Intraop Consults

[Castro Viejo]

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So I'm lounging in the office today. It's conference day and it usually isn't very busy.

I get a call from the consult resident about a case GYN was doing. 40-something year old lady with a history of bleeding fibroid disease, multiple C-sections in the past, is on the table for a TAH/BSO. The GYN Chief Resident tore a gaping hole into the sigmoid colon and was looking at poopy stuff spilling into the pelvis.

So I head over to the OR, stick my head in, and the GYN resident, Chief Resident, and now the GYN attending were all standing there scratching their heads about how best to fix it.

This hole was big enough to drive a truck through.

So I scrubbed. Looked around. And told them I thought they patient needed either to have a Hartman's done or we could attempt to repair it primarily and then bring up an end colostomy to divert the fecal stream proximally. But I didn't think that we could get away with saving her from having an ostomy of some type.

"What?!" the GYN attending replies, "I want your attending in here. You obviously are f*cking crazy. We can repair this primarily."

So I call the attending of the day. He comes in and scrubs. Agrees with me that we're gonna have to do the colostomy and the GYN begrudgingly agrees. So my attending and I go at it. GYN also asks us to help them mobilize the uterus for them while we're there fixing the colotomy. WTF?

So we're doing our thing. Lysing some adhesions, mobilizing the sigmoid, the distal left colon, all in an attempt to do the Hartman's. We decided on that to get it out of the way so that they can take out the uterus. But while we're doing all of this and basically saving their asses from the fire, the GYN attending keeps huffing and puffing throughout the case while I'm dissecting stuff.

"Do you even see where you're cutting?"

"How do you know where you are?"

"STOP! You're cutting into the small bowel mesentery!" (While we were mobilizing the sigmoid colon off the uterus.)

"THAT'S the ureter you just cut!" (It was a band.)

"Where are you putting your hand? WHERE ARE YOU PUTTING YOUR HAND?! You're gonna rip out the aorta!" (My hand was in the pelvis, trying to see what I could do with moving the colon off the uterus -- last I checked, the aorta was nowhere near there.)

So I stopped dissecting. Handed my attending (who's my former Chief Resident) the Metz and told him that I'm not gonna keep dissecting while I'm distracted. I found myself really annoyed.

I really felt like lashing out at the GYN attending and telling him to STFU, that he called me and I really had no interest in getting involved with his nonsense other than to protect the patient from his blocks of wood for hands. But I held back. Primarily because he was an attending and I was just a resident, but also because I could see why he was so antsy and pissed about the situation.

But what would you guys have done? Sit there and take it like me and keep quiet about it, or go at it with him. In retrospect, I think I did the right thing. But I sure would've liked to give him a piece of my mind.

 

[mfreema1]

I find it hysterical that not only did they consult surgery to fix their mistake (don't OB/Gyns claim to be surgeons? And isn't that a fairly straightforward procedure?) but slammed you while you were fixing it. I'd have handed over my scalpel to the complainer, and let him fix his own damn problem while I left to go take care of my business elsewhere. But that's just my personality.

 

[tussy]

Been there, done that! Probably the gyne guy was pissed off at himself for tearing a big hole in the sigmoid (he should be mad because that's bad) and he's taking it out on you (becuase he doesn't have the balls to just own up to his own mistake and thank you for helping). I would have just subtley handed the metz to my staff saying "maybe you should be the one to do this" - i'm sure he'd understand.

I was in a similar situation recently - got called into the OR with gyne to "repair an enterotomy". I found 4 enterotomies and a belly full of small bowel contents from the ongoing spillage (from where they tried to take down adhesions). I took down the rest of the adhesions and repaired the enterotomies and irrigated and told the gyne to irrigate more at the end of the case.

I find out a week later that the patient developed a pelvic abscess and then ended up getting perc drained and the radiologist put the drain thru a vessel so they got a huge hematoma - i found out about it because the gyne was going around telling everyone that it was "the colorectal fellow's fault" because all of that was somehow a result of how i repaired the enterotomies!!!!! I was sooooo pissed.

 

[Fah-Q]

I've had similar experiences. General surgery and pediatric surgery will occasionally call us when they get lost or hurt something in the neck (I'm in ENT).

