Hurricane Jill

You might be a surgery intern

If…

you wake up at 6am on your day off, and you panic for a minute before you realize you’re not late for work

you automatically estimate your fluid losses from vomiting/diarrhea/blowing your nose when you’re ill

you ask “what did it look like?” when someone else does any of the above

when you see a skinny person, your main thought is how easy it would be to put a central line in them

you’ve forgotten how to sew with a straight needle and just your hands

when the cashier at Walgreen’s complains about working eight 10-hour shifts in a row, you realize that’s how much time you’ve spent off work over the last eight days…

… and you think your job would be much easier if you didn’t have to go home for those 10 hours

you see a wreck on the way to work, and you wonder if any of the people involved are going to need chest tubes

you hope one of them does

you check the local TV news in the morning to see if any really sick patients came in overnight

at home, you use a scalpel as your exacto knife

you also have all the equipment you need to perform most minor procedures

you don’t care anymore what people think about your support hose

you’ve developed such a thick skin that people don’t even bother insulting you anymore

you tie your trash bags with a one handed surgical knot, not to show off, but because it’s automatic.

And finally,

If your little black book is full of medical record numbers instead of phone numbers, and not really very many of those, even, you might be a surgery intern.

Resident Awards

I’ve been on both ends of the whole awards nonsense, and I have to say, giving them is much more fun than getting them. Very rarely do I think, “Damn straight, I deserved this award!” Usually it’s more like, “I deserved this award 3 banquets ago, now I don’t care.”

Or else, “WTF? Are you people smoking crack?”

It’s much more fun to give an award to someone who worked their butt off when they thought no one was looking, or who does so in a manner that avoids calling attention to themselves. So here are my awards for the year:

Best rotation signout: JG – always hilarious!
Most fun to be on a rotation with:
PGY1 – CO and AH
PGY2 – DF and KM
PGY3 – NM and EG
PGY4 – 6/8ths of them
PGY5 – PC and MG
PGY6 – EP and NN (second-hand crack, I swear!)
Hardest act to follow: AM, CO, ML
Best intern: KR
Tries hardest: MW

In general, it’s a program full of good people. But it truly mystifies me how the powers that be seem to gush over people whom I think are crappy surgeons and unpleasant on a personal level, and disapprove of people whom I think are excellent on both counts. Really, is there any clearer indication that this program was a poor fit?

As for me, I finished my work for this last rotation a mere hour ago. Needless to say, I missed the intern party last night. And yesterday evening, I very nearly told one of the new chiefs where he could stick his insistence that I cut short my signout to the new intern to tell him about a stable patient in the ER, about whom I had already spoken to the day chief, whom he could easily have gotten the information from instead. The only reason I didn’t tell him off was because I had, in fact, ignored his page until I was done signing out. Although I did try to call him several times, and got a busy signal. Not that I knew who it was that was paging me. I actually figured it was one of our myriad medicine consultants, who have a habit of leaving call-back numbers that don’t actually work. But he acted like I ought to have known it was him, jumped to attention, hung up on the intern and called him immediately.

Mind you, this is the same guy who I had paged one Friday afternoon after a long and busy day as the only resident in clinic (he had ditched clinic to go to the OR) to let him know I was leaving, and to call me if there was anything else to do before heading out, who called me back 45 minutes later when I was in my car driving home, made me come back, change into scrubs and hang out in the OR until all the cases were done for the day. To be fair, I never told him that I was already driving home. But come on, if someone sends you a page like that, and you wait 45 minutes before calling back, you can reasonably expect them to be long gone. Fortunately, I got to do the next case, otherwise I’d have been sitting there plotting some sort of untraceable revenge.

Unfortunately, that’s one of the hazards of the heirarchy: sometimes you have to work for people who like to yank your chain, just because they can. Now, if he had said, “hey, I need you here to scrub on this next case, because I have something else I have to do,” that would have been a whole different story. I’d have felt no resentment at all over turning around and coming back. But this whole “because I said so” business lost what little legitimacy it ever had shortly after kindergarten.

So this last day on the service was even crazier than the day before. Not only did the consult list keep on growing, but then around noon I get this call from the Thoracic attending, asking me to cover his clinic that afternoon because he had to go to the VA for an emergent operation. Our chief resident had meetings with faculty all afternoon, and my fellow intern had OR cases all day. He gave me a brief rundown on each patient, and said to page him if I had any questions.

So, yay! I got to be intern, chief and attending yesterday. And I have to admit, clinic is much less painful when it’s your own.

