Surgical Residency-101

Hi Nat!
I just wanted to say thank you for allowing us to peek into your world. You have been such an inspiration to us all. :O
While others may be too busy or may not care to share - you have certainly given us a treat.
I am inspired by you and continuosly look forward to your posts. Again, thank you so much.
:laugh:

Hi folks,
Last night, I was on call for my three-service coverage as usual. As soon as the day residents signed out to me, the calls started to trickle in about 15 minutes apart. Here at UVa, all my vascular, thoracic and cardiac surgery patients are on 4 West, the TCV/PO, TIMU and 8 West. Having four floors in between these patients is evil. If I am on the 8th floor reading, the fourth floor is calling. If I am on the 4th floor reading, the 8th floor is calling. One thing to do to head off too many little calls is to appear on the floor about 30 minutes after the nurses change shift in order to answer questions. In the case of the cardiac and thoracic patients, I am something of a babysitter and cannot give much guidance as to the long term management of these patients. I just put out the fires like elevated temps, chest tube malfunctions, nausea and vomiting, acute dyspnea etc. In the case of my vascular patients, I have to head off loss of limb by keeping an eye on pulses and checking in on patients often. I can’t tell you how much I rely on the nurses to keep me up to date on what is going on should I be off one floor putting in a chest tube or some other procedure. The nurses are really outstanding here. If I go to another hospital where the nursing care is not as good, I am really going to be at a disadvantage because I am so spoiled.
Last night, I was called to share the duties of inserting a chest tube on a morbidly obese patient. The patient’s size made the thorocostomy tube insertion a little more tricky than the usual routine insertion. This lady had a malignant pleural effusion that had all but completely compressed her right lung. She was also Spanish-speaking so language was a bit of a barrier. My third-year resident helped me through the procedure. We had her son translate for us. The technical difficultly came with making sure that she had enough local anesthetic to make the procedure bearable. I really work on making sure the patient is positioned properly and is not completely covered by drapes should the patient become claustrophobic. It is bad enough that the patient has to undergo this procedure and I didn’t want to add panic to her distress. I am also anal about getting everything set up and in position for the insertion. I set up the three-chambered drainage device, got extra 4 x 4 dressings and lots of povidine-iodine solution for prepreparing the skin well. I also keep a couple of extra pairs of gloves handy should one pair tear.
We located our landmark fifth intercostal space in the mid-axillary line by using her nipple as a guide. After infiltrating as much subcutaneous tissue as possible, we waited for the lidocaine to take effect. When her son assured us that she only felt pressure, I made a 2 cm stab incision and bluntly dissected down to the level of the rib. My finger went into the tissue as far as I could reach limited by the length of my fingers which are very long. I was able to just snag her rib so that I could inject more local anesthetic. After a couple of minutes, we made a stab incision over the top of the fifth rib(why did I do this for all you first, second and third-year medical students?) and fed the tube in using hemostats to push the tube in place. Amost two liters of bloody fluid poured from her chest through the tube. The tricky part came with holding the tube in place so we could get it sewed down after proper positioning. This is where having a knowledgable assistant came in handy. I also clamped the tube at 1800 ccs and monitored her oxygen saturation and heart rate before making the final sutures. My hand shook so much that tying the sutures was difficult but doable. I put in three anchoring sutures and sealed the rest of the site with petrolum gauze. As the patient stabilized, I unclamped the tube and placed it to suction. A portable chest film confirmed the placement of the tube as my senior resident wrote a procedure note for me. It was great to have Mike there to guide me throught the process and help with the technical aspects of this procedure that I had only performed on dogs and pigs previously. The chest film looked great so I made quick social rounds and hit the rack for some sleep and decompression. Throughout the night, I was paged at 45-minute intervals so I didn’t get too much REM sleep. On one page, I was in the middle of a nightmare about the chest tube that I was grateful for the awakening. ( Don’t tell the nurses about this :D
For the rest of the night, I did things like investigate post-op cardiac patients who had gone into atrial flutter and had elevated temps. I ordered sleeping pills and adjusted pain medications. The good thing about this experience is that I am going to be a great sign-out resident. I will have all of these things ordered for my patients before I check out so that the cross-cover is not burdened by these things.
My interactions with the attending physicians is getting less scary. Mike has been a large part of that. He is going into Plastic surgery so he is great with suturing techniques and teaching me the fine points of procedures. He is patient and allows me to trouble-shoot my mistakes without being sarcastic. Even the thoracic fellow that yelled at me one night was grateful for my patient management when he read my note in the morning. Someone wake me up from this dream because things are getting to be downright fun that are supposed to be drudgery. I was prepared for Surgical internship to be a purgatory and it is something akin to heaven. For those who know me well (JP and Mary), you can now certify that I have lost my mind. :p
Natalie

