November 2009

This will tell you what my nights have been like lately:

I woke up in the evening to go in for the next shift, and my shoulders were really sore. I couldn’t figure out why. I’d been trying to study a little more, but surely I hadn’t spent so much time hunched over a book to hurt that badly. I was at the hospital for half an hour before I remembered that I’d been doing chest compressions the night before.

1am in the ER, one of the ER residents asked about a patient we’d admitted at 7pm. I couldn’t even remember who they were talking about.

A MICU resident asked, How did that laparotomy from earlier in the week do? I said, Which one? The 80yr old with diabetes, the 60yr old with cirrhosis, or the 70yr old who’d arrested? Doesn’t matter, they all did badly.

The OR charge nurses recognize my voice, and start protesting as soon as they know it’s me on the phone. . . doesn’t stop the cases from coming.

Time to go to sleep. . .


It’s been a long time since I’ve had a patient imply that I was too young to be competent. Last night, though, one of the nurses stopped me outside the ER room and told me, “Don’t be offended, but they said they want a real doctor to do the procedure.”

Of course I was annoyed, but it was also funny, because I’d just been congratulating myself on how much experience I had with that procedure, and how quickly I would be able to do it. Since I’m now the senior surgery resident at night, the only available doctor more “real” than me would be the ER attending, and I hadn’t wanted to waste time by waiting for him to finish with all the other critical patients he was handling before getting around to the procedure, which I do all the time on my own outside the ER. (It was a bad night in the ER: three or four intubations in two hours, at least one arrest, and the ICU admitting team basically never got to leave. Plus traumas.) Served me right for being cocky, I guess.

I told the family very simply that I had done the procedure dozens of times and felt sure that I could do it safely, but I would be happy to go get the ER attending instead. I was just about out of the room to go find him, when they said no, go ahead, you do it.

After that I was sure I had set myself up for a complication, but it went just fine.

Not sure what the moral is. I knew I could do it, and I did. I thought I’d acquired a professional enough and confident enough manner that I wouldn’t be considered too obvious of a trainee any more, but apparently not. (I guess I’m going to turn into a feminist before I’m done: would a man my age, in my place, still be getting this response? Or maybe the family had just had enough hospital experience to be wary of residents with perhaps good reason. . . )

Only 8 more days of nights; and about time.

Half of the general surgery attendings at my hospital will do appendectomies laparoscopically. The other half routinely do them open, arguing that it’s faster and requires less equipment (and is thus less frustrating than trying to get techs trained mainly on ortho equipment to get right in the middle of the night), and that a 2cm open scar is no more painful or unsightly than three 0.5-1cm port sites.

My problem is that, after two and a half years, I still can’t remember which half is which. Thus, when I’m explaining to patients – you have appendicitis, you should have surgery tonight, I’ll call my boss and set it up – I usually give them the wrong spiel. Whether that laparoscopy is quick and easy, or that an open incision is quick and easy –  I always get it mismatched. Overall I’m getting better at telling patients ahead of time what the attending’s plan is going to be, which only makes it more painful to have to go back and correct. . . (You may wonder why I’m trying to predict the plan. It looks extremely unintelligent and unprofessional to take the history and physical, and then walk out of the room without explaining anything. If you can’t give the patient some kind of diagnosis, and an idea of whether they’ll be admitted, and whether or how soon they’ll need surgery, it looks as though you’re completely clueless, and not a doctor at all. Much more satisfying all around to immediately say, this is what’s most likely wrong, you’re undoubtedly being admitted, and I expect surgery tomorrow morning; let me check with the boss, and I’ll let you know the final plan. Of course, only satisfying if you get the diagnosis and plan right the first time.)

Tonight it was fun, though. One of the ER residents, feeling cocky, decided to try selling us a case of appendicitis based only on history and physical (how old-fashioned). I had to admire his idea (unlike some of his colleagues’ other attempts, he picked a patient with an appropriate history and physical, rather than say a 24-yr old woman with atypical symptoms). So I bought it, and then I managed to sell my attending on coming in to operate in the middle of the night without a CT scan. . . and we were both right, which was good for us and for the patient.

(And you thought the title referred to the Democrats’ scheme of taking the “public option” off the table to quiet public outrage, then slipping it back in and squeaking it through without adequate debate. . . don’t get me started. Here’s to obstruction and deadlock in the Senate.)

