Estoy mirando el cambio de una cultura.

I was doing a case with one of my attendings the other day. She asked for her next stitch. A specific stitch, 4-0 Vicryl, which unfortunately the scrub tech did not have open and on the field.  But she did have a 3-0 Vicryl, which was offered to my Attending. The entire room was then strongly reprimanded for not having the correct stitch open and ready. The scrub tech and circulator offered up their defense and counter argument. But in the end, heels were dug in, and everything stopped until the correct stitch was collected, opened and handed over.

I watched the all too familiar scene in silence.  Why did it have to be like this? The 3-0 Vicryl would have sufficed for our present need just fine, why couldn’t we have just accepted the 3-0 Vicryl and moved on? There are a few reasons I have pondered, not in any particular order...
1) A surgeon’s OCD personality. Like a check-list, the steps of a procedure are completed routine, sure and safe. Deviation or flexibility allows for unsure steps, mistakes, complications and then death.
2) Responsibility. A patient has put their life in the surgeon’s hands. Taking that trust to heart, the surgeon owes the patient their absolute best in every cut and in every stitch. There is no minor surgery. There is no minor stitch.
Taking it a step further, a wrong stitch placed in a surgeon’s hand in a time of emergency is enough to waste 4-5 seconds of that patient’s life. Take a transplant surgeon, handed the wrong stitch during the venous anastomosis, watches his patient hemorrhage for those 5 seconds while the mistake is corrected. By the second or third time it happens, it has now been 10-15 seconds of their patient hemorrhaging, well past their 20th, 30th, on their 40th unit of pRBCs. They throw the instrument, and in so doing emptying their hand 3seconds sooner and receiving the correct stitch that much sooner in the race to save their patient’s life.
Perhaps is can be argued that by allowing argument in a case of nonemergency like our example, would then make it acceptable in a case of emergency when time and life are in the balance.
3) Hanging onto a time past. The era of the Physician. Their word was golden and followed without argument. That was an era past. We can trace how medicine has evolved from that time, through an era of the Patient into what today could be called an era of the Payor. Greatest evolution noticeable outside of the operating room, but it has now greatly altered the environment within as well. Did you notice how the tech and circulator not only defended themselves by argued back? I personally do not know a time when the nurses did not argue back, but my attendings do. Was this simply the right to be heard and followed?

I did not ask my Attending why we couldn't use the 3-0 Vicryl. I know if it had been me in that situation I would have. But then I think of the possible reasons (as mentioned above) for holding out for the correct stitch, the one that I actually asked for and I feel chastised. Is it just my inexperience and lack of understanding that makes me want to use the 3-0 Vicryl instead of the one I asked for. And then I come to myself again and remember, God may send me to a jungle some day, a desert, a mountain village...wherever I am needed. Where a plethora of sutures and needles (as we are blessed with here) will not be available.

If it’s routine, flexibility will be my routine. If it’s responsibility, I owe it to my patient to use what is at my disposal to make it work. If it’s about time, times change. And I pray God grants me the grace to Love through it all and despite it all.

Much Love.

Estoy rogando para los niños

Does it make me a bad doctor to not want to see a patient? Sounds awful when I put it simply like that. In my head I have a million point five excuses of why it would be better for all parties involved if I did not stop by and say hi.

Halfway through the month I transitioned from transplant surgery to pediatric surgery. We discharged one of my harder cases today. A little guy, big for his age, but still just a toddler, who came to us quite sick. He ended up exhibiting the worst case of white-coat syndrome, I’ve ever seen. And, we don’t even wear white coats on peds!!! I kept asking him to come play with me, and he would just scream and scream. My intern joked that he was going to record his little “no! no! no’s!” And make it the alarm on his pager! Broke my heart that he didn’t want to play with me, but honestly, his story is still happy at the end of the day.