Hey Nat,
I noticed that you wrote that your hands were shaking. I often had this problem when I was doing mouse surgery. However, mice don't sue you when they wake up. Neither do their relatives. I found that I got shaky hands sometimes when my blood sugar was low, but more often when the procedure was new or in any way upsetting to me–whenever I was stressed, as in your example. And this made me think that I was going to have a really hard time in my surgery rotations. So, is this common? How do you and other people you know deal with it?
–sf/dc joe

Quote (joewright @ July 21 2002 6:46 pm)
Hey Nat,
I noticed that you wrote that your hands were shaking. I often had this problem when I was doing mouse surgery. However, mice don't sue you when they wake up. Neither do their relatives. I found that I got shaky hands sometimes when my blood sugar was low, but more often when the procedure was new or in any way upsetting to me--whenever I was stressed, as in your example. And this made me think that I was going to have a really hard time in my surgery rotations. So, is this common? How do you and other people you know deal with it?
--sf/dc joe

Hey Joe,
My excitement and adrenalin rush tend to make my hands shake when I have accomplished something new. It is almost my response to letting go of the stress. I tend not to shake during the complex parts but shake when everything is over and my senior resident is congratulating me on doing a fine job. I also need to get the chicken breasts out and practice suturing with silk! :p
Nat

Nat, first of all you are a delight. You display all of the characteristics of an excellent physician and an exemplary surgeon. I'm so proud to have you representing our community of women surgeons, as well as all of we 'non-traditionals'.
I wanted to assure everyone…virtually every surgeon's hands will shake when the stress levels get high enough. Early on…putting in a new chest tube (or operating on a mouse) is all it takes. Later in your career, it will be an unexpected on-table catastrophe requiring quick intervention to save a life. You're absolutely right - it's a natural function of being adrenalinized. But your threshold becomes much higher as your exposure increases.
Keep up the good work. Have you had your first central line yet? Emergent intubation? Keep us posted.

Awesome discussion!!! Thread pinned, 'nuff said…
:D

Hi Nat!
Got another question for you-Yesterday, I made rounds with my two internist mentors and assisted them with several procedures including TLC placement. I asked Dr. Bisel why he uses heparin to flush the lumens prior allowing access amd he told me that it keeps clots from forming unless the patient has thrombocytopenia. Then I told him the reason I was asking is because when I set up TLC placements for surgeons when I'm working on the floor, they tend to only use saline for their flushes. He replied that generally, surgeon use saline because the patient is going to surgery pretty soon if we're asking one of them to put one in so the clotting issue isn't really a factor. It does become a factor on the floors because generally, the lumens get clotted due to multiple factors, mainly incorrect procedure in blood draws, etc form them and using the heparin gives us a safety factor in keeping the lumens open and saving the patient multiple placememts. Is that a prevailing thought when you do a TLC or what is your response to that? Thanks for your time!!!

Quote (OHIO DO 2 B @ July 22 2002 1:10 pm)
Hi Nat!
It does become a factor on the floors because generally, the lumens get clotted due to multiple factors, mainly incorrect procedure in blood draws, etc form them and using the heparin gives us a safety factor in keeping the lumens open and saving the patient multiple placememts. Is that a prevailing thought when you do a TLC or what is your response to that? Thanks for your time!!!

