Coffee and Commitment

At about 8pm I got the smart idea to have a cup of coffee and now I'm having trouble feeling sleepy. Since I don't have to be at the clinic until 9 tomorrow, I figured I could spend some time writing on my blog. 

On Sunday I spent the afternoon at the Air National Guard base in Phoenix. One of my fellow students, Tim, joined the Guard a couple of years ago and occasionally we chatted about his drill weekends on base. At the beginning of my medical school adventure I was quite seriously looking at joining the Air Force for their HPSP scholarship. HPSP is a full ride through medical school paid for by the military in return for 8 years of service. There are a lot of conflicting views on whether or not it is a good idea to enroll for many different reasons, however, in the end I decided to withdraw my intention of joining up. One of the downfalls of HPSP is that in many instances the military will tell you which residency you will go to. If you were interested in doing ophthalmology for a career, for example, they may tell you that the military doesn't need any of those at the present time and that their well spent money on you would be much better suited to a family medicine or other primary care residency. In other words, due to the fact that they pay your entire way through school, they also have the ability to tell you what you will be doing. This idea did not appeal to me, so I decided to stay put as a civilian. 

When I started my surgery rotation several weeks ago, I met one of the partners in the practice who was a Lieutenant Colonel in the Air National Guard. We began talking about military medicine and I voiced my concerns about HPSP and why I had not ended up joining the Air Force. The Air National Guard is a division of the Air Force. It is primarily a reserve force that has been assigned the mission of domestic protection/aid. In times of peace (and mostly in times of war), the Air Guard is used to aid in natural disasters and other conflicts in the US. In fact, the fires in Colorado about a month ago were put out by the Air Guard using their C-130's to dump water and flame retardent. Anyway. After talking with the Colonel, I began to be interested in the prospect of serving. The commitment for the Air Gard is one weekend a month from 6:30-15:00 and two weeks during the summer. The Air Guard is mostly for those who have a full-time career, but would like to volunteer their service once a month. I use the term 'volunteer' loosely, the Air Guard does pay its members for their time. In addition to being paid for your work there are also some repayment options for students as well as eligibility to the GI bill, which is for any soldier to help pay for school. There are many other incentives that I won't get into. For the most part, I am interested in the Guard not for the financial benefit (although I'll take it!) but for the chance to scratch my Service itch once a month with a low risk of deployment. 

After my interest was roused, I got in touch with my school friend, Tim, who is a 2nd Lt in the Air Guard. He gave me some great information about the Guard and invited me to join him on his drill weekend to get a taste of what a day in the Air Guard would be like. To make a long story short, I ended up at the gate of the 161st Air Refueling Wing with Tim meeting me to bring me in. By chance, it turns out that to his surprise, he was promoted that morning to 1st Lt. His family had come to base to see the ceremony. He showed me around the base and we climbed into a KC-135 Stratotanker that was being prepared for its mission to Germany later that afternoon. There are so many knobs in those damn aircraft, I don't know how they do it! Later, some of the men from the unit took Tim and I out to lunch to celebrate Tim's promotion and to chat with me about the Guard. I learned a lot of great information and it was very nice to talk to some real medical officers who are in the guard rather than a recruiter who gets paid to have me sign up. An unbiased opinion, I suppose you could say. All of the docs were really excited to see that I was interested and all asked me to join as soon as possible! I told them I was going to take some time to think about it as it's not a decision to take lightly. 

All in all I had a great day on base and I'm definitely leaning towards joining. Word has it that in September they will be offering a $10K sign-on bonus, so I was advised to perhaps wait until then to join. I'm taking the time now to decide whether it is something I'm prepared to devote my time to for the next part of my life. Who knows what I'll decide.. perhaps in a couple of months I will be signing my entries as 2nd Lt! 

-Student Doctor Benjamin D. Smith

Eat when you can, sleep when you can...

SURGERY


"Have you heard of the three rules of surgery?"
"No"
"Eat when you can, sleep when you can, don't fuck with the pancreas."

I just finished with my surgery rotation yesterday and I have to say that it was quite the experience. I don't even really know where to start! I suppose, as Bilbo might say, the best place to start is the start itself.

