warning signs

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.

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inescapable

One of my friends, an intern, is struggling with the belief that they killed their patient.

I’ve thought that more than once, and in cold reflection I believe it to be true in at least one and two halves. That is, one I’m personally responsible for, and about two others I’m definitely responsible for significant failings. There were several other times that I felt very guilty about for a week, but as time passes I think my responsibility is less weighty in those. I haven’t written about them before because, in close temporal proximity, I was too upset to write, and I didn’t want any time correlation for the lawyers to find.

The one patient that I think of particularly, I personally failed to notice something, and that thing being overlooked led to another thing, and the complications of that other thing led to the patient dying. So it’s not like I directly administered an overdose. But it seems reasonably certain that if I hadn’t overlooked that particular thing, the patient would have been much more likely to survive. Also there were several other doctors, both residents and attendings, from my own and other services, who also had cause to notice that particular thing and act on it, and none of them did, either. But it was my patient, on my service; so I can’t decrease my own fault by saying that others, who were not as directly responsible, although more senior, made the same mistake. It comes down to, my lack of attention led to the patient’s death.

The other times are similar: I didn’t do anything – I didn’t cut a major artery, or cause a laparoscopic injury – I’m sure those are down the road – but I failed to pay close enough attention, or to pay attention soon enough, and then the patient died. If I had done a better job – if I had done well the job that I was supposed to be doing – it probably wouldn’t have ended the way it did.

I don’t know what to tell my friend, though. There’s no way around it. Sometimes I’ve tried to reason with interns (because they’re the ones to whom it happens for the first time; for the rest of us, the feeling of guilt is familiar and feared) and tell them, in this case it wasn’t their fault. But inevitably there comes a time, probably before six months are out, when there is no honest way to reason out of it: it really is my fault – your fault – our fault.

I can’t remember now how I dealt with those times. By not thinking about it, I suppose. I considered the facts enough to realize what I had done, maybe asked a senior resident what they thought about it, and then I closed a door in my mind. I think the phrase is from King Lear: “That way madness lies.” Now, one part of me knows I’ve killed people, and the rest of me is for all practical purposes unaware of that fact. It takes time, though, to get that door closed, and to keep it closed. And so for a week or two, it’s quite miserable. M&M helps a little, to have it out in the open. The attendings’ conclusion, surprisingly enough, has rarely been as harsh as my own. After all, only I know exactly when I knew certain things, and exactly what conclusions I drew from them, and whether I could have taken certain actions sooner than I did. The final picture, in public, is always a bit blurry; the blame never settles very definitely. Inside my own mind, though, I know that I failed – and it will happen again, no matter how careful I am; it will happen again. . .

It’s hard to watch interns learning that.

 

work ethic

Last year, I mostly viewed the scutwork the seniors demanded as an exercise of their power, nothing else. I did it, of course, but I couldn’t really see why they didn’t just do it themselves. Why the interns and juniors had to write all of the notes in the morning, write most of the post-op orders for the seniors’ own cases, write the post-op notes on the patients the seniors had just been operating on – it seemed rather pointless; or rather, too pointed: they got the fun of operating, and I got all the busywork.

Now, with a little more experience in the OR, I can see more reason to it (or perhaps, now only a year away from being a senior myself, I’m starting to rationalize giving a lot of the work to the intern). For one thing, the work hour limits hurt the chiefs a lot: simply being present for all their cases takes pretty much all the available time. Being in the hospital a few hours early every day to round would put them way over. Nevertheless, the good ones seem to know more about their patients than I do, for all they spend less time on it. The most fearsome chief I had this year seemed to be able to put me in the wrong every time we sat down to run through the list: despite having been in the OR all day, and me not, there was always some test result, some lab value, some change in the patient’s condition, which he knew about and I didn’t. He wasn’t trying to do anything in particular to me, either; he was just taking care of his service.

