Shadowing a Surgeon - Part 1

This is almost an exact replica of the OR I shadowed In

NOTE: I am writing this to record my recollection of this event, so it will most likely be a long read.  I completely understand if you don't make it through.  I feel that it is necessary to write down this astounding experience before it begins to fade from my memory.

On Friday I showed up to the hospital bright and early to shadow a Neuro-Spinal specialist.  I honestly did not know what to expect, and I was a little bewildered by how relaxed they were.  When I arrived, I called the department office and they let me in.  A few seconds later I was standing there alone and unattended.  Knowing I only had about half an hour before I had to meet the doctor, I tracked down a nurse who got me set up with a locker for my belongings and some scrubs to change into.  Normally when I go into a new work place, I am used to being micromanaged, followed everywhere and lectured endlessly so as to ensure that if anything goes wrong, they can be assured that I can take the blame.  It was refreshing to be given an implicit level of professional trust from the outset.

Once I was all suited up I wandered around confused, but I found the OR the doctor was scheduled to work and decided I would wait for him there.  Fortunately there was a window for me to look in, and I took note of how everyone was dressed.  I am glad I did this, because it would have been embarrassing to immediately get kicked out of the OR upon walking in.  After looking around, I found a mask, rubber gloves, some shoe covers, and a cloth surgical cap that I promptly donned before walking into the room.

It didn't take them long to ask who I was and what I was doing there.  Of course I went through the litany, "I am a pre-med student, and I will be shadowing Dr. XXXX today."  Apparently that was good enough, and they quickly went back to their various tasks of prepping the OR for the upcoming surgery.  Soon the patient was wheeled in, a kindly looking elderly woman.

The nurses were very kind and attentive to her, letting her know exactly what was happening and instructing her as necessary.  For me it is always the small details that really stick out and make an impression.  I specifically remember one instance where, as the nurse was telling the patient to breath through the mask she set her hand on the patient's arm and lightly patted her in a comforting manner.  That told me that this nurse was someone who really cared about what she was doing, she was someone who wanted the best outcome for the patient, and she was still able to display compassion when it was necessary.  That is someone I could  work with every single day, if I could.  To me medicine represents a perfect outlet for my compassion, and to see someone else display this trait so openly made me realize that I am not wrong in making this drastic career change.  Maybe many people will think that this is too idealistic and naive of a viewpoint, but I will have to simply disagree.


After the patient was anesthetized the nurse proceeded to double up the patient's legs, which would immediately straighten out when she let go.  After a few attempts she quickly looked over at me and said, "Come over here and help me.  You hold her legs, while I put this Foley in."  Not knowing what a "Foley" was, I innocently walked over and held the patient's ankles, pushing her legs into a butterfly position.  The nurse quickly raised the patient's gown as I now realized what she was going to do.  I had a front row seat to see my first catheter insertion, which means I was spared nothing when it came to "presentation" of the patient's body.  My first instinct was to look away in embarrassment, but I quickly quenched this sentiment, because I wanted to know how it was done.  I calmly forced myself to look on, despite my discomfort, and saw the Nurse quickly and efficiently insert the Foley.  It was on the next step of this process, that I was in for a little surprise.  Grabbing a syringe filled with saline solution she inserted it into a side valve on the catheter and began to inject.  Unfortunately she did make the connection completely and I was greeted with a face full of spray.  I thought I would be horrified, but strangely I found the whole event amusing.  I have to admit I was extremely happy  I was wearing the mask.

With my participation complete, I resumed my vigil in the corner of the OR, trying to stay out of the way as much as possible.  The whole prep took about half an hour before the surgeon made his grand entrance (yes I deliberately made that sound overly dramatic).  He greeted his staff in a friendly manner and I was pleased to see that there was a playful banter that existed within the team.  I could see that they worked well with each other, and that they enjoyed working together as a team.

After working in corporations for the last 8 years, I am used to seeing discord, backbiting, false sincerity, and above all avoidance of any sort of responsibility.  Here I was confronted with a group of people who were about to take someone's life into their hands.  Each one had a very specific role to fulfill to ensure the success of today's surgery.  If anything went wrong, there would be no way to obfuscate the mistake with a self excusing email that would pass the blame to some other unsuspecting coworker.  They would have to face it, resolve it immediately, and deal with the consequences that would result from it.  It was heartening to realize that incompetence could not survive in this environment.

The surgeon soon greeted me and gave me an introduction to the procedure they would perform.  There was a 50 inch flat screen monitor on the wall with MRIs of the patient's spine.  He showed me where the vertebral foramen on the L3 and L4 vertebrae had closed in,  so it was compressing the spinal cord and causing loss of feeling in the lower extremities.  Since the spinal cord passes through the vertebral foramen, he was going to enlarge the foramen again, so that the spinal cord would not be constricted anymore. 