But it’s a good thing I didn’t have to leave by 8 o’clock yesterday evening, because I wasn’t even close to being done. And then I got kicked out of the computer system while I still had 10 dictations and 45 notes to finish. It was awesome. I debated whether just to throw my hands in the air and let the system pay for its own mistake, or to ask for extended access so I could finish the work. I did the latter, for the same reason I dictate such complete notes in the first place: I refuse to let some stupid insurance company shortchange my attendings’ reimbursement over something so utterly unrelated to the quality of care they provide. Although all reimbursement goes to the program as a whole, since my attendings are on salary, and it would have been the program’s just deserts not to get paid.

So for future reference, it’s a really bad idea to screw someone over, and then make them responsible for so much documentation in the last few days that they’re there. And then to cut them off on the last day as though you can’t wait for them to be gone. Yep, that’s a class act all around.

But the poor intern coming on service seemed a bit overwhelmed, and I knew he’d be the one stuck with the work. After all, I personally had had upwards of 15 or so missing discharge summaries dumped on me by the prior intern class, and I remember well how much that sucked.

In any event, I’ve done all I can do. Now it’s time to get some sleep, and start looking for a job bright and early Thursday morning.

Stay on target. Stay on target.

Holy crap, everyone and their dog decided to consult vascular and thoracic surgery today. I should just do like my fellow intern does, and send everyone back to the ICU. It would make my life so much easier.

People can say what they want, but eventually the outcome data speaks for itself. And I take some pride in the fact that my patients rarely have setbacks that severe. Even if it makes my life as an intern miserable.

You know, I’ve read Catch-22. Or, at least, it took a few chapters to get boring and predictable. And I sometimes wonder if I’m the crazy person for caring about my outcomes, instead of being solely concerned with lightening my load at any cost. I don’t know.

Nonetheless, the list was ridiculous today. For every person we managed to get off it, we got at least one more added on. It’s insane to have one intern running this service. Particularly one who knew nothing at all about vascular disease just 8 weeks ago.

Anyway, enough venting. I still have work to do this evening.

Last call

Done with my last call night as an intern. It was a good day, although very busy. It’s hard to be the intern and the senior on the service all at once.

Normally, after we finish rounds, I get started on my scut work for the day while the chief calls all the attendings and goes to the OR. He then calls me with updates on the patient plans and I write the notes and make it all happen. Then we regroup in the evening after I sign out to night float. With our census the way it is this week, it’s hard enough to finish my work when I’m just being the intern.

But yesterday I had to play all those roles. I rounded, talked to the attendings, went to the OR, wrote notes, wrote orders, spoke to consults, booked OR cases, pulled the chest tubes, checked the EKGs, updated the patient list. The whole nine yards. AND I was night float.

Craziness.

Before this rotation, the thing I dreaded most about becoming a senior resident was having to phone round with attendings, or call them directly to discuss patients. As an intern, there’s always that buffer between you and the attending, and the only time you ever present directly to them is in clinic. I had heard some horror stories about chiefs being grilled on intern-level details, and it didn’t escape my attention that the same chiefs who led our rounds so coolly and confidently were much less at ease on their phone rounds afterward with the attending.

But on this service, the intern rounds alone on Saturdays, and calls the attendings directly.

So my first call weekend, I sat there for a good ten minutes thinking, “crap, can’t I just poke my eye out with a sharp stick, instead?” But I made the call anyway, and for the entire phone call I had this awful sensation that I was walking on quicksand, and that any minute it might give way and I would sink irretrievably into the quagmire. But it must have been OK, because since then no one on the service has been treating me like I’m incompetent.

This weekend it was much easier. In part because of some advice from my chief. He said, “Of course they want to know how the patients are doing, but what they really want to know is whether anyone is sick enough that they might have to come in that day and operate.” And I thought, aha! That’s the secret. If I address that issue first, and then present the key supporting data as I talk about each patient and my plan for them, that should make for an appropriately detailed presentation.

Those are the kinds of things that make someone a good chief.

One track mind

Well, I’m one week away from the end of internship. Still jobless on June 25th. And everytime the subject comes up, people say “oh, I’m sure something will turn up.” WTF? It doesn’t work like that, and the people saying so should know better. It’s all I can do not to flip out every time I think about it, which is at least every ten minutes or so.

Seriously, I can relate any patient issue to the fact that I don’t have a job next year in 5 steps or less. And you can cut that to two steps, if the patient also has a neurologic injury.