I'm always amazed at how dismissive they are of our recommendations.

Some of the quotes I can remember:

(intraop consult for stridor after total thyroid)
Gen surg attending: "Trach!? Trach!? That stridor is due to laryngeal edema, not because we injured both recurrent nerves...I mean, we didn't even see the nerves for crying out loud!!!"

(While peds surgeon attending is attempting to repair a hypopharynx perforation)
Me: "So where's your superior laryngeal nerve?"
Attending: "The what nerve?"

Me (staring at the obvious cut end of vagus): "What's this?"
Gen Surg chief resident: "Oh, we sacrificed ansa to get better exposure."
Me (trying to be diplomatic): "uh, well...I'm not so sure that was ansa"
Him: "Look, I do this everyday and I know my anatomy...now quit messing with that and help us find vagus."

I'm sure it happens with every specialty.

 

[Castro Viejo]

I'm pretty rah rah when it comes to getting into fights, especially with specialties/fields I don't like and who abused me as a medical student.

I'm usually only that way with the ED or with Medicine residents. Other services I tend to get along with rather well.

1) He throws you out of "his" case

I was hungry, so this may not have ben a bad idea.

2) Your attending throws you out of the case

See above.

How exactly did they manage to rip a hole in the bowel anyway? I get nicking the bowel, but a giant hole?

So Edward Scissorhands apparently had the Metz in his hands and was lysing some adhesions when what he thought was a band turned out to be serosa, panicked, spazzed, had a seizure, and then just pushed his Metz to tear a 3cm hole in the sigmoid. I've never seen anything like it, not even from GYN.

I guess my reaction to this particular person's attitude was that just several weeks ago I had to deal with similar nonsense from another service, and I just was tired of playing cleanup. A patient who had a staghorn calculus went to IR for a neprhostomy tube. SOMEHOW the nephrostomy tube missed the kidney and slammed into the liver, went through that, and ruptured the gallbladder and poked a hole in the transverse colon. Mighty impressive, I'd say, but WTF? So the patient had a cholecystectomy and a two-layer repair of the hole in the colon.

My feeling is if you've called me to come help, then don't scream at the help just because you're unhappy with yourself. If I was Hillary Clinton and started crying because of "all the pressure" and wigged out, who's gonna bail you out? I'd just keep my mouth shut if I was the one creating problems for others to fix.

 

[Castro Viejo]

i found out about it because the gyne was going around telling everyone that it was "the colorectal fellow's fault" because all of that was somehow a result of how i repaired the enterotomies!!!!! I was sooooo pissed.

I wonder if they realize how stupid they sound sometimes.

 

[SLUser11]

But what would you guys have done? Sit there and take it like me and keep quiet about it, or go at it with him. In retrospect, I think I did the right thing. But I sure would've liked to give him a piece of my mind.

I think you did the right thing, which is probably a reflection of your training level. I would think it more likely for the junior/mid-level resident (myself included) to call out a Gyn attending. It is the wiser upper-level that realizes the repercussions outweigh the benefits.

In my environment, where a lot of my bosses are in private practice, I obviously see a lot fewer malignant outbursts, etc, because they know that bad behavior negatively affects their referral base......

I've had similar experiences. General surgery and pediatric surgery will occasionally call us when they get lost or hurt something in the neck (I'm in ENT).

I'm always amazed at how dismissive they are of our recommendations.

Some of the quotes I can remember:

(intraop consult for stridor after total thyroid)
Gen surg attending: "Trach!? Trach!? That stridor is due to laryngeal edema, not because we injured both recurrent nerves...I mean, we didn't even see the nerves for crying out loud!!!"

(While peds surgeon attending is attempting to repair a hypopharynx perforation)
Me: "So where's your superior laryngeal nerve?"
Attending: "The what nerve?"

Me (staring at the obvious cut end of vagus): "What's this?"
Gen Surg chief resident: "Oh, we sacrificed ansa to get better exposure."
Me (trying to be diplomatic): "uh, well...I'm not so sure that was ansa"
Him: "Look, I do this everyday and I know my anatomy...now quit messing with that and help us find vagus."

I'm sure it happens with every specialty.

