|Beetle-Sweeping & Jellyman
||[May. 29th, 2004|12:21 pm]
|||||(The Airplane, drying the surgical drapes)||]|
Every now & again, I’m able to reflect on how different my life is from what it was in the States. All last night, studying diagnostic imaging until my eyes bled (I don’t have a good enough imagination to be a radiologist), the beetles hurled themselves at my porch light: crack crack CRACK! Each morning, I sweep the piles away from my door mat, which they seen to cluster around, as if they’ve been tidied up by a stray monk, building a shrine to honor the spirit of beetles. This morning, when I left to go get my weekly supply of fresh coconut water from the Jellyman downtown (fresh green coconut is slightly jellied, and tastes nothing like the dried stuff, being simple and refreshing, and not at all sweet), the beetles were actually piled in what resembled a cairn – a funeral pyre of beetles, awaiting the torch. Not a single beetle anywhere else on my porch. I paused for a moment, honoring the dead, before sweeping them away.
In a week and a half, our surgery dog will die. We named her “Terracotta”, as she’s a simple little brown earth-colored dog. She has such a wonderful attitude – happy to see us, wags her little stump of a tail, jumps up to have us catch her paws and dance with her, puts up with just about anything (except the thermometer – she really doesn’t like that part). She answers to “Terra” – perks up her sail-like ears, wags her stumpy tail, looks up expectantly. When we got her, she was pretty emaciated – dry, brittle hair coat, worn spots over her ischial tuberosities where her too-thin pelvis contacted the hard ground, cuts and abrasions, ticks and fleas, ear mites, ribs too prominent, stretched teats from some past litter (her teeth are healthy, white, shiny – puppy teeth…she probably was impregnated in her first heat). So we fed her, and fed her and fed her. She gained weight – looks better, now; her ribs and iliac crests aren’t so prominent. We bathed her and sprayed her with Frontline – her coat is shiny golden brown (with charmingly gold-spotted paws), and the brittle stuff is being replaced. The thin areas are growing in. And the ticks and fleas and ear mites aren’t in evidence any more. And last Thursday, we took her into surgery: the gastrotomy.
I was the primary surgeon. I’ve been looking forward to this since I first came down here – having scrubbed in on so many surgeries, having loved the focus and intensity of it, having dreamed of perhaps becoming a surgeon myself, I wanted to see what it was like when I was the one doing the work. I studied Dr. Spackman’s notes exhaustively. I watched the video in the LRC. I practiced my suturing techniques. I practiced hand-tying (for ligation). I discussed the protocol with my surgery partners – Stephanie assisted me, and Elise handled anesthesia. We all knew what we were going to do, when we were going to do it, in what order. And then the moment arrived…and everything went wrong.
Surgeons are not usually known for their patience or gentle temperaments. Dr. Spackman is absolutely what one would expect: sober, straightforward, not particularly social, takes her work very seriously, works very long hours. She’s temperamental, easily irritated with extraneous information or questions that have been answered by her lecture notes, and fierce to defend her surgical staff and surgery dogs. So I begin the day by sticking my foot in my mouth and telling the technicians – whom I have always liked, and gotten along great with – something about how I don’t get a good close clip when I clip the hair the way they were suggesting…but it comes out WRONG. (I’m so worked up I don’t even notice.) They immediately go tell Dr. Spackman. She immediately comes over and tells us to STOP CLIPPING AND GET THE DOG INDUCED. The clip job is half-done, but we do. We’re all shaking, now. Elise blows the first vein, tries again, misses. Gets the catheter in the other cephalic vein with Dr. Wright’s help (she’s the anesthesiologist helping us). Fluid bolus, induction with propofol, intubation, move to surgery to hook her up to isoflurane/oxygen. Dorsal recumbency, put booties on her feet and warmies on either side of her, Dr. Bruhl-Day (one of the other surgeons, and a big imposing Argentinian, even if he is a kind man) comes up and comments that the clip job is half-done, and shaves the remaining hair with a #10 blade. Stephanie begins to scrub. I’m about to walk her through the process and Dr. Bruhl-Day