A few names have floated on my list periodically during my time on the service the past couple of weeks. Oncology patients. When the Oncologists talk with us about their patients, the conversation goes something like this... “Well,  it could be this... but it might not be... but with a biopsy, we could have more information... but they’re too sick... maybe not... so no then... but it could be that... maybe when we know... but we don’t know... and now the patient is more sick... we could have a window... perhaps you could... or you shouldn’t... here’s another idea...” ...and so on it goes with Pediatric Oncology. I get a very unsettled feeling when trying to work with them. As exhibited above, not only can you hardly ever get an actual answer from them, but just any conversation in general leaves you feeling completely useless. What can you do for these kids? I can’t even offer an encouraging word knowing that they would just see right through it. Time. Sometimes just as hard for the doctor to prescribe as it is for a patient to take as a treatment. And once it is prescribed, there’s not much altering from the course, except for the occasional patient that turns 180 degrees. Hence why they float on and off the list. They get a bit better one day, and surgery quick gets called, maybe there’s a window to get a procedure or two, or three done quick, before the window closes again.

Much Love.

Estoy celebrando mis amigos.

I was able to attend the wedding of my co-worker and friend this past weekend. It was a small gathering in Brooklyn, loud, close, and half-spoken in Russian. The groom, Balazs, is from Hungary, and therefore most of his family was unable to attend. Which gives Alex and Balazs excuse to then have another wedding/reception in Hungary for his family at a later date ;).

Monica and I were unofficial wedding party so we met at a park prior to the wedding for photos. We arrived 75 minutes late (thank you NYC traffic) and we were the first ones there.

 Selfies to the rescue! 

 And then when selfies are done, let the inner-child out for a play! We are at a park afterall!

The Verrazano-Narrows Bridge also proved to be quite photogenic.

 Yay! The beautiful bride!

 Enjoyed the view en route to the ceremony/reception. The Verrazano-Narrows Bridge.

 The residents table at the Orange Grill. All of those clocks had a different time, you know... because Love is Timeless! ;)

Congratulations Alex and Balazs!

Much Love.

Estoy sanando.

I've been sporting some new jewelry lately.

The colorful cartoons were an added embellishment for the photo ;) I keep to the flesh colored ones on the regular. You can guess what happened. Part of the hazard of the job I guess. Thankfully it was a new blade, nice and clean and super sharp! I was actually over in anatomy lab when it happened. We cracked open the first aid kit and wrapped up my hand so I could finish my superficial parotidectomy and radical neck dissection. Hours later, after the lab was finished, I finally took down the bulky dressing and as expected, was still hemorrhaging. I'm pretty sure I had taken out my digital arteries. Not the worse thing, nerves were still intact, arteries at least can build up collaterals and revascularize. This is where having friends who are surgeons comes in handy. I got my own supplies together, set up down in the trauma bay and called one of my friends to come and stitch me up. Didn't care how it looked, just wanted it to stop bleeding finally.

My fingers have been healing up nicely. I put multiple layers of tegaderm around my fingers prior to scrubbing in for surgery. It's unfortunate that it happened on my dominant hand as it gets used so much. At the beginning, by the end of the day, my hand would be incredibly sore and throbbing. But like I said, they are healing up well and the soreness is getting better each day.
 

 My friends are good surgeons. You can hardly tell anymore!

Much Love.

Estoy corriendo.

The sour unsettling of my stomach resolved and moved on to plague another unsuspecting individual elsewhere. I didn’t miss it and busied myself the remainder of March enjoying a month of pure operating. I would head to the OR bright and early, in time for the MidHudson OR to get up and running. I would then stay and only leave once all the cases were done and rooms shut down for the day. For the most part that ment a full day. But on the rare occasion, cases ended early and I would find myself with a Spring afternoon and no further case pending. I took advantage.

 The Rail Trail

 Looking South down the Hudson from the Walkway Over the Hudson



 Looking South down the Hudson from the Walkway Over the Hudson

Due to our 24hr call schedule  that was implemented this year I have been able to use the majority of my post call days to run in the afternoons. Done more out of need for sanity than for bodily wellbeing. My own personal self-therapy session. With music in my ears, and eyes focused on the path in front of me, I pass the time mulling over interactions and issues, decisions made or failed and attempting to solve the world’s problems in my head, all the while, willing my coronaries to fill and blood to flow and heart to strengthen. Doing what I can to withstand the grind and survive the system.

I’m back at Westchester now. Back to reality. I need to go for a run!

Much Love.