Just Say Yes

As I mentioned before, surgery is a tremendous learning experience. I’d contend, though, that the amount of clinical and “book” knowledge is met or even exceeded by the so-called “shadow curriculum” – the socialization into the life of medicine that goes far beyond the words in a textbook. It’s why you can’t simply read everything and know what you need to be a doctor.

One little pearl I learned is that the answer to the question, “Do you know how to do ____?” is, with few exceptions, yes. Of course, if someone asks me if I know how to perform a crazy surgery, I’ll say no, but for basic procedures the answer is always always always yes.

Here’s why:

Scenario One:

“Hey, Nate, do you know how to take out a chest tube?”
“No.”
“Oh. Okay. Um, then why don’t you watch me do this one.”
<Med student does nothing>

Scenario Two:
“Hey, Nate, do you know how to take out a chest tube?”
“Yes…”
“Great!”
“…But been awhile since I’ve done one, though, so could we talk through the steps first?”
<Med student learns, then pulls chest tube>

See the difference? Lesson learned here is “say yes.”

Now before I told you the story where I learned this, I need to make a disclaimer: in the operating room, the attending surgeon is a very small step down from God. He is always in charge. He is ultimately responsible for the success of the operation and the safety of the patient and would never let a resident or a student do something he considered unsafe.

Butt-covering over.

I was walking with my resident to the first case of the day, a lipoma excision on a guy’s thigh. A lipoma is essentially a ball of fat that grows under your skin. No one is really sure why it happens – it’s sort of like a mole, but under your skin and they can grow fairly large – but they can hurt just from friction. Taking them out is a safe and fast operation we do all the time. I had read up on the patient, but I’d never seen an excision before.

The attending showed up. I’d worked with him a couple of times before and liked the guy. During a lull in the conversation, the attending asked, “Do you know how to perform a lipoma excision?”

No. I have no idea how to perform a lipoma excision. I am still not even sure what a lipoma is. Buuuuut it can’t be that hard, so… “Yep.”

“Great,” he said, “walk me through it.”

I thought I was just getting pimped as usual. So, I did what I always do when pimped on a subject I don’t know: I made a guess.

“You make a small incision with the knife, dissect through subcu until you get to the lipoma. Use blunt dissection to free the capsule if there is one, cauterize any blood vessels in the area, take out the lipoma, close in layers.”

“Close enough. What blade size do you use for the skin?”

“Uh… 15?” 15 is the only blade I’ve ever seen used, so…

“Right. Okay. You ready to do this?” the attending said.

I was confused. “Do what?”

“The excision. You’re going to do it.”

Heart rate to 140. “Yes, of course. Sounds good, sir.”

A few minutes later, we were standing over the patient’s leg, prepped and draped, and the attending just said, “Okay, go for it.”

I still couldn’t believe this was happening. Now, I need to temper this enthusiasm by saying the skill needed for a lipoma excision approximates the skill needed to core the pit out of an avocado. BUT STILL. STAND BACK I AM ABOUT TO TRY SURGERY.

6736Inside my head was the little “PEANUT BUTTER JELLY TIME” dancing banana. Outwardly, I said with the dispassionate tone of someone requesting new silverware at a restaurant, “Fifteen blade, please.”

With some coaching from the attending and resident, I made the incision. “Okay, now the Bovie,” said the attending. (“Bovie” is the name of the electrocautery tool, used for going through fat and for sealing off blood vessels. I have no idea who Bovie is or why it is called that.)

I love using the Bovie, because it combines two of my favorite things: fire and buttons. The machine also makes a annoyingly satisfying BOOOOOOOOP sound as it burns to let you know it’s working.

I merrily sliced my way down through thigh fat to the lipoma and took it out. CHECK IT OUT GUYS I CUT OUT THIS FAT BALL! WOO!

Like I’ve seen others do, I called out, “SPECIMEN. Lipoma, right thigh.”

I have no idea why you do this, but the scrub tech took the lump of fat from me and put it in a jar, so I guess that was the right thing to do.

I sort of figured that I’d be done at the point, considering I’ve never had to stitch up layers beneath the skin before.

“Alright, Nate, go ahead and close.”

I had very little idea for what I was doing, so I pulled the same trick I had done earlier. “What sutures do you like to use for this?”

The attending gave me a strange look, perhaps divining that his medical student knew about the same about closing fascia as he did about medieval Russian art. “3-0 Vicryl.”

The scrub tech put the needle driver into my hand. Here goes.

With some pointers from the resident, I got to close the fascia – a connective tissue layer that separates the muscle and fat – and then the skin. The whole procedure took twenty minutes.

Walking out of the OR after that procedure was completely different from my ignominious exit from the OR after Wedge Day. I had just… well, in reality I had made someone’s day to day slightly less irritating from no longer having a ball of annoying fat on their leg.

May or may not have done a full-blown Tiger Woods pump in the hallway.

I didn’t save someone’s life or cure them of cancer. I hadn’t brought a baby into the world, like on the obstetrics service, or assumed total control of their body like on anesthesia. The patient will probably never even know that his entire operation, start to finish, was performed by a med student.

But damn. That was cool.

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6 thoughts on “Just Say Yes

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