For example:
Pt FiO2 requirements decreasing-> has been on a ventilator-> due to chest wall disruption-> it was work-related injury-> I don’t have a job next year

Pt has pneumomediastinum-> also has subarachnoid hemorrhage -> being followed by neurosurgery-> still looking for a neurosurgery job next year

Pt beginning to autodiurese after vascular surgery-> had a big aortic aneurysm-> worried about post-operative MI-> I may have a post-surgery-internship MI if I don’t find a job

Pt’s BAL growing streptococci-> current antibiotic regimen doesn’t cover strep-> surely the ICU pharmacist will pick up on that and get the ICU resident to change it if he hasn’t done so already-> crap, I’ll have to renew my pharmacist license if I can’t find a PGY2 spot

And so on, throughout the day.

In case you’re wondering, I don’t feel like any more of a doctor today than I did at the beginning of internship. I’m less hesitant to use the title if it will cut through any bureaucratic nonsense for my patients. And when people make reference to “the surgeon” I’ve stopped looking around to see who they’re talking about. But it still feels weird to be called Dr. by any of the hospital staff.

There’s a huge amount of anatomical knowledge that I need to dust off and review. It wasn’t critical to know as an intern. Frankly, when I started intern year, it felt like I had learned nothing useful in medical school at all. But now I’m getting questions about things that I know I knew at one time, and can’t remember. So at least it’s in my brain somewhere, which is a little more reassuring than the constant sense of “how the hell was I supposed to know that?” that’s characterized most of this last year.

And it’s gotten easier to think about patients by systems. I couldn’t even grasp the concept at the beginning of the year, and by the middle of the year I understood what was meant but still couldn’t do it. Sometime in the spring I started forcing myself to do it with every patient, every morning before rounds. And now I can sometimes do it on the fly.

Now, when I get sign out of an ICU patient from off service and visiting ICU residents, if they haven’t done it by systems (which they usually haven’t), I write it down that way, and when they finish I’ll go back and ask, “so neurologically, what does he get for pain? Any other neurologic issues? Is he on oxygen? How much? Any rib fractures, chest tubes, pulmonary toilet? How about cardiovascular issues? How have his blood pressures been running? Any history of hypertension, heart failure? What’s his current diet? Any drains or NG tubes? etc.” It feels a little mean-spirited, but then there’s always a lot of “oh yeah, he has xyz that we’re doing yada yada yada for and you’ll need to follow up on this, that and the other,” that would have been a complete and unpleasant surprise, so I don’t feel too bad about it. But I can feel the culture shock on the other end of the line. And believe me, I can sympathize.

I can’t explain it, but sometime in the last few months the job has become markedly easier. Things make sense to me now that were too complicated to grasp earlier in the year. I usually know what to do, and when I don’t, I know what to do about that. And, critically, I know what decisions I’m allowed to make, and what I need to run by someone senior no matter how sure I am of what’s going on.

But I still don’t have a job next year.

Defensive Doctoring

Wow, this is such an exhausting service. The attendings on this service are pretty uniformly good people and excellent teachers, and the chief is my favorite resident from his year (which is saying a lot, because they’re all pretty great to work with). So it’s a fabulous service to end the year on, from that perspective. But the load we carry is almost crushing.

These patients are as sick as any medicine patient you’ll encounter. Between their heart failure and their renal insufficiency, their diabetes and their COPD, most of them are teetering on the edge of decompensation. And then we deliver another huge insult to their bodies by operating on them. There’s no doubt in my mind that the benefits outweigh the risks, but my God are these patients high risk. In fact, I’m always a little surprised when they actually wake up from anesthesia.

Add to that the fact that these attendings are all fairly young, and new to Harborview, with growing referral bases. Not to mention all the emergent cases that come in through the ER. And the interns follow all the patients, not just the ones on the floor. Plus the chief is a 4th year resident. So each person on the service is doing a challenging job for their level, and I always feel like we’re only a step or two away from complete disaster.

I know this is not true. Between the residents and the attendings, we have the service well in hand.

But I took defensive driving a number of years ago, and since it was a comedy defensive driving course, I actually managed to stay awake and listen. Plus, the comedian who gave the course did all the same kinds of dangerous things I used to do behind the wheel. She would put makeup on with one hand, shift with the other, use one foot on the clutch and drive with her other knee, all at the same time. So she had some credibility with me on the subject of driving. And I’ll never forget one particular point she made. She said, “I’m not going to tell you to stop doing those things. But occasionally, while you’re driving along in traffic, take a moment to think about what sorts of things the cars around you might do to cause an accident, and then figure out how you might either avoid the accident entirely, or what sort of maneuvers you might do to minimize the damage to yourself and your vehicle. Pretty soon, it’ll become automatic.”

