growing up

Another memory that sticks out from my third year surgery rotation was the night I was on call with the trauma night chief. Nights at that hospital, the trauma service was responsible for all ER consults and emergency surgeries, as well as a fairly busy knife and gun club, and several major highways and intersections. So they had their hands full. The trauma chief had his own hospital-provided phone, because he made and received so many calls that it would have been impossible to function with a beeper alone.

There was one patient he was trying to see in the ER, to explain the reasons for doing or not doing surgery (I forget by now which one it was). The phone went off about three times in four minutes, and finally he handed me the phone and said, “Please take this thing out of the room and take care of it for me for a couple of minutes.” In the next five minutes, I answered four more calls and took notes along the lines of, “The patient in ICU 13 just got reintubated.” “The OR will be ready for you in fifteen minutes.” “The trauma patient in ER 34 is having increasing pain and tachycardia, what does he want us to do?” “The xray on ICU 14 came back, the feeding tube is in the wrong place, please come change it.”

When he came back for the phone, he seemed to think that wasn’t too bad of a haul. And I thought, I was ready to pull my hair out, just holding the phone and taking messages for five minutes. Am I ever going to be able to handle this in real life?

And here I am, taking pretty much the same kind and volume of calls, and so far nothing’s fallen apart. I’m not looking forward to doing this overnight, and the prospect of two years’ worth is rather depressing - but one day at a time, it’s not too bad. Eight or ten consults in eight hours, one to the OR, not too horrible. The ICUs had the sense not to make much noise, which helped. I made the ER resident quite furious by declining to admit one patient, and insisting on sending it to medicine; the fact that I got another patient into the OR in half an hour didn’t make him much happier. Most of the trouble came from the medical ICU, which gave me half a dozen perfectly useless consults, of the kind where I had to spend five or ten minutes simply figuring out why on earth they had consulted me (usually it turned out to be a reason they were unaware of, eg their consult order listed abdominal distention, whereas the patient was having GI bleeding, and really needed a GI consult, or the order listed GI bleeding, and what they really had was gallstones). Then I had to call the attending on those, and he got upset at me for wasting his time with such nonsense. Which is why within a couple of months I can see myself being quite crushing to the MICU residents if they call me with such things.

 

where did I put the books?

Weekend rounds with myself in charge of the service. . . I could barely get myself out of the hospital, because I kept going over the list trying to figure out what I’d forgotten. Before there was always someone else to check on me. Now, it’s my job to decide what needs to happen today, what I and the intern need to get done before we leave, how much we can sign out, and to make sure that we sign out all the important things.

I need to go study. The interns and students expect me not just to be able to answer questions, but to spout whole lectures about all kinds of subjects, with detailed information; and I ought to be able to. The attendings, as well, regard the junior residents as the ultimate pimping targets. Yes, the medical students - but at this time of year, they’re pretty lucky if they can present the patient on rounds without having to be straightened out a couple of times. Yes, the interns - but they’re excused for not knowing a whole lot. The junior residents, on the other hand, are fair game for anything: incidence of PEs? mortality rate of PEs, treated vs. untreated? Incidence of pancreatic cancer? Mortality rate, life expectancy? Proper treatment of acute cholecystitis? Failure rate of conservative management with antibiotics? Mortality rate of persons taking coumadin? That was from one hour’s worth of rounding, and that’s not counting questions about patients’ obscure surgical histories before they arrived in our institution, and their labs and imaging studies for the past two months.

 

give and take

The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (”Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

 

urine is good

I got to do my first transplant today.

More precisely, I assisted the attending for the first time today; but I have high hopes of getting to do more of the procedure later on. I really didn’t want to ask for anything more; I was still figuring out the anatomy (well, ok, so the external iliac artery and vein are not that complicated; but the way that the donor artery, vein, and ureter fit in is), and I don’t have much experience sewing blood vessels yet. So I’m content to wait through a couple more of these till he feels like letting me do some of the work.

The transplant attending, as I’ve mentioned before, is completely dedicated to his work, and is extremely hyper when there’s a transplant in the air. He haunts the OR, pacing back and forth, waiting for his room to be ready, calling the coordinators to check on the exact location of the organ in transit. He greets the patient, hugs them, asks if they’re all ready, or have any last-minute questions. He helps position the patient, helps anesthesia put the lines in (ok, so I’m not sure anesthesia wanted any help, but they got some), helps put the foley in, helps arrange the blankets, all the while commenting, “transplant means paying attention to details, Alice; you have to check on everything.”

Then we’re scrubbed in, and the noise level drops off. Everything has to be just so for him, but he has a reason for all of it, so I just do my best to adjust to the way he wants things. No extraneous movements. No unnecessary tension on anything, and above all on the donor tissues. Stay in the bloodless plane between tissue layers; watch the muscles split apart, the artery and vein separate off of each other. Tie countless knots onto nearly-invisible branches off the artery and vein, which will bleed all over the field after the anastomosis if we don’t get them now (”you’re tying better now than when we first met, Alice”). And then the nerve-wracking, painstaking business of matching the veins together, placing the stitches, sewing down; repeat for the artery. The ultimate test: “we’re about to take off the clamps, anesthesia, you all set? all the meds in? the pressure is good? here we go. . .” And the dead-white kidney turns in a split second to a beautiful pink, and you can feel the blood pulsing through if you just lay your finger against the capsule. Watch, and the urine comes dribbling out the ureter. Success! Then the last steps, catching all the little bleeding spots and sewing them shut, patching the ureter onto the bladder, tucking the whole thing into that artificial space at the edge of the pelvis, and watching as you close the muscles to make sure the pulse stays strong, nothing kinks.

