gowning up and putting on gloves. It's almost sacred.
- Driving the camera. For a laparoscopic procedure, it's usually the med student's job to hold the camera such that the surgeon and/or resident can see the field of operation. It's not always an easy job because you have to anticipate where the surgeon/resident will want to see next and have the camera centered there ASAP. So one can't zone out as usual, which I'm okay with.
- Thankful patients. More so than on medicine, surgical patients are very thankful for the care you give them (once their pain is under any semblance of control), particularly if you show that you care.

Hate:
- The hours. I cannot stand waking up in the dark, going to the hospital in the dark, and occasionally leaving in the dark. Also, being on call for up to 28 hours straight is rather rough (though the residents are usually nice and let you have at least 5 hours of sleep). I was perpetually tired and grumpy on surgery. I refrained from coffee on days that I knew I would be going into the OR, because caffeine tends to make me pee within 1-2 hours of ingestion. That was tough.
- The OR. While I love scrubbing in to the OR, I disliked the hours in the OR itself. I felt trapped like a prisoner. There are many things I couldn't do, for fear of breaking the sterile field. I couldn't scratch my face, or adjust my glasses, or let my arms fall below the level of the table; I couldn't accidentally brush up against someone's back (sometimes easier said than done in a cramped OR). I also couldn't sit. I'm okay standing for 1-3 hours or so, but after that I begin to stare longingly at the clock. My lower back never hurt as much before or afterwards as it did on my surgery rotation.
- Retracting. While I like doing things, I hate retracting. Retracting is basically where you use an instrument to hold open the surgical field for however long as asked. This could be holding open the abdomen, the intestines, the leg, and yes the anus. At least my arms probably got more toned as a result . . .
- The people. Most residents and surgeons are actually really great people to get along with. But every now and then you encounter one of those stereotypical surgeon-type people that just ruin your world.

Surgery is for those who like action, who like the immediacy of results, and don't have an aversion to blood or really messing with people's bodies. As a friend who wants to go into surgery once said, "In what other field can you cut people open, do horribly painful things to their bodies, and then close them back up without getting sued and thrown in jail? In fact, people pay you to do just that! Because you're a surgeon and are fixing them." For them, few things break the sometimes Zen-like concentration of operating.

In retrospect I almost enjoyed the hours between dawn and dusk on surgery. But I will forever be reminded by the days of staring at the rising sun from a patient's room during rounds, or saying hi every morning to the constellation Orion. And yet, I shall regard surgery as a privilege - for another human being to trust you so completely that they allow you to cut them open and do what you will, all for the sake of improving, even fixing, them. I have nothing but respect for surgeons but it's a lifestyle that I will not miss.

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Medicine: Managing Disease

medicine by ~bloodred on deviantART

Internal medicine, in my experience thus far, focuses on acute management of chronic diseases. This makes sense given the nature of inpatient hospital medicine - you're there to manage the patient acutely and get them better to the point where they can safely walk out the door and not keel over.

Almost every patient I saw while on inpatient medicine was admitted because, for whatever reason, their chronic diseases got the better of them and they suddenly get ill. An alcoholic patient came in with delirium tremens due to alcohol withdrawal. An alcoholic patient comes in with alcohol-induced pancreatitis. A patient with congested heart failure comes in with acute shortness of breath and chest pain. A diabetic patient comes in with a non-healing foot ulcer/injury. A patient in chronic renal failure comes in with shortness of breath. As you see, the majority of our medicine patients have long-term chronic diseases such as alcoholism, diabetes, congested heart failure, or chronic renal failure.

For one reason or another, their disease gets out of control and they experience symptoms that prompt them to seek immediate care. Much of the time it's because these patients don't keep their chronic diseases well-managed and under control, thus they let their health slide. The reasons behind why patients do this is complex and something I can't even begin to explain, so suffice it to say that many patients let their health slide to the point where they need to be admitted to the hospital. They sometimes come to us and almost literally say, "Save me."

We do our best to manage their underlying chronic disease as that usually does the trick in making them feel better. But do we "fix" anything? Not usually. Alcoholics continue to drink alcohol. Diabetics still have diabetes. Congested heart failure can't be fixed. Chronic renal failure is irreversible. The question now is: will these patients be able to take better care of themselves so they don't get re-admitted (at least, not for a while)? From what I've seen the answer is all too often a "no."

