22. Miley
I am in the OR waiting for Rhonda to arrive and as the doors open, I can already hear her chatting away with the transporter.
“I came in because my diabetes was out of control and now here I am getting surgery. Can you believe it?” she asks him.
Before he even gets a chance to answer, she continues, “They found a…” She drops her voice to a stage whisper, “cancer,” and then goes back to her normal volume which is high at baseline, “in my pancreas! Can you imagine!”
Again, she is not looking for an answer. “But these two beautiful young women doctors came into my room to tell me about my surgery. Are you single? Do you know them? Dr. Zo and Dr. Chen, although I think Dr. Chen has something going on with my nurse. I saw them…”
Her voice trails off as she sees me and flashes me a sheepish smile, knowing she just got caught talking about me.
“What exactly do you think you saw, Rhonda?” I ask with a smile so she knows I’m joking.
“Oh, you know, you guys were making googly eyes with each other. I know young romance when I see it. I was young once. I’m still young, damn it!”
“Damn right, Rhonda,” I say, agreeing with her. “But Rohit and I…"
Before I can finish my sentence, I see Dr. Kumar walk in. I wonder if he heard what I was about to say. I don’t want him to think I am unprofessional since he is my attending. He’s also Rohit’s father, so that adds a layer of complexity to the situation that I don’t want to think about right now. I stop mid sentence, trying to end this topic of conversation.
Rhonda has other ideas. “What were you about to say about you and Rohit?”
I freeze. What are we? Do his parents know about our fake relationship? Do they think it’s a real relationship? My eyes flit to Dr. Kumar in the corner of the room and then back to Rhonda. I have no idea what I’m supposed to say, so I go with the truth, minus the confusing bits.
I lean closer to her as I whisper, “Uhh, our best friends are engaged! So I know him, uhh, socially and through work, obviously. I just saw him in the ICU when I came to see you.” Now I feel like a blubbering idiot.
Rhonda has the social grace to ignore my awkwardness and just gives me an exaggerated wink. Subtle she is not.
I sigh and hope for the best, noticing Dr. Kumar is probably still out of earshot. Maybe.
Even though my social life is chaotic, the OR should never be, so I turn my attention back to my job. Rhonda has two peripheral IVs already placed, one in each arm. ICU patients always have the best access. Both of them are clearly labeled with the date they were inserted. Rohit knows what he is doing.
That just leaves me to place an A-line, and set up a flotrack so we can monitor her volume status and help us gauge if she’s putting as much fluid out as we are pumping in. Once I finish that, I help her sit up for the epidural.
When Rhonda and I had discussed this earlier, she was surprised, as most patients are when I first explain this part of the anesthesia process. Everyone always thinks that epidurals are only for pregnant women in labor.
“Rhonda, I’m going to have you sit up now. I’m going to place the epidural.”
“Yes, I remember we talked about it. I’m probably one of the only mothers you’ve met that never had time for an epidural. Both of my babies came so quickly,” she explains.
I hope I can keep her talking through the procedure. “This epidural is slightly different. Pregnant patients get a lumbar epidural, but this is a thoracic epidural. It is higher up and the purpose is for pain control. Have you eaten anything today?” I ask, knowing full well she has not. She has been NPO since after midnight. I open up the epidural kit and I clean the area on her back where I will be placing the epidural. I only ask as a conversation starter and she doesn’t disappoint.
“Dr. Chen, you know I haven’t eaten. I am starving, and even if I was allowed to eat, the food in the ICU is not appetizing. Just because all the other patients are asleep is no reason to serve food like that.” Rhonda shakes her head.
“Rhonda!” I chide as I throw away the Betadine cleaning solution. “Your meals have nothing to do with the fact that you’re in the ICU and everything to do with the fact that you’re on a diabetic diet. Rest your chin on your chest, please.” I put on a pair of sterile gloves and then lay a sterile drape across her back with an opening exactly where I need to go.
“Pshh, diabetic diet, my foot.”
“Yes, exactly, diabetic foot is a terrible complication of diabetes,” I say without missing a beat, making her laugh as I have her lean forward a bit more so I can get a better angle. “Drop your shoulders and curve your back a little more.”
She does as I say.
“Great, you’re going to feel a little pinch and a burn,” I say as I inject a little wheal of 1% lidocaine into the superficial layer of the skin.
“This will numb your skin,” I explain, as I quickly change the needle to a larger one and continue to give topical anesthetic into deeper tissue. I make sure to pull back as I go along, to assure that I’m not in a blood vessel. “This is numbing the deeper tissue before we get to your spinal canal,” I continue.
Then I grab the Tuohy needle and insert it into her spine, and confirm placement by the loss-of-resistance technique.
Dr. Kumar nods his approval. He’s been watching everything I do carefully, ready to step in if need be. Luckily, it went smoothly, and I feel relieved. Even though he hasn’t needed to intervene during the procedure, he has to take every opportunity for some teaching. Whether it’s relevant to doing the procedure or not. He smiles almost mischievously as he asks, “Who invented the Tuohy needle?”