I appreciate the alternative perspective. It's funny to think that there are small circles of OB residents clowning on gen surg's lack of uterine skills, etc, and I guess we should all realize that we are trained to possess a certain amount of snobbery about our small focus of medicine.

 

[Castro Viejo]

Me (staring at the obvious cut end of vagus): "What's this?"
Gen Surg chief resident: "Oh, we sacrificed ansa to get better exposure."
Me (trying to be diplomatic): "uh, well...I'm not so sure that was ansa"
Him: "Look, I do this everyday and I know my anatomy...now quit messing with that and help us find vagus."

The same thing happned to one of the Vascular guys here during a CEA.

Cut right through the vagus for better exposure thinking it was the ansa. I'm not sure how that vagus was lying, and I can't imagine how it would be overlying the business end of where they would ideally need to be... Maybe they were too low on the common?

Hmmm... (I'm not a fan of thyroid surgery, so you'll never catch me taking that part of the pie away from you)

 

[Blade28]

I get a call from the consult resident about a case GYN was doing. 40-something year old lady with a history of bleeding fibroid disease, multiple C-sections in the past, is on the table for a TAH/BSO.

By this point in your story, I already knew it was going to be an intra-op consult for a bowel perf. 🙄

They didn't want a colostomy because:

(1) They wouldn't know how to explain the technical error to the patient
(2) They didn't want to present this case during M&M
(3) They wouldn't know how to manage it post-op

An small intra-op bowel perf that's able to be repaired primarily doesn't result in much stress on the part of the patient. "What's that, doctor? There was a little bowel injury but you fixed it right away? Oh, OK." But a colostomy? Now it's more like, "Why was my OB/GYN operating near my colon? Where's the phone book so I can find the number for a lawyer?"

 

[Castro Viejo]

By this point in your story, I already knew it was going to be an intra-op consult for a bowel perf. 🙄

Sad how this scenario plays out again and again from coast to coast and around the world. 🙂

They didn't want a colostomy because:

(1) They wouldn't know how to explain the technical error to the patient
(2) They didn't want to present this case during M&M
(3) They wouldn't know how to manage it post-op

An small intra-op bowel perf that's able to be repaired primarily doesn't result in much stress on the part of the patient. "What's that, doctor? There was a little bowel injury but you fixed it right away? Oh, OK." But a colostomy? Now it's more like, "Why was my OB/GYN operating near my colon? Where's the phone book so I can find the number for a lawyer?"

Damn straight. You can't hide a colostomy for too long before the patient says, "Hey, what the hell am I crapping into a bag?"

Not that this is related, but I just remembered a patient I saw in the ED who came with a colostomy. A 99 year old guy with every cardiac and pulmonary issue known to man came for abdominal pain that turned out to be probably gastroenteritis. I saw him and on exam noticed he had a colostomy and asked, "Hey, when did you have that colostomy done?"

"1971, doc. And I hate the f*cking thing. It was for diverticulitis. Life's just been terrible since then."

"Why didn't they ever put it back together?"

(Puzzled look on his face) "What do you mean? They could've done that?!"

Ha ha...

 

[Blade28]

On a related note, I love how we consent for these things. "OK, Mr. Smith, here's your consent form for your operation, where we're going to remove part of your colon. Oh, there's a chance you'll have a bag here," as we point vaguely to the abdomen, "but it's not permanent. So please sign here."

The patient nods, and dutifully signs. A "bag"? No problem, right?

Yeah, if only a colostomy were just "a bag."

 

[smq123]

I find it hysterical that not only did they consult surgery to fix their mistake (don't OB/Gyns claim to be surgeons? And isn't that a fairly straightforward procedure?) but slammed you while you were fixing it. I'd have handed over my scalpel to the complainer, and let him fix his own damn problem while I left to go take care of my business elsewhere. But that's just my personality.

If you're planning on going into surgery, you should probably fix this part of your personality.

What has impressed me the most about the surgery residents that I've worked with is that most of them are very protective of their patients and conscientious about good patient care. (And, yes - as soon as Castro Viejo stepped in to fix the colon, that woman became "his" patient.)

By arguing with the Ob/gyn attending, it just delays the case, and it could lead to serious repercussions from both the Ob/gyn attending and from the surgery attending.

