One of the best decisions I made in PA school was to spend my surgery rotation away from Hershey Medical Center at a small, rural hospital in Coledale, PA. The advantage being that I was the only student on the surgical ward, so I got to participate in every surgery (and act as first-assist on several). That is not to say that there aren’t advantages to rotating at a large academic institution like Penn State. At an academic institution you get to see traumas and complex cases that will never present to a smaller hospital. However, you also have to compete with residents and other students for hands-on experience. I, personally, preferred as much hands-on stuff as possible.
My preceptor, Ken Sherry, organized my rotation to give me the widest breadth of experiences possible. The majority of my time was spent with the Orthopedic and GI services, but I also got to rotate with general surgery, surgical oncology, radiology, urology, podiatry and wound care. Approximately 80% of my time was spent in surgery and 20% in clinic. I appreciated being exposed to so many different aspects of surgery. Even if I never work in surgery, I now know first hand what is involved in many procedures that my patients may undergo.
The Operating Room is an interesting environment. It is a world with its own gravity. It has its unique set of rules, rituals, and culture. It may feel like you are relearning how to walk. You are expected to learn quickly what not to touch, how to walk past somebody who is sterile, how to scrub your hands, how to gown, how to glove, where/when you must wear a mask, how to pass tools, how to talk, etc. And every nurse and scrub tech is watching you constantly, waiting for you to screw up. This was frustrating the first few days in the OR. However, once the surgical staff got used to my presence there, they started to be more lax and treat me like a member of the team.
Overall, I enjoyed my time in the OR. The surgeons would play music while we worked, the nurses and scrub techs were friendly, most had a crass sense of humor (which I was used to in the ED), and there was a sense of family among the surgical team. A few of the nurses even took me under their wing and made extra time to teach me about the surgical tools and the intricacies of sterile technique.
My responsibilities varied, depending on with whom I was working. On the GI service, I generally was the one to operate the camera when we were doing laparoscopic procedures. If we were repairing a hernia, I would provide retraction and suction. On the Orthopedic service, I did everything from make the first incision on arthroscopy procedures to drilling in screws during a femoral fracture repair. In the Ortho clinic, I saw patients on my own and performed joint injections. The surgeons seemed to enjoy teaching and always gave me plenty to do.
Of course, there are a few cases that stick out in my memory.
For starters, I got to cut off a leg. I know that is not exactly the sort of thing you brag about because it is tragic for the patient… but as a student it was pretty cool. Most of the cutting was done with bovie cautery. Essentially, we slowly burned our way through tissue, cauterizing or ligating bleeding vessels as we came to them, sawed through the bone with a power-tool, and then continued cutting until the leg came off. It was a strange sensation to hold a leg that is detached from its body. It felt a bit like a horror film.
Another memorable case was what started as a simple inguinal hernia repair. The patient’s bowel had herniated into the scrotal sack and was incarcerated. As we did our initial exploration of the contents of the hernia sack, however, what we found was visually baffling. The patient’s ileum and parts of the colon had fibrosed together into a single large mass. To complicate matters more, there was a large chunk of tissue that had twisted and cut off its blood supply, causing it to undergo necrosis (it looked like a large, spongy black egg). We had to call in a specialist for a second opinion before we tried to dissect this thing apart. What started as a simple, hour-long procedure turned into a 6-hour case. By the end, we dissected apart most of the large bowel and removed the necrotic material. Parts of the bowel that could not be saved were removed while the remaining bowel was anastomosed back together.
- Practice suturing before this rotation. Things I would focus on would be hand-ties (single and double-handed technique) and internal sutures. You will rarely be asked to place simple sutures. Internal sutures look much easier than they are in real life. The difficulty rests in holding the instruments properly as you drive the needle. I would suggest watching one of the surgeons or preceptors do this on your first day and noticing how they hold their instruments. Even better, watch some YouTube videos before you walk in the door.
- Ask for experiences. By far the most important thing I could tell you for this rotation is to be proactive about asking for experiences (especially if you are at a larger teaching-hospital). About halfway through my rotation I approached the anesthesiologist on our case and asked if he would let me intubate the next patient. I wish I had done this earlier in the rotation, but felt fortunate that, by the end, I was allowed to intubate over a dozen patients. Don’t be afraid to ask!
- Be aware of your surroundings. The last thing you want to do as the student is to contaminate the surgical field. Equally as bad, don’t contaminate the instrument table! You might have some minor slip-ups while working in surgery (like scratching your head with your sterile gloves). Be sure to IMMEDIATELY notify someone when they happen. Also speak up if you notice someone else contaminate themselves, especially the surgeon. They shouldn’t get mad at you; this is about patient-safety. On a side note, my preceptor told me about a case where the student lost his contact INSIDE THE PATIENT’S ABDOMEN. Try not to let that happen…