18 January 2011

The thing is, I'm not super - anything

(still on brains)

Wednesday, surgery from 10 am to 6:30 pm. We were standing, in lead coats from neck-to-knees (starting at thyroid), in an already unseasonably-warm OR. It was the same surgery on Friday (see last), but it took much longer, even though the patient’s case was technically easier.
No eating. No leaving.
A nurse brought in cold juice with straws for the surgeons – I guess it’s sterile if you do that below the mask – but they didn’t end up taking it.
(The lights are flashing in the neuroradiology reading room as I write. Am I leaving? Not yet. Things I ignore. Does it mean a machine is going off? Mostly, it’s not beeping. I’m early because parking was easy for once. In this city of public transportation and convenient shuttles between hospitals, neither option will get me here early enough. Driving alone at 5 am…that’s another story).

10 am to 6:30 pm. The intern and resident were closing around 5:30; they had already pulse-lavaged the spine, all clean, no active bleeders. The muscle was back together. The fascia. The subcutaneous fat…almost to skin. The attending walks back in. “WAIT – did we **???” The resident. “Mostly, yes, but we didn’t re-do that after the surgery.” The attending walks out. Few minutes pass. Attending walks back in, having deliberated. “..And we’re going back in.”
At this point, starting to feel faint – all of us had realized (and this was true) our scrubs were completely soaked through with sweat, it was so hot under full lead wraparound coat…), standing there a few feet from the surgical field and leaning, leaning to peer in as much as I can…(this attending did not let me do as much/get as close as the one from last week)…

I stepped away from the table. I went to sit down in the back of the room. Do I go back? Is there a point, at this point? After a minute, I pulled off the top pair of gloves, pulling the gown off with them, putting the entire spattered bundle into the trash. Second pair of gloves. Now, dear gods, the lead coat….

And I stood, hands crossed in non-sterile gloves, and I stayed.

(The lights are still flashing. How do you even evacuate a hospital? They didn’t, for Katrina).

There was another surgery that was going to go as an add-on. Maybe. The patient was stable, urgent but not emergent, and she’d taken two (full, 325 mg and not the 81s) aspirins that morning. (One of our attendings/teachers in the first two years tells the story of his famous third-year mishap. On morning rounds, he proudly pronounced that the patient was taking “ecasa.” Not knowing what it was. “ECASA”… is enteric-coated acetyl salicylic acid. Aka, aspirin). The attending was worried she’d bleed too much. The surgery was a ventricular shunt revision, which basically means they go in blindly, apparently, and if there’s internal bleeding in the brain, they won’t see it.

It was unclear when or if the add-on would go. I left. 7:30.

(Buckets on my porch in Mvangan, waiting to gather water before the impending storm)

The next day, I found out the surgery had gone, and rather than being fairly straightforward, as they had expected, it went until 4am.
A sub-intern would have stayed.
A superwoman, super-medstudent would have stayed.

I went home.
I couldn’t stay.

I was barely lucid even going home after the first one. We had to jump my housemate’s car, and I kept not understanding what she was saying, that we had to do it now (and could do it now) because she did have cables and I did have a working car and we were not, after all, waiting for someone to arrive, bearing cables, magically.
(if that doesn’t make sense as a sentence, neither did the situation in real-time in my head).
I just kept talking, and I alternated standing and jumping back onto the kitchen counter, finding odd bits of food I had. This was a day, and I’m even on a two week (done) rotation without evaluations.

There is nothing super or more than human about me.

And yet – and yet. I’m mostly close enough to see the surgical field when scrubbed in, in the OR. I’ve gotten used to crowding surgeons and they’re trained to be used to elbows. Small field, small incision (funny how scalpels are the symbol for surgery in word and in deed – they’re only used to cut skin, nowadays, and that’s so little of what’s done. Tiny minutes of the hours).
It’s a small surgical field and there are a lot of people. It’s useful to be claustrophilic.

