In normal circumstances, I might have watched a movie on a Friday night. Two days ago, however, I spent my Friday night watching cardiac surgery! It was incredible.

(Disclaimer: This paragraph gets technical. Please skip to the next paragraph if you don’t find it interesting!) The procedure on the board for the cardiac OR was a triple-bypass, technically known as coronary artery bypass grafting (CABG). The CABG (pronounced “cabbage”) procedure is used as a treatment for coronary artery disease (CAD). CAD is a decline in the ability of the coronary arteries to deliver oxygenated blood to the heart. During the CABG procedure, vessel grafts are attached to provide an alternate route for blood to flow from the aorta to the heart muscle. The grafts themselves are harvested from the arm (the radial artery), the leg (the saphenous vein), and from within the thorax itself (the mammary artery).

The cardiac surgeon herself was a walking contradiction. After scrubbing into the OR, she began jovially chatting with the nursing staff and walked over to introduce herself to me, the observer. She graciously talked me through the procedure I was about to see (a generous move, as not all surgeons will waste time on a mere observer). My initial impression was of a wizened woman with a great sense of dignity and compassion.

Not long later, however, and that same surgeon split a man’s chest open with a Black-&-Decker saw, and then used the full force of her body weight to rip open the rib-cage! Her personality also changed with scrubbing. In contrast to the pre-surgery woman, the during-surgery woman was frighteningly efficient, scrupulously precise, and inflexibly demanding of her team to do their jobs no short of perfectly. She displayed the stereotypical “surgeon’s personality”, which the speciality of cardiac surgery is especially noted for. I do wonder whether her self-assuredness and intense drive for excellence were both necessary to succeed as a woman in what, in her training days, was a male-dominated field.

It’s cliche, but true: There’s nothing else quite like seeing a living heart, beating within a man’s chest. Additionally, if you look to the sides of the heart, you can see the lungs inflating and deflating with each breath. You can see the diaphragm ballooning up and down, and you can even pick out the nerves to the diaphragm descending on either side of the heart’s chamber (the pericardial sac). Anatomy is wondrously beautiful, especially in a living body.

Bypass surgery is also remarkable, in that during the procedure the heart must be stopped. Blood is redirected through tubes to a bypass machine next to the OR table where it is oxygenated and sent back to the body via the aorta. The heart is completely cut from the circuit. This permits the surgeon to administer a drug that stops the heart so that she can do her work. Once the grafts are installed, normal blood flow is restored and the heartbeat returns. During Friday’s procedure taking the patient off the bypass machine proved tricky, and at one point electric paddles were needed to rescue the heart from fibrillation (random, non-productive contractions). Thankfully, the surgery ended well, and he’ll likely be alright. In fact, once healed he’ll have a heart in his chest with rejuvenated blood supply!

I’m racing to keep up, both on my feet and mentally. The Charge Nurse gives the doctor a quick run-down of the patient being brought in by the paramedics. While we wait for the ambulance to arrive, the ER Resident comes over, gives a quick but thorough description of her patient, and asks the doctor for guidance. One of the Nurses interrupts, and asks for clarification on an order. There are three patient areas to monitor. The waiting room is filling, and the Triage Nurse has been separating those out with Flu-like symptoms for segregation to a private H1N1-designated area. The doctor I’m observing with turns to me and, to my amazement, apologizes because of how slow an evening it has been! I suppose ER Docs like it chaotic.

Observerships are an incredible opportunity for us students. Meeting a real patient is incomparably more impacting (and more memorable) than anything we can learn in the classroom. They are the best chance for us to practice our skills at taking histories, examining patients, and using problem-solving clinical reasoning. Depending on your preceptor, they may also be your first chance to learn a new skill! Such was the case this past Wednesday, when the ER Resident was generous enough to teach me how to suture – first time on a real patient! The experience was exhilerating. Particularly as, the laceration was to the patient’s face, and so an aesthetic result was paramount.

Observerships also give a window into the lives of various specialities. My superficial observations of the ER team, are that they are generally fun-loving, easy-going, and active people. They’re also super friendly! After our shift, the entire doc team went for beers together (and invited me!); I understand they do this regularly! Seems like a fun group of people.

After observing for a day with the General Surgery service, I’m struck by what a trusted privilege the surgeon is given to enter within the body of a patient. Cutting through the protective layer of skin that separates the ‘us’ from the ‘outside’, the surgeon enters the most intimate recesses of a person – the cavities and tissues of their body. Such intrusion; such vulnerability. Yet every day, patients entrust surgeons with this privilege, literally bearing their inner biological lives on the table.

What an intimate privilege to enter within a body, and I’m so immensely grateful to have briefly had the opportunity today. Shadowing a general surgeon, I was allowed to witness a superficial parotidectomy (removal of the superficial lobe of the parotid gland), a lumpectomy (breast-lump removal), and  a lumpectomy with axillary dissection (removal of lymph nodes from the armpit). Those last two cases were for women with confirmed breast cancer. My role was, of course, exclusively to watch the procedures, but they did ask me to retract here and there, or cut stitches. I think they wanted me to feel included!

