Natalie, thanks for sharing that story and the update. I have witnessed some similar poignant moments (though none quite as challenging) during my month of general surgery, and it has been a truly uplifting experience. I will be honest, I hadn’t counted on seeing nearly as much human contact and continuity of care between surgeons and their patients. What I’ve seen has left me feeling very positive about surgeons (yay) and how they care for people.
A few examples: a simple ‘removal of sebaceous cyst,’ scheduled for the OR instead of the office because the patient had COPD, turned into a long discussion when the surgeon found out that, in the two week interval between scheduling and doing the surgery, his patient had been diagnosed with lung cancer. All of a sudden an innocuous bump on her back took on a new sinister meaning. And instead of excising a cyst, he was doing a needle biopsy with immediate pathology consult. We waited long minutes in the OR with this lady while her surgeon talked to the pathologist; the woman cried softly and said, “I knew it as soon as he said there might be something wrong.” Eventually the surgeon came back and with incredible care, told her that the lump was metastasized lung cancer. It was a heartbreaking scene.
Another day, a young woman had to be told that TWO excisions for ductal carcinoma in situ had failed to produce the “clean margins” that would mean her breast was cancer-free; and what was more, the second biopsy had showed lobular carcinoma in situ as well, which meant that she had a much higher chance of developing cancer in the other breast too. So despite a “good” diagnosis - non-invasive breast cancer - this woman had to confront the question of whether to have a bilateral mastectomy. The surgeon who steered the conversation was so gentle and very solicitous of her feelings.
Lastly, I witnessed a surgeon talk to a woman with inoperable gastric cancer that had spread to obstruct the gastric outlet - everything she drank or ate came back up because there was no place for the food to go. She had hoped that an additional surgery could release the stricture and at least allow her to eat. She knew that she had liver mets and spreading cancer, and just wanted to do more than drink sips of apple juice. Sadly, she could not, and the discussion was about transferring her to hospice and how surgery would not help her. We all left the room and slumped against the wall - I am sure I was not the only one blinking back tears.
Sad as these circumstances were, it was a real privilege to share them with the patients involved, and inspiring to see the way they were handled by the patients’ physicians.
Back several weeks ago Nat expressed the hope that I'd tell everyone that the surgery rotation is fun.
Now I've completed my four weeks of general surgery and I can say, it was THE coolest thing I have ever done! I had no idea I would enjoy it so very much. I don't think I want to be a surgeon - although my classmate on my team is seriously considering it after our four weeks - but I also don't feel averse to the idea, like I did before. It was just a fantastic experience in every sense of the word. Even the bummer situations like I wrote about above contributed to the sense of what a wondrous thing it is to be involved in surgery. I loved it!
(now on to urology and ENT, my two subspecialty portions of the surgery rotation - supposedly also a lot of fun)
I think to this day, the most difficult news I have had to deliver was one event very early in my intern year. It must have been the first 2 weeks of my residency.
It was a weekend night, and we were taking level one traumas seemingly one right on top of another. My attending and the chief were in the OR with a gunshot victim; the junior resident was resuscitating an unstable motor vehicle collision patient; and I had been left to tuck a 15 year old boy - self inflicted, gunshot wound to the head - into the ICU until the family and the organ donor network arrived. We had already made a clinical determination of brain death.
The mother arrived, alone and frightened, having heard only that her son was injured in a shooting, but knowing nothing of the severity of his injuries or of the details.
I ran down to the OR to let my staff know about her arrival. The case in the OR was going poorly and both attending and chief were working feverishly to isolate and control bleeding.The wounded child upstairs had already experienced uncal herniation, and with his massive intracranial injury, was beginning to develop hemodynamic instability. My attending informed me that I would have inform the mother of the situation, and try to illicit permission for organ donation before the boy degenerated into irreversible shock.
I went back upstairs and brought the mother back into a conference room. I honestly can't even remember the words I chose or how I spoke them. I just remember the moment before I spoke, that nanosecond of intense hope in her face, how I was so loathe to proceed beyond that point. Then how injured she was by my words, and how inconsolable.
That same night, early in the morning hours, I sat and listened while my attending called parents in another state, awakening them from sleep to tell them that their 18 year old daughter had died shortly after arrival from the scene of a motor vehicle collision. She'd been one of several kids in one car, visiting a nearby college town for the weekend.
Too, too heartbreaking.
Well, thanks for listening.
Hi Folks,
I am so happy to know that there are a few other surgeons in the country that are feverishly trying to break out of the mold of “uncaring and unfeeling” pricks that we have been labeled by the rest of the world. GED2MD’s concern for that mother’s feelings on losing her son and Mary’s observations show that we do invest something of ourselves in our patient’s care. It is almost impossible not to do so.