Hey Kimberley,
We tend to flush the lumens with heparin when we first insert the line but after that, the nurses generally use saline for flush. Since triple-lumens are a pretty big deal (the patient or patient's family has to give consent for procedure), the nurses tend to be extra careful with these lines. They generally last until we have to change them out. :)
Nat

Hi folks,
One more night of triple service call is in the can. That leaves only two more left and I will be onto another service and more interesting experiences. My next rotation is breast surgery or Gold Team here at UVa. It will be a virtual vacation compared to the hectic pace of vascular surgery. I am looking forward to having some good time for in-depth reading. So far, I am only reading stuff that pertains to handling emergencies on the floor.
My latest adventure:
Last night, I settled into the rack at 10pm. I had checked all of my vascular patients on the 8th floor and had given the nurses the green light to go to “AutoPilot”. This means that they don’t call me for things like sleeping pills and laxative orders. They have standing orders for electrolyte replacement and I generally wake up and sign several verbal orders that they have put into the computer during the night. This system would only work if you can trust the nursing staff. I am fortunate because they are the best here and have better judgement than mine. I trust them without question to do what is in the best interest of the patient.
I moved down to the 4th floor because I was covering about 20 thoracic and cardiac patients down there. It is easier to sleep near the most patients. Since I am doing this triple-service duty, I have my choice of three call rooms. Let’s see, one call room for afternoon nap and one call room for night sleep. I drifted off to sleep only to be awakened a couple of times for minor things and questions.
On my next call, a panicked nursed shouted for me come out to the floor immediately because one of my patients had cut his chest tube, stabbed a nurse and run off of the floor. She asked if I wanted to chase him? :p
I grabbed my labcoat and headed down the hall where several dozen security guards were running around “Chinese fire-drill style” shouting that they were trying to “flush him out”. How far can a man with one lung and a cut chest tube run? :O In this case, he had run down to the third floor and into the Medical Intensive Care Unit. I caught up with about six security guards and four nurses wheeling my patient back to the elevator on one of the ICU beds. He had stopped in the MICU when he realized that he could go no further. The nursed that he had stabbed (with scissors) had been taken to the emergency room.
We managed to get the now-exhaused but dyspneic patient back on oxygen. I found another three-chamber device and hooked the chest tube to water seal after I verified that he had not displaced the tube under the dressing. He had a leak but the site and wound were intact. I put the chest tube to suction and the patient’s oxygen saturation level immediately moved into the high 90s (normal). I ordered a chest film, electrolytes, complete blood count and a nebulizer respiratory treatment with albuterol. (For the uninitiated, albuterol is a very selective beta sympathomimetic that is commonly used as a bronchodilator in patients with asthma and reactive airways disease.
For the rest of the night, my patient slept like an angel. He went into atrial fibrillation which converted with IV lopressor. I also ordered a sitter to watch him closely and four-point soft restraints. By 5am, he was very apologetic and did not need the wrist restraints. His blood pressure came into the normotensive range and he was more comfortable.
As for my sleep, the night was over for me. I rested in the sleep room after I called the thoracic fellow who was very surprised that my patient had even moved from the bed. I rounded early and went on to “rocket clinic” with the chairman of the department. All in all, it was a very interesting night. I will be asleep in my little bed in about two hours. :cool:

Dr. Belle,
I love reading your posts about your surgical internship experiences.
Any idea what made the patient try to escape? Reaction to a medication, a pre-existing mental condition, or was it just a case of a person being ill and not really in their normal state of mind?
Ian

Quote (racerx @ July 23 2002 7:41 pm)
Dr. Belle,
I love reading your posts about your surgical internship experiences.
Any idea what made the patient try to escape? Reaction to a medication, a pre-existing mental condition, or was it just a case of a person being ill and not really in their normal state of mind?
Ian

Hi there,
My guess is that it was a reaction to a medication though this patient did have some history of psychiatric pathology. He was discharged from the hospital today. This event made the morning news on the local Telly station. This fellow's attending physician brought goodies for the nurses to make up for this event. They were nice enough to share with me :D
Nat