For the rest, writing orders and helping to get cases started, I’ve realized that “simply” doing three or four cases in the day can be quite tiring, and it’s only kindness to the seniors to use my energy instead of theirs to move in and out of the OR. (My hospital has an inefficient OR setup; neither the OR staff nor the anesthesia staff has any motivation to move quickly. It doesn’t decrease their workload or their hours, or improve their pay, to turn things around quickly. This leaves the surgery residents as the only people who really care whether it takes twenty minutes or fifty minutes to get the next case started, so the day will move more quickly if there’s one of us turning up to make sure that the patient has in fact arrived in pre-op holding, that their pacemaker is being turned off appropriately, that the CRNA is aware when the scrub tech is ready for them to come back to the room (instead of both parties sitting waiting for the other to call, as I frequently find them doing), that there are enough hands available for transport and to finish setting-up details in the room.)

So, I think my approach has changed since the beginning of internship: instead of figuring out what the chief was going to check to see if I’d done, now I look for any work at all that needs to be done, and take care of it, regardless of exactly whose responsibility it technically is. I wish I knew how to teach this work ethic to the new interns; but luckily, I think it’s primarily transferred by example, so I just need to keep doing my job properly.

 

balancing

I thought it was hard being the intern and figuring out how to relate to the attendings and all the various levels of residents senior to me.

Figuring out what to do with my intern is even more complicated.

He’s not brilliant, but he tries hard enough that I can’t just write him off as a bad job. But how do I balance between pushing him hard enough that he learns what he needs to do to make a surgical service work, and being friendly? How do I let him make enough mistakes that he takes things seriously, but keep anybody from getting hurt? There are so many things that he ought to be doing, that we’ve told him about, but he forgets or doesn’t know how. So do I just do them myself, which would be the simplest, remind him endlessly and start looking like his mother or older sister, or let them go until he gets embarassed in front of the chief and/or attendings, to make him remember?

He’s not like I was as an intern, which also makes it complicated. If I’d had an intern as naive and hopeful and trusting, and incompetent, as I was, maybe I’d know better how to relate. Someone who says, I want to do it right, but is rather clueless, seems to me easier to deal with than someone who talks brashly and confidently, but doesn’t have the knowledge or skill to back it up. An intern mouthing off like a senior resident throws me off. The older residents have earned the right to make flippant remarks; my intern doesn’t have the experience that in my minds earns a little tolerance for making unkind remarks about nurses or patients. If the chief says he doesn’t care, I know that his record of hard work, long hours, and lives saved show he doesn’t really mean that. But for my intern to say that – it’s too early. The attending can say, “Ah, fibromyalgia, consult rheumatology,” because we know he has the experience to be confident that there’s nothing really the matter; the intern needs to think a little deeper before brushing someone off.

But I’m not the censor. My intern is an adult, and needs to sort things out for himself. I try not to comment on his attitudes or remarks, just on his work. Hopefully in a few months he’ll learn what’s acceptable and what’s not. I trust the nurses, too, to set him down when he needs it. They can do that better than I can. Time will tell. Like me, he needs to see bad things happen just to learn that they can; then he won’t talk about them so lightly.

 

what not to say on rounds

There’s really not much to say about this academic year, so far. I haven’t gotten to do really any more surgeries. The chief keeps intending to let me, but then the case turns out so wildly complicated that I can’t honestly say it would be a good idea to let me in, so I can’t complain.

I don’t know any more now than I did a week ago, it’s just that the amazingly naive intern at my heels makes me look relatively well-informed, and even almost sophisticated. (One thing I learned the painful way: you do not have to tell the attending every single detail of what happened in the last 24 hours, such as, we wanted to check such and such a lab, but it took forever to draw, and then the lab lost the blood sample, so it was twelve hours after admission before we discovered. . . The tactful thing is to say, About twelve hours later we discovered that. . . And if the attending cares, he can take up the twelve hours, and then the chief can explain; but the intern should not attempt it, neither such details as, The patient had a fever eight hours ago, but since the nurses haven’t checked since then, I don’t know what the temperature is now (to which the answer is, a thermometer is a simple piece of equipment, if you consider it important to know the temperature, go find out; similarly for pulse and blood pressure and pulse ox). As I said, I learned that the hard way, by having both the attending, and then later the chief, jump on my unguarded statements. Trying to blame the nursing/lab/radiology staff for your own lack of information does not go over well.)

