I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)


My plan for the last night of March was to keep things quiet, get some sleep, and study up for a laparoscopic procedure that I had been semi-promised on my new service the next day. Semi-promised, as in, “X procedure. . . you do know how to do that, right? [alarmed] Have you ever done one of those?” Me: “Oh yes, sure – at least, I did one.” So every time the junior residents saw me, they egged me on to make sure I did the case, and every time the chiefs saw me, they expressed skepticism over the wisdom of the plan, coming off of nights, a complicated patient, and so on, and reassured me that one of them could do it if I couldn’t. Needless to say, after a very few of these conversations, I was quite determined to do the case no matter how tired I was. After all, in three years, as a chief, I’ll need to be able to operate after being up 24 hours or more, not to mention what is likely to happen in private practice. (That’s how I persuaded myself I wasn’t needlessly endangering the patient.)

Of course, the night wasn’t quiet. I had shared responsibility for one patient, and individual responsibility for another patient, who both crashed and went emergently to the OR at the same time. My particular patient was bleeding dramatically – the kind where you transfuse massive amounts of blood, and the hemoglobin comes back lower than when you started; and when you open in the OR, the floor gets covered with blood. I did my best to do hands-in-the-pockets, and thanks partly to that, and to the fact that it was actually a straightforward case – the only thing to do was give blood and go back to the OR – and to the attending turning up quickly when called, the patient did just fine. But even after the OR, I still had to spend a lot of time in the patient’s room, talking with the nurse, doublechecking orders and labs. So I slept for maybe an hour altogether, and had no time to study for the case.

Fortunately, after four hours of mandatory lecture, the case was delayed for a little while, so I had a chance to go read. It was good I did, because the way I had assumed the procedure should be done was incorrect, and there was a fair amount of background material which I ought to know, and which it made me feel much more confident to face the attending, having read. The case went fairly well; as in, it took twice as long as it ought to have, and there was a slightly larger blood loss than usual (usual being 20cc, that’s ok). It was complicated, for me, by the presence of a new medical student. She did her absolute best to keep the camera in focus and to follow my movements; but the result was that it bounced worse than any other med student I’ve seen this year; and when I already felt a little unsteady on my feet, and was trying to do the most delicate maneuvers I’ve tried yet, laparoscopically – it was all I could do not to snap at her. But as in the parable of the unforgiving debtor, what could I say, when the attending was silently putting up with my infuriating slowness and blundering?

Finally, I had to leave late in the evening, signing out a rather unstable patient to the new night float. The intern on this month is one of the program’s characters. He’s ten times as competent as I am, and I completely trust him to take care of my patients. The trick is that his good care will be quite unorthodox, and I’m sure I’ll be in for some surprises when I get back in the morning and see what his management has been overnight. And then I’ll have to explain to my chief and attendings, who will somehow hold me responsible for all events. Ah well. Have to let go sometimes.

Time to go read a little bit; we’ve been warned of pimping sure to occur tomorrow, and having been warned, it would be unforgiveable to be unprepared.

Business was steady last night. I somehow managed to always have two or three patients still needing to be seen, no matter how diligently I worked on my list. But it was fair, because the night before I was quite bored.

I was always impressed, as a child, by my father’s memory for phone numbers. Any doctor he wanted, any nurses’ station in the hospital, he could dial from memory without hesitation. I couldn’t understand how he did it. He can pick up his cell phone, look at the number, and address the caller by name before they say anything.

It was force of repetition, of course. Get paged to a certain number ten times in one night, and you’ll know where it is. Similarly, have a nurses’ station that you need to call and check on five or six times in a night, and you’ll get tired of calling the operator to ask what the extension is. I know the recovery room phones, all the OR phones, two or three phones at all the nursing stations for surgical units and the ICUs, the lab number, the CT number, most of the ER numbers, and some charge nurses’ numbers.

And then of course, there are the numbers to which I get paged infrequently enough that all the recognition I have of them is a sense of impending doom: I can’t remember who answered the last time I called this number, but it didn’t lead to anything happy. Those tend to be the ICU numbers, or else ER numbers that I don’t recognize yet, or else an area of the hospital that really shouldn’t need to talk to me, so if they do there’s something wrong.

Plus, there are the pager numbers and cell phone numbers for the other residents. Once you work with someone for a couple days, it gets tiresome to ask the operator to page them, and you learn the numbers by heart, and how to code your message to say that it’s you calling, and whether it’s urgent or not. (Our hospital has not progressed to the sophistication of letting the residents send their own text pages. We communicate, Morse style, by dots and dashes.)