I walked into the Tucson Medical Center OR and there wasn't much going on. I met with the nurses and tried to work my magic to get on their good side early. A nurse who likes you can do wonders but a nurse who dislikes you can make your life hell. Especially as a student. After meeting my fellow student and shooting the shit for 30 minutes or so, our preceptor finally showed up. He introduced himself and said that usually he would have us scrub in on each individual procedure, switching off each surgery. He told us to meet him in the hallway outside room 78 and Scott (the other student) and I trotted off with big smiles to get to the room. After both of us being too indecisive/polite about deciding who should scrub in on the first procedure, we decided the best way to settle it was with some old-fashioned Rock-Paper-Scissors. Naturally, I won. I scrubbed up at the scrub sink just as we had been taught and walked in to the room ready to get started. I got scrubbed in and Dr. Stevenson (our preceptor) was waiting patiently by the patient. "Pt is ***** here for a right inguinal hernia repair, possibly bilateral. Attending surgeon Dr. Stevenson, First Assist Dr. Stephenson and everyone who is supposed to be here is here. Pre-operative antibiotics have been administered? Right. Blah blah blah, everyone knows the rest. Let's get this show on the road!". Dr. Stevenson turns to his scrub tech and points at the stereo. In less than 5 seconds I get WHAAAAAAAAAAAAAAAAAAAAAA EEERRRRRRRRRRRRRUMMMMMMMM.... (which is my best text description of Pantera blasting through the speaker). Dr. Stephenson, the general surgery resident who we would spend most of our time with (not to be confused with Dr. Stevenson, our preceptor/attending), takes the 11-blade and begins to make the incisions for the ports for the laparoscopic hernia repair.

During the next couple of weeks I fell into the general way things go as a surgery student. The first surgery of the day was usually at 7:30, so I would arrive at 7 to introduce myself to the patient in PreOp and make sure that the scrub tech had my gloves and gown ready. Either Scott or I would scrub in on the surgery and when it was over, stay with the patient as they went to PostOp to recover from anesthesia while the surgeon/resident wrote their post operative note. Once that was finished, we'd have about 10 minutes to look up the history/meds/allergies/etc of the next patient and to refresh ourselves with the procedure that was going to take place. Usually I would read up on the procedure the night before and then refresh right before the procedure. Then we would do the whole thing over again; go to PreOp, Operating Room, Post Op, 'Pt History/Refresh'. During our time in the operating room, the students would get 'pimped'. Pimping is basically where the attending asks you question after question in which the student is supposed to answer. If the first student doesn't get it right, they turn to the second student to answer. If neither knows the answer you usually get the general reaction of "Oh christ. Make sure you look that up tonight, you better know it tomorrow". And you know what? They remember that shit. We were in the middle of an appendectomy and the attending asked me about the appendix blood supply. When I didn't know that, he began pimping me on colonic blood supply. When I only knew about 25% of that, he told me to look it up at home. I didn't get home until pretty late that night and by the time I'd eaten and showered, it was time for bed. No reading up on colonic blood supply.  The next day I went in and I saw Dr. Stevenson coming to the OR and I thought to myself, 'Oh shit! I forgot to look that up! Hopefully he doesn't remember...'. Sure enough, the first thing he said to me is, "Good morning Ben. What's the blood supply to the appendix?". Game Over.

And so, the days went by and so did the surgeries. I got better at being pimped and could control my fear and think more clearly to get the answers. Slowly, the 'deer in headlights' look that I'm sure I had faded away and I began to feel like more a part of the team. Then I scrubbed in with Dr. P.

Dr. P is this hardcore vascular surgeon. My attending asks me to watch Dr. P on his surgery. I walk in and introduce myself and begin watching his surgery; an endarterectomy (an endarterectomy is where you open the artery and remove the buildup of plaque by hand). Dr. P looks at me while I'm standing there and says "Well are you gonna scrub in, or just stand there? You're not gonna learn anything by just standing there". I quickly wash up and scrub in. "Hold this.". Dr. P was stern but he gave me one of the best experiences during my four weeks there. His first assist was his resident, Kate. While he and Kate were performing the surgery, he had me hold the retractors in particular positions and begin thinking about what needed to be done next. As Kate said, "think about what we need next. If he starts tying, ask for the scissors!". And so I did. Soon enough I was getting the hang of it. I felt great. In fact, I did so well that at then end of his second procedure, he left me with Kate to close the patient's incision on the thigh. So there I was, suturing closed the 6cm incision on the upper thigh, talking to Kate about surgery and other things. Saying things like "Pickups. Scissors. DermaBond." and other things to the scrub tech. It felt great.