Dr. Belle,
I read your post on cartoid endarectomies and have yet another question related to my encounters with these pateints post-surgically. When the patient comes to our floor, they always have an arterial line established. Is that to make sure that the pressure remains stable in the repaired area? In another post, you said that an occasional Anesthesiologist comes on the units when you work to provide patient management as well as the surgeons-can I assume that person specializes in critical care or just a specialist in managing surgical/trauma ICU patients? Finally, for someone that may be interested in managing surgical/trauma ICU patients but is not interested in Surgery,do you feel that they should look into an IM residency with a fellowship in Critical Care Medicine or an Anesthesiology residency with a fellowship in Critical Care Medicine? Besides all of the relevent medical info your posts give, you also give insight on how important it is to have a good working relationship with your medical support staff-nurses, RT’s, X-Ray Techs, and all the way down to the Nursing Techs such as myself. I’ve seen on the job that the physicians that tend to treat the ancillary staff with respect are the ones that get the maximum effort from us. I’m not saying that we don’t give 100% to our patients because we do but, your’e willing to go that “extra step” for someone that respects you and what you do to assist in the successful outcome for their patients. Thanks again for all of your posts and hope you have a great day under the “bright lights and cold steel”! :D

Quote (OHIO DO 2 B @ July 25 2002 8:28 am)
Dr. Belle,
I read your post on cartoid endarectomies and have yet another question related to my encounters with these pateints post-surgically. When the patient comes to our floor, they always have an arterial line established. Is that to make sure that the pressure remains stable in the repaired area? In another post, you said that an occasional Anesthesiologist comes on the units when you work to provide patient management as well as the surgeons-can I assume that person specializes in critical care or just a specialist in managing surgical/trauma ICU patients? Finally, for someone that may be interested in managing surgical/trauma ICU patients but is not interested in Surgery,do you feel that they should look into an IM residency with a fellowship in Critical Care Medicine or an Anesthesiology residency with a fellowship in Critical Care Medicine? Besides all of the relevent medical info your posts give, you also give insight on how important it is to have a good working relationship with your medical support staff-nurses, RT's, X-Ray Techs, and all the way down to the Nursing Techs such as myself. I've seen on the job that the physicians that tend to treat the ancillary staff with respect are the ones that get the maximum effort from us. I'm not saying that we don't give 100% to our patients because we do but, your'e willing to go that "extra step" for someone that respects you and what you do to assist in the successful outcome for their patients. Thanks again for all of your posts and hope you have a great day under the "bright lights and cold steel"! :D

Hi Kimberly,
You can drop the "Dr. Belle" stuff. I am only "Dr. Belle" to my patients. :D In the STICU, the anesthesia critical care fellows rotate through and do the post-op management of the surgical/trauma patients. They are the only non-surgery folks who manage patients in the STICU so anesthesia residency with a critical care fellowship (total of 5 years) will get you into the STICU and into the OR but on the other side of the drape (the bloodless side).
If you go the internal medicine/critical care route, you will cover CCU or MICU but you would not generally cover STICU unless you were called in as a consultant. Believe me, we consult the medicine folks quite a bit with patient management. We have a cardiologist who handles most of our toughest patients with cardiac issues such as a patient that we did an abdominal aortic aneurysm repair on earlier in the week. He had a poor heart and poor lungs. Now he has a great abominal aorta, a poor heart, poor lungs and even poorer kidneys. We have a nephrologist and a cardiologist on board with us but the ultimate patient management is our responsibility. The patient has a long recovery road ahead.
Stay tuned to this thread for my next installment called, " My parade of cousultants."
Nat

Hi Nat, I just got to tell you that I LOVE reading your posts! I just found this thread on the OPM site, it's almost 1am, I'm tired and there was no way I was going to bed until I read all your posts as well as everyone else's comments. I just love reading what you do everyday at the hospital. I've been an OR nurse for the last 10 years and I've worked with a lot of med students, residents and attendings but I never knew what they did when they weren't in the OR. Your posts really help me understand what you're all going through. I too, even after all these years, get excited when I'm in the OR. I just started down the pre-med road and I'll be 50 or close to it when I apply. The funny thing is I don't feel my age ( I ride horses and I've run 3 marathons) when I am all finished, I hope to be an OB/GYN doc. Please, when time and energy allows, keep the posts coming, they are sooooo inspiring and informative. Thanks Nat! Vita (in Milwaukee)

