luck of the draw

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

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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.

 

loose ends

I have more stories from vascular, but the best ones are so unique, they’re almost worthy of being published case reports, so I don’t want to tell them for a while, for hipaa-type reasons.

In general, I’m going to miss this month. Usually it’s a service the residents love to hate, because it’s so insanely busy, and the patients, though wonderful people, have a propensity to spiral at any moment. You have to have a much higher level of suspicion for all kinds of things, from heart attacks and strokes to UTIs and wound infections.

But I had perhaps the best chief of the year, and one of the best junior residents, and the attendings are great. Most vascular attendings are. There’s something about the field that attracts people who like to dissect a problem with protracted analysis (for ischemic disease in the leg, you can do almost innumerable angioplasties, you can do femoral-femoral bypasses, iliac-femoral bypasses, femoral-popliteal bypasses, femoral-anterior tibial bypasses, femoral posterior tibial bypasses, and all of the above with either harvested vein or one of three different kinds of prosthetic grafts; now let’s discuss which one would be best for this patient), and yet also enjoy intense surgeries which can last all day long and get into serious blood loss and potential for complications. It’s different from general surgery, which I think tends more toward quick, clear-cut solutions (either the bowel is dead or not, so you should operate on it, or not).

Sign-out at the end of the month is time-consuming. Figure 15-20 patients per intern, plus 5-10 consults, all of whom need to be explained in rather more detail than just the nightly sign-out (which, if the person’s been there for a few days, often consists of “post-op day three, eating ok, working on increasing activity and planning for discharge; no impending problems”). At the end of the month, you need to give what surgery was done, why it was done, what the other medical problems are, what you’re doing about them (on vascular, this consists of a lot of afib-coumadin and hypercoagulable disorder-heparin drip arrangements, as well as blood pressure meds and other things), what infections they’ve got and what antibiotics have been gone through so far, how well they’re walking, what their family situation is like and how likely they are to have good help at home when they leave, in addition to who needs surgery in the next few days and who’s at risk for major cardiac or respiratory issues in the near future. Plus, it’s nice to give the next intern a heads-up about which attending wants his notes written by a certain time, which attending hates consulting endocrinology, which attending wishes you would consult all the specialty services and don’t mention medicine to him, which attending does all the fistulas, and all the details that keep you from stepping on the invisible mines. That takes 3-45 minutes, if you’re both being conscientious; and then you still have to go and get signed-out to about your new service. It’s nice when it happens on weekends, there’s more time for talking. Otherwise you find yourself running up against the end of the day, when staying for an hour and a half (total, spread out) could mess up your hours.

And then, I also like to walk around and say goodbye to my patients, especially the ones who’ve been there for more than a day. I don’t know what they think, but I’m under the impression that we have a little bit of a relationship, at least some recognition by them that I work for their surgeon and have been trying to take good care of them, and it’s nice to give them some warning that a stranger will be walking in to wake them up at 5am tomorrow.

 

horns of a dilemma

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

 

unexpected

I went by my mailbox the other day to clean out the usual accumulation of useless fliers and advices from the administration (a new administrator; a new policy; a hospital picnic), and was astonished to find a card in the box.

It was from a woman whose husband’s hand I had sewn up back in March. It wasn’t the most horrible injury I saw that month, but it was certainly sickening to people, like the man and his wife, who hadn’t seen anything like it before. It had taken me some effort to talk him into letting me take my time and do things carefully. Once I got the anesthetic in it hadn’t been that bad. I think the previous ER where he’d been had tried to do a digital nerve block and failed. I got it right (for the first time ever, to my own surprise; but I didn’t tell them that), and then he let me cut and sew as I saw fit.

Anyway, the card was to say that his hand was working well, and the doctors thought the nerve would grow back in time, and it was nearly as good as new. This was not a short card; it was a big hallmark card, filled up with writing. I think I started crying in the hallway. I’ve had people say thanks before, but to take the time and effort to write a whole card and mail it to the hospital – unbelievable.