walks up and tells her everything she’s doing wrong, before I can open my mouth. So I’m waiting for him to finish, so I can open the outer wrap of the pack and get the gown and gloves set up, and Dr. Spackman walks up and tells me to GO SCRUB. I try to catch Steph’s eye (Dr. Bruhl-Day is still talking), but no dice; I go scrub. Stephanie joins me – Dr. Spackman told her to scrub, too; the techs would help us gown up. We finish our scrubbing, gown & glove up; Elise, focused intensely on getting the monitoring set up, tells us Dr. Bruhl-Day yelled at her for not having the final spray with betadine done, or the pack opened (in that order). He did it for us, apparently. I apologize to Elise, who is now grabbed by Dr. Wright, discussing anesthetic level. I can’t stop shaking. I towel off the incision site, clamp; Stephanie helps me drape (which I do wrong, and get caught for later). Fenestrate, clamp…there’s bare skin, facing me. One of the lab assistants (John, a student in the semester ahead of mine – he was my anatomy TA, and I like him a lot), asks me what the first thing to do is; I draw a complete blank. (Small part of brain wailing “if it isn’t the incision, it wasn’t on the video!) “Ask your anesthetist if it’s ok to make the first incision,” he says patiently. He’s right, of course. If the patient isn’t stable, it isn’t good to add the stimulus of surgery. (The anesthetist runs the show, right up until the surgeon makes the first incision.) I begin.
“When it comes to surgery, Lord hates a coward,” Dr. Torbeck, beloved advisor on The Centaur, told me. I take a deep breath, and make a perfect incision through the skin, all in one motion, xiphoid process to umbilicus. And then the hemorrhage starts. I’ve scrubbed in on more than 500 surgeries. I’ve seen hemorrhagic patients. But Dr. Roush used an electrocautery unit – we had hemostasis down to a fine art. (I blot, stretch the tissue with the dry sponge; he clamps with a hemostat as soon as he sees the first flash of blood. I hold the hemostat; he touches the cautery to the instrument and cauterizes the vessel. Sometimes he just grabs the bleeder with Brown-Adson tissue forceps and cauterizes. Instant hemostasis.) I clamp. Or try to clamp. The cheap instruments won’t grab unless I take a big bite of tissue, which is traumatic, and I don’t want to do. I waste a lot of time, and can’t seem to instruct Stephanie how to blot. The skin bleeds. Finally, I get everything clamped, and decide I’ll leave the clamps on to effect hemostasis while I continue with the abdominal approach. 1 millimeter into the subcutaneous tissue, there’s the cranial superficial epigastric artery…RUNNING LENGTHWISE OVER THE MIDLINE, EXACTLY WHERE I NEED TO MAKE MY INCISION. I try finding it high up over the xiphoid, clamping either side before cutting (god, I should have LIGATED first)…hemorrhagic nightmare. Followed by lots of frantic clamping. Dr. Bruhl-Day asks why we have so much hardware on the surgical site, I cannot seem to get my tongue to work, to tell him we’re in the middle of a losing battle with arterial blood supply; he tells me to remove the clamps. I try encircling ligatures, then remove the clamps. The ligatures don’t hold – more hemorrhage (I was using the wrong size suture). I try again. Same results. I go back to the clamps, and back to the approach. Dissecting the subcutaneous tissue from the rectus fascia – Dr. Bruhl-Day tells me I need to dissect bluntly first, then slide the Metzenbaum scissors up along the rectus fascia, rather than cutting small bites, causing more tissue trauma. I make the stab incision through the linea alba at the umbilicus, continue the incision cranially to the xiphoid process. More hemorrhage. I have Stephanie apply pressure with sponges, and dissect the falciform ligament as per the video, clamp off the cranial aspect with Carmalt forceps, try to deal with the hemorrhage from the body wall (I’m out of hemostats). I can’t see anything, at this point, and am slowly trying to fight down the panic and attempt a transfixing ligature (my encircling ligatures kept slipping off, and I CANNOT remember the hand-tie anymore – I’m in full fight-or-flight); Dr. Bruhl-Day comes up and accomplishes hemostasis for me with a few transfixing ligatures, 1-2-3. Tells me I need to ligate the stump of the falciform ligament, or it will continue bleeding into the abdomen (it is). (Small part of brain screams “it didn’t bleed on the video! He didn’t ligate it!”) I take a few deep breaths.
