Only in health care. The above is a quote from one of our trauma surgeons. And its so true. I've never actually tried to add up the cost of all the stuff I order in a day, but its considerable. Probably cheaper now than when I was in the ICU, but still. Labs for all, scans, tests, medications, consults . . . the list is never-ending. Medicine is crazy; every piece of equipment has an extraordinary amount of labor/engineering/technology behind it, plus the fees of the person giving it. It adds up quickly. Take the OR, for example. They charge for OR time by the minute, and although I'm not sure how much the exact amount is, I can assure you its not pennies :) If I think about it too hard I start to feel guilty about how long it takes me to do stuff like suture.
In other news . . . Wow, its been awhile since I've blogged. Its been quite a busy month, despite my being on one of the 'easy' surgery services. My first two weekends were on call, so I logged over 90 hours each week. Last week was lighter, but I was out of energy after working 22 straight days, so it was hard to get my butt to the gym after work. Now, I had last weekend off, and I'm refreshed! What a difference a couple of days of sleeping in makes! Sleeping in for me is now until about 8am (sounds hilarious, but its a weird feeling to wake up when its light out, freak out for a second that you're late for work, then realize its your day off and snuggle back under the covers).
And I've gotten to operate a fair bit. Mostly small breast surgeries, but I've done a couple mastectomies and helped with some implants on the plastic surgery service. Tomorrow I do some melanoma resections. Pretty sweet huh? I'm getting more comfortable in the OR, asking for instruments and knowing what the next step is. And I love the attendings I've been working with, they're so patient and give me great tips for how to improve. Its been overall a very positive experience. A little too much clinic time, but otherwise a good month.
Today was fabulous. Our last OR case cancelled (sad but okay for today), so I got to go home at 4pm! Its funny how a 10-hour day seems short now. Makes me realize how warped my view of life and work is. I probably wouldn't know what to do with myself if I only worked 40 hours a week. Anyhow, this afternoon I had time to work out, walk the dog, pay bills, blog, and I'm on my way to have ice cream with my surgery team. Its great to have time to do more than drive home, see the BF and fall asleep.
Several of you have asked about my BF. He's doing well, loving it here as much as I do (in other words, "It's not terrible"), but meeting people and enjoying his job for now, at least so he says. He's still working on school, but has plenty of time to watch me sleep when we hang out together. I'm not exactly sure how I keep him interested/entertained, since I do sleep so much of the time we're together, but I try not to dwell on that. I think we'll be okay here in VA, and although we might never fall in love with this area, we'll be happier and happier as time goes on.
Tuesday, September 25, 2007
Wednesday, September 5, 2007
Finally, the reason I'm here . . .
I'm on my first general surgery month. Finally. A real team, with a chief, midlevel, and intern (me). My service includes breast and endocrine surgery. That means we take out breast cancers and thyroid nodules and cancers, for the most part. Usually relatively simple procedures, and the patient goes home the same day or stays overnight and goes home the next morning, if all goes well.
And when I say "we" take out nodules and cancers, of course I mean the grand "we." As a team, we look at the case list for the day, and my chief picks the cases she'd like to do. Then, the midlevel picks his cases. If there are any cases left, they go to me. Its sort of like being picked last in dodgeball, but in reverse. At any rate, the other day I got to go to the OR!!! Victory :)
Let me try to explain why I love the OR. First of all, its where surgery generally happens. That's a given. But also its where surgeons feel at HOME. Its where we're in our element, as it were. The OR is full of mini-rituals and very, very anal retentive practices, which is why surgeons are generally type A people. I'll run though the prepping of a patient for surgery for you, step-wise.
1. I go and see the patient in the preop area. All I have to do is say hello, and maybe update his documented History and Physical. The patient also needs to be consented for the procedure, if that hasn't happened before.