Plus, by just "walking out" on this patient's case only because Edward Scissorhands is trying to pick a pissing match with you doesn't benefit the patient - who is the only one in the room that truly matters at that particular time. (She just went in to get her uterus removed, and now she has a huge hole punched into her colon and has a colostomy bag. That poor woman.)

I can't imagine that a "real" surgeon would willingly leave a colon repair in the hands of an Ob/gyn, who is clearly not trained in that procedure. I certainly wouldn't, no matter how pissed off I was. I think that Castro Viejo did the right thing, even though I'm sure he would've loved to speak his mind at the time.

 

[ESU_MD]

Screw that gyne for trying to criticize your operative skills/style. A gyne "surgeon" telling a chief resident to "stop"? yea, ok pal. A story like that really makes me mad and I will think about this all nite now. Your attending should have not let him talk to you that way. I commend you for being able to tolerate that situation.

I never let the ER or nurses or anyone talk or discipline my juniors- ever. even if they are dead wrong. there is a clear chain of command in surgery and it doesn't involve residents learning or being criticized by non-surgeons.

I hate the lack of respect surgeons are tolerating.

In the olden days you could've told him where to go, or just scrub out and have your attendings back you up, but unfortunately those days are long gone in the days of political correctness, etc.. There is very little respect for any hierarchy these days, and some gyne can tell off a surgeon just the same as a medical student or some clipboard nurse. Dr Halsted has turned over in his grave.

The only way to avoid this is just send the juniors in on cases like this and don't even put yourself in a position to deal with these guys. As a chief, I know I can't tolerate the ER, GI guys, trauma, or gynecologists so I just stay away from them and give up the cases. It's worth it for my mental health and blood pressure.

And NEVER let those guys think that it is beyond the skill of a general surgeon to take out a uterus. My staff regularly resects the uterus/ovaries should they need to in a case without calling in the gynes. a hysterectomy is a joke of a case.

 

[ESU_MD]

and since I am so mad about this I will add another comment-

As a pgy-5, I consider you a peer with a gyn not to mention rads, IM or its specialists, er guys, etc..

Even though a chief is technically still a resident, I don't feel the need to display a traditional resident-attending relationship with them(gyns, er, IM, etc). I regularly call them by their first names, sometimes on purpose(yes I admit it, I especially like to do this to the er guys)

Chief surgery residents should have enough pride to realize that they arent just avg residents since they have trained longer. DO NOT FEEL that you should bow down to another specialties personnel just because they are an attending. we all need to stop being so nice to everyone, and go back to old school

 

[Castro Viejo]

I think that Castro Viejo did the right thing, even though I'm sure he would've loved to speak his mind at the time.

Oh, trust me... I almost busted a nut holding it in.

But you're right. General Surgeons tend to have a "gotta save the patient from the ***** trying to kill him/her" mentality over every patient they come across. It's unfortunate but in my program we round on the consults as if they were our own even if they're primarily on another service (e.g., OB/GYN, Medicine, Rehab, etc.) and even write orders. This is just convention and certainly not the rule.

 

[Castro Viejo]

I never let the ER or nurses or anyone talk or discipline my juniors- ever. even if they are dead wrong. there is a clear chain of command in surgery and it doesn't involve residents learning or being criticized by non-surgeons.

I agree. My juniors are my responsibility. If anyone has a problem with them, they should address me and not them.

I hate the lack of respect surgeons are tolerating.

Ditto.

And NEVER let those guys think that it is beyond the skill of a general surgeon to take out a uterus. My staff regularly resects the uterus/ovaries should they need to in a case without calling in the gynes. a hysterectomy is a joke of a case.

We don't routinely call in GYN unless my attending is building some bullcrap private referral base separate from what the faculty practice is getting. My Chairman and their Chairman pretty much hate each other and will do things to piss the other one off... Like we'd just go ahead with a TAHBSO and thumb our noses at them. Then they'll do something like try LOA, where they invariably mess it up and create enterotomies that would make even a Viking blush.

