Surgery: Fixing Disease
>> Friday, December 30, 2011
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.
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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