A few days later I ran into the wife of the man with really the worst injury I saw that month, the one that I could barely stand to look at. (Broken bones turned all wrong-side-out really turn my stomach.) I didn’t recognize her, but she stopped me and started exclaiming about how well it turned out, and how the plastic surgeons in the office had said I’d done the right thing, recognizing how much tissue was viable and should be repaired, and removing what wasn’t salvageable.

I don’t know what to say about any of this. I’m disturbingly surprised to hear that my hand surgeries turned out well, and touched by the patients’ gratitude. Getting this feedback is even more satisfying than simply looking at the hand when I was done and thinking I had done well. This is what it must feel like for the attendings in their offices, to have people come back and say that they’re better and the surgery helped them. This could be fun to keep doing.

 

advice for patients

Since I’m handing out advice right and left (I think I’ve run out of intern advice, though; maybe next year I’ll have some things to say about annoying interns, of whom I’m sure I’ve been one), maybe I’ll throw out some for patients.

Although really these are more anecdotes about my favorite patients. Out of the whole year, I think my favorite, and best memory, is this one old gentleman who learned my name pat the first time I introduced myself. After that, every time I walked into the room (usually at 5am), his eyes would literally light up. “Dr. Alice! Thank you for coming! It’s so good to see you!” I was almost embarassed to be there, because here I was waking him up, and I hadn’t done a blessed thing for him yet, and he was so happy about it. Actually, I think it started because one of the first days I came to see him, his wound dressing had gotten all disarranged, and he was worrying that when the nurse finally came to change it, it would hurt a lot. I needed to see the wound for myself, so I just changed it quickly and fairly painlessly. Since then, although he kept coming back in with complications, he was always so cheerful and grateful that everyone loved talking to him.

Then there was another lady, who had what you might call a chronic hospital course. She’d stay for a few weeks, go home, come back in less time than it took her to leave, and stay a while longer. When I got signout about her, changing services, I got the phrase “pain issues,” which usually indicates a drug seeker that people have gotten tired of dealing with. For the first couple of days, that seemed to be all there was to it. She had had a lot of surgeries, which resulted in a lot of pain. She’d spent enough time in the hospital to be fairly tolerant to narcotics. But then I started to realize that if I came to talk to her at the times when she wasn’t in as much pain, she was a very nice lady. She wasn’t defeated by all that had happened to her. She worked hard with the physical therapists, and could be often found up moving around by herself. Finally, I realized that she had the same goals we did: despite her complaints of pain, more than anything else she wanted to move away from iv narcotics, and get out of the hospital and back to being independent. At that point it became easy, and she and I worked together as a team to wean down the doses.

Basically, don’t make the doctors and nurses afraid to come in your room. The people who smile when they can, say thank you every now and then, and speak politely, will have nurses come quickly when they call for help, and doctors who come to check on them frequently, and are willing to spend a while discussing plans and alternatives; whereas the patients who make it unpleasant to come into their room will get much more grudging service all around. Unfortunate, and despicably human on our part, but there it is. A little politeness will go a long way towards making your hospital stay smoother and a little more pleasant.

 

two months left

I am now on the vascular service, which is probably the busiest surgical service in this hospital (as at most). There are enough attendings operating that I will probably get a few cases a week – of course, the ones no one else wants: ablation of varicose veins, amputations, simple angiography.

This service also tends to pick up a lot of pointless consults: our favorites are femoral pseudoaneurysms as a complication of cardiac catheterization (which a priori means that if the patient eventually requires surgery, they’re going to be a very poor cardiac risk), and generally whenever anyone is bleeding. Somehow, to the ER and ICU doctors, bleeding means vascular surgery should be able to help. Sometimes it’s interesting; most of the time, our advice is to hold pressure for a lot longer.