Yes, I am impatient where the comfort of my patient’s is concerned. Two days ago, I had to cut a path through the radiology department when they left one of my patients sitting in a wheelchair for hours after a simple procedure. This poor man couldn’t get to a restroom because of his inability to walk. He weighs more than 400 pounds and had an ileus after a laproscopic gastric bypass procedure. I ended up wheeling him back up to his room myself after the transporters didn’t want to go near him because he smelled. He was sitting in an alcove alone, without a call button and no means to summon assistance. The transporter forget that she left him in the wrong spot. I have written to her supervisor, the chief of radiology backed up by my chief resident and the attending. No human should be robbed of their dignity.
I had a lump in my throat as I read about the emotions of GED2MD as that mother heard that her son was no longer alive. I don’t think that we ever forget some of the patients who touch us in so many ways.
Natalie
Helloe Everyone,
It's truly wonderful to hear stories from both physicians and physicians in training about the efforts you make to help your patients. I just wish any one of you had been around last year this time when my father was diagnosed with and eventually succumed to colon/prostate cancer.
Unfortunately for me, your stories are the exception and not the rule in my experience either as a patient ( I have my own atypical hyperplasia issues) or the daughter of a patient.
Please, keep up the good work. Your kindness not only touches the patient but as you probably know, the patients family as well.
Kim
Hi Folks,
Here I was struggling to juggle all of the discharges and orders for my Thoracic Surgery patients and I get a page that says the party on the line is David Kelley. My first thought was that it was the manager of the Vascular and Thoracic Units and I had screwed up with some administrative thing. Well, it was Old Man Dave and he was in town to check out the Anesthesia Department at University of Virginia. What a great surprise! I called a couple of my friends in Anesthesia (Surgery and Anesthesia usually hang together) and told Dave that we would get together when I was free for the day. My Thoracic Fellow likes for the post call resident to get out of the hospital early. I finished my dictations and headed out.
Dave and I did a car tour of Charlottesville (not too hard because C’ville is just not that massive) and chatted over some Tex-Mex. The next day, he joined me in our War Room, until Dr. Arnold and one of the residents could spend some time chatting with him over coffee. They were terrific because Dr. Arnold took some time to mention some great anesthesia programs that Dave hadn’t really thought about. Chris Grubb, the resident, also took the time to say why he was happy to be at UVa. Dave and I hung out while I did all those resident chores and got the work-ups done for the next days surgeries. We did a small tour of the hospital and then Dave took off. I think he is doing a good thing in visiting some of his first choice places away from the interview time.
The wisdom of visiting while not on interview is that you get more of a realistic idea of what a program is like. One of the hazards of the interview is that they only show you what they want you to see. Couple that with some nerves (it is an interview after all) and you have the makings of not getting a true picture of what you need. If you have contacts and you can visit before hand, you can ask more directed questions. Interviewing for residency is like interviewing for a job and far from interviewing for medical school. Since Dave is applying for a competitive residency like anesthesia, he needs to have as much information as possible. He is an excellent candidate and will match in a top program. He just wants to be sure that he can maximize good teaching and academics for his professional development, maximize a good lifestyle for Wendy and his child. While I am a bit biased (I think Charlottesville is great) he needs to find a program that will meet all of his needs and his family’s needs.
While anesthesia residency is four years long, one you have gone through the match, you don’t get to change your mind if you have made a mistake. You have to be sure. Pictured on my little website over at the MSN Communities (Howard University School of Medicine) will be a photo of Dave and me hoisting our well-deserved margaritas in a little Charlottesville watering hole. The only person missing is Dr. Linda Wilson and I am sure she will be in the area soon! 
It was great having Dave in town even for a couple of hours. He also got a good idea of how residency is more about juggling a couple of hundred things at the same time.
Nat
Hi Folks,
Most of my attending physicians have hurried off to San Francisco to enjoy the City by the Bay and the Annual meeting of The American College of Surgeons. I have been using the down-time to get some reading done and dictate all of my charts. I only had one that was late. Somehow, it slipped my mind because the patient was only in for one day and we don’t usually dictate discharge summaries on 23-hour patients. Oh well, it’s done now.
The exciting stuff is that we have a lung transplant cooking. I am salivating at the chance to get to scrub in on a lung transplant. My fellow intern on the Thoracic service is an Emergency Medicine intern who has no interest in going into the OR. He also doesn’t want to dicate any charts so I get to do all of the surgeries in exchange for dictating all of the charts for the service. I call it an even trade.
I am quickly reviewing my surgical anatomy and will see if I can bribe the third-year to let me take his place. He may want to take it easy and let the intern scrub in or better yet, we both can scrub in. I am so excited!!! 
Nat
Good luck Nat! I wish you could make a video of this for us! 
