Intensive Surgical Skills Course

I did say it was a gnarly looking fracture

I’m standing in bottom level of a three story wooden tower. Smoke lazily drifts around the small room. Beams of light dance through the gaps in the wood siding and create patterns of light in the lazy smoke. Gun shots ring and I drop to the ground and curl in the fetal position. Looking down I see a gnarly yellowish-white femur sticking out of my left pant leg. I hit the go button on my remote and blood comes gushing out of my wound. My backpack only holds 3L and I was instructed to use it wisely. After a little puddle of blood formed around me I stopped my pump (I didn’t want exsanguinate just yet) and spread some blood around and prepared for my acting debut.

SWAT burst into the room (extremely fast response time, must have been right there waiting for the drill…). Better safe than sorry, treat everyone like a potential threat, even the amputee screaming over a bloody stump and the guy rolling around on the floor in his own blood screaming that he is going to die. With a quick glace SWAT cleared the room and moved on… Okay, this isn’t the purpose of my writing but I just want to pause and say “BAAAAAAD!” I feel a little better but I’ll get back to that. Yes, SWAT has a job to do but I felt like being a drama queen to see if I could get a little attention so I turned back on my blood pump to make a bigger puddle and increased my volume, tone, and language. No go. By now I really want attention, my blood puddle is my surrounding me and not something that should be ignored. Finally all of my screaming paid off! Someone decided to drag me out of the building… it’s a start… but somehow that turned into the only step as he re-entered the building. Time to bleed a little more and scream more still. Still no attention. Then the building blew up so someone decided I needed to go so he screamed at me to get up. Okay, again I’ve been sitting there at least 5 minutes (inside and outside of the building) and no one even looked at my leg or anything and he expects me to get up… hypovolemic shock anyone? Also I’m fairly sure I learned multiple carry methods in Boy Scouts for moving an injured person quickly out of danger. Being cooperative like I normally am (just ask my parents) I drug my shot leg while thankfully the SWAT member realized that I could use some support. After hobbling a safe distance again I was deposited while my most recent SWAT friend went back. This time however was different, someone (I’m assuming a supervisor) noticed that I did not have a tourniquet on and jammed my femoral artery with his knee while he started screaming about me not having a tourniquet on and needing one. Apparently he didn’t have a training tourniquet and didn’t want to use his real one so he informed me that I had a tourniquet on and then he supported me to our ER (thankfully it was close because it was miserable hopping on one foot while attempting to not use the good leg and to appear hypovolemic). Once I was triaged into a bed in the ER I decided to pass out because I had run out of my 3L of blood and was tired of screaming.

Thankfully, this was a training exercise with Strategic Operations. I was there as a medical student to participate in Intensive Surgical Skills Course or as we like to call it, Cutsuit Week. Students at Rocky Vista University on military scholarship (ooohhh that’s me!) are able to participate in “hyper-realistic” training along with first responders and some super human heroes (two Navy SEALs took on California Highway Patrol in a paintball game and destroyed them… those type). First responders rescue the victims and we medical students triage and treat in an emergency room setting while other classmates “operate” on surgical cases in our operating rooms.

They do impressive makeup,
I think Nathan got in a gun fight

Training is a great thing. For myself and my classmates it was the first time we had exposure to mass casualty (well besides a mass casualty drill at our school but we were just bodies for that and not doing medicine) and honestly we may have more experience than most practicing physicians in the US for mass casualty events. For the first responders (aka the SWAT members that let me exsanguinate (I’m just going to say I like its sound a lot more than “bleed out” even though Word doesn’t have a definition for it)) it was a time to take what they’ve learned and apply it. No matter what you know, when you’re caught up in the moment you tend to forget things. I’m sure all the SWAT members that cleared the room, dragged me out of the building, and dragged me to the ambulance know that tourniquets are the top priority because it doesn’t take long to bleed out and DIE. In the heat of the moment I’m sure the first batch wanted to find the bad guy while the others forgot their primary assessment and didn’t remember that controlling massive hemorrhage (that whole bleeding out thing again) is top priority.

What training did I get to do (I guess its only fair because I pointed out the flaws of the SWAT members)?

I feel like I had the best order for going through this experience. I started off as a patient and got to observe first hand mistakes being made on me, and then I was an observer where I got to observe the staged incident then all parts of the medical treatment. After a skills workshop my group was ready to start playing doctor.

My first doctor assignment was that of senior ER resident. That meant my job was to oversee everything going on in the ER (okay well my side, we had a 6 bed ER and each “senior resident” got 3 beds to oversee. Additionally I should add that ER is not the most politically correct term, it is now ED for Emergency Department, its not just a room… anyways I still prefer ER because I feel like most people are like myself and hear ED and think of erectile dysfunction…) and coordinate our resources such as x-ray machines and surgical consultations. It was the perfect job for me, I got to bounce around and see what was up with multiple patients and confer with their doctors (my groupmates). Oh, I also got to tell people what to do and that was fantastic, it’s a part of my personality that I have attempted to hide so that I can make more friends but when it was needed it came out and I forgot how much fun it was to make decisions and go with it! I kicked someone out of my ER! … well actually it was just a delay… Someone stable got past our triage (I think fire carried her straight in because she had a gun shot wound to the arm, however in a mass casualty situation she was low priority because her bleeding was controlled with a tourniquet and she was stable) and we needed the beds for those in more critical condition. That’s mass casualty medicine; treat the ones that you can treat with efficient use of your resources to try and save as many people as possible. Being emergency resident was a good learning experience to manage multiple tasks at once and prioritizing. Personality wise, it was a great match for me and again I am considering Emergency Medicine (but we will have to see once I start working with real patients).

