CUT ME OPEN – The story of a clinical rotation in general surgery as told by an aspiring physician.

 

I look down at my blood stained hands. My mind races, thinking about the possibilities of how I got blood on them. Did I murder someone? Unlikely. I must’ve hurt myself. But I don’t see any cuts or bruises. How could a seemingly innocent person have blood on their hands? Doesn’t it seem mysterious? I could be tested for DNA, or worse, be thrown into jail for it, if the person that this blood belongs to is dead.

//deep breaths//
I’m okay. I shouldn’t panic. I haven’t done anything wrong. I trace back my steps to this morning.
Okay so I woke up, begrudgingly, at 6.30 am, showered and set off for the day by 8. Then someone asked me for the reports to an abdominal CT. I pretend not to hear them and walk towards the cafeteria because I didn’t have time to drink my morning coffee. A second person came up to me and asked me to write a discharge. This seems like white noise at this point, blaring in the background; mixed voices echoing about ceftriaxone and betadine and non healing ulcers.
I close my eyes for a second and look up at the ceiling. When I look down I find my hands stuck inside a patients abdominal cavity while the singe of flesh triggers my sensitive gag reflex. I am not in a super awesome mystery about an unsolved murder. The reality is that I am a surgical intern and I have to pretend like poop doesn’t smell every time my attending does an exploratory laparotomy (which is everyday). Also plot twist : that was poop on my hands not blood.

You know, my father is a surgeon, as are many relatives in the family. Surgeons pride on being surgeons. My father once said he doesn’t need my mother to sew on a button for him because he is a surgeon and he could (most possibly) do a much better job than she could. He always wanted for me to be a surgeon. My initiation ritual was to observe a radical nephrectomy at the young age of 13. It was spectacular in a way that it changed my life. I was never the same again.
What my first surgical experience did was, it taught me about vasovagal triggers. But the first five seconds before I fainted were definitely spectacular.

So I, being a bunch of vasovagal triggers to multiple things like the smell of a freshly excised segment of necrotic bowel, or a 10 blade, or any patient that lists main complaint as “pain abdomen” am forced to intern in general surgery. What’s worse is the surgical unit I am in-
1. Makes me dislike surgery even more.
2. Does not realise the difference between abdominal pain and constipation (inside joke.  Sorry if you don’t get it)
3. I would not trust one of them to even cut my toast in half.

How does one navigate this cat-piss ridden, foul-smelling, manic-depression inducing rotation without one turning into a foul smelling, cat piss soaked, manic depressive? They elect not to do surgery of course! But if you have impaired decision making ability, or are forced into a bonded contract of humiliation by multiple people with God-complexes, you can follow my guide to refusal of informed consent to the procedure (definitely an ex-lap).

1. Remember these words – Conservative management. They’re going to be your best friends. If at all someone mentions conservative management for treatment, jump on it and campaign for it. Because if that guy is posted for surgery, YOU will have to beg the anaesthesiologists to give him anaesthesia because there is no time for 700 chest X rays. YOU will have to face the attending if the case is postponed and he will scream at YOU because he thinks anaesthesiologists are incompetent even though you tell him you will never be an anaesthesiologist and agree to curse 10 generations in your family so nobody can dream of being an anaesthesiologist.

2. If you are a nervous fool like I am, don’t stand next to anything important or anyone important. If you do, you will be asked to do a million things like foley the guy or ‘reassure him’ while they’re DJ-ing his insides. Just be a fly on the wall. I once thought standing in the corner was a good idea so nobody would notice me. But as my terrible luck had it, I was asked to stand right next to the operating surgeon with the fumes of the cautery finding their way ONLY to my nostrils. I am perpetually put off by barbecues now thanks to that day. The other time I was standing behind everyone dry-heaving at the granulation tissue they casually minced, I was asked to adjust the lights so many times that I have permanent vertigo now.
I tried to run out of the OR but my semicircular canals failed me. I am trapped. Send help when you see me blink twice. If I blink once it means adjust the lights.

