This morning the other medical students and I arrived before 6am and started seeing our tremendous list of – four patients. I saw one patient together with the girl, because I had been in the operation and it’s not responsible not to write notes on your post-op patients. I let the third year do the talking, because I always hated having senior people talk to “my” patients for me. Only a year different, but she’s so much younger than me (actually, she’s probably a year older than me). When the patient, two days after massive gastric bypass, stated that she had back pain, my instinctive response was, ah, it’s from the surgery, and from lying flat in bed for two days. The third year, however, went into the whole careful spiel: where is the pain, where does it radiate to, what does it feel like, sharp or dull, does it make you nauseous (which was one of the actually important questions to ask a post-op patient, but not for that reason). I listened to heart and lungs by putting my stethoscope over two spots on her chest, satisfied that I heard good heart sounds, adequate lung sounds, and didn’t feel obliged to investigate pulmonarily any further. Listened to her bowel sounds through two spots. The dear third year listened in six places on her chest, asked her to take several deep breaths (which is also important pulmonary toilet), undid her binder, and listened in four places on her belly. A long time ago I used to do like that. I did, however, put on gloves and strip her JP tube the way the resident had instructed me to. Also, I knew what to make of her decreased urine output overnight, and explained it to the third year. Made me feel semi-intelligent. I can’t remember what it was like not to know that you give a liter fluid bolus as first step for decreased urine output or hypotension.

The residents came in hours later, 6:45, and we rounded leisurely, and spent nearly an hour eating breakfast “as a team.” They talked with me about surgery residencies, giving some unsolicited advice, which on this topic I appreciate. And I guess you could say I solicit advice by existing as a fourth year, and expressing interest in their specialty and in this program. They gossipped tremendously about their attendings and colleagues and patients. Some of it was extremely unedifying. I did, however, learn that this program seems to have fewer, shall we say, moral lapses among residents, because the vast majority are married. Another reason to stay here. After some thought, they could only name three or four single residents. For surgeons, I think that’s fairly impressive.

I went to one of the bariatric surgeon’s clinics this morning. He saw a succession of follow-up patients: some were years out from their surgery, weighing less than half what they originally did. Others were a few months away, and already 50 or 60 pounds lighter. Not all were as successful, but all the patients were pleased with the results. They all adored him.

I resolved to lose weight immediately, so I never end up in their situation. I promptly got into a surgery which lasted till mid-afternoon – almost no lunch, and then saw consults all evening till the cafeteria closed – no dinner. I guess that’s one way to manage it!

The female resident, Dr. G, had scrounged up a breast biopsy from another service to do, and very helpfully set me up with one of the chiefs (who I am afraid had been quite happy without a medical student) to go see his inguinal hernia repair case. It was a simple operation, which he accomplished almost singlehandedly, with the table up comfortably high for him, and the attending surgeon and I, of a similar height, stretching our necks from the other side and mostly looking at the retractors. He knew me back at the beginning, when I could barely close a trocar incision, so only let me do the last two inches of his incision, and of course I promptly became so nervous I could hardly place the needle for that simple job. I was disgusted with myself. One of these days, I will be competent and confident. Of course.

Later on, Dr. G helped another resident float a Swan in the ICU, and I admired her further. Just second year, and she has memorized an endless amount of facts and procedures, can do so many things, never seems at a loss. I am looking forward to having a place and a job, and not trailing in an aimless fashion behind people who don’t need me. I think for me surgery is the ultimate “in” group, like the NICE was for Mark in That Hideous Strength. That’s not a good comparison, but it’s an overwhelming feeling. I want to belong in here. . . That’s bad. I’ve never let myself belong to or be influenced by a peer group before, certainly not this much. I try to stop myself, but I’m tired of being the appendage, the medical student, the fifth, or seventeenth, wheel.

I asked Dr. G to call me tonight if she has to go see patients on the floor, so I can get some experience dealing with those floor calls, before I’m actually a panicked intern. She very generously responded by spending an hour teaching me about ventilator management, intubation protocol (use etomidate 20mg, sedate the patient before paralyzing them, and once you’ve pushed the succinylcholine, get the airway in fast, etc), and other intern survival tips, such as, if you think you should go look at a patient, do it immediately; and if you think maybe you should call someone else, call them immediately. Straightforward, but of course the kind of thing I’ll forget under stress.

Around 6 she started getting a flood of consults, one from the floor (no, Medicine, that’s not an abscess, it’s a cellulitis, why are you treating cellulitis with Flagyl? Vancomycin is good enough, plus unasyn), one “cold foot” in the ER (vessels too small to do surgery on, going to try radiology and iv meds), one complicated bariatric patients. The ER was wild tonight: the ortho surgeons stopped to commiserate about having received two open tib-fib fractures at once, plus another drunk patient who insisted upon getting out of bed, whereupon his closed tib-fib suddenly converted to an open tib-fib, necessitating an operation tonight. Being less urgent than other cases, this patient merited a hallway bed, so for an entire hour of working up our consults, we listened to him demanding to call his wife, and attempting to get out of bed on his splinted leg, and nurses all over the ER calling to him through the halls to lie down and be still, because they were too busy with several trauma cases and other serious events to come keep him down. Everyone who walked by would take turns calling to him to be still, and now and then forcibly encouraging him to lie back. I wrote two H&Ps for Dr. G, so now we like each other very well.

Time to go to sleep before anything else happens.