I love the sewing and tying, the part where I got to help the most. When I read him right, and had the sutures ready to throw down the minute he had the right-angle clamp where he wanted it, it was beautiful, like a miniature dance. I can’t wait to do this some more, so I get better at predicting the next step, and can do more to smooth things along.

At last, everything closed, we got ready to move the patient off the OR table. The foley bag was already filling up with pale urine, the first that patient had made in years, and it was the most beautiful thing in the world. We changed that patient’s life. We, and the family who donated the kidney. (I didn’t ask how the donor died; I knew it was a young person, and I didn’t want to think about it.)

 

tribal conflicts

Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.

. . . ok, got it?

That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal - maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)

Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.

When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.

When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)

This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.

 

what not to say on rounds

There’s really not much to say about this academic year, so far. I haven’t gotten to do really any more surgeries. The chief keeps intending to let me, but then the case turns out so wildly complicated that I can’t honestly say it would be a good idea to let me in, so I can’t complain.

I don’t know any more now than I did a week ago, it’s just that the amazingly naive intern at my heels makes me look relatively well-informed, and even almost sophisticated. (One thing I learned the painful way: you do not have to tell the attending every single detail of what happened in the last 24 hours, such as, we wanted to check such and such a lab, but it took forever to draw, and then the lab lost the blood sample, so it was twelve hours after admission before we discovered. . . The tactful thing is to say, About twelve hours later we discovered that. . . And if the attending cares, he can take up the twelve hours, and then the chief can explain; but the intern should not attempt it, neither such details as, The patient had a fever eight hours ago, but since the nurses haven’t checked since then, I don’t know what the temperature is now (to which the answer is, a thermometer is a simple piece of equipment, if you consider it important to know the temperature, go find out; similarly for pulse and blood pressure and pulse ox). As I said, I learned that the hard way, by having both the attending, and then later the chief, jump on my unguarded statements. Trying to blame the nursing/lab/radiology staff for your own lack of information does not go over well.)

I do have my hands fairly full trying to manage the intern plus the patients. It’s amazing how much simpler it is to just do the work myself, rather than to gently show the intern how to do it, and then stand back and give them time to do it themselves. I shudder to think what a headache I’ve been giving the rest of the residents for the last year, and must be giving my chief now; it’s astonishing that they still talk to me.

In a few days we’ll have a completely fresh batch of medical students, and then the chaos will be complete. All we can do is be thankful that this year (unlike last) the medical students’ first day doesn’t coincide with the interns’.

 

so far, so good

First day on call as junior resident wasn’t too bad, largely thanks to no really sick transfers or admissions coming in, and the ICU patients behaving themselves perfectly. One person had a minor airway problem, but was already intubated, so by the time I arrived the nurse had already figured out a way to make it work. Another patient wouldn’t wake up, and I was concerned about a stroke, but a young attending happened to be walking by at the moment, and came to help without me even having to ask (and started asking unhelpful questions like, “are you the only one here? don’t you have senior in-house backup? are you sure you’re the only one?” Which was kind of him to be concerned, but not extremely reassuring; I told him I’d been about to call a chief at home if he hadn’t shown up.)

My intern was good: hardworking, fairly smart, and didn’t seem too flustered by his pager going off every two minutes. It reminded me how happy I was not to have his job; although my pager was going off on a regular basis too. I told him to write short H&Ps, and he managed to fit everything into half a page - a little shorter than I had in mind, but acceptable.

The only thing I didn’t manage very well was the trauma part. The junior surgery resident, in addition to handling all ER consults, all floor and ICU consults, and all floor and ICU issues, is also supposed to attend at the trauma alerts and be of assistance, in case several patients come at once, or in case one is so sick that the team needs more help than the very young interns can provide. Somehow the trauma alerts didn’t make it as high on my personal triage system as they perhaps should have, and I didn’t get to many of them. As it was, I stayed nearly two hours after the end of the shift, finishing leftover work, so it’s perhaps as well that I didn’t spend more time with trauma. I thought it would almost have been easier if I’d been on overnight call, because then I would have had a few quiet hours after midnight in order to get things cleaned up before everyone came back.

