advice for surgical interns, part five

Another piece of advice that you won’t get from many attendings: invest in some good shoes. It will make your life much more bearable.

There’s a reason Danskos are so popular. They really do feel much better than any other shoes I’ve tried. Back for the first several months, I had “nurses’ shoes,” which did absolutely no good. My feet used to be so bad, by the end of a 14-hr day, that it hurt more to sit down in the car to drive home, than to keep standing up. When I finally decided to pony up ~$100 for some Danskos in January, this improved dramatically.

As any surgeon will tell you, the problem with sitting down is that you fall asleep much faster sitting down than standing up. So when you’re going to be tired a lot, you have to be able to keep standing up.

Speaking of being tired, I have to share our chairman’s take on fatigue, in the context of the ACGME’s mandate to teach residents how to deal with (or avoid) fatigue (and bear in mind this is one of the nicest guys you could meet, completely not fitting the surgical stereotype): “If you’re tired, you’re tired. Deal with it. What’s this fatigue nonsense?” I think some people think the surgeons are the ones who were born with less need for sleep than other people. While that may be true of the neurosurgeons, whom I have literally calculated to sleep no more than 4 hours every night, I don’t think it’s the case with most of us. We just have something we consider more important than sleeping. (Ask my family: when I was on vacation recently, I spent more than half the day sleeping. But when I’m at the hospital, as long as I’m not sitting down in a dark room for conference or radiology sessions, I’m usually fine. I’m scared enough of failing to do something important that it keeps me alert.) So I think most of us agreed with the chairman: of course we’re tired. It’s a fact of life. We just don’t spend much time thinking about it.

Anyway, get some good shoes; as long as your feet aren’t killing you, it’s easier to keep moving.

 

juggling badly

I can’t decide whether it was a good or bad day.

A lady who was supposed to have a major vascular procedure developed a very serious complication early in to the operation. Through a complicated series of events, the attending got the impression that she was better, and went to his office. I came back to check a little later, and found her much worse. (And I didn’t get up the nerve all day to go and chew out the people who were responsible for letting her deteriorate unnoticed; not that noticing would have changed the course of events. I need to grow a spine and some teeth, and they’ll hear about it tomorrow.) By this time the attending was gone, and every single other surgery resident in the hospital was scrubbed in the OR. So I had her to myself all day.

It was good, because I got to handle an ICU admission, with lines and diagnostic tests and everything, on my own. It was bad, because it took me four hours, and I didn’t get to pay attention to any of my other patients till late in the day. It was good, because I finally put in my first radial arterial line completely unsupervised (as usual, when you are the only person who can help at all, the impossible becomes possible; the attending said categorically - one of the few instructions he gave me - “put in an a-line;” and I wasn’t about to call him and say I couldn’t do it, until I’d tried all four options; fortunately the second radial artery worked); it was bad, because it took me nearly an hour, between trying, and thinking about it, and trying again, to get it done. Starting in July, I’m going to need to be able to do this whole thing in one hour or less.

The really bad part was talking to the poor lady’s husband. We needed his consent for something part way through, so I had to go track him down in another part of the hospital, and then explain quickly that things had deteriorated, we needed him back over there, and we needed consent. . . I am not good at giving bad news. I think if I hadn’t been choking up, and probably visibly disturbed, myself, he might not have taken it so hard. Probably he would have been just as upset; but it’s not reassuring when the doctor is on the verge of tears. I felt like someone could be videotaping me as an example for medical students of how not to give bad news.

One reason I decided to avoid OB was because I couldn’t stop crying for joy every time a baby was born (yes, ok, irrational; I couldn’t help it). Now come to find out, although I’m getting better at not crying while taking care of my patients, I have trouble keeping my voice level and my eyes dry while giving bad news, or discussing a poor prognosis or imminent death. The prospect of the family’s grief almost bothers me more than the patient’s condition, maybe because the patient isn’t aware of what’s happening.