I do have my hands fairly full trying to manage the intern plus the patients. It’s amazing how much simpler it is to just do the work myself, rather than to gently show the intern how to do it, and then stand back and give them time to do it themselves. I shudder to think what a headache I’ve been giving the rest of the residents for the last year, and must be giving my chief now; it’s astonishing that they still talk to me.

In a few days we’ll have a completely fresh batch of medical students, and then the chaos will be complete. All we can do is be thankful that this year (unlike last) the medical students’ first day doesn’t coincide with the interns’.

 

advice for medical students

I wrote kind of a depressing post, about being tired, and not having any days off for several weeks, and worrying about next year. No fun. Just as well, the computer ate it. I guess the computer knows best. In response to requests (and because I actually know more about this subject than about advice for interns), here we go. . .

Bear in mind that this advice is specifically directed to students on surgery clerkships. Some things would get you high praise from medicine doctors, but will only get you laughed at by the surgeons (writing three page history and physicals, taking care to include a detailed social history; mentioning the eye exam or neuro exam in your report, if it’s not specifically relevant). Conversely, some things will fly very well with surgeons, but will not get you high marks on the medical service (carrying lubricant, gauze, and scissors in your pocket; being prepared to give details of all the patient’s previous surgeries if asked for).

Let’s hit three highlights:

1. Good books: the books I liked best as a student were Pre-Test: Surgery (also excellent for all the core SHELF exams) and Surgical Recall. Those two alone are nearly all you need. You can read Schwartz or Sabiston in the library, but those two you should buy, and carry one in your pocket. Pre-Test is a little harder than the SHELF, and covers all areas. The SHELF does include a lot of medicine-type knowledge, so surgery alone won’t get you through. If it’s your first rotation, you’ll just have to pay extra attention to the medical side of the surgical patients. Recall is nearly miraculous in its ability to predict what questions you’re going to get pimped on. If you know the facts from Recall, you are guaranteed to come across as intelligent and studious in any area. If it’s not in Recall, your questioner probably won’t be too unhappy if you don’t know it.

2. Attitude: People who walk into a surgery clerkship telling themselves, “I know surgery is not for me. This is going to be a horrible three months of waking up early, standing for long hours in the OR, and listening to conversations about blood and guts, which are completely boring to me,” are obviously going to have a bad experience, and give their residents and attendings a bad taste, too. Surgery, for students, is about observing the cases, and following your own patients. Even if you know for sure that you’re not going to be a surgeon, you will see patients who have had surgery, or who need surgery. You need to have a basic understanding of when a patient is sick enough to benefit from surgery (but not so sick that they’ll only die of it), and some idea of the pre-op workup the surgeon will want in order to be interested in the patient. You also need to have some understanding of the effects of various surgeries on the rest of a patient’s life (cholecystectomy is liable to give you diarrhea and discolored stools; that’s not unusual, and shouldn’t be concerning), and some idea of what the postop complications may be.

If you just want to survive surgery, you need to know that you will learn some beneficial things. If you’re aiming higher than mere survival, you need some enthusiasm. If you’re offered the chance to scrub in, take it. Don’t make us ask you twice (because we won’t), and don’t give excuses like “I’m tired,” “I want to eat lunch/dinner,” “I have a test to study for.” Everyone’s tired and hungry, and the test excuse is only respectable the night beforehand. (Seriously; my least favorite student this year was the one who, when offered the chance to scrub on a combined pancreas/kidney transplant, replied that it was early in his call night, and he wanted to get some rest. Unbelievable. So I scrubbed instead; I guess I owe him for that opportunity.)

Get some suture, and tie knots on anything – scrub pants, lab coat, drawer handles. Get good enough that you won’t be impossibly slow (reasonably slow is ok) if you’re offered the chance to tie something.

