Which Way is Up?

28 02 2012

Ob/Gyn at my medical school is organized much like any other med school:  they split up the group, and each student has a month of obstetrics and a month of gynecology (which is further split into general gyn and gyn-onc, which is the branch that deals with female reproductive cancers).

After finishing the obstetrics portion, I definitely had some expectations for the gynecology portion.  For one, sleep: I don’t have to be to the hospital now until 6:00 am (which, let me tell you, is a far cry from the 4:15 arrival required in OB.  I actually see other cars on the highway when driving to the hospital in the morning.  Crazy, I know).

I’m also in the operating room a lot more: a total of 6 half-days per week.  The ORs that the gyn folks use are in the “main house” (read: main hospital) rather than the couple of operating rooms in the maternity ward used almost exclusively for C-sections.  The biggest major difference is that the scrub techs are much… less nice than the ones in the maternity ward.  The other thing to notice right off the bat is the complex Is huge—something like 40 separate operating rooms—and it is easy to get lost.

The biggest hurdle for me at the moment isn’t scrubbing properly—after the initial awkwardness of learning with the nicer techs, I’ve mostly got the rules down.  It’s the temperature of the room, which typically hovers around a cool 66 degrees.  God knows why, because the patients freeze, and the techs freeze, and we all freeze.  The only way you can stay warm is to hope you’re allowed to scrub in, because the sterile gowns are long-sleeved and at least make things feel room-temp.  In the beginning, it seemed conceivable to just wear lots of layers, but all you can really get away with is a short-sleeved tee under the scrub shirt.  Anything with sleeves is against regulations.  So today I shivered through most of a 3-hour abdominal hysterectomy & bilateral oophorectomy (read: all female parts above the vagina removed).

Which brings us to the title of this post.  Yesterday was my first day of Gyn, and I was permitted by some good fortune to be able to assist on a robotic surgery.  It was pretty sweet, and from my understanding not an opportunity that many students get.  The robot is basically like operating laparoscopically through 4 small ports stuck into the abdomen.  After the ports are in, gas is pumped into the abdomen to make things easier to see, a camera is stuck into one port, the “robot” arms into two others, and the fourth is left open for the assistant to stick either a retractor or a suction/irrigator through manually. The whole setup is pictured below.

First of all, it’s important to clarify that the robot isn’t really a robot in the conventional science-fiction sense.  It’s just a big, fancy piece of equipment (“A toy,” one of my professors would say in his thick accent, “because those surgeons, they had a bad childhood.  Their parents never went to Toys-R-Us, so now they play with toys at work.”) that is operated from a console at the other end of the room from the patient.  There are 2 views from the camera in the patient, which you can see through these really cool , hi-def flatscreens on the wall.  I was very impressed with the image quality.

[This is what things looked like from my seat in the OR, but imagine the giant clunky robot arms obscuring a fair amount of the picture.]

So it was me, the R3, and the attending who were scrubbed in (one of my peers was hanging out and watching, too).  The attending removed one side of the uterus with the robot and the resident sat at the bedside, showed me briefly how she was using the two tools she was delegated, and then she got a chance to operate the robot.  Which meant I took over place.  Let’s keep in mind, just for a moment, that I had had a total of maybe 25 minutes on the laparoscopic trainer last week during which the most complicated thing I had done was unwrap a Tootsie Roll in one piece, and I had never used the instruments in front of me before.  Needless to say, I was sending prayers to the heavens that my resident was able to do everything perfectly.

Fat chance.  In many regards, she’s still a student, too.

“Hold the ovary up,” somebody said.  I had no idea he (the attending) was addressing me until after he’d repeated it a couple of times, primarily because the microphone for the robot was turned off and it was very difficult to hear all the way across the room.  All this meant for that moment was that both of the doctors immediately thought I was incompetent.

So I stuck the retractor into the port, had some trouble finding where the camera was without being able to see it, and finally found where I was supposed to be.  He told me where to grasp with the tiny, but long,  retractor, and so I turned my hand, opened the clamp, and missed altogether.

Fact:  it is much more difficult to maneuver a 3-D object in a 3-D field while looking at one 2-D image of that field on a screen than it seems.

