Cut On The Dotted Line

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.

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>

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.

I am inordinately pleased with myself, and much more optimistic about my future as a surgeon. After the blunders of the last week, something went very right. The chief and I found ourselves elbow-deep in a difficult case, and I was the one with the bovie. (Surprisingly, the junior person is often the one cutting, because the other surgeon needs to have their hands free to see and feel what’s happening and give directions.) The medical student was providing much-needed retraction (you guys have no idea how wonderful it is when you hold the retractors right, and we can really see what we’re doing), so I had both hands free to do surgery with. There was a difficult angle to get across, so for quite a while I found myself guiding a kelly (clamp) with my right hand, and using the bovie (electrocautery) - by now literally a foot long - with my left hand. It went a little slow, but I did the job nearly as well as I would have done with my right hand. I asked the chief later if there were any technical improvements I could make. He said he supposed some speed would come with time. I said yes, it was a little difficult using my left hand. He didn’t even realize I’d switched hands. So I’m happy; I can apparently use my left hand well enough that the awkwardness doesn’t show (title pun intended). And it was a big case; I was so thrilled to have been involved, even after I had to scrub out to go see consults, I was nearly skipping down the halls. But that would be indecorous and unprofessional, so I stopped myself when anyone else was in sight. I wonder what the security folks watching the cameras thought - escapee from the psych ward?

I’m convinced I’m a white cloud, and I’d like to know how to change that.

“White cloud” is residents’ slang for a person who doesn’t seem to have patients come in, surgeries or codes happen, or patients transfer to the ICU or die on them. I think it really developed more as a corollary to the original phrase, “black cloud,” which is someone who attracts bad luck: when they’re on call, their team picks up more than their fair share of new patients; their patients always go to the OR, or the ICU, or die.

Being a white cloud is nice for a while, since it means less work - fewer admissions, transfers, and postop orders to write. But it really adds up to worse education. Getting slammed all day and night with admissions and disasters isn’t fun while it’s happening, but it’s extremely educational. A quiet day where no one crashes, no disastrous transfers land on the doorstep, and almost no one gets admitted to your service is pleasant, but not useful.

As long ago as third year, I knew I was a white cloud. On OB, even though I was crazy to deliver babies, they would rarely come on my shift. When it was another student’s turn on labor and delivery, they’d have four or five babies in eight hours. When I was on, six women would labor for twelve hours, and five of them would deliver after I had to leave. On trauma as a student, the gunshot wounds always came in on other people’s nights. On medicine call, I always got rule-out chest pain and COPD exacerbations. The other students picked up the fancy autoimmune complications, complicated cardiac issues, new cancer diagnoses, and so on.

This year, for being nearly done with a surgical internship at a tertiary care center which routinely picks up the disasters of several counties and states surrounding, I have had remarkably few people die on my hands, and have been present for remarkably few emergency trips to the OR. It’s always on someone else’s service that the patients develop bleeding that requires operation, perforated viscus, mesenteric ischemia, intra-abdominal sepsis, etc, or come in hypotensive and coding from the transport. It’s nice, I suppose, because I really don’t like it when my patients crash.

But I can’t believe that this white cloud effect is going to persist for my entire career. If it is, I should start marketing myself as a means to reduce the morbidity and mortality of almost any operation. (And it’s not because I do anything special. One of the chiefs is extra-paranoid about her patients, and boasts of having the lowest morbidity/mortality as a result. I’m not that good.)

This weekend, of course, is a case in point. Last weekend, the team on call got slammed. They doubled their list, and spent half the weekend in the OR. Two or three people ended up in the ICU, and all kinds of drama occurred on the floor. But now that I’m on call, we had one admission and one OR. No disasters. Everyone got out of the unit. What’s up with that?

I really should start tallying the morbidity and mortality of my patients compared to my fellow interns. Either I need a bonus from the hospital for improving their statistics, or I should get rid of this superstition about white and black clouds.

I’m just afraid that the other shoe is going to drop sometime. Like in two months, when I’m alone at night, and patients will start doing things that I’ve never seen or heard of before, because I have such incredibly good luck on call.

(Actually, I do know how to change this. Go around talking about “quiet night,” “being bored,” and “nothing interesting in the ER.” This really works very well, so well that the rest of my team curses me every time they hear me say it; so I don’t do it so much anymore. It tends to produce four ER consults in a row, and two or three admissions at once. I’m not sure what it does to the ICU; I haven’t tried it there.)

