Surgery Clerkship Part Two

Patient (Pt) is coming in for colonoscopy and hemorrhoidectomy under general anesthesia. After lying down and going to sleep, the patient is rolled onto his stomach. The bed contorts with the whirring of engines to drop his legs down and lift his ass proudly to the Heavens. We pull his legs apart and place them into the anal stirrups. Two physicians (HPS and Brian) are sitting on stools between Pt’s legs for the show. Tape is applied to each ass cheek and then pulled around the bed for even “better” exposure.

The hemorrhoids are enormous and angry looking. They are each cut from the anus and the incisions sewed together. Brian, under the supervision of HPS, grabs the colonoscope. The c’scope is then fed into his rectum and maneuvered past the sigmoid colon, snaked around the splenic flexure, pushed along the transverse colon, and then descends down the ascending colon for a a good look at the cecum. No polyps or other masses. Everyone is happy. Brian pulls the colonoscope out of the colon, HPS leaves the room to dictate the operative note, and I begin taking down the drapes. Brian takes off his sterile gloves, gown, and plastic face shield. I lean over the patients back to release a clip holding the drapes in place and my weight compresses the patient.

PHBLLEEBBTHURUUUURP!

During a colonoscopy, air is pushed into the colon to inflate it for “exposure”. As the colonoscopy is finished, this air is typically sucked out so as to leave the Pt as comfortable as possible when they leave. Brian forgot to do this.

The shit sprays everywhere. On his cheeks, his eyelids, his forehead, arms, and neck. It turns his blue scrubs brown. The anesthesiologist screams. Brian is on the other end of the room, having kicked himself reflexively from the patient on his sliding stool. In fact, he’s still coasting towards the far wall as we watch him panic, trying to find a poopless place on his body to wipe away the poop on his body. He can’t find anything. The panic sinks in its teeth.

“Somebody HELP ME!” But we’re the ones that need help. We’re twisted in knots, fighting for gulps of air as we struggle against the laughter. We’re not even human right now: the laughter owns us. The patient begins to wake up. Hearing the commotion, HPS reenters the room.

“Oh GOD!” And HPS leaves the room to dry heave in the hall. It’s been 40 seconds since my last breath and my chest is starting to spasm. I can’t tell if we’re even making noises anymore or if we’re all quietly dying of laughter.

The scrub nurse walks over to Brian and, afraid of the hand-off, throws a towel at him. He begins to wipe himself clean. The patient is awake now with the embarrassment that only a person with his asshole winking at a room full of laughter can ever truly know. Brian has wiped his face and is now storming to the wash room to clean himself. He walks by the head of the bed and the patient pieces it together.

“Oh, I’m so sorry if I pooped on you.”
Brian manages an “It’s okay” before walking out.

From the halls, we can hear the heavings of HPS start up again.

Surgery Clerkship Part One

*I wrote the following for friends and family a long time ago. Thought I’d share*

My third year is fractured by discipline and geography. Watch me as I hurdle across the great states of Pennsylvania and New Jersey through Surgery, OBGYN, Psychiatry, Pediatrics, Family Practice and Internal Medicine. I plan on writing once/twice per rotation.

For now, I’m beginning my third month of Surgery in Pittsburgh.

Who knows for certain, but odds are that I’m going to cut people for a living. Others want to be physicians in order to help people and that’s great. I’m just looking for stabbings minus the jail sentence.

We begin with Trauma, a painfully slow field punctuated by bursts of exhausting speed like the sprintings of the obese. From 6am to 6pm, we waddle the four corners of the Trauma ICU tending to the most serious cases from the last week. It takes 12 hours to see 15 patients for several reasons, though I am unaware of any good ones. Attending Spanish Physician has sleep apnea. This causes him to fall asleep standing up at times in the middle of rounds while someone works up the nerve to tactfully clap their hands. Attending Scottish Physician never uses two words when ten would do. He has held court on the following:

1. George Washington’s teeth
2. The French and Indian War
3. Mussolini’s v. Hitler’s fascism
4. Why flying airplanes is so difficult
5. Things back in his day

Imagine it: twelve hours every day spent on two hours of real work. You can’t escape. Attendance is mandatory. “If you ask him a question, I sear to God, I will kill you.” So I don’t ask questions. I just stand there, eyes glazed over, praying for a midday TRAUMA ALERT: 30M 20FT FALL FROM TREE +LOC HEAD LAC ETOH 5MIN ETA VIA GRND.