Hi folks,
My parade of consultants: I have been vicariously taking care of an elderly patient in the TVC/PO for the past week(He is actually managed by my chief residents and a second-year resident but I try to follow along and learn some fine points critical post-op care) He had a 6.5 cm abdominal aortic aneurysm on top of poor lungs and a very poor heart. Why did the attending physician choose to perform such a huge surgical procedure on a gentleman with such significant comorbidities? The patient wanted the surgery and was willing to take the risk to get this abdominal “time bomb” out of his body. Actually, his best chance is exactly where he is located and with this attending physician who is an excellent and nationally-renowned vascular surgeon.
We had the patient worked up pre-operatively by a cardiologist who optimized his left ventricular function with beta blockers and other cardiac drugs. We also had the patient evaluated by pulmonary function testing so that we would have an idea of how to ventilate him during the post-op period. As we guessed, the years of smoking had taken their toll and he had significant lung disease. Anesthesia did their usual pre-operative evaluation and the surgery got underway.
The patient was transferred directly from the PACU (Recovery Room) to the TCV/PO without extubation. We had a Swan-Ganz pulmonary artery catheter and art line in place too. This man is what we loving refer to as a “seven-tuber”. Nasogastric tube, endotracheal tube, foley bladder catheter, Swan-Ganz catheter, arterial line catheter, epidural pain catheter and peripheral IV catheter. For past week, we have been adjusting up and down on various drips such as Bumex, dopamine, dobutamine, propafal etc. to optimize the patient’s cardiac output and keep his kidneys perfused. With the abdominal aneurysm located so close to where the renal arteries take off from the aorta, his kidneys took a pretty good jolt during the aneurysm repair and cross-clamping. He has rapidly developed renal failure. Today we added CAVH (Continuous Arterialovenous hemofiltration) and a nephrologist to the parade of specialists. So now this patient has an acute pain management specialist(the epidural pain catheter) a cardiologist (assistance with the pressor drips and arrhythmia management) a pulmonologist (assistance with mechanical ventilation) a nephrologist (assistance with renal failure) an infectious disease specialist (assistance with treating a gram negative pneumonia) and a critical care surgeon (overall management of the patient). :O
We also have a critical care pharmacy specialist who does things like get the proper concentration of drips so that we can minimize the fluid load that this patient’s sick kidneys have to bear. We are hoping that the CAVH will unload the kidneys enough for them to get a much needed rest from the stress of surgery and anesthesia. If all goes well, they should begin to kick back in this week. We also have a critical care respiratory therapist who optimizes the ventilator in consultation with the pulmonologist to keep this gentleman’s heart properly oxygentated.
As you can see, getting this patient through surgery and the post-operative management has been a huge team effort. I have been able to keep up with his care and take notes. He is slowly inching his way back from the surgery and is 7 days out at this point.
Every morning, the parade of consultants gathers around his room. We all discuss his care as a team and we all pay close attention to the notes and suggestions of the team members. For me, this patient’s care had been one huge teaching experience. I am reading and learning so much. Since I have a STICU rotation coming up in April, I want to have as much critical care experience as possible.
Unless a catastrophe like total circulatory collapse happens, this patient will recover slowly. The ticking “time bomb” in his abdomen is no longer ticking but will his quality of life be better after this? Was it worth it in the long run if he ends up permanently disabled or unable to wean from mechanical ventilation. We will take him into the OR in the next couple of days to perform a tracheostomy. This should aid in his wean from the ventilator. At present, he is on minimal settings but still ventilator dependent.
And the parade of consultants goes on… We could even add the assistance of the pathologist in the form of the transfusion medicine specialist who helped us with getting this patient’s sluggish platelet count back up.
I will update you all on his condition as he recovers.
Nat

Hey Nat!
That was really cool reading and, it pretty much solidified where I want to be…on the front line of consulting and helping manage critically ill patients from the medical point of view-hence Cardiology or Critical Care Med via IM. But, like I’ve relayed before, I really enjoy the complexity and varied thought process that Cardiology entails and how it interacts with other specialities. Hopefully, I’ll get done with this quest of mine in enough time to be fortunate enough to consult for you. It would be an honor and pleasure to do so. Looking forward to your next installment… :D

Going…through…withdrawal…
Must see…new post…from… gasp …N A T…
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me…
Geez, I haven't felt this way since I used to watch Dallas episodes every afternoon after classes before I headed off to my night job as a bartender (yes, I'm that old…).
Is this thing on? (tap…tap) Hello?

