co-written with Lauren Westin, MD and Andrea Kanakredes, RN, MSN
The day begins early for Laurie and Andrea. It is not uncommon for both to wake around 4:00 am after going to bed around 11:15 – 11:30 pm the previous night. After getting their first cup of coffee, both settle at their desks in a darkened home office. They carefully review the overnight notes on their patients, at their respective monitors. They often chat in hushed whispers as not to wake the rest of the household. A couple of the kitties sit with them, carefully watching the printers in action. After reading the overnight notes and print-outs, they take their turns walking 2½ miles on the treadmill before having breakfast. A little after 5:15 am, both have changed into their scrubs but still walking around in their slippers. They’re pretty much talking about the day’s schedule, and those patients who may need extra care and checks. In between the “shop talk”, they’re talking about everything else. By 5:45 am, they are on the way to work.
A trauma surgeon by profession, Laurie handles some of the most difficult surgical cases coming directly from the emergency room. When not handling a trauma case, Laurie specializes in thoracic and abdominal surgery. Andrea is the lead nurse on Laurie’s surgical team. They work in concert, making sure there is no seam or mistake made in patient treatment and care. The slightest oversight could impair a patient’s recovery, or worse yet, result in their passing.
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A couple of years ago, a new medical drama debuted on Cinemax called “The Knick“. The opening scene of the first episode riveted your attention. A young woman in the late stages of her pregnancy, hemorrhaging heavily, is wheeled into the surgical theatre. It is very much a theatre as other doctors watch from the gallery above. The doctors trying to save the young woman and her baby are also instructing the doctors in the gallery on their new procedure. Unfortunately, the procedure fails despite the best efforts of the deputy chief surgeon performing the emergency C-section. Both mother and child pass. The chief surgeon, who was overseeing both the procedure and the instruction, commits suicide afterwards. Very, very dramatic.
Often, medical dramas have their stories set in a sea of “managed chaos” along with a heavy dose of melodrama. Quite the opposite is the norm. No one is rushing around. No one is shouting. Monitors are not alerting every few seconds. Instead, it is very ordered in which everything moves like a well-choreographed ballet. While it may appear to be chaotic on a hectic day, all remains very ordered though it doesn’t seem that way. The more interesting stories are those of the patients themselves. Each have their own, more compelling than one conjured from a writer’s imagination. And, stories devoid of the melodrama. For some, their story may be touching and emotional. Others, very funny, especially when they are facing a serious condition. Many, though, see their story as a “normal” one.
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Arriving shortly after 6:00 am, the first order of business is gathering any additional information beyond the overnight notes. It is the tidbit of information or observation that didn’t quite make it into the patient charts for whatever reason. While the shift change among the overnight residents and nursing staff is already in progress, a few are always around for a quick chat before they head out. This allows Laurie and I to prioritize the patient order during morning rounds with the more urgently ill patients always seen first. Also, it helps Laurie to determine which cases to let her three residents participate while on rounds. When the residents do participate, Laurie expects much of them. Not only in thinking, but also in listening along with observing and doing. They are learning their craft as doctors.
Once rounds are completed, it is a short question and answer session with her residents. What did they observe or didn’t observe? What did they hear or didn’t hear? What were their impressions from today versus from the day before? Though she knows the answer to every question, Laurie expects her residents to have concise, specific answers. If they cannot, that’s their homework assignment for tonight. The other part of the continuing lesson is interacting with the patient (the bedside manner).
The next stop is checking the whiteboard with today’s surgical schedule. With three surgeries on our schedule, and posted on the board, we’ve been given the second slot on the trauma level.
Joining us today will be Laurie’s three residents as observers, watching off the video monitors. Our assisting surgeon is Jeff, from a previous rotation, a very sharp young man. And, rounding out our team today are two new nurses in the nurse-three position. They are new in the sense they’re moving from pre-op into the surgical suite. They will be setting up the instrument trays in addition to overseeing the instrument count. Should we be given a trauma surgery case, Shelly will become our assisting surgeon. She’s a very impressive, very skilled young lady. And, we’ll have trauma-experienced nurses in the nurse-two and nurse-three positions.