Anyway, after a few days’ worth of consults like this, I’ve learned not to be concerned about blood in reasonable quantities. I spent an hour holding pressure on one of our patients and practicing my calm, this-is-perfectly-normal voice. He was very pleasant, and not disposed to panic anyway; and I think my smoothing voice is getting better. Next time I’ll just remember to take my white coat off before getting close to arterial puncture sites. We got to talk about books, politics (noncomittally; I do know better than to start firecracker conversations with people whom I have to sit with for an hour to keep them from bleeding to death), and crafts.

The bad thing about this service is that they regularly have patients admitted in the evening for hydration prior to angiography/procedures the next day. Somehow, these patients always come right at signout, so we usually leave an hour or two later on this service than on others. Ah well, that’s how it goes.

 

educational experiences

Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned something else to try very hard not to do; of which I already had a long list.

I’m still not happy with my moral position during conversations which I disapprove of. But at least I resolved, again, to try very hard not to say anything I wouldn’t say if the subject of the conversation were in the room. Maybe I can’t help what other people say; but I don’t want to contribute.

I really love this type of patient conversation:
Me: “. . . So basically everything that brought you in to the hospital has been corrected, and you are ready to go home, although you do need to continue taking these medications.”
Patient: “Great, I feel fine, I was ready to get out of here yesterday. Let’s go.”
Spouse (with the most suspicious tone of voice you can imagine): “You’re not kicking him out of here again, are you? I’m sure he was deathly ill with this xyz the last time you discharged him, because he was sick immediately [although we didn’t come back to the hospital or talk to any office staff for a month].”
Me: “Ma’am, I understand your concern, but I assure you that there were no signs of this problem the last time he was discharged. And anyway, right now [laundry list of tests] have all been completed, and show that the problem is completely under control. The best thing is for him to get back home and on the road to recovery, and you just let us know immediately if anything concerning comes up.”
Spouse: “They should have listened to me the last time. . .”

Which is such a horrible note to close on if, as there’s a decent chance given his underlying disease, the poor fellow gets sick again and has to come back. But right now he’s fine, and he wants to go home, and I want him to go home, so please, try and give some credence to the long list of negative test results. Some people do seem to feel better after you explain it all in detail; but this lady had our negligence firmly in her head, and she wasn’t listening to reason. Ah well. I’m sure we can resume the discussion at the next admission.

 

observing

The other day I got to watch the chief doing a laparoscopic cholecystectomy (gallbladder removal). For him it was easy. He only took the case because going in we were concerned about a lof of inflammation and scarring, which turned out not to be there.

As a student, when I watched laparoscopic cases, there was a fair amount of boredom involved. On one hand, I could see everything much more clearly than during an open case, when only the two people directly operating can actually see what’s happening, and not always easily even then. On the other hand, I have a strong propensity for falling asleep whenever the ambient lighting falls below a certain level; even holding the camera didn’t always keep me from drifting off.

Now that I’ve done a [very] few lap choles myself, it’s another story. I was very interested to watch the chief’s every step: how smoothly he peeled the gallbladder off the liver, and swept away the adhesions, how precisely he dissected down to the cystic duct and artery. No wasted steps, no fumbling – every move went exactly where he intended and moved the procedure forwards.

————

One of my patients last week was just about perfect: young enough to recover very quickly, with a disease that absolutely warranted surgery, but shouldn’t affect her much once she’s gotten over the surgery. Her family was supportive, practically living in the hospital, attentive, but not smothering. She herself asked intelligent questions, exactly the things she needs to know and ought to be concerned about, but not too many silly questions or impossible ones – and she seemed to understand the answers. We don’t often meet such ideal patients. Everything went smoothly in the hospital for her, and with as wonderful a family and an attitude as she has, I expect she’ll do very well at home, too.

 

hospital gunman

Ok, this is scary. We actually had a workplace shooting incident turn up at our trauma center lately. I comforted myself with the idea that people come to the hospital after such incidents. Remind me to check and see if our security guys have guns. I think they do.