I wasn’t comfortable with that whole part, either, being basically the only person to discuss symptoms, diagnosis, treatment plans, and prognosis with the family. We did consult a couple people, but of course they didn’t talk to the family. The attending was unavoidably detained (he’s a good guy, he talks to families reasonably often, unlike some surgery attendings, who always leave the whole social interaction bit to the residents), and the rest of the team was also in the OR. So it was the intern doing all the talking; at least I’ve learned to be vague about the prognosis. That way if it’s better than I realize, someone else can always give the good news later; and if it’s worse, I’ve just introduced the subject gradually.

Then once that was somewhat settled, I discovered that various others of my patients had had significant things happening to them, and no one had thought it worth calling me, so at 5pm I was trying to fix a day’s worth of trouble. Splendid. I’m learning why the senior residents are so paranoid. There isn’t time to say, I’ll come back and think about this later. You have to act on everything as soon as it comes in front of you. I thought I had a busy day, with one ICU patient and three troublesome floor patients (many others were behaving nicely). What am I going to do in July, with thirty or forty ICU patients, and fifty or sixty floor patients on my hands at once?

 

rat race

My service is a mess. Despite me and all the other residents and some mid-level providers scurrying around all day, every night we find ourselves with a crazy list, on which I don’t recognize half the names, don’t know what procedures they had done, why they’re in the hospital, what medications they’re taking, or what we’re supposed to do with them tomorrow. I’m not sure how it happens. Perhaps the habit of sending the intern to do the last cases of the day, which are the small potatoes, at the same time that the ER and the office flood us with new admissions and consults, might have something to do with it.

A few months back, when I was covering at night for vascular, I used to be very frustrated with the intern who signed out to me. He’s perhaps the most incompetent of our year, and he told me nothing useful; I was always left to figure out for myself who had had surgery and who hadn’t, who needed coumadin (blood thinner) and who didn’t, who needed to be prepared for surgery in the morning and who didn’t, and was always taken by surprise when patients were admitted in the evening.

Now, I’m ashamed of my frustration with him. I sign out nearly as badly (at least I make sure of the coumadin status before I leave) because even after evening rounds with the chief, it would take me another hour to go around by myself and figure out what’s happening, and although I’m fairly responsible, I’m not that crazy. So every morning I come in to find half a dozen people whom I’ve got to figure out completely in seven minutes each before sign-in rounds with the chief. Then it’s off to the races again, and by the time I’ve got the overnight people sorted out, a third of the list has been discharged and replaced by a whole new crowd with new problems.

I feel like I’m running very fast and just barely staying in the same place. It’s frustrating, after spending a year learning how to be a good intern, to find myself unable to manage what I think I ought to be doing. There’s just too much going on.

On the other hand, I’m doing way more surgery than I expected to, so I ought to be happy. This is how the service is, controlled chaos, and no one seems to expect any different from me or the list. Plus, the chief and other residents are almost a dream team - the ones out of the whole program whom I would have chosen to be on a crazy service with. We have a lot of fun, in spite of everything, and they don’t leave me alone with all the work, which some people would do. The patients are doing mostly well, as well as can be expected from the kind of sick people with lots of comorbidities who have vascular surgery, and that’s the best that can be hoped for.

 

advice for surgical interns, part four

Learn to tie knots really well.

Admittedly, I’m a slow learner, but I was a couple of months into the year before I really grasped the meaning of a square knot, and I’m still working on how to pick up the threads so that they naturally fall into a square when I tie them. Privately with bare hands, and under observation in the OR with bloody gloves on, are two different things.

The nature of surgery is that the senior person is guiding what happens, and the junior is left doing a lot of the mechanical work: tying off vessels that the other surgeon has clamped, for instance. And believe me, they notice what you’re doing, especially the first few times you work with that attending. They notice how easily you tie, and how smoothly the knot falls, even if they don’t say anything.

