The ins and outs of surgery

Sometimes the designation of ins and outs can be arbitrary. We tend to think of a toilet or a garburator, for example, as being unidirectional. What goes in doesn't come out- at least not where we can see it. So it is with certain body parts. Yet, as I learned today, the line can definitely be blurred.
I just started a practicum with a gastrointestinal surgeon and found my first day in surgery with him today to literally be at the backside of medicine.
We started the day with seeing a few ward patients and then scrubbing in for the first surgical case- a lower bowel resection. The unfortunate gentleman had had his fill of diverticulosis (no pun intended, but diverticulosis involves inflammation of little pouches in the intestines that fill with fecal matter) and had elected to have part of his colon cut out.
Once he was thoroughly anesthetized he was positioned in a modified lithotomy position- which most mothers know all about- and most men can't even imagine- and most of his extraneous body hair removed by a scary looking resident with an even scarier pair of clippers. Of course removing hair during surgery makes sense, but I can just imagine the poor guy waking up and thinking, you shaved me where?
The second case was a colonoscopy- done under a sedative, not general anesthetic, so the poor lady was awake for the uncomfortable procedure. (A colonscopy involves inserting a camera up into the intestines and taking a video for diagnostic purposes.) I had just tried to convince my Dad the night before of the necessity of people over 50 getting regular colonoscopies, but after watching one today I decided to keep some of the finer details to myself and hope that he doesn't disinherit me after he has his first one.
The third case was a poor man with one of the biggest sets of hemorrhoids that I've ever seen- plus an anorectal fistula that had to be cut out. (Briefly, a fistula is an abnormal opening between two places, and in this case was a sinus that tracked from inside his rectum and opened up outside where it was not supposed to, and had frequently been infected.) Unfortunately he hadn't received proper bowel prep before the surgery- which nicely means that his bowels hadn't been evacuated first, so they evacuated during the surgery all over the doctor and the resident and the floor. Thankfully I was standing back far enough to escape judgment. The hemorrhoids were massive and there was copious amounts of blood and the smell of burning flesh when the cautery tool cut, and the infected fistula....
I've been suffering from a bad cold/cough but was feeling better today and decided to go to work anyway, but my nose was tickling and I could feel snot begin to drip down inside my surgical mask. There is nothing to be done about snot in surgery- but the feeling of snot dribbling down my face and not being able to wipe it was almost too much to handle. I just kept staring at that bloody, crappy mess of a surgery and tried to think beautiful thoughts.
The fourth case was another internal hemorrhoid repair, then the next two were both inguinal hernia repairs. During a break I went into the staff room and one of the anesthetists was sitting there with an open bag of plain bran flakes, eating them by the handful. I started to laugh cause I'd been thinking about bran cereal too.
“Hey, I work in gastrointestinal surgery.” He said pointedly. “I'm going to eat my fiber if it kills me. I never want to end up like one of those guys.”
The next case was an excision of a pilonidal cyst. Basically it involves an abscess formed by an ingrown hair of the anal cleft. I will leave you to imagine why the young man having the surgery was so embarrassed to see me appear in the operating room. Sometimes youth and beauty are distinct disadvantages to fostering patient trust and reassurance.
The last case of the day was long and drawn out- the woman had a ruptured appendix that needed to be removed. I was standing at the head of the bed talking to the anesthetist as he prepared to anesthetize the patient, and he was asking me questions and making fun of me. He had begun to run the general anesthetic via IV and asked me to come and hold the oxygen mask on the patient's face. Slowly she began to drift to sleep as she received nitric oxide and the anesthetic and when she went limp the anesthetist showed me how to keep her breathing by 'bagging' her (squeezing a balloon attached to the mask.) He had got out his utensils for intubation and explained to me that as long as I could bag her manually there was no hurry to intubate, one could take their time.
He held up the tongue blade and demonstrated to me how it clicked open.
“The most important thing to remember,” he said, “Is to go in gently. You can kill someone if you go in roughly. Or you can permanently damage their vocal cords, or perforate their esophagus. So gently is the way to go.”
And then he handed me the tongue blade.
I should add at this point that not only have I never intubated anyone in my life, but I have also never actually closely watched someone do it. And it is not an easy skill. Many medical students practice on cadavers first. I had no idea what to do with the tongue blade, nor with the airway tubing or all the other pieces.
“The thing you need to know,” the anesthetist said, “Is to go gently.”
The thing I need to know, I thought, is just how to do this in the first place. And he lifted the mask off her face and suddenly I had my golden 30 seconds to get that tube in. Well, I got the tongue blade in and tilted her head back and the anesthetist asked if I could see the vocal cords and I thought, is that what vocal cords look like? And I slid the tube down her throat and lodged it in her esophagus and then pulled it out again and the anesthetist helped me find the trachea and then I advanced the tube down into her lungs and removed the tongue blade and connected her to oxygen and her chest began to rise and fall.
“Be careful about pressing the blade against her lips.” He said to me. “Because if you cut them, there's a lawsuit. Now next time you do it, it will be a lot easier.”
I felt suddenly like I'd broken into a cold sweat of relief. Although it could have been the snot dribbling down my face, but at that point I didn't care. The ins and outs of surgery are not what I imagined them to be- sometimes grosser, sometimes scarier, usually exciting. And most importantly; they're educational- which explains why at this point I'm heading up the kitchen to drink some prune juice and have a bowl of bran flakes.