flashback

I’m making my way through Cameron’s Current Surgical Therapy, specifically the vascular section, since this is the kind of problem I am most worried about handling alone at night. For one thing, I have a terrible knack for imagining that I feel pedal pulses when there aren’t any, so I always have to make myself get the doppler and check (if the pulse is palpable, it necessarily ought to be audible with doppler; although sometimes, finding the doppler in the depths of the nurses’ station, or on another floor entirely, is almost more challenging than finding the pulses). For another thing, there are so many possible ways to treat vascular problems nowadays, and I feel inadequately versed in all the options, and which ones are appropriate in the middle of the night, and which ones are adequate in emergencies and which ones aren’t.

So I’ve gotten to the chapter on pseudoaneurysms, which touches on infected pseudoaneurysms of the femoral artery, and mentions that proximal control on these can be difficult. Which gives me flashbacks to vascular rotation last year, when I somehow found myself scrubbed with one of the most senior and demanding (but also rewarding) of the vascular surgeons. The case was supposed to be a simple oversew of a leaking femoral patch angioplasty. Half the subsequent bloodbath can fairly be blamed on the attending, for being so silly as to suppose that it would be that easy (as he acknowledged later, it was an ostrich-like plan; not that I made any objection at the time). The other half can fairly be blamed on me, for not yet being facile at controlling bleeding vessels with forceps or right angles to facilitate tying off, and for not being good at using the last two fingers as a third hand, in order to retract one thing and hold another at the same time (which faults he explained loudly, in between recommending anesthesia that if they hadn’t called for quantities of blood for transfusion yet, they’d better hurry; anesthesia, not having looked into the field or at our suction canisters, did not understand the urgency).

By the end of the case, a certain quantity of the patient’s blood volume was in those canisters, and another, smaller, portion was on me and the attending; and I had a much better grasp of the concept and significance of having proximal and distal control before trying to do anything to a blood vessel. These two pages of the textbook sound like a reminiscence about that case. . . The site turned out to be infected, and required one or two more operations to thoroughly correct the problem.

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taboo

One of the attendings the other day was trying to debunk some of the superstitions of medicine, particularly the one which warns against saying “quiet” about the ER or the OR, if you want it to stay that way. This myth can be almost paralyzing at times, since all of the nurses and a good many of the doctors subscribe to it. Sometimes at night I find myself running down the thought exercise, ‘try not to think of a pink elephant for a whole minute,’ in other words, don’t consider how much you’re enjoying the night being quiet, because if you think about it being quiet, it’s as bad as saying it.

The attending, as I said, was mocking this superstition. Very well for him, but there’s another piece of magic which is real, even if the taboo on “quiet” is ignored.

It works like this: Anytime the most junior person on call gets close to lying down on a bed, something will happen. I’ve tested this. I could go work on the computer list; I could do busy work somewhere; I could even conscientiously get out an ABSITE book and study – and nothing will happen. But the minute I lay out a blanket on the bed in the call room, and go to lie down, then the trauma will arrive, or the ER will finally decide that the kid in 3 must have appendicitis (after having thought about it for five hours), or all the nurses on the floor will think of some urgent questions (to be asked one at a time). This phenomenon is so reliable that I’ve considered doing a scientific study on the subject, but I can’t quite figure out how I would control it: maybe have one intern who never tries to sleep all night, and one who tries to sleep whenever not actually standing up?

I don’t have enough experience yet to be sure whether the principle applies for the seniors on call; I suspect not quite as rigorously, since the ER has to call the intern first. When I finally get back to my own hospital, and get to be the senior on call again, I’ll let you know my results.

 

attendance records

We had journal club earlier this week, the first one of this academic year that I haven’t managed to find an excuse to avoid. . . Ahem. Actually, I go to journal clubs and conferences religiously – in the truest sense of the word, since there is an exponentially higher chance of my getting to any given conference than to church that Sunday. (Come to think of it, M&M has an eerily religious quality to it: everyone always comes, and confesses guilt. . . absolution not to be had reliably, though.)

I was the kind of student who could never skip class even when I knew for sure that the professor mumbled in a foreign accent, had never explained a concept meaningfully in his career, and would spend the entire class going over the first two pages of notes (out of 50). So now, even though I know that I will inevitably fall asleep halfway through the lecture (it’s a real point of suspense, whether I’ll be able to last past 20 minutes; I consider staying awake to the half-hour mark a real victory), I go to every conference, unless I am unavoidably detained in the OR. The surgery residents I knew in medical school were very nice folks, but that was one thing they taught me quite sternly: never skip lecture unless you have an ironclad excuse, and only a code qualifies for that.

