Venturing into Pediatric Surgery

The sun was shinning today, beckoning me to come outside. Despite the impending surgery shelf exam and a pile of incomplete reports, I made a decision to go running. A run to the ocean and some sunshine was exactly what I needed to recharge before another week of surgery. I have come to realize that it's better to live life when you have a chance rather than put things off for a more convenient time.

It's evident the list of things to do just gets longer.

***

"Medicine is like music. You have to listen for notes before you can appreciate the melody."

A truly insightful comment from the pediatric surgeon I worked with last week.

I am still struggling to put the notes together.

My first week on pediatric surgery was interesting. Just when I started adjusting to the world of general surgery, I was transplanted to an entirely different place, where the patients are smaller, have rare congenital anomalies and typically can't communicate directly with me.

You see the entire spectrum, everything from neonatal in the intensive care unit on bypass for respiratory failure to toddlers undergoing hernia repairs that require no hospitalizations to children with appendicitis to teenagers with midgut malrotation.

I spend my mornings in the neonatal intensive care nursery, collecting the numbers that reflect the respiratory, cardiovascular, fluid, electrolyte and hematologic status of the critically ill infants. I feel more like a recorder, writing and reciting the numbers without fully understanding the meaning. I was only beginning to understand adult ICU values. Neonatal intensive care is far more complicated and requires more than one week to grapple the ins and outs of management.

I have come to really appreciate the complexity of pediatric surgery. The operative approach is unique in pediatric surgery. The instruments are so much smaller and special attention must be paid to every little motion. When I watch the surgeons, I am amazed at how they navigate through such small holes to identify vital anatomical structures.

I have three more weeks of surgery left. We'll see what my last week of pediatric surgery brings...

Golden Weekend

"No one ever tells you that you are doing a good job. But everyone yells the moment you mess up. It's a thankless job. Welcome to surgery."

While we were operating on Friday, the surgeon made this statement as I drove the camera during a laparoscopic hernia repair. His statement is true on many levels.

In the OR, you move when told to move, or you stand and watch. It's almost paralyzing when you are called on to do something. Time stops, as everyone waits for you to complete your task. You pay close attention to detail to make sure you do your task right- be it cutting suture (no matter what you do it's either too short or too long), suturing (it's always a struggle to approximate everything properly and you move too slow), driving the camera during laparscopic cases (following and keeping the horizon straight takes some experience), or retracting tissues (you never quite know how much tension to apply).

Whatever the task maybe, you always find yourself fixated on the smallest details. It's perhaps this close attention to detail, which makes surgeries successful and makes surgeons perfectionists.
***
Friday was my last day on the general surgery service. I move from the world of hernias, appendectomies, cholecystectomies, fistula repairs and gastric bypass procedures to an entirely different world- pediatric surgery.

I've had my first preview of pediatric surgery over these last two weeks, while I took care of a patient with midgut malrotation. I was the first to meet this family in surgery clinic and review here films. While in the hospital, I have been their point person. In working with the family and patient through her admission and surgery, I was felt lucky to work directly with my her and her family. In getting to know her story and in interacting with the family, I was able to learn far more than any pediatric surgery book could teach about such anomalies. It's such longitudinal experiences which make this rotation so memorable.

Before venturing forth to my next surgical rotation, my chief resident graciously gave me this weekend off. I have to stay this is true golden weekend. I am lucky to be spending time with my family and friends during the last day of Ramadan (the month of fasting) and Eid (the holiday marking the end of Ramadan). I am looking forward to eating my mother's home-cooked meals (actually anything other than crackers), catching up with my friends, having normal people conversations that do not conist of asking about bowel habits, sleeping, studying and exercising.

A perfect balance. I am now officially half-way through my general surgery rotation.

Surviving on Crackers

I was once told by an anesthesiologist that he made his way through residency by surviving on saltines and water. When I heard this, I did not entirely believe him. But the more I think I about it and having spent 3 weeks on surgery, I can see the truth in his statement.

My daily diet (when I'm in the hospital) has been mostly consisting of two things- saltine crackers or graham crackers (and if I'm lucky- a whole wheat bagel with peanut butter). With ice water. Very appetizing.

While in the hospital, you sometimes go hours without really eating or thinking about stopping to eat. Between pre-rounding and rounding early in the morning, meeting patients before the case, prepping the patient for surgery, scrubbing in on the case and accompanying patients back to the PACU to write orders- you are left to scavenge for bites of food in the few minutes you have before the next case starts. And your body gets used to it. This is why dinner has become my favorite meal. I can actually sit and chew my food.

There a few things I have come to appreciate while being on surgery.

1. There is nothing like breathing air. By that I mean, being able to take a deep breath in and out without a mask on your face. It never felt so good.
2. Sitting- it's a wonderful thing. Wow, what a different it makes for your back, legs and achy feet.
3. Medical students do have a useful job on surgery. We are glorified supply cabinets. Need four by fours, gauze, tape, saline, suture removal kits? Don't worry- we got it on our person, or know how to get some.
4. I think my patients think I am preoccupied with bowel habits. Because every morning I ask the same questions- "have you passed any gas? Had any bowel movements yet?"

With three weeks down, I can truthfully say that surgery has consumed my life, taking up most hours of my days. There has very little time to see friends, sleep, study and exercise (although I think standing all day and running around rounds qualifies as exercise). I leave my apartment when it's dark and return home when it's dark. The only glimpse of sunlight I get is when we round on our patients, I can sometimes catch a view of the sun setting on the city. Even when I'm not in the OR or hospital, I am thinking about my patients and their diseases, the surgeries of the day, the suturing techniques I have learned, and the hospital course of my new patients.

The hours are long. And you work hard. Despite the challenges (namely lack of hours in the day to sleep and study), I feel lucky to be actively involved in my patient's care. There is something very special about taking care of the patients you have operated on. By performing surgery, you not only become acquainted with your patient's anatomy, but you are also able to use your hands to fix a problem, whether it is a hernia or enterocutaneous fistula or excision of a mass or a bowel resection. Postoperatively, you see how your patient regains bowel function, has improved pain, and starts eating food. The transition can be rewarding, when you see your patient discharged in good condition. It can also be frustrating, when your patient does not improve and remains hospitalized and you are left to wonder what went wrong.

I spent Friday night taking trauma call at SF General Hospital. The motto for SFGH is "It's as real as it gets." The SFGH Emergency Department serves as the only Level-One Trauma Center for the City and County of San Francisco and northern San Mateo. With over 58,000 visits annually, the Emergency Department serves both critically injured patients, as well as a large underserved and urban population.

The night was fairly mellow. We had a couple of 900 emergent pages (a gunshot victim and motor vehicle accident), which upon further evaluation did not require surgical intervention. We also had some patients with acute appendicitis, a patient with pneumothorax requiring chest tube placement, and a patient with an abscess. I performed my first incision and drainage on this woman's abscess. In doing so, her pain was improved and she was able to go home.

My first overnight call (with 2 hours of sleep) done. I left at 10 AM the next morning, completely exhausted and hungry- looking for some crackers.