(Kalabash! Market in Tourou, EN, Cameroun)

Time in the OR can drag, but that case didn’t feel like it was 8 hours long, and it’s fine and interesting. Fine. Then..I’m directly over the surgical field and I’m stunned. I’m fixated.
It’s unbelievable, unbelievable, unbelievably incredible that I get to be here. Looking into the interior of this person’s body. And not just looking but acting.
Part of me… a not small part of me…is a surgeon.

Proprioception is important at all times in the OR (see: the neuro exam). Proprioception – sense of your body in space. There are blue things everywhere. Blue means sterile (except for the blue non-sterile ubiquitous gloves by the door. That’s confusing). But everything else blue is sterile. The blue (Kimberly Clark has the monopoly, here) sterile surgeon gowns we spin around in. The OR dance everyone does. The blue gloves that go on beneath the whiter ones (though, sometimes, these are green). The blue cover on the instrument table. The blue towels. The blue drapes over the patient. The blue drape that separates anesthesia from surgery.

And your personal sterile field is a tiny window, just-below-shoulders to waist, basically. Arms, but mostly up to elbows. And that’s it. The back of you is not sterile. Do not turn your back to the patient. Do not touch the front of a sterile person with the back of your gown. Do not brush against the instrument table with any non-sterile part of you; they will have to completely re-open (and if you come close to doing this, you get yelled at. A lot). And somehow, magically, in the large OR that becomes a tiny, crowded, space, this almost never happens. You have to know exactly where you are in relation to everything and everyone else at all times to know how you can move. Awareness of yourself. Awareness of where the patient is.

I’m getting better at this, maybe.

This Friday, I saw something I’ve never seen before.
An attending had to back away from the case, sit down, scrub out, put his head down, and not pass out. He didn’t pass out. Attending, high-powered way-up-in-his-career surgeon. Super-sub-specialized. He had to stop. Another doctor, a non-scrubbed one, went over to him. Checked if he was okay. Spoke to him, gently. Was he having chest pain. Did he need to lie down. Someone went to get a stretcher. Someone else went for juice and chocolate. The sugar helped with the hypoglycemia. Whatever else… he left the room for awhile then returned and resumed his part in the case as if nothing had happened.
Doctors are supposed to be super-everything, surgeons in particular. I had never seen this happen.
Later in the case, this attending’s resident had a break in his work; ie, the resident from the other surgical team (this was a collaborative case) was taking over for a bit.
The resident backed away and sat down. You can do this and be sterile. But he sat down. At some point, he also scrubbed out to go to the bathroom, maybe, get food, maybe.
This was new to me.

For the other cases, it’s amazing to count how many nurses come and go. They have shift changes and they have mandated breaks (doctors don’t have unions. Or clauses). Anesthesiologists take breaks, too. Every few hours they’re relieved by someone else. In and out, in and out, faces and names and voices (behind masks) change all day in the OR. The surgeons are the same. And they almost never leave and never falter.

(Rhumsiki, EN, Cameroun. Continuing to be random)

I might take back some of what I said about neurosurgeons. Maybe it's the hospital where I am. And the particular team.

But in medicine...

Take the case(s) of Ms. Lee and Ms. Li. One is 35, the other is 65. One speaks Mandarin, one speaks 7 Chinese dialects and some English. One has metastatic cancer to her brain. The other has a primary tumor, we think, without the full pathology report, and all that's been done so far is a biopsy.
One went home yesterday and the other is still in the hospital.
And the team can never remember which is which.
"The Lees".... luckily, they're on different wards in the hospital, but that doesn't actually end up helping a lot.

"This" thing. Woman dying. Old. Sick. How much does she understand? We're not always there with an interpreter, we don't know.... and the family won't get together to make her DNR. As if this is the only acceptable option. It's true that for this patient, intubation might count as battery in the sense of...do more harm than do good. Legally bound to, however, without that order. Without physicians declaring "futility of care." (I can't remember if I told that story... perhaps later).

There is an actual story coming later this week. Almost done. Perhaps a little more...upbeat? 
There's also a much funnier story about the rest of what happened on Wednesday, during the surgery. Perhaps. If asked. And with a little levity.


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