3. Chart everything. I mean everything. How much is the patient peeing, what’s his pain like, how many florals is he wearing for Spring-Summer ’18. Surgeons never care about charting but they love dissecting interns about not using a comma while writing an 8 part novel about the patient’s post-op condition.
I don’t even know half of the things they want me to chart. And they bark orders all the time, so I don’t understand what they’re trying to tell me either. This one time I saw the previous day’s rounds included “serous output” which was written horribly (because all surgeons use the pen like they’re welding a scalpel. The papers are filled with incision like pen marks). So OBVIOUSLY I thought serous output was actually ‘serious output’ and I spent half a day charting how the patient passes urine.
250 ml- serious
300 ml – happy
100 ml – crying about the indwelling foley’s.

4. Look around you. The surgical department is a treasure chest of knowledge and resources. All those blades strewn around? You could use them to chop someones appendix off. Or, you could use them to chop some beerakaya (bottle gourd?). Get creative! Your resident wants you to do the dressing while he gets to drink chai? Dress the patient up as an anaesthesiologist, complete with a constant ‘no’ for every question and the occasional ‘how much is his hemoglobin’. That will spook your resident into never making you do anything for him ever again.

5. Try not to answer anything on rounds. I don’t know about the other surgical units, but the one I’m in absolutely hates it when an intern answers a question. Almost as if the whole point of doing medicine is to never learn anything.
If you do have the answer to something weird, say “why is nystatin not a statin” then they will bring their claws out. Or 10 blades, same thing.
I once knew the answer to a question about gall bladders and my attending followed up with “what was the size of Emil Theodore Kocher’s gall bladder” just to mattress suture my lips shut.

6. What is a consult? A consult is an elaborate ritual in which surgeons find the smallest thing wrong with the patient like hemoglobin being 10.9 instead of 11 and try to shuttle them off to other departments because they’re so tired of doing wound dressings and meshing hernias.
Here are some reasons to turf patients to other innocent departments.
Does the patient have a headache? Page neuro stat. Every headache is a subarachnoid haemorrhage to them so they won’t ignore you. Easy peesy.
Turfing the patient to ortho is a tad difficult as they are also always looking for reasons to completely empty their wards so they can make castles out of POP. If you have any non-emergent, geriatric patients, ortho will be more than happy to replace all of their replaceable joints with their shiny, new toys.
One of my patients said he was so in love that he was “blinded” by it and I called ophthalmology in a heartbeat because love is blind, and this kind might just be curable.

7. Do you want to impress your surgical residents/attendings? Do you want to turn their constant frown into an occasional half-smile? Follow these simple steps!

~Mention on rounds that at least two patients’ BP is over 130. They will convulse at the thought of sending them over to internal med for hypertension and having two less dressings to do.
~Always have some betadine on you. Surgeons love betadine. They even drink betadine flavoured energy drinks to keep them awake between wound debridements. One surgeon I know even threw a betadine themed party for his kid.
~Spend some time on mastering the ‘snap’ every time you wear gloves. This will both intimidate and impress your residents. “She’s one of us” they will whisper to each other as their noses pick up the unbeatable smell of glove powder.
~All that work and no pee breaks giving you kidney stones? Refer yourself to urology first, that’s one less intern off the hands of gen surg. Then beg your urologist about letting you keep your kidney stones. He might think you’re weird, as most gen surg interns are, but will most likely comply.
Then proceed to use your kidney stone in a ring to propose to your future husband/wife/10 blade. If there’s a surgical resident around, he’d most definitely let out a half-smile at your dedication.

8. If you want to survive general surgery you need to put up with diarrhea every single day. You see all surgeons hate cafeteria food and they frown upon vegetables and essential nutrients, stuff like that. They love eating food that’s from questionable places with questionable looking meat. Somehow none of the surgical residents get diarrhea. Maybe because they tag team with the patient for metrogyl. They love metrogyl. It’s like they play the ‘he loves me, he loves me not’ game but with metrogyl. ‘Patient gets 500 ml, I get 500 ml’.

