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A Day In The Life Of A Surgeon A Surgeon's Day Begins With The Rising Sun. At 6:30 a.m., Robert Shack, M.D., Section Chief of Vascular Surgery for Saint Barnabas, visits the physicians' Communication Center at the Medical Center. From this office, he can see the most up-to-date laboratory data for the patients he plans to operate on that morning. He reads these reports religiously, rather than relying on notes taken two weeks ago from each patient's visit. This is the first in a daylong series of steps Dr. Shack will take to assure safety and accuracy. In Good Company After checking on his patients' progress, the next stop is the Physicians' Lounge. Inside this room, doctors are drinking coffee, reading, making phone calls or meeting informally as a quiet prelude to the hectic day to follow. Dr. Shack joins a table with Dennis Filippone, M.D., Acting Chairman of the Department of Surgery, and William Sloan, M.D., attending gastroenterologist, both colleagues and longtime friends. Dr. Filippone affectionately calls Dr. Shack "The Last Angry Man," a reference to a movie of the same name that follows the life of an idealistic Brooklyn physician. Dr. Shack jokes about the enormous dog once owned by Dr. Filippone and his fear of visiting the chairman's house. Dr. Shack also recalls a friendship with Dr. Sloan that began 30 years ago as residents at Mount Sinai Medical Center, N.Y. "Bill had a patient that had been bitten by a dog and was in need of surgery," says Dr. Shack. "I still remember that the patient he brought to me was purple from head to toe. It turned out to be a landmark case published in medical journals. The man had been bitten by a German Shepherd and was allergic to the dog's saliva, which caused acute renal failure. It was a unique meeting and Bill and I have been friends ever since." Surgery Begins The first surgery of Dr. Shack's day is the laparoscopic removal of a gallbladder at 7:30 a.m. Before meeting with the female patient, Dr. Shack speaks with family members, coordinating where they can be reached after the procedure for a discussion of operative findings. He then speaks with the woman privately to offer reassurance. After dressing and scrubbing, surgery begins. For this procedure, Dr. Shack brings his personal surgical instruments, preferring the particular curve of one piece, the mouth of the dissecting instrument on another. Under two layers of gowns he wears a lead suit for protection during x-rays. The patient has been anesthetized and, after making the proper opening, Dr. Shack inserts a laparoscope under direct vision that views at a zero degree angle. The image, magnified to 16 times normal size, is projected onto two high-resolution television screens. "I use the scope with the 30 degree angle when I want to make Cora seasick," he teases, speaking to Corazon Tolentino, R.N., the good natured and highly competent operating room nurse who assists him. For what is considered a routine surgery, the procedure appears to be a wonder of orchestration and precision. The tiny, opalescent gallbladder is located next to the liver. The main artery and duct must be precisely identified. While holding the laparoscope in one hand, Dr. Shack mobilizes the artery with a long, angled instrument in his other hand. The process oddly resembles a carnival game where the player manipulates a long metal arm to grab prizes at the bottom of a glass case. This particular patient is found to have an aberrant cystic duct with an abnormal configuration, which means that the duct is not found in its normal location with respect to the artery and the main bile duct. This complicates the procedure for both the surgeon and his friendly and unflappable assistant, fourth year surgical resident Richard Miller, M.D. After a careful system of double checks, they identify all the pertinent structures and confirm the dissection with an x-ray of the bile ducts. The gall bladder is then safely removed. "That was a very interesting situation, but I don't want all cases to be that interesting," says Dr. Shack later. "Obviously, there is no such thing as a casual or routine surgery. If you think that, and a problem comes along, you are going to wish you were in another specialty very quickly. Every case is unique and different." Dr. Shack has three surgeries scheduled on this day, a total mastectomy next followed by a hernia. On days that he performs vascular surgery, he prefers to schedule only that procedure. He refers to the vascular surgery as "the agony and the ecstasy" because performing a difficult case is "extremely gratifying," but, he relates, vascular surgery is a discipline that leaves little room for error