The most bothersome part of it all was calling the attendings. As an intern, you’re shielded from the attendings (or perhaps, they from you). You tell everything to a junior resident or chief, and they talk to the attending if they need anything to be cleared. This year, I have to learn how to get all the relevant data (because no one else will be there to correct me), call the attending, present the information succinctly, and suggest a reasonable diagnosis and plan of action. The attending listens silently the whole time, giving very little idea of whether you’re on the right track, or making completely insane suggestions, and then finally gives his interpretation, and rattles off a plan, which you’re then left to implement as best you can. I hadn’t realized how time-consuming it would be, though, after having seen the new patients, to first call the chief, talk to them, then call the attending, talk to them, then call the chief back (if the patient is going to the OR, or will be soon, the chief has to know), all the while trying to write the necessary orders, arrange the procedures, and handle a dozen new calls. It’s most efficient if you collect two or three admissions and consults per service before calling people, but if you’re not careful you wind up after several hours with a dozen phone calls to make, and no time.

I have a couple more daytime calls, and then I’ll be on overnight at the end of the month. The good thing is that, in spite of the stress, I do seem to like the adventure that comes from working under pressure. It’s kind of like skiing down a steep hill - how far can you get before things fall apart?

 

balancing

So far, not too bad. I’ve always been involved in tutoring the students a year or two behind me, so showing the interns the ropes isn’t much out of the way. So yes, I’m the one actually doing most of the work, but then I’m used to doing intern’s work - that’s nothing to complain about.

Today I got myself a little bit stumped. There was a problem, and I knew what it was, and I knew what to do to fix it. Except I wasn’t sure about one piece of equipment; and the whole thing wasn’t technically my responsibility. So I opted for the low-resistance route of notifying the people who were responsible, hanging around to make sure nothing happened till they got there, and then leaving. But what’s going to happen tomorrow, when I am the one responsible - for everything - and I don’t know which of two pieces to use? Am I going to stand there wringing my hands until I find an attending to figure it out for me? Or am I going to rush into something, end up using the wrong thing, and maybe having things worse than they were to start with? Enough decisions already.

It doesn’t help that the guys are all teasing me about being too aggressive. Early on, I thought I would establish a reputation for being willing to do anything, anytime; I’d start off doing the most minor procedures, the dirtiest cases, and earn the right to be offered any loose cases that weren’t yet assigned to a specific resident, by demonstrating my willingness to be available at all times for all things. Well, I don’t know what the attendings think of me, but the guys latest joke is, “Stay away from Alice. She’ll put a line in you when you’re not looking. I saw her the other day, there was this guy walking down the hall, and she just stuck a chest tube into him.” I think they’re not disturbed about it, otherwise one of the senior ones would tell me seriously to settle down, but their joking makes me second-guess myself even more, when I think a procedure is indicated: am I doing this because it’s right, or because I’m trying to be a cowboy? These guys seem to be born with a cowboy sense; they know when to push and when not; when to be aggressive, and when to back off. I try to imitate them, but I can’t seem to make it natural.

 

a little at sea

It feels so strange to sign out with the third year residents. Last year they were my juniors, I tried to do everything the way they wanted it, and looked up to them so much. Now, we’re almost equals, the way this hierarchy works. Of course the attendings have a higher regard for them than for the new 2nd years, but we’re nearly equal when it comes to the authority structure and case distribution. And they generously treat us as true colleagues, as well. Still strange.

I’ve lost my sense of time. For the last year, I was waiting for the end of internship. Every week or so, I’d count up again how many months were left. Lately, I was counting the days. I would have been counting hours, but by the end of trauma, I didn’t have enough brain cells left to be able to multiply by 24. And now here I am. Simply by virtue of having survived, it seems, I’ve moved on to the next level. I’ve hoped for this for so long, right now I have no ambition left. This was the height of my dreams, to be really a surgery resident, not just an intern on probation.

Rounding now is a breeze. By the end of June, I was rounding on nearly twenty ICU patients in less than two hours. Now, two ICU patients and a handful of floor patients seems like nothing. A note here, a note there, no rush. June was a baptism by fire, but it worked.

 

new faces

July 1 - a very good day for staying out of the hospital.

Actually I don’t know why everyone repeats that, because nothing very bad happened. The attendings and seniors were practically breathing down the juniors’ and interns’ necks, and there was not much opportunity for error.

My service was relatively light, so I wasn’t called on to do anything out of the ordinary, which was just fine with me. I mainly babysat the intern all day. At first it was fun, because I wanted to help them and smooth the transition. By the end of the day, though, I was rather annoyed, and am trying to figure out whether all the interns are that infuriating, or mine was special. I’m going to try to keep giving them the benefit of the doubt for at least another week, and try to remember that I must have some of the same mannerisms, and must have been annoying my seniors in a very similar way through the last year. But hmmph, he/she/it is going to get in some trouble if they carry on at this rate.

Friday, on call, if the rest of the interns are like this, is going to be quite a nuisance. I guess I’m mainly used to my intern class, for the last several months, being able to do all kinds of work; which it isn’t fair to expect of the new guys at first here, so I need to adjust my expectations of “having an intern to do work with me” to “having an intern whose work I need to do as well as my own.” Ah well, a few weeks should straighten them all out.

It is funny, though, to see the new interns in the halls. Even the ones I didn’t know as medical students wear their new long coats so stiffly that they look out of place, as though they picked up someone else’s coat by mistake. Now if I could just find my new coat (supposedly somewhere in the hospital) so I can stop looking as though I’ve been sleeping in mine.

Welcome to the gang.