2. The patient gets wheeled into the OR suite. We do a TIME OUT, which means we all agree that we're doing the right procedure on the right patient on the right side. The patient then gets moved from their bed to the operating table, a very skinny very hard board that goes up and down and lots of other nifty directions. They pretty much get strapped in, covered VERY BRIEFLY with warm blankets, and anesthesia does their magic to put the patient to sleep. Usually they put an endotracheal tube in to help the patient breathe during the case. They also tape the patients eye's shut to prevent any corneal damage. Squeezy boots are put on their legs to prevent clots from forming during the case.
3. As soon as the patient is asleep, the fun begins. We immediately strip off all those warm blankets, put a catheter in if its a long case, and shave any really hairy body part we're working on. I then use a sterile prep to clean the patient's skin where we'll operate. Usually its betadine, so I'm (carefully) slopping this wet brown stuff all over them. Starting at the middle of the site, and moving outward in a circular motion until my sponge gets dry. Then get a new sponge, reload, and repeat. I do at least 4 runs with scrub, and 2 runs with dye. This shows us where we've prepped once the scrub dries.
4. Then I go to the scrub sink to scrub myself. This is a 5+ minute process of cleaning under my nails, then scrubbing every side of my fingers and hands (5 strokes each side of each finger, 30 on each palm, 20 on the back of the hand, 30 on each side of the arm to the elbow. um, scary that I count this? probably). Then I walk into the OR, careful not to touch anything, and the scrub tech helps me into my gown and gloves. Hopefully I've already put on safety goggles, but usually I forget and get yelled at by the circulating nurse. Once I'm done getting gowned/gloved, I start draping the patient. This is the part where my heart rate goes up, because I don't want to mess the draping up and have to start all over, and get called incompetent. Its very important that the patient stay sterile, so nothing can touch the prepped part except our sterile towels, drapes and instruments.
5. The patient gets fully draped with towels and drapes to cover every single part except the part we operate on. This is key, and its the reason why the OR's not really as grisly as people imagine. Its quite easy to focus on the part in question, and forget you're operating on a full person, in some ways. Keeps the queasiness to a minimum. This is not the case for an operation on the head, where the patient is pretty much in plain view. Anyhow, the draped area is sterile now, and not to be touched by anyone except those who have scrubbed as I described above. Usually this will include the attending surgeon, the assisting intern, a medical student, and the scrub tech. In the room, there is also an anesthesiologist and a circulating nurse, who gets us anything that's not already sitting on the instrument stand.
6. The scrub tech then wheels her stand over, full of fun operative equipment that I'm just starting to learn the names of. Tools sometimes have many names, and include blades, clamps and graspers of all types, and retractors, among other things. A key feature to any case is the Bovie, an electrocautery device that can both cut and coagulate bleeding areas. Also key is the suction. Any med student who has had that job can probably laugh along with me as I fondly remember my first case in the OR: "suck, dammit, suck. I can't see anything. That's better, now try to keep it dry, and suck whenever I'm not in there, okay?"
7. Then the magic happens. The magic first involves staring at the site for what seems like forever, trying to figure out where to make the perfect incision. If I get to decide, my mark usually gets altered once or twice before actually proceeding. The area of choice gets marked with a (sterile) pen, and I ask for the scalpel. "Fifteen blade" is actually what I say. Then I get to make the cut. Either I do okay, and get praise, or I do a bad job, and halfway through the attending screams at me to stop.
And I won't continue boring you with my favorite things, but that's basically how the OR works. And it works that way every time, and there's quite a sense of ritual and exactness about it that makes me happy. Probably because of my borderline OCD.
Here's hoping I get to get back in the OR frequently this month!
And when I say "we" take out nodules and cancers, of course I mean the grand "we." As a team, we look at the case list for the day, and my chief picks the cases she'd like to do. Then, the midlevel picks his cases. If there are any cases left, they go to me. Its sort of like being picked last in dodgeball, but in reverse. At any rate, the other day I got to go to the OR!!! Victory :)
Let me try to explain why I love the OR. First of all, its where surgery generally happens. That's a given. But also its where surgeons feel at HOME. Its where we're in our element, as it were. The OR is full of mini-rituals and very, very anal retentive practices, which is why surgeons are generally type A people. I'll run though the prepping of a patient for surgery for you, step-wise.