Hi folks,
Here's an update on my lung transplant patient. She died three hours after we were able to get her into the TCV ICU. She started to have bleeding problems on the table. My attending physician called in every pair of hands that we could find to help control the hemorrhaging. Even as the harvest team got back with the lungs, she was so unstable. The surgery was intense and time seemed to pass so rapidly. My attending physician was so cool under fire but we could all tell that he was having problems that were escalating. He kept pushing all of us in a very professional way. I learned so much from participating in this surgery.
A double lung transplant with VSD repair is a huge piece of surgery for any patient let alone one who was pretty sick going into the case. This lady had been a very difficult match and lungs are very difficult to obtain. Since cigarette smoking is so prevalent in our society in the population that is likely to become organ donors (young and male and engaging in risky behavior), it is very difficult to obtain a good set of healthy lungs that would have been suitable for transplantation. This lady was fortunate to find a good match.
Our patient finally stabilized and we go her off pump (we had to repair a VSD) and into the TCV ICU. Her vital signs and blood chemistries held for a very short period of time but she started to become acidotic. Her kidneys started to fail and then her battered heart finally gave up. We opened her chest but there was nothing that anyone could do. She was gone.
She was a 41-year-old lady with pulmonary hypertension and a ventricular septal defect. She had been fairly stable and had been on the transplant list for two years. Her family was very supportive and everyone was so nice. They understood that her chances for living a long life were pretty slim. He son is scheduled to be married in two months. She had wanted to have her transplant and go to his wedding.
Again, surgery is a total rollercoaster ride both physically and emotionally. As we head into the M & M conference next Wednesday, we will thoroughly go through this case to see if there was anything else that we could have done. Sometimes even with the best technical surgeons and the best match, organ transplants are very difficult. Couple the technical difficulties with the addition of a heart-lung machine and you have more problems that need to be addressed. Surgery is long and hard but I still think that I have the greatest job in the world. I keep learning so much at every corner.
Natalie
Hi folks,
I have an esophagectomy cooking in the wings. I love getting a chance to do these extensive cases on the weekends when I don’t have to do floor chores the next day. My partner on this rotation is a first-year emergency medicine resident. He is 44 and was a former firefighter in San Diego. He won’t go near the OR but is happly to do the post-op stuff while I do the operating. I am loving this rotation.
I have been doing little chores like removing chest tubes and putting out little fires like putting in a Swan-Ganz catheter and dropping a lung. We simply ended up putting in a chest tube. I needed the practice anyway but the second-year resident, Allison, did the honors. We have been a great team in the TCV ICU this weekend.
Oh well, I have to dicatate a couple of charts and check some x-rays. There is a home football game today so the trauma service will be busy later this evening.
Natalie
Nat,
I can only imagine how exciting it must have been to be participating in a double lung transplant. I am sorry your patient didn't make it, but I know you and your fellow surgeons and surgical team gave it your all.
Now, go enjoy your football game. . . . and thank you for keeping us posted as you go through your residency rotations. It gives all of us a few years behind you a graphic insight into a possible future for ourselves.
Hey Folks,
I have moved my recollections of my residency to the “Diary” section. Enjoy reading. When I go back and look at the things that really unnerved me at first, I am really surprised at how much I have learned in three short months of residency.
I am totally comfortable in the Operating Room. I know how to do many types of sutures without thinking. I can concentrate on the case as it unfolds. I can see the technical nuances of each procedure. I can put in chest tubes, pigtail catheters and even float a Swan-Ganz if I have to. I am a whiz at subclavian and femoral lines. My IJs still need some work. I have 17 cases that I have logged at Surgeon Junior. I have far more that I have logged as First Assistant. It has been a total blast and I keep growing at every turn.
Finally, I love taking care of my patients. I can have “balls” in the OR and be totally compassionate at the bedside. Each patient is a unique challenge and it is a privilege to take care of them. I have earned the respect of my colleagues and I enjoy the interworkings of this residency system. My chiefs have been good teachers and good mentors. My attendings are wonderful.
I still think that fourth-year of medical school is the best year but residency is why you go through the stuff of first and second year. I can sit and study for ABSITE and it’s not even a chore. It has been great to go in for conferences and totally focus on learning. I have had time to work on putting together a research project for my PGY-3 and PGY-4 years. I am thinking about working on the melanoma vaccine project with Dr. Craig Slingluff. He loves my techniques as a protein biochemist and analytical chemist. Every minute of this residency is a total blast.
Check out all of the “Diaries” on the front page. Reading some of the accounts of JP and others brings back memories.
Natalie 
Dr. Belle’s diary can be reached from the main page under the diaries section at www.OldPreMeds.org
or directly at
http://www.OldPreMeds.org/diaries/natalie/
Please post any further related messages there.
Thank you.