I’m not old enough to be doing this much reminiscing, but something about having spent two years at this is making me retrospective (is that an adjective?). In medical school we changed specialties every few weeks. It’s still a bit funny to be spending years straight on one thing, and to plan to spend even longer on an even smaller area of that. . .

Anyway, when I was a medical student on surgery I was fascinated by the trauma service. Most medical students who have any procedural (or should I say violent) bent at all are; they’re attracted by the excitement of the trauma bay, and the acuity of the ICU. They don’t understand how the residents get frustrated by caring for geriatric and head injury patients instead of doing surgery.

So it was July, and I was supposed to be doing something else, but I decided to spend the night with the trauma team; their assigned medical student wanted to do peds, and had no interest in contesting my presence. A patient on the floor needed a chest tube. It was one of the first for the intern, so there was no chance for me to get involved, but I went along to watch. The main thing I remember was the violence of it, and how the patient seemed to be having so much pain. As a student I couldn’t tell for sure whether the surgeons had premedicated him adequately or not, but I was a little shocked by how they all focused on explaining the steps to the intern, and getting the tube in, and seemed not to care how much the patient was grimacing.

We had a chest tube to put in on the floor today. I always hate chest tubes on awake patients; at least in the trauma bay the gunshot victims are short of breath enough to understand that something needs to be done quickly. On the floor, the problem isn’t that acute, and it’s harder to justify. This lady certainly qualified. Her effusion was occupying nearly 70% of her thorax. I made sure the nurse gave her some medications ahead of time, so they could take effect while we were laying out our supplies and setting up, and I did my best to let her know what would be happening.

But I was thinking more about the technique of the insertion, and how angry I was that the fellow felt the need to supervise me. For crying out loud, I’m a third year resident now (just two weeks and I already feel confident calling myself that). I put in a dozen chest tubes just last month, assisting the trauma team at night. I know how to do it, and how to do it quickly. I know about numbing up the periosteum and the pleura, about entering the chest over the rib rather than under it (to avoid the intercostal artery and nerve), about dilating the tract with the hemostat, angling the tube in so it goes up and posteriorly, and suturing it tightly down afterwards and putting an occlusive dressing over it. I don’t need supervision anymore; and especially I don’t need this guy, neither whose character nor whose knowledge do I respect, chattering away giving me superfluous instructions (the opposite of what the last three attendings told me), and disturbing the patient by the graphic nature of the instructions. She doesn’t need to hear about how doing it the wrong way will cause excessive bleeding, while it’s being done.

It went in smoothly, for all that, and the only commotion came from the fellow, not me. Despite adequate iv pain meds (she was as sleepy as I could tolerate on the regular floor), and plenty of correctly applied local anesthetic, she wasn’t really comfortable. The tube irritates all the pleura it touches, not just where it goes in. But once I was sure she’d gotten all the meds she could, it was more important to finish the procedure in a timely manner, and technically correct, than it was to spend time trying to calm her down. Once I was done, the pain would alleviate. So here I am, just like those residents I wondered at only a few years ago. I don’t know if that makes me heartless, or a good surgeon, or both.

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