hilarious

I have to link again to Frank Drackman’s (highly R-rated) list of differences between surgeons and internists. Among them, “internists spend ten minutes securing a central line and it still falls out” - drove me crazy when I was sharing my patients with a MICU team. I didn’t want to say I could put a line in better than the medicine intern, but I sure knew I could sew it in tighter. (And anesthesiologists, Dr. Drackman, just don’t sew the arterial lines in at all, because by the time it falls out, the patient will be out of the OR; and because the surgeon is hounding them to start the case.) And “surgeon knows it’s an artery because it’s squirting across the room at 150mmHg;” yeah, I’ve seen my share of those. As long as the patient’s not hypotensive, there’s not much mistaking an arterial puncture or laceration.

 

pay the piper

Somewhat related to yesterday’s post:

Today was splendid. I spent the entire day in the OR, running from one thing to another, so much so that at the end of the day I realized with horror that I’d hardly paid any attention at all to my floor patients. Fortunately, they were all with good nurses, so I was able to reassure myself while scrubbed in that I would have been paged if anything had been wrong; and indeed they were all cruising along smoothly when I went to check after the cases were finished.

Anyway, I had a tremendous time, being with one of the attendings who doesn’t believe in giving constant instructions. He just kind of stands there (after very carefully marking the place to start; my blog’s title is no joke), and lets you call for the instruments from the tech, make the incision, and proceed as you see fit. He says something if you’re about to do something absolutely disastrous; otherwise, he just hums a little bit and smiles to himself. Since he’s slightly deaf, no little hints like murmuring, I s’pose this is where we go next, will get you any help. You have to say loudly, I’m not sure what to do next, if you want to get any directions; which is of course a surrender and an embarassment to say, so you keep trying. But so amazing to realize that I actually do know a great many useful things to do.

At the end of the day, rounding with the chief, he could see that I was enjoying myself vastly. He smiled at my account of the day’s proceedings and said, “You know, Alice, you’re going to have to pay for your fun eventually.”

What he meant was that all these cases were on the schedule because he and the attending had been called several times a night for the last five nights, the team being on call. All I had to do was admit a few patients in the afternoon, and see a longer list in the morning, and then I got to do cases. He was the one who’s been awakened by calls at home several times a night for the last two years, and he and the attending were the ones who came in for emergency cases over the weekend. They’re tired.

And I was thinking. The chiefs at this program operate all day every day, it seems like. But they pay for it. They look pretty tired - noticeably more so now, at the end of the year, than at the beginning, when the cycle was just starting. They are never not able to do anything that’s called for; but they’re exhausted a lot, and they look like it. Most of them have grey hair. None of them are much past thirty, but they look older, especially after a string of days and nights with their attendings on call.

He’s right. I thought I was paying in advance, this year, doing all the pre-op and post-op work and not getting to operate. But next year, covering all the surgical patients at night, I’ll start paying; and after that, taking real call continuously - that’s when the bills come due. I’m worried about next year; but I’m even more scared of having a chief’s responsibilities. That’s only a little more than two years away. I need to stop doing math.

 

SurgExperiences, 10th Edition

Welcome to the 10th edition of SurgExperiences, a blog carnival dedicated to all things surgical. (And apologies for the late appearance; I realized at work tonight (where blogs are blocked from computers) that this was the important event I’d forgotten about when my days and nights got mixed up.)

The posts from our contributors this edition are so fascinating that I am sure you will enjoy them despite the lack of any fancy graphics here.

First, my favorite: Bongi’s tales of the black mamba. Read on to discover what dangerous anatomical structure he’s referring to. Also from Bongi (guest posting on All Scrubbed Up) a hilarious post on the realities of life in the OR.

Surgical education and error
Orac explores a recently published study of surgical errors showing more errors are made by experienced surgeons doing common operations (not necessarily junior surgeons just learning the operations).

A journalist comments on the difficulty of accurately measuring the number of wrong-site surgeries.

Buckeye Surgeon presents a case of wasted resources on the road to definitive surgical treatment. Orac expands on this with a scathing indictment of surgeons’ refusal to be involved in anything which doesn’t directly lead to cutting on a patient as a source of inefficiency in American healthcare. As an old-fashioned advocate of the surgeon being responsible for pre- and post-operative care, I echo the commenter who remarked that internists are ill-fitted to be responsible for the medical management of surgical
diseases, since they’re not trained to recognize when the patient has failed medical management. I recently saw a similar scenario play out, where a patient was admitted and had a million dollar workup for possible cardiac origin of epigastric pain. He returned to the ER the next day with excruciating epigastric pain, which yours truly recognized pretty quickly; a simple set of liver enzymes and an ultrasound revealed the gallstones which were the true culprits. So much for medical management.

