03 February 2007

Typical Day on Pediatric Surgery

When I was a PGY-3 general surgery resident, I was one of four senior residents on an away pediatric surgery rotation. The pediatric hospital where I rotated for peds surgery was located away from my base hospital. It was a large tertiary referral center for the sickest children from a tri-state area. General Surgery residents from other hospitals and programs rotated with me. This hospital had a burn unit, that was managed by surgery, in addition to all of the other things that a very strong pediatric surgery department would cover like trauma and surgical emergencies.

Pediatric surgery is the one surgical subspecialty that covers every surgical aspect of their population. Pediatric surgeons create fistulas for hemodialysis access in the pediatric population. A pediatric surgeon will ligate a patent ductus arteriosus (persist vessel between the pulmonary artery and aorta). A pediatric surgeon will perform hepatic resections and resections of choledochal cysts in addition to removing lung tumors and repairing chest wall abnormalities. Pediatric surgeons will also remove thyroglossal cysts and cystic hygromas (neck malformations). Pediatric surgeons will perform skin grafts, tracheotomies and transplants in infants and children. In short, pediatric surgeons perform procedures in children that would be performed by surgical subspecialists in adults.

A pediatric surgeon first completes five years of a General Surgical residency. Most complete two years of dedicated research in addition to the five years of residency making a total of seven years of training just to get to the pediatric surgical fellowship. In addition, the fellowship is two additional years making a total of 7-9 years of training beyond medical school to enter pediatric surgery.

Landing a pediatric surgical fellowship is no easy task either. There are presently about 23 fellowships nationally which means that applicants for pediatric surgical fellowship will apply to all fellowship programs and hope for enough interviews to be able to land a fellowship. Criteria for selection are scores on the American Board of Surgery In-Traning Examination (ABSITE) and a high level of performance in general surgical residency. The small number of fellowships nationwide in addition to the fairly large candidate population makes obtaining a pediatric surgical fellowship one of the most competitive if not the most competitive that any physician can obtain. In short, pediatric surgeons are the elite among all surgeons.

My pediatric surgery attendings fit the mold of pediatric surgeons completely. All four did fellowship in top programs in the United States and Canada. They all were extraordinary teachers and all had amazing surgical technique. It was a joy to stand across the table and see not a single wasted motion or miscue. They were equally gifted in teaching both the craft and the art of all aspects of surgery not to mention being some of the most professional folks to work with in the operating room. They treated the OR staff and the resident staff with great respect and made learning quite enjoyable. Here were four individuals who were the absolute best of the best among surgeons and they were just wonderful to learn from and work with and were the "least malignant" personalities I have ever met. Some of my best times in the OR were on the pediatric surgery service as both intern and chief resident.

On a typical day, after finishing up cases in the OR (around 4pm) I would receive sign-out from the folks who were not on call. I would be responsible for checking all post operative patients to make sure that they did not have problems urinating or had adequate pain control. I also carefully checked all vital signs and dressings to make sure that there were no problems that needed to be taken back to the OR. In addition, the attending surgeon that was on call with me would check in before he left for the day, just to make sure that the house was good for the night. If there was an impending admission, he would let me know when the patient would arrive.

I could generally grab a bit of dinner from the cafe and then head off to check the burn unit and emergency department. I would also check for any patient who might need pre-operative orders. Most surgical patients were either emergency admissions, who would go to surgery that night or AM admissions who were still at home. Many nights, trauma patients would be flown in by helicopter from neighboring counties and thus would have to be cared for by my service (me alone after 5pm). The best thing was that most children are not out after 10 pm so traumas after 10pm were rare in pediatric hospitals and more common in adult hospitals.

By midnight, I would be napping in the call room. My naps would be punctuated by calls and questions from the nursing staff. In general, few things needed my presence at bedside if I had done my post op checks thoroughly. Usually, questions would be renewals of orders or an extra pain medication dose. I usually covered my post operative patients with something for nausea with a call to me before it was administered.

Often a first-year pediatric resident and a couple of medical students would take call with me. It was my duty to be sure that this resident and the medical students got the best experience. If I received a routine call from the emergency department, I generally didn't awaken my staff unless there was something that was going to the OR that night. I preferred to perform my own history and physical exams but I always gave the students a chance to check and observe the incoming pathology.

Patients who had been burned would be sent directly to the Burn Triage area and would not stop in the Emergency Department. Usually the Burn Triage nurse would let me know if a patient was coming. I would check over the burns, write the necessary orders and the nurses would take care of the patients. Again, adequate pain management was usually the most important aspect of burn care along with very strict attention to wound care.

My most memorable case was placing a newborn on Extra Corporeal Membrane Oxygenation or ECMO. This patient had been born with a diaphragmatic hernia that allowed abdominal organs to form in the chest cavity causing the patient's lungs not to develop properly. When these children are born, ECMO allows the hypoplastic lung to grow and takes over oxygenation for the child. Two large bore vascular catheters are placed in a neck vein and artery. I jumped at the chance to participate in this procedure because ECMO is rarely used. It had been 2 years before that ECMO had been done at this hospital. The resident that was on call had no interest in the procedure but I was thrilled to do this. Later I participated in the definitive repair of the hernia with a good recovery from a potentially lethal congenital defect. It was awesome.

I also participated in a liver resection in an 8-month old with cancer. Again, I had a chance to participate in a fairly rare case with very interesting pathology. This patient also did well after a week-long stay in the Pediatric Intensive Care Unit. The power of regeneration in the liver is nothing short of remarkable. In a pediatric patient, the physiology of these cases are amazing. Liver anatomy is also very interesting as are the techniques used in liver surgery. My favorite surgical instrument is the Argon Bean Coagulator which is used to coagulate the raw edge of the resected liver. This is literally a plasma scalpel.

By 4am, I am usually up, showered and making my early AM rounds. I try to get my notes written so that work rounds are not rushed before we start AM cases. I am required to be out of the hospital by 12 noon on my post-call day but usually, I am done by 9am. I try to make sure that my patients are taken care so that the incoming call resident is not weighted down carrying my patient load and his. For me, it's all about planning. I usually give a very complete signout with anything that needs to be watched and what I would do if there is a problem. The on-call resident only has to look at my sheet to be able to jump in and do what may be needed.

Another interesting aspect of pediatric surgery is seeing the patients in clinic. In general, the attending who is on call is in office while I am on call at the hospital. This made getting over to clinic more difficult but I did get some clinic time. It is good to see the patient in clinic, do the work-up, perform the surgery and post-op care and then see the patient back in clinic. I love to see how my closures worked and the patient pain-free. Clinic was always interesting.

I thoroughly enjoyed my pediatric surgery rotation because the patients are great fun to take care of and because peds surgery pushes the limits of a surgeon's diagnostic capability. A surgical abdominal problem in a pediatric patient present far differently than in an adult patient. Even hernia repairs in pediatric patients are more fun than adults because the anatomy is seldom distorted.

I also always keep in mind two quotes: One from Alfred Blalock, the late chairman of surgery at Johns Hopkins. He said, "It's takes arrogance to cut open a human being." and the other from one of my pediatric surgical attendings who said, "You wouldn't hand the keys of your car to a total stranger, yet these parents hand over their child to you, the total stranger. You have been given a great trust."

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