Protocol Snow

Over a year has passed since I last wrote about my adventures in medical school. The last time I discussed anything school-related, I was just starting 3rd year. This is when the fun begins and fresh medical students with zero clinical experience are tossed head-first out of the classroom into the hospital workplace. You might think that after two years of medical school, we would know a thing or two.

But no.

After we hurtle through the air and land in the hospital, we are immediately and ruthlessly punched in the face with the grim reality that we know nothing about taking care of patients. Truth of the matter, the first two years are dedicated to studying basic science subjects like physiology of the human body, anatomy, microbiology, biochemistry, pathology and all sorts of other “-y’s”. All important information, sure, but the challenging part of being a doctor is applying that massive amount of information in real life, with all its subtleties and complexities. Learning how to apply medical knowledge for patient care goes beyond just 3rd year and takes years, which is why we have residency training after graduating from medical school.

3rd year is about more than just getting our first clinical experiences. It’s also our only exposure to the practice of every major medical discipline (pediatrics, surgery, OB-GYN, and so forth). We spend one-two months rotating through each medical specialty and getting a taste for everything. That’s why 3rd year is so critical because guess what? We have one year to try everything out before we pick a specialty and apply to residency in 4th year. One year to choose our career.

Most students enter medical school with some idea of what kind of doctor they wish to be, but faculty always advise us to keep an open mind because nobody really knows for sure until we actually spend two months in a specialty rotation grinding out the hours. Students may be deadset on becoming pediatricians, for example, because they “love kids”. Well, spend two months working with very sick kids, a few who may die under your care, and some people change their mind because they can’t take it.

Before I started 3rd year, I was strongly considering a surgical career. Working with my hands, using cool surgical instruments, taking advantage of my manual dexterity, curing patients (surgery is the only way to eliminate many diseases) … all of that sounded very appealing in theory. But less than a week into the surgery rotation, I was already miserable.

My surgery rotation was January-February 2010. As I reflect on the experience now, a flood of memories reminds me why I disliked surgery so much. The long, long hours. Aggressive surgeons and operating room (OR) staff. The intense pressure of the OR. An ever-present sense of awkward incompetence as a lone medical student standing at the operating table, feeling that I did not belong here.

But let’s start with the operating room environment. “Scrubbing in” means going through an elaborate ritual to completely sterilize your hands and arms and suiting up in a sterile scrub ensemble with gown and gloves. This is essential for every person who will be in direct contact with the operating table. The scrub nurse is the person whose main job is organizing the surgical instruments and passing them to the surgeon when requested. But scrub nurses are also responsible for ensuring sterile conditions and will help you put on gown and gloves so that you don’t contaminate anything.

The operating room is a very strict and tightly regulated environment, for understandable reasons. Maintaining a sterile field on the operating table is the paramount rule. As a medical student, sometimes your only job is to be sterile. Keep hands in front of you, above belly button and below face at all times. Never adjust your itchy facemask and foggy eye protection with your hands. In fact, don’t touch anything unless told otherwise.

Luckily I didn’t do anything foolish in that regard, but I’ve heard about classmates who instinctively reached up to adjust their glasses and were ordered by the surgeons to change out of the scrub suit and return to the hospital floor. When your ONLY job is not to break sterility, screwing that up and being asked to walk away in the middle of a surgery is humiliating. I quickly became hyperaware of my hands’ location at all times. The threat of disgrace was heavy and relentless. If the frigid temperatures in the operating room don’t keep you awake, this foreboding peril certainly will.

You might wonder how difficult it is not to touch anything, but imagine standing still at the operating table for three hours and counting, with the end of the surgery nowhere in sight. The surgeons are huddled around the operating field doing the real work while you’ve been holding retractors for hours. You literally can’t see anything they’re doing because they are deep in the body cavity, and they haven’t said one word to you in an hour because they’re so focused on dissecting an organ and not hitting any blood vessels or nerves. Your participation in this surgery is akin to being a doorstop. You’ve been up since 5 AM. Your concentration will lapse. It happens to the best of us. Adjust your glasses or drop your hands to your waist, and if you’re lucky, your only punishment is changing gloves and being scolded by the scrub nurse, who all seem to have eagle eyes.