Buckeye Surgeon also meditates on the complexities of educating residents.

From beyond the blood-brain barrier
A reminder from our anesthesia colleagues that good anesthesia counts.

Terry at Counting Sheep presents a lament for abandoned elderly people being “treated” by surgery that can do nothing to truly help them.

A tale of chaos in the OR that trumps any I’ve heard yet - glad I’m not working at that hospital.

From the front lines
A picture is worth a thousand words: military surgery in Iraq.

From the inimitable Dr. Schwab, an essay in fiction which leaves me shaken. Dr. Schwab explores possibilities I’d rather leave in silence.
Also, a collection of his best real-life stories.

Plastic surgery weighs in
Educational summaries by Suture for a Living on extravasation injury from chemotherapy agents, and on the potential for skin necrosis from the use of methylene blue dye in identifying sentinel lymph nodes during breast cancer surgery.

From another plastic surgeon: a discussion of how much bariatric surgery vs. plastic surgery can contribute to decreasing the morbidity associated with obesity.

Medical education
Jeff at Monash Medical Student makes plans to not faint during long cases. For his encouragement, I will admit to coming close to fainting during burn cases. (Ok, so you try turning the temperature up to 85 F, putting on a long paper gown, covering your face with a nonpermeable paper-and-plastic concoction, holding a heavy extremity motionless for twenty minutes, and see if you don’t get orthostatic.)

On a similar note, advice for medical students on what to do when scrubbed in.

Thank you for visiting. I hope you’ve enjoyed this collection of surgical blogs. The next edition of SurgExperiences will be hosted by Buckeye Surgeon on December 23. You can view past editions of SurgExperiences here, and if you are interested in hosting a future edition, you can find out more at that site. (I highly recommend hosting this carnival, if only because it obliges you to read all of the posts. I discovered several fun new blogs this way.)

 

why tv is dangerous

This is going to come close to rivalling my old story about Dr. House in real life:

Doctor: This procedure is really important to help us understand what’s making you sick. There are very few risks, and it’s relatively simple to do.
Patient: But whenever they do this on House, it always looks like it really hurts. I don’t want that.
Doctor (grinding teeth quietly): Don’t believe what you see on TV.

a comfortable conversation about art and Christmas preparations later:

Doctor: There, all done.
Patient: Already?
Doctor: So was it as bad as on House?
Patient: Nothing like that at all; I hardly felt a thing- they have no idea what they’re talking about!

See? Watching House/ER/Grey’s Anatomy/Scrubs can be hazardous to your health (or, if you’re a health professional, you already knew that you put yourself at risk of apoplexy by watching).

 

one way to find out

One of my patients is sick, and there are two schools of thought about him. When I get back tonight, we’ll see if he’s in the ICU or not, and then I’ll know whether my hunch was right. For his sake I hope I’m wrong.

Or maybe he’ll just be waiting for Brad and me to take him to the ICU tonight. . .

 

Stockholm

For how much I complained about this rotation for the last month, I’m surprised by how sad I feel about leaving. Almost every single night I was angry at the residents for making me stay so late. I guess it paid off somehow, because this last week they’ve trusted me with a lot of things, to wit, their call pager. Which is their way of getting to do surgery and not worry about minor details like the urine output, intracranial pressure, blood pressure, or temperature of the ICU patients. (They do care, really, and much more efficiently than I do; but in the OR it’s a distraction.) The junior residents especially, I think, have enjoyed dumping all their calls from the ER on me. I know that most of their interns haven’t done this much work.

But it goes two ways. Even though they were dumping on me, they trusted me; and I like that. I was starting to feel like part of the team this last week (albeit the team’s division of labor consisted of: Alice, write the notes, write the orders, see the consults, and do the admissions, while we are in the OR and clinic).

This morning they discovered one of my management plans from yesterday afternoon, which at the time had seemed so simple that I hadn’t thought to check with one of them. So of course today on rounds everyone was exclaiming about what a bad idea it had been, how completely and obviously wrong, and how detrimental to the patient’s physiology. I spent about an hour feeling guilty for 1) hurting the patient, 2) not checking with them (which was my one real mistake), and 3) still not realizing why my method had been wrong. Then the repeat labs came back, and the patient’s vital signs continued to do their thing, and it became clear that I’d had the correct diagnosis and a fairly correct treatment. I didn’t feel too good about it, though, because if I’d been thinking clearly yesterday there were some even more correct things I could have done. Anway, the patient wasn’t hurt, thank God. I hate this medicine stuff: always more than one right answer. Electrolytes especially are my downfall; and that seems to be the majority of what happens in the ICU.

