neurosurgery


(For HIPAA purposes, this didn’t happen last night.)

All afternoon we were getting one consult after another. The resident eventually gave up on his pager, and just answered every number with, “What’s this consult’s name and medical record number? Thanks, we’ll get there.” All of this activity finally produced, between the ER and the ICU, both a subdural and an epidural hematoma urgently needing surgery.

Around 6pm we started setting up for the subdural. As I have mentioned, whether because of my luck, or lack of initiative, or poor planning, or some other factor, I had a fairly uneventful and therefore less educational surgery experience in medical school. I had scarcely, until this rotation, seen a patient *with* a subdural, let alone seen an evacuation of one. I am now wildly in love with neurosurgery in general, and these guys in particular, because they apparently take the old surgical adage, “see one, do one, teach one,” a step farther, and skip the “see one” part. The chief handed me the scalpel and said, “Get down to the skull.” By this time I’ve learned enough not to *say* anything surprised, even if I can’t help my face. He had me open the skull, and even the dura itself. I could not believe that he was letting me hold a scalpel a millimeter away from the brain surface, but if he was nervous he managed to conceal it pretty well. The attending didn’t do much at all. He just stood and looked over our shoulders, and agreed with the chief’s ideas.

Being after hours, the OR had opened up another room, and we were able to start the next case as soon as the first patient was safely tidied back to the ICU. (Another great thing about emergency cases: no one dawdles about turnover.) This was a younger patient with a recurrent epidural in the space that had been evacuated a few days before. There was no cutting for this one, just lots of irrigation and careful removal of the blood, which was clotted all over the brain surface. (It had gotten under the dura, too.) I got to close half of the large incision, which meant a lot of stitches tied very tightly. After not being in the OR for nearly two months, I was very happy to find my stitches and knots coming out both neat and tight. (The chief doesn’t have the bad effect on my hands that some of the other residents have.)

I didn’t leave the hospital till 11pm; but who needs to sleep, when they can do surgery? After going for so long hardly seeing the OR, and not scrubbing in, I was starting to wonder about my choice of specialty. I wasn’t as miserable as I had expected to be, stuck on the floors. Last night was great. They let me do surgery (neurosurgery!),
and I realized that although I’m not unhappy with doing paperwork in the ICU or on the floors, there’s a big possibility beyond “not unhappy.” I felt ready to stay up all night (the chief, poor guy, still had to, as the ER hadn’t stopped producing people with back pain).

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This morning the chief decided that I’m now competent to handle the call pager. Idiot that I am, I was thrilled at being given such responsibility. One hour and a dozen stat pages later, I wasn’t thrilled any more. “Patient is unresponsive, come see her now.” “Patient would like to discuss completely changing the plan for his surgery that’s scheduled in two hours, come talk to the family.” “Is this patient stable enough to go to the OR for major surgery tomorrow?” Or better yet, “The patient with the PE is unresponsive,” and “your post-op patient is tachypneic, tachycardic, febrile, hypertensive, and has low sats; and his ICP is high.” [intracranial pressure; supposed to stay low] But I learned a lot about emergencies on the neurosurgery floor, and how to handle a dozen urgent items at the same time. If someone doesn’t stop me, I have the feeling I’m going to volunteer to hold the pager tomorrow.

Unfortunately, there’s an adrenaline surge that comes from scrubbing in the OR that somehow doesn’t last twelve hours later when you’re stuck in the ER. Someone insisted on giving us a lecture this afternoon, and I fell asleep in a group of four people looking directly at the lecturer. Very bad form, Alice. I kept myself going by contemplating the fact that in a few years I’m going to be on a schedule like this regularly. The chiefs can operate all night, and still have all their responsibilities during the day. There’s no one to cover for them. But I’m looking forward to when I’ll be keeping long hours in the OR all the time, not dancing around on the outside.

No time to write more now, because I’ve got about four hours left to sleep in, but they let me do neurosurgery. Twice. I can’t believe these guys. Who needs to sleep?

I never thought I would enjoy lectures this much. When I was interviewing, I was rather incredulous about the residents professing vast enthusiasm about how many lectures they had. Now, the chance to take time away from the constant issues on the floor is always welcome. So is the opportunity to concentrate on learning. There is so much I
don’t know, and need to know *right now*, that I’m glad of any chance to learn it. Plus, M&M can always be counted on for some fireworks. Whether it’s our one particularly fierce attending interrogating a senior, or an argument where the vascular attending decides to tell the trauma attending how to handle a trauma code, or a chance to dump our frustrations on the computer specialists who come to explain how to use the new system – academic days are always exciting.