One of the attendings interrogated me once: “Alice: can you tie knots well?” “Umm, I hope so, maybe.” “No. If you can’t tie, you’re no good to me. Can you tie knots well?” “Oh yes sir, absolutely.” “Okay, fine.” Later he told me, “If you can tie well, attendings will be willing to give you more to do. And if you can’t tie, they won’t trust you enough to let you do anything.” I’m pretty sure he noticed, because a few days later was one of my best days this year, during a liver transplant. I showed up just to watch, figuring that between multiple attendings and senior residents there would be no place for me, but they needed another pair of hands, and had noticed me hanging around their service whenever there was the slightest thing going on, and told me to scrub in. (I don’t think I want to do a transplant fellowship, but I’m fascinated by the surgery: the potential, the dramatic implications of taking organs from a dead person and using them to make another person stay alive, and the technical demands of the procedures.) So I got to help with the back-table dissection, and spent an hour tying dozens of tiny knots all over the specimen. That was one day, maybe because I knew it was vitally important, where my knots worked well.

If you’re in to surgery, you know how to get the clean left over sutures from the scrub techs at the end of a case (preferably the ones where you don’t conclude with blood and guts sprayed all over every inch of the instrument tables) and practice all over your scrubs and coats and pens and drawer handles. (The nurses like you better if you clean these off when you’re done.) I think it would be a great idea, though I haven’t managed it yet, to get some gloves to practice in.

 

two months left

I am now on the vascular service, which is probably the busiest surgical service in this hospital (as at most). There are enough attendings operating that I will probably get a few cases a week - of course, the ones no one else wants: ablation of varicose veins, amputations, simple angiography.

This service also tends to pick up a lot of pointless consults: our favorites are femoral pseudoaneurysms as a complication of cardiac catheterization (which a priori means that if the patient eventually requires surgery, they’re going to be a very poor cardiac risk), and generally whenever anyone is bleeding. Somehow, to the ER and ICU doctors, bleeding means vascular surgery should be able to help. Sometimes it’s interesting; most of the time, our advice is to hold pressure for a lot longer.

Anyway, after a few days’ worth of consults like this, I’ve learned not to be concerned about blood in reasonable quantities. I spent an hour holding pressure on one of our patients and practicing my calm, this-is-perfectly-normal voice. He was very pleasant, and not disposed to panic anyway; and I think my smoothing voice is getting better. Next time I’ll just remember to take my white coat off before getting close to arterial puncture sites. We got to talk about books, politics (noncomittally; I do know better than to start firecracker conversations with people whom I have to sit with for an hour to keep them from bleeding to death), and crafts.

The bad thing about this service is that they regularly have patients admitted in the evening for hydration prior to angiography/procedures the next day. Somehow, these patients always come right at signout, so we usually leave an hour or two later on this service than on others. Ah well, that’s how it goes.

 

accidentally

The “special features” section on DVDs is uniformly worthless, except for this one revelation: even the greatest stories, the ones that come closest to the ancient myths, are made by people who have no idea what they’re doing. Even when the characters are closest to being true heroes - chivalrous men and the women who go with them - the creators when they talk about the story can only spout modern pop-psychology nonsense. How can they tell stories about commitment and sacrifice and redemption without understanding it? I know the idea that all happy stories follow redemption/wedding arc, so I see how the plot can be accidental, but how can they get the characters right without understanding any of the truth behind it?

 

advice for surgical interns, part three

Always be prepared.

Practically, this means you should at all times have the following basic supplies about your person:

- Trauma shears, because trauma patients are not the only things that need to be cut. Vascular dressings can be taken down with these; and I have found them handy for cutting JP stitches when it’s impossible to get ahold of a proper kit (after first cleaning them asepticly, of course). Attendings and chiefs tend to get testy when no one, not even the intern, can produce scissors upon demand. We live to cut, after all. Keep something semi-sharp handy.

- Lube. You’re a surgery intern, and there’s something else that you should be doing with practically every patient you see, especially the ones with abdominal complaints. (Which is one thing I love about general surgery: no matter what the reason for the consult, you can always write down the chief complaint as being abdominal pain, and you’ll be close enough.) You don’t make yourself popular with the seniors by saying, “I skipped the rectal exam because I thought you would like to see for yourself.” They are very happy to take your word for whatever you find.

