medical education


I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.

Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.

Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.

I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.

We’re revisiting the subject of restricted duty hours. As Aggravated DocSurg comments in his humor-laced sarcasm, any sane person would be happy to be working less; so I must not be sane, to be a resident arguing for longer hours. But I think the “old fogies” have a point; and we ought to listen to them before it’s too late to turn this around.

This essay by a neurosurgeon (beyond being an extraordinary demonstration of how to claim to be superhuman, without being arrogant) has applications for all surgeons. Dr. Vates argues that neurosurgeons are unique because they deal with the only non-replaceable, non-repairable part of the human body, which is true; and that they are a breed apart, and that’s true as well. But he also suggests that if you think a surgeon’s ability to perform complex or delicate operations is impaired by fatigue, the solution ought to be to get really good at the procedure, so as to have room to work with when you’re tired. He repeats the line, which ought to be a self-evident truism, but apparently doesn’t compute for the folks at ACGME, that there are no hour restrictions in private practice, and that if we’re concerned about fatigue impairing judgment, that too should be practiced first under supervision.

Apparently some idiots are seriously proposing limiting the work week even farther, to 56 or 48 hours. I object. 80hrs is barely enough now; frequent readers of my blog will have recognized that I regard this as a rule made to be broken. If they cut it down to 56, they will have to extend the length of the residencies; right now, most people are 30 by the time they finish residency, let alone non-traditional students. Lifestyle may not be an issue under that regime, but paying back debts in time to have some money saved for retirement will be.

So I highly approve of Dr. Vates’ solution: The ACS needs to take its toys and leave, ie opt out of the ACGME, and set up its own standards for residency accreditation. Of course, since ACGME recognition is a prerequisite for Medicare to pay for anything, and for board eligibility, this is the kind of thing that would have to be orchestrated with 100% participation, essentially a boycott of the ACGME by the surgical specialties. I’m looking to see where I can sign a petition to that effect. . .

I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.

Okay, now I’m annoyed. I left the hospital at 8:30pm, not because the patients were so sick or I was so busy (although they were and I was), but because the attending took twelve hours to round. I’m telling myself that I’m not upset just by the time of day, but because the time was wasted. I’ve stayed till 8 and 9pm before, and not been too unhappy, because I was doing procedures, or taking care of a patient who seemed too unstable to sign out. But twelve hours rounding?

This is the attending who can be found in the hospital most nights of the week, regardless of the call schedule. This morning we came for sign-in, and he told us about something he’d taken care of overnight. “But you weren’t on call last night. You’re on call tonight.” “Yes, but I was here, taking care of some things.” Um, sure. Today, the night shift nurses had gotten their change of shift report and were ready to discuss their patients, before we finished rounding on some people. Totally insane.

On the bright side, I am now better at putting in brachial and dorsalis pedis arterial lines than I am at radials, better at IJ than at subclavian central lines, and very handy with an emergent chest tube. I skipped half of rounds, taking care of those things. (That encompasses two or three patients who are terminal, and need their families persuaded that it’s ok to withdraw care; two critical head injuries in the ER that needed to be checked on every two hours; a tension pneumothorax that came up out of the blue; an emergent intubation; and a-lines and dobhoffs scattered like pepper and salt all over the unit.) And at the end of all that, I still had a long list of things to be done; I could easily have kept busy until midnight just fixing the feeding tubes, changing vents and checking repeat blood gases, and repeating electrolytes on my patients. That’s what sign-out is for, because this stuff goes on around the clock. So now I have one hour to eat and do anything else – scribble this – before I go to sleep and get ready to start again, with another slow attending, in the morning. At least the attending today has a sense of humor, and doesn’t mind if we crack jokes about his lengthy rounds; the other attendings take themselves much more seriously, and are consequently more difficult to work with, since there’s less legitimate stress relief.

One week. I can do anything for one week, right? And then I won’t be an intern anymore.

(And to be precise, I learned several tricks about chest tube placement; got to do a needle thoracostomy (actually two, just to be sure we did it right); got enough practice to get a dobhoff feeding tube in right on the first try; learned how to calculate how many amps of bicarb are needed to correct a base deficit (wt in kilos x .25 x base deficit = meqs of bicarb; don’t ask me why, I take this attending’s word for it); reviewed what to do for traumatic diabetes insipidus; did a bronchoscopy, and got the best explanation of bronchiolar anatomy I’ve heard yet; changed another whitman patch (basically velcro over an open abdominal wound, used to gradually pull the fascia back together) at the bedside; reviewed inumerable chest xrays, head CTs, and abdominal CTs, and discussed the significance of a wild variety of findings; and had at least six significant discussions with families; and exchanged jokes with an intubated patient (and what kind of a day is it when you feel cheered up by an intubated patient teasing you? unbelievable). Put like that, it was 15 hours very well spent. Until I wrote all that down, I’d forgotten some things that happened in the morning.)

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

Somewhere in the last couple of years, I was near a city where the Body Worlds display (or one of the copy-cat shows) was stopping. After thinking about this for years, I’ve had enough of the ads (as it keeps travelling around the country), so here you go.

There are two primary ethical objections to these displays:

1) Our common humanity is denigrated by dissected bodies being displayed to public view as a matter of entertainment and moneymaking.