and is very unforgiving. No matter what type of procedure is on the schedule, Dr. Shack demands nothing less than his best for each patient. "Surgery involves discipline," he says. "It does not matter if you had an argument with your wife or a tough night before, you are obligated to provide a professional product for your patient, and good doctors do." At 10:30 a.m., Dr. Shack meets with his next patient who is here for a total mastectomy. He leans in close to her as she lies on the stretcher, touching her hand and offering reassurance. At least 30 patients a week come to Dr. Shack for breast care and surveillance. When surgery is required, he is careful to mark the breast designated for surgery with a dermal patch in the holding area just before the procedure. A seasoned surgeon for 26 years, he knows the importance of doublechecks. In addition, he has patients with diagnosed breast cancer meet with an oncologist preoperatively to be sure that they are making an informed choice from the available options of therapy. The only cut he makes with a scalpel is the first incision. From there, the breast tissue is cut with a pen-like electo-cautery instrument. Then, an appropriate lymph node dissection is carried out. Upon closing, care is taken to tailor the skin flaps to the contour of the patient's chest wall. While one can never underestimate the devastating emotional impact of losing one or both breasts, Dr. Shack reports that many women feel "an overwhelming sense of relief that the cancer has been removed." A Team Effort At the end of the mastectomy, the team relaxes. They are a pleasant group that includes operating room nurse, Nicole Rusignuolo, R.N., and attending anesthesiologist Richard Monti, M.D. They tease each other ("I need that scalpel today, Cora") discuss vacation plans, birthdays and children, including Dr. Shack's new grandson born the previous night at Saint Barnabas. During operations, the mood is more serious. "I do not play music or allow a lot of talking and I want the anesthesiologist here the whole time," the surgeon says. "I do not want anyone's attention diverted. When I am here, I am not fooling around." Dr. Shack is honest in his discussion of the profession of surgery, a field that has seen great technological advances and has also been affected by the changes in health care reimbursement and the legal environment. While he still finds surgery to be a gratifying profession, Dr. Shack views the environment as increasingly difficult on many levels and would not recommend it to others without realistic forethought about the "life and lifestyle" of a surgeon. He finds that many people who thrive in the field share one personality trait: they are not intimidated by taking control of the situation and carrying out a plan of action. Despite the need for confidence, Dr. Shack relates that "there is no one that has never struggled in this field," and that good surgeons are honest with themselves about complications and the need to review and learn from what may have gone wrong. At 12:30 p.m., Dr. Shack begins his final procedure, the hernia. After the patient's insurance company delayed the original procedure, Dr. Shack added the hernia to this day to accommodate his patient. Because of the size of this particular hernia, a careful examination is made to be certain that there was no hydrocele (fluid-filled sac surrounding the testicle) present that might mask as a hernia. The concern is that 30 percent of patients in this age group (20s) have testicular cancer presenting as a hydrocele. It is clear immediately that this will be another challenging case. The man is large and his hernia is hugely oversized. One nurse comments that she has not seen a hernia this size in her seven years in the operating room. In addition to fixing the problem, Dr. Shack must remove a portion of the omentum (an apron of fatty tissue from the abdominal cavity) to be able to operatively reduce the hernia. Prior to concluding the procedure, Dr. Shack then injects a local anesthetic into the abdominal wall to ease postoperative discomfort. "You picked a good day and a good doctor," Dr. Miller comments to the Family Health Magazine reporter. It is obvious that this has been an intense, physically and emotionally taxing day for the entire team, a day filled with unexpected twists and decisions made swiftly and accurately. It is a surgeon's day. Postscript: All three of Dr. Shack's patients from this day recover completely. The gallbladder patient returns to her job in seven days; the hernia patient is back at work in ten. Within a week, the mastectomy patient fully resumes her home responsibilities. [ top ] |
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