Classical surgery.

Cross posted from The Weekend Scrub

The surgeon gave me the specimen, said it was ileum. A bit later the circulator asked me what we were calling the specimen. I told her ileum, or Troy, her choice. She said "Oh".

Nobody gets my jokes.

Just Do It.

Cross-posted from The Weekend Scrub

This is a bit of a rant.

I work weekends. I have to be able to do just about any case that comes along. I understand that the wimps fine scrubs who work during the week are stuck in their specialties and don't have a lot of exposure to other specialties. I don't care though. There are certain cases spread through all of the specialties that every scrub working in a large hospital must be able to do. (I may make a list of these someday.) If you can't do them, go work out an outpatient surgery center, or L &D, or specialty hospital and let your position be filled by a competent scrub. Even if you don't see them every day, you gotta be able to day a crani for subdural, a thoracoscopy, an ORIF and other procedures in the "scary" specialties of ortho, CV and neuro, even if you a GYN, or Plastics or General scrub. You just have to be able to do them, or get the hell out of here.

There, I feel better.

When worlds collide.

I haven't mentioned it here before, but I have spent some time over the last couple of months doing volunteer work at the special collections department of a local university library. I have been considering a change of career and going to library school. Before I jumped off that bridge, though, I thought I should have some idea of what doing library work was actually like. I also thought that it would be a great way to find people to write letters of recommendation for me.

My first project has been to inventory the library's World War I collection. They started the collection years ago, based, in part, on the fact that almost the entire male student body enlisted en masse and became part of the Rainbow Division. The donations of several alumni of their war memorabilia made a nice start and the library has, over the years, actively collected things since. They have a lot photograph and letter collections, a German code book, various logs, and lots of ephemera and other things that old men have saved from their youthful adventures. One of the collections they acquired along the was of a army surgeon named William Jason Mixter.

One of the standard instruments used in surgery is the mixter right angle clamp, seen here. Much of the instrumentation for modern surgery was developed in the first half of the 20th century, and most instruments are named after the person who developed them. Since Mixter is an unusual name, I was intrigued. A quick Google search confirmed that William Jason Mixter was almost certainly the inventor of the mixter right angle. What's more, he was a major figure in the history of neurosurgery. He was the first head of Neurosurgery at Massachusetts General, and a pioneer in back surgery. He was the first to realize that herniated discs could pain by compressing nerve roots and the spinal cord, and along with Joseph Barr, did the first successful discectomy.

The library did not buy the Mixter collection because of Mixter's importance in the history of neurosurgery, indeed they were unaware of it. They bought it because contained some interesting items that fit well with rest of the World War I collection. Nevertheless, they did end up with some stuff that was much cooler than they realized. And I got an unexpected collision of two of the different worlds in which I live.


William Jason Mixter

How in the hell?

Cross-posted from The Weekend Scrub.

Working in surgery can lead to interesting questions.

Today's question is: How in the hell is it possible that someone can shoot themself in the leg with a bow and arrow?

HIPAA and me

Cross posted from The Weekend Scrub.

So there is this law that says that we medical folk can't divulge patient's medical information without a good reason. We also can't act on it for any reason other than to treat or aid the treatment of the patient. The rules are so strict that if I saw my mother's name on the surgery schedule, I couldn't go and see her after surgery unless I also got the information from a non-hospital source. HIPAA can cause some problems for bloggers, as the best stories involve patient information. I feel that on this blog I am abiding by these rules in the following ways.

I, of course, never use patient names. I don't use my name or the name of my hospital. I don't even explicitly name the city where my hospital is located, although it probably isn't difficult to figure out. However given my other interests, as seen on my other blogs, anyone who knows me would recognize me here. I am the only scrub in my town, who works the weekend shift, with my set of interests. I have a limited set of patients, so it theoretically may be possible to figure out which patient I am talking about. I doubt anyone will actually go to the trouble to figure out which town I work in, then who I am, and therefore which hospital I work at, and then connect my patients with a blog post. It could be done, but only by someone who has access to my hospital's records, and who knows me. Still I protect myself further by lying. When I say "this weekend", I mean, "sometime in the last 19 years". I can and will change the nature of a patient's injuries, disease or treatment in ways that don't change the core of the story. If I can, I might even change the patient's gender. In other words, this isn't the patient you're looking for. Go away.

