Absolutely awesome. I had settled down for a boring call day with no interruptions but to put foleys in, but no. A vascular consult came in for compartment syndrome in a guy with such a massively dramatic medical history that no surgeon would ever touch him – except that his leg was about to die. The chief took one look at him and called the
attending, who took one look and called the OR.
Determined to stay in my place, I didn’t say anything about being involved in the surgery, just asked to watch. The chief told me to scrub, and the attending handed me the bovie (without asking about the electrical principles behind its function!). I kept waiting for one of them to take the sharp instruments away from me, but no: the chief suctioned, and the attending kept drawing dotted lines, and I cut, and cut, and cut. We opened not only all four calf compartments, but two thigh compartments as well (so rarely done that even the orthopedic guys we checked with couldn’t tell us how to do it; google is an awesome textbook). I could not believe what was happening: I was
really doing surgery. I was so shocked, and anxious not to displease the attending (who had just met me for the first time), that I could hardly enjoy it at all, till we were done.
At which point, with impeccable timing, my beeper went off: “xxxx STAT.” The nurse was almost stammering: “This patient is unresponsive, we just found him like this, he’s bradying down, his blood pressure is dropping, what should we do?” I couldn’t even catch the patient’s name, or which attending the call was for. I just got the room number
and ran – after calling over to my senior resident that he’d better get up there too. Running through the hall gave me time to think, and come up with a semi-coherent plan. I actually was working through the ACLS ABCs when the crisis team and senior residents arrived. My main failing – admittedly significant since the chief complaint was
bradycardia – was forgetting to get him on a cardiac monitor. Now I know why the test situations insist on you saying all the things you want – oxygen, ivs, monitor – because on the floors, the nurses don’t always know that stuff! I did get the oxygen, and we were looking for ivs (because this insane hospital doesn’t allow the nurses to have iv equipment on the floors, we had to page someone else for that); it was just the monitor that I forgot. The patient magically perked up when we tried to get a femoral
stick. I was extremely relieved to realize that the correct surgical procedure at this point was to turf to medicine for a workup.
So next time: order the ivs, monitor, oxygen, and fluids, while still on the phone, before starting to run. Another round or two, and I’ll even be able to think of the proper meds, too. (This is incredibly well-staged training I’m getting: last weekend, some close calls, but the seniors were right there with me. This weekend, a close call that
I started to handle on my own. In a week or two, I’ll be up for the real thing. Statistically, it can only be a few more calls away.)
The night continued well. I set my beeper to wake me up every hour to check on that patient, and the nurses usually paged me about five minutes before my alarm, because of some concerning signs. So I would stumble around the call room, trying to remember how to put my coat on, and run upstairs to see him, and call the senior. We went through the routine about three times before the nurses got totally frustrated with the interactions between the admitting medicine residents and the consulting surgery residents, and with the patient’s instability, and insisted on him being moved to the ICU. I continued to observe how my senior was unfazed and almost unconcerned by things which were wildly distressing to the nurses, and fairly alarming to the medicine people.
This senior resident is amazing. He was supposed to be keeping an eye on me and my four specialty services, and the general surgery call intern, and her five or six services, plus all the ICU patients. Somehow he managed to be always available and reassuring to both of the interns, more on top of all of our patients than I was (shame on you, Alice), and also in the trauma bay assisting that overworked team as they took admission after admission all night. Plus he was in at least two surgeries that evening. I don’t know he pulls it off, but I want to be like him. That’s something I am truly pleased with at this program: all the residents, juniors, seniors, and chiefs, seem very strong. I unreservedly trust every single one I’ve worked with so far, and I’m impressed by what I’ve seen of the others on rounds or in M&M. I do hope this is not just the luck of the draw, but something that can be taught, that by next year I’ll be as knowledgeable and cool as they are.
I’m still working on learning the surgery culture by observing them. Apparently I had a misconception about overnight call. The point is not to go to sleep if you can. The point seems to be to stay up, keep moving around and checking on the critical patients, so that you know what’s happening before the nurse (or the intern) calls you. I think that’s how the other residents achieve an apparent omnipresence: always just walking up to whichever patient is crashing, or into whichever room a procedure is about to happen in.
Which brings up the PEG (percutaneous endoscopic gastrostomy) tube. The senior resident sent me to do one, because the other intern “had already done tons.” So I didn’t feel bad about taking a procedure away from her, since I hadn’t even seen one of these yet. The attending, the most senior trauma surgeon, was amazingly pleasant when I said I’d never done one before. He walked me through it in such a way that I didn’t get too nervous to think straight, and actually managed to do every step myself without much fumbling. I can see how these will get boring in a few years, but yesterday it was just enjoyable to do a necessary procedure, one of the basic general surgery skills, without tripping.
Of course, after such a splendid night, I was due for a fall in the morning, and boy, was it a fall. Teaching rounds went on for a couple of hours, and I was just thinking how exciting these could be when I actually knew some of the answers, when we walked into a patient’s room, to discover first of all that he was being allowed to do the exact thing the attending had just been lecturing us about the importance of him not doing. Which would be my fault, because I checked on him yesterday, and saw it, and didn’t realize how contrary it was to the attending’s plan. Then, the mother brought up an aspect of his condition which, let’s just say, I ought to have known about. I felt a little bit upset at her for waiting a week to tell the attending about it, instead of telling me, when I’ve been in and out of his room three times a day for the last week asking if there’s anything else he needs, but honestly, I should have asked, I shouldn’t have needed to be told. When we got outside the room, one of the attendings looked at me and said, “So, generally speaking, from an intern’s perspective, it ought to be . . . humiliating. . . to find that out on rounds.” What could I do except look at the floor? I was in fact humiliated, and there was nothing more to be said. Fortunately it was close to the end of rounds.
That’s surgery. Either an honest concern for the patient’s well-being, or else sheer pride, not to be shamed in front of colleagues, should motivate one to know every single detail, no matter how irrelevant it may appear at the moment. Details, Alice, details. What good does it do to have fun playing with sharp objects, if you can’t be trusted, or can’t trust yourself, to know everything about the patient outside the OR? (But I did a whole surgery yesterday!)
Two more days left on this service, and then on to a hopefully fresh start on a general surgery service.