Believe it or not, I have never watched a medical TV show in my life but I’m sure surgeons are commonly portrayed with a stereotypical personality. Arrogant, aloof, aggressive, dominant, no-nonsense, not a hint of self-doubt. That stereotype is very real. Surgical specialties are the most demanding fields, with the most training required and the longest working hours. Typically only the best medical students become surgeons. So when a surgeon acts like he’s hot stuff, as obnoxious as that may be, his attitude is likely deserved based on his superior knowledge and achievements. Which only makes it more annoying, because he’s always right.

Fortunately, most of the surgeons I worked with, while maintaining hints of the stereotype, are at the very least minimally friendly. I have however witnessed a couple spectacular rage moments in the operating room.

The scrub nurse stepped out for 20 minutes during a slow part of the surgery to take a lunch break. A somewhat new scrub nurse introduced herself and came in as a substitute. Whether due to inexperience or nervousness (perhaps both), she confused a couple of the surgical instruments when the surgeon asked for them. When asked to fetch a device from the stockroom, she came back empty-handed. We had to put the surgery on hold for a few minutes waiting for the device while she went back with help to search. In the operating room, our faces are entirely covered so looking at the eyes is the only way to read facial expression. The surgeon didn’t say anything and seemed to be desperately trying to restrain himself, but a quick glance at his eyes was sufficient. He was seething with fury.

After what seemed like an eternity, the original scrub nurse returned to tag out the substitute. The surgeon checked that the substitute had left the room before launching into a ten minute tirade, laser focused on her incompetence. His words dripped with venom as he cursed her failures, profanity gushing freely like a rap song without the lyricism. Silence in the room save for his incensed rant. What could we say? Poor nurse, but she knew she had screwed up and at least the surgeon was merciful enough to spare her presence from his rampage.

We were not so lucky.

Impressively, he continued the surgery throughout his rant. To be so infuriated, yet have the clarity of mind to continue operating successfully… that is why surgeons are exceptional. You may question, “He’s not so great if he gets this angry over small things”, but above all else, surgeons always have their eyes on the goal. No matter their personality deficiencies and quirks, no matter the obstacles, they will always take care of business for the sake of the patient. They are the consummate professional.

Another story, different surgeon. This time the ire was focused on a senior resident, my immediate boss, who was performing the surgery under the attending surgeon’s supervision. We were about an hour into the operation and still working on cutting through a forest of adhesions in the abdomen. Surgeons have their particular way of performing operations, and apparently the attending did not like some aspect of my resident’s technique because all of a sudden he started literally screaming and berating the resident. Colorful swears were whipping around the operating room at gale-force speeds. To his credit, the resident kept his head down with eyes on the goal, only nodding and saying “yes sir”.

Surgical residency is apprenticeship by fire. Fragile egos beware.

More than any other medical specialty, hierarchy reigns supreme in surgery and your superiors will not hesitate to reprimand. In the OR, the attending surgeon is God with a capital “G”. Residents will gladly take the punishment because this is the pressure that will mold them into exceptional surgeons. This is the good pain.

For the most part, medical students are largely immune to this treatment. As disposable as medical students are in the operating room, we are also harmless. The main tasks entrusted to the medical student — holding retractors to pull back the skin/tissue and clear the operating field; suctioning blood in the field of view so that the surgeons can see what they’re doing; and suturing skin incisions shut after the operation. Unless you’re a colossal screw-up and somehow inconceivably bump a surgeon while he’s in the middle of cutting tissue, there’s no way you’ll be put in the position to do any real damage.

Surgeons do have an opportunity to test you though, and that’s with the dreaded operating room pimping. Unlike the first two years of medical school, your main education in 3rd year is on the job. In the surgery rotation, medical students spend most of the day in the OR in close quarters with the residents and attending for hours at a time. A major part of your education is their teaching, the quality of which depends on your luck. Especially when you consider that their job is to treat the patient, with your education a far lower priority.

