Bleeds Like Stink

The quintessential surgical experience of my young clerkship occurred the other day between two different ORs. In one, the burn victim from last week’s call night was returning for a second or third procedure, this time to harvest skin for grafts. In the other, a two surgeons from two services were working to resect a tumor from the vena cava of an elderly retired neurosurgeon.

In the first room, the mood varied from morbid curiosity to abject horror as the techs and RNs gathered the story from those of us familiar with the case. This is sort of surprising, because you sort of expect all the OR participants, from the surgeon on down, to know these things. But because I was the only person aware of the patient’s circumstances, I was momentarily the center of attention. This rarely happens in the OR. In any case, the chief resident arrived shortly thereafter, and then the attending burst through the door. Order was restored. I took my place in the hierarchy and became a silent helper. The attending used a hand-held machine resembling a palm sander to remove the viable epidermis on the patient’s back. It then went into a little cup on a sterile table for future use. The skin bleeds quite profusely, so there was much dabbing and then bandaging. We worked only for a short while, though, before this first part of the procedure ended. The attending rushed off, and the resident and I scrubbed out quickly. A quick note–burn victims are unable to regulate their body temperature as well as healthy people, so the OR was heated to about 85 degrees. We were soaked.

Since things were sort of at a standstill, I exited the theater and entered the adjacent OR. That case was well underway, and two students were already observing. The mood here was one of excitement and nervousness: the biliary/liver surgeon is quite renowned for his technical expertise and flamboyant arrogance, and he was to do the big vena cava incision and repair to retrieve and resect the tumor. The urologist was present in his capacity as the kidney expert, where from the tumor originated. They took turns at the table, first gaining control and exposing the vena cava, and then working backward toward the renal vein and kidney. In a friendly bout of pimping, the urologist taught me that the adrenal, lumbar, and testicular veins drain into the left renal vein (and then into the inferior vena cava). He scolded me for not knowing the anatomy precisely, but since I was hitchhiking on this case, I just didn’t care. It would be different if I had actually prepared for the case. The two other medical students were being pretty smart, though, so I hid behind them as we stood on stools behind the docs scrubbed into the case. I couldn’t really see anything, so I moved around the table and weasled my way behind the patient’s head, where the anesthesiologists do their thing. They were cool with me standing there, and I had a great view of the case. The tumor was clearly visible in the vena cava, where it fluttered in the low pressure flow of blood returning to the heart, looking very much like a moth in a dome light. When the surgeons were through dissecting all the necessary planes, the clamped all the surrounding veins and the right renal artery. They noted the time, and the biliary surgeon sliced a 4 cm opening in the cava. It was much less bloody than they anticipated, but two senior residents were suctioning like crazy. Nine minutes later, the surgeon was done removing the tumor (which reminded me of a large chunk of boiled cauliflower) and sewing then oversewing the cava, and all the clamps were undone. It was viable. The senior anesthesiologist commented that this was much cooler than watching professional athletes. I’m guessing we were all breathless.

I snuck out and returned to the other case next door. The attending had resumed his work, and he was holding the burn victim’s leg up in the air while he and the chief resident removed eschar for the eventual skin graft. It was silent with the exception of occasional muttered directions.

I fled.