3. Fulfill your responsibilities. The surgical services run at a fast pace, and although it may seem like scut to you, the residents do count on you to do some things, and we appreciate your help. Retracting can get tiring and boring, but if you’re ever the one with the knife, you’ll know how much difference a few millimeters of angle can make. Writing notes at 5am is a chore, but your intern will love you for it, and you’ll learn from the regular contact with your patients (ok, so not so much when they’re sound asleep). So here are the basic responsibilities of a student on surgery: Round in the morning and write notes on the patients whose cases you saw yesterday, and any others you were assigned. (Do not be late for rounds.) Plan on scrubbing in for every case possible that day, and do your best to find out ahead of time what the cases are, so you can read up on them. The chief should be able to help you figure this out. Be present for attending rounds, if they exist on that service, and go to clinic if it’s expected. And finally, plan on doing postop checks and notes on your patients. This again may seem like scut, but you don’t know how many nearly-narcotic-overdoses, nearly-acute-renal-failure, nearly-hypotension, nearly-exsanguination episodes have been caught by careful postop rounds, not to mention all the other complications particular to a certain surgery. Unless specifically dismissed because it’s getting too late in the day, you probably shouldn’t leave until your team has made afternoon rounds. (I usually try to let my students go if this is going to run later than 6pm. It varies between hospitals.)

So yes, you will be working 12-14hr days, but you’ll be seeing things that you barely even heard about during medical school, and you can get a lot of hands-on experience. If you come prepared to work hard and learn, you’ll probably have fun (and also get started on the sleep deficit of the rest of your career; but there you are). 

Anyone have something to add?

 

advice for surgical interns, part six

Barbados Butterfly wrote some eleven or twelve posts on advice for interns (incidentally way more valuable than mine, since she wrote from a few years’ seniority, rather than only ten months, like me). If I could remember more of them, I’d try to reprise them a little more precisely. But the one that sticks in my mind most vividly contained her song, “Call A Code.” The words went something like this: “if the patient looks blue, call a code. . . if you can’t find a pulse, call a code. . . if you think you need help, call a code. . .” only much more poetically. (Does anyone else remember the words better?)

The basic point was that the intern should not hesitate to call for help, even as dramatically as calling a code, if they have any suspicion that it’s needed, or if they’re at all uncomfortable with the situation.

Many hospitals in the US are developing pre-code teams, which everyone is encouraged to activate if they feel the patient is unstable but not absolutely in cardiac or respiratory arrest. At least in my hospital, there seems to be a little stigma among the surgery residents associated with calling one of these. And for the senior residents, that’s probably reasonable. What these teams do is guarantee that xray, blood draws, ekg, and chest xray will be rapidly available. A confident resident (that means me in two months – hmmm) should be able to handle a patient who’s still breathing and has something resembling a blood pressure by stat paging these services independently, and getting one or two extra floor nurses to help bring medications. Of course, the other thing that these teams bring with them is a hospitalist attendings, who will take charge of the situation. Which is the real reason the surgery chiefs hate these teams: they don’t want to relinquish control of their patient, no matter what the problem is. (And they always have anecdotes of MICU patients on pressors through a peripheral iv, with no a-line in place, to back up their concerns. [This is bad because if vasoactive agents extravasate from a peripheral iv, they can cause severe skin necrosis; and if your patient’s blood pressure is bad enough to need pharmacological support, a cuff isn’t accurate enough to be measuring it by; not to mention that cuffs get more inaccurate as the pressure gets lower.] )

Anyway, my point is: if you feel the least bit uncomfortable with your patient’s status, call for help of some kind immediately. Try for a senior resident first, if that’s how your team is arranged, but if not, or if that’s taking too long, don’t put saving face above your patient’s welfare.

 

advice for interns in general

Get a PDA of some kind, and put Epocrates on it. This free downloadable PDR gives all the essential information: drug names (brand and generic), indications, dosing, adjustments for renal/hepatic failure, side effects, contraindications, interactions, and pharmacology. There are also some nifty medical calculating gadgets that come with it, which will calculate FeNa for you, calculate equivalencies between different narcotics or steroids, and other mysterious details.

This program is tremendously useful for those times when, as usual, the patient gives you some funny spelling of their medication, or only knows the brand name and it’s a very tiny brand, or can’t remember the dosage. You can look up variations on the names, and find out what the usual doses are (if something only comes in 10 and 20mg, it’s very unlikely that they’re taking 300mg of it).

It’s also good for cancer patients being admitted for other reasons. The chief or attending will invariably ask what chemo regiment they’re on, and if you’ve run all the strange-lookings names on their med list through Epocrates, you can look brilliant by saying that they’re on X tyrosine-kinase inhibitor and Y mitogen inhibitor (which is usually used in advanced renal cell carcinoma, but has a new indication for this tumor).