I’m not quite up to my father’s level, though. He also practices pure telepathy: on phones with no caller ID, he can pick up the phone and know who’s calling before they say anything. I think it has to do with knowing how the patient flow is going, and who’s going to have a problem next, or perhaps whom he really would rather not hear from and therefore must be calling; but there has to be some telepathy, in addition.

Due to some convolution of hospital politics (of which no one has really informed me; I deduce its occurrence by the effects on me), I find myself covering yet another service, about which I know even less than some others. Talk about sink or swim. Fortunately none of the patients I’ve handled like this have been truly sick yet, although they always come billed as something quite frightening, and it takes a little investigation to assure myself that they’re actually stable. Also the attendings are still new enough at having resident coverage at night that they actually appreciate my calls – unlike some other attendings, who now take us for granted and regard my calls as a nuisance.

At one point tonight I found myself wandering into the ICU to check on one of my few patients there; I didn’t really want to check on them (since the simple act of a doctor looking at an ICU patient tends to remind everyone of previously ignored issues that need to be addressed now), but somehow I felt like I had to. And there around the corner was another patient crashing. So I got to watch the senior resident taking care of him, for quite a while, which was instructive. I think a major part of his technique consists of putting his hands in his pockets; it’s hard to get too agitated in that posture. I need to practice that.

Lately I’ve started shadowing the senior residents as intensely as, a year ago, I watched the interns. I can remember making quite a nuisance of myself back then. I know this, because the medical students now are nuisances: very eager and enthusiastic and anxious to learn – but only the fact that you can never again leave the hospital early makes one realize how special it was to be a student who could be sent home, or to bed, away from the boring routine chores. So I don’t really mind the students being there, but somehow the fact that they could be free makes me mind having to do the chores even more.

And now I’m hanging around the senior resident at night, asking intrusive questions like, who did you call? why did you call them? what are the rules for calling people at night? why did you do that? why did you pick that medicine? because I’ve only got three months left of being a carefree intern (used to think that was an oxymoron). So far he’s being very nice about it, explaining what he’s doing; I think because he knows quite well how terrifying it will be to pick up those responsibilities in July. It’s good for me to watch his style, because I think up to this point I tend to imitate Brad a lot; and he is way too much of a cowboy. He has the experience to pull it off; but I don’t, and it will be good for me to imitate a resident with a little more restrained manner.

Which brings up another point: now that I’m a little more comfortable with taking care of patients, and then calling somebody who’s outside of the hospital to tell them what happened and ask for further advice, I’m able to feel guilty for waking people up. They, after all, have to come to work the next day. It makes me feel really bad to wake up people I like, and hear them struggling to pay attention and think about the question. That’s also not going to be fun next year, having to call the same person several times a night, especially knowing that they’ve been up in the hospital the last couple nights.

I have two pet peeves about nursing reports. Not peeves, really, that’s too strong, but things I can’t understand.

Number one, respiratory rate. When you ask for the vital signs, the nurses and aides always tell you respiratory rate. Which is good, because that’s what they were told to do. But it doesn’t really matter. First, in the hospital, respiratory rate is always reported as either 18 or 20, depending on what the nurse’s aide’s favorite number was for that shift. No one stands for one minutes and counts the patient’s respirations, and if they did it would be a tremendous waste of time. Secondly, the normal respiratory rate ought to be more like 12 or 14, or maybe 16 (and yes, it has to be an even number, otherwise there’s some serious pathology going on); so if someone actually had a rate of 20, you would want to think about it. Finally, it doesn’t really matter. If the patient is breathing comfortably, you could tell me they had a rate of 40 and I wouldn’t care (ok, maybe just a little); on the other hand, if they seem to be in distress, struggling for air, unable to catch a breath, I’m not going to wait till we count the number of breaths before trying to do something about it. We try to explain this to the medical students; it’s difficult for them to break past the litany of vital signs they were taught only a year or two ago.

(Caveat: respiratory rate can be of value when you’re considering weaning someone off the ventilator. Intensivists vary on this subject. My favorite ICU attending extubates purely on gestalt. He certainly gets it done faster than the guys who calculate NIF (no relation to the Knights) and check multiple abgs on different settings.)

Number two, bowel sounds. After [relatively] minor procedures, we often write orders for “clear diet, advance as tolerated.” To the surgical mind, this implies that if the patient can drink a glass of water, they should try apple juice. If they can drink that, they should have crackers and/or jello. And if that’s ok, for goodness’ sake please give them a regular meal tray at the next mealtime, so we can discharge them to home. This could all happen within the space of a few hours.

