this year’s windblume

cyno: *insert horrifically bad joke here*

albedo, giggling and twirling his hair: omg you’re so funny cyno, let’s kiss

Reflections on Surgery

I went into surgery scared.  I heard rumors of crazy schedules, apathetic residents, confusing pimp sessions in the OR when you just don’t know what to say, and people cursing and yelling more than what’s considered to be normal.  Well, all of things happened.  I was at the hospital from 430am-630pm EVERY DAY. On weekends, it was only 5am-noon.  I never worked so hard in my life, but the work was different than I expected.  I had to work hard to be heard by residents and actually contribute to the team.  I had to really come up with good ways to be involved in patient care.  My goal everyday was to do one thing that was actually helpful for a patient, not just helpful for my education.  When I scrubbed out of my last surgery, an emergent abdominal bleed due to a mets carcinoid tumor coming from the ED, I actually felt sad.  I didnt want to go.  I had been so busy, but I could sense I really loved surgery.  But as I walked out on my last day feeling genuinely depressed it was over, I was certain I had loved it.  Surgery is probably the most difficult rotations because of the exhaustion compounded onto a fast schedule.  I barely had time to catch up with my own thoughts during the rotation, and it was only over this last weekend I realized what I thought about it and how to do well (I got my evaluations this weekend and I was told by an attending I was the “best medical student he’s ever worked with.  I thought it was a prank, but apparently not!).  

How to Succeed on Surgery Rotations:

Realize right now that you are not the focus.  These people are tired, have to run the list, round, operate, run the list again, etc and don’t want to waste time.  You need to get into the flow, or you’re not going to contribute.  Be ready with all the information you need about a patient, but only say the basics.  If they ask for yesterdays labs or the IVF he’s on today, you can spit it out.  Otherwise, only talk about the basics (vitals, ins/outs, labs, what happened overnight, relevant physical exam of wounds/drains/closures.).

Talk to the nurses every morning and every afternoon.  As a med student, you have time.  When residents are charting, get up and find your nurses.  I would ask them to tell me about patient X and take notes while they talked.  90% of the time, the interaction was pleasant.  When people didnt tell me about the patient, I’d just ask more specific questions.  Why does this help you? You learn the story from the nurses, something that gets lost on the chart.  You find out if there’s a wacky family member, if the patient is cheerful or sad, what small obstacles might “not matter” to the team, but that you can keep an eye on.  I would make sure my patient got his throat spray for his NG tube everyday and readjust his abdominal binder frequently.  It made him feel better, the family felt reassured, the pack of doctors coming in to round looked informed, and it gave me something to do that (sort of) helps.

When someone talks about your patient, get close by and add information.  Get in the conversation.  Yes, you will feel weird and awkward joining the VIP circle of attendings and residents, but fake it til you make it.  Pipe up when they say “labs arent back yet” and they are.  When they say “I think he had a bowel movement last night” you can say “he had another one an hour ago, too.”  Say it fast, don’t interupt someone else mid sentence, and importantly: act like you know what youre doing (I swear, this is essential). They will quickly realize you understand whats happening and know when to contribute AND you actually follow your patients.

Have a plan. Always. Even if it sucks. When you finish your 45 second patient presentation, wrap it up with a plan.  On surgery, it should be focused on getting out of bed (OOB), advancing the diet, getting rid of Foley’s and NG tubes, replacing electrolytes (” ’lytes,” as they say), and ordering any additional images.  If someone needed respiratory therapy last night, order a chest xray.  If someone seems nontender and is hungry, advance the diet.  Keep in mind: you can’t win here.  On the same service, we had attendings who basically did the opposite with their post-op patients and you can’t really predict what they want.  But have a plan anyway, and say it.  If it sucks (which it might), write down their plan and make sure it happens.  Don’t defend yourself unless you’re sure they are making a mistake (which as med student, you really can’t be sure about that!).  Just nod courteously and move on.  Later in the day, you can ask a resident about why they chose a certain aspect of the plan, but don’t bother them during the morning rush with this.

In the OR:

Know basic anatomy.  Like BASIC: the arteries and veins in the region, muscles, and maybe a major nerve supply.  Even though I tried to review anatomy the night before a case, I would ALWAYS panic under those lights and freeze up. 

When you suddenly freeze up and don’t know what to say mid pimping, talk through your thoughts.  Now you look less dumb and you help yourself out.  Once I could not identify this giant vessel in the lower abdomen, I was stuck.  I started talking, “well it’s not a midline structure, so its not the aorta.  It’s not pulsatile, so it’s not an artery anyway.  it’s too thick to be a nerve.  I think it’s the veins that merge into the IVC..it must be the iliac vein!” They thought I was so smart to walk them through my thoughts, but really I was doing it for me.

Ask to close.  Everytime.  90% of the time, they say yes.  Just do it.  Be ready to be hotly criticized the entire time, but regardless, they helped me out.  Don’t panic, and just move your damn hands and do it.  Unless you abruptly ask them, it’s like they forget you’re a med student that wants to learn.  So speak up.

Once I knew my team, I would come in at the end of a case (if I had been in another one that ended early) and ask specifically if I could close.  They thought that was “good initiative.”

Know how to instrument tie.  This is the easiest thing ever, and you need to learn this.

Stack up stools before the case starts, and hold the suction like it’s an extension of your arm.  If you make yourself a part of the case, even in this small way, they’ll let your hand hold other things.  By the end of the clerkship, they let me use a Ligasure to cut a met tumor off the liver.  It was awesome.

If you know the detailed patient history, you can ask questions about the procedure relative to the patient during those OR “quiet times.”  Once we waited on a fudiciary for about 7 minutes, and it could have been awkward silence, but I asked about the chemo regimen for the patients tumor and mentioned comments found in her chart.  It ended up being a great learning experience, I appeared interested and knowledgeable, and there wasn’t an awkward 7 minutes of use just standing there.

Go to handoff.  This might be obvious to some of you, but in our school, this isn’t explicitly required of med students.  Some teams dismiss med students when cases are over around 3-4, others kept us around forever.  Whatever team you’re on, insist on going to handoff.  This is a normal request of med students, so you shouldn’t get much resistance.  Have the list printed off, and WRITE DOWN EVERYTHING they say.  Pretend you are the intern and track the plan for each patient.  The next day, you will be invaluable.  When attendings quickly ask about patient social work needs during rounds and the intern stepped away for a second, you can chime in.  You’ll also know what to look for in the charts (has the PT/OT stopped by yet?).  This was my best advice from a resident and it worked really well.  Go to AM and PM handoffs, write down everything, check it off when it happens.  You are officially being helpful if you do this.  

Be ready to fax and call.  When they casually mention “we probably need that person’s records...” go get them.  Get the patient consent form from the nurse station, fill out all the information you can, have the patient sign it.  In my experience, I had to call back the other hospitals or PCP offices repeatedly until I got records to be sent over, but I usually had what we needed in 30 minutes.  

I hope you find this list useful!  It’s exceptionally difficult to integrate into surgery teams as a “useful” med student, but it can be done!  And don’t forget to set aside time to 1) take of yourself and 2) study for the shelf exam.  Good luck =)