residency


Last year, I mostly viewed the scutwork the seniors demanded as an exercise of their power, nothing else. I did it, of course, but I couldn’t really see why they didn’t just do it themselves. Why the interns and juniors had to write all of the notes in the morning, write most of the post-op orders for the seniors’ own cases, write the post-op notes on the patients the seniors had just been operating on – it seemed rather pointless; or rather, too pointed: they got the fun of operating, and I got all the busywork.

Now, with a little more experience in the OR, I can see more reason to it (or perhaps, now only a year away from being a senior myself, I’m starting to rationalize giving a lot of the work to the intern). For one thing, the work hour limits hurt the chiefs a lot: simply being present for all their cases takes pretty much all the available time. Being in the hospital a few hours early every day to round would put them way over. Nevertheless, the good ones seem to know more about their patients than I do, for all they spend less time on it. The most fearsome chief I had this year seemed to be able to put me in the wrong every time we sat down to run through the list: despite having been in the OR all day, and me not, there was always some test result, some lab value, some change in the patient’s condition, which he knew about and I didn’t. He wasn’t trying to do anything in particular to me, either; he was just taking care of his service.

For the rest, writing orders and helping to get cases started, I’ve realized that “simply” doing three or four cases in the day can be quite tiring, and it’s only kindness to the seniors to use my energy instead of theirs to move in and out of the OR. (My hospital has an inefficient OR setup; neither the OR staff nor the anesthesia staff has any motivation to move quickly. It doesn’t decrease their workload or their hours, or improve their pay, to turn things around quickly. This leaves the surgery residents as the only people who really care whether it takes twenty minutes or fifty minutes to get the next case started, so the day will move more quickly if there’s one of us turning up to make sure that the patient has in fact arrived in pre-op holding, that their pacemaker is being turned off appropriately, that the CRNA is aware when the scrub tech is ready for them to come back to the room (instead of both parties sitting waiting for the other to call, as I frequently find them doing), that there are enough hands available for transport and to finish setting-up details in the room.)

So, I think my approach has changed since the beginning of internship: instead of figuring out what the chief was going to check to see if I’d done, now I look for any work at all that needs to be done, and take care of it, regardless of exactly whose responsibility it technically is. I wish I knew how to teach this work ethic to the new interns; but luckily, I think it’s primarily transferred by example, so I just need to keep doing my job properly.

Early in my intern year, I started learning one of the key principles in any residency program, which is that if anything goes wrong it’s my fault. The applications range from the mundane to the serious: wrong date on the notes because I’ve lost track of what day of the week it is, let alone what day of the month – my fault. Didn’t preround on a patient because I didn’t notice their name scribbled on the bottom of my list of consults from the day before – my fault. Didn’t reorder the statin after the patient started eating – my fault. Didn’t get in to the OR in time to help write postop orders for the chief’s big case – my fault. Didn’t make important vent setting changes till late in the day – my fault (I think I’m making that one up; I can’t say I’m 100% sure it never happened).

Today it was definitely noticeable, and the event was somewhere between annoying and infuriating for various members of the team (not least myself). One could argue that I wasn’t the only one at fault. But so to argue would be a waste of time and energy. As I’ve said, whatever goes wrong, is my fault. The chief I have this month is very helpful in this respect. Some seniors allow a little doubt to arise about whether it was entirely my fault. This chief leaves it in no question: undoubtedly, at all times, under all circumstances, my fault. This certainty saves a good deal of time and mental effort on my part. . .

(I’m not even sure myself if this is written with tongue in cheek or not; as you like it.)

By the end of the day, the beginning was so far away that I spent half an hour, while finishing orders and signing out, trying to remember whether or not I had eaten anything for lunch. It seemed as though a couple weeks had passed since then, along with an appropriate amount of excitement and emergency.