This creates an endless loop. Some patients have been pegged as "frequent flyers" because of how often they're re-admitted for the same problems over and over again. I've heard an entire department snicker upon hearing one particular patient's name because the patient kept getting re-admitted for the exact same issue. And every time they manage the patient's chronic disease, symptoms resolve, they reiterate to the patient how to manage the chronic disease, and send the patient out the door. Weeks to months later this is all repeated. I've sensed either a distinct jadedness or detachment from some of the attending physicians.

The longer I spent in internal medicine, the more of that jadedness I felt in myself. I began to feel almost a sense of futility in caring for some of these patients. Many of them I know are unable to adequately make the necessary changes to better manage their health, indeed it can be very difficult for any of us to do! A patient about my age but weighing almost 3 times as much got stuck in a CT scanner. How does that even happen?! Why do I even bother?

Even so, I've had some wonderful patients on medicine. These are people you work your butt off to help get better. These are the people you say goodbye and hope to never see them again, and in all likelihood you won't (not for a long time at least). Every few days there's always that one person to make it all worth it.

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Farewell to the Big Three

Three Fates by ~vivalastan on deviantART

Yet again it's been forever and a day since I last blogged here! o_O Holidays have come and went: Halloween, Thanksgiving, and Christmas. Before I could take notice, even the seasons have come and gone: summer, autumn, and now into winter.

Where was I during all this? Mired in "the big 3" rotations: - 2 months each of internal medicine, surgery, and pediatrics. Because this has practically dominated my life since the beginning of M3 year, it's only fitting that I spend some time elaborating on some of my thoughts regarding these 3 rotations. Here I'll only give a brief intro to each, with the next several posts going into some more detail.
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Medicine (July, August)
I first began describing internal medicine in this post several months ago. Again, internal medicine (usually just referred to as "medicine") is the prototypical idea that people have of what a doctor is - someone with a lot of medical knowledge who listens to you, physically examines you, then orders a bunch of tests and prescribes medications with the hope of figuring out what's wrong and getting you better.

My 2 months of medicine were exclusively inpatient; that is, spent entirely in the hospital on wards. My first month was on the hospitalist service at one hospital, then I was on a ward team at another hospital for my second month. The ward team structure is very hierarchical consisting of 2 M3 med students, 1 M4 med student, 2 interns, 1 senior resident, and 1 attending physician. The med students must "pre-round" before the rest of the team on their patients and then present their patients to the team during rounds. Rounds is basically when the entire ward team goes from patient room to patient room and discusses the action plan for each patient that day.

Surgery (September, October)
In contrast, surgery was an entirely different beast. Whereas on medicine the day began with rounds around 8am to 9am or so, surgery rounds frequently began before 6am and occasionally as early as 5am. The hours were grueling as the days rarely end before 5pm and too often later. While surgery also contains a similar ward team structure, each patient encounter goes much quicker because the first surgeries of the day typically begin around 8am.

Surgery was truly a love-hate relationship. I hated the hours with a fiery passion. I hated some of the people I worked with. And I hated standing for hours on end in the OR (operating room) - my lower back never hurt more than it did on surgery. But I loved doing something tangible with my hands - dressing wounds, removing drains, removing staples, removing sutures, removing lines, suturing, etc. I loved the act of scrubbing into the OR; not sure why, but there's something ritualistic and almost sacred about it.

Pediatrics (November, December)
Pediatrics (more affectionately called "peds") was a world apart from either medicine or surgery. In essence, it's the children's counterpart of medicine. At its core only the patient population differs, but that singular difference is more profound than one would think at first glance. With children come parents and families. And it's a rare occasion to find a child without an adult nearby. So when you address the patient, you're also addressing his/her guardian - if not the entire family. It requires a particular kind of skill to not only deal with kids, but also keep parents in the loop.

The benefit of the peds rotation is that one month is inpatient (with all the trappings of ward team structure) and one month is outpatient in a community clinic. The contrast between inpatient and outpatient is quite literally like night and day, and that deserves a post in and of itself.
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P.S. And why have I chosen a picture of the Fates to represent the big 3? Because, like the Fates attending to the loom of life and death, these 3 major branches of medicine are also intertwined and have to rely on the expertise of the others. It's an intricate balance and each one deserves respect (which incidentally can be a topic and post in and of itself as well, lol).

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