Terra is holding steady. Elise is concentrating hard. Stephanie and I are sweating. WHY AREN’T YOU IN THE STOMACH YET? Asks Dr. Spackman. THERE ARE SEVEN GROUPS CLOSING THE STOMACH NOW! I take a few more deep breaths, force myself not to cry. I can’t remember anything anymore. Dr. Bruhl-Day comes up, grabs the stomach with Babcock forceps, elevates it through the incision. Grabs dry laparotomy sponges, dips in sterile saline, packs off the stomach. Stephanie is still standing there, holding our soaked lap sponges – he tells us they’re too wet. Tells us those would soak through the drape and cause a breach in the sterile field. I take the sponges from Steph and drop them on the floor (will pick them up later, but I don’t want them soaking through the instrument table, either). “Don’t bend when you drop things,” John reminds me. I forget to remove the Babcock forceps after Steph and I place stay sutures to elevate the stomach with – it causes a hematoma. Dr. Bruhl-Day is watching – so of course this is where I go and put a pinhole in my glove. I go to re-glove; Crace, one of the technicians, pulls off my glove but not the sleeve with it, and stands there, staring, saying “uh oh.” I start to use my other sleeve to work my hand back into the sleeve, as I know very well how to perform a closed re-glove; he panics, telling me to “stop stop!” and runs off to find Lynette (who comes back and tells me to do exactly what I HAD been doing). Back at the surgery table, Dr. Bruhl-Day starts mopping blood out of the abdomen – Terra starts breathing hard. He tells Elise she’s too light; Elise hasn’t wrapped her brain around the concept that surgical manipulation of the viscera will stimulate response in an animal that isn’t at a deep enough plane of anesthesia. (Last semester, when we anesthetized dogs, we didn’t need to take them to a surgical plane of anesthesia – we only needed to take them deep enough that we could practice intubating, catheterizing, etc.) Dr. Wright comes up and helps Elise, who has just turned up the anesthetic level; Dr. Wright wants her to turn it back down. Stephanie reaches to help – touches the anesthetic machine – has to go re-glove. When she gets back, we have a tangle while I tell her how to hold the stay sutures, then I go to make the stab incision through all four layers of the gastric wall, using the #11 blade Crace gave us. I have carefully selected the least vascular part of the gastric wall. I can clearly see the branches of the right gastric artery and left gastroepiploic artery. I make the incision – O GOD – major artery. It sprays me (coats my glasses, which I have to look over for the rest of the day), sprays Stephanie, sprays Dr. Wright up by the anesthesia machine (I see it happen in slow motion, like a scene in an axe-murder film), sprays the ceiling, the wall, the instrument tray – basically everything and everyone in a mile radius. Steph can’t pack it off properly, I’m beyond giving instructions, I can’t grab it with a hemostat, there’s blood EVERYWHERE, I can’t see. I finally grab it with a BIG chunk of tissue, am taking a few breaths, Dr. Spackman comes up and tells us quietly that we’re causing terrible trauma to the tissue, and takes the hemostat off. It doesn’t bleed. She tells us to continue our gastrotomy. I insert the Mayo scissors, and it starts spraying again. I clamp like mad. DON’T CLAMP THE GASTRIC WALL! Says Dr. Spackman. YOU’LL CAUSE AN INFARCT! Dr. Betance comes up at this point. He gently tells me that if the stomach bleeds, that makes him really happy, because he knows it’ll heal well. “Just let it bleed and keep going,” he says. We’re almost out of sponges. We started with an enormous pile. I try to inspect the gastric mucosa – see nothing but blood. Start closing.
