On call

This last Thursday I went to shadow one of my instructors, Dr. S, at OSU. He is my learning society mentor and a general surgeon who specializes in burn, trauma, and critical care. He is also one of the main faculty for the residents and somehow finds time to interact with 1st year med students. It was a pretty eventful evening. I arrived rather rushed at 3:45pm to his office. We were supposed to attend a morbidity and mortality conference. He wasn’t in his office, as “on call” surgeons usually aren’t and his secretary wasn’t expecting me. He had forgotten to tell her I was coming and she was a little annoyed. It must be hard working for a surgeon when you can’t handle unexpected changes to your schedule. She looked him up for me though and told me how to find to him. He was beginning a case in one of the ORs, on the 4th floor of the hospital. I caught him just as he made his way in to the surgical area. He seemed a little surprised to see me also and had probably forgot I was coming.


The first case was an elderly gentleman who had come in with a horrible case of acute cholecystits (gallbladder attack). He had been having pain for a few days and only recently came to the hospital. Dr. S performed the procedure laparoscopically with his 4th year resident. At first I thought, “O great another cholecystectomy. This was supposed to be on call trauma, wasn’t there anything more exciting than this?” I have seen videos and another live gallbladder operation previously but this one turned out to be a good experience. I was the only medical student in the room and had a clear view of the patient and the TV’s.


They made a small incision just above the navel and began to insert the first port. (Ports are plastic tube-like anchors which are stitched into the flesh and allow the passing of the laparoscopic instruments into the abdomen. They are removed after the operation.) The inserted some suture on either side of the incision and tie the port into the abdomen with the remainder of the long strands. This port is the insertion point for the camera. The camera is inserted and the abdomen is inflated with carbon dioxide gas. It slides into the peritoneal cavity underneath the abdominal muscles and you get your first view of the organs inside. The liver is easily noticeable and the intestines are covered in a fat laden apron called the mesentery. The patient’s gall bladder was easily noticeable as it protruded its way out from underneath the liver. It was grossly swollen and looked about ready to pop. Apparently the duct that allows bile to leave the gallbladder was blocked. The nearby tissue was also very swollen and glistening.



The next step is to insert 3 additional ports into the abdomen: one just to the left of the midline near the base of the ribcage, and two on the right side of the abdomen also near the ribs. Surgical tools are inserted into these ports which allow the Surgeon to inspect, dissect, cauterize, clamp vessels and remove the damaged gallbladder. Dr. S had to remove about 20 mL’s of bile from the gallbladder with a needle and syringe before he could get a good enough grip on it to proceed. The next step is to locate, clamp and cut the cystic duct which conveys bile to the intestine and the cystic artery which is the blood supply to the gallbladder. They are clamped with small metal clamps which remain in the patient. Once the vessels are clamped, the gallbladder must be cut away from the tissue attaching it to the underside of the liver. They use an electrocautery device to burn through this loose tissue and cauterize and small blood vessels along the way. The gall bladder is then placed in a tough plastic bag and pulled out through the large port hole near the belly button. They had to make that incision a bit larger to get this patient’s gallbladder out. They final step consists of irrigating the abdomen and rinsing out any bile or tissue which may have leaked. The abdomen is then deflated, the ports are removed and the incisions are stitched. The whole procedure lasted about 40 minutes.


After the surgery we went to round (check up on/evaluate) on a few patients. The 1st was an elderly woman in the surgical intensive care unit with a bad case of pneumonia. She had recently had multiple antibiotic resistant infections and was in contact isolation (that means you have to wear gloves and a gown to even enter the room). The pH of her blood had become increasingly acidic and the doctors were worried that maybe a section of her bowel had become necrotic (died). Dr. S recommended to the staff that an endoscopic examination of her bowel be performed.

The 4th year resident from earlier and I came back a little later and she performed the “scope.” This was not the highlight of my night. I don’t know that there is anything enjoyable about this experience from the perspective of the patient or the doctor, especially in someone whose bowels had not been thoroughly evacuated prior to the procedure as is common in a screening checkup with a gastroenterologist The scope didn’t show a lot. The resident couldn’t get past the sigmoid colon just beyond the rectum because the patient was in too much pain. Normally they would probably sedate the patient but this patient refused to be "tubed" (intubated) so they had to perform the procedure with only pain meds. The patient was in a lot of pain and probably pretty embarrassed from the whole ordeal. When all was said and done, the “scope” turned up nothing.

