Watching blood clot

MCN posted a comment suggesting that what I do is really interesting. Sometimes it can be, and the chance to perform a really amazing lifesaving surgery is what drew me to this admittedly long and sleep-deprived road. But most of the time what I do as an resident is, strictly speaking, boring as hell.
This rotation, in particular, makes me wish I could be at home organizing my sock drawer. I wake up at 4:00 so I can get to work by 4:30 to "pre-round", which is a glorified term for groggily accumulating the data that our patients have generated over the night: what their blood pressure's been, what their temps are. Any lab values that were drawn that morning.

By 5:15 I present all the data to my chief resident, and I spend the next half hour reciting to him all the numbers I've gathered so _he_ can write them down onto his own piece of paper. The act of passing on this information is a time honored method used to assimilate information - I think the act of speaking them out loud internalizes the data in a special way. But if it seems like we're re-creating the wheel, you're right.

After the chief gets all the data, he goes over med lists, reviews the mental picture we've created of our patients' progress (trends in their lab values, their reaction to medications we've started or stopped). Then we create a plan. Run this test. Advance their diet. One of the most exciting parts of surgical rounds is being able to announce that a patient has passed gas - this indicates that their bowels have begun to function after the brief paralysis that can occur after abodminal surgery, and they can eat.

Then I get to rehash all this data a third time after rounds, when I rewrite all the data into progress notes for the formal chart. At the end of the day on a busy service at the county hospital, I can barely hold a pencil, my fingers so palsied from frantic scribbling. At the VA, which has a computerized charting system, I'm crosseyed and headachy by one-o-clock.

If I'm lucky I'll get to go into the OR. Unfortunately on cardiothoracic surgery they're not often prone to allowing their junior residents to crack open people's chests, so I don't get to cut too much. But I do get sew, which I find fun, but which was typically considered a chore in pioneer times.

Operating is fun, if you like that kind of thing, if you like taking things apart and teasing out the individual components, if you like popping zits and digging for buried treasure.

There's also a sense of near-familiarity with each new operation. Each body is uniquely the same the other - there's enough difference to give you that jolt of excitement, that sense of newness, yet each procedure is like reading a different book by the same author.

I've also talked before about the beautiful harmony that exists between a surgeon, her resident, their scrub nurse, and their anesthesiologist. A good operation has the regularity and rhythm of a good fugue, with each line of movement anticipating the other.

Then there are the parts of surgery that you kind of put up with. Every surgery, you wait around politely for the anesthesiologist to put the patient to sleep, then to wake them up. You wait for pathology to come back with the results of a tissue sample you gave them, like a tennis player patiently waiting for a serve while his opponent bounces the ball over and over again. You wait for x-ray to set up, and for the circulating nurse to get you the right piece of equipment. And in the case of the surgery I wrote about a few days ago, sometimes you just have to wait for the bleeding to stop.

The surgical control of bleeding, otherwise known as hemostasis, can be performed with panache, or it can be achieved through brute force. The best surgeons know where to cut so they avoid the prominent blood vessels. They cauterize or tie off arteries in quick succession. But even the best surgeons can't always stop all the bleeding, especially in cardiac surgery when the whole theory of cardiopulmonary bypass relies on the administration of large doses of blood-thinners to stop blood from clotting in the heart-lung machine. Even the best surgeons can reach a point like the one that was reached last tuesday where you've tied up all the arterial bleeders, turned the flesh into a charred mass, and the patient still bleeds like stink.

We've got all kinds of tricks to slow the deluge: special hundred dollar sheets of collagen that bind platelets; purified clotting products that you can squirt into the area of interest. But sometimes all the tricks up your sleeve fail, and you punt the ball to the anesthesiologist, who administers blood, platelets, plasma, and any number of concoctions to reverse the blood thinners already on board.

Then you cross your hands and wait.

Every resident has heard some variation of the reassuring maxim: "All bleeding stops," whether because of clotting or death. The funny thing is, it does. I don't know how many times I've flitted into the OR to gauge how a case is progressing, only to see my attending surgeon and my resident sitting in a chair with their arms akimbo, just waiting for the bleeding to stop before closing. They don't call cardiothoracic surgery a glamorous profession for nothing, you know.