I just experienced a revelation.

I’m a doctor, in fact a not-an-intern doctor; and doctors can call the ICU to check on their patients, right? So now I can worry about my patients with great accuracy even after I leave the hospital. All those times when I’ve lain awake (ok, only for about 30 seconds before sleep deprivation catches up, but still) worrying whether something bad happened yet - now I can call and find out that the something bad did happen, and keep worrying about what has happened rather than what might happen.

Life was better before phones and beepers.

I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.

There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle - but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.

So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole - a hole, any hole - actually the internal ring - back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.

I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.

(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

I thought it was hard being the intern and figuring out how to relate to the attendings and all the various levels of residents senior to me.

Figuring out what to do with my intern is even more complicated.

He’s not brilliant, but he tries hard enough that I can’t just write him off as a bad job. But how do I balance between pushing him hard enough that he learns what he needs to do to make a surgical service work, and being friendly? How do I let him make enough mistakes that he takes things seriously, but keep anybody from getting hurt? There are so many things that he ought to be doing, that we’ve told him about, but he forgets or doesn’t know how. So do I just do them myself, which would be the simplest, remind him endlessly and start looking like his mother or older sister, or let them go until he gets embarassed in front of the chief and/or attendings, to make him remember?

He’s not like I was as an intern, which also makes it complicated. If I’d had an intern as naive and hopeful and trusting, and incompetent, as I was, maybe I’d know better how to relate. Someone who says, I want to do it right, but is rather clueless, seems to me easier to deal with than someone who talks brashly and confidently, but doesn’t have the knowledge or skill to back it up. An intern mouthing off like a senior resident throws me off. The older residents have earned the right to make flippant remarks; my intern doesn’t have the experience that in my minds earns a little tolerance for making unkind remarks about nurses or patients. If the chief says he doesn’t care, I know that his record of hard work, long hours, and lives saved show he doesn’t really mean that. But for my intern to say that - it’s too early. The attending can say, “Ah, fibromyalgia, consult rheumatology,” because we know he has the experience to be confident that there’s nothing really the matter; the intern needs to think a little deeper before brushing someone off.

But I’m not the censor. My intern is an adult, and needs to sort things out for himself. I try not to comment on his attitudes or remarks, just on his work. Hopefully in a few months he’ll learn what’s acceptable and what’s not. I trust the nurses, too, to set him down when he needs it. They can do that better than I can. Time will tell. Like me, he needs to see bad things happen just to learn that they can; then he won’t talk about them so lightly.

After work I stopped by the only farmer’s market in the city that doesn’t close before I get out of work, and was pleasantly surprised to find some good vegetable still around, and the farmers eager to dispose of the produce. I think I walked away with ten pounds of corn, zucchini, cucumbers, and tomatoes, for five dollars. I also acquired home-made sharp cheddar cheese, and fresh honey. It’s a good thing I waited to go shopping till I had the weekend off, to cook all of this.

I have a bad habit of flipping through the Living section of the newspaper when I go to the medical library, and there’ve been all these articles lately about the joys and virtues of cooking and eating fresh, local produce (the Slow Food movement, or something like that). Apparently it is only virtuous to eat fresh food if it has been produced within a twenty-mile radius of your abode.

I personally like this honey because it tastes good, not because it was made by bees flying over fields a couple of miles from here. (In fact, given the level of pollution, perhaps it would be better if it originated farther away.)

I’m not sure whether to label as puritanical or hedonistic the fallacy that it is right to eat good food simply because the good food was grown nearby. Somehow epicureanism is now the new virtue, because it is supposed to “help the planet” if you promote local horticulture.

I’ll be going back to this farmer’s market because the food is good, it’s close, and it’s cheap. Not because I think I’m saving the panda bears, improving the ozone layer, decreasing the rate of decline of the polar ice caps (which actually aren’t declining, by latest reports). Invisible hand, anyone? (Adam Smith, 1776, Wealth of Nations)

New attending syndrome. It’s the well-known phenomonen of attendings fresh out of residency being a little hesitant to diagnose anything during the month of July.

Mostly you can work around it, but when a radiologist comes down with it, things start going haywire.

There’s a new radiologist on staff, and I keep running into her and her readings. So far they’ve been exemplars of non-specificity, but today was the worst. I got called about a patient in the ER, a boy with abdominal pain. “The radiologist says he could have perforated diverticulitis, please come and see.” Now a teenager shouldn’t have diverticulosis, let alone diverticulitis, let alone perforated. So I looked at the scan, and I couldn’t really make out what the radiologist was worried about, but hey, I’ve been not-an-intern for two weeks, and this is an attending radiologist, so I’d better be careful. I went and saw the patient. He was sore, but not too bad. In fact, he and his father seemed more scared by what the ER doctors had told them about the CT reading than about his actual symptoms.

I looked at the scan and I looked at the scan, and all I got was more puzzled. Finally I went and told my attending that the patient was tender, but not too extremely so, but I was concerned because we had an official dictated and signed report saying possible perforated diverticulitis vs. small bowel obstruction due to Meckel’s diverticulum. He listened to me arguing back and forth with myself, and came to see the patient. He spent a long time calming them down, but when we finally got outside of the room he wasn’t exactly pleased. “That radiologist! What is she reading it like that for? A third-year medical student could tell there’s no diverticulitis. In fact, there’s no inflammation of any kind whatsoever!”