I also feel bad about leaving because we have some interesting patients: the above-mentioned, who turns out to have a relatively rare disorder, which I wish I could see play itself all the way out; a new subarachnoid hemorrhage in tenuous condition; some trauma patients whose final outcome I want to know; and the pleasantest guy who came in today with a sad story and a completely abnormal neurological exam, with findings I’d thought I’d never see in real life.

The chief even invited me to come around to their surgeries again, and I hope he meant it seriously, because if I get any spare time next month when he’s in the OR, I will. I feel almost drunk with what he lets me do in the OR; it’s addictive; I can’t stay away.

 

no doors

Somewhat better today. We had conference literally all morning; which was ok, because I’ve worked out an efficient way to sleep during lecture without amusing the residents and annoying the attendings by nodding visibly. (Back wall works wonders.) Neurosurgery has combined teaching with neurology; I remember why I didn’t want to do neurology, or ENT. (Although how one can look at a diagram of the inner ear, with all those delicate structures intertwined, and all the complex nerve signals which combine to let us walk and see, and not believe in the Creator, escapes me.)

My basic problem is I’m too helpful. I’m too happy to be semi-competent at doing things in the ICU to avoid work fast enough when the residents start dumping on me. It’s only after they’ve walked off (to do something else - these guys are the busiest people I’ve ever seen) that I remember that I’ve now got two extra lists of work, in addition to my own basic list. In spite of that, I got out before 6, which was an improvement. The main thing was that my patients all improved, got off their drips, and remained alert and oriented, so they could leave the ICU - to their delight. Our ICU is of the old-fashioned, open ward, flimsy curtain design. I hate that. It drives all the patients who aren’t intubated crazy, interrupts the family’s visiting hours, and essentially destroys any privacy. At least glass walls are solid.

We withdrew care on a patient today, and of course they dumped the DNR and comfort care orders on me. I wrote them in the corner while watching the family crying and praying with a minister. Somehow, it wasn’t so bad just examining the patient, seeing him lying there, looking at his hopeless labs and CTs. It felt like he was already effectively gone. But seeing the family mourning makes the patient much more of a real person - after all, I’ve never seen him conscious - and his loss much worse.

 

not an option

In the hospital for 15 hours today. This is so not going to keep happening for the rest of the month. In emergencies, fine; but this is the way the neurosurgery team operates.

The junior residents think my job is to do all the scut for them, which is enough to last 14 hours in itself. The senior residents are wondering why I’m not in the OR, whether I don’t like surgery. And the critical care attending thinks my job is to go to conferences, listen to him lecture (which is indeed valuable), and read journal articles to present to him. I feel like the donkey owner who was trying to get his son and the donkey to market at the same time. It is impossible to please all of these people.

Tomorrow I’m going to have to put my foot down, and refuse to be overawed by at least one, if not two, of these sets. Both for hierarchy (chief resident always wins) and preference, I think I’m going with the chief’s “surgery intern should be in OR” theory. Critical care is nice, and I’ll have several rotations specially for that. Not this month, though.

Although since all the patients I’m following are in the ICU, I already learned a great deal today. After last month’s 14 patients a day, seeing 6 ICU patients feels manageable; and the nurses are very agreeable to my management strategy of “I’ll tell you as soon as I talk to the senior. . .” Although, amazingly enough, I am also starting to come up with the right ideas before the nurses or residents tell me what to write down. As far as unique neurosurgery issues, I’m completely at sea; but general problems like urine output and tachycardia are starting to feel everyday.

 

short and sweet

Another incredibly good day. The chief let me leave by 3pm. Of course today I absolutely adore her.

Partly by my aggressive management (I don’t think I’m very popular with the case managers anymore; on the other hand, if they would answer their beepers sooner than noon, we could get more work done) and partly for lack of emergencies the last couple days, I’ve pared my list down to about seven or eight patients. After formal rounds today, the attending remarked in a disgusted voice, “We could just call it SNF rounds: every single patient is just waiting for skilled nursing placement.” Tomorrow we have a long case schedule, so I’m sure this will be quickly corrected.

But Sunday is my last day before vacation, so I just want to survive this week, and I don’t care if the list doubles by Monday.