There are some other good PDA applications, like the Johns Hopkins Antibiotic Guide (you can search by type of infection and bacteria involved, not just the name of the antibiotic), but to my mind Epocrates is the only really essential one. It’s gotten so ubiquitous that people really expect the interns and med students to have it available to solve problems with.

 

advice for surgical interns, part five

Another piece of advice that you won’t get from many attendings: invest in some good shoes. It will make your life much more bearable.

There’s a reason Danskos are so popular. They really do feel much better than any other shoes I’ve tried. Back for the first several months, I had “nurses’ shoes,” which did absolutely no good. My feet used to be so bad, by the end of a 14-hr day, that it hurt more to sit down in the car to drive home, than to keep standing up. When I finally decided to pony up ~$100 for some Danskos in January, this improved dramatically.

As any surgeon will tell you, the problem with sitting down is that you fall asleep much faster sitting down than standing up. So when you’re going to be tired a lot, you have to be able to keep standing up.

Speaking of being tired, I have to share our chairman’s take on fatigue, in the context of the ACGME’s mandate to teach residents how to deal with (or avoid) fatigue (and bear in mind this is one of the nicest guys you could meet, completely not fitting the surgical stereotype): “If you’re tired, you’re tired. Deal with it. What’s this fatigue nonsense?” I think some people think the surgeons are the ones who were born with less need for sleep than other people. While that may be true of the neurosurgeons, whom I have literally calculated to sleep no more than 4 hours every night, I don’t think it’s the case with most of us. We just have something we consider more important than sleeping. (Ask my family: when I was on vacation recently, I spent more than half the day sleeping. But when I’m at the hospital, as long as I’m not sitting down in a dark room for conference or radiology sessions, I’m usually fine. I’m scared enough of failing to do something important that it keeps me alert.) So I think most of us agreed with the chairman: of course we’re tired. It’s a fact of life. We just don’t spend much time thinking about it.

Anyway, get some good shoes; as long as your feet aren’t killing you, it’s easier to keep moving.

 

advice for surgical interns, part four

Learn to tie knots really well.

Admittedly, I’m a slow learner, but I was a couple of months into the year before I really grasped the meaning of a square knot, and I’m still working on how to pick up the threads so that they naturally fall into a square when I tie them. Privately with bare hands, and under observation in the OR with bloody gloves on, are two different things.

The nature of surgery is that the senior person is guiding what happens, and the junior is left doing a lot of the mechanical work: tying off vessels that the other surgeon has clamped, for instance. And believe me, they notice what you’re doing, especially the first few times you work with that attending. They notice how easily you tie, and how smoothly the knot falls, even if they don’t say anything.

One of the attendings interrogated me once: “Alice: can you tie knots well?” “Umm, I hope so, maybe.” “No. If you can’t tie, you’re no good to me. Can you tie knots well?” “Oh yes sir, absolutely.” “Okay, fine.” Later he told me, “If you can tie well, attendings will be willing to give you more to do. And if you can’t tie, they won’t trust you enough to let you do anything.” I’m pretty sure he noticed, because a few days later was one of my best days this year, during a liver transplant. I showed up just to watch, figuring that between multiple attendings and senior residents there would be no place for me, but they needed another pair of hands, and had noticed me hanging around their service whenever there was the slightest thing going on, and told me to scrub in. (I don’t think I want to do a transplant fellowship, but I’m fascinated by the surgery: the potential, the dramatic implications of taking organs from a dead person and using them to make another person stay alive, and the technical demands of the procedures.) So I got to help with the back-table dissection, and spent an hour tying dozens of tiny knots all over the specimen. That was one day, maybe because I knew it was vitally important, where my knots worked well.

If you’re in to surgery, you know how to get the clean left over sutures from the scrub techs at the end of a case (preferably the ones where you don’t conclude with blood and guts sprayed all over every inch of the instrument tables) and practice all over your scrubs and coats and pens and drawer handles. (The nurses like you better if you clean these off when you’re done.) I think it would be a great idea, though I haven’t managed it yet, to get some gloves to practice in.