Ex with Benefits

A man in his early 20s arrives at the emergency room for a chief complaint of abdominal pain. As the surgical clerk posted at the triage station, you ask further details and palpate the abdomen. Noting diffuse abdominal pain with non-localized tenderness, among other unremarkable findings, the resident-on-duty advises to wait and see for either resolution or progression of the symptoms. Eager to assist your senior for emergent surgeries, you promptly monitor the patient, sending samples and following up the requested laboratory results. While waiting, you sit idly and review a bit of the must-know topics for your end-of-rotation examination. The absence of other interesting cases in your dreaded night shift, puts a welcoming lull on your 20th hour of wakefulness. You are intermittently jolted to consciousness by requests for vital signs monitoring. Life gets a bit dragging, save for the quips and jokes of your co-clerks, interns and residents.

On his serial abdominal examination, the surgeon-on-duty notes localization of tenderness to the right lower quadrant of the patient’s abdomen. Along with other characteristic findings, the diagnosis is now confirmed to be acute uncomplicated appendicitis. Once the routine red tape are done, and operating needs acquired, you accompany the patient to the operating room where you gleefully scrub in, intermittently pausing the monotony of your duty.

The first year surgery resident confidently prepares the patient thru circular motions of the chlorhexidine-soaked gauze, spiraling out of the patient’s torso. The senior resident agitatedly points out some areas missed, that might become room for preventable post-operative complication or infection. The newly minted trainee remedies his shortcoming and to avoid further exasperation from his senior, he swiftly places an indwelling urethral catheter for output monitoring. Forgetting to prepare his syringe, he asks for help from the circulating nurse, whom he had earlier tense work-related conflicts. As the observer in the room, you note this lack of chemistry as a lesson to not only be knowledgeable in the science of medicine but in the art of communication and interpersonal relations as well.

With the patient draped, and the team donning the sterile blue surgical gowns with tight-fitted gloves, the surgical procedure commences. Firmly pressing down on the skin, the surgeon incises the skin a third of the way from the belly button and the bony prominence of the hip. Further exploring down the subsequent fascial and muscular layers, the surgeon notes difficulty in palpating inside and taking out the cecum and appendix. He then proceeds, with permission from his already irritated senior, to expand the incision site. Now successful in his attempt, he is questioned by his senior on the theoretical information on the appendiceal artery. With wrong answers for basic anatomic questions, the senior has come past the tipping point and a prepared to give a harsh beating to the ill-prepared trainee. As the senior glances back at the appendix, he sees something unusual. A firm, bulbar yellow mass, 1.2 centimeters long, is noted at the tip of this popular vestigial organ. Everyone in the room gets fired up as this may be a carcinoid tumor and not a run-of-the-mill appendicitis instead. Intrigued, the senior calls up his consultant with this new development of the case. The primary surgeon’s pupils dilate in excitement for his possible first right hemicolectomy. His adrenaline rush comes to a stop when the advise was to do a simple appendectomy instead. After excision and wash, they close the patient via a fast layered suturing, with the patient transferred out of the room in the next fifteen minutes.

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As you scrub out and make your way to the ward call room for an hour of rest before your next post, you make some realizations:
1. Some things are not as straightforward as you think. The patient still ended up with an appendectomy but if it were not, the event could have been more memorable, a more extensive learning opportunity and a graver concern for the patient.
2. The swiftness and efficiency of an operation lies on the dexterity and anatomic knowledge of the surgeon. Outside the written references laying out the step-wise approach is the estimation of adequate surgical exposure for justifying cost, time management, and minimization of risk
3. In an industry with extensive face-to-face interactions, operating room dynamics is as essential as having complete OR needs, sufficient lighting and comfortable room temperature.
4. A high-quality post for a student is defined by variety and favorable chances for learning. If not, at least the people around are fun to work or chat with.
5. Being a doctor is an upstream battle. But there are other battles being waged that we must all immerse in to better understand, assess and mend the daily injustices we blindly accept.

* This review is not a substantial source for medical nor surgical consultation. Do not use this as a reference for self-diagnosis or second opinion.