Friday, January 6, 2012

First weeks of Surgery rotation


So my first couple of weeks in Surgery have been pretty interesting. I think I've narrowed down my interests even more since I've started this rotation. Internal is much more interesting to me, however Surgery I find, a little disappointing. I guess in general its a much less structured program, which seems to be inherent across all the hospitals, I can come and go as I please, no one seems to really notice or care that much. In some ways  I feel like the surgeons don't take as much interest in the education of the students as the internists do. I felt very close with my ward by the end of my internal rotation, however I have to say that for surgery I feel as though I am more of a burden rather than someone who they want to take an interest in teaching. It's hard to be enthusiastic when you feel as though the teachers aren't interested in teaching you. Also Ichilov has 18 students which can get a little irritating because everyone is trying to get into the same surgeries etc, so there's a lot of issues I am still trying to work out as far as how to maximize my experience during surgery.

I don't think I want to do surgery at this point, and I am trying  to make that decision in the most objective way possible despite my opinions of the program so far. I think the thing I like about internal is that your mind is always consumed, you're always thinking, preoccupied with some aspect of the ward. In surgery, I think initially watching these operations was interesting, however I began to realize that each one of these surgeons are specialized and have done the operation 500 times before. I think there's a level of routine to any medical profession, however I think that standing over a table and doing a surgery for the 100th time in a row, becomes less of a mind occupying exercise, and more of a muscle memory maneuver. There seems to be no differential diagnosis in tying 100 knots in a row.

Although I haven't said anything very positive about surgery thus far, I do have to say I've had some interesting experiences that I can take from my clerkship. During my first week my tutor called me up at 10:00pm to tell me there was a liver transplant procedure happening. They had already begun harvesting the organs from the donor who was taken of life support machines a couple hours before. One student who stood in on that surgery felt the heart fibrillating as it began to stop when the pulled the plugs. I cam to the OR at 3am, where they spent 2 hours prepping the liver, tying off collateral vessels that were supplying some of the surrounding connective fat tissue etc. One the liver was prepped, they started operating on the lady who has a cirrhotic liver due to NASH. She was getting ready for her 50th birthday party, when they called her up and told her a liver donor was available, get to the OR now, so ironically quite the birthday present. The surgery went until 1pm the next day, I stood in for all of it. It was my first real interaction in the OR and I was definitely fascinated by it. I thought one of the most interesting things about the whole procedure was watching the anesthesiologist manage the patient. This was obviously a major surgery and there were huge amounts of blood loss occurring as they were anatomizing the IVC and the major vessels of the liver. You'd see the hematocrit drop to 7.9 on the blood analysis and then 10 minutes to 15 minutes later when they go a new blood report you'd see the HCT go up to 10 as they added a couple units of blood. It was a marathon of a surgery but quite the education. 

Another disconcerting point is how often I've seen or heard of patients waking up in the OR. I was sitting in on one procedure where a woman was in a lithotomy  in order to close of a perianal fisutula secondary to Crohn's Disease. While they were debriding the granulation tissue, all you could see was legs starting to move in the braces, which was a bit of a crazy scene. Imagine someone in a lithotomy with only their anus exposed in the sterile field waking up .. needless to say, the anesthesiologist had to move quickly. I heard of another story occurring at Assaf Harofeh where a patient with a laprotomy woke up in the middle of the procedure and most of the intestines started spilling out of the abdomen. Another horrifying story, however one can only hope that the propofol and the fentanyl were enough to give the patient sufficient amnesia and pain control, to make the situation ok, one can only hope. Either way the surgeon that case lost it, and demanded that another anesthesiologist come in, rightfully so...

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