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With the residents in place, anesthesia given, we’re ready to operate on our first patient. He’s a 12-year old patient in for an appendectomy. While a laparoscope would be used in most instances, in pediatric cases it is not recommended. Through the open incision, the appendix is easily located and removed. No infection is found at the site, but a thorough clean-up is done nonetheless. One more inspection, we’re ready to close. Unlike the “TV surgeons”, I don’t hand it off to my assisting surgeon to close the incision. Good job to everyone. In the waiting room, I bring the parents over to where we have some privacy to talk. I tell them their boy will be fine. His appendix was enlarged, but not to the point where it was ready to burst. We caught it early. I tell the parents their son will be in recovery until the anesthesia wears off before he’ll be returned to his room. In the meantime, I let Jeff conduct a short Q&A with the residents. He’s impressed with their knowledge but said they need to be more precise. An excellent observation on his part, and not much different from mine.
It’s an hour before the next patient will have their surgery. I tell my residents not to wander off too far afield. Squirreled away in one of the prep rooms, I re-read my notes and review the imaging scans of my next patient. He’s in his early 50s, here to have another hernia repaired. Complicating the case is his history of multiple hernias. I told him that I’d like to make this his last hernia repair ever. He said he would like it too. In my patient’s case, his multiple hernias have occurred near his diaphragm. Though not hiatal, they could have easily been so.
I collect my residents and we head to the surgical suite we’ll be using. With the scans on the lightbox, I explain to them what will be going on during the operation. A full incision will be done instead of a laparoscopic procedure with his past history of hernias. The aim is not only to fix the hernia, but also to make this his last repair ever. While the residents take their place around the video monitors, I briefly walk Jeff through the procedure. Everything seems straightforward, and so that’s our hope everything will go according to plan. And, indeed everything does go smoothly. The hernia is located and repaired. Though there was some infection at the site, that’s cleaned up nicely. Jeff helps in palpitating and visually sighting for any additional hernias. Three small ones are found and fixed. A tension suture or a synthetic mesh can be used to tighten things up. While a mesh would be ideal in light of my patient’s hernia history, I opt for a tension suture. I can adjust the tightness (or tension) as needed. Done correctly, the likelihood of another hernia repair is reduced. This procedure wraps up nicely.
Before taking a break for lunch, I check on my appendectomy patient from earlier today. He’s awake, ready to head back to his room. Vitals are strong. The young man asks if I’m from Australia. I ask him if he would be disappointed if I was to say I was from Texas. Not really was his reply. “I’m from Texas. My accent just turned out this way.” He nods okay.
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While the day has that hectic feel, Laurie and Andrea use their lunchtime to relax. They chat about how well the riding season has been for the girls. Both are looking forward to spending a few days watching them ride. They were amused by Pinky and Susie studiously watching the printer in action earlier in the morning. “They’ll catch a page being printed one of these days.” Soon, their conversation turns to the exploratory surgery scheduled for the afternoon. Andrea said their patient is very scared, afraid of what will be found. Laurie said she’ll talk with her in pre-op and try to calm her fears. Being anxious is rather normal. A million things can run through a patient’s mind. It is a time when a person has very little control. It is a time when a person senses their mortality.
In talking with patients, Laurie sees this as the most important part of being a doctor. While there is a mixed opinion on the efficacy of the bedside manner, it lends the patient a sense of comfort and hope. It goes far in reassuring the patient and easing their anxiety level. A more confident patient makes them better able to handle any kind of news and makes for a better recovery process.
