(Unbelievably, there have been no traumas for five hours, the intern has finished her rounds, and we’re sitting in the library till lunch time. . . Let’s see how much longer this will last.)

From the top down:

Attendings: They scare me worse than any other attendings. Not just that they’re so much more likely to ask questions about which I have no clue (“How do you diagnose a splenic laceration, and what is the treatment?” (not out loud): “I barely realized yesterday that there are different kinds of splenic lacerations. Since we diagnosed the one in this patient by CT scan, I guess that’s how it works. I thought you kept them in hospital for 24 hours for observation, if you didn’t take the spleen out right away, but since this patient has been here for 48 hours, I guess that’s not correct. Blush? Embolization? Search me!”) – but the way they interact with the residents is different, too. They’re very quiet, except when they’re giving definitive orders, or questioning the residents’ management. They have little facial expression (beyond stern or grim). For example, in one trauma, I had put on the lead gown and a paper gown, but skipped eyewear, because I figured this case wouldn’t be bleeding much, and I wasn’t going to be that close to the injuries. The attending, standing at the back of the room as the patient was rolled in, said to me, “Where’s your protection?” I had no idea what he was talking about. As he repeated himself, I was about ready to walk out of the room, just to be sure that I wasn’t violating some unknown protocol by failing to put on every piece of paper in the supply cabinet (most of the team doesn’t usually put on that much; I was just copying the residents). Finally, he smiled, and said, “Your armor.” So I think he was joking about what all I had put on, and I felt free to turn around and pay attention to the patient. The surgery attendings don’t hesitate to dress-down even senior residents, or experienced PAs. It’s not just the students and junior residents who are vulnerable to them. Almost everything they say to the residents is questioning, undercutting, challenging: “Why did you do X? Why did you miss Y? What made you think Z would help this patient? Do you have some literature evidence supporting your strategy here?” (That last being an especially cutting way of saying, you’re stupid, and you’re hurting your patient.)

Chiefs: I’m puzzled by them. The chief resident is a black woman, pregnant with her first child. She’s calm, gentle, and well-liked by both residents and nurses. She wears a cross necklace. But she uses the most awful language, freely. I can’t square that. One of her colleagues was very nice, teaching the students about suturing. But he seems to be at the root of the latest scandal, making an almost pornographic video mocking some of the attendings (from what it sounds, they did set themselves up for it), and playing it at the resident’s graduation party, for which all the senior residents received a long and public rebuke, and had to write an apology to everyone involved. Discussing him, people say he has a very bad temper, and can always be counted on for a colorful explosion.

Interns: Only one I’ve really worked with so far, the smart guy on the night team. He really knows his stuff. One question I asked, and he didn’t know the answer, he responded, “I haven’t memorized that yet.” He hasn’t memorized it yet? It sounds like he really memorizes, not just studies; and how he manages that with this schedule, I can’t imagine. What little I’ve seen of him operating is also impressive. Even though he’s not yet allowed to do complex or important things, he takes even the skin lacs seriously, washing them out carefully, piecing them together, placing the stitches delicately, so it comes together beautifully. He jokes with all the nurses, and they love him. But, he also uses awful language; and when he’s talking with other men, I really start considering whether I could telepathically open a hole in the floor to disappear into. So dirty. And he’s married, I think to an internal medicine resident. One minute he’ll be giving me a complete recital of the causes of intestinal obstruction, with treatment and complications, and the next he’ll be joking with the male PA like high school boys in a locker room. Which gives me the impression (I hope it’s wrong) that this is what all men think like all the time, and I’m just lucky if they don’t say it out loud. Of course, most of the female surgery residents laugh, if they don’t join right in.

So: The trauma team is exciting. With their ICU patients, they’re managing more complex medical issues than most of the medical patients I saw last fall. The surgeons all know so much, both general medicine, and about every single surgical disease and operation. They have the most impressive knowledge base I’ve seen all year. This place is exciting; and I’m starting to wonder if maybe I shouldn’t do just straight surgery, not ob/gyn (they despise ob/gyns for being sloppy surgeons and making messes that they have to ask the surgeons to clean up). But I really don’t want to be in this high-tension environment for five years. I don’t think I could handle the dirty language for that long. Last week, there was an older lady, a PA, who had been working with the team for a few months, but was unable to satisfy the female surgeon who was supervising her, and so left to go back to the children’s hospital. I don’t know what her mistake was; she looked competent and decisive to me. But the surgeons said she wasn’t good enough dealing with trauma. If she couldn’t do it, I don’t think I would be any better. I don’t know if I want to be good by these people’s standards.