To the nurses, however, “diet as tolerated” seems to mean something else entirely. If you’re too busy to pay attention, it could just mean “clear diet for the next several meals until the doctor notices and specifically changes the order.” Or, and this is what really gets me, it could mean “patient is tolerating diet if they’re not throwing up, and if you hear appropriate bowel sounds.” (No one has ever explained to me what counts as appropriate; maybe in all four quadrants.) So the patient could be feeling just fine, ready to eat whatever you’d let them, but if the nurse doesn’t like the bowel sounds, they won’t feed the patient. Sometimes, way over the line, I could specifically order a regular diet, and the nurse could still decide to hold it, because of these nebulous “bowel sounds.”

For the nonmedical reader, bowel sounds are just the noise of fluid moving inside you; sometimes, you can hear it with the unaided ear. This is frowned upon in polite society. Medical people listen with a stethoscope. Now I admit that in some cases bowel sounds are significant: if there are none whatsoever, and the patient has a fever and is complaining of excruciating abdominal pain, that is consistent with peritonitis. But you don’t really need the absence of bowel sounds to make the diagnosis. There is also, according to legend, a particular “high pitched tinkling” that should be heard with bowel obstruction. I thought I heard it once, and said so, which the seniors seemed to regard as one of the most hilarious faux pas I’ve made all year. I still listen, for the same non-reason that I listen to people’s lungs before sewing up their hand injuries, but I don’t talk about what I hear anymore.

Note to nurses: I admire the thoroughness and regularity of your nursing assessment. You often catch important details and bring them to our attention. Bowel sounds, however, are not important. Please feed my patients.

I’m still learning from Brad, the senior resident I worked with on night float last fall.

I am a very shy person. When I was 13, nearly as tall as my mother, and still hiding behind her whenever we went out in public, she decided that was enough, and took us children to a homeschool speech and debate league. I got very good at it, and had great fun. But what I learned was how to be comfortable speaking – in public, to a set audience, for a limited amount of time, and with a great deal of previous preparation (although I did impromptu well, too).

But how to speak to people on average – on the street, in the hall, in the cafeteria, at the store – I still don’t like that. Ask my med school classmates. I think there were some of them, in a relatively small class, that I never spoke to for four years, and only about ten that I talked to on a regular basis. I hate going to fast-food places, or restaurants in general, because you have to talk to people there. (At least that saves money.)

For the first few months this year, I was still trying not to talk to people at the hospital. At least, I had to address them, but I tried to keep them at arms-length, to use my white coat as a shield, or a substitute for actually getting to know people.

Brad changed that, not by anything he said to me, but by the way he interacted with everyone else in the hospital. I think he knows the name of every single janitor, every transport tech, every medic in the ER, and certainly every nurse on the floors or in the ICU. He also chats with the phone operators and the CT and x-ray techs. We used to be walking through the halls at night, and random people we met would stop to discuss – their marriage, their mother’s health, their children’s education, their career ambitions, anything – with Brad. He doesn’t just know names, he knows individuals, in detail. So when he needs anything done, he doesn’t have to stand on authority to get it. He talks to his friends, tells them what he needs, makes them feel important by explaining how sick the patient is and how important it is that this get done – and then they do it for him.

So I try to use his style. I’ll never be as flamboyant and cocky as he is; but I introduce myself by my first name to every new nurse I meet whom I need something from. I try to ask about people’s children, their hours, what they do when they go home, what their favorite TV shows are. I’ve learned the secret phone numbers for the CT scanners and the radiologists, and the names of the ER techs and secretaries. I know that writing a stat order is not nearly as effective as writing it, and then immediately calling the person who needs to do it, to explain why I want it, and that I really mean now.

Hopefully after a few more years like this, it’ll be ok to be shy, because there won’t be any more strangers in the hospital.

I knew I was going to get in trouble. It involved a line that I couldn’t get in, and had to be fished out of by the chief. Ignominiously. It was the one line I’ve never yet succeeded in placing (radial arterial line, if you have to know), and a semi-unstable patient, and a medical ICU, whose nurses were more interested in standard operating procedure and paperwork than in taking care of the patient. The fact that the chief proceeded to explain to me loudly how and why he dislikes the MICU nursing staff didn’t really make things go any smoother.

(Here’s one example of why the surgeons here mistrust the MICU: There is a code called in the MICU every one to two days. There is a code called in the surgery ICU once a month, if that. Maybe the patients in the MICU have worse medical conditions, I don’t know. But maybe the SICU nurses do a better job of recognizing when their patients are going down, and then organizing the necessary resources early, rather than waiting till the patient actually arrests before calling for help. It would be good to study someday the relative comorbidities of the two populations.)