On the intern’s days off this month I get to take care of the floor, since dealing with the myriad annoying details of a busy floor is completely beyond the patience of a chief resident, especially by this time of year (there’s tylenol tablets ordered and the patient would like liquid; patient in ten really needs to be reassured, by the doctor, for the third time today, that the bump on her stomach is normal after surgery; patient in eleven hasn’t voided today – or in fact since yesterday evening; clear liquid diet is ordered, may the patient have coffee (x 3 or 4); please order physical therapy, or the patient will not want/will not be assisted to walk today; please reorder physical therapy, they lost the last order in the computer; please order occupational therapy separately; the patient being discharged doesn’t like percocet, they would like vicodin instead (great, and I already wrote all over the controlled substances script, and have to go get another one from the sub-basement safe deposit, or wherever they keep them these days); the patient has a fever of 100.2 (no, that isn’t a fever, call me when it gets to 100.4, or better yet, not until it gets to 101+); the pharmacy says the dilaudid order for the patient who had surgery yesterday has run out, he’s having pain, and I can’t give him anything unless you reorder it right now) – and I can’t blame him.

Plus some of my favorite floor consults (the patient was going to see your attending next month, but since we’ve admitted him with another acute problem, please fix this one right now), and my favorite ER consults (where my attending knows the patient is coming, and I get labs and CT ordered and my whole admission and orders written up before the ER intern fills out their T sheet; that makes you popular with the ER attendings, and the intern too, because they don’t have to call you).

But for all the sarcasm, this stuff is amazingly easy to deal with. Last year I would have spent at least a few minutes thinking about all kinds of questions, or about the slightly more real dilemmas (how to treat pain when the patient throws up with everything you give them; what to do with a blood pressure of 200/110; is a fever on the night of postop day 2 worth working up, or not); but now I’ve seen enough that this is all reflexive. I’ve finished most of the scut work by 8 or 8:30 am, and have the rest of the day free for the OR, for catching up on the ICU patients, or theoretically for studying. It’s nice to know that I’ve learned something in the last two years, if only how to deal with minor questions fast enough that neither I nor the nurse have time to get annoyed about them.

Next week the schedule picks up, and I should get some more cases. I think the chief thought I had finally taken leave of my senses (which he’s never regarded as very formidable anyway) with glee, when we discussed that part of the schedule.

The week was fairly quiet: only a few cases to go to the OR at night, no remarkable activity in the ICU, no dramatic traumas. I was figuring that my white cloud had stuck with me; and indeed it was remarkable how all the arrests on the floor, and all the gunshot wounds for trauma (which it’s part of my responsibility at night to assist with) should all happen during the daytime for a solid week.

Of course Friday night that all changed, and I was completely swamped, to the extent of almost recklessly leaving things unfinished with one patient in order to hurry off to the next, leaving large jobs for the interns to do alone that normally I would help with, and being quite curt in my discussions with patients (completely contrary to the rules of don’t interrupt, and don’t ask closed-ended questions). Once again, though, everyone survived quite nicely (except for the one patient who, sadly, was not expected to; so I am not too cast-down about that death), and not too many anxious families were mortally insulted. The only lucky thing about the night was that the hospital was suddenly smitten with an excess of empty ICU beds, such that no critical patients had to wait to get in the ICU, which was very convenient.

I am developing a great respect for one of the surgical ICUs in particular, whose nurses are so used to having imperious attendings stroll through handing out orders, and then disappear out of range of pages, that they commonly put in all the orders themselves as verbals; and I find them taking care of all kinds of scut for me, and correspondingly ridiculously pleased when they see me putting in housekeeping orders on my own. This is also the only ICU in the hospital in which the nurses are actually excited when something dramatic happens, and all join in happily for bloody bedside procedures; unlike even the other surgical ICUs, where they don’t mind blood and commotion, but prefer peace and quiet.

On the other hand, I am getting quite frustrated with the medical ICU, where the nurses are certainly competent, but have a very different set of priorities. They will not call to tell me that the patient’s urine output is drifting pretty much to zero for a couple hours on end, or that the blood pressure is creeping steadily down to 80. They will however call to say that the potassium is 3.5 (lower limit of normal) or that the troponin (cardiac enzyme, marker for possible ischemia) is 0.12 (lower limit of abnormal); or that the patient’s lungs sound wet, even though their sats are fine. I wish I knew a tactful way to tell them that I would appreciate being told about borderline blood pressures and urine outputs, in addition to the labs; but I can’t come up with any statement that doesn’t sound insulting (as in they’re not doing their job properly) or lazy (I don’t always have the time to walk through the unit every 1-2 hours to check the numbers for myself).

