A lesson in the OR that prepared this doctor to be a surgeon

Hope Amantine, MD | Physician | July 7, 2015

Just around the corner in my mind, there is always another recollection of my training. As I was recently writing about ruptured aneurysms, I got to thinking about my vascular surgery mentors, and this came to mind.

The case was an elective aneurysm. These cases were much different than the bedlam of the ruptured variety — every move scripted, rehearsed, perfectly executed. I had one attending that would not allow the resident to do any of the case — observe only — if the drapes were not positioned "just so" to his satisfaction. Of course, there was an intricate set of steps to getting it just right, rivaling a Japanese tea ceremony in complexity.

As it happened on this particular day, we were dissecting to the aorta, in preparation for what looked would be a routine case. As I spread my Metz (Metzenbaum scissors) to develop the planes that needed to be free before we could proceed to the heart of the operation, the attending noticed that I was more ginger around the IVC.

A quick anatomy lesson for the non-surgical reader: The aorta comes out of the heart, and heads down the middle of your torso to eventually branch and feed everything in your body below your heart. The aorta is the mainline, if you will. It always lives just ever so slightly to the left of center. The return line, the inferior vena cava, courses upwards just slightly to the right of center, eventually returning to the heart. The two sit next to each other through the middle of the abdomen, right next to the spine. Arteries carry blood away from the heart under pressure and, therefore, have thick, muscular walls that resist pressure, both of blood within, and surgeons' instruments, without. Veins carry blood back to the heart with a much lower pressure, and their walls are thin and flimsy and tear easily. When torn the flow of blood is torrential, as with arteries, but the thin slips of tissue to the edges of the hole require delicacy to sew without mangling. When torn the flow of blood is torrential, as with arteries, but the thin slips of tissue to the edges of the hole require delicacy to sew without mangling.

So here I was, handling the plane (the layer, or space) around the IVC with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, "Why are you being so dainty with your dissection there?" I answered that I wanted to avoid ripping the cava because they're so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, "Well, are you just going to stand there or are you going to fix that?"

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow. I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me. This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole. No problem.

All he said was, "Good job." And we proceeded to complete the case uneventfully.

I made no comment to him about what transpired that day, as it was not my place. Surgical hierarchy is rigid and absolute, and even a second in command does not comment on the general's decisions, and furthermore, that is the only way it can be. There are no committees in the operating room.

Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn't control the bleeding, he would have taken over. And I would have failed.

Perhaps it's not that an individual is made into a surgeon, but more like a surgeon is molded or honed, to develop natural traits they possess but never had a chance to demonstrate. There are some people, many people, who just can't stick their fingers on the hole, take control, take a breath, find a solution, and execute it. And that's OK. What a world it would be if everyone were a surgeon. Yikes! So I think instead, that as surgeon trainers, these attending surgeons' role was to look through candidates and filter out who belonged in the OR and who did not. Thankfully, we did not have crises all that often, and yet the crisis is the only way you know how that trainee will respond.

We have in surgery, a final exam: the American Board of Surgery Certification Examination. It is a two-part exam, the first written, which is miserably difficult, and the second, oral. The day of the oral exam, the candidate sits in a hotel room, bound and gagged. (No, just kidding.) You only feel that way. The candidate sits in a hotel room with two appointed examiners from the ABS (in three separate rooms, a total of six examiners in 90 minutes), and they proceed to present you with a clinical scenario, and ask you how you would manage it. The topics of discussion range from garden-variety general surgery, to vascular, to thoracic, surgical oncology, head and neck surgery, endocrine surgery, trauma and critical care, whatever. The rarer, the better. They can ask you pretty much anything.

Maybe the exam has changed since I took it years ago (though I hear it really hasn't). Some examiners are polite and professional, and others, not so much. Every trainee hears horror stories about the malignant examiner, and every trainee has nightmares about it. The classic line from this terrifying examiner: "You would do THAT?!" He tries to psyche you out. He tries to derail your thought process. He tries to make you second guess your answer. He will do anything to make the wheels come off your wagon. And why? Because that is absolutely the only thing that cannot happen, when there is a crisis in the OR. The captain of the ship cannot jump ship.

So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

Author's note 7/8/2015:This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.