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Laurie and I can understand our patient’s anxiety. She is in her early 30s with two young children at home, and a very worried husband. Experiencing abdominal cramps, her primary care doctor referred her to a gynecologist, who then referred her to an oncologist after seeing the initial imaging scans. A second round of imaging was unable to gain a better resolution over the initial imaging, hence the need for an exploratory. Laurie sits next to her anxious patient in pre-op, getting her to laugh to break the ice. It is in this one-on-one moment where you see Laurie at her best. The calmness and steadiness in her voice, so very reassuring. Her patient hears and receives the reassurance she needs and wants. The advances in imaging, technology, and treatments are no substitute for the human touch.
With this afternoon considerably more busy than earlier today, the delay in getting into a surgical suite was about 15 minutes. To an anxious patient, 15 minutes can seem to be quite long. But, we get our surgical suite ahead of time. The residents who followed Laurie this morning, they have moved on to their other duties. Jeff, our assisting surgeon, was needed to help on another surgery. Laurie managed to find Shelly was available to assist.
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Shelly and I walk into the surgical suite, and meeting us is Dr. M., our patient’s oncologist. He explains where he wants us to investigate during the exploratory using the patient’s imaging scans. Then, I describe what I’d like to do.
The aim of any exploratory is primarily to obtain an extensive view of the area of concern and retrieve biopsy samples. Depending upon what is observed, excising the abnormal tissue may occur. If we have eyes on a tumorous growth, and if it’s manageable in size, we would proceed to remove it completely. It would save the patient from another surgery in two or three days later. If there are orphan tumorous growths in the area, we would harvest some of the smaller growths for biopsy.
Shelly continues to review the imaging scans and a copy of my notes to familiarize herself with the case as I continue discussing it with Dr. M. It is my intent to keep the procedure fairly straightforward as possible. As our discussion draws to a close, our patient is ready to go. It is scrub time. She’s fully anesthetized. Her vitals monitored, they are strong.
I ask Shelly if she has any questions before we begin. Her first question is if we find a tumorous growth, do we excise it? Only if it’s manageable in size and we are in a good time position. Second question, are any complications likely? I don’t expect any, but. Shelly nods in agreement. Two trays of instruments are moved into position. We’re ready to begin.
Andrea and Gail, the other surgical nurse, both anticipate which instrument Shelly and I will need during the course of the operation. It is this kind of teamwork that makes a procedure go smoothly. And, smoothly was an apt description of the first part as we reach the area of concern. Slowly and deliberately, we visually inspect and palpitate the suspect tissue and the adjacent tissue as thoroughly as possible. The orphan growths are numerous. We collect a broad “cross-section” of these smaller growths from the affected area for biopsy. While I hoped for a more encouraging situation, you have what you have. Except for some very, very minor bleeding, the exploratory ended well. Another job well done for my team.
Afterward, I spoke with Dr. M. and described what I saw and felt in the area of concern, and offered my recommendations. One is for additional imaging since we now know what we are looking at. With the rush on the biopsies, we should also know whether the growths are malignant or benign in 2-3 days. It’ll give the patient time to rest and recover a bit before the next surgery in a few days.
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Though it is late afternoon, it is not the end of the day for either Laurie and Andrea. An afternoon check on her two surgical patients from earlier today. And, both have some paperwork to complete. Maybe head home by 6:00 pm, which is early for them. Returning home shortly after 7:00 pm, the two are able join us at the dinner table tonight. No warmed plate of dinner, which is their standard fare. With a chance to relax, both have changed into more comfortable summer clothes. They unwind a little more before both adjourn to the home office to work on reports for tomorrow, and reading reports they had requested.
By the time they are finished, it is almost 11:00 pm. Laurie and Andrea go through their late-night routines before slipping into bed and sleep. In a few hours, they will start anew with that early morning cup of coffee.
The long hours. The studying and reading. It is about applying every scrap of knowledge and experience they have. It is work both Laurie and Andrea love. It is their higher calling. It is a life, and professions, they would not trade for anything.
And, if you thought this day was a challenge, the next day was more challenging with a nearly 5½ hour surgery on a critically-hurt accident victim.
Photo credit: The surgery photos are courtesy of Andrea. They were taken with her Blackberry Q10 phone.