Attendings are funny creatures. The purpose of their existence seems to be to frustrate the chiefs by doing old-fashioned things with little evidence to support their practice. Several of our attendings here are relatively young, and a few graduated from this program not too long ago. I can’t figure out how they changed from chiefs into attendings. At what point do you decide to start doing things because it feels better, or is more convenient, rather than because there’s evidence? (Not that there is evidence for a lot of surgical practices; but sending lap chole patients home, or using a particular method of graft implantation for hernia repairs, does have good evidence.) M&M today was curious. One of the strongest chiefs had a series of disasters to present, and essentially spent most of his time at the podium saying, “I’m not sure why we did it this way; it was attending preference.” Sometimes the preference turned out well, and sometimes not, but either way, even the chief, who is loyal and competent, had no rationale to give other than, the attending likes it this way. And somehow, the chief came out looking a little badly, because he tried to shift responsibility onto the attending, rather than standing up and giving some kind of explanation (even though it wasn’t his decision, and he probably argued against it when the choice was made). I don’t know. Most likely the attendings have just as good rationales as the chiefs do, but because we (or at least interns) spend more time with the chiefs, their side is the only one we hear. (But this seems to happen in all specialties. Medicine attendings have funny quirks that have to be humored, too.)

 

winding down

Today was wild, again. (Maybe I need to readjust my idea of “wild.” Plastics, after all, was calm compared to the other services.) We took a load of heavy consults from the trauma team early this morning. There must have been some bad stars over the city. All kinds of crazy mechanisms of injury, tragic social stories, and unusually bad results from common mechanisms of injury. There were so many new names on the list, I didn’t mind staying out of the big surgery this morning, leaving it to the medical students with the fellow while I and the assistant (who it turns out likes me) tried to divide and conquer with all the new people.

So far, so good. Then - I don’t want to go into this in detail, because what eventually happened was the attending threw me out of the OR with accusations of malpractice mixed in (because of floor management, not any actions in the OR itself). The medical students were partially involved. I was pretty scared for a while that, since he was talking like that, he might be going to call my program director, and things would get serious. I don’t think it’s actually that bad, although I have no way of knowing what he’s saying about me, unofficially, to the other attendings. Anyway, what I did was something that I had had experience with many times as a medical student and even this month. Neither the fellow, who was aware of my actions, nor I, had any idea that it could be objectionable. So oddly, I made the attending as angry as he’s been this month, and for a change I’m not beating myself up about it too much. Most of the time, we residents have such a highly developed sense of professional responsibilty -cum- fear of God (aka the attending) that the attending just has to say a few angry words, and I at least really force myself to examine my actions, find the problems, and make definite plans to do differently. But this time, there is no way that I could have known to avoid this, so I just had to keep my mouth shut, as usual. Surgery residency - or internship - is definitely good for the character. Learn to keep quiet, take correction, whether just or unjust, silently. “In the multitude of words there wanteth not sin.” “Let a wise man rebuke me. . .”

I’m not sure how to communicate this to him, certainly not in depth. The fellow I’ve been working with is absolutely amazing. He took good care of me, and taught me a lot. He managed to protect me from the attendings with the utmost reliability - when it was a misunderstanding, and I couldn’t say anything, he said it for me. When I really was wrong, he deflected them. When we were both in trouble, he took the brunt of it. At the same time, he pushed me to stand on my own as far as handling patients on the floor and in the ER. He gave me confidence in my decision-making. I don’t know how he combined those two accomplishments. He was always ready to explain anatomy, operational procedure, and clinical decisions. Most amazingly, he was never angry or impatient with me - and for the number of mistakes I made this month, that’s pretty close to sainthood. I don’t know whether the old truism, that I would do more for his kindness than for fear of the attendings, is totally true, but I would much rather do something for him.

Anyhow, it’s high time to move on to another service. This will be my first real general surgery service, which means longer hours, much less time in the OR, more scrutiny from the attendings, and higher expectations. Also, unless I’m overestimating the amount of time I’ve seen this team’s members spend in the hospital, I may have to start fiddling with my hours. There’s no way to work 14 hours a day six days a week, and take call, and round on the seventh day, without going over 80 hours. Everyone talks a lot about keeping the 80 hour week, but I can’t tell yet whether they really mean it. Of course the chiefs don’t. They practically live in the hospital, and there’s no one who can cover for them, or send them home, or give them a break. I’m not sure how the junior residents manage. I don’t want to be the only one to break out of the pattern, however they do it. I know that these residents are good, smart, and well-trained, and I intend to do things their way.

(One month done! How did this happen? It feels like yesterday that we started, but on the other hand I can hardly remember what it felt like not to be an intern. Only eleven months left. . .)