So, as I say, having made it to my first journal club this year, I discovered that it’s much better this time round: The interns are usually called upon to present, by way of making sure that they get educated, and learn to be responsible enough to read the articles. Then the chiefs are invited to comment, in the confidence that they will have something worthwhile to say. The juniors are, for a rarity, left to themselves. It was quite a novel sensation, to find myself senior to a whole crowd of interns, and consequently with no need to worry about how I was going to explain some complicated piece of statistical reasoning in three minutes flat, to an attending who knows it all backwards and forwards anyway.

(Don’t worry, the juniors make up for it at all other conferences, where any time you see a CT scan coming up, you know you’re going to be asked to read it and defend a management plan based on your reading. Depending on how genial the attending is feeling, he may correct your misreading before asking for your plan.)

 

retrospect

Last year for the first few months my heart rate shot up to about 140 every time the code pager went off. I learned to do femoral lines in the middle of a code, with no pulse, and the patient bouncing around so much that you couldn’t have found the pulse anyway if it had existed. I had no idea how my juniors managed to remain so calm about a pulseless patient and me waving long needles in the air in the middle of the chaos.

Now I’m smiling coolly when the new interns look at their code pagers and express some concern about being responsible for putting in lines, when they’ve never done any yet. Don’t worry, I tell them, you’ll learn just fine; I’ll come and watch.

Because I know, if they don’t get it, I will. Sooner or later. Me panicking won’t make the patient’s heart come back any faster, so we might as well take it easy, and do the line neatly.

(Now let’s see what happens the next night I’m on call, and how well that works in practice. And don’t worry, if they really need the line immediately, I’ll make sure it gets in sooner rather than later.)

 

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’.

 

new faces

July 1 – a very good day for staying out of the hospital.

Actually I don’t know why everyone repeats that, because nothing very bad happened. The attendings and seniors were practically breathing down the juniors’ and interns’ necks, and there was not much opportunity for error.

My service was relatively light, so I wasn’t called on to do anything out of the ordinary, which was just fine with me. I mainly babysat the intern all day. At first it was fun, because I wanted to help them and smooth the transition. By the end of the day, though, I was rather annoyed, and am trying to figure out whether all the interns are that infuriating, or mine was special. I’m going to try to keep giving them the benefit of the doubt for at least another week, and try to remember that I must have some of the same mannerisms, and must have been annoying my seniors in a very similar way through the last year. But hmmph, he/she/it is going to get in some trouble if they carry on at this rate.

Friday, on call, if the rest of the interns are like this, is going to be quite a nuisance. I guess I’m mainly used to my intern class, for the last several months, being able to do all kinds of work; which it isn’t fair to expect of the new guys at first here, so I need to adjust my expectations of “having an intern to do work with me” to “having an intern whose work I need to do as well as my own.” Ah well, a few weeks should straighten them all out.

It is funny, though, to see the new interns in the halls. Even the ones I didn’t know as medical students wear their new long coats so stiffly that they look out of place, as though they picked up someone else’s coat by mistake. Now if I could just find my new coat (supposedly somewhere in the hospital) so I can stop looking as though I’ve been sleeping in mine.

Welcome to the gang.

 

imitation is flattery

One more day of internship left. It’s a little hard to believe.

I’m making a couple of notes for myself about what I most admired in the junior residents I worked with over the last year, because I know that within a month, if not less, I’ll have completely forgotten what it was like to be an intern. (The same way that I’ve forgotten what it was like to be a medical student. For the med students out there wondering, “How can the residents treat us like this? Don’t they remember what it was like?” the answer is, no, we don’t remember, because things change so fast in just a few years. I remember third year of medical school about as much as I remember college, unless I concentrate. Even my own blog from back then seems foreign. I’m a different person now, immeasurably more cynical, skeptical, overbearing, determined, confident – hardened. For instance, when people ask for pain medicine, I have no problem saying flatly to the nurse, “That patient has been told that they will have no more iv pain medication. Tell them those are the rules that the attending discussed with them, and please try not to have to call me about it again.” The other day, as we were setting up the trauma bay for a gunshot victim, one of the residents told me, “You can put in the chest tube, but you have to really throw it in. No time for lidocaine, no dissection – cut and push. It doesn’t matter if the patient feels it. In fact, if he feels it, that’s good [because it would mean he was alive enough to care].” I told him, “It doesn’t matter to me what the patient thinks. You watch, I’ll throw it in.” And I did, because by this time I care a lot more about the technical affair of getting the tube in fast, and the overall implications of getting it in fast enough to prevent a tension pneumothorax or overwhelming hemothorax from killing the patient, than I do about whether it hurts him for a short time.)

