By By Vietrez P. David-Abella, MD
posted 23-May-2015  ·  
1,002 views  ·   0 comments  ·  
The dictum in surgery is, "See one, assist one, do one."

For elective or planned operations, we first year residents started our climb in the surgical hierarchy as the second or third assistant. Our main job was to arrive the earliest in the operating room, bearing imaging results, such as x-ray or CT scan plates. The anesthesiologist would already be there, so we could watch and even assist him or her inject pre-anesthetic drugs, do the spinal or epidural tap, or intubate the patient. The nurses would also be there, opening the instrument packs, preparing the back and instrument table, and making sure that the right materials were available, including sutures and drains.

After the patient had been correctly positioned, we prepared the operative site: shaving, cleansing, and covering in sterile drapes. We would do our hand scrub, don our gown and sterile gloves, then wait for the surgeon to scrub up and take his or her position on the operative table.

Since most surgeons are right-handed, most of them would stand on the patient's right. I had one or two lefty surgeons, who I closely watched, being left-handed myself, but I had to learn to work with my right hand, to which scrub nurses usually hand instruments.

During the operation proper, the second and third assists helped in exposing the operative field, or holding the retractors. We mastered this to the point that first and second year residents are also called RODs: Retractors on Duty. We could keep retractors in place while snatching a wink of sleep, learned good body mechanics to conserve energy for surgeries that take up 4 to 6 hours, while fending off questions from consultants about the case and the patient.

That meant being well-versed about the patient, which entailed not just reading the history and physical examination findings in the chart, but taking the history and doing the physical exam ourselves. <This was training that started in med school: to never rely on others for this information, and to ALWAYS get this first hand from patients.> Occasionally we'd be able to pick up symptoms and signs that our busy senior residents may have not elicited and thus "score" with a consultant.

We were also expected to read about the cases that we'd be scrubbing into. Our consultants emphasized that each patient was clinical material, and since no 2 patients are alike, each case was an opportunity to learn something new. So we had to brush up on anatomy, physiology and even histology and pathology. We were also expected to read up on the operative technique from surgical atlases. And of course, to learn from the actual operation.

From seeing one procedure done by several consultants, I realized that there is no one correct way to do an operation.  Each has his or her own style, which I had to learn and adapt to as an assistant, from the way the drapes are placed, to the incision, use of electrocautery, and the sequencing of the steps. Through the years, I developed my own style, picking up the techniques that emphasized directness of action and economy of movement.

The dictum in surgery is "see one, assist one, do one." A few months into the training, we would be initiated as surgeons by doing our very very first appendectomy. Why the appendectomy? Perhaps because this is one of the most common operations performed by general surgeons, the relative ease of access into the operative site, and comparatively less chances of morbidity.

Before being bestowed the operation, we learned to diagnose it first. Despite the advent of new imaging techniques, such as ultrasound and CT scan, appendicitis is one of the few diseases that could be diagnosed with 90% accuracy using history and PE alone. To do this, the abdomen pain must be characterized as to Quality (is it burning, gnawing, stabbing?), Radiation (is it steady or does it move to the back, to the right or left, or downwards?), Stimulus (does it worsen with movement or walking), and Timing (did it start at night, after eating, etc.?) which we had memorized as PQRST back in med school.

Other symptoms must be elicited: fever, anorexia, nausea, vomiting, constipation or loose stools. Other illnesses, like diabetes or kidney disease, must be discovered. And for women, conditions related to the menstrual cycle, such as pre-menstrual or ovulation pains, as well as ectopic pregnancy, urinary tract infection, etc., etc., must be ruled out.

Then the diagnostic tests: complete blood count and urinalysis are usually all that's needed. And of course a trained surgical examining hand, that could differentiate between slight, moderate, or severe, or deep, direct, indirect, rebound, or contralateral tenderness; as well as abdominal wall guarding.

My very first appendectomy is burned into the hard-drive of my mind. Of course I had evaluated the patient myself, convinced that it was indeed a case of appendicitis. I explained the procedure to the patient and relatives, to get a proper consent, ordered the preparations, including anti-biotics and NPO (non per orem, or nothing by mouth). At the scheduled time, I had the patient brought down to the operating room, did my own preparation, while my senior resident and the scrub nurse waited. I was lucky to be assisted by an experienced nurse, who was not only efficient, but cool under pressure.

Cutting time! This is one of the defining moments in my life. I was handed the knife, and without hesitation made the skin incision. Point of no return. This was it! My mind accessed the step-by-step, as I had read it in the surgical atlas and seen it done. In times of extreme stress, the mind seems to work in automaton: I could see my hands going through the motions, my mouth enunciating orders: "Knife." "Clamps." "Sponge." "Retractors." In the meantime the consciousness was processing the stream of information: Thick subcutaneous fat, must wash well to prevent site infection; too many bleeders, must check again before closing; some pus, needs to be cleaned out; appendix swollen but not ruptured...

After taking out the appendix, washing the site, and closing the incision, I would have to take charge of the post-operative period: preventing complications like pneumonia by early patient mobilization; checking on the wound every day for signs of infection; and generally encouraging the patient. After all, the patient is ultimately responsible for his or her recovery.

(To be continued)

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