All the pages I didn’t get for the last week finally caught up with me. I spent a lot of the time on the phone having this kind of conversation:
Nurse: “You know Mrs. Smith, in room 324?”
Me: “What kind of surgery did she have done? Who was the surgeon?” [flipping wildly through my stack of lists, which somehow all turn upside down every time I put them down]
Nurse: “She had x procedure, and her blood pressure is now 85/40; her heart rate is 95, and her urine output is marginal.”
Me: “Um, any idea at all about her cardiac history? You don’t know. Have you been giving her any beta blockers? Just an ACE inhibitor. Is she having trouble breathing? What room did you say were in, again?”

And then I run over there as soon as I can, and spend a few minutes flipping through the chart (this is why H&Ps are important, why do the day people never see fit to remark on the cardiac status of the patient? can I afford to give her a liter of fluid, or would 250cc only be more prudent? is it time to send repeat labs, or not yet? somebody ought to write the pre-op hemoglobin down somewhere) Then, once I’m in the room, the patient is lying calmly in bed, rubbing her eyes upon being awoken, almost always more disturbed by my sudden entrance and concerning questions (“Any chest pain? Any difficulty breathing? Have you ever had a heart attack or heart surgery? Do you smoke?”) than by any previous symptoms.

Late in the night, I got called by an ER resident. “Would you come see Mr. Jones? His CT scan is done.”
Me: “Yes, but what did it show? Why are you calling me?”
ER: “The last guy signed out to me that you knew about him.”
Me: “I knew about him, as in, he exists, and he’s in the ER. All I did was tell your colleague not to call my attending directly, and certainly not to call him before the CT scan was done. What do you need surgery for, now?”
ER: “No fair. He told me, Call Alice, she’s nice, she’ll take care of this guy. Your attending’s name is in the records; come see him.”

Which is why you see it doesn’t pay to be nice to the ER. I had been down there earlier, being friendly, commiserating about how the ER was getting snowed, and in the middle of the week, joking about who needed to admit which patients, helping out with the discharge paperwork on the other consults I was seeing. I made friends with a lot of the ER interns during orientation and ATLS, and we’re still mostly on speaking terms. But you see what it gets me: dump this patient on Alice, she’s nice. And I know my senior will kill me for inviting consults like that; the rest of the surgery residents talk about “putting up a wall,” blocking ER admissions, turing every non-urgent surgical issue into a hospitalist admission. It’s not polite or collegial, but in the middle of the night, when you’re struggling with necessary admissions and ICU issues, having the ER think twice about calling you might be good.

Of course, because it was my bad night, it turned out that when I mentioned the patient’s existence to my senior (while the ER guy was still trying to think of exactly what surgical thing he wanted us to do, before calling me back), he was forced to admit that this particular attending would want him admitted, no matter that his problem was medical in nature and he didn’t need surgery any time in the foreseeable future. So I’m “nice,” and when I try to fight back, I pick the wrong patient to argue about. Tsk. No luck. (I’m such a pushover that the senior ER residents have taken to calling me before they have any lab or CT results; that, I really am not going to accept any more.)

It’s not so much a problem now, because I can always fall back on, “The senior resident won’t accept this.” But next year, when I’m responsible, if I let them give me too many silly admissions and consults, the chiefs and attendings whom I’ll have to call at night will really not appreciate my “weakness.” I like being able to joke around with the ER people; but if it’s going to get me so much grief from my own program, I’ll have to adjust the relationship.

I ought to add that this relates to the quality of patient care, as well. One of the main reasons the ER residents think I’m easy is because, if I agree that the patient needs to be in the hospital, I tend to find it simpler to just admit them immediately to the surgical service in question, rather than making them sit in the ER for hours while we argue back and forth – surgery, ER, hospitalist, medicine specialty – about who exactly needs to take the patient. Sometimes the patient is better served by being gotten up to a bed quickly. On the other hand, it’s probably even better for them to be on the correct service. After all, though I maintain that we can provide good care for patients with medical problems, that care will be as old as our med school diploma. We don’t read the recent medical literature; the surgical literature is quite enough for us. There may be a few cutting edge variations, or abstruse specialty tests, that we’ll miss. Moreover, I think most surgeons have an element of ADD in their personality. If we can’t play with it (cut it, sew it, poke needles in it), we lose interest pretty quickly. We’ll be polite and conscientious about it, but a patient who hasn’t had, doesn’t need, and won’t have surgery during this admission is very boring to a surgical service. The patient will simply get more thought and attention on a service which specializes in thinking rather than cutting (to adopt the stereotypes).

« Previous PageNext Page »