Also on the score of good news, I have a delightfully competent intern to work with. She is remarkably good at assessing things on the floor or in the ER, and calling me only at appropriate times. Also, she is good at procedures – nearly better than me, I am obliged to say.

This job is unique because every decision, every action, seems to have a moral quality. If I make a mistake, it’s not merely an error, it’s wrong. I feel it to be so – a sin against my patients – and my superiors act similarly horrified. Not only major failures: misjudging the need for an operation; choosing the wrong course intra-operatively; failing to recognize an important change in the patient’s condition – but the small ones: tying a knot wrong; not cutting exactly in the plane between tissues; forgetting to order morning labs; one liter too much or too little in resuscitation; imperfect phrasing in a note.

I don’t think this is just in surgery. It seems to be across the board in medicine, part of the nature of professional responsibility. Perhaps the rigidity of surgical training means it’s voiced more clearly, but I think my friends the medicine residents feel just as badly about errors small and large.

That’s the problem, of course – there are no small errors in medicine. Every single mis-step could have disastrous consequences, even if most of the time things work out ok. Getting morning labs a few hours late, to take one example, could mean missing a significant acidosis or hemorrhage for a length of time that could impair our ability to respond quickly and effectively. Sure, it would be rare for a few hours to make much difference; but I can easily picture it happening.

So every decision, every action or lack there of, carries a tremendous potential for guilt, which only increases with the size of the decisions. And every night, you can go home and spend hours second-guessing yourself: was I wrong? and if wrong, how wrong?

Other jobs may have long hours, but I doubt that any have this weight of moral implication attached to every moment.

Some peculiarity in the schedule this year has arranged that I’ve spent most of my time so far on rotations which are not part of the general call pool; and when I have been in the call schedule, it’s mostly been for the short, 12-hour shifts. So handling all the surgical services at night is still a little new to me. The last such night went much better than I had expected, and seems to augur well for the next month, which will be all nights. (You’ll have to excuse some elaborate phrases; I’m reading Mallinson and O’Brian, historical novelists of the British cavalry and navy in the early 1800s, and their latinate constructions are catching.)

One of the first highlights was a call from the OR holding area: “The vascular patient your attending is expecting has arrived, direct by ambulance.” Which did not sound good: a patient being admitted directly to the OR for vascular surgery? And of course the attending, having said that he would take the patient, and informed the OR, had not felt a need to tell the residents about it. Fortunately, a tourniquet, although limb-threatening, had the bleeding well under control.

A little later things became more complicated. One intern had a patient on the floor with progressive shortness of breath and hypertension, while supposedly hemorrhaging - altogether a puzzling picture. While he was being transferred to the ICU, the other intern called me with a patient in the ER, who had a dramatic CT scan and peritonitis. By the time I got down to the ER, the patient was unwilling to talk much; whether because she was tired of explaining to multiple doctors, or because she was actually so ill, was unclear to me. But she had rebound on exam, and the CT was clear, so I called the attending and the chief resident to come in from home, and told the OR to set up for them.

No sooner had that been settled, than the first intern called again to say his patient was struggling to breathe, and had an ABG on which the CO2 was nearly three times normal, whereas the O2 was one-third normal, and he was going to call anesthesia to intubate him. At our hospital, because of the presence of an anesthesia residency, anesthesia is responsible for all intubations – if they arrive in time. For a few minutes after I got upstair, as we were bagging the patient in an attempt to correct an oxygen saturation of 60% (which had developed after the intern called me), I thought I would really have to use the intubation kit which is kept in all the ICUs, and do it myself. However, anesthesia did arrive quickly enough that it was still safer to wait for them than to try it myself, and the patient was soon intubated and stable.

