Fat passes

When I was a third year medical student, I did my surgery rotation at a community hospital based in a wealthy neighborhood. Nowadays, many hospitals are struggling to stay afloat financially, so many of them rely on certain money making procedures. Plastic surgery, orthopedics, and gastric bypasses were the bread and butter for the hospital that I rotated through, so I became very well acquainted these procedures, especially gastric bypass.

Gastric bypasses are quite complicated. They take a good couple of hours to complete and usually require a fairly large incision. For a medical student, the larger the incision, the better because it means that you'll be able to see more. If you've had your appendix removed recently, you'll know that the incision they use is hardly 2 inches long. The surgeon basically has to use their finger to feel into that incision and dig out the appendix. The result is a small scar, but for the medical student, there isn't a whole lot to see, and this can be kind of boring.

Gastric bypasses usually involve stapling part of the stomach so that you feel fuller after eating just a small meal. Then the end of the stomach is cut off and rejoined at a point farther down the intestinal tract. This way, once food leaves the stomach, it bypasses a large portion of the intestine resulting in less absorption of calories.

The first few times I saw a gastric bypass, it was pretty fascinating. Cutting off the stomach and then re-attaching it at a different point (anastamosing) seemed like basic plumbing, but was surprisingly complicated. It involves careful stitching with delicate hands. And the fact that there is such a large incision means that you can see other organs: the liver, gallbladder, stomach, small intestine, large intestine, and if you're lucky a urinary bladder.

There was one unusual attending at this hospital that everybody loved working with. Surgeons are typically a different breed of doctors. They are mean, demanding, arrogant, and have a certain air about them. But this attending was different. He was the nicest guy and was very approachable. He wanted desperately to get people interested in surgery so he would let medical students do a lot during surgery.

As a medical student doing a surgery rotation, the most involved they get, procedurally, is retracting, or holding "stuff" back. Surgery is all about exposure. You can't cut or stitch if you can't see it properly. So exposure is incredibly important. But it is tiring and boring. It basically involves holding a metal instrument in one position for 10 minutes until the surgeon repositions you to hold for another 10 minutes. Repeat x10 and you're done. When you start holding back 50lb pieces of flab, it gets tiring.

But this one surgeon would get you more involved than just retracting. He would let you make the first cut, do part of the anastamosis, tie off bleeders, and even close the wound. And all the while, he was walking you through it very carefully, almost like a father would, and teaching the finer points of being a surgeon. He once let me do an appendectomy all by myself. These are the moments every medical student dreams of--actually making a difference.

I remember one gastric bypass that I did with him. The abdomen had been opened up and I was staring down at the intestines, ready to proceed. The surgeon took my hand and guided it into the abdomen. He said, "here, reach in and feel this woman's bladder." So I reached down cautiously and felt around the wound. "Farther," and he proceeded to shove my entire arm into the woman's abdominal cavity. I was in up past my elbow feeling for the woman's bladder. I wasn't quite sure what I was feeling for, but all of a sudden, I realized how strange it was to have my arm sticking into the belly of a 400lb woman. It was warm in there (I don't know why it wouldn't be)and you can kind of feel the intestines beneath you squirming around. I was holding my arm into darkness. For all I knew, there was something lurking in there about to bite me. I had no idea what a bladder felt like. Everything in there is soft and mushy. The surgeon pushed my arm in even further and all of a sudden I knew I had reached the bladder. It was slightly firmer and had a round contour. Exactly where I remembered it would be from my anatomy class. "Alright now get your arm outta there, you turkey!" (he called everyone a turkey).

That was cool.

Eventually any surgery becomes boring when you watch too many of them. And we typically did 2-3 gastric bypasses a day. We got really sick of them and eventually it became a chore. We affectionately renamed the procedure to a "fat pass". On rounds our presentations went something like, "this is a 45 year old woman, post-op day 2 from a gastric fat pass".

Very rude and insensitive, but hey, this was our surgery rotation.