M&M last week was scary. Scary as in, I don’t let myself say, I would never have made that obvious of a mistake. Instead I say, someday I will be the one to make that mistake, so I better watch out.

No details at all, just the lessons I got:

Never believe anyone. Verify everything for yourself. Seriously, not just an axiom.

Look at all xrays as a matter of course. In addition, I must personally look at every CT done on every patient I’m caring for (let’s say done within the last week), regardless of whether radiology has read it, and regardless of whether other surgeons have told me it’s ok.

Every CT, slowly, head to toe. Then on lung windows, head to toe again, slowly (this is a different penetration view of the CT, to show lung findings, abdominal findings in a new light, and check for free air).

If a patient feels like they’re doing badly, start from scratch and look through the whole story again for yourself.

I’ve gotten through the first week of nights without any major disasters. That isn’t a good thing; that means they’re still out there, waiting for me. . .


Of course that isn’t true – on another level. Of course I said I’ll never be the one to make that awful of a mistake. It’s a game of roulette: if I concentrate hard enough, maybe I can make it through; as though will-power can bend chance, or concentration will never fail. . . but if we didn’t all think there was a chance we could try hard enough to not make the mistakes, we would have to stop right now.

More codes last night. That makes the intern happy; she still thinks it’s a game. Which is all well and good, but I’m the one running the code, and I don’t think it’s quite so much fun any more.

In a way, yes. It’s the nice that the nurses say, “Oh Dr. Alice, it’s great that you’re here. This isn’t your patient, is it? What do you want us to do?” Um, you’re doing good compressions, and I see we’re ventilating nicely, and you paged anesthesia to intubate (that’s how it’s done at my hospital). (These nurses are good. I much prefer codes in the ICU.) How about finding the doctors whose patient it really is? Because I’m getting tired of running codes that I’m not even responsible for. The medical people are supposed to be responsible for codes at night, especially on their own patients. So why am I the only one there for twenty minutes?

So my interns work on lines (they’re good enough with lines on still patients; people bouncing around they’re not so good at yet; we’ll have more practice), and I work my way through every single drug in the ACLS protocol, first-line, second-line, and last-resort. We intubate nicely, and defibrillate more times than I can count. I ask the nurses in the hallway, for the third time, if they would please make sure we’ve paged the medicine folks. By the time they show up, much to my own surprise, we have a perfusing rhythm, a central line, and even an arterial line (which is nice in a prolonged code because it tells you for sure whether there’s a pulse or not, and how much good it’s doing).

I’m a little ambivalent about the value of what I did. After a 45-minute code, I’m skeptical that the patient will have much neurological function left, or that he will even survive till morning. But I couldn’t have decided to stop earlier, without knowing anything at all about his background, and without having managed to get in touch with the primary team. (Also the arterial blood was bright red the whole time, which made me think we were oxygenating and perfusing pretty well, so there was no urgent need to stop.)

On the other hand, I’m making myself a reputation for successfully running codes while also placing impossible lines. A reputation for invincibility doesn’t hurt, until it breaks. It is true, though: the key to being relaxed while someone else learns how to do a procedure is being confident that you can fix it. I knew I could get the lines any time I really wanted them, so it was ok to let the interns try for a while. Next time, maybe I won’t have to run the code, and I can coach them through it better.

(I guess that paragraph definitely qualifies me as a cocky surgery resident. I never thought I would be that person, so I’m going to enjoy it, until it breaks in a night or two.)

(Next time I’m going to see if I can think coherently enough not to have to ask the nurses every five minutes what the patient had been admitted for. They must have told me the same thing six times, and I just kept asking again, as though they had a secret that would tell me why the patient arrested.)

Not so bad for nights so far. Not much luck at making people come in to operate in the middle of the night, but no one but adrenaline junkies like me and the night float interns really mind that.

Speaking of adrenaline: somebody was messing the code pagers tonight. There was one real one, early on, at which I practiced not touching and not talking while the intern did the line (harder than you’d think), and verified that after working on three-hour long resuscitations on open-chest patients in the cardiac ICU, I no longer care very much what particular order the code drugs are pushed in. Epi; bicarb; calcium; is there a pulse? it must have been three or five minutes; more epi. . . And never let the fact that you got pulses once after CPR delude you into thinking that the pulses will still be there two minutes later.

