Let me tell you one of my favorite stories from my Rural Med placement in Small Town, Iowa. Believe me, there are MANY. My roommate would share the week's happenings with my women's small group, and they were kept on the edge of their seats for the entire month...
Surgery Day in Small Town
There was a Tuesday after a 30-hour call that both of my preceptors were on vacation. So I requested a day in the OR instead of a day off. I'm a workaholic like that. I love being in the OR, and I love the meticulousness and controlled danger of surgery. That Tuesday was probably my favorite day of the entire month.
I followed Dr. M, the only general surgeon for the entire town for the last 30 years. He does everything from colonoscopies (usually done by GI specialists) to laparoscopic hysterectomies. He happened to oversleep the day I was supposed to be in the OR with him, and so the entire hospital staff sat around and drank coffee while awaiting his arrival. It was really strange. First, they went to look at the parking lot ("Nope, his car isn't here") and then called his home ("No, you do it. No, you do it. Maybe we should have the med student do it...") and an hour later, he arrived with the look of someone slightly bewildered and fresh out of bed. We've all been there.
Most of the rest of the morning went well once we got on track. I'd only ever scrubbed into surgery a few times prior (for C-sections with my preceptor) and even those procedures aren't exactly sterile. So to be scrubbed into an actual open surgery was a big deal.
The first procedure was a hernia repair. I had scrub training before, so went through the motions of iodine scrub and nail pick, sterile towel, etc. I asked for size 6 gloves, and they had to get them from a special supply since those are rarely used. And then I proceeded to tear through my gown as I was gloving. Embarrassing. I had to de-glove and start over. The second time, as someone was tying my gown for me, a nurse said, "Oh wait, there's going to be radiocontrast. Have you had kids yet? You'd better get some lead." So I had to break scrub yet again and don a lead apron and a thyroid shield. By then, someone had grabbed a stash of gloves specifically for me so they didn't have to keep running back and forth to supply. Everyone was SO incredibly nice about it. Finally properly armored with lead and sterility, I stood in the sterile draped field across from Dr. M. It was just the two of us in the field, plus a scrub nurse. I imagine early residents to have less access than I did.
Dr. M allowed me to make the first incision on every patient and the last stitch. It was glorious. My only prior experience with scalpels was in my four months of cadaver dissecting in anatomy lab. Live human flesh has a very different feel than tough, preserved tissue. I didn't know how much pressure to apply (Dr. M: "More!"). I got the hang of it after maybe three incisions. The scrub tech was also being trained at the same time, so it was helpful to have narration during the surgery. The senior scrub nurse would say something like, "And then he'll want a pickup, so hand him that. And then she'll want an army navy, so give her that." I had no idea what an army navy was, and why I wanted it, but learned the instruments as I went.
I learned quickly that surgery is very physically demanding (as a med student, at least). The student does most of the retracting, which means holding open skin and fat in order to allow the surgeon access to the organs and structures. Different types of metal retractors are used to achieve this, and some of them don't have great grips and slipped all over the place. I was glad that I started working out in med school and actually had upper body strength this time of year.
The surgeries felt like a well-choreographed dance to me. Dr. M would place a stitch, and I would pick it up and hold it taut. We'd repeat until the neat rows of sutures came together. I'd dab with a lap and suction. He'd clamp instruments and I'd remove them. It was strangely the most fun I'd had in a long time. Maybe that says less about the surgery than it does about my definition of fun (and life in general).
The last surgery of the day was a laparoscopic cholecystectomy (gallbladder removal using small windows and fiber optic cables that project onto a screen--minimally invasive surgery). We'd done a consult earlier that day. I like surgery consults because they're quick and to the point. We basically stood bedside with a diagram of gallbladder anatomy, and told the patient what we'd do, and if he had questions. He consented, signed papers, and we had him in the OR within the hour.
The procedure was going well (and by then I had no trouble making incisions and plunging the sharp ports through the skin) until it wasn't. Dr. M couldn't find the cystic duct. To remove the gallbladder, certain structures need to be clamped completely. Two hours into the procedure (this is a one-hour max procedure, mind you) we had to open him up. This means connecting two of the port incisions with a large, 8-10 inch incision and gaining access to the abdominal cavity. We were no longer laparoscopic. Dr. M rooted around for a while longer to try to discern the structures. It was a very diseased gallbladder, which was what made it difficult. The patient was also quite obese, which made my retracting job harder.
Three hours in, I was getting sleepy. I'd basically stood at the table for 10 hours by then, and was coming off of 30-hour call. I was holding a retractor at an angle that didn't allow me to see much. So I was half-dozing when I realized that Dr. M was closing up with sutures. I thought to myself, "Wait, where's the gallbladder?" but wasn't lucid enough to speak up. A minute later, the scrub nurse said, "Wait, where's the gallbladder?" Dr. M's next words were, "Scissors, please."
He'd forgotten to take out the gallbladder somehow.
I was awake by then, mostly because I found it so amusing. We had to open the poor guy up TWICE that day. We pulled all the sutures and tied off the appropriate structures. And yes, we finally did get the gallbladder out. The second set of closing sutures were hastily done, because the surgery had taken by then four times longer than normal. I tried to place some nice, even ones subcutaneously for good aesthetic effect, because Dr. M was pretty tired by then. We finally finished. The guy goes on to develop sepsis. I was at morning rounds 12 hours later, and sheepishly explained the story to the hospitalists. They were not amused.
Classmates and medically oriented people everywhere are gasping in disgust and disbelief right now.
Things like this make me wonder what kind of care most of America gets. This was just one instance in Small Town, America. General surgeons perform most of the US's procedures. Academic medicine is a rarity, and it is such an elitist bubble. It's not a feasible model of healthcare for most people.
I think I do want to become a surgeon, but I'm not sure what scope of practice I'd want. I could subspecialize from there, and focus on one body part. I might even be able to practice on that one body part finally when I'm 35. Or I could stay general, because that is where the most need is. People have to wait so long these days for even basic surgeries. I could help fill the gap. Change the culture of surgery. And then I stop and realize that I've never considered what life would be like for myself, or my potential family. I'd always been so focused on serving the greatest need and having it all at the same time. I need to be mentored by a woman surgeon who has a family and a balanced life. I'm sure such a woman would have the mental fortitude of a concrete fortress, dedication forged by thousands of hours of work, and resilience beyond belief. I want to be her.
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