Surgical cases that suck

Cross posted from The Weekend Scrub.


I made passing reference to the something that made a case suck over here, but I thought that the causes of surgery sucking could be further expanded upon. Note that some of this list is subjective. It is also viewed from the scrub staff's point of view, rather than the surgeon's, patient's, anesthesia's or circulator's point of view. I suppose that ophthalmologists actually like eye surgery. Some circulators like long cases because they get to sit. Anesthesia has a completely different set of priorities from the rest of us. They seem to think that just because the patient’s blood pressure stays in the 50s it is a bad case. There are even some scrubs who might some theses cases.

First and foremost, harvests suck. Nothing sucks worse.

Second, eyes suck, but not as much as harvests. Retina and vitreous surgery sucks more than other eyes.

Third, any case with certain doctors suck, because the doctor is an asshat. Luckily, this is actually a small set of surgeons.

Any case involving more that one surgical specialty sucks. The suck factor goes up exponentially. A case with two specialties sucks 4 times as much as a similar case with 1. Three specialties sucks 27 times as much. Four specialties sucks 256 times as much. If we get to five specialties, just put a central line in me and hook it to wall suction.

Any case which departs from its script sucks. Some departures suck more than others. This includes, for example, the unscheduled opening of an endoscopic case. Note that just because we don’t know what we are doing going in doesn’t mean that there isn’t a script. For example, an exploratory laparotomy for bowel obstruction has departed from the script if we find a huge diaphragmatic hernia. It hasn’t if we find a tumor or adhesions.

Dead bowel sucks. Smells too. That’s why it sucks.

Any case scheduled to last more that 150% of what a normal version of that case would last sucks. First it's going to last twice as long as it's scheduled for, and second the surgeon knows something, and it's not good.

Any case scheduled for longer than two hours sucks. (Corollary, heart scrubs are crazy.)

Any case that requires re-draping sucks.

Any case with broken bones in more than one limb sucks.

Any case in which the circulator has to leave the room for anesthesia more than twice sucks. The circulator is there to get me things, not them.

Aneurisms suck. All of them.

Holding retractors on vaginal cases sucks.

Interesting cases suck. After 19 years, if I haven’t seen it, I probably don’t won’t to. OK there’s one exception. Years ago, when I was a baby scrub, a case down the hall was a removal of a cyst. When the surgeon cut into the area an insect stuck its head out of the wound. The patient had been in the tropics recently. I didn’t see that case, but I’ve always wanted to see another one. Otherwise interesting is out.

So there it is, an incomplete list of ways that cases can suck. I leave out that there are certain case and doctor combinations that suck and that certain staff have people that they can't get along with, which sucks. I, of course, can get along with anyone.

Damn.

Everyone in surgery and the ER has made the same joke. A young man, often African-American, comes in having been shot or stabbed or beaten to a pulp. After the patient is anesthetized, someone will ask what happened. Then The Joke starts. "He was sitting on his front porch, after coming home from church, reading the Bible when TWO DUDES, came up and shot, stabbed or beat him for no reason. And then stole his Bible." A while back we had a young man in who had been shot and had horrible injuries. He was one victim of this drive-by shooting. Other hospitals in town had three more. At one point we had the state police come in to the lounge and ask we if we could look for identifying scars, so that family could know which kid was which. One of the kids eventually died. I didn't hear The Joke, but I did hear someone say, "Don't these guys have anything better to do." The Joke is funny because the sarcasm is true. It is usually assholes who are doing things that they should not who get shot, beaten and stabbed. In this case, it really was four kids, all doing well in school, one of whom was a star athlete, who were coming home from church, and were mistaken for some gang bangers and got shot.

Damn.

How not to do surgery.

Hat tip to Ace of Spades

Bag of guns

Another tale from the surgery department of the big-city trauma center.

No story that begins, "My buddy brought over this bag of guns." is going to end well.

He survived.

Stupid Names

One of the joys of working in medicine or any other field in which you see many peoples' names, is the opportunity to see truly stupid names people inflict upon their children. For years I thought that the winner was the two separate women my wife found when working for the state Tax Commission named Aquaneta. But we have a new winner. This is, sadly, third hand so it is beginning to rise to the level of urban legend.

