“I’m a circulating nurse – I circle, I fetch, I judge silently”

Florence Nightingale

     I walked into the room, and there was no sign of Budros.  I let out a sigh of relief.  The patient was asleep and intubated.  The circulator was a large, tall woman, and she introduced herself as Annie as she handed me a razor.  In every case there is a circulating nurse, who prepares the room, gets the patient into the room, charts and documents what happens during the case, and gets any supplies that are needed during the case,

“I’m the new intern, Carol Sawmiller,” I replied.

“Okay, new intern, let me show you the right way to shave and prep a Budros patient.  He whines like a three-year old if it’s not done just exactly right.  And write your name on the board so we can remember it.  We’re just a bunch of old farts with bad memories.”

“Hey, speak for yourself.  I’m Dianne.  I always scrub for Budros.  Did you meet him?  Did he give you a hard time?” the scrub nurse inquired. Each case has a nurse or scrub tech standing beside the surgeon, handing instruments, suctioning, retracting and assisting.

“Yes, I just met him in the hall, and he told me his rules and that I shouldn’t ever hold up a case again,” I responded in a gloomy tone.

“Oh, don’t worry about him.  His bark is way worse than his bite.  You need to remember the next two things I say to you.  Repeat them after me:  superficial branch of the inferior epigastric vein and hernia of Morgagni.”

“Superficial branch of the epigastric and someone’s hernia,” I fumbled.  She repeated the words, then I repeated them two more times.

“She must like you, she’s doing you a big favor,” Annie said.   We finished the prep.

“Now go scrub,” Dianne instructed.  “He should be just about finished with his last cigarette and heading back here.  He likes the patient all prepped and draped, then he strolls in like the queen of England.”

     I got scrubbed, gowned and gloved, and we got the patient all draped and ready, and exactly on cue, Budros came in.

“Where’s your tiara?” Annie asked him as she tied his gown.  He gave her a funny look, then gave Dianne a funny look.

“What?” Dianne asked.  “You don’t think I would have said anything about how you love to relax and drink champagne and eat bon bons while the rest of us get everything ready, so you can stroll in here at the last minute like the queen of England, do you?  I have no idea what she’s talking about.”

Budros looked at me.  “The hospital tried to fire her a few years ago, but she filed an age discrimination lawsuit.  She accused the hospital of trying to get rid of her because she is over a hundred years old.”  The mask covered his mouth, but I could tell from his eyes he was smiling. 

“Well, honey, if I’m a hundred, so are you.  We were born the same year.”

Dianne scrubbed for Budros’ cases almost every day and had for the last twenty-five years.  She had worked in the OR since Budros was a resident here, years ago. She had known him as the new inexperienced intern and watched him progress to one of the busiest attending general surgeons.

Budros took the scalpel and made the incision.  He explained to me that he would, if I proved to have any skill doing minor assisting, eventually allow me to handle the scalpel and do some dissection.  He very meticulously cauterized the tissue.

“We obviously have gone through skin.  What is this layer?” he inquired as he gently grasped a wispy, nearly undetectable layer within the fatty tissue.

Yes! I thought.  I know this one!

“Scarpa’s fascia,” I casually answered, trying not to sound overexcited that I knew the answer.

He carefully isolated a small vein, placed silk ties around it and cut it.

“What is this vessel?”

I didn’t even know that tiny vein actually had a name.  Oh, crap, I already am going to look bad again.  Then I remembered what Dianne had said earlier.

“The superficial branch of the inferior epigastric vein,” I answered.

He raised his eyebrows, glanced over at Dianne, then went back to his tedious cauterization.

     The anesthesiologist looked over the drape, watching him. 

“We usually estimate blood loss in milliliters, or even units.  But in Budros cases, we count the actual individual red blood cells.  He may lose two or three red blood cells.  Maybe five during a big case, like an aortic aneurysm repair,” he told me.  “If you want to see him get really excited, just poke your finger in there and stir up a little bleeding.”