Which is an example of my dangerous inability to believe maxims without testing them for myself; like reinventing the wheel constantly. There’s an old saying: if you think about intubating the patient, just do it – don’t wait for things to get worse. And I had thought about it, after getting that man down to the ICU, before I left for the ER. His sats and blood pressure were fine, he just looked labored. I had thought he could wait a few more hours, or perhaps might improve with more aggressive care in the ICU. In this instance, the delay didn’t hurt anything, except that it created a commotion and meant the patient had to be intubated as an emergency. Next time, I would order the intubation a lot sooner. And for the future, I swear I’m going to actually follow all those maxims, rather than discovering them for myself.

After that the intern and I put in a line together. Which was for me a significant point: the first time I’ve guided an intern, not comfortable with lines, through the procedure by myself. That sounds ridiculous, for surgery residents more than halfway through the academic year. But picc lines (peripherally inserted central catheters) are so ubiquitous now that only in true emergencies in the middle of the night do we usually place central lines any more.

The rest of the night, while busy, was calm compared to that. No deaths on my watch, which was a relief after the last few calls, and after the signout I’d gotten on some of the more precarious ICU patients.

One of the characteristics of a good surgery resident is being able to have your finger on the pulse of the surgical services – not just keeping up with what’s happening with your own patients over the course of the day (and especially keeping ahead of the chief and the attendings, because it is bad form to be informed by them of something important with your patient), but knowing what else is happening: when the trauma service is being overwhelmed with operative cases, and may need to pull residents from other services to help; whose ORs are running slow, and may end up bumping your attendings; what disasters are being transferred from other hospitals or admitted from the ER; because eventually all those things can add up to you being needed to help cover other services.

As for the surgical floors, there’s a complicated calculus, taking into account the number of patients on a floor, the number of tubes connected to them, the number of days since surgery, whether it’s a surgical or a medical floor, whether it has cardiac monitoring or not, which determines how often one needs to stroll through in order to catch low urine output, tachycardia, uncontrolled pain, persistent nausea, and wound problems. The best senior residents have this down to an art form, and will always just be walking onto the floor as shortness of breath or chest pain reaches crisis proportions, or as the vascular patient’s slow ooze suddenly becomes a squirter.

On the other hand, one can get in trouble this way. Being too good at keeping your ears open means you get involved in problems that aren’t necessarily strictly your responsibility. Like today when I heard the nurse trying to page a resident, who wasn’t even in the hospital, because everyone else on the team was tied up in the OR. I could have let her go through the rest of the coverage algorithm, and maybe eventually arrive at someone who was free to help. But I was standing there; so I took care of it.

Sorry guys, short on further stories. I think at some point it has to get tiresome to an outside observer to keep hearing how excited I am about simple things like hernia repairs (well, ok, not simple, but today I finally managed an important step in the procedure myself, without the attending handing it to me).

Other than that, I am disappointed to observe that I have become as cynical as any jaded resident I’ve ever watched and wondered at. Maybe it’s the time of year. I’ve had conversations with nearly all the junior residents in the last week or two, discussing our regrets at being in surgery, and our fantasies about what we should have, or perhaps still could, do differently. Some of my colleagues had remunerative careers before going to medical school; unlike me, leaving is at least theoretically an option for them.

As for students, I make no effort now to attract medical students. If they’re enthusiastic, I’ll help them find where the most interesting things are; and I’ll always answer questions. But I have no patience for the silly ones, who talk as though they know something only to reveal their own ignorance, or who are so bored by the whole concept of surgery that they walk off in the opposite direction while the intern and I are pulling up a CT scan to see if we can confirm a diagnosis of appendicitis. (I mean, come on; CT scans are fun. You can always learn something by looking at a scan, especially a positive one.) I did grab the student and make him look at the appendix (classically swollen and inflamed, in this instance), but I had no energy to carry on to general principles of reading CTs, or general principles of how to behave when seeing a new consult with the team. As far as career choices, I haven’t even finished second year, and I’ll advise anyone to do something other than surgery.