The next surgery with Dr. P didn't go so well. A HepC positive patient with C. diff comes in for a femoral-popliteal bypass and the tone of the surgery changed. There was no music. There was no talking. Every sharp that was used was handled with great care so that there would be no mistakes. Getting stuck with HepC is no joke. In fact, getting stuck with HepC is even worse than getting stuck with HIV since the protocol after an HIV stick can reduce the chance of actually contracting HIV by a huge amount. For HepC, the chance is something like 100 times higher. I tried to stand out of the way as I could tell the feel of the room was very tense and was not the place for a student to be asking stupid questions or to be getting in the way. Then out of nowhere, things get crazy. "OH GOD DAMNIT! YOU JUST STABBED ME! MOTHER FUCKER!!!". The surgeon steps back from the table, almost tripping over me as I stood behind him. The resident, Kate, is looking up at the ceiling and I could just tell she was trying her best to keep it together. Dr. P turns to me and yells "WHAT ARE YOU JUST STANDING THERE FOR?! THE SURGERY'S NOT OVER, GET IN THERE AND HELP HER!". And so, just like in the movies, this was my time to shine. My heart was beating so hard I could feel it in my ears as I stepped up to the table into the first assist position and looked at Kate. Everything but our eyes were covered, but it was enough to tell that there was no room for error now. "DeBakey please", I asked the scrub tech. "What would you like me to do, Dr. Gillman?". Kate asked me to follow her suturing, so I did. We worked in silence, but we worked like the wind. My hands moved with such precision that I was surprised with myself. And that's when it happened. I was no longer the annoying student who was straining to get a good look, asking stupid questions. I had become a part of the team, relied upon to get this patient fixed and closed up. We moved in sync with each other and I was able to keep up with her, ensuring that I had the correct instruments in hand before she even asked me for them. Dr. P walked back in 10 minutes later and saw that we were almost done. He asked us to finish up and then left again. We closed up together. Once again, I was rewarded for my good work by completely first assisting the next procedure with the resident, a debridement of a patient who had an infected hip amputation. I felt great. It was the most involved in surgery I ever got for the rest of the rotation.

My attending's office. He's in the Air National Guard and comes from a long line of USAF pilots.

The remainder of the rotation paled in comparison to my day with Dr. P. My attending had not seen my work in those surgeries and I was rewarded for answering a pimp question right by holding the occasional clamp or even suturing closed the port holes. However, I had a new sense of confidence in these surgeries. I was not afraid to ask the scrub tech for instruments and had them ready for the surgeon and his first assist, but I was never totally involved again. Later on, I met Dr. P in the outpatient clinic but he did not know who I was. In the end though, it doesn't really matter. I'm just a student on a surgery rotation. I learned a lot more than most in that day of surgery and I feel that it really helped me to excel in the remainder of my surgeries. Slowly, I pulled away from Scott in terms of my surgical skills. Scott was pimped on a question that I had researched, the attending posed the question to the other student in the room and she didn't know, and when he asked me I stood tall and proud and gave the answer without a hint of questioning in my voice. "Great job" he said, and I was so thankful for the mask that covered my face as it hid the biggest grin that I couldn't get rid of for five minutes.

My attending brought his blowgun on the last day.. school can still be fun!

All in all, I would say that I enjoyed my rotation. I worked long hours, usually about 13 hours a day with no lunch break. However, it was extremely interesting. Would I like it as a career? Maybe. I would hate the schedule. I want to be a good father and family man and I don't want to spend my life in the hospital. Perhaps the perfect career for me would be a Family Practitioner with some surgical procedures every once in a while. I loved the time that I spent in their outpatient clinic and seeing patients in the exam rooms was something I looked forward to. The resident and other students thought it was boring, but I loved it.

Surgery taught me a lot about not only the rules of the hospital, but also about myself. I may not be the smartest of the bunch (far from it, in fact), but I can really shine when working with patients in a hands on setting. I'll keep on trying to show my best and learn a lot along the way. So far, 3rd year is blowing the first two years out of the water. It has definitely been worth all of the pain.

-Student Doctor Benjamin D. Smith