I think that’s enough about Mormonism and Islam - especially at the same time. As some have suggested, it’s perhaps best not to tackle two giants at once. On the other hand, next time we could include Jehovah’s Witnesses, or maybe the Unitarians. Three times the fun? Thanks to all who commented.

In response to many questions lately, I am working on a post or two of advice for surgical interns - a subject I take up with some trepidation because among those who remember her, that phrase instantly brings to mind Barbados Butterfly, a surgical registrar in Australia, who was, until forced by her hospital’s administration to take her blog down, one of the very best medical bloggers; certainly my favorite. She combined a dry sense of humor with a good deal of medical wisdom, and was both entertaining and instructive to read. Some of us still keep an eye out for a reincarnation, but have so far been disappointed.

Anyway, she had a series called “advice for surgical interns,” which still runs in my head. I can’t replicate her style or her experience, but there are a few highlights we could address. Tomorrow.

Christos anesti! Elithos anesti!

Alleluia.
Jesus Christ, the King of Glory, has risen from the dead.
By death he trampled on death,
And gave life to those who were in the graves.

Christ is risen! Truly he is risen!

Ok, it’s still a bad day. As predicted, I got involved in trouble. I don’t think it was my fault; on the other hand, I didn’t do much to stop it. On the third hand, I’m not sure what I could have done differently. On the fourth hand, the senior residents either think I could have done something, or are determined to enjoy teasing me about it; probably the latter.

Let’s just say that I was involved in doing a cardinal thing that you’re not supposed to do, because it has bad results; and now I know why, and I will devote a lot of thought to never being in that place again.

The chief, bless his heart, stopped the teasing long enough to make a real teaching effort, and went through all the things that someone should have done differently. So that was worthwhile. Now I’m just trying to figure out whether I was part of that someone, or not. Perhaps I should stop considering what I did or didn’t do, and think about what I could do next time. . . Mainly, never walk into the room in the first place; but that was not allowed as an option.

Thanks for all the comments, folks; I do intend to get to them, but maybe tomorrow, when I haven’t been mis-speaking all day long already.

That’s the other problem. I thought I had learned how to handle “the guys’ “ kind of jokes, but it’s stepped up the last few days, and I can’t handle it. Either I turn bright red, which just stirs them up, or I try to answer back, and say something stupid. Witty repartee is definitely not my forte.

It’s a bad day. I discharged my poor fellow with terminal cancer - again. We ended up crying and holding each other’s hands, and it was all I could do not to hug him, because if I had he would never have let go, and I would have dissolved, and it would have been too hard to go on to the next patient. The fact that he’s a little demented and doesn’t remember the details of our conversations doesn’t make it any easier to say goodbye to him.

Another patient, a good ways out from a big surgery, had a major setback today. We were all crushed. We thought he was good, he was flying, he was going to be a success, almost ready for discharge - and now this. So utterly disappointing.

I keep doing stupid little things; nothing major, I just can’t seem to get the details right. I feel like an idiot, and like everyone else thinks I’m an idiot. It helps a little when the OR nurses say things like, “Oh, here’s Dr. Alice! So nice to have you today!” But really, it doesn’t matter if people like me, if I can’t do my job as well as I ought to. Being friendly isn’t a substitute for getting things right, because people’s lives depend on me - and will do so even more next year.

And tomorrow, I’m assigned to a case which has an 85% chance of turning into a real mess. The other interns and I have been playing hot-potato with this scenario, and I lost. Hopefully we’re overestimating the potential for all-around trouble; but with our luck so far, we’re only underestimating.

And I have a beautiful controversy on my blog, and I don’t have time to write as much as I want to.  :S

But I am still thrilled to be doing surgery. I’m just getting to realize what fun it is to have spent an entire year (mostly) on surgery, not rotating through other things like medicine and peds and neuro. So nice to be out of medical school and able to throw all my energy into one area. (And seeing how little all that has accomplished, it’s a good thing I haven’t had any more to work on!)

I just thought I’d share that, although some of the most common search terms that lead to my blog are the expected, like “internship” and “what to do with an NG tube” (at least those people know they need to ask), one of the most puzzling lately has been “what is a priority check?” Which suggests a level of cluelessness so intense that I don’t even know where to begin.