9. Casual misogyny is always welcome in gen surg. There are so many wonderful female surgeons, but male surgeons love to make the occasional sexist remark to compensate for their imperfect suture technique. Here are some phrases to get you started with your misogyny 101.
“Of course I won’t be a surgeon! I’m too delicate and weak. I’d rather do something tailored for my gender like family medicine or dermatology”
“Yes I absolutely agree that all female interns MUST wear sarees. We can even get navy blue saree scrubs and spend 7 hours pre-op perfecting the pleats”

10. Surgeons are very serious about contamination. My father even complains about an extra LED light contaminating the cricket field. So it is in your best interest to be proactive about not contaminating anything and everything in addition to the surgical field.
You can’t be friends with radiologists because according to surgeons, they will contaminate your young mind with fancy MRIs and CTs.
You can’t cry during surgery because the OR lights hitting your retinas are making your eyes bleed. Because that will contaminate the patient’s clean-contaminated wound.
You can’t even eat a salad for dinner because that’s too clean and you need to contaminate it.
You can never win.

Hope this unhelpful guide helps you on your gen surg rotation, and hope I take my own advice for the rest of my rotation because I advised myself a head CT and some bed rest. And a repeat hemoglobin (because of anaesthesia).

THIRD WORLD MED STUDENT PROBLEMS PART-2

Picture this. It’s summer in the tropics, which means it’s pretty fucking hot, say 41 degrees C. You are forced to go to a hospital 4789236 kilometres away from home. You park your car in the crumbling semblance of a shed, bump your car around a few other frustrated drivers, trees bang in the middle of the road, and obvious manholes laced in between the intricate one-car lanes.

You are extremely tired and it’s only 9 am. Delightful. Then you have to do a 100m sprint from the parking to the hospital building and while doing so you have to dodge a few birds trying to take a shit on your white apron. You are basically an Usain Bolt who also does relay-runs. Why do you need to run you ask? The professor comes in at 11.45 am, but he will enquire when the students came in because he is trying his very best to invent new ways to torture us. Poor guy, A+ for trying.

Then you are barraged with questions, as soon as you can catch your breath. Mostly from residents because they are in a constant fight for power in the food chain. You try to answer whatever you can while also experiencing grade 4 dyspnoea. But tough luck, you trip on a bum tile and fall down in a tub of used gauze. Ha-ha. You laugh awkwardly. But inside you are dying.

Welcome to one day in my life.

In my previous post of third world med student problems, I made a lot of people laugh (sure, go ahead, laugh at my misery), but i spoke da real 100% truth. Though I might have left a few points behind, because you can’t really describe a third world hospital. It’s a museum, a zoo, a dustbin, a movie set and maybe sometimes, a hospital.

Third world hospitals are like a parallel universe. It’s like stepping into Narnia, only the white witch is Tuberculosis. In this strange world, we have endangered art work such as “Jai Telangana” splattered across walls, the ritualistic outdated surgeries using instruments John Hunter himself forged out of rusting metal. And how can I forget, the mesmerising sing-song voice of the nurses saying ‘pakkaku jaragandiiiiiii’ (translation : GTFO) . It’s all fun and games until your professor makes you examine a hydrocele case sans gloves. Why? Because it makes him inexplicably happy and don’t whine, it’s *practical knowledge*. It must be my damn birthday because the icing on the cake was that the hydrocele guy had TB too. Ha-ha-ha (crying slowly turning to tears) I want to switch places with the coma guy.