- Notes on your patients. You should be able to spit out the creatinine, potassium, hemoglobin, and white count of all of your patients upon demand; and since I doubt that you can memorize all these, especially the first month, I recommend making a habit of writing down every lab value you see, since someone will inevitably ask about the one you didn’t write down. If the value is significant (new anemia, leukocytosis, renal failure) also make notes of the previous values so you can show the trend. At the beginning of the year, I also had to write down lists of medications, since I found it difficult to remember which antibiotics and antihypertensives everyone was on. As you get more used to the job, these things will start to stick without notes.

- A working pen. This is almost more important than any of these other things. If you can’t write on the chart, you basically can’t get any work done. The worst possible way to start the day (other than with a code) is with your pen running dry at the first chart, and there are no loose pens in the nurses’ station because either they’ve confiscated all of them and aren’t sharing, or they’re all using pencils tonight. With as many drug reps as there are floating around, this shouldn’t be too hard (but be wary of the cheap reps, whose pens fall apart after five days).

- A penlight is handy, if you can find a small one that works reliably. I tried four or five, but they all either quit working or fell apart on short notice, so now I borrow other people’s when I really want a cranial nerve exam. This is not efficient.

- Your beeper. I’ve tried leaving mine at home, and somehow it never makes the day any smoother.

Other articles which are not as universally necessary: needles, scalpels, lidocaine, stitches. In my hospital, at least, these things are now (for “patient safety”) kept tightly locked up on only one floor, and it’s usually a long run through the hospital if you want to restitch a wound, or put a stitch on a bleeding vessel at the bedside, or anything like that. Fortunately, these happen rarely enough that you don’t get good return for the weight by keeping them in your pocket.

 

pay the piper

Somewhat related to yesterday’s post:

Today was splendid. I spent the entire day in the OR, running from one thing to another, so much so that at the end of the day I realized with horror that I’d hardly paid any attention at all to my floor patients. Fortunately, they were all with good nurses, so I was able to reassure myself while scrubbed in that I would have been paged if anything had been wrong; and indeed they were all cruising along smoothly when I went to check after the cases were finished.

Anyway, I had a tremendous time, being with one of the attendings who doesn’t believe in giving constant instructions. He just kind of stands there (after very carefully marking the place to start; my blog’s title is no joke), and lets you call for the instruments from the tech, make the incision, and proceed as you see fit. He says something if you’re about to do something absolutely disastrous; otherwise, he just hums a little bit and smiles to himself. Since he’s slightly deaf, no little hints like murmuring, I s’pose this is where we go next, will get you any help. You have to say loudly, I’m not sure what to do next, if you want to get any directions; which is of course a surrender and an embarassment to say, so you keep trying. But so amazing to realize that I actually do know a great many useful things to do.

At the end of the day, rounding with the chief, he could see that I was enjoying myself vastly. He smiled at my account of the day’s proceedings and said, “You know, Alice, you’re going to have to pay for your fun eventually.”

What he meant was that all these cases were on the schedule because he and the attending had been called several times a night for the last five nights, the team being on call. All I had to do was admit a few patients in the afternoon, and see a longer list in the morning, and then I got to do cases. He was the one who’s been awakened by calls at home several times a night for the last two years, and he and the attending were the ones who came in for emergency cases over the weekend. They’re tired.

And I was thinking. The chiefs at this program operate all day every day, it seems like. But they pay for it. They look pretty tired - noticeably more so now, at the end of the year, than at the beginning, when the cycle was just starting. They are never not able to do anything that’s called for; but they’re exhausted a lot, and they look like it. Most of them have grey hair. None of them are much past thirty, but they look older, especially after a string of days and nights with their attendings on call.

He’s right. I thought I was paying in advance, this year, doing all the pre-op and post-op work and not getting to operate. But next year, covering all the surgical patients at night, I’ll start paying; and after that, taking real call continuously - that’s when the bills come due. I’m worried about next year; but I’m even more scared of having a chief’s responsibilities. That’s only a little more than two years away. I need to stop doing math.

 

advice for surgical interns, part 2

Here’s something important, which not many attendings will include in their list of valuable advice: Enjoy the last two free months of your life. Get out in the sun, get some exercise, spend time with family and friends - because that’s the last you’ll see of them.

