Surgical Subspecialty Wrap-up Part 2 of 3: Vascular Surgery

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“If you want to take care of people, do medicine. If you want to fix people, do surgery.” – Cardiothoracic Surgery Resident

Vascular Surgery – Eskenazi Hospital

For my next rotation, it was off to Eskenazi Hospital. This is one of the three Level 1 trauma centers in Indiana, all of which are located in Indianapolis: Eskenazi, Riley, and Methodist hospitals. It is a relatively new hospital, which was finished in late 2013. It is the re-branded version of Wishard Hospital, which was historically known as the place where mainly uninsured patients received their care. Going by this fact sheet, Eskenazi has about 45% uninsured, and an additional 45% of Medicare plus Medicaid patients. For a brief note here, which I might explain more fully in another post, Medicare is government provided insurance for those over 65, and Medicaid is for those below a certain income threshold.

Vascular surgery is an area where I came in with less preconceived notions than plastic surgery. Beyond the name, which I took as meaning surgery….on vasculature (arteries and veins), I had no idea what to expect. Right off the bat, I liked Eskenazi as a hospital. It was new, clean, nice, and has windows practically everywhere! Our team room was on the corner of the 8th floor and had windows on two sides which provided for an amazing view. It made me happier being able to see outside, and occasionally the sun. Seeing the sun for more than 30 seconds is usually worth its weight in gold in a hospital. However, the OR’s were a lot more…drab, for lack of a better word. It just felt a little too sterile. Which is ironic, considering in any OR the level of sterility reaches levels most people would call insane. Only touch blue things. Don’t touch your face. Don’t put your hands there. If you touch the wrong thing, be prepared to completely change out of your sterile gown and gloves, re-scrub, and get new ones. I’m surprised I didn’t have to change into a new gown and gloves if I so much as thought about touching something not sterile.

But on to vascular surgery. Vascular surgery is similar to plastic surgery: it has an integrated residency that is 5 years, or has a fellowship from general surgery, generally adding 2 or 3 years to the 5 years of general surgery. It is surgery on any of the arteries (which take oxygenated blood away from your heart) or veins (which take deoxygenated blood toward your heart) that lie outside of the heart and brain. Medicine has these weird sort of divisions between specialties, and this is one of them. If the blood vessels are in the heart, a cardiothoracic surgeon or interventional radiologist (IR) takes care of it, while in the brain either neurosurgeons or IR’s take care of it. It is a little more well defined than plastic surgery in that it has a subset of conditions that are pretty much solely vascular surgery problems. Any time a bullet or knife hits an artery or vein, it’s a vascular surgeon’s territory. When your aorta (a big blood vessel that essentially acts as a “trunk” that most of the arteries in your body run off) is injured or expands like a big balloon (called an aneurysm), it’s also a vascular issue. Same with if your carotid arteries (which run to your brain) or your lower limb arteries get gunked up with fatty plaques (atherosclerosis).

The types of procedures that vascular surgeons do can be split into a few categories:

1. Suturing vessels back together that are open/torn when they’re not supposed to be.

2. Re-opening vessels that are blocked due to various reasons.

3. Bypassing arteries that can’t be opened using methods in #2.

4. Putting in a tube (called a stent) to restore flow in an artery or protect it from rupturing.

5. Blocking or ablating vessels (mainly veins) that have become problematic.

In a very short amount of words, that provides a fairly decent picture of the entire specialty. It, like plastic surgery, is a small field that is often confined to bigger medical centers. There isn’t such a thing as a “neighborhood vascular surgeon”. Examples of their procedures that I witnessed include a carotid endarterectomy, which involves clamping off one of the two arteries that goes to your brain, filleting it open like a fish (or steak? or cow? meat?) and cleaning out the junk that has accumulated; this helps prevent a stroke, which is incomplete blood flow to your brain due to occlusion or a bleeding problem. They also do some really cool surgeries, especially for trauma. If a bullet destroys part of an artery, a vein can be harvested (normally from the leg) and used to replace that piece of injured artery. Which, if you think about it, is sheer madness. And it works, really, really well. Turns out you can actually get away with missing a few veins. There’s a fun fact for you people.

See, the thing is, I’ve just described all of the cool stuff in vascular surgery, which is mainly what are called “open” procedures, AKA when they cut open the skin and actually look at the artery and then fix it. Turns out, that’s actually becoming a smaller and smaller fraction of the operations that a vascular surgeon does. Most of the procedures are endovascular. This means that only a small hole is made in the skin, and then through the vessel to allow various wires, catheters, tools, and tubes to be placed into it in order to repair it. A gigantic, continuous x-ray machine is used, in a technique known as fluoroscopy, to provide little gif-like snapshots of what is happening. All of the wires are radiopaque, which means they are visible on x-ray. But Brandon, you say, what does this mean? It means everyone has to wear gigantic lead aprons under all of the already sweat-inducing sterile gown+gloves in order to protect from radiation, most of the surgery is looking at big TV screens, and the surgery amounts to basically poking a wire through a hole 100 times until something happens. Honestly, this is what it feels like I’m watching during an endovascular procedure. Procedures are becoming more and more endovascular because they have better recovery times and are usually more well-tolerated by the patient.

So, to make sure you’re visualizing this properly, I’m standing up, sweating profusely under this lead, fogging the crap out of my mask, unable to touch my face, watching a surgeon repeatedly stick a wire in and out until it somehow goes through, when a balloon is then inflated or a stent is placed. People, it’s Boring with a capital B. That was my opinion of it at least. The open stuff was incredibly cool. The endo stuff made me want to rather sit and watch Donald Trump try and say something intelligent. I’d rather watch paint dry. I’d rather play Super Mario with my eyes closed. Or play 18 holes of golf with a pool cue. And I hate golf. Or sit and list more ways I could beat this dead horse.