Drunks in trees. All the time.

I like responding to traumas because I am an important member of the Trauma Team. I am make-sure-they’re-naked guy. I stand poised, trauma scissors in the air with blades just slightly opened, waiting to cut away your dignity. You’re a trauma, you’re getting naked. No negotiation.

“Are you cutting my dress?”
“Yes, ma’am. We have to check you for injuries.”
“But I just fainted!”
“Yes, ma’am. But you fainted in a car. That makes you a ‘trauma’. Please stop moving your head; you may have a broken neck.”

Because it is hard to schedule traumas, there was little time in the operating room and the majority of this service felt like ER with knives. Fun, but glad when it ended. After three weeks, I moved on to the Colorectal surgery service.

You would never guess it, but poop surgery is great. The incisions are huge and the anatomy is straightforward, so it’s easy to play along. You take people that are absolutely miserable with constant nausea, vomiting, diarrhea, fevers, etc who can’t remember what it feels like to enjoy a meal. You cut out their colon: cured. Thanks to preoperative bowel preparation, there is actually very little stool (or succus) during surgery, which is fortunate when you’re a 250lb ex-football player turned Head Poop Surgeon (HPS) that vomits at the sight of it. During an operation where the small bowel was being cut in two, some green stool began to leak from the lumen.

“Oh my God, I’m gonna throw up. IMGONNATHROWUP! Brian, get it away! GETITAWAY!” HPS stutters back from the table, dry-heaving.
Brian wipes away the small amount of stool with a lap pad as those not twisted in hysterics stare on in horror at HPS’s reaction.
“I hate that. Oh, I hate that. Okay, let’s finish.”

Poop surgeons don’t like to be called “poop surgeons,” by the way. It’s no use explaining to them how funny it is. They just don’t get it.

Much has been made of “pimping”, the art of harassing medical students with questions in order to expose their ignorance. This is often described as being malignant. This has not been my experience. If anything, I have wished aloud to be asked more questions in order to better learn what is and is not important and to have a chance to show that I am studying in my spare time. Barely touched on Trauma, Colorectal gave it a good try. With mixed results. Here is a smattering:

“Christian, what is the social muscle? ”
“The tongue, sir?”
“No. It’s the anal sphincter. If it doesn’t work, you have no social life and no home. Watch a bunch of monkeys. They hang out together, all poop, and then they have to move. That’s why monkeys don’t have houses.”

“Christian, what are the indications for surgery?”
“Hemodynamic instability.”
“That’s a trauma answer. This man is having his colon removed, so that’s a pretty stupid answer for this man, isn’t it.”
“Sorry, sir. Any condition that has been refractory to medical management for which a surgical solution exists that is not otherwise contraindicated.” To myself: booyah.
(Pause). “Wrong. Um, what’s the most important thing to remember when irrigating the abdomen?”
“To suck the fluid back out, sir?”
“Um. Wrong. It’s to not use too much. Okay smart guy, what’s that?”
“The uterus, sir.”
“Good.”

“Christian, why did Brian call you ‘topher’?”
“It’s my nickname. It’s short for ‘Christopher’.”
“So you’re name isn’t ‘Christian’?”
“No, sir.”
Brian: “We told him we’d kill him if he ever corrected you.”
“Oh. Good.”

Playing the role of the good surgical student slowly earns you privileges in the OR. I have the privilege of cutting sutures with the scissors. I have the privilege of holding and pulling things. At the end of the case, I have the privilege of using staples to close the skin or use sutures to close a small hole. Execute each of these without error, and you are praised. As much as I gripe about being compared favorably to a seven-year-old with appropriate motor skills, the simple “nice job” can make your day. I was graduated to eight-year-old after being offered the scalpel to make the first incision for a case. This was no nick, but instead went from his sternum to his pubis. When HPS made it clear that I was going to make the cut and the he was not joking, the surgical masks in the room nearly popped off from the slacked jaws.

My post-op juice box never tasted so sweet.

All for now, topher.

P.S.
Trauma Lesson: Car + anything = trauma = naked = rectal exam.
Colorectal Lesson: Poop kills.