“Mind your own business up there.  Go back to taking your nap or reading your magazine, or whatever it is that you do up there” he responded.  “You will quickly learn that most of the people working in the OR are assholes.”  He emphasized the word “asshole” so the anesthesiologist would hear him, then chuckled.

     Budros opened the external oblique fascia, isolated the spermatic cord structures, and identified the membranous hernia sac adherent to the cord tissue.  I had been amazed as a student how the surgeons could actually find this, as it looked exactly like all the other membranous stringy tissue stuck to the cord structures.  Would I ever be able to do that?

“Okay, you’ve had it easy for a while.  Dianne is trying to distract me with small talk, but it will no longer work.  What layer is this?”  Budros demanded.

     Now I was in trouble.  Hernia anatomy was hard to understand after just reviewing it, let alone three months later.  I ventured a guess, which was wrong. 

“No, this is not the conjoined tendon.  It is the transversalis fascia.  This is the conjoined tendon.  Since you brought it up, what makes up the conjoined tendon?”

“It’s where the abdominal wall muscles come together to form a tendon,” I offered, already knowing this answer would not cut it.

“Which abdominal wall muscles?”

“The external and internal obliques,” I answered confidently, with absolutely no idea whether I was right or wrong.

     He pointed to the external oblique fascia, which was clearly not a part of the structure in question. 

“Then what is this?” he asked.

“The external oblique fascia,” I stated.

“Well, if that’s up here, how the hell is it a part of the conjoined tendon?”

“It’s not,” I said.

“Tell me the difference between a McVay repair and a Shouldice repair.”

     I was sinking fast, deeper and deeper into a hole.   As a student, I had seen a few hernia operations done, but the student doesn’t actually get to see much of what the surgeon and the resident are doing.  It is a small incision with the fingers of two people and several retractors shoved right in there in the way.  Even when they do point something out, it all looks the same anyway.

“With the McVay repair, the transversalis is opened and reapproximated, and then the repair is from Cooper’s ligament to the conjoined tendon, using interrupted sutures” I stammered.  “In the Shouldice repair, the inguinal floor is reconstructed using the ileopubic tract and closing the internal ring more snugly around the cord structures to prevent another indirect…”

He interrupted me.  “I can tell when interns are bullshitting me.  You are bullshitting.  Throwing out some anatomy terms to try to convince me you know what you are talking about will not work.  Let’s see if you can redeem yourself at all.”  He continued suturing the mesh in, never breaking his rhythm.   “There are many different types of hernias.  People can get hernias just about anywhere.  What kind of a hernia comes through the anterior portion of the diaphragm?”

     I could have given Dianne a huge hug right there.

“A hernia of Morgagni,” I proudly answered.

He paused and looked at me.  “So, you know something.  You need to know more and be prepared for these cases.”

“Yes,” I agreed.  “I will read more in my spare time.” 

     Dr. Budros laughed heartily.  “I have a secret for you.  You no longer have spare time.  Spare time no longer exists in your world, you are an intern.  Now, why weren’t you more prepared for this case?”

I paused, then answered.  “There is no good reason.  I will read and be prepared and get the case moving without any delay next time.”

     His eyes were smiling again.  He turned to Dianne and said “There is hope for this one.  She has proven she can learn.  She tried to give me some excuse in the hallway this morning, and now, no excuses.  So, she learned that pretty quickly.”

     He went on to try and show me the importance of the “transition stitch”.  If this is not done correctly, the patient can get a femoral hernia, Budros explained.  He made this out to be such a big deal, but every time I leaned in to see what he was doing, he told me to get my big head out of his way.  I never did see the big transition stitch.  We finished the case, put the dressing on, and woke the patient up.  Budros left to go talk to the family, leaving me to finish all the paperwork and write the prescriptions.

“He likes you,” Dianne stated.

“Really?!  I think I must have looked like an idiot.”