To my recollection, the surgery took about two to three hours total, not including the prep time.  Several things stand out vividly in my mind.  First, the technology that was put to use was incredible.  Within the room there were three hanging flat screen screens, that were on moveable arms so that they could be adjusted to give view to whoever needed to see.  These were in addition to the 50 inch wall screen I already mentioned.  There were two large OR lights, that were in the center of these screens that extended out on retractable looking arms.  Within those bright lights was a camera that would give a feed into those screens.  So by merely standing in the back, I was still given a front row view into exactly what the surgeon was doing.

As a preface to describing the actual procedure, I want to describe how I felt at this point.  I have never seen a surgery so I had no idea what to expect.  More importantly, I had no idea how I would react to this experience.  I have heard of people becoming nauseous, passing out, and all manner of other horrible reactions.  As the surgery began I have to admit I was extremely amped up on adrenaline.  It was all very unreasonable, because it was all self-induced based on my uncertainty about my own reaction.  It was like a self-induced recursive reaction (if that makes nay sense at all :P ).  To combat any possible adverse effects I made sure to bounce from leg to leg, and to keep my legs slightly bent.

The vast majority of the surgery seemed to be "digging" through the various tissues to actually reach the site that they wanted to fix.  The surgeon used a cauterization tool (a laser scalpel?) to burn through the layers of dermis, and underlying adipose and muscle tissue.  The smell of burnt flesh was initially uncomfortable until I forgot about it in my fascination with what was going on.

Diamond Coated Burr Bit

Once the bone of the spine had been reached a new phase of the surgery began.  The surgeon started using a diamond coated bur bit to drill start removing bone.  Up until this point my conception of surgery, was that it was very fine and meticulous, but the usage of this tool was savage and intrusive.  The rotation of drill, suction, drill, suction, became rhythmic for ten to fifteen minutes as he quickly worked his way through the lamina of the spine.  Once he approached the meninges, the membrane protecting the spinal cord, he switched tools from the mechanical device, to a manually operated tool that I am guessing was a Rongeur.  Basically it was a surgical wrench for grasping and tearing away bone.  He did this so that he would not drill through the membrane, which would have been a huge mistake, and quite the headache to fix.  Using this tool, he methodically pulled out bone, piece by piece and exposed more and more of the spinal meninges.  Once done with L3, he drilled over to L4 and repeated the process.

All of this I watched on the monitors, and he periodically spoke up to instruct me on what he was doing.  He pointed out specific parts of the anatomy, and thankfully indicated where the head and feet were.  It sounds obvious, but if he hadn't done that, I wouldn't have realized that the head and foot were interpolated on the screen (e.g. -- it was opposite on the viewing screen from how the patient was laying on the table.)  My only complaint about this procedure was that I was behind the surgery, and he had music going while operating which made hearing what he said very difficult.  I feel like I lost some key points of instruction, but seeing as I was just an extra observer the fact that I was able to intrude on their environment and still receive patient instruction is more than enough for me.  I am very grateful they allowed me to participate.

The surgery finished up with a quick and careful closing up of the spine.  At various points I noticed the nurses would take counts of the linens used for cleaning the blood, and the needles used for suturing the wound.   It was a very organized and practical step, that seems like common sense, but obviously has been ignored in the past seeing as some of those items have been left in patients before.

Having completed the surgery the surgeon helped re-situate the patient on a gurney to take her to recovery, while the anesthesiologist started to bring her out of sedation.  As she regained consciousness I noticed the surgeon had already left the room, and I had about half an hour until the next surgery.  I took advantage of the time to run to the lounge and grab a snack, because it didn't look like lunch would be coming any time soon.  From 7:30am until about 12:00 o clock I was in the operating room watching the pre-op and the surgery.  I didn't know how long the next surgery would be, but I didn't want to miss a moment.

In closing to this chapter of my shadowing experience I want to recount my final interaction with the surgeon.  As he closed up the patient he turned back and asked, "What did you think?"  Already experiencing a complete sensory overload my only answer was "That was awesome!"  I could see his cheeks raise up in a smile behind his mask and he began to teach, this time I could hear everything.

"My rule is that the surgery should be fun.  The more interesting and fun the case is, the more I want to do it.  If I get a referral I evaluate by two criteria.  Number one -- Is it fun?  Number two -- Is it imperative?  If it is yes to both, I'll take the case.  If I say no to both questions, I'll refer it to one of my partners...and if it is yes to one or the other I have to decide whether or not to take it."

Obviously the bit about passing it off to a partner was a joke, but I understood the lesson he wanted to convey.  He was promoting a love of your job, enjoying what you do, and taking pride in it.  I don't think he understood just how deeply that resonated with me.  I will always be grateful that he took the time to pass that one on to me.  I was never serious about surgery, because I thought you don't get to spend time with patients....my time with this Surgeon taught me just how wrong I really was.

Next time I will talk about the second part of my day, and reveal to you just how wrong I was regarding patient interaction.  Stay tuned!