It would be both difficult and dangerous to tell a surgery attending that you appreciate him, so I’m going to use this as an outlet to repeat how much I like my program. The hospital is good, most of the nurses are good, the food is edible, there are plenty of computers around (whether for checking labs, or playing with email). I like and respect the majority of the other surgery residents. The attendings are mostly much nicer than I had hoped for, and all seem to be enthusiastic about teaching. This program is as good or better than I could have hoped for, and I’m happy to be here. (No matter how grumpy I get sometimes.)

A couple of times every day I need supplies for patient care, and every single time I have a reason to smile: the nurses gave me a secret code to get into the supplies. Like most hospitals, this one keeps not only the medications locked up, but also all the basic supplies, like needles, syringes, gauze pads, wound dressings, lubricant, stitches, cotton swabs, steri-strips – you name any useful article, and it’s locked up. Which for most residents means that every time they want to do anything more advanced than touch a patient, they have to interrupt a busy nurse, get her to go into the locked room, open the locked cabinets, find the hidden items, and sign them out, before they can do anything. Towards the end of last month, whether because they now trusted or me, or because I had made myself so annoying, one of the nurses gave me a secret code. I had thought it would take me a couple of years to arrive at this, because so far I’ve mostly seen chiefs entering the supply rooms alone. But now I have a code (I have a code!) and I can get supplies for myself. I can do things on my own, and I don’t have to bug the nurses. I’m still thrilled every time I do it, because I hated asking the nurses. (It was always a dilemma: ask the one who’s already in the room doing something, the one who’s closest, the one at the other end of the station who doesn’t look too busy, or go find the nurse for the patient you want to take care of right now?) Now I can take out drains, sew incisions, change dressings, take cultures, and several other small jobs without having to waste time finding a nurse and wasting her time, too.

I’m also slowly starting to understand exactly how draining it is on the neurosurgery residents to be on overnight call q4 or q5, forever, and never leave the hospital before noon the day after. They don’t sleep on call nights, either. They’re responsible for an ICU full of sick patients, a floor full of post-op patients, and there’s always something in the ER. Usually there’s at least one emergent surgery overnight. I really can’t blame them for getting as irritable as they do, whether it’s their call day, and they’re contemplating the coming night, or the day after, when they’re exhausted, but have too many jobs to do to leave the hospital. I try to help, but there are some things that I’m no good for: placing ventriculostomies, for example.

Today I finally made myself gossip with one of the other general surgery residents about the neurosurgery program. Turns out there was a lot I didn’t know. The program has been in turmoil the last few years. No wonder I couldn’t figure out who was senior to whom. No wonder I couldn’t figure out what their hierarchical structure was. And no wonder a couple of them are so bitter. One of the neurosurgery residents told me he wakes up every morning praying, “God, please don’t let me get fired today.” I couldn’t live with pressure like that. Resolved, to make a few more excuses for their behavior. (Although, even knowing that, and knowing that my dumb questions must be a tremendous nuisance to him, it’s still hard to work with a guy who bites your head off every time you open your mouth. Still, I’d rather ask dumb questions, than make an assumption, and hurt one of the patients.)

What he especially hates is me being reluctant to talk to family members who come asking about prognosis, and instead forcing him to talk to them, when he’s got a million other things to do. I know what everyone says, “you’re the doctor now, you do it,” but I’m honestly not competent to go and give definitive answers to people who want to know whether their father or mother is going to live or die. They’re going to decide whether to withdraw care based on what we tell them; and I don’t know enough to honestly go and tell them, this is how it is. I would be cheating them. No matter how annoying it is to the neurosurgery guys, I refuse to say that stuff.

They don’t explain enough to me, anyway. They talk in shorthand to each other (as I’m sure general surgeons do, to our med students’ annoyance). The trauma guys ask me what neurosurgery thinks of the CT scan. I can only shrug my shoulders. “They pointed out a couple of spots that were different from yesterday, and they said this scan isn’t enough to explain the clinical picture. But what the name is of what they were looking at, I couldn’t tell you. All I know is, they said the patient needs to stay in the ICU.” How am I supposed to talk to families like that?

The neurosurgery chief resident has so much autonomy I’m jealous. He does cases almost singlehandedly – far less supervision than I’ve seen a general surgery chief have. But it comes with a price. He also has so much responsibility, sometimes it hurts to watch. Today a critically ill patient was on the receiving end of several miscommunications between various team members. The patient is in such critical condition that I doubt that anything short of a major dose miscalculation or misadministration (which thank God we’ve so far avoided) could do any more harm; but it’s certainly not helping, either. There was no one person totally at fault; which means in the end, the chief takes responsibility. Just watching him listen to the trail of errors unfolding at signout, watching his shoulders sink as he chose not to get angry at anyone, but simply to take the guilt on himself and call the attending with it – was painful just to watch, being totally on the outside and knowing I hadn’t contributed. I’ve written before about how as a medical student I admired the interns who accepted responsibility for mistakes I’d made while they were supervising. I hadn’t completely realized that this responsibility just keeps growing. The chiefs have a whole team full of residents and students that they’re responsible for; it’s all on them, in the end. (I guess the attendings are responsible, too, but the chiefs are more directly involved; and I haven’t seen many attendings hesitate to ream out a chief or a senior when they could choose to accept involvement in the problem, rather than distance themselves.) (His silence, of course, probably made the rest of the team feel worse about the mess than we would have if he’d chewed us out.)

