On a related question for the surgeons, how do you feel about long operations (8hr+)? Do you lose interest in doing big whacks the older you get? Does your caseload change with experience? In the ENT dept where I'm at, a lot of the radical necks and flaps are done by the young guns in their 30's. The senior attendings tend to do quick in-n-out procedures. Is this pretty typical?
It depends on what body cavity I'm working on, what my role as a resident is, and how annoying the attending is going to be for the next 8+ hours.
Complex redo, redos in Vascular Surgery? I like them, but they get frustrating after the 8th hour and I get bad, almost debilitating headaches.
The longest vascular case I was scrubbed on was an 83 year old patient who had had an EVAR about 2 years ago, lost to followup, previous history of multiple laparotomies, who at some point in the last two years prior to presentation developed a Type 1 endoleak that ruptured. It was a Saturday morning that I got called (the fellows were away at a course in California) by a hospital about 40 miles away who had received him through their ED hypotensive the night before. They had "resuscitated" him and were arranging for a transfer because they had no vascular surgeon on staff and no general surgeon willing to deal with the leaking aneurysm.
So around 1PM the patient arrived and we prepped him for the OR. The CTs showed he still had some space to slap an extension cuff over the endoleak without covering the renals. So the attending said, "We'll fix this endovascularly." Somehow I knew my weekend was shot. The angio showed a type 1 endoleak that had been previously treated with coils by an outside hospital (we never found out where and by whom) and that now the whole sac had blown, extravasation of contrast, and all sorts of nastyness were in the retroperitoneum. The coils had also blown out and were half in the sac, and half out in the retroperitoneum.
By about Hour No. 8 an extension cuff was deployed across the neck and seemed to have stopped flow into the sac. The coils all kind of hung out in the sac and floated around, but otherwise there was no contrast seen.
So we deemed this a successful save. The patient was tachycardic and hypotensive and stuff, but the attending was confident that the patient would be well resuscitated.
I checked for pulses in the legs. No dice. No femorals. The angio had showed sluggish flow through the iliacs.
So we re-prepped for a LE angio and found no flow below the common femoral artery. Dunno why. Both were out. So the attending decided the patient should have an axillary bifemoral bypass.
Hour No. 13 into this case and the ax-bifems were done. There was now blood flow. We were cleaning up, closing the wounds, and Anesthesia said, "We're having trouble ventilating."
The patients abdomen was severely distended with bladder pressures in the 20s. He had an abdominal compartment syndrome and so we lapped him! All that work with the stents and the wires and stuff were all flushed down the toilet! He got lapped after all! So we opened the abdomen, a General Surgeon came in to run the bowel. She felt the bowel was fine and we left the belly open and put a vac pack over it. By the time the patient got off the OR table it was 3:30AM. Fifteen and a half hours in the OR. It may not have been the swiftest decision making I've seen by a vascular surgeon, but he took a calculated risk and things just went to crap.
I thought several times about quitting during the case, but it was damn fun. My role during the endo stuff was minimal since it was a rupture. But I had my own side for the ax-bifem. I did the laparotomy. I ran the bowel with the General Surgery attending. I made the vac pack. So I had a good time.
I stayed the rest of the night and basically stayed in-house until Monday night, when I finally went home. I know it's not kosher by the ACGME standards, but it was the right thing to do. Eventually the patient died, but you knew that was coming, right?
Anything head/neck related, I'm not a fan of. Chest cases I like generally. I'm not crazy about Whipples. Call me nuts but I just don't like it.
Long bypasses? The fem-far aways? Love them.
I think with certain long operations the more senior guys will just punt to their younger associates, as a form of dumping. Senior people will certainly do more ambulatory type stuff to pay the bills, but these are usually the same guys who want to do only Whipples, or be only the TAAA guy. No one really wants to be the "redo gastric bypass" guy with all its inherent problems, so I think the young 'uns get screwed with those.