Once I had finally managed to grasp the correct ligament solidly, the attending repeated, ” Hold it up.”  So I did.  Then he said, “No, hold it up.”  I tried again.  “Up, hold the ovary up,” he used my name that time.  I tried again, wondering how many places could ‘up’ be referring to?  Quite a few, as it turns out.  There’s ‘up’ with regard to the camera images (which are slightly different from each other), there’s the ‘up’ that refers to the almost-3-D image shown in the robot command center (which is different from the images that I can see on the screen), ‘up’ with regard to the floor and ceiling of the room, ‘up’ referring to my position outside the patient, ‘up’ referring to my position inside the patient (meanwhile, the patient’s bed is tilted back at a 30 degree angle, which messes up my sense of direction even more.  So I asked the only thing I could think to ask:

“Which way is up?”

I had meant for that question to come out sounding much more eloquent and competent.  Fail.

Everything worked out, and I became better as the surgery went on.  Still a little trouble with the directions, but I always got there eventually, all the while dodging this direction and that just to keep the stupid robot arms from literally clocking me in the head.  At one point, the resident hit a blood vessel that spurted onto the only camera I could see, and she started panicking, Eventually she regained control of the situation, but it was kind of nice to know that yes, these people do make mistakes, too.

And then it was time to close, and my only job was to put the sutures into the retractor clamp and drop them through the port for the robot arms to catch them.  I did as instructed, but a few inches down there was resistance.  A lot of resistance.

The needle was stuck.  Like, stuck stuck.  Everybody was looking at me again, and I told them about the resistance.  The senior scrub tech leaned over and tried herself.  No good.  Then she tried to pull the needle out via the suture thread.  After a lot of oomf, she got it, and had the junior scrub tech load a new needle, which I obediently dropped through the port.  Again, resistance. Again, the needle was stuck.   I had no idea what was going on, and it was clearly something that didn’t happen every day.  The attending was saying my name in a stern tone, asking what was going on.  The junior scrub tech replied “oh, you know, she’s just a student.  She’s new at this.”  Strike, what is this, 28?  But who’s counting?

This time, they had to take the entire port out and switch it for another just to drop the needle in.  The kicker is that the reason the needles kept jamming was because the tech-in-training hadn’t known to flatten the needle before trying to stick it through a too-small port.  And she’s learning from her superiors that blaming the med student is the path of least resistance.  Not cool.  The upside of this is that at least my resident heard this conversation and knew I wasn’t a complete fool (that time).

The scrub techs, most of them, like to bully med students.  Probably because we are the only ones they can bully, because everyone else is either higher on the totem pole or is one of their students, and nobody but the physicians bullies their own students.  But I digress.

The point of this post?

When you are in medical school, even the term “Up” is subjective, and can mean whatever your attending physician or resident wants it to mean.

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2 responses

4 03 2012
sabamc

A lot of times when people are explaining things, they expect that the other person has the same frame of mind. Properly communicating with someone about how to do a procedure (or a specific shot/ move in a sport) is a skill few have.
I don’t think they teach that in med school.

(btw thanks for the blog invite, just this week 3 blogs I used to follow shut their blog down when people found out who they were 😐 )

18 03 2012
CanDoc

Okay, #1, I’m absolutely salivating that you were able to help with a “robotic” surgery. This is the sort of thing that most practicing Gyns (like me) have the occasional wet dream about (or whatever the female Ob/Gyn equivalent is).
And #2, the OR is freezing cold because it’s so darned hot under the scrub gown that otherwise the surgeons would pass out, and apparently that’s bad for patients. I think it has to do with cognitive exertion and stress response, because when I assist I’m euthermic under the gown, but when I operate (even straightforward surgeries) I’m still boiling and dripping in sweat, no matter how cool the room is. Sorry. I find a thick camisole under the scrub t-shirt helps when I’m not operating.
And #3, sounds like you’re training in the Amazon surrounded by piranas. Hang in there, it really doesn’t stay this bad forever. Oh, and we always talk about the med students, but mostly they’re keen and smart and nice, and so there’s not much negative to say. Unless they can’t find the vagina and are accidentally doing rectal exams on the laboring patients. (True story.)

Great blog, looking forward to future posts.

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