Friday, September 21, 2012

Getting owned by a surgeon: adductor myotomy,

I got owned. I was headed to a surgeon's office because I want to continue my research from the summer as to whether a questionnaire filled out be parents can adequately reflect a child with cerebral palsy's treatment needs and whether they will benefit from surgery.

 I should make the disclaimer that Monday, the day before, I was owned by a final exam on immunology, on a textbook of over 800 pages that was 90 questions in 105 minutes. And the questions were hard. I believed a failed it due to a classmates joke that other people didn't take seriously (found out Friday that I actually passed by a good margin). I have not reviewed anatomy and was studying for a pathophysiology quiz (Wednesday) pharmacology quiz(thursday) and pathology exam (next monday) so anatomy was not on my mind.

I was meeting the surgeon I would work with at EVMS for the first time. I was late. I showed up at 7:07 and should have been there at 7:00. I couldn't find my ID badge, I couldn't find the office, etc, etc, etc.

Then (surgeon): what muscles lift the thigh? The iliac, the psoas (iliopsoas)... this is as much as I remembered.
Surgeon: "What else?"
 Me:Blank. Blank. Random guess#1...#2....#3...

We go in to see a little boy who has broken his arm above the elbow and will need pins and should be operated upon asap in order to correct location. He also has a bronchitis for which be was put on antibiotics a week earlier, but his parents only gave him one antibiotic pill because they don't like medications, so we can't operate until the internal medicine doctor comes and sees the boy to give him IV antibiotics and ensure that he can be operated upon hopefully later that day without dying. Call the internist and pneumonologist.

Back to the elevator, where a fourth year med student is standing... great, now I get even more of an audience for my wrong answers...

 Surgeon: What else lifts the leg?
Random guess #4: Rectus Femoris
Surgeon: "Where does it insert"
Me: (thinking facial sheath, but now completely discombobulated) the femur?

 This continues...
Surgeon: And what else lifts the leg?
Me:......... (correct answer, the tensor fascia lata)
 Where does the iliopsoas insert?
Me: The femur below the acetabulum (this is the head of the femur)
Surgeon: There is a specific place
Me:......... (right answer is lesser trochanter)
Surgeon: Time to put on your scrubs

In the operating room. Three year old boy who is under anesthesia. Surgeon shows me the limited range of motion at three joints despite no possible residual tone: ankle (foot permanently pointed, can't go to 90degrees), knee, (can't extend knee past 90degrees, not even close to straight), and hip.

 He cuts open the hip right under the boy's scrotal sac on the right side. Grabs a muscle with a hook-type tool...
 Surgeon: What muscle is this?
Me: An adductor (it is an adductor myotomy, the point is to cut the adductors so that the kids spastic adductors stop pulling the hip joint out of socket).
Surgeon: Which adductor? Me: ........RG (Random Guess)....#1Gracilis....#2adductor longus#3...adductor magnus....
Surgeon: adductor brevis
 Surgeon repeats this process with all other adductor muscles.
Surgeon shows random white stringy thing. "What is this?"
Me: Obturator nerve. (Ding I got one right!)
Surgeon: Which branch?
 Me: ........fml.....mental cursewords

Surgeon: what important structures are here?
Me: Everything in the femoral triangle.
Surgeon: What is the medial boundary of the femoral triangle?
Surgeon: It starts with a P
Me:.... Pectineus? I can only think of muscles in the knee like popliteus....
Surgeon: It's the pectineus. ***I got one kind of right***

 This continues as he performs the hamstring myotomy and opens up the side of the back of the knee, visualizing it. He showed me the muscles, and I correctly guessed the biceps femoris long headand the short head.
Surgeon: So why do we open up this area?
Me: Because there is an important structure you want to save?
Surgeon: And what structure
Finally an audience member intervenes! Note that  this is all infront of the entire OR team of 6 people + Me + The Surgeon
Nurse: It's a nerve
After many more hints...
Surgeon: it's the peroneal nerve. (this means he gave up on me. darn.)

 He opens up the medial rear of the knee. I am watching this and not paying attention. He continues to ask me questions, me not realizing it. Then I zone back in to him talking to me.

 Surgeon: Too nervous? Me: No, I was just interested in what you were doing, what did you ask?
Surgeon: What muscles are here?
Me (not thinking, not nervous, distrcacted by watching him): Semitendinosus
Surgeon: And what's underneath there?
Me: Semimembranosus.
Surgeon: and what important structures are there?
Me: I don't know any.
Surgeon, that's right, there aren't any, that's why we aren't invasively opening it up.

This process continued through the other leg as well.

So I got owned by a surgeon and left knowing how utterly inadequate I am. He reminded me that he took anatomy in 1985, not last year. Why did I choose to do this for fun? And why have I arranged to go back asap? That will be discussed in Part 2: How I have no ego and it has made me able to achieve a lot AKA what it means to be a little sister.

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