I think I’m getting the hang of this service. By the chief’s set rounding time, I had at least seen everybody, and collected the most important facts on them, if not written notes. (I hate going around after rounds to write notes; such a duplication and waste of time. The only encouraging thing is that then I get to see the medicine people’s two-three page-long notes, and it makes me so happy not to be doing that. Even if I am functioning as a medicine resident for this year, as the saying goes, I don’t have to write their notes. I also enjoy being a doctor, and being able to write slightly more telegraphic notes than medical students are expected to write. Being an intern, I can’t telegraph too much; but in a few years, I’ll be able to get down to, “Patient is doing well. VSSAF [vital signs stable, afebrile] Wound healing. Continue current plan. scrawl“)

After a couple of simple cases (which I barely even smelled from a distance; I don’t think this program has the concept of “intern-level cases;” for them, intern level is, not even in the OR), the chief and attending proceeded to work on the poor guy who’s been floating around the hospital for the last couple days. In fact, I owe an apology to my medicine friends (if we’re still friends). The medicine senior wrote that this guy had rebound tenderness and peritoneal signs. We said he didn’t. Technically, we were correct, because he didn’t, but functionally, the medicine resident was closer to the truth, because when opened up, he turned out to have a ruptured viscus and a widespread peritonitis. Oops.

That’s the problem with surgery. Most of the time, when you operate against your better judgment, things don’t go well. You don’t find anything significant, the patient feels worse instead of better, and whatever their underlying problem was is still there. So you resolve to be cautious and avoid such disasters, when along comes a patient who really does need surgery; but there you are, being cautious. . . and there you are with a disaster again. Which is why I’m actually not too unhappy to spend a year observing patients before and after surgery, starting on my database of what a patient looks like when they need surgery, and what they look like when they would be better off without.

Most of our attendings’ patient are on one floor in the hospital, which is pretty nice for me. I get to settle down and build my day around one location, rather than moving constantly from unit to unit. I’m getting to know the nurses, and I’ve learned that this unit (as befits a floor for complicated surgical patients) has some top-notch nurses. I haven’t met a one yet that I wouldn’t trust, and they all know more than me about day-to-day management of the patients. They are also so nice that they don’t push me much about what to do next. I know that I’m doing some things different than what they’d choose, but they don’t make a big issue out of it.

One pretty smart nurse clearly developed a pretty poor opinion of me after I stumbled over managing a patient’s hyperkalemia. I’m still scared by high potassiums: I don’t know when it’s so high that I should rush to get EKGs, monitors, insulin, etc, and when it’s low enough to sit back and take one’s time waiting for a repeat to see if the lab was mistaken. (Hyperkalemia can cause life-threatening arrhythmias. Or it can be the result of a miscalibrated lab machine, or a sample which somehow had the blood lysed before being run.) So after she knows that I don’t know what to do about this, I asked her to put an NG in a patient who was vomiting and at risk for aspiration. She made it clear that she thought that was unnecessary. I resigned myself to having a bad relationship with at least one nurse. Half an hour later she came back and said I was right, and the patient had needed it. Which was not a big deal, but it’s a nice sign that I’m starting to get my feet under me, and be able to make decisions based on my assessment, rather than someone else’s hints.