Chief surgery residents should have enough pride to realize that they arent just avg residents since they have trained longer. DO NOT FEEL that you should bow down to another specialties personnel just because they are an attending. we all need to stop being so nice to everyone, and go back to old school

In a way I agree, but these truly are different times. And as it's been said before by many a banned user, "Chief Resident" in General Surgery doesn't mean as much as it did. The Chief Resident of 20 years ago was the shiznit and the baddest ass MFer in the whole house. Now we (I'm) reduced to a paperwork, paper chaser machine that does nothing but round, prepare lectures my attendings don't want to give, and an intern babysitter. Yeah, occasionally I'll do a case with only a junior, but it's never anything complicated. It's always something bread and butter.

Growing up where I went to med school Chief Residents did Whipples with an R3 while the attending was passed out in the lounge. That's awesome, but it no longer exists (not even where I went to med school).

I still believe that we're the most competently trained physicians in the whole house during the off-hours. Anywhere where there's a problem, a Chief in house can do wonders that would scare the shizat out of even a "Medical Intensivist" or an EM doc.

It's all good... That same GYN will need us down the line again. I'm thinking next week. I'm just waiting for the "Oops... We lacerated a bunch of small bowel during the panic-stricken minutes of doing a C-section." That would be messed up.

 

[Pir8DeacDoc]

I can't see how taking a bunch of flack from an armchair QB Is good for patient care. I would have maybe asked them to step out while we finished our part and then we'd turn the patient back over to them.

 

[SocialistMD]

I'm sure a litany of clever and humbling replies were on the tip of your tongue (I know they were on mine while reading your post), and as gratifying as they would have been at the time, it would have ended badly. As frustrating as it no doubt was, you did the right thing. I agree with the fact that your attending should have stepped in at some point to stop the abuse you were taking from the gyn, but to have said anything (however warranted it may have been) would have only made things worse.

The difference between today's surgeon and the surgeon of the past is that today's surgeon has to show restraint (just like the rest of the world).

 

[SLUser11]

and the surgeon of the past is that today's surgeon has to show restraint (just like the rest of the world).

Great statement....should be your sig.

 

[Castro Viejo]

Well in defense of my attending even with all the huffing and puffing, he never even hinted that he wanted me to give up the Metz. He just let me continue with the dissection. So for that I give him due credit. Plenty of other guys would've been so crapping all over themselves about "ruining their referrals" that taking the case from their Chief Resident and the lack of respect that comes with taking a case away wouldn't have even been a second thought. He let me decide when I was tired of the trash talking by that guy.

So when I gave up the dissection and assisted my attending the complaining seemed to have stopped. But then he started it up with my attending too!

"I think we should run the small bowel from the ligament of Treitz down to the ovaries." Hmmm... Perhaps we studied a different anatomy book.

"I think you can get to the uterus by dissecting into the retroperitoneum, rotate the viscera out, and heading into the pelvis to get around the adhesions." Yeah right buddy... It's called "uterine fibroid embolization." F-that!

"Or we could try dissecting under the left colon and follow its blood supply to the ovaries." This is as stupid as the other suggesting. I suppose we can crack the chest and follow the aorta all the way down to the iliacs or something too.

And all this crap was through a Pfannenstiel. I absolutely hate Pfannenstiels. Probably as much as I dislike laparoscopy (another supposed GYN invention).

My experience with the GYN service is that they know every irrelevant piece of history. So things like allergies, medications, social and family histories, and blah, blah, and more blah, they're experts on with their patients but the important clinical shiznit? Not a chance.

 

[smq123]

"I think we should run the small bowel from the ligament of Treitz down to the ovaries." Hmmm... Perhaps we studied a different anatomy book.

My experience with the GYN service is that they know every irrelevant piece of history. So things like allergies, medications, social and family histories, and blah, blah, and more blah, they're experts on with their patients but the important clinical shiznit? Not a chance.

The thing about OB/gyn that worries me (particularly because, against all odds, I actually like it and am thinking about doing it) is that it's quickly evolving into a primary care out-patient specialty, but still proud of its "surgical" roots - but those roots are drifting farther and farther away from the current state of the specialty.

If you look at some of the training programs in this country, you'd think that ob/gyn was a primary care field that was trying to morph into a surgical field, instead of vice-versa. They focus a lot on social history, family history, psychosocial stressers, etc., but then try to haphazardly train their residents in gyn surgery. The dual focus, in my opinion, isn't really doing the field any favors - contrary to what many ob/gyns will tell you. Either figure out a way to combine both in a way that assures competence in both surgery and out-patient care, or split the field up into in-patient ob/gyn surgery and outpatient gyn care.

