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Ten percent more: Skirting the line between life and death in surgery

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

I was in the middle of my surgery rotation and was scrubbed in on a gastrectomy. A gastrectomy is a procedure to remove a patient’s stomach; in this case because of a stomach cancer. It’s a major operation that requires the manipulation of delicate structures but it offers an excellent outcome for many patients.

My job during the gastrectomy was to be a retractor – a classic medical student role. Retraction is a simple mechanical job that involves pushing skin, muscle, and other tissue out of the way in order to help the surgeons visualize the field in which they are working. More specifically, the attending surgeon handed me a metal plate and told me to use it to push down hard on the intestines so that we could get a good view of the stomach and associated blood vessels in the area. I was positioned behind the resident, who would be the one taking advantage of that view.

I pushed down with my left hand as the attending and resident went about clipping vessels and clearing tissue. Suddenly, the field of view filled up with blood. Some bleeding is to be expected during any surgery, particularly one like this. But this was more than expected.

The attending immediately started calling out orders. He told the resident to find the source of bleeding so that we could ligate it or clip it off. He asked the anesthesiologist to get blood ready in case we needed a transfusion. And then he turned to me and said, “Akhilesh, I need you to push down 10 percent harder. If we lose the field of view here, we might not find it again.”

I pushed down harder, and the search for the source of bleeding continued. The attending told us not to panic (when the attending says “Don’t panic,” that’s how you know there’s a reason to panic). He turned his attention back to me.

“Akhi, I need 10 percent more pressure.” And then: “20 percent more.”

I was getting tired.

“I know you’re getting tired bro, but give me 10 percent more.”

Finally, after a great deal of suctioning, searching, and approximately 130 percent more pressure, we found the source and stopped the bleeding. Everyone paused for a second to breathe a sigh of relief, and then it was back to the procedure.

The surgery was successful, and the patient ultimately went home without complications. Even so, the experience left me reflecting on several things.

First, it served as a reminder that medicine has high stakes. Surgery changes patients’ lives (generally for the better) while they lie unconscious on a table. In the case of this patient, a successful surgery represented the difference between near term death versus potentially many more years of life. Medical interventions have the ability to do the same.

Second, surgery is a remarkably unique environment. The feel of the room can progress from routine, with music playing and everyone chatting, to heightened to crisis and back to routine in the span of just a few minutes. And then it can do it again. Even a task as trivial as pushing down on a metal plate can suddenly come to the fore. In many ways, surgery demands that practitioners live in the moment because life and death takes on more immediacy.

Of course, relatively few surgeries have these moments. But knowing that they can occur prepares us to put in 10 percent more.

Akhilesh Pathipati is a third-year medical student at Stanford. He is interested in issues in health-care delivery. 

Photo by Shutterstock

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