Friday, September 19, 2008

More Cool Subspecialty Surgeries

I've scrubbed in for a lot of cool surgeries in different subspecialties this week. Tuesday it was ortho, as I've already mentioned. Wednesday I scrubbed for a mastectomy. This was a lot more interesting than I expected it to be. The surgeon I scrubbed with does what is called a nipple-sparing mastectomy. Besides him, there is only one other surgeon in the entire country who does this particular procedure.

In a nipple-sparing mastectomy, the surgery team takes out all of the fat and glands from the breast, but they leave behind the skin and nipple. They also remove what are called the sentinel lymph nodes (lymph nodes closest to the breast) from the patient's armpit. This is done instead of taking out all of the lymph nodes in that area. The benefit of taking out fewer lymph nodes is that it decreases the chance that the patient will get really bad edema (swelling) in that arm. Edema can occur because with the armpit lymph nodes gone, fluid tends to back up in the arm with nowhere else to go. It's cool how they find the lymph nodes, too: they inject a blue dye (methylene blue) into the breast, and the dye gets carried out into the lymph nodes under the patient's arm. This dyes the lymph nodes that are closest to the breast a dark blue so that the surgeon can see them. The nodes are pretty small, about the size of a pencil eraser.

The woman can choose either to have implants placed in the breast during the surgery, or use temporary implants so that she can see what she'll look like before having permanent implants put in, or not have any implants at all. Some women choose not to have implants because of all the problems (leakage, immune reactions, more difficulty screening what is left of the breast tissue for cancer, etc.) that can happen with implants.

The main question that occurred to me while I was watching all of this was how they can keep the nipple and skin of the breast from dying. They are removing all of the tissues underneath, so how does the nipple get enough blood supply? Well, amazingly, it does.

Yesterday, I scrubbed for a nose septoplasty with an ENT (ear, nose and throat) attending and his resident. The surgery was cool to see, but I didn't get to do anything since it's all laparoscopic. It's also really tight to be in there around the patient's head with a few other people! ENT is cool, but as you can probably imagine, it's also pretty gross. The attending was surprised that I thought ENT was grosser than colorectal surgery, but I did. Somehow, sinuses full of snot and pus kind of get to me.

This morning, we had our normal surgery and medicine case presentations. I have to present again for surgery next week since there are only two of us in my group on surgery right now, so that kind of sucks. I'm getting a little tired of preparing these presentations. It's a lot of work, especially when you're on a time-intensive rotation like surgery. Afterward, we had a seminar on coughing and shortness of breath. That was pretty good. There were a bunch of cases, and an internist and surgeon went through them with us.

In the afternoon, we had an FCM session about apologizing to patients for medical mistakes. We had to do an exercise where one person pretended to be the doctor who had to explain about a mistake, and the other person pretended to be the patient. I was "lucky" enough to be selected to play the doctor, and I was doing my best to try to explain the mistake (the patient was given an antibiotic she was allergic to) the way I would have really done it. My partner kept laughing every time I looked her in the eye and started talking. After a few false starts like that, she started apologizing to me for not being a good actor, so by then, everyone was laughing. To add insult to injury, one of the faculty came in to tell us that we had standardized patients we could use instead of having a student pretend to be the patient. At that point, we were all hysterical. My classmate told me later that the reason she kept laughing is because I looked so serious. :-P

Next week is my last week on surgery. I just found out that my oral exam will be on Tuesday afternoon, so this is not going to be a weekend of fun and games. Tuesday night is also my last call. Yeah, I really know how to have a good time.

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