The last patient I saw was a younger woman in her thirties. She had come to the hospital with extreme abdominal pain and constipation. Dr. S visited her with a panel of surgical residents and myself tagging along. The patient had gastric bypass (GB) surgery previously and lost about 115 pounds over the course of a year. Dr. S explained that it was not uncommon for patients with such dramatic weight loss from GB to have problems with their intestines becoming intertwined or stuck to scar tissue from the previous surgery. A CT taken earlier of her bowel suggested that it was partially obstructed. Dr. S called one of the surgeons that specialized in GB and asked him what he thought. This surgeon recommended exploratory surgery of the abdomen. He mentioned that 9 times out of 10 typically he had found a problem in patients who had previously undergone GB. The 4th year resident and I came back a little while after the initial visit to tell her what the recommendations were and to get consent for the surgery. The patient wanted to know how large the incision would be. The resident explained that they could go in through her previous midline incision and it might not have to be as large. The patient mentioned that she didn’t have insurance and the resident reassured her that was not the most important thing to worry about at the moment.

After we got the consent form and left the room I asked the resident if it were possible to perform the procedure laparoscopically. She said yes and it would probably take a very experienced surgeon. The importance of this is in the recovery. Laparoscopic procedures yield much faster recovery times that open procedures and have a smaller risk of infection. Our patient would have the open procedure. Maybe it had something to do with the fact that her GB was also performed "open."It seemed unjust to me that the laparoscopic procedure is available and yet it wasn't even considered in this case. One of my professors back at BYU had to have an abdominal exploration for a very similar condition and the were able to execute it laparoscopically. In this patient's case it would cut the recovery time in half. I am not an expert and don't have any idea about the rationale behind the open vs. laparoscopic procedure in this case but I can't help but feel that it may have had something to do with the training level of the residents who would perform the surgery.


After this consult, we had some down time. I got to talk to the resident a lot about surgical residency and what her plans were. She gave me some insight into fellowships and about what to expect. She is married and has two young kids of her own. It seemed like when I brought up the fact that I had three of my own she lightened up a bit and really started talking. Of course that could have been because we finally had gotten some food and were able to sit down for a second. I asked her why she had chosen surgery. Everything she said seems right in line with what I want in a specialty and reconfirmed my impressions about general surgery. (I am trying to be objective about my future career but I keep coming back to this specialty)


After dinner, we headed back to the OR. It was about 8:30 at night. The patient had been prepped and two residents were ready to begin. They had paged Dr. S and he was on his way. The residents made a large midline incision down the initial scar and then opened up the muscle and fascia with electrocautery. They pulled out a small loop of intestine and began to follow it along. It looked a lot thicker, redder and softer than what I have seen in cadavers. It also seemed endless as they kept pulling more and more out. The small intestine can be up to 21 feet long! When Dr. S arrived he insisted that they lengthen the incision so they could get a look at things as they were supposed to fit inside the abdomen. Prior to this, the residents had heaped most of the small intestine externally onto the patient’s abdomen. The incision now extended from just below the breastbone to just below the navel. They followed the whole length of intestine along from the stomach to the colon. Nothing seemed abnormal or out of place. They placed the intestine back where it belonged, stitched up the muscle and fascia with thick suture and then closed the skin with a line of staples. The procedure took about 40 minutes also and was conducted entirely by the residents. Dr. S didn’t even need to scrub in. He supervised the surgery from over the shoulder of the residents.It was very interesting to watch and was the first open abdominal surgery I have seen. I felt bad for the patient though. In the end, the surgery didn’t reveal anything. She would be in the hospital recovering for the next 6 days and probably off the job for the next 3 weeks. She had no insurance either.


With respect to the open vs. laparoscopic decision made in this case - I think that surgeons may forget the impact that an open procedure may have on the patient. The open surgery seemed so simple and straightforward. It is hard to imagine that recovery could be so different.


After that surgery I went home for the night. I learned a lot from this shadowing experience. First, it seems like residency is a completely different world from med school. I enjoyed talking with all the residents. Although overworked, they were all very upbeat and excited. It was nice to talk with someone that is on the other side of their training. I got to go to the OR again which is always a good time. I like seeing how everything works in the OR, the surgical staff, the instruments, and of course the surgery. The "lap chole" (gallbladder removal) would prove immensely beneficial to the patient. Dr. S mentioned that if we went to his room later that night he would probably be feeling much better already despite the surgery. At the same time it was sad to see patients have to go through so much, knowing that they have a long recovery, possible complications and large expenses ahead of them. The last two procedures I saw didn’t necessarily help the patients either. At best, they ruled out a diagnosis but didn’t find the problem.