Some surgeons prefer to work in very quiet operating rooms and will say MAYBE ten words to you in two hours. Others may drill you on anatomy questions and obscure medical trivia, then ridicule you for not knowing the answers. Most of the time the taunts are in a joking fashion, since some surgeons assume medical students know absolutely nothing as a baseline and will be happy if you can answer any of their questions (although that sounds a little demeaning when I put it that way, doesn’t it?)

But others may be incredulous that you don’t know the answer to even their most simple question, shaming you into going home that night and working extra hard on studying. At the end of each day, I’m always exhausted from being in the OR all day, and having to go home and study is a painful ordeal. But there is no better motivation for studying than knowing that the next day, you’re working with a surgeon who absolutely terrifies you.

I’ve painted a rather dreary impression of the surgery rotation. But all the negatives and humbling moments helped mature me as a physician. As I mentioned earlier, I came into medical school thinking I wanted to be a surgeon, but completely changed my mind less than a week into my surgery rotation. Still, I was determined to make the most of this experience with the 7 weeks I had left. In fact, once I knew I didn’t want to become a surgeon, that took a little pressure off since I didn’t have to try so hard to impress the attendings for a future letter of recommendation. Some days of surgery were actually… enjoyable.

Like anatomy dissection, like delivering babies, like so many other medical school adventures, the surgery rotation was an experience that I will never have again in my life. I scrubbed in on all kinds of surgeries. Gastric bypass and gastric bands for the morbidly obese. Operations to treat thyroid cancer, breast cancer, liver cancer, GI cancer… I’ve seen them all. I assisted with so many breast cancer surgeries that for months afterward, female breasts seemed strangely desexualized. I held breasts as they were sliced open, saw the mounds of glistening fat globules, and smelled that unforgettably acrid yet ever so slightly sweet aroma of cauterized human tissue as the Bovie electrocautery knife sliced and diced.

My favorite surgeries were the laparoscopic surgeries, also known as minimally invasive surgeries. Traditional surgeries involve cutting open the abdomen, for example, to make a large enough hole for surgeons to go in with their hands and operate. However, only tiny incisions are required for laparoscopic surgeries, just big enough to squeeze into the body a tiny camera, scissors, and graspers mounted on the ends of long instruments.

In these surgeries, my job as a medical student was to control and steer the camera. Very cool! The camera magnifies the view on a TV monitor, so in essence the entire surgery is performed by watching a digital screen. Hand-eye coordination and spatial visualization are crucial skills for this type of surgery. You might have heard about research showing how playing videogames improves laparoscopic surgical skills. Laparoscopic surgery may be the world’s most sophisticated, most expensive, and most risky video game.

As an aside, at the end of day 1 in my surgery rotation, one of the surgeons wanted to “measure my potential as a surgeon” for fun. He took me to a resident training simulator that uses the same OR laparoscopic equipment for testing manual dexterity and 3D spatial orientation. He was instantly surprised with my performance. “Do you play a lot of video games?” he asked curiously. If only he knew the truth…

In fact, he was sufficiently impressed that a few weeks later, after I had some experience in the OR, he let me be first assist in an abdominal hernia repair operation. The nurse took over the camera and I manipulated the grasper instruments to move tissue and hernia mesh as the surgeon did the cutting and suturing. Awesome surgery and the highlight of my surgical rotation.

I may not have enjoyed the surgery rotation as a whole, but the ordeal was absolutely worthwhile and vital to my development as a doctor. At the end of the rotation, I met with a couple surgeons for debriefing and evaluations. One told me it was a shame I did not want to be a surgeon because he felt I would be very successful. Wow, maybe surgeons can be nice. That was the nicest thing I’ve heard in those two months.

If my life were a movie, at that point a montage would have started playing. Showing me waking up at 5 AM everyday, driving to the hospital in the snow, and coming back home after sunset. Going days without seeing sunlight. Standing at the operating table for hours and sweating with the intensity of the surgery, even though I wasn’t doing anything. Trying to avoid eye contact as the surgeon began fuming yet again. Operating the laparoscopic tools with a smile on my face.

Then the montage would cut back to me, and I would shake my head wistfully. I had survived my two months, and that was enough for me. So long, and thanks for the memories.