“This seems like a trick question, so I’m going to say not Tuohy?” I joke.
He laughs. “That’s correct. It was actually a dentist named Ralph Huber, but Tuohy popularized it, so he gets his name on it.”
I now advance the catheter into the spinal space. “Rhonda, can you please take a deep breath for me? Thank you.” The catheter slides in easily. I remove the Tuohy needle and advance the catheter at the same time.
Hannah walks in with her attending, Dr. Rosato. She is a formidable hepatobiliary surgeon that will eat you alive. I usually cower on my side of the curtain when she is operating. She likes to do a lot of teaching in the OR and has incredibly high standards for her residents.
Thank god for everyone involved today that Hannah is a genius. I hate witnessing a reaming on the other side of the curtain. Dr. Rosato’s criticism sometimes crosses the barrier and comes to my side, so I have to make sure I am on my A game as well. Not to mention, I feel like I have to impress Dr. Kumar, too. The stakes seem impossibly high today.
I finish up the rest of my procedure and have Rhonda lie back down. A nurse comes to place a Foley so I can monitor her urine output during surgery.
After a quick chat with the patient, marking the site of surgery, and pulling up her images, the surgeons leave the room again to scrub in.
“Rhonda, we are going to be putting you to sleep now,” I say as I flush her IV.
She reaches up and grabs my hand. “I am terrified of the anesthesia.”
I give her a warm smile and say, “I get that a lot. It’s often scarier than the surgery itself. But I can assure you it’s very safe, and we’ll see you when you’re done.” I then lean down and whisper into her ear, “And cancer free.” That elicits a wide smile for her and she nods her assent.
“My grandbaby is coming…” she says as I give her a cocktail of anesthetics into her IV, and she falls quickly asleep. I place the face mask over her mouth and nose which is also delivering anesthetic. I move to the head of the table, tilt her chin up, and see an easy way into her airway. I pass the scope easily and intubate her, allowing a ventilator to breathe for her while she is deeply asleep so that she doesn’t feel any pain during surgery.
Surgery begins, and Dr. Rosato is pimping already.
“Hannah, we usually talk about a six-step clockwise approach to a pancreaticoduodenectomy. Can you please tell me the six steps?”
Hannah is smart, but Dr. Rosato’s question seems more appropriate for a hepatobiliary surgery fellow than for a surgical chief like Hannah. Luckily, Hannah knows Dr. Rosato’s expectations and she always rises to a challenge. She probably studied her ass off last night to prepare for this case, and can anticipate any and all of Dr. Rosato’s questions.
Hannah starts, “One, exposure of the intrapancreatic SMV, two, extended Kocher maneuver, three, portal dissection, four, transect stomach, five, transect jejunum and dissect ligament of Treitz, rotating duodenum under mesenteric vessels, and six, transect pancreas and complete retroperitoneal dissection by removing specimen from SMV and SMA.”
“Excellent,” Dr. Rosato replies, and I breathe a sigh of relief even though I’m not the one in the hot seat. “Have you had the chance during your residency to cut the GDA or common bile duct yet?”
“No, this is a first for me, Dr. Rosato,” Hannah replies.
“This is a momentous occasion in every surgeon’s career. We’re taught never to cut the GDA or common bile duct, and here I am telling you to cut them, so please go ahead.” When the attending allows you to do something you’ve never done before, you know you’re on their good list and that they trust you.
Dr. Rosato continues, “This will be the easiest gallbladder you ever do, because it’s actually healthy. Surgeons usually are not in the business of removing healthy organs, but this is for the greater good.”
Hannah’s eyes crinkle, betraying the smile behind her mask. “I just hope she does well,” she says wistfully.
“Now that you’ve brought that up, what is the five-year survival after a Whipple?” asks Dr. Rosato.
“Just twenty-five percent,” Hannah replies with a sigh.
“That’s right.” Dr. Rosato moves the laparoscopes to give Hannah a better view of the gallbladder.
I watch the monitor closely and see her blood pressure is starting to drop, 110/70, 100/65, 90/50. I don’t like this trajectory. I immediately administer a bolus of IV fluids, to help bring the blood pressure up. I also prepare vasopressors, in case the blood pressure continues to go down.
I quickly glance at Dr. Kumar, who nods that he notices the trend as well. He then nods his head towards the surgeons, urging me to alert them to the issue. I take a deep breath, because I usually like to fly under the radar, especially when Dr. Rosato is operating. Intentionally drawing the attention of the surgery team to me is the opposite of my goals in the OR.
“Dr. Rosato, the patient’s blood pressure is dropping. Steadily,” I say.
Dr. Rosato does not look up from the field, but acknowledges that she heard me.
“The field looks pristine. There’s no bleeding. Did you over-sedate the patient?”