That doesn't even look that bad now

Next I actually got a patient! After having seen a lot between being a patient, observing, and then running the ER, I had figured out what should be done and I was determined to rock it! I feel like I did well, my patient had a gun shot wound to the abdomen and I got him stable and all of the important information that surgery would need before operating on him (well okay I forgot to ask about a prior history of getting shot, for some reason that is not one of our normal questions we are trained to ask during a patient encounter. They do say that you should ask about prior experiences with the condition and apparently that applies to gun shot wounds). Surgery told me it would be 10 minutes and thankfully an actual practicing physician (we call them attendings) told me that it really means to plan on 30 minutes and sure enough a while later they came out and told me that it was going to be even longer of a wait than expected. Sadly, because of the delay they thought it would be great to simulate different changes in my patient (in addition to constantly monitor his blood pressure and level of consciousness) including a sky rocketing pulse and coding. The code was a great learning experience, at the time of cut suit week I had not had Advanced Cardiac Life Support (ACLS), but there were paramedic students assigned to us that had ACLS training. Delegation is a great thing, I told them to run the code and I stepped back and let them follow their training.

It was great to work with paramedic students in the ER. Both parties learned from this experience. In medical school we are not taught much about other provider types (other than be nice to nurses) and people still refer to paramedics by the derogatory term of Ambulance Driver. They do more than that. Medical training focuses so much on the “why” and “how” things happen during our first two years and we get very little “what” training. The paramedic students get the opposite training, they learn the “what” and get very good at it. They knew how to run the code, quickly evaluate the patient, and what drugs to give them for different conditions (however I knew why we gave different meds for different situations). My student looked at me a little (maybe a lot) disappointed that I didn’t know things that were so basic to him but my time came when the attending physician wanted an H&P and he didn’t know what an H&P was. After explaining it was a history and physical I started going into more details about what happened and doing a full physical and that was a foreign concept to him. Different education for different reasons.

During our surgery blocks we rotated though being surgical techs, circulating nurse, first assist, surgical resident, and anesthesia resident. I found my calling… if med school doesn’t workout. Surgical tech was so great, it helped that I had a great surg tech student helping me learn but the great part was that I could be completely obsessive about where my tools where. The surg tech keeps an organized tray of instruments to hand to the surgeon or first assist, they keep track of tools and keep things organized. That is a job that was basically made for me. Also, I didn’t know but they are taught a lot about different types of surgery and what tools are needed for different tissues so they can be prepared for what the surgeon needs. Again different training for different purposes but still extremely vital.

Next I was with the anesthesiologist learning about what goes on behind the drape. Its one of the mysteries of medicine, what goes on behind the drape… besides Sudoku and crossword puzzles. Our anesthesia attending was fantastic, he walked everyone through the process pre-op considerations, putting the patient under, management of anesthesia during surgery, and waking the patient back up. It was an applied look at the pharmacology we have been learning for the past year. He did such a great job that I think a lot of people are now considering anesthesia that had never considered it before (yup I’m in the category but I’m not the only one. I was actually told by a classmate that they could see me doing anesthesia because I’m so chill… she apparently hasn’t seen me outside of class when I’m not so chill).

Don't turn your back to crazy bloody patients
even if running to the safety of the OR

As circulating nurse I was sent out to see what was going in the ER because we heard that there was a mass casualty and gunshots but we didn’t know what we were expecting. I walked into the ER and saw at least three people with gunshot wounds being carried in and knew that it was about to get busy so I turned to return to the OR and was attacked from behind by a crazy bloody patient. Lesson learned, don’t turn your back to the patient. I returned to the OR all bloody and the looks I got were awesome.

Assisting and operating were both interesting. I do really enjoy doing things with my hands and fixing things so in that aspect surgery has interested me in the past but as I have done more with patients I really have enjoyed getting to know the patient and working with them face to face and I think I would miss that in surgery. It was fun for my case, I had to attempt to suture the inferior vena cava (the vein returning all the blood from below the heart to the heart). Personally I think I did fairly well until I cut the knot that I tied on accident. Its not easy sewing something back together that is so deep in the body and fragile, also the fake blood was really sticky and my gloves would stick to the thread I was attempting to tie. Closing the abdomen was easier because it was a large needle and I was able to get into a groove with that.

That was my week.

Looking for bleeding

Sew 'em up

What did I learn? Initially I didn’t think that it was going to help us as much for boards but as I’ve been doing practice board questions as part of my study routine I’m finding that something we were exposed to helped me answer some questions. Most of what I learned will be good for me over the next two years during my clinical rotations. I learned that I can actually do stuff, the didactic portion of medical school stomps all confidence and good feelings you have about yourself out. I’ve heard an adage “Ask four surgeons their opinion and you’ll get five answers.” That I learned was true, I was the last of five to operate and I got a surgeon that we had already worked with. Over the previous four surgeries I paid attention to the way surgeons wanted things and attempted to apply those just to get a lot of “why are you doing it that way?” Not only is the adage true but it has prepared me for surgical rotations to know that surgeons are different and I can ask the surg techs the different preferences. Actually, I really learned to make friends with the techs and nurses from this experience and what’s a good way to make friends? One don’t act like you’re better than them because you’re going to be a doctor and they’re “just” a nurse or tech, they know more than me in what they do because they’ve been doing it longer and I’m good with that and want to learn from them. Second osteopathic manipulation can make good friends, especially with those that stand on their feet all day in an OR. Just saying I had many classmates wanting a quick spinal manipulation between operations.

I hope that I won’t be involved in a mass casualty event during my life. Sadly, the world is very crazy right now and there is a chance that I will have to apply this in real life. My Eagle Scout attitude comes out and I do want to “Be Prepared” for anything that can happen and this training did great for that.

Tyler