From a Christian perspective, the body is an integral part of what it means to be human. The Bible describes God forming Adam’s body and breathing life into it, and says that Adam was made “in the image of God.” To turn the human body into an object to be displayed for the enjoyment of crowds makes this crowning miracle of creation nothing more than any other animal displayed in a zoo.

But even if you wish to avoid a religious rationale, surely we can agree that the concept of Body World is of a piece with the modern entertainment culture, where horror films like Saw, Saw II, and Saw III (not to mention all the rest of their ilk) are viewed as acceptable amusements. Violence perpetrated on human bodies is now just a way to pass the time, not something revulsive. Similarly, Body World teaches us to accept the image of human bodies dissected, distorted, displayed – for our entertainment.

One of the greatest nightmares of medical school, gross anatomy, for centuries an illegal secret, and until recently at least a private activity, has been turned into mass entertainment for the crowds. I cannot express to you what it was like to cut up a human body, to destroy what another human person had used to live in, to love with, to see the sky from, the feel the ground by. . . At least I had the comfort, the excuse, that I was doing it for a reason – to be able to help hundreds of other people live, love, see, feel, a little longer, a little more comfortably. And it was, at times, a paltry excuse. To saw a skull open? To split a pelvis in half? To peel the skin off a face? To split a hand into useless threads? Who can do that calmly and claim to be still human himself? These phrases are the description of a monster’s activity. At least we had a reason; and I think our humanity survived. 

But what excuse is there, for the general public, to go and stare at bodies split open, splayed apart -amusingly posed? If you want to know what your inside is like, read Grey’s Anatomy; get a plastic model from the school supply stores; read Netter’s, if you prefer color. If you want to know how the thing works, there is no scarcity of physiology books, in all ranges of readability. The craze about Body World has nothing to do with a sudden hunger for anatomical knowledge. It stems from a fascination with the forbidden, the weird, the indecent.

Like the rest of the violence and indecency which is now commonplace in our society, the Body World displays serve the purpose of destroying our conscience and filching our reverence for humanity as something separate from the animal kingdom.

2) These particular humans almost certainly had no say in the disposition of their bodies; and even if you allow that it might be all right to use bodies this way, if their owners had knowingly and completely consented, it is wrong to participate in the exploitation of individuals who in their lifetimes were the victims of a cruel state.

We all ought to have known better than to think that Chinese bodies were come by honestly (and you had only to look at their faces to know they were Chinese). Recently ABC’s 20/20 removed the possibility of further self-deception by investigating the body-selling trade in China. Protest as he may, the inventor of plastination cannot deny that his original bodies came from a shady source, as he is now loudly promising not to use unethically obtained bodies anymore. The news stories mention thousands of people currently offering their bodies to be used in these displays, but the fact remains that there is no good documentation of the origin of the bodies that are currently touring the country. And for anybody who thinks any Chinese person whose body is being used actually freely consented to this arrangement, I have a bridge in Brooklyn to sell you.

But, even if all the unethically obtained bodies were cremated, the objections in my first point would still be reason enough not to see these exhibits.

For a much better-written exposition of the moral objections, please see Thomas Hibbs’ essay, “Dead Body Porn”.

I’ve learned the geography for maybe 120 miles around my new city by dint of making polite conversation with my patients, and hearing that they live in such-and-such a city, ten miles east of X small country hospital, and two hours north of our place; and so on. Thus, my picture of the surrounding territory consists of outcroppings of towns labeled predominantly with the names of our referring hospitals.

The attendings and chiefs are a step ahead of me. They know not merely the hospitals, but the physicians who transfer patients to us regularly. In fact, they know them too well for their own happiness.

There’s one doctor in particular, I’m not sure yet whether he’s ER or a surgeon, but when the attendings hear his name (“Dr. Smith called about transferring a patient to your service”) an expression of disgust comes over their face, usually accompanied by several unprintable words. We’ve figured out, through too much experience, that when he bills a patient as stable and ok for a regular floor, we’d better prepare an ICU bed, and maybe have the OR on standby. Whereas when he describes a patient as septic, on death’s door, requiring urgent operation, we can safely order a regular floor bed, and consider whether a CT scan might suggest the need for surgery, or simply send the OR staff to bed. If he describes right upper quadrant pain, it’s invariably in the left lower quadrant. If he says the patient has no cardiac problems, they’re most likely in decompensated heart failure and/or infectious endocarditis. If he says a patient has necrotizing fasciitis, we can safely conclude that it’s simple cellulitis. If he says there’s a rigid abdomen, it’s sure to be as soft as a kitten.

The real problem is when he says he’s not sure what’s going on. Then we have nothing whasoever to base our conclusions on.

So my question is: was he always this poor of a doctor, or did he change after he left residency? If I’m a conscientious, careful resident, and learn how to accurately assess my patients, will that protect me from becoming this kind of terror to my colleagues? Or is it that once you leave the demanding academic environment, where there’s always someone looking over your shoulder and evaluating you, it’s just as easy to slip into this lackadaisical, “we’ll let the big hospital handle it,” mode? What can I do to keep myself from becoming this doctor?

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