Maybe not quite that bad, but after July 1, you’ll have to plan ahead and ration your time carefully, between errands and housekeeping, to get time with people outside of the hospital. (I have to plan for a week to get to the store for bread. Maybe I’m worse at time management than some other people.) Having only four days off a month, and those randomly assorted depending on your chief’s whim, makes it difficult to get things done outside of the hospital. Again, maybe I lack willpower; but I am not good at getting home from work, and setting out to clean the house, wash the dishes, run the laundry, and take out the garbage, before bed, instead of sitting down to read or get on the internet. One of the other female residents lamented the other day, “It’s not like we wear anything but scrubs; so why are there piles of laundry all over my house?” And we all said, “Yes.”

Anyway, enjoy your last two months.  <evil grin>

 

advice for surgical interns, part 1

Since this is what I’ve been asked most often, we’ll talk first about good books to read in the month or two you have left, and also in the first year of residency.

Right now, I would recommend getting started on a basic surgical textbook, like Schwartz, Sabiston, or Greenfield. I’ve been using Sabiston this year, and it’s ok, but I was recently pointed towards Greenfield, and I like it much better. The chapters are a more manageable size, and the writing overall is better organized and more focused on useful information. These books will give you a lot of basic science information: some anatomy, a lot of physiology and pathophysiology, and the decision-making tree, how to diagnose, how to treat, when to do surgery, when not to do surgery. This covers the information you will get pimped on as an intern. I started to say it will give you the information you need when admitting a patient for surgery; but actually it’s way more information than you need on a day-to-day basis. One of my chiefs loves to advise us to read for one hour every evening. It seems like an impossible goal, but the more you can read at least a small amount on a regular basis, rather than sporadically, the better off you will be. I realized this after the ABSITE.  These books cover things like surgical infections, critical care briefly, trauma protocols, and medical issues in surgical patients, so this is probably the best place to review basic medicine from a surgical perspective.

Regarding the ABSITE, the surgical intraining exam given in January: some programs care more about it than others, but it does seem that fellowships will look at your scores. That’s what I hear from the residents who were interviewing this year. The absolute best book, beyond regular reading, is The ABSITE Review Book. There’s a second edition out this year. You need to start reading this a few months before January - October might be good - because although it’s a thin book, it is so crammed with information that you will not be able to absorb it if you try to rush through it in the month of January.

If your program has interns in the ICU much, The ICU Book by Marino would be valuable. He has some idiosyncrasies, but he explains physiology better than any book I’ve ever read. He goes through every aspect in detail: cardiovascular, respiratory, electrolytes, infections, and gives the reasons behind (or against) common practices.

Other than that, once you get into residency, you should have a surgical atlas to refer to, at least the night before cases. Some people (better disciplined than me) read these for recreation, and as a result sound extremely intelligent on rounds. A very basic one is Zollinger’s Atlas of Surgical Operations. There are many others, in more detail. Mastery of Surgery is a two-volume book (best found in the library; not a good way for interns to spend money) which both gives extreme details on the conduct of an operation, and most of the possible variations, as well as a brief overview of the pathology and diagnosis. If you have time, this would be a good one to read before an operation. For general information, I recently became enamored of Chassin’s Operative Strategy in General Surgery. This book starts at the beginning, as in how to tie knots, why to tie knots, and so on. It tells you all kinds of secrets which people seem to assume you ought to know, but will never think to tell you, and explains how to approach a problem, as well as the specific steps of many operations. Be careful, because it covers a lot of archaic operations that it would not be a good use of time to read much about. Later, when you’re senior enough to get called for the emergency Billroth 1 or 2, you might like to read some of these chapters again.

That’s really it. Overall, I’d say you’re better served by picking a few books and trying to read all the way through, and studying specifically the areas that you currently have patients in, than by trying to read all possible books. Not that you’ll have the time or energy for that after long.   :)  Oh, and UpToDate is wonderful, if your hospital has access. You’d be surprised how much surgical information is covered there. If you’re going to buy one or two books, I’d say Greenfield (if your program isn’t planning to give it to you - a lot of programs will provide the interns with one or two textbooks), and The ABSITE Review Book.