1. I go and see the patient in the preop area. All I have to do is say hello, and maybe update his documented History and Physical. The patient also needs to be consented for the procedure, if that hasn't happened before.
2. The patient gets wheeled into the OR suite. We do a TIME OUT, which means we all agree that we're doing the right procedure on the right patient on the right side. The patient then gets moved from their bed to the operating table, a very skinny very hard board that goes up and down and lots of other nifty directions. They pretty much get strapped in, covered VERY BRIEFLY with warm blankets, and anesthesia does their magic to put the patient to sleep. Usually they put an endotracheal tube in to help the patient breathe during the case. They also tape the patients eye's shut to prevent any corneal damage. Squeezy boots are put on their legs to prevent clots from forming during the case.
3. As soon as the patient is asleep, the fun begins. We immediately strip off all those warm blankets, put a catheter in if its a long case, and shave any really hairy body part we're working on. I then use a sterile prep to clean the patient's skin where we'll operate. Usually its betadine, so I'm (carefully) slopping this wet brown stuff all over them. Starting at the middle of the site, and moving outward in a circular motion until my sponge gets dry. Then get a new sponge, reload, and repeat. I do at least 4 runs with scrub, and 2 runs with dye. This shows us where we've prepped once the scrub dries.
4. Then I go to the scrub sink to scrub myself. This is a 5+ minute process of cleaning under my nails, then scrubbing every side of my fingers and hands (5 strokes each side of each finger, 30 on each palm, 20 on the back of the hand, 30 on each side of the arm to the elbow. um, scary that I count this? probably). Then I walk into the OR, careful not to touch anything, and the scrub tech helps me into my gown and gloves. Hopefully I've already put on safety goggles, but usually I forget and get yelled at by the circulating nurse. Once I'm done getting gowned/gloved, I start draping the patient. This is the part where my heart rate goes up, because I don't want to mess the draping up and have to start all over, and get called incompetent. Its very important that the patient stay sterile, so nothing can touch the prepped part except our sterile towels, drapes and instruments.
5. The patient gets fully draped with towels and drapes to cover every single part except the part we operate on. This is key, and its the reason why the OR's not really as grisly as people imagine. Its quite easy to focus on the part in question, and forget you're operating on a full person, in some ways. Keeps the queasiness to a minimum. This is not the case for an operation on the head, where the patient is pretty much in plain view. Anyhow, the draped area is sterile now, and not to be touched by anyone except those who have scrubbed as I described above. Usually this will include the attending surgeon, the assisting intern, a medical student, and the scrub tech. In the room, there is also an anesthesiologist and a circulating nurse, who gets us anything that's not already sitting on the instrument stand.
6. The scrub tech then wheels her stand over, full of fun operative equipment that I'm just starting to learn the names of. Tools sometimes have many names, and include blades, clamps and graspers of all types, and retractors, among other things. A key feature to any case is the Bovie, an electrocautery device that can both cut and coagulate bleeding areas. Also key is the suction. Any med student who has had that job can probably laugh along with me as I fondly remember my first case in the OR: "suck, dammit, suck. I can't see anything. That's better, now try to keep it dry, and suck whenever I'm not in there, okay?"
7. Then the magic happens. The magic first involves staring at the site for what seems like forever, trying to figure out where to make the perfect incision. If I get to decide, my mark usually gets altered once or twice before actually proceeding. The area of choice gets marked with a (sterile) pen, and I ask for the scalpel. "Fifteen blade" is actually what I say. Then I get to make the cut. Either I do okay, and get praise, or I do a bad job, and halfway through the attending screams at me to stop.
And I won't continue boring you with my favorite things, but that's basically how the OR works. And it works that way every time, and there's quite a sense of ritual and exactness about it that makes me happy. Probably because of my borderline OCD.
Here's hoping I get to get back in the OR frequently this month!
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