First lesson this morning: why never to take your white coat out of the car: because at 4am it’s so easy to forget to put it back. I spent all day walking around in scrubs, when everyone else had their white coat on, trying to look like there was nothing out of place. It didn’t help that the chairman met me in the hall, and asked where my coat was. I felt like the unprepared guest at the wedding feast. Also it had my beeper, my meal card, my pens, and other essential items in it. Thank God my id card and stethoscope were separate.

As a result of the economics explained in the previous post, it is more profitable for the surgery attendings to consult other services, like cardiology and critical care, to manage their patients’ medical issues. Those attendings can bill independently, whereas for the surgeons anything that happens within ninety days of the surgery is covered in one fee. So, my sweet old lady, who had half her intestine removed, and her leg amputated, two weeks ago, is being managed by a critical care consultant. I haven’t seen him, but the nurses said he’s “older,” and I know his practice style is old. The surgery residents can’t do anything but look at her GI issues, because it would be rude to him to address her cardiac, respiratory, or diabetic problems when he’s “on board.” So, he doesn’t have her on an insulin drip, although the evidence shows that ICU-type patients do better when their sugars are tightly controlled like that. She’s been struggling to keep her O2 sats up for two or three days, and he only got an ABG today when she was almost crashing. She’s been on one antibiotic since admission, and has apparently developed a new pneumonia since then. He doesn’t want to put her on a new antibiotic to cover for a hospital-acquired infection resistant to the first antibiotic. Although her main problems are respiratory (ok, when her afib got out of control, he did put her on a calcium-channel-blocker drip), he isn’t pushing the nurses to work on that, and he won’t give orders for face mask oxygen, let alone CPAP or BIPAP. She is a level two DNR, which means no intubation and no chest compressions, but any meds short of that; but just because you can’t intubate her is no reason to let her slide till she needs intubated. For the last several days I thought I was just imagining all this stuff; but this morning I talked to the senior resident, and he said, he can’t touch her as it is. But if he were managing her himself, he would be doing all these aggressive things. She does seem to be doing well as far as her GI system, and the various surgical wounds; it’s her lung problems that are keeping her dangerously sick. I hate it, I hate to see my patient dying, and I can’t stop her, and I can’t even try anything to change it. I know logically that me sitting next to her all day wouldn’t help; but I almost wish I could. Jesus, could she please not die?

I can tell this is going to be an issue for me in residency: submitting to the attendings, and not putting up a big argument every time you disagree with their management. Especially in surgery, where the residents are trained to handle a lot of things, and to be decisive, and not to back down once they’ve given an opinion – but still for five years they have to defer to the attendings. (Surgery isn’t really¬†more black-and-white than other areas, but they hate indecisiveness: if you answer a question one way, you’re far better off defending it than trying to switch partway through the interrogation.)

The students have these H&P cards that we need to get filled out: do a complete history and physical on an inpatient, then present to both a resident and an attending. I have one left to do, and the secretary has been promising basically since the first day that we won’t even be allowed to take the SHELF, if we don’t have these done and turned in. Two days left, and I was about ready to panic. So – obviously should have tried this earlier – I started praying. The first patient I tried this morning, before her gallbladder was taken out, turned out to have CP and multiple other issues, and be an impossibly poor historian. Plus anesthesia walked in and took her away when I was halfway through. Tsk. But this afternoon, while the intern and I – miraculously unaccompanied by seniors – were doing an amputation with one of the nicest attendings, he got a consult. The internal medicine people said their patient needed carotid endarterectomy, and would he come see. So I got to go, and I did the very thoroughest history and physical you ever saw, and looked at every single note in his chart, and all his labs and imaging results. I wrote a two page report for the residents – which is an “internal medicine” kind of history, far longer than theirs. It was fun. They were all impressed with it, and when I talked to the attending, he already knew the story, so he only listened to the immediate history, and asked me a couple of questions about carotid surgery – to which I miraculously knew the answers. As my mother says, I should try praying about hospital things more.

And, I asked another one of the very nice vascular surgeons, and he agreed to write me a letter of recommendation. Now I just need to make the time to get into ERAS (Electronic Residency Application ——), and figure that system out.

I’m feeling depressed about leaving surgery; the next two weeks are ortho, primarily in the office. I miss this stuff already. I never thought of myself as a very scientific or intellectual person, but come to find out I’m extremely curious about surgery, all the diseases, and all the procedures, and all the research proving that this type of suture works better than that one, or this type of wound dressing heals better, or this particular incision works better. . .

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