“No, he was just giving you a hard time, not to see what you know.  He knows new interns don’t know shit about anything, no offense intended.  He does that to see how you handle it.  Are you gonna break down and cry, are you gonna lie, are you gonna get frustrated.  He tests everyone out like that, you did fine.”

     That was a little bit of a relief.  I accompanied the patient to the recovery room and got his paperwork all done.  I looked up the dose for percocet and the correct way to write out a prescription.  I sorted through the paperwork in my pocket and found my institution DEA number, which made it legal for me to prescribe narcotics, and wrote his discharge orders.  I was about to leave when the recovery room nurse called after me.  She explained I had written the prescription on the wrong type of prescription pad.  I had to use the yellow pad, for all narcotics, and the green for everything else.  So I rewrote it, on the yellow, and tore up the green one.

     I met my student back up on the floor, and we discharged two people.  One guy had his appendix out yesterday, and Dr. Trevino had seen the patient and scribbled something illegible in the chart.  I couldn’t read it, the student couldn’t make it out, but the unit clerk could read it.  He had written that the patient could go home.  I got the yellow prescription pad, not the green one, and got him all set to go.  This brought me to the next task I had been fearing.  I needed to dictate discharge summaries.  Every patient needs a brief summarization of their hospitalization, including procedures, diagnoses, medications, and any significant events that may have occurred.  I had been assigned a number to sign into the system, and I had my little pocket book with sample dictations.  It was amazing to me how long this task actually took.  After finally getting signed into the stupid dictation system and figuring out what to say, I accidently erased it all halfway through.  I started over, and got it done.  The student had looked up all the labs on our patients, and we pulled some charts to write orders to replace low potassiums and make some IV fluid adjustments.  Mrs. Jackson, another patient ready to go home, had some questions for me, which I answered as best I could.  I tried to get out of the room, because I had wanted to run by the cafeteria to get something to eat before the next case, but she just kept going with the questions.  I finally broke away, but headed straight to pre op.  I would eat later.  I didn’t want to be responsible for delaying another case.  I saw the patient and got the history and physical done, just as Dr. Trevino arrived.  He was Dr. Budros’ partner, but was quite different.  Dr. Budros was soft-spoken, well-mannered, very meticulous in everything he said or did, and very specific about the way he wanted things done.  Dr. Trevino was loud, irreverent, forged ahead without much discussion, and let the residents take care of most of the details.  As we stood over the prepped patient in the OR, he looked at me and bellowed, “Well, this lipoma isn’t going to take itself out!  What are you waiting for?”

     I couldn’t believe it.  He was going to have me make the incision.  I had done some lump and bump removal as a student, but this was the real thing – I was doing an operation.  I took the scalpel and held it in my hand, feeling its weight, mesmerized by the bright OR lights reflecting off the blade.

“Well, are you just going to stand there admiring it, or are you going to use it?”  Trevino roared at me.  I made the incision where he had drawn it.  The lipoma was a big one, about ten centimeters by five centimeters, in the middle of this older man’s back.  It had grown large enough to irritate him when he leaned back, so he finally was having it removed.  I carefully tried to separate the lipoma from the surrounding tissue, using the forceps and a delicate hemostat. After several minutes of very little progress, Trevino asked me if I knew which surgical instrument was the best one available.  I didn’t know.  He held up his hand and wiggled his fingers.

“Your hand is the best instrument you’ve got.  It retracts, dissects, grasps, separates, stops bleeding.  It defines tissue planes, identifies masses, and it doesn’t even need to be sterilized and processed.  Let me show you how it works.”

     He used his index finger to sweep around the lipoma and it popped up out of the wound in about three seconds.  I grabbed it before it rolled onto the floor and handed it to the nurse.  We finished up and I sutured the wound closed.  It was just a small thing, removing this lipoma, but it was so very satisfying.  I looked at the nice, neat incision, and the flat area that a few minutes before had been a big bulge, a constant source of annoyance for this man.  He would no longer feel pain as he leaned back in his chair, and his wife and kids would stop bugging him about his big lump.  We made his life a little bit better, and it felt pretty good.