I choose an inverting Connell pattern of suture. I’ve practiced it over and over. It goes slowly (my hands are shaking wildly), but well. I over-sew with a Cushing pattern. It goes somewhat faster. I ask Dr. Betance if I should invaginate the area infarcted by my attempts at hemostasis; he tells me to go ahead. I ask him, when I finish, if I’ve enfolded too much stomach wall; he checks it and tells me I haven’t. I mop up some of the blood in the abdomen at Dr. Bruhl-Day’s urging, and start closing the linea alba with simple interrupted sutures. I put my sutures a bit too close together, but I’m paranoid of dehiscence. Dr. Betance comes up to watch; I ask him what he thinks. He puts his gloved finger in the abdomen and lifts up on the linea; it holds. “Good,” he tells me. I run out of suture, and am forced to borrow from the table next to ours. I close the subcutaneous tissue with an inverting Connell suture, but cannot get the knot to bury properly – it’s exposed in the skin. I have several bad starts at suturing skin – I’m using smaller suture, now – the sutures keep slipping and tightening too much. I keep cutting them out, starting over. Dr. Bruhl-Day comes up with good suggestions; they work. He tells me to apologize to the technicians; I’m confused, until he explains what they thought. I’m horrified. I run out of suture and have to borrow 2 more packs (note to self: bring ALL of the suture in, next time). Finish, mop up, take Terra outside to recover. I suddenly realize my knees are shaking, I’m desperately dehydrated, it’s over 100 degrees in the OR. Dr. Spackman turned off the air conditioning, to keep the dogs at a better temperature. (Terra’s temp was normal – she woke up immediately.) Steph and I get the OR cleaned up while Elise sits outside with Terra.
It’s twilight. Ghost town. We’re the only ones there. The docs and techs are long gone, as are the other students. Terra drowses in the grass. Elise is starving. I have too much adrenalin in my system to think I’ll ever be hungry again. Finally, when Terra wakes and gets up on her own, we put her in her kennel (with a big soft fuzzy blanket and a towel); she immediately lies down and goes to sleep. The three of us go to dinner – Bambu’s, which I don’t like. I get a slimy (rotting) salad (which is why I don’t like it there). I get a “virgin” drink which isn’t the least bit virginal. We rehash all the mistakes we made, and why we made some of them, and what we want to change for the next surgery. Elise and Steph are really supportive of me; I feel like I’ve let them down. We go back to school to check on Terra; she’s still drowsing. I go home to write the surgery report – it’s 9 o’clock. It takes me an hour and a half. I’m so tired and depressed I can barely think. Cry myself to sleep, hoping I don’t drag my lab partners down with me.
The next day, Terra looks good – happy to see us, wags her stump, lets us inspect her. The suture line looks good! I’m immensely relieved. I turn in the surgery report, go to class. Get the report back later; find out that Dr. Spackman hadn’t realized the bleeder we were clamping on the stomach wall was arterial (let alone like a fire-hose). I let her know, which she receives. The report isn’t too marked up. I feel a little better. Elise asks her if we can meet with her on Monday, as there were some points we wished to discuss on our SOAPs; she tells Elise she was going to ask our group to meet with her anyhow. We all feel worse. At noon, Terra has thrown up blood. We can’t offer her water. (Another student tells me this as I’m on my way to see Terra. In not a nice way. I resent this.) Steph and I go find Dr. Spackman, and tell her that even though she warned us that this was a likely sequela, we wanted to let her know. She receives this with a smile on her face (I think she was glad we were so concerned), and tells us to offer water later. Later, Terra has vomited blood again (as well as a couple of blades of grass, which I hadn’t seen in the stomach because of all the blood). No water. Evening, no vomit; she gets water. I gave her a small breakfast this morning, when I SOAPed her; will offer her more in a few minutes, when I go back to school to check on her, providing she’s kept that down.
So in addition to studying for next week’s two exams, and next week’s surgery (spay – Elise is primary, and I’m assistant), I’ll be practicing LIGATING techniques. (I think we’re going to have a “blanket party” – practice ligating pieces of blanket.) And discussing protocol, so we don’t get flustered by others’ orders and lose it. Study the video. Study Dr. Spackman’s notes. Practice burying knots. And worry about what Dr. Spackman will say to us on Monday.