I was thrilled today to be assigned to a couple of short, dirty cases. These were the kinds of things that made me seriously consider not going into surgery, just to stay away from this part of the body and its problems. Two things have changed my mind. My attendings, very dedicated, serious people, take this stuff seriously; which kind of destroys negative connotations. I think one of the problems I had as a med student was the attending who specialized in this stuff; he made the residents miserable no matter what they were doing, let alone these cases. Also, I’m so hungry for cases, I promised myself I would enjoy this stuff if they threw it to me; so I did.
I’m getting a better handle on the floor patients. Somehow, after spending months away from a straightforward general surgery service, I’d forgotten how to work the floors. Checking on the patients two or three times a day isn’t enough. You need to be in their room every two hours. This will ward off the pain control/fever/low urine output/missed orders issues which will otherwise stay dormant until evening rounds. There’s a reason they don’t want the intern in the OR. I’m supposed to be ceaselessly walking around my patient’s rooms checking on everything. Now that I’ve got the hang of that again, things are better. The nurses on the surgical floors are good, but they’re so busy that they inevitably miss a couple of orders like “adjust iv fluids,” “remove foley,” “advance diet,” “put NG to gravity drainage” which don’t make much difference to them, but are very important to my seniors when we round, because they’re part of moving the patients towards discharge. (On the other hand, the nurses spend a fair amount of time reminding me that I forgot to discontinue or reorder other important orders when I should have, or that one of my colleagues wrote inappropriate post-op orders that I need to fix. It goes both ways.)
On the other hand, the more I’m around, the more I hear about pain control. I’m kind of stuck here, because between several attendings, the chief, and the fellow, I have very few options: Some of them hate valium for muscle spasms; others hate toradol (a kind of super-strength iv advil, which works wonders), because it’s dangerous for the kidneys; some of them object to me adjusting the dosage of the dilaudid pca; and others dislike additional doses of dilaudid (different from the baseline patient-controlled analgesia that everyone uses). So no matter what I want to do, the next person to round with me will be unhappy about it. The chief and the fellow have variously threatened to hold me responsible for all urine output problems (since I give people toradol) and all sedation/confusion/aspiration problems (because I gave people valium and or dilaudid). They have a great time, of course, walking around lecturing people about getting out of bed and taking deep breaths, and simultaneously threatening me with dire consequences for giving more medications. Then they leave, and I get to hear about it from the nurses and patients. Ah well. I can always blame them when I get tired of arguing.
Actually, to be fair, they’re pretty good at telling who enjoys the iv push narcotics, and who’s not saying much, but really has a lot of pain. I’m too soft-hearted. I believe everyone. Not as much now as six months ago, but still more than I should.
And then there’s the whole question of who gets to eat and who doesn’t. For abdominal surgery, patients spend a few days after surgery not eating, waiting for things to wake up after being manipulated during surgery. Some of the attendings are agressive about diets, and will start feeding people quite soon. Other attendings are more conservative, and want to wait a while longer. So whichever one of them comes around first, and lays down the law for the day, within a few hours someone of the opposite persuasion will come by to check on their patients, and want to know why on earth I’m feeding (or not feeding) them. Or they’ll demand to know why on earth I’m wasting the patient’s blood by sending these tests, and start off on a pimping session about the sensitivity and specificity of the tests. I struggle through the answers, and am finally allowed to blurt out that it wasn’t my idea, it was the other attending.
But being an intern means learning the art of answering to many bosses at the same time. It’s another thing I watched the first and second-year residents doing when I was a medical student. At the time I was amazed. I remember one girl in particular. One month she had four different senior residents and attendings, and they would all talk to her separately, asking the same questions, and coming up with different plans. And she would just sweetly make her presentation to every single one of them, no matter how many times she’d already gone over it, or how contradictory the instructions she was getting, mildly pointing out when necessary the instructions she’d gotten from the others. She made the team work, because she somehow smoothed over the differences between different management strategies. After all, it doesn’t do any good to argue.