General Surgery: PEGs

Today was a pre-call day (and JB had 2-3 surgeries scheduled), so after rounding on patients I went to the OR to see if the surgeries had begun yet. As it turned out, JB couldn't do his first surgery (VATS, video-assisted thoracostomy) until the vascular surgeon, Dr. A, put in a pacemaker on another patient first. So I hung out in the call room and then followed RB on rounds for a while before the two of us went to the OR and found the patient being prepped for surgery. Then RB left to take care of floor patients while JB and I scrubbed in.

The patient, SP, was an African man who had a leak in his left lung secondary to bleb formation(s) that landed him at JPS with pneumothorax. Our goal: enter the chest laparoscopically, find that bleb, and help SP breathe better. SP had smoked for years and a good portion of his lung was actually stuck to the ceiling of the chest; those adhesions were removed with relative ease. It was interesting watching the lung inflate and deflate with each breath after the adhesions were removed and the lung was no longer stuck. JB then filled the chest cavity with saline to find the bleb ("Look for bubbles with exhalation") Sure enough, we saw what could easily pass as a bubbling geyser on the medial side of the lung, but the bleb was nowhere in sight. It didn't help that the saline was mixing with blood, making visibility even worse. Dr. A came in and couldn't find the bleb either, and with an exasperated sigh he said that they might have to operate by opening the rib cage instead of just working with the laparoscope. Then JB was called away to fill out consents and paperwork on the cancer patient we saw yesterday (whose surgery was after this one), and Dr. A immediately flushed the chest with saline to see if he could find the elusive bleb. My job was to hold the camera, and suddenly, there it was. The bleb looked like a long "proboscis-like" piece of flesh (Dr. A's words, not mine) with a round tear in the tissue, and Dr. A handed me a laparoscopic stapler and told me to cut it out. "Come on, let's get this done before [JB] gets back," he said. "He'll be sorry he missed this one." Under Dr. A's instructions, I snipped the bleb in half, just in time as JB reentered the ER. "Sorry, we're all done! Your med student saw the bleb and took action, I couldn't stop her," said Dr. A. JB didn't bat an eye, just replied, "That's good, I've been trying to get her to talk for a week." At any rate, JB finished up by capturing the bleb with laparoscopic forceps and pulling it out. Fortunately that was the only bleb, and SP emerged from surgery with no complications.

Immediately after we finished the surgery, we went next door where the other patient was waiting. She needed a MediPort put into her chest (for chemo treatments) as well as a PEG feeding tube (radiation treatment to larynx muscles makes swallowing difficult, so she'll need a PEG tube throughout her treatment). PEG is short for The doctor sticks an endoscope down the throat to the stomach, then wires a thread into the stomach through a stomach incision. The endoscope attaches to the wire and pulls it through the esophagus up to the mouth, where the PEG tube is sewn on and then transferred via wire back to the stomach. It's a fairly interesting surgery, and it was cool watching the peristalsis in the small bowel. We also found a small polyp in the woman's stomach (possible mets?) and biopsied it; we also saw an ugly white patch on her throat that had to be her cancer. The port insertion was uncomplicated also, except when the central line went up the internal jugular instead of to the IVC (confirmed by on-site X-ray).

By this time it was very well past noon and I was getting fairly hungry, but JB immediately went to ICU where he was scheduled to do another PEG and tracheostomy on an ICU patient. Somewhere around 2:00 I couldn't take it anymore and told JB I was going to the bathroom. That was partly true; I also ran back to the call room and gulped down a NutriGrain bar so that I wouldn't feel so hungry. I followed JB from around 9:30 to 4:00, and I never saw him eat anything. Don't surgeons ever get hungry? I understand the need to get through as many patients as possible, but surely people need to take time to eat also? Of course, certain people will say that all I think about is food, but I'm used to eating at regular intervals. That has never happened in surgery; I have to carry food with me and eat at opportune times.

The ICU procedure was a waste of my time b/c JB was training one of the FP residents to do a PEG. He kept getting paged by the OR for another procedure, and at one point I asked what to do. Dr. K (who was watching the procedure) looked a bit exasperated and told me to go outside and return the page to see what was going on. *sigh* Some things never change; even back in obgyn Dr. K thought I was too timid for my own good. Since I was reduced to watching, I got bored and nearly fell asleep on my feet. After that we returned to the OR and I watched as JB taught the FP resident how to put in an IVC filter, but after that...another PEG and tracheostomy. At 4:00, after he finished the IVC, I asked if I could take off early. (Nothing else for me to do, after all). Fortunately JB let me go.

I've had three regular patients in Tele East. One was a man with a spinal contusion; another was a man who, along with his wife, got hurt when an 18-wheeler hit their car. His wife was in ICU until today, and now she's been moved into his room. He's happy that now he can just look across the room and see her now. My third patient was a 28-year-old woman who had a Roux-en-Y gastric bypass after she was diagnosed with gastric cancer (big shock right here, since she's so young). She'd been making a lot of progress (eating solid foods, graduating from a feeding tube to no tube at all), but today she fell ill with severe LUQ pain. And now radiology says that more than half of her abdominal lymph nodes test positive for cancer. =( It's just so sad.

Another call day awaits me tomorrow =( Fortunately (sort of) I have lecture in the morning, which will be a break from the OR. My feet are killing me after standing for so long, I hate to think what tomorrow will be like. And of course, I need to load up on snacks.