Thursday, March 4, 2010

Warm and Squishy

The nurses have all warned me about The Endocrine Surgeon - “he’ll expect you to know your stuff!” Well I haven’t been feeling well, so I only had time to cram for my session today. I’ve heard a lot about his thyroid surgeries, so I read up on thyroids in my anatomy text, my second-year notes (which consist mostly of unrelated drawings) and two of my clinical textbooks. It’s a bit rushed, but I think I’m ready. And then I get to theatre, and see that the list consists of all breast surgeries and a hernia repair. Oh dear.

He doesn’t ask me a nasty, tricky anatomy question straight out like I’ve been warned. He waits until partway through the mastectomy, points to the muscle layer and says, “This is the pectoralis major muscle here. What lies directly beneath it?” I’m not sure if this is the famous First Question that he has reserved for me, so I hesitate, then realise he is waiting and say in a small voice, “pectoralis minor muscle?” Yes. Yes it is. And I am on edge from then on, because (a) it must be a trick, the hard question must be coming, and (b) the nurses still look like they’re ready to swoop in and rescue me.

Between patients, the nurses make me go and get a coffee because everyone else is. And my GP supervisor (who is assisting the surgeries today) quickly gives me some answers to some breast-related questions that the surgeon might ask.

Sure enough, as I am scrubbing for the next operation, the surgeon comes in and asks me to list the reasons for removing a fibroadenoma of the breast.

Thanks to my timely GP tutorial, I can answer:
· Symptomatic (I.e. painful)
· Fine needle aspiration results showed some suspicious cells
· Lump is growing in size
“Very good”, he says, “and interestingly it is the same for thyroid nodules”.

He starts letting me do a lot more then, like cut sutures and hold retractors. During a partial mastectomy he hands me the offending fibroadenoma, so that I can feel its bossilated surface for myself. I marvel at its surface (yes it’s bossilated, but very shiny), its texture (very hard), and silently at the fact that it is warm and the surrounding fat is squishy. And then further marvel at the fact that I wasn’t expecting it to be warm and squishy.

Later, he is repairing a paraumbilical hernia (hernia at the umbilicus, but apparently only congenital ones can be referred to as “umbilical hernias”). He pokes and prods the herniated omentum, trying to force it back into the abdominal cavity, and eventually gets it all back in. Then he invites me to put my finger into the hernial orifice and feel the abdominal wall from the inside. How strange it is! I can feel the muscles, and the fat, and even a loop of small bowel. And OH MY GOD IT’S WARM AND SQUISHY!

I thought the warm and squishy theme might end after lunch, when we started consulting. After all, my specialist consulting experiences so far have involved me sitting in the corner trying to stay awake enough to ask and answer questions. But The Endocrine Surgeon follows up a lot of his mastectomy patients year after year, so of course there are a lot of breasts to examine. I learn his technique, learn to identify ribs, normal breast parenchyma, and fibroadenomas (“like a marble under a newspaper on the kitchen table”). He also tries to teach me how to feel axillary lymph nodes, because apparently in slim people, he can feel normal lymph nodes 70-80% of the time. I can’t feel them at all, but I try ... digging my fingers into a large lady’s damp armpit until he finally allows me to give up. Mmmm. Warm and squishy.

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