As for the patient and the mistakes themselves: definitely signout was involved. Too many signouts between too many people added up to a seriously jumbled decision-making process. We’ll see in the next few days how much the patient has been affected.

The residents wound up signout with some appreciative quotes from House of God. When I was a first-year student, I thought I would acclimate myself to my new world by reading this much-referenced classic. About three pages in, I gave up on the obscenity and cynicism. So far I’ve avoided returning to it; but it’s probably a marker for my deterioration that I now think the quotes are funny and witty rather than crass. (To make it clear, this is not a book recommendation; I would not want to be responsible for somebody getting this stuff in their head. There’s no benefit to reading this or any other book about life being miserable in residency. If you’re the general public, it’s too much information. If you’re a med student, you’re already stuck, and there’s no need to borrow trouble. If you’re a resident, you know for yourself, and there’s plenty of dark humor right in your own hospital. And if you’re a practicing physician, you survived, so why think about it anymore?)

Lately we’ve resumed the regular academic schedule which most residency programs suspend for July and August, while the interns are surviving their first days on the wards – and the wards are surviving them. I hadn’t realized how much I missed the challenge of academic demands, and the prospect of intellectual competition. (As in, which one of the sleep-deprived interns can manage to read and remember more of the text from which the week’s questions are taken? Actually, for a pleasant surprise, they quizzed the seniors, not the interns. I guess we’re still a pretty hopeless lot in the attendings’ eyes.)

Getting away from neurosurgery and back to “my people” for a few hours was also a morale-booster. Already, after only a few months, all the interns have completely identified with their specialty and their group of colleagues, contributing to a group identity and a group defense. (At the end of fourth year, we thought we had identified ourselves; but a few weeks of refusing consults from the ER, and bouncing difficult patients to other teams, will work wonders for making you feel that you belong to one particular group, and everyone else is other, an enemy.) (This is an exaggeration. So far, I still like the ER people; they haven’t done anything bad to me; they can’t help that the patients pick bad times to come in; and I love how the medicine people take patients whose list of medicines I can’t bear to look at.)

Other than that, I don’t want to talk about neurosurgery. The residents are grouchy, and when they cheer up, they have more graveyard humor than I like. The patients are either intubated or severely handicapped from strokes or trauma. People who came in talking in the ER are going down the tubes, despite us trying every established and experimental treatment in the book. (This is why I hate the brain: you can’t handle it, like you can handle a sick belly; and once something dies, it’s gone, it will never heal. For an abdominal wound, there’s always hope; once a neuron dies, it’s gone forever.)

For a while there I thought I was being exceptionally stupid, because one of the senior neurosurgery residents has been giving me a pretty hard time. Not bad, really, just lots of comments and jokes. Today I finally figured it out: he despises all general surgeons, not just me. He phrased it as “what you need to learn from this rotation,” but asking me questions that second year medical students ought to know the answers to, and acting surprised when I knew them, was not purely instructional.

I’ll be the first to admit that surgeons can look down their noses at most of the rest of the hospital. ER, internal medicine, the subspecialists that we consult less frequently. . . We get to feeling superior, just because maybe we’re better at putting in central lines (not me, the others!), or aren’t as worried by abdominal pain as everyone else is. Not that we’re really any better, we just have different areas of expertise.

I guess it’s good for us to be despised by someone.

These neurosurgery residents make me so nervous. Now that I’ve grasped what they’re really saying, there’s a pretty constant level of sniping from some of them. I never know whether they’re making a straightforward statement, or trying to trip me up somehow. I really want to remember and not do this to other people. No doubt a similar atmosphere from some of us is what makes some medicine residents nervous about consulting us. Too bad there’s absolutely no one who ranks higher than the neurosurgeons. They are unquestionably smarter than all the rest of us – and they know it.

If this resident explains to me one more time (asking wouldn’t be so bad) about the anatomic location of the dura, arachnoid, and pia mater, or the difference between an epidural and a subdural and an arachnoid hemorrhage, I think I’m going to give up on being quiet, and saying something sharp. Like: yeah, I think someone mentioned that to me back in first-year anatomy. Not that it will help, because I could never beat him at the sarcasm game.

Two of our patients are getting sicker and sicker, and nothing we’re doing seems to make much difference. They’re both relatively young, with a very acute illness. Their families are devastated, and even the senior residents are worried about them. How many times can I say that I hate this? God, I don’t want them to die. . .

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