September 8, 2009

MedZag's First Night on Surgery

If there's one thing you can count on during your surgery rotation, it's that you'll have at least one occurrence a week where you will stop, survey what is going on in the room, and think in your head "what the f**k is going on in this room?!?" The residents take a certain amount of glee in finding ways to induce nausea and/or vomiting in the new, cute and cuddly little medical students on service. So of course on the first day of our rotation, with the knowledge they will be soon gaining some fledgling MS3s on service, the residents on my team saved all their *ahem* hands-on *ahem* floor work for the day for evening rounds when we would be joining them.

Case #1 was a patient we called Boss. Ms. Boss was the first patient I saw on my surgery service. Now keep in mind, I had just rotated off pediatrics, where I was used to seeing adorable kids all day. Sure, they may have been covered in poop, or really sick, or doing their due vigilance to prevent atelectasis by screaming for 23 hours a day, but they were still kids, and I freakin love kids. So we roll into The Boss' hospital room here I am confronted with a 350 pound elderly woman lying in her bed as Jerry Springer blasted from her television set. Our resident instructs myself and my fellow med student to glove up as it was time to change The Boss' wound. He peels back the dressing to reveal no wound but rather a massive gaping hole. You see, Ms. Boss had had a previous ventral hernia repair with a mesh. She got discharged to her nursing facility and the mesh subsequently got infected - necessitating removal of said mesh and all surrounding infected tissue. What was left was a 14" crater in her abdomen, with loops of bowel showing through a thin layer of tissue at the base. The tissue was still infected and I was immediately struck with the smell of... sherbert ice cream. Needless to say no sherbert ice cream was consumed this past month. So we get the supplies together and the resident gets to packing the "wound" with xeroform and two packs of kerlex. As I watch the resident place gauze on the exposed bowel, I step back for just long enough to think to myself: "what the f**k is going on in this room?!?"

Later on in rounds we come to a patient who the team had come to call Mr. Rabbit, for reasons which HIPAA will not allow me to explain but unfortunately not due to resembling a rabbit in appearance or size. Mr. Rabbit has originally presented to the ER with what was originally diagnosed as a rip-roaring case of panniculitis. As Mr. Rabbit was homeless and weighed in at a hefty 628 lbs, there was obviously quite a bit of pannus to become infected. He was taken to the OR where they found that while yes, his pannus was infected, it was actually due to a large sack of herniated bowel which was eroding into the skin. His hernia was reduced and he got a non-cosmetic panniculectomy (aka tummy tuck). The weight of his excised pannus: 78 lbs. So we reach Mr. Rabbit on rounds, now a svelte 550 lbs, who was beginning to show signs of a wound infection: rubor, dolor, calor, tumor (you have to say these in as dramatic a voice as possible). The team decides its time to open the wound to let it drain, a staple of proper wound care on surgery. The protocol for opening an infected wound is to (1) open, (2) assess drainage, then (3) follow the pocket of infection to get a sense of how large it is and where it tracts. For small wounds, this can be done with a wooden q-tip. For larger wounds, a gloved finger is often necessary. Our resident gloves up, removes the necessary staples, and begins to follow the pocket of infection. More and more pus begins to pour out of his abdomen. Despite his newfound surgically-enhanced physique, Mr. Rabbit still had quite a bit of subcutaneous fat, and before we know it, the resident has his entire hand, up past the wrist, inside the patient's infected incision. I stand back, take the scene in, and think... well you already know what I think.


ab said...

I'm curious as to whether the nicknaming of patients is common among residents and med students?

I understand HIPAA and the need to provide aliases in public forums to protect the identities of patients, but it seems from your post as if you're actually referring to the patients privately among yourselves by nicknames.

I ask because it seems rather disrespectful of the individuals - but not being there I can't really say whether this is so. No doubt you experience a lot of the underside of life in teaching hospitals. In theory the nicknaming of patients insulates you from some of this - but does it also dehumanize your patients? I'm not flaming on you - this is a sincere query.

Is it more difficult to view the morbidly obese, self-inflicted disease-ridden with compassion? There is a lot of hate speech among med students on the forums about the obese and I'm curious if this continues through the training - or if you're provided training in dealing with these situations.

Really do love your posts. Thanks for taking the time to update. It's very useful and insightful.

MedZag said...

Legitimate concerns ab, and questions I figured I'd get with this post.

To answer your question concerning my specific experience - on my surgery rotation nicknames were almost solely used for the sake of patient privacy when we had to discuss patient care in public places, the elevator, etc. Nicknames often rhymed with or were a play off the patient's real name. I can't recall any specific circumstance where a patient was nicknamed in a stereotypical or mocking fashion (i.e. gomer, lol, etc), and I consider myself pretty sensitive to that sort of talk. Though those do exist in medicine still to this day.

That being said, we often used humor and made jokes in private which I doubt any of us would like our patients to hear. But I never felt any venom from the jokes, and we always made sure such conversations were held in private. In psychiatry, humor is actually considered one of the three mature defense mechanisms in response to stress. And medicine can be a very, very stressful environment. I'd rather work in an environment that's a little un-PC if it means colleagues don't have to resort to other, less healthy means of debriefing and destressing from their experiences.

Janovec said...

I'm so sure this is not the point of your story but how do you get to 600 pounds if you're homeless? The soup kitchen food can't be that good.

ditzydoctor said...

loved this! :) shall be reading from now on :)