Then there were several more code pages over the course of the night, none of which were real. In fact, for most of them, there wasn’t even a patient at the location we were sent to. I was never trying to sleep when it happened, so it didn’t bother me too much. I think the intern was mainly disappointed not to get any more lines.

I’ve also been carrying on a heated argument with the chief and attending on one particular service, for the whole month to date, about one particular patient. Every evening I come in and try to persuade them again of my diagnosis; and every morning the chief has some more barbed comments about my sad lack of clinical acumen (as demonstrated by my disagreeing with him). I think the final result is that I was half-right, and he was half-right; and of course each of us thinks our half was the more important. (I was right that the patient needed surgery; he was right that I had the wrong diagnosis.) Note to self, there’s no percentage in fighting with a chief; but next time I’ll show him. . .

In one sense it was a bad night, because I didn’t get much sleep, spent a lot of time in the ER, and had my patient die anyway. On the other hand, I surprised myself by handling the problems well. I probably shouldn’t talk about it too much, being just starting into a month of night float, with so many upcoming opportunities to make mistakes and act idiotically. But . . . I talked on here a lot, especially a year or two ago, about how much I admired the senior surgery residents. . . how they took control of bad situations, and knew what to do, and stayed calm. I thought I would never be like them. Much to my astonishment, and I have no idea when or how it happened, I found myself acting like them last night.
It was one of those messy situations, where the ER knows the patient being flown in needs surgery of some kind, but the diagnosis is unclear till the patient can be seen and have a CT scan. At least this time they called the surgical services ahead of time; perhaps after the series of fiascos last week our attendings yelled at them enough to impress the importance of calling ahead for ruptured AAAs and such like. (Not that the ER got around to informing the surgery residents, but my radar is getting pretty good.) Which meant that I, also bearing past miscommunications in mind, called the OR ahead and had them getting ready. So everyone was in the right place when the patient arrived.
He looked deceptively good for about 30 seconds, and then fell apart. Maybe it was a little longer, because I had time to at least make sure to my own satisfaction that he belonged to my service and no one else’s, so he was mine. Then it was the usual chaos of trying to intubate and do CPR all at once, get iv access, get monitors on, get blood and fluids lined up. . . The ER attending was technically responsible, because we were in the ER, and the patient hadn’t been officially diagnosed yet (I was just extrapolating freehand, taking the most pessimistic interpretation of the available data); but I was responsible too, because I knew if we could stabilize him, my attending needed to operate on him; and if you’re a surgeon and you’re present, you can never blame anyone else for anything that happens. The ER nurses and attendings knew he was ours, so they kept looking to me for directions. Gratifying, but scary.
Also I got a central line so fast, despite my hands shaking, that I was almost too surprised to finish threading the catheter. Now the ER folks think I’m magic, which is fine, I guess.
I’m not saying I have the calm part completely down; I was certainly pacing back and forth, and – not quite wringing my hands, but touching everything, the ivs, the bags of blood, checking for pulses repetitively. But I didn’t change orders and contradict myself, or give orders too often to be meaningful, and my voice wasn’t squeaking.
In the end we stopped. Despite occasional fleeting spontaneous pulses, we weren’t getting anywhere very encouraging with CPR, and it was clear that the patient was never going to be stable enough to move to the OR, let alone even start an operation on, which made further efforts futile.
The only thing I really still want to fix is, my voice keeps breaking when I talk to family members. It’s bad enough getting a midnight phone call to say your loved one is dead or dying, you would think the doctor should at least be able to speak coherently and audibly. It doesn’t really do much good for me to call people to give them bad news, and then have my voice be too shaky to communicate anything except that something bad is going on, leaving them to imagine for themselves what that must be. . . I know, sympathy and emotion from the doctor are good. . . but when you don’t know each other from Adam, probably simple transfer of information would be more valuable.
I especially hate calling 80-something wives – widows – who you know are home alone in the middle of the night. They’re half deaf, and sleepy, and don’t want to hear that their husband is dead. . . and when they do hear you, you can hear them just about collapsing. . . but so often the wife is the only phone number listed, and if you want to reach the adult children you have to go through her. . . . and you can’t just not tell people, and hope the morning will make it better. . . I have no idea how, but the ER social worker does miracles. She discovered the pastor and sent him over to keep her company. Now that was probably the most useful action of the night (and another profession to add to my list of people besides doctors who don’t get to sleep at night).