recognition

It’s kind of touching when patients and their families notice the hours we’re working.

The service I’m on right now is particularly opportune for this, since the attendings start operating so early, and demand such detailed knowledge of the patients by the residents, that the entire team (intern, resident, chief, couple medical students) has usually come through each patient’s room, severally and ensemble, by 6am every day. Which is certainly annoying, but also noticeable.

In the course of the day we’ll round with an attending. Then we all also come through around 5-6pm, as well as the intern multiple times in between. The people who aren’t completely asleep, or completely absorbed in the TV, can’t help noticing that we’re there around the clock. They also notice that the same small group of us is there virtually every day of the week. They’ll comment, after one of us has had a day off, that they’re glad we got to sleep in. (They didn’t, though, because someone else was in just as early. . .)

One patient has run the entire gamut of the service: preop admission to the floor, postop transfer to a monitored floor, and now in the ICU (don’t ask me why the downward progression; we wish we knew). The family has been so polite; asking the right questions, but also not pestering us when we give our best explanation, and admit that there are things we can’t explain. They’ve also been commenting on the amount of time we spend in the hospital. One of them asked me today if I’ll be off for the weekend, and I said no; he was interested and inquisitive, so I told him the 4 days/month rule; which sounds shocking, when you say it out loud to a person with a semi-normal life. We see it in contrast to the old rules (or non-rules) so to us it sounds good; but although I will, rarely, tell patients and families about 80 hours and 4 days, somehow the old rules seem like a secret that belongs inside the clan.

Which is strange, now that I write it down. Because people do expect their medical providers to be available 24/7 (or to have a thoroughly informed colleague covering), and yet on a personal level, they’re surprised by our lives.

At any rate; it’s nice to be thanked, every now and then.

Advertisement

 

still green

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.

 

moving up in the world

When I was a medical student and there was a VIP patient, I and the rest of the medical students were carefully herded away. If it was in surgery, we weren’t allowed in the room, and only caught glimpses of the patient during group rounds. On medicine, I seem to remember the attending and a senior resident rounding on the patient by themselves, without the rest of the team at all.

Now, a VIP patient means I get reminded by several different people (chief/fellow, attending, nursing supervisor) to pay immediate attention when the patient reaches the ER or the floor, and I had better have every detail of their history and current condition memorized for all the people who are going to ask me about it. I won’t get to touch anything sharp in the OR, but I’d better be there to help set everything up.

In my experience so far, doctors and their relatives are the best behaved (once they’ve decided to let go and let someone else handle it; otherwise, troublesome); nurses are impossible to manage, since they quite frequently refuse to do what you tell them to (basic things, like walk and take deep breaths), and want to do all kinds of things you’d rather they didn’t; CEOs and their relatives are fairly well-behaved, just incredibly stressful.

The worst one was a former CT surgeon, with a temper to match, who had open-heart surgery, and then I got to take the drains out afterwards. Predictably, my method didn’t coincide with his method, and I heard about it. . .

 

perspectives

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.

 

bad news

Before we started the third year of medical school, the clinical years, they had us do a workshop on breaking bad news. We had to (individually) tell an actor portraying a young woman that she had melanoma, and then help her deal with the shock of the diagnosis, and get her to understand a bit of the prognosis and the treatment plan. I did pretty badly, as I recall. I blurted out the news baldly, and then sat there, unsure whether to hold her hand, and unable to control the conversation enough to communicate anything else meaningful through her (very fake) tears.

I don’t know if I’m any better at it now, but it’s not for lack of practice. In surgery, there’s a lot of times when people come to see you, somehow not realizing that if they’ve been sent to a surgeon, they’re going to have surgery. Whether it’s in the office, or the ER, or a consult in the hospital, I’ve had a lot of conversations along the lines of: “We now know what the problem is, and you need to have surgery in half an hour/in two hours/tomorrow/next week. The risks of surgery include, but are not limited to, death, serious injury, abscess, wound infection, respiratory failure. Please sign the paper.”

That is of course merely an outline. Depending on how much time we have, I try to spend a little while explaining the diagnosis, and how it leads to surgery, so that it doesn’t seem like we’re recommending this out of the blue – that there is in fact a reason for the commotion. Then I explain what we’ll do during the surgery; depending on how much blood and guts is involved, I may edit this extensively. Then the consent, which always sounds bad inside my head; if somebody asked me to sign a paper accepting all those risks, I don’t think I’d cooperate.

The more of an emergency it is, the sicker the patient usually is, the less likely family members are to be handy, and the more of a rush I’m in. Usually, after calling the attending and the OR, I have half an hour to get the consent signed, have my note written on the chart, get blood drawn for type and cross, a last minute EKG if needed, antibiotics ordered (and call the pharmacy and explain that I mean now, not tomorrow), get the patient transported to pre-op holding, and a quick talk with the anesthesiologists about what we’re planning and what kind of lines might be needed. Plus answering all the other pages I’m going to get in the meantime.

So sometimes, like last weekend, it really does boil down to this (at the top of my lungs, because of course the elderly patients are all hard of hearing, more so under stress): “You have a very serious problem, and if you don’t have surgery you will almost certainly die very soon. You need to have this surgery, right now. But even if we do our best, there’s a very high risk that you will still die, or end up in the ICU, even on a ventilator, for a couple of weeks. Do you understand that? Ok, please sign.” (That was for mesenteric ischemia – dead gut, which had already been sitting around for a while. And then the nurses found the DNR papers, and I had to persuade everybody that since the patient had just insisted that they wanted to have surgery, and wanted everything done, the DNR orders were implicitly revoked, and it was ok to intubate for surgery. Why are DNRs always there when you don’t want them, and never when you need them? Fortunately for all concerned, our preop assessment turned out to be an overestimation of the seriousness of the situation, and the patient spent only one day in the ICU.)