 

[SouthSideSteve]

I bet she was piss ed when she woke up and had to poop in a bag. I know I would be.

 

[Castro Viejo]

The thing about OB/gyn that worries me (particularly because, against all odds, I actually like it and am thinking about doing it) is that it's quickly evolving into a primary care out-patient specialty, but still proud of its "surgical" roots - but those roots are drifting farther and farther away from the current state of the specialty.

Honestly, you seem to be really intelligent to me. Why would you do something like OB?

If you look at some of the training programs in this country, you'd think that ob/gyn was a primary care field that was trying to morph into a surgical field, instead of vice-versa. They focus a lot on social history, family history, psychosocial stressers, etc., but then try to haphazardly train their residents in gyn surgery. The dual focus, in my opinion, isn't really doing the field any favors - contrary to what many ob/gyns will tell you. Either figure out a way to combine both in a way that assures competence in both surgery and out-patient care, or split the field up into in-patient ob/gyn surgery and outpatient gyn care.

In certain surveys of "primary care doctors," OB/GYN is lumped into that category along with physicians such as IM, Peds, Psych, FP, etc.

The issue with OB/GYN in my mind is very definitely related to their terrible experiences with litigation from the OB side. This has forced many of them to stick to GYN surgery and outpatient "women's health" stuff. Funny how the OB version of women's health doesn't include the Breast.

And how many GYN operations are there really? There's like four unique operations. So the majority of your money-making ability will be as an office based OB/GYN who does nothing but PAP smears all day and LEEPs and that kinda crap.

Then again, Urogynecology, GYN oncology, and REI are supposedly big deals... At least the first two could potentially be pretty operative heavy.

Just stick to being a real surgeon and train in the ACS-eligible residencies. Or better yet, General Surgery. 🙂 And if you're really into that mushy, mushy primary care "let me hold my patient's hands all day" stuff, try Vascular Surgery or Transplant Surgery on for size. 🙂

 

[Blade28]

The thing about OB/gyn that worries me (particularly because, against all odds, I actually like it and am thinking about doing it) is that it's quickly evolving into a primary care out-patient specialty, but still proud of its "surgical" roots - but those roots are drifting farther and farther away from the current state of the specialty.

You need to stop saying that. It hurts my ears. 😉

 

[DrDawg]

We don't routinely call in GYN unless my attending is building some bullcrap private referral base separate from what the faculty practice is getting. My Chairman and their Chairman pretty much hate each other and will do things to piss the other one off... Like we'd just go ahead with a TAHBSO and thumb our noses at them. Then they'll do something like try LOA, where they invariably mess it up and create enterotomies that would make even a Viking blush.

Sounds like your chair would have enjoyed cleaning up the mess if you told that ob/gyne where to go.
Good restraint. I think I would have had to leave before I put a foot in his mouth. I'm still learning how to play nice.

 

[SocialistMD]

Great statement....should be your sig.

I'd rather everyone know that I don't wear pants.

 

[jdm51]

As anyone experienced in academic institutions would know, the correct course of action is...

1) graciously offer your humble services to the unfortunate consultee for an intraoperative complication that was most likely the result of exceptionally atypical anatomy or a pre-existing undiagnosed condition of the patient and something that could happen to the best of us

2) make fun of them behind their backs afterwards

 

[Castro Viejo]

Sounds like your chair would have enjoyed cleaning up the mess if you told that ob/gyne where to go.
Good restraint. I think I would have had to leave before I put a foot in his mouth. I'm still learning how to play nice.

Yeah... But with just about 130 days to go in my residency, the last thing I need to do is visit the school nurse about my "anger management issues" and having to go through "sensitivity training" classes.

Sigh...

 

[Docgeorge]

Then again, Urogynecology, GYN oncology, and REI are supposedly big deals... At least the first two could potentially be pretty operative heavy.

Thanks to a urogynecologist I got to do a trans-vaginal small bowel resection. I'm still trying to figure out how to log it.