And medicine interns. Don’t get me started on them. It makes me so angry when they write an order for a stat surgery consult, and then walk off, leaving the secretary to call us, not caring that it may be 12 or even 24 hours later that we finally hear about the situation. As often as not the matter is not urgent at all, but if they are puzzled, or concerned enough to mark the order stat, then they ought to take two minutes to call me themselves. Or, when they consult us for a longstanding hernia in a patient admitted for a completely different matter. We’re not going to operate during this admission. I personally will be off rotation by the time they finally follow up in the office and schedule surgery with my attending; so why do you force me to go through the pointless exercise of talking to the patient, writing up a complete consult note, and then calling my chief and attending to tell them about it? Or when every day they try to feed the patients who’ve just had surgery for a bowel obstruction, and still have an NG in. Such a temptation to write rude things in the chart (which I never do, though).

My friends and I all seem to come to the same conclusion: no matter how tired we are of residency, or of the hours, or of the hierarchy, or of our inability to perform miracles, in the end, being in the OR makes up for everything. There’s nothing else in the world like it, for pressure and power and danger and reward; that’s why we stay. (That, and the paycheck; which of late months is more appreciated.)

(Equal-opportunity grumpiness: the surgery interns sometimes drive me crazy, too. There are a couple that have a knack for always choosing the less correct of two possible options, or of doing whichever thing will annoy this particular attending the most. Then there are some who will call me late in the afternoon to announce that there are four consults on the floor, and two patients in the ER, and maybe one coming in from the office. . . why they couldn’t tell me some of them sooner, I don’t know. But them I have a little more patience with, because I know was, and probably still am, just as annoying in similar ways.)

Call last weekend was one of the wildest days of my career to date, including some events that I’m literally not thinking about because, despite my predilection for seeing how close to the edge of a cliff I can get without falling over, I don’t dare to examine those events in detail. And that was only the beginning.

The last consult of the day was for an elderly patient with peritonitis. She had multiple other comorbidities, making the idea of operating on her quite daunting. Nevertheless, as I’ve told the medical students many times, if somebody honestly has peritonitis, then they need surgery. So I had to explain to the family, who thought they’d come in to the hospital for just another bout of the stomach flu. The altered mental status, clammy skin, absent urine output and glazed eyes didn’t have the same instant significance for them that they had for me.

Once they agreed that, despite the risks, they would rather take the risk of death with surgery than the certainty of death without surgery, I had some more calls to make: the senior resident, to come in from home. The OR, who suggested that they had other cases running and perhaps we could wait a couple hours; which returns to the principle that real peritonitis means surgery right now if physically possible, even if that means calling staff in from home. (Perhaps it comes from so many years listening to my father the anesthesiologist making call after call trying to arrange anesthesia and nursing coverage for night and weekend ORs; I haven’t quite adjusted to being the surgeon, the one who declares that it needs to be done, and then leaves it to the OR team to figure out how to make it happen. Not to be authoritarian, but someone has to be the one to say that an emergency is an emergency.) And the attending, one of the older ones, who believes in rattling the juniors at all opportunities. He drilled me with questions (all the labs; the medical history for the last two weeks; recent imaging; why didn’t we do this or that test); and above all, are you really sure that this sick old lady has peritonitis – so sure that you’re going to put her through the risk of an operation. I stood up to him, but by the time he hung up, I was very glad to see the senior resident arriving, and equally impressed by the patient’s physical exam.

She did well – much better than I expected. She’s already extubated, ready to start eating, and looking ten times better than that night (when she was nearly ready to be intubated simply for respiratory distress, by the time we got to the OR).

That was the first time I’ve made a hard call on a patient needing surgery. Deciding that a patient with a moderate small bowel obstruction can have an NG tube and be observed for twelve hours, or that a child with a good story and a good exam has appendicitis, that a patient with a cold, ischemic leg needs intervention, or that someone with a perforated ulcer needs surgery – those aren’t hard; they’re cut and dried. This patient wasn’t straightforward at all. I was the senior surgery person in the hospital, and I dragged everyone in from home, and forced the family to make a difficult decision, based on my clinical assessment. I’m sure this story is not that impressive to any experienced doctors who may be reading, but it was new for me.

And next month I get to do that every single night. . .

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