Hi Folks,
I left the world of vascular surgery behind and have moved to the Gold Team. This service is Surgical Oncology. Once again, I have a great chief resident who is very comfortable letting me do many things independently. I have spent one day on the service and he has taught me a couple of neat things on how to evaluate patients quickly. He is an MD-Ph.D who is going through the 5-year surgical residency program. He wants to do only General Surgery with no fellowship.
Today, I spent the whole day in the Cancer Clinic. We had a total of 31 patients, most were breast cancer patients who came in for follow-up. My attending for this clinic is a master with making great looking incisions. Every mastectomy patient is doing just great. I also had a young man with melanoma, which had started as a mole on the sole of his left foot and has now spead to his groin and lungs. We posted him for surgery on Tuesday. It was very educational to look at his slides, his PET scan, his CT scans and his x-rays. This case is going to be pretty involved. My chief will probably take it but I am going to bump the medical student if I don’t have to scrub on my own cases on Tuesday.
I had a couple of patients with sarcomas (tumors of the muscle) and a couple of patients who had colon cancer. We share the clinic space with a great oncologist who provides care for our patients who need chemo or radiation therapy. I enjoy reviewing scans with him.
Unlike Vascular Surgery, where I was breakneck busy all of the time, Surgical Oncology has very few inpatients. I have a grand total of three patients. Two are in the intensive care units and one is on the general ward. I will discharge my last patient in the morning so I go into the weekend on call with no patients on my service. I do have to cross-cover the Transplant service which is pretty busy.
On my last day of vascular, one of my patients died in the middle of the night. I had admitted him earlier that day for an infection. He was pretty depressed because of his pain issues so I decided to seek a consultation from the Chronic Pain service. Chronic Pain service is a division of the Anesthesia department. The fellow and the attending physician came over and spent about 45 minutes with my depressed patient. When he was done, the Anesthesia attending physician asked if he could download something from the internet. It was a newspaper story about restoring a couple of B-52 bombers. It seems that my depressed patient had been an aeronautical engineer who had worked on some of the designs for the B-52s. He was overjoyed to read about his designs being restored.
When my patient finished reading the Internet story, he was smiling and didn’t ask for any additional pain medication. He started to tell jokes and tease some of the nurses. That anesthesiologist had discovered a common interest with this patient and had shared some stories about the old war planes. The anesthesiologist had been a Navy flier back in Vietnam War. It took about 15 minutes for him to download the pictures and newspaper story but the joy to my patient lasted for hours.
My patient drifted off to sleep and never woke up again. Unfortunately, he didn’t have a primary directive so the Code team attempted to revive him. Since he was discovered cold and blue, it was an exercise in futility. When I came in to do my final day of floor call, I was stunned that he had died during the night. I phoned the anesthesia attending physician who took time out of his busy schedule to come over to personally thank me for the phone call. He was delighted to know that he had brought some joy into the life of a man who really had just hours to live.
That’s the cool thing about medicine. You never know how you are going to touch your patient’s life or what impact you will have by a simple act of kindness and interest in your patient’s well being. When you stop and wonder if all of the studying and sacrifice are worth it. Yes, a resounding YES!
:D

Hi Nat!
The one thing I can say about your posts is that it makes me look at medicine from a humanistic stand point and, it has helped me on my job as a nursing assistant…it's the little things that are important to patients whether they are in the forefront or the twilight years of their lives…Thank you for sharing that important lesson about medicine with us…

Hi Natalie,
I had to let you know how much I enjoy reading your posts. I keep thinking after every post, I can’t wait to do that! I’ve applied to medical school for the entering class of 2003. I want to go into surgery and UVa is one of my top 2 choices. Because of my surgical aspirations, I love hearing what you are doing - it’s so motivating! I’m also happy to note that you work with such a variety of cases and the extent to which you are working independently. I was a little concerned about variety of cases while I was applying because Charlottesville isn’t a major metropolitan area. But you’re As a clinical trials coordinator for Washington Cancer Institute, I’m waiting for more of your tales from Surgical Oncology.
Keep up the wonderful posts as long as you can, they really give us upcoming students a view of what we are waiting for!
Kristin
:)