neurosurgery


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. . .

I got out late today only because I was in the OR for a couple of hours this morning. Not that I got to do anything, but they let me scrub and were friendly enough. This is one rotation where I have absolutely no desire to touch anything. I’m too scared of the nerves.

I also got to do my first ever central line. It took several tries, but eventually went in successfully, and no punctured lungs. The patient was actually very dramatic, and occupied whatever part of the day wasn’t spent in the OR. He presented to the ER complaining of an unbearable headache for several days, fainting several times, constant dizziness, frequent nausea and vomiting, and visual changes. CT showed subarachnoid hemorrhage, and he was sent for an angiogram.

Then we got paged that he had “had an episode of asystole.” Calculated to give us tachycardia. When we got to radiology, he was awake and talking, but his vital signs were classic for Cushing’s triad: hypertension and bradycardia (the third feature being either altered mental status or elevated ICP, depending on which one you can measure). So the resident put a drain in his ventricle, right there in angio. It was a quite circus, trying to be ready for a code, and do a couple of complicated procedures, using supplies available in radiology, and frequently breaking down and sending urgent messages for help to the ER or ICU to get another piece of equipment. Neurosurgery involves so many specialized materials.

When it came to drilling a hole in his skull and running needles through his scalp, the patient’s stoicism, which had kept him out of the hospital for nearly a week, rather broke down, and he fiercely accused us of breaking our promise that the only thing going to happen in the lab would be a simple angiogram. By this time, however, he was losing his orientation, and we soon had to give up discussing the matter with him, and proceed to simple wrestling, in the knowledge that it would be better to save his life, and talk about consents and assault and battery and risks/benefits later on.

This patient was amazing to me because (after four years of medical school and two months of internship) this is one of the few times that I have seen a patient with a classic disease, lifethreatening, deteriorating in front of our eyes. Somehow the hospital starts to feel safe, as though things are under control there; but with this patient, even though we knew what was happening, that didn’t stop his mental status from disintegrating within hours.

In other news, I have my first patient with whom I feel there are serious ethical issues involved in the plan of care. Hopefully I can talk about it later. I hate what’s happening, but since the attending is angry, too, and can’t do anything, there doesn’t seem to be anything I can add.

The schedule remains pretty long, but I’m resigned to it now. Surgeons are supposed to be in the hospital at all hours and never leave a job unfinished; but neurosurgeons have us beat hands down as far as work ethic and hours go, and we know it. The only goal now is not to shame my service; for this one month, I’ll keep up with the neurosurgeons. (Not to mention being the only woman in sight for the first time in a while – another reason not slack off.)

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