Which is all to say that, as in my medical school days, I’m still trying to figure out how much time to spend commiserating and comforting, and when to move the conversation on to what our plans are. Sometimes it’s easier to have the pressure of the impending OR to set the timetable.

 

motivation

It was an extremely busy day. I did not stop running the whole time, and really the only reason I can think of why nothing bad happened was that the ICU patients had the good sense to keep in order. If one of them had gotten in trouble, the whole juggling act would have fallen apart.

There was an elderly lady with a huge abscess. I mean huge; I could fit my hand in it. I spent fifteen minutes draining it, feeling bad about hurting her, because it was so big I couldn’t possibly numb the whole thing up, so I had to do it with only lidocaine in the area of the incision, and the rest of it was relying on elderly ladies’ well-known capacity for stoicism. It was a really ugly abscess, too. It made me nauseated, and that’s hard to do these days. It smelled so bad I had a headache for the rest of the day, and I could still smell it – it had to have been imagination – after changing my clothes and showering.

Finally, when I’d used up several packs of gauze, plus towels and washcloths, emptying it, packing it, and then cleaning her up afterwards, she reached for my hand. “Thank you so much, honey. People have been telling me for weeks that they can’t do anything to make me feel better; that I’m too old to do anything, or that my heart history is too bad, or my lungs are too bad. You’re the only person who’s actually done something about the problem. God bless you.”

Well, by the time I saw her, it was impossible not to do something, so I can’t take too much credit for the action. But her smile was worth the whole ugly mess.

 

compliance

They told us in medical school that in modern times, patients have much less regard for what the doctor says, and are less likely to follow instructions or be compliant with medications, than fifty years ago.

With that expectation, I’m always amazed when people about to be discharged after surgery inquire scrupulously into what they are “allowed” to eat, drink, walk, climb, carry, etc. Often my first thought is, “How should I know, and why should I be setting you limits on that?” Nevertheless, it seems best to give some instructions when asked. For a doctor to say “I don’t know” is discouraged. And of course there are the common-sense rules like, don’t drive while taking narcotic pain medications (which is also the rule that people will argue about the most, at least while talking to us in the hospital).

So I wonder, when we give specific instructions about diet (one area of discharge orders that surgeons actually do care about, as opposed perhaps to adjusting the precise dosage of blood pressure medications), how much people really follow them. Advice like, don’t eat red meat for a few weeks; don’t eat solid food for the next week; don’t drink fruit juice (high in sugar, low in nutritional value), must be difficult to follow.

They told us in medical school that only 50% of patients will actually take medications in anything resembling the prescribed manner. I wonder whether surgical patients are more likely to follow instructions, since they probably feel sicker than people being treated for diabetes or high blood pressure, and since our medications and prescriptions (antibiotics) only cover a few weeks at most.

 

connection

Some doctors have a great way of interacting with patients. They strike a friendly, humorous (when appropriate) note immediately, and the rest of the proceedings are just like a plain conversation. They can crack jokes that the patients find funny, and always have a wisecrack response to the patient’s jokes. This especially works for the young male residents, who pick up the inner city slang, and can speak that dialect without sounding fake.

I’ve never been like that. I can be professional, calming perhaps; I flatter myself that I’m good at explaining the problem and the potential solutions in understandable terms. But camaraderie and humor are not my suit.

So I was tickled today when I went in to talk to a patient who’d been giving the nurses a bit of a hard time, and suddenly found him laughing as though the two of us had a private joke. “I like your style, doc,” he said. “You and me get along. We understand each other. I like your style.”

I don’t know what I did differently, but it was fun that he was so satisfied. Now when I have to tell him something he won’t like tomorrow, maybe it will go a bit smoother. . .

 

prejudice

A few hours into a busy morning – the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do – I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed.

So my seeing the patient and writing a formal consult was going to contribute absolutely nothing to the patient’s care or to my team’s knowledge of her; but it had to be written.

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise.

She was polite, pleasant, and a very coherent historian (first clue; real seekers try to muddy the waters). She was able to tell me all the studies that had been done, and gave me a timeline of her symptoms and the path to the final diagnosis.

I asked how long she’d been on disability, and all of a sudden she started talking. She’d been injured a few years before, but had kept busy up till last month taking care of her father, whose health had declined precipitously. Last month he died at home.

I didn’t have to say anything at all; she just wanted someone to listen. She told me about her mother’s poor health and inability to care for her husband, about how painful it was to watch her father getting continually worse. She told me about how he joined the army right after Pearl Harbor, flew several bombing missions, and was eventually interned in Switzerland, then came back to get married and start a family.

There was a lot more – his death had hit the family hard, and it sounded like the siblings weren’t relating to each other well now – but I wasn’t looking for holes in the story any more. No slacker takes disability, then works 24/7 caring for a dying parent. Most healthy people don’t do that much.

At the end of that talk, I understand why psychiatrists don’t believe in physical exam. After that much sharing, it’s rather anticlimactic to ask if you can listen to the patient’s lungs.

 

too much practice

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?