“I have not changed the rate of sedation and she was doing well before, Dr. Rosato. I’ve just given her fluid to help with the pressure, but I am concerned she may be bleeding.” I force confidence into my tone and keep the fact that I’m about to shit my pants to myself because I talked back to her.
Hannah looks at me for a split second, then down to the field again. “RP bleed?” she asks in a hushed tone.
“Unlikely, but I have learned to trust my anesthesia colleagues over the years; they are not the enemy, as we learn in medical school,” Dr. Rosato says with a chuckle.
I am surprised at Dr. Rosato’s willingness to take my opinion into account. But maybe I shouldn’t be. Maybe that’s why female surgeons have statistically better outcomes.
“Let’s investigate,” Dr. Rosato acquiesces.
Hannah seems somewhat surprised. “You mean open up the abdomen?”
“That’s the only way to do it,” Dr. Rosato replies.
The concern is that Rhonda is bleeding in the space behind the abdominal organs, but that area isn’t easily visualized. The blood pressure dropping clued me into the possibility of bleeding, and luckily I noticed and alerted the surgeons before it was too late.
“Here we go again,” I think out loud.
I’m glad I placed the thoracic epidural. It’s not always needed for a laparoscopic Whipple, but I always like to be prepared. You never know when a laparoscopic procedure will need to be converted to an open procedure.
I call the blood bank to be on standby since we don’t know how long it will take for them to find the source of the bleeding.
Hannah and Dr. Rosato have made the incisions needed to open Rhonda’s abdomen to better look for the bleeding. Unfortunately, the minute they retract to get a better look, Rhonda’s monitors start beeping like crazy.
“BP 80/45, heart rate rising. What do you want to do, Miley?” Dr. Kumar’s voice cuts through the noise.
“We need to aggressively resuscitate.” A quick glance at the opening door shows a blood bank runner entering the OR. “The blood is here. We should hang it wide open,” I say.
Dr. Rosato barks from the other side of the curtain, “She’s losing a lot of blood. Anesthesia, get that blood hung, now.”
Though I’m eager to correct the blood loss, there are safety checks that should never be skipped. I check the patient’s chart and verify her blood type, then locate the matching information on the blood the runner brought in.
“Dr. Kumar! The names don’t match. The blood type is all wrong. We can’t hang this!” I shout.
“What the hell?” Dr. Kumar asks. “Good catch, Miley. Hang pressors, I’m calling the blood bank.”
I quickly hang the vasopressors that I’ve prepared and monitor Rhonda’s vitals. Meanwhile, Hannah and Dr. Rosato have located the source of bleeding and stopped it.
After what feels like eons, a runner comes with the proper blood for Rhonda. I hang it and let out the breath I had been holding for what feels like hours.
“Excellent work, Dr. Chen. An anesthesiologist must always remain calm. While a patient on the verge of coding for blood loss is terrifying, skipping protocol can lead to an even worse outcome. You kept cool and followed procedure and helped save her life. A hemolytic reaction would be the worst complication to add to the situation.” Dr. Kumar’s eyes reveal that he’s likely smiling underneath his surgical mask.
I should feel a swell of pride, but right now, all I feel is relief. The procedure finishes uneventfully and Rhonda is taken to the recovery room. I sign out the case to the night team because I’m already past due to end my shift and honestly, I have no adrenaline left in my body.
I can barely place one foot in front of the other, but somehow I make it to the hospital lobby. My eyes are unseeing as I try to forge my way to the exit, to my apartment, to my bed.
“Miley!” I hear a familiar voice cut through my brain fog. I look and Rohit is loitering around the lobby.
“Rohit? What are you doing here? Your shift must have been over ages ago.” I am genuinely confused. Am I hallucinating?
Rohit is watching me, then averts his eyes, looking bashful. “I called PACU when I noticed how long Rhonda’s case was running, and they explained to me about some of the complications. I also heard about how you were a badass, not once, but twice. Not only did you catch the bleeding but also noticed that the wrong blood was sent up. The case took forever. You must be exhausted.”
“Yeah, it was intense,” I say wearily. “Luckily, it all went well in the end and she should be discharged in a few days. The surgeons think they got everything, so that’s great.” I stifle a yawn.
“I got you something to eat from the cafeteria before it closed,” Rohit says, holding out a brown paper bag.
I must be sleepwalking… dreaming… because why would he do something so nice?
“What?” I stare at the bag in his outstretched hand, but make no move to take it from him.
“You haven’t eaten, I assume. You probably have nothing in your fridge and are about to pass out in your scrubs on your bed in approximately ten minutes by the looks of you.” His eyes flicker over me, then land back on my heavily blinking stare. I am exhausted. “But you should eat first, so, I hope you like chicken salad sandwiches and diet coke…” Rohit’s voice trails off.
“Diet coke is absolutely the way to my heart. And thank god you didn’t buy egg salad,” I say, grabbing the bag from his still outstretched hand gratefully.
Rohit chuckles. “Only psychopaths like egg salad.”