Surgical dissection can be exquisitely precise, and particularly for the parotidectomy it was important for the surgeons to identify numerous nerves and arteries as they slowly worked around the resection. Damage to any of these nerves could have resulted in paralysis of the patient’s facial muscles – a horribly debilitating and life-changing complication. Once a nerve was located, the surgeon would electrically stimulate it to observe for an effect. For example, if he stimulated a nerve to the orbicularis occuli muscle, the patient’s eye would squint.

Practising medicine is surely a privilege – to have the invested trust of patients for their lives and well-being. But the intimate privilege granted to physically enter within the body is greater yet.

Geriatrics is medicine for the elderly. As a specialization, it’s actually quite complex since elderly patients are more likely to have multiple concurrent diseases, and require individualized treatment plans. 

Last week I had the opportunity to spend the afternoon in a Geriatric Day Clinic. Patients are referred from hospitals after having an acute event (like a heart attack, or a stroke), or by their Family Doctors when it is noticed that the patient is having difficulty coping at home. The goal of the day clinic is rehabilitation, and the care-providers working there strive to give patients whatever help they may need to remain functional and active. Many elderly people only need a few well-chosen interventions to keep them living independently and out of long-term care facilities.

Geriatric care is necessarily multi-disciplinary. The clinic is composed of a really neat spectrum of professionals:

• Physiotherapists: can prescribe exercises to recover  muscle strength and range of motion
• Occupational therapists: can teach patients how to maintain their activities of daily living with possible physical or cognitive impairment e.g. how to take a shower without needing to stand up for too long
• Recreational therapists: spend time with the patients and find ways to stimulate their interests
• RNs: educate patients about their conditions, advocate for patient concerns, and provide much of the primary care required
• Social workers: can refer elderly people to services that are available in the community to help them, such as meals on wheels, grocery deliveries, etc.
• Pharmacists: review medications and optimize wherever possible. This is especially important for the elderly who can be on as many as 20 or more medications!
• MDs: Assess physical and cognitive status. Make treatment recommendations.

A patient of the Geriatric Day Clinic may visit with a few, or even all of these professionals! Once every two weeks these team members all come together to have a shared discussion of what each patient particularly needs, and to set goals for care.

I participated in some incredible observserhips (observership = shadowing a doctor) last week, which I’ve yet to blog about! Here’s the first of a few reports.

On Tuesday I was permitted to spend the day in an Orthopaedic Clinic. The types of patients seen here include post-operative follow-ups (e.g. knee or hip replacement), people wanting to know whether they would benefit from an orthopaedic surgery, and referrals from Family Doctors for orthopaedic problems which they are unsure about.

The doctor running the clinic was great about encouraging my participation. He frequently let me assess the patients (sometimes alone!), and we spent a great deal of time reviewing x-rays for positive findings.

An orthopaedic clinic has a neat set-up. They have their own x-ray unit at the end of the hall, and physiotherapists and occupational therapists working on-site.  There was also a fracture clinic on the same floor, but I didn’t observe any of the operations there.

There are some great things about orthopaedic practice:

• For most patients, you can have a tremendously positive influence on their health! I found the clinic to be a generally happy place, as most follow-ups were delighted with the results of their surgeries. It was remarkable to hear an older man describe how two days after his hip replacement he was experiencing less pain than ever before, and shortly thereafter had regained his mobility and could resume activities he had stopped before the surgery because of his arthritis.
• You get to read x-rays! In most specialities, official x-ray reports are made by radiologists. In orthopaedics, the surgeons are equally (if not more) qualified to read x-rays and are generally better at picking up musculoskeletal abnormalities on the image. If you like x-ray reading, this is a great plus!
• Almost all orthopaedic surgery is elective. Choosing whether to have your ankle bones fused, or your knee replaced, must necessarily be a balance between the benefits and risks of the surgery. It’s ultimately up to the patient to decide whether the pain and disability they are experiencing is sufficient to warrant the risks of surgery. In many cases, people will decide that it isn’t. There are often many lifestyle alternatives to surgery: reducing body weight can significantly reduce arthritic pain. 
• To quote our fearless Orthopaedics instructor: “It’s not rocket science!” In this speciality, first principles and a good physical exam go a long way to discovering the diagnosis.
• Lots of patients, and always increasing. As people live longer and our Canadian population is aging, the prevalence of osteoarthritis and other orthopaedic diseases is increasing. The amount of OR time dedicated to orthopaedics has only been increasing.

Here’s some not-so great things about orthopaedic practice (in my limited opinion):

• Short patient visits. As a specialist, you don’t truly get to know your patients and are often concerned with little more than their specific orthopaedic complaint. There is little time afforded to the person behind the arthritic knee. 
• Long, hard, gruelling residency. But then, that’s true of most surgical specialities.