But I have left behind my snobbish ways of wanting cleanliness and wanting to NOT die from fright every time I trip on the ghoulish winding staircases with no lighting whatsoever. From my last post on third world hospitals, up until now, I have come to realise that,
a) I cannot change anything
b) All pigeons are going to want to poop on me
c) I need to get waterproof makeup because I cry a lot whenever I am confronted with a patient and his family who all have a coughing contest on me.
d) My professors expect me to love this hospital and worship the ground they walk on. Which I cannot because it is inevitably covered in dust/pus/blood/urine of animals or humans/all of the above

So while I cannot change the fact that I have probably stepped already on someones urine and/or blood, I can at least help you, if you ever have the misfortune of going to a hospital in India. You must first remember that bravery is key.
You cannot run like a pansy when you see poor med students being harassed and asked to feel for axillary lymph nodes in someone who has not showered in 10 days and is sweating like an Indian bride on the day of her arranged marriage .

You must instead give them moral support and stay with them till they regain consciousness. Okay here is your survival kit : Updated

1.How is your hospital back in the west with your beautiful shiny, expensive things and your spotless scrubs? All good? I thought so too.
While you lead a life of rampant luxury, we fight gladiator-style for the last pair of OT shoes . It’s cool 🙂
Also, must be nice to have a hospital stocked with ESSENTIAL things like hand sanitiser and soap and surgical masks.
You know the last time I walked into an OR and I forgot to bring my own surgical mask, I had to run around the entire hospital asking in each department if they could spare a mask for a poor child like me.
One nurse in the medicine department finally took pity on me seeing how I was close to tears.
I am free.
Master gave Dobby a sock.

2. Where do you go for your summer vacation? The theme park? Or probably the beach?
I go to the hospital.
When it is dangerously hot outside, it’s even hotter in the hospital. Because we have maybe about 10 ceiling fans and 2 out of them work on a good day.
So you are sweating half of your body weight and finally faint and fall into a puddle of your own sweat out of sheer dehydration. Only to be rudely woken up by the colossally inexperienced interns poking you with IVs, who can’t find a vein if it slapped them in the face.

3. There are a few words you need to know to get out of any situation in each department.
Surgery – ‘Pain and suffering’
For example,
Professor : What are the symptoms of acute appendicitis?
Me : Pain.. and suffering.
Professor : Ok. What are the symptoms of hernia?
Me : Pain. Maybe suffering too. Definitely pain though.
Professor : (Impressed) Good job. You can assist on the next surgery.
Me : OMG THANK YOU!! Which one?
Professor : Lateral anal sphincterotomy
*cue PAIN AND SUFFERING*
Likewise, the important word for internal medicine is ‘hypoxia’, or basically any word with a ‘hypo-’ prefix. It will give your attending little shivers of excitement.
For Ob-Gyn it is obviously ‘emergency C-section’, or if they’re feeling particularly risqué, ‘Bladder injuries’, ‘I-thought-the-ureter-was-the-fallopian-ha-ha’
For paediatrics you just wail along with the other children.

4. Why study about symptoms when you can demonstrate them on yourself?
Do you want to know what hypoxia is you silly child? Run from the OR to the blood bank because your attending surgeon wants to *make sure* you have enough blood, and then back to the OR from the blood bank because the blood bank lady won’t give one unit of blood to the patient. Try explaining to her that it’s redundant to call it a blood bank when they REFUSE to sanction blood to patients. She barks at you without ever breaking eye-contact.
What you feel right now is dyspnoea, hypoxia and pain and suffering.

What is the puddle’s sign? You don’t need a textbook for that! You’re already constantly in the knee-elbow position to prevent the blood-thirsty residents from seeing you sobbing because you got told off for showing slight displeasure at doing all those per-rectal examinations actually to be done by them.

5. When you see case files for the patient’s case history, don’t stroke out if you only see three words in the chief complaint, present and past history, combined.
Our precious residents and interns have other major things to do, like drink chai 792 times a day, always borrowing your stethoscope, and asking you to “man up” when you have an MI because you almost stepped on the maze made out of discarded needles.
So if you see something like “pain in chest”, assume immediately you will have to say drug names like ‘metoprolol’ without stammering even once, or you will be thrown to the wolves, i.e, casualty department.