This month ended with the most exhausting day of residency to date: up most of the night, between patients who were supposed to be admitted and didn’t show up, and patients who weren’t expected but wanted to be admitted anyway. (This “patient autonomy” deal can be quite over-rated: you let them tell you when they should stay overnight, when they’re ok to go home, and whether and how much pain meds they need? The old paternalistic system was simpler.)

Then in the morning I found myself scrubbed in the longest case I’ve been in since med school, seven hours (thankfully it required several changes of gown and gloves, so there were opportunities to at least get a drink of water before scrubbing again). It wasn’t a particularly satisfying kind of case, so I was starting to run out of energy by the end. I’m hoping that more technically interesting cases will be easier to get through long hours in. Between that, and some cases to follow, and issues to track down back on the unit before leaving, and having been in late the day before, it was a long day.

Plus, my ICU patients seemed determined to go into every sort of organ failure known to medical literature. Every morning for the last week I’ve come in to discover at least two or three mini-disasters among my people, while my fellow interns’ patients seemed to be coasting along. So they got to watch me floundering to deal with everything. Not only was I very upset that my patients kept getting worse (I think this is the point for developing some emotional detachment; it is perfectly true that feeling sad about a patient’s impending death makes it harder to think clearly about how to stop them from dying), but it became more and more stressful to deal with their problems alone, as it seemed. My attending was around, but although very friendly, and great in the OR (I never realized till this week what fun it can be to work with an attending who likes you, and treats you as a colleague; it’s thrilling), is not big on detailed discussions of pathophysiology and treatment options, which are what I need to learn. The medical ICU team was around, but either I talked to their interns (and it gives me no comfort to share half-baked opinions with fellow interns, no matter what rotation they’re on), or I could argue with their attending (who tried vitamin K for acute bleeding on me again today; I didn’t buy it). Neither one made me feel like I was learning anything, or like my patients were benefiting, since by this point in the month I can’t tell any more whether I actually know anything, or whether I’m just disagreeing with the medicine people for the sake of being contrary. I disliked almost every single treatment decision they made; so I had no objective way to tell whether I was right, or just way too prejudiced. (And I don’t know what good it does to write three-page-long notes, if you don’t put them in the chart till late afternoon. By the next morning, when I see them, they’re out of date. Notes are things to be written and left as a record to other team members, not works of literature to be kept in your pocket and edited all day.)

At the end of the week, my patients are all still alive, so I guess either the crises weren’t as bad as I thought, or I didn’t make as many mistakes as I feared, and perhaps the medicine team helped some too. But I am so glad at the prospect of getting away from that insane system, and being back in my own hospital (amazing how quickly I’ve given my loyalty to this place), where there’s a surgical ICU team, and senior surgery residents, so that I can be an intern again safely, knowing for sure that if someone disagrees with me, I’m wrong. (And to get away from incompetent scrub techs who hate me and are starting to pick fights about totally irrelevant subjects. . . didn’t make that long case any smoother to have the tech sitting in the corner wondering loudly what we were wasting our time on, as we picked our way through one of the key aspects of the procedure. . .)

It took me nearly an hour extra to get out of the hospital, since I felt I had to stop and say goodbye to the families of all my ICU patients, and explain the upcoming change in personnel. They were all so sweet. I need to think of a good answer to overpoweringly grateful comments. And in regard to recent discussion about informed consent to being treated by trainees, these families all recognized that we were in training. We talked about moving on to completely different roles every month, and they all wished us luck and good experience, and one woman advised me to imitate one of the attendings if I want to be a good doctor. They knew we weren’t experts; but they appreciated our care anyway.

This post is too much of a complaint. This was a good month overall. I learned a lot about the surgery itself, and got to do three times as much as in all the months before. I learned about teamwork with the other interns, and I learned what kind of OR support staff not to hire when I get into private practice. I learned about making relationships with patients and families, and how to win over nurses who know better than to trust new residents. I had the best time ever with the attendings, who were unbelievably relaxed and encouraging. I learned what it feels like to be left out of the loop on patient care, and I vow from now on to 1) page every person I consult directly, and 2) be meticulous about communicating to the medicine teams what surgery’s plans are about their patients. I learned more about ICU care than in any month so far; there’s nothing like being thrown in headfirst for learning to swim. I came closer to establishing my own commitment to the surgery ethic of never letting yourself sit down, eat, or leave the hospital until all the jobs have been done,  no matter how long it takes. Most tangibly, I learned that I can do lines unsupervised; this, like knowing the private codes to the supply cabinets, is a secret treasure in the back of my mind: I can do this.