Getting back to the stated topic: There were some residents I worked with for whom I would do absolutely anything, from something I simply could barely get up the willpower to do, like calling family members with bad news, to pure scut errands, like running to the other end of the hospital to get a paper they should have remembered to bring with them in the first place. Other residents (the minority) could make me silently furious simply by reminding me to do a job which was clearly my responsibility, and which I had been planning to do.

I think the biggest difference between these two groups was that the first kind of resident acted as though we were on a team, together; working toward the same goal, taking care of the same patients; they knew as much or more than I did about our patients, and didn’t have to have the whole story told to them fresh when I came to ask question. They routinely helped get all the work done, no matter whether it was “intern-level” or not; and if they didn’t help, I knew it was because they were overwhelmed with their own work. They cared about whether I got to sit down or eat, what time I came in and left. (Speaking of which, all year, all the seniors seemed to work at getting the interns home at a very decent time, no matter what that meant for themselves. I think now that I’m ready to commit to the longer hours the seniors worked; I need to remember to think about the interns’ hours.) Since I knew they cared about me and my patients, I would do pretty much anything for them, and still will, as we both advance in seniority. The second kind of resident clearly regarded me as a working machine, who existed to save them from having to do any work, and preferably from having to know much about my patients. That is purely bad leadership, and bad medicine.

So my primary resolution is, not to enjoy having an intern to do the scut work so much that I stop caring about the intern’s patients, or stop sharing in the general work of the team. (Although after these last two weeks, desperately short-staffed, without even medical students to help out, having someone junior to me, to do work, when I haven’t even had a senior to help out, will be an unbelievable luxury. I’m not sure what I’ll do with it.)

The other thing that I know I loved about seniors was when they let me do procedures, or enabled me to scrub in on cases. That may be a little more challenging, since I know I’ll be grasping to do every case that comes my way, now that I’m finally allowed/expected to do more, and as for procedures, I’ll still be gaining confidence at doing them on my own – let alone supervising someone else. Many juniors, who seem to have ice in their veins, taught me how to place lines in coding patients, by standing back and forcing me to try myself, before they would take over. I don’t know if I can be that cool.

 

backwards and forwards

Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster – first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now.

There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs – and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with – hopefully not reverence, but a little respect. And looking ahead, the increasing certainty that the new chiefs don’t feel any  more confident with their role than I do with mine. . . We all perform for each other.

The unit has stopped whirling a little bit, and settled down to more straightforward feverpaced activity. I had my first patient go into a grand mal seizure in front of me – actually the first real seizure I ever witnessed, and she had to go and be in status epilepticus for nearly forever. The seniors were all off elsewhere, in traumas, so I was left rummaging through my memory of the neurology rotation in medical school, and telling the nurses, “Since this patient has been in status for the last 30 minutes, her neurons are seriously burning out now; and we’ve already tried multiple doses of three different medications, so at this point I don’t particularly care what medication that we have to get from the other end of the hospital that the neurosurgeons do in these circumstances, iv valium is the handiest thing we haven’t tried yet, go ahead and push it.” And it actually worked. After we stopped the seizures, then the neurologists, neurosurgeons, and seniors turned up, and of course all looked at me skeptically: “Who’s seizing? I don’t see the patient moving at all.” No, because she’s had high-dose ativan, dilantin, valium, and propofol, she better not be seizing. So I was reduced to imitating the seizure for them, and the EEG confirmed my diagnosis. But I can hardly feel pleased about handling it, because it makes this patient’s prognosis so bad, and the family doesn’t seem to understand yet how bad things are.

I’ve also spent too much time in the last week talking to doctors about their relatives in the unit. Something funny is up, there are so many doctors’ mother/grandfathers/aunts/cousins through here lately. It’s a tricky conversation. You have to show courtesy between professionals, and also deference, since they’re all attendings a long way into private practice, and you’re just an intern. On the other hand, mostly they’ve been in very non-surgical specialties (pediatrics, heme/onc, family medicine), so in all honesty, between their nonsurgical mindset, and how far they are from medical school and internship, I may be (and my attending definitely is) a little more familiar with the management of critically ill trauma patients than they are. I’m still trying to figure out the exact phrases to use for telling them something that they may or may not already know or remember. But they are certainly the most wonderful historians; they can tell you all the medical history, medications, allergies, and surgical history of the family member; it’s like having a walking medical record. And then there’s the concern that if I use a technical term incorrectly, they’ll walk away thinking, “What kind of incompetent residents do they have working here, they can’t even name the fractures correctly?” Mostly, though, it goes ok. Just as I would be in such circumstances, they’re very glad to get some definite information in medicalese – the guild language.

 

lessons learned

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

 

a little backwards

I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.