This rotation brought a small, albeit important, revelation to my specialty decision: the trivial things that aren’t even medicine related matter. What I mean by that is simple questions like, “Do you want to wear 15 pounds of lead every time you do surgery?”, “Do you want to be able to touch your face when you want to?”, and “Can you tolerate 4+ hours without eating or drinking or going to the bathroom on a consistent basis?” are incredibly important, almost as much as the content of the specialty that you like. It wouldn’t matter how much I loved surgery if I hated being and working in a sterile field. The frustration of that on a daily basis would mount and make me grow to resent my entire life. Comfort in the OR is a fickle thing, and not being able to scratch that random itch that only popped up as soon as you have scrubbed in might be too much for some people to handle, and I don’t blame them. Even things such as being able to sit down frequently (medicine specialties) or having to stand for long periods of time (surgical specialties) also play a factor in that decision. What I’m saying is I really, really hate wearing lead aprons. This is my career and my life, I’ll be darned if I won’t at least be comfortable during all the time I spend in medicine.

The one thing I’ll give to this rotation is that it really whipped me into a better medical student in a hurry. Even though the rotation was only 10 days, I was expected to know my patients and their history; I actually got to see and present patients in clinic, and I was relentlessly grilled with questions in the OR about anatomy. Which turns out, I forgot a lot of. This is known colloquially as “pimping”: when attending physicians, and sometimes residents, ask us questions to test our knowledge. And if you miss one, they will just keep pouring them on. It can be humiliating. I’m far from the smartest med student, but I’m not a completely idiot, and I would whiff on the most simple of questions. Advice for your surgery rotation (if you’re a medical student): go back and memorize all of anatomy. ALL. OF. IT. My attending actually asked me a question of “Where are we going to make this incision?”, and after my hesitation (because it was a trauma case and I had no idea what type of surgery we were doing, let alone how to do it or what he was even asking me) he then proceeded to say, “We aren’t starting this surgery until you tell me where. Don’t waste our time.” I then got the question wrong and proceeded to feel terrible. He eventually started the surgery, thank God. I was maybe hitting 25% of questions that surgery. I was rattled. It was a bit traumatizing. Not all attendings are like that, and I know he was just trying to challenge me, but at the time I was  angry at him. I got over it and realized it should push me to be better.

I think I’ve effectively babbled long enough about vascular surgery and the things it helped me realize. It’s time to grade it, this time using lead aprons:

Vascular Surgery, Graded

Cool factor: 7/10 aprons for open procedures, 2/10 for endovascular. The open cases, especially the trauma cases, were really interesting. It’s pretty crazy to see where a bullet or knife has damaged a blood vessel, or how you can effectively clamp off half of the brain’s blood supply. The endovascular stuff was cool in the sense that all of medicine is cool, but that’s about where it ends. Maybe it’s fun to actually be the one poking the wire up an artery, but honestly I’d rather be doing almost anything else in medicine.

Type of work: 5/10 aprons. Surgery is fun work, but the endovascular stuff slaughters this rating down to a 5. This is probably the lowest-rated I will ever do in this category for a surgical specialty. Vascular is mainly a surgical field with approximately 4 days of surgery and 1 day of clinic per week. I’m not a huge fan of clinic more than a day or so per week, so it fits that pretty well. However, the extreme specialization of the field, combined with the limited array of procedures (in my eyes) makes it not up my alley so much. Besides, they don’t get to deal with the coolest vessels, which are in the heart and brain. Oh, and usually the structures vascular surgeons work on are pretty tiny. My gigantic fingers won’t get along well with trying to baby their way around tiny things. As a disclaimer, I didn’t get to see any of the abdominal aortic aneurysm repairs, as these wasn’t done at my hospital. That might have bumped this up a little bit. 

Lifestyle: 5/10 aprons. The situation here is similar to plastic surgery: it’s a small field, highly specialized, and the workload can be high due to those factors. Again, it’s also surgery, so it can kind of suck in terms of hours. However, they do get compensated very, very well. High number of hours per week, along with relegation to an academic center are the norm.

Ease of attaining residency: 3/10 aprons. Again, this is similar to plastics, there isn’t much to say here. It can also be accessed via a general surgery route, but there are very few spots for an integrated residency program. Board score requirements are high and the number of spots are low; this is a sign of a selective residency.

Bonus category – Lead addicts anonymous: 11/10 aprons. If you love lead, this is the specialty for you. The hug of it on your body might be comforting, but the sweat and weight are not.

Pros: Surgery is surgery, it’s good being in the OR, they get paid well, open procedures and trauma are interesting and varied, procedures often make an immediate difference in a patient’s life.

Cons: Endovascular surgery is boring, having to wear lead, hard to attain a residency spot, having to wear lead, being confined to an academic center, being trapped in lead, relatively small spectrum of procedures, working on small structures, small number of overall physicians, and being forced to accept lead overlords.

Overall likelihood of me choosing this specialty – 4/10 aprons. Honestly, I just wasn’t a big fan of vascular surgery, as I’m sure you guessed by the tone of my article. I’d rather do it than some non-surgical specialties, but I can confidently say it’d be my last choice among the surgical ones. It’s a “If I was the last surgical specialty on Earth, would you choose me?” sort of thing. I mean, I suppose, vascular surgery. But only if you were the last one.

-Brandon

A song from my STEP 1 studying playlist. Mrsuicidesheep on Youtube is a great channel for chill music for studying:

Oh Wonder – Technicolour Beat

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