I spent the afternoon today in a clinic downtown observing a Family Doctor! What a meaningful way to remind oneself about what’s waiting at the end of all this studying, and also why it’s so important to learn everything that we’re being taught! During my observership I:

• Listened to a premie baby’s heart rate: SO fast!!! It becomes nearly impossible to distinguish the individual heart sounds.
• Looked into a little girl’s ear – she was so brave and sat very still! Unfortunately she has had multiple ear infections recently, and so maybe she is getting used to strange big people poking scopes into her ears.
• Saw a bite that may have been from a tick, although it didn’t look characteristic of tick bites
• Learned the technique for giving a flu shot. This time I was just watching, but the doctor warned me that next time he wants me to try it … scary.
• Observed a few well-baby check-ups to monitor growth and development. One was with a VERY hyper two-year-old. He was literally climbing the walls !
• Listened as the doctor explained to a patient that he would need to start taking medication for his blood pressure… and learned something from the very difficult discussion that follows a diagnosis of hypertension about exercising and eating right

Family Medicine is a neat speciality because you really get to know your patients, and, well, their families ! Seems obvious eh? But increasingly I’m realizing how rare an opportunity that is in medicine. There’s also a lot of variety in Family Meds, both in the types of patients that you care for, and the types of complaints that they may have. But perhaps what I find most attractive about Family Meds, is that you get to have those longer conversations with your patients where you answer random questions that they have about their health, and work through issues that really matter to them. There is a true partnership at play.

Anyway, what an illuminating day! I rounded it off by going to an art show put on my classmates, then some quick swing dancing, before I now must buckle down to some work.

Have I told you about the observership program? It’s one of the greatest strengths of Queen’s medicine, and it basically involves contacting a doctor in the community and requesting to shadow him/her at work. The idea is for junior medical students to gain experiences that will inspire their learning, guide their thoughts about speciality choices, and give them ideas for what to do with their clinical clerkships in senior years. Hopefully I’ll be doing a number of these observerships, and I’ll do my best to keep track of them here! Not only would I love to tell you about them, but I’d like a storage spot for my thoughts. Then when it comes time to make difficult speciality decisions, I’ll be able to review my first impressions.

Yesterday and today I had the incredible opportunity of doing an observership in General Surgery. I’m still a little flabbergasted that they let me do it! The surgeon who took me on was amazing – he was so willing to teach and he put up with all of my questions, which must have sounded pretty stupid to him.

On Friday night I was in for a laparoscopic appendectomy. In case you’ve never heard of laparoscopic surgery, it consists of making a very small incision in the abdomen and inserting a laparoscope to view the inside of the peritoneal cavity. The surgery is then performed using the scope’s feed on a TV-screen for guidance, and by passing tools through other equally-small incisions. I’ll be posting more about laparoscopy soon! 

This morning I was in for a colostomy, which is a procedure to connect the large bowel to the abdominal wall. Essentially an opening (a stoma) is created from the gut to the outside of the body so that faeces pass out into a collection bag instead of through the rest of the colon. This procedure was done “open”, as compared to laparoscopically, so I was able to compare the two! This afternoon I was in for a cholecystectomy, which is removal of the gallbladder.

All three surgeries were amazing!! The two today were especially interesting because I was allowed to scrub in to the sterile field, and even to lend a hand once or twice to retract or cut a stitch. The OR was somewhat surreal, and there were a lot of surprises. Once again, I’ll play a horrible trick and save those surprises for an upcoming post because I want to use this one to concentrate on reviewing the observership.

General surgery has a lot going for it. It involves a lot of different procedures in a lot of different areas of the body. In short, there’s a lot of variety – also, in the patients that you treat. A general surgeon’s patients can range from young and otherwise healthy people who need an appendix out, to those who are critically ill. Often general surgeons head-up trauma cases because multiple organ systems are affected. Additionally, general surgery is versatile. Even smaller towns need surgeons so it’s a very portable speciality.

As a speciality, it’s also not very likely to become irrelevant any time soon. That may seem to be given, but it’s not unheard of for newly discovered technologies to suddenly put medical specialities out of business. The best example may turn out to be the marked decrease in jobs for cardiothoracic surgery after advancements in interventional cardiology. 

Personally, I felt that one of the best aspects of general surgery (actually this applies to all surgical specialities) seemed to be the emphasis on teamwork. The OR team that I observed were so well-tuned with each-other, and they were having a great time together. 

Of course, getting into general surgery means going through a particularly difficult residency. The residents that I spoke to today were intentional to point out that the general surgery residents always work the most of everyone in the OR. Plus, being on call can make for a difficult lifestyle. The surgeon who I was observing commented that “if you want a 9-to-5, this is far from it”.  That’s particularly true if you practice in a small town where you might be the only surgeon around.

More details about the OR visit forthcoming, and hopefully more reports from observerships!