So now I feel like an idiot. I knew the patient wasn’t sick, and I knew there was nothing wrong with the scan, but I let the radiologist talk me into miscalling it, and presenting it to the attending as something concerning. I’ve learned not to trust the radiology residents too far, and now I’m afraid I have to learn not to trust the radiologists much at all (except for three, who are nearly infallible, and all the attending surgeons take their word as gospel). Which scares me more than anything, because I don’t think I’m good at reading CT scans, and clearly I need to be a lot better.

Last year for the first few months my heart rate shot up to about 140 every time the code pager went off. I learned to do femoral lines in the middle of a code, with no pulse, and the patient bouncing around so much that you couldn’t have found the pulse anyway if it had existed. I had no idea how my juniors managed to remain so calm about a pulseless patient and me waving long needles in the air in the middle of the chaos.

Now I’m smiling coolly when the new interns look at their code pagers and express some concern about being responsible for putting in lines, when they’ve never done any yet. Don’t worry, I tell them, you’ll learn just fine; I’ll come and watch.

Because I know, if they don’t get it, I will. Sooner or later. Me panicking won’t make the patient’s heart come back any faster, so we might as well take it easy, and do the line neatly.

(Now let’s see what happens the next night I’m on call, and how well that works in practice. And don’t worry, if they really need the line immediately, I’ll make sure it gets in sooner rather than later.)

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.

I’ve discovered something extremely useful that the medical doctors do.

I hate walking into patients’ rooms (or into an office encounter), introducing myself for the first time, and within the next ten to fifteen minutes trying to familiarize a patient with an operation enough for them to consent to it. It feels like such an imposition - Hi, I’m Alice, you have cholecystitis, you need to have your gallbladder taken out, we have an OR slot available tomorrow morning, the risks include death, heart attack, stroke, damage to your liver/intestines/bile ducts, bleeding, and infection, please sign this paper. That is really what I say, except more smoothly, and spread out over fifteen minutes. Or, Hi, I’m Alice, your father really is not getting off the ventilator any time soon, he needs a trach and a feeding tube, he can fit into the schedule tomorrow afternoon, please sign this paper. Or, Hi, I’m Alice, I regret to say that your increasing abdominal pain is due to an obstructive colon cancer, you need to have surgery, you’re first on the list for the morning, please sign this paper.

That’s how it happens, because we try not to drag our feet about inpatients. If they’re inhouse, and they need surgery, we’ll do it within the next day or two. And I simply don’t have the time to walk by the room three times in the next 24 hours, to give the patient time to think about it, and then answer questions, and then get the consent signed. The attending will come around, too, but I’m the one who has to get the paperwork in order.

So the medicine guys are great, because they get the patients and families accustomed to the idea of having an operation, and give them some time to come to terms with it, between when it first comes up, and when we arrive to talk about it. Ok, maybe they could stand to check some coagulation labs for patients on coumadin when they call us for an urgent problem, but there’s a limit to how much surgical thinking you can ask from nonsurgeons. Maybe the patients end up with the strangest ideas about how the operation proceeds, or what they can expect afterwards, but I daresay the majority of those miscommunications come from their ears, not from the medical doctors. It is nice to get into the room, introduce myself as a surgical resident, and have the patient say, “Oh yes, they told me I need to have my gallbladder out, my children agree, let’s get it over with, where do I sign?” Sometimes I regret having the wind taken out of my sails, since the patients often don’t want to listen to my speech about the chances of recurring incidents if they leave the gallbladder in, and the possibility of nonsurgical treatment, but I can’t exactly argue about that.

Not much going on these days. The medical students are fun. They’re so incredibly young and naive and eager to please. It’s a great responsibility, to feel that we’re responsible for their first experience of clinical medicine, their first understanding of how to deal with real patients and function as part of a real team. I’m afraid we’re rather a dysfunctional bunch, this month, and I hope it doesn’t teach them too badly.

I’m not happy about the case distribution, but I’m telling myself that all the cases belong to the chief, absolutely; if he decides to let me do any, it’s a gift, not a desert. I knew that last year, because I made myself have no expectation of doing any cases at all; then I was purely grateful if the chief threw me one. I need to hold on to the same attitude this year: if the chief lets me operate, it’s a gift. I wish it weren’t that way, but that’s how the chief sees it, so I’d better fall in line.

It’s actually still a little funny to me, how little say the attendings have, openly, about which resident comes to which of their cases. They make general rules - no interns or second years in cases of a certain complexity - but beyond that, they don’t say anything, even about the residents they like the least. The chiefs control who goes where, even to the point that some chiefs can send junior residents into big cases if they want to. My chief this month is not the kind to do that; he’ll go recruiting residents way beyond our service to cover cases, if he thinks the case is too big for me, and he won’t let me operate at all unless we have two rooms running constantly. I don’t appreciate that, but it’s July, and I’m sure in a year or two I’ll be horrified to see young second years doing anything like good cases.