One of our fine CRNA's at work tells the story from his days in anesthesia school. It seems that one of his colleagues had child patient. Paperwork had his name as "Liam". No problem, Lee-Um, nice Irish name. Anesthesia student goes into room and starts the usual routine, "What is little Lee-Um having done today?" Cold response from mother "His name is "Yum". "Oh, I'm sorry, we have his name as Liam." "It's pronounced Yum." I'm going to interject here that this family were white. I only mention this because some of the transliteration schemes for Asian and African languages can lead to surprising pronunciations. That's not in play here. Back to the story. Stunned silence. "OK, I'm just curious, how do get "Yum" out of L-I-A-M?" "He's named after his father......William."

Doctors

Doctors are wealthy. No big surprise there, but given what they do most people don't begrudge them that. You want smart, skilled people to there when you come into the ER at 3:00 AM with a heart attack, or stroke, or injury. The only way that will happen is if you pay them well.

Not every body sees it that way though. The Tulsa World recently ran a letter from a gentlemen who refers today's doctors as "capitalist businessmen who masquerade as doctors", and hopes for the day of socialized medicine. Seems he doesn't like being asked how he is going to pay for the services he receives. He draws a comparison between today's routine office visit and the procedures during a disaster. I've been in a hospital during a big disaster. The ER saw hundreds of patients, and I bet not one was asked anything about finances.

All this is interesting, because I read the letter in the OR break room. When I was done with my break, I went and gave a lunch break in the trauma ortho room. On that room, a board certified, fellowship trained, trauma orthopedist was fixing a horrible break to the proximal humerus on a young man who had wrecked his motorcycle. He was assisted by two certified scrub techs and two certified radiology techs. There was a board certified anesthesiologist given anesthesia. The surgeon was using some very sophisticated (and expensive) plates and screws to fix the multiple fractures. A representative of the company that made the plates was in the room to make sure everything went well with his products. This is a lot of talent and expensive technology being used by this young man. Now many young men who crash motorcycles don't have a lot of insurance. This young man had several tattoos, one reading "Thug Life Bitch", and another reading "Fuck All". (We were left wondering if the thought was left incomplete, Fuck all... accountants, public employees, goats?) I may be showing bias, but I think it is safe to say the surgeon, the anesthesiologist, and the hospital are not going to be paid for this man's care. Some times life provides a nice ironic juxtaposition.

If you have the right to demand my services, and I have no right to demand to be compensated for my labor, then I am your slave.

Scrub tech blog?

It seems that scrub techs don't blog much about their jobs. There are several emergency room and ambulance people blogging, but I have yet to find a single scrub tech blogging about the job. There are scrub techs with blogs, but they seem to all be for sharing family pictures and stories. I guess this is because the job doesn't provide the same number of interactions with a wide variety of people. I really big case will have maybe six or seven people in the room plus the (unconscious) patient, and will last for several hours. The average ER person will see dozens of people in that time. Just more opportunity I guess to have those unusual experiences.

Harvest Time

This weekend we had an organ harvest. I hate organ harvests. Hate them. Will do any other case in the OR, with any doctor for any amount of time in order to not do them.

The reason I hate them is not rational, but what it comes down to, is I don't want to be part of the machinery of death. Don't get me wrong, I fully understand that these people are already dead. I accept, at least intellectually, the concept of brain death. We are not killing them. I have no problem with organ transplantation. I will happily participate in an organ transplant. (OK, not happily, but as a happy as I am to do any other long surgery with finicky surgeons.) If I needed it, I would sign up in a heartbeat to be organ recipient. If it weren't for my medical history, I would be an organ donor.

None of that matters. We bring a patient into the room with a pulse and 02 sats, and then we take out organs and turn the machines off and send the patient to the morgue. In the pit of my stomach it feels like we are causing death. I've tried, I can't get around it. It gives me nightmares.

Luckily, the other tech on my shift doesn't have these qualms. She understands my reservations and does all of them. This weekend it looked like the cases were going to fall in such a way that I would have to do this one. I was going to suck it up and do it, but man it depressed me. But my coworker came through. Thank you.

This should not have to be said.

Another work weekend.

I know it is spring, because the lawnmowers are out.

For those of you who might forget, power lawnmowers have large, rapidly spinning blades underneath them. Don't stick you fingers under there.

This weekend's patient only lost the tip of one finger.

Work

Another work week(end) has passed, and I am once again reminded of a now familiar joke in the OR.

What are an Oklahoma redneck's last words? "Hey, y'all, hold my beer and watch this."

Rule #21 for scrub techs: You can't see through blood.

The grossness of surgery

People often tell that they could never do my job because they couldn't stand all of the blood and gore of surgery. I usually reply that what you see in surgery is not that gross. It's the smell.

Tedium and tragedy

It is Monday morning, and I am recovering from my weekend at work. I often describe my job as "tedium punctuated by tragedy." Now, this weekend was not a bad weekend, and nothing really horrible happened. We didn't have to work for twelve hours without a break. We didn't have any crash cases. We all got lunch. None of the surgeons were assholes. It was just a typical weekend. But thinking about it can be depressing. There was the fasciotomy. A fasciotomy is done when a patient has a condition called compartment syndrome. This is when a muscle becomes traumatically injured and starts to swell. However the fascia, which is a tough membrane surrounding the muscle, won't allow the muscle to swell, causing pressure. The pressure can be so great that it can cut off the circulation to the muscle, killing it. The solution is to split the fascia, relieving the pressure. If this is done quickly enough, the muscle can be saved. This patient had been pinned under a truck for upwards to twelve hours. The surgeon told us that he had treated people with similar injuries after an earthquake in the Philippines when he was in the military. Every one of them died within a few days.

The same surgeon fixed three broken hips. I like these operations. They are technical, but I understand them well. They keep me busy and they don't last too long. There is the satisfaction in moving through a well-rehearsed dance. Underlying it all, however, is the knowledge that half of these patients will be dead within a year. Old people's health, and it is almost always old people who break their hips, is often like a spinning top. One push can destabilize it quickly and lead to its collapse. My grandfather died this way.

I got lucky and didn't have to do the PDA on the 1 Kg baby in the NICU. I hate going up to NICU. There's no space, it's hot, and there are too many people. The babies are all so small. They always run all the parents out so that we can operate and I know from experience how frustrating that can be for the parents of the other kids. There is always a gaggle of parents crowding around the door as we leave. The all seem so young, and so tired.

On the plus side we did a couple of normal appendectomies. Nice healthy people, with a single problem, that we fix. People used to die a horrible, painful death from appendicitis. We are saving these people's lives. But it is all so routine.

The weekend is over. I have the satisfaction of knowing that we helped people. We even saved people's lives. Perhaps the fasciotomy patient will survive. Perhaps all three of the hips will be in the half of people whose tops keep spinning. The appendectomy patients will hurt for a week and continue with their lives. Their surgery will a become a minor part of their past. The other patients will likewise continue. By next month I will have forgotten about most of them. Because although the job can be depressing to think about, the dirty secret is we don't. We do the job and move on. That is all.

Rules for Scrub Techs

Today was a work day, and I was reminded of the set of rules I have been formulating for scrub techs. I was inspired by the Fat Man's rules in The House of God by Samuel Shem. Some of these are serious, a few are well known aphorisms in ORs around the country, and a few are just a bit cynical. Work for 16 years in an OR and you will end up that way too.

1. You can never have too many towels.
2. Puss is always under pressure.
3. There is no point in having preference cards if you refuse to believe them. (A preference card is a listing of what a particular surgeon will want for a particular case. They used to be actually in index cards. Now they are usually computer files.)
4. The preference card is always wrong.
5. It doesn't matter what the preference card says, never open an abdomen without having stick-ties open.
6. Never suck on the brain.
7. Sterility is a state of mind.
8. Give the Doctor what they need, not what they ask for. Only do this if you know what the Doctor needs.
9. Muscles are in the way. This is all a scrub really needs to know about them.
10. Know the boundaries of your circulating nurse's ignorance.
11. Sometimes it is as important to know the names of the surgeon's children as it is to know the names of the instruments.
12. A doctor who says he only needs three things for a case will need ten.
13. The patient is not on the back table.
14. Knowing why is more important than knowing when.
15. Never turn down a break.
16. Sit whenever you can.
17. Almost every time a sponge has been left in a patient, there was a correct count.
18. Every surgery, no matter how minor, is an opportunity to kill someone.
19. In a pinch, all you need on your mayo stand to start a case is a scalpel, two hemostats, a pair of pickups and pair of scissors. Everything else can be faked.
20. When setting up, the ideal is to touch everything once and only once.

There are more rules, but I can't think of them now. Maybe later.