So I took her advice, and started thinking about things like, which lane would give me the best chance of avoiding an accident? If some truck’s wheel came off in front of me, what would I do? If that car fails to stop at their red light, would it be better to speed up, or to slow down in order to avoid getting T-boned?

Morbid, I know. But then came the day when that car did fail to stop, and in a split second decision, I floored it and didn’t get T-boned. In fact, I nearly avoided the accident altogether, and ended up with only some minor but expensive damage to my rear bumper. But I count that as a win, seeing as it could have been much worse. The other car was being driven by some teenager without a license, who hadn’t seen the red light at all, never even slowed down, and drove off without stopping to exchange information. Someone got the license plate number, though, and when his mom found out about it from the police, she did call me to apologize, and offered to pay for the damages. I told her it wasn’t necessary, and she said, “Oh, no. It’ll be a useful lesson for my son.”

Go mom!

Anyway, my point is that taking care of these patients is like driving in the middle lane of a freeway with eighteen-wheeler trucks on both sides, and a motorcycle gang coming up behind you. Even though truck drivers are some of the best drivers around, and chances are good that nothing bad will happen, it’s nerve-wracking because there are so many ways that scenario could go wrong. And if I at least think about them, I might be able to minimize the harm, should one of them actually happen.

Wizard of Oz

One of the more interesting things about medicine, considered on a broad scale, is its inherent conflict between precision and effectiveness. The kind of people who tend to choose medicine are compulsive about details, and in the overall care of a patient that’s a good thing. But in considering any particular detail of care, it drives me nuts how people get all worked up over things that simply don’t make a significant difference.

For example, why would I calculate a dose based on a population estimate of its pharmacokinetics, when individual variability is high, and I’m going to get a trough anyway and make changes based on the actual value regardless of what my calculation says it should have been. Particularly when my own eyeball estimate is likely to be just as accurate (or inaccurate) as any calculation.

And why, for the love of God, would I check an INR on day 1 of restarting someone’s coumadin, when it was a low dose that they were stable on before, and we’re not even bridging with heparin? Even an INR on day 2 is pretty useless, since there’s absolutely no reason it would shoot up dramatically, and if it’s low I’m not going to do anything about it anyway.

These things drive me crazy.

The details that were important in the first scenario were: 1. starting the drug for the appropriate indication, 2. getting a trough at the appropriate time, 3. setting the appropriate target for the trough.

In the second scenario, the important items were: 1. starting the drug for the appropriate indication, 2. the decision whether or not to bridge with an antithrombotic agent and/or add an antiplatelet agent, 3. ensuring appropriate followup.

Of course, it doesn’t help that I think pharmacokinetics is mostly voodoo–at least, as it applies to individual patients in a clinical setting. I mean, it’s certainly possible to predict the serum level of a drug based on patient-specific variables. And yes, I know how to do that. Or at least, I know exactly on what page of what book on my bookshelf the appropriate calculation can be found when I need it. The problem is, there’s no way to measure those variables reliably and accurately in an acute or critical care setting. So all you’re doing is hiding what is fundamentally a SWAG behind a bunch of scary calculus you hope no one else understands well enough to see through.

Maybe people don’t feel comfortable admitting that it’s just a guess, and they go through the motions to make themselves feel better. But whatever gene it is that lets people hide the truth from themselves like that, I just don’t have it.

Of course, there are places in medicine where it’s important to be very meticulous. Hemostasis in surgery. Anastomoses. Infection control.

And there are a whole host of details that can matter, or not, depending on the clinical status of an individual patient. And what I care about in a particular patient varies based on that. So it irritates me when people get nitpicky over the shibboleths of their field, without considering the whole picture.

I guess, if there’s anything that being an intern has taught me, it’s that there are lots of things that people care about, and few that really make a difference. And the things that matter are things that no one really connects to a good outcome, so if you screw it up, no one will ever blame you. It will just be ascribed to statistics, or patient disease.

But there are people who have statistically better outcomes than their patient population should support. So I try to pay close attention to what they do, and figure out how it differs from people whose outcomes aren’t as good. Particularly in neurosurgery, I watch what instruments people use, how they do various things, and what parts of the operation they take particular care with. And then I pay attention to what kind of problems the patients have postoperatively, and think back on any differences between that surgeon’s technique, or that particular operation, and other operations or other surgeons’ techniques.

Certainly I’m no expert on neurosurgical technique, but there are differences that even I can see between the ways that various surgeons will do the same operation. That, for me, has been the biggest benefit of doing away rotations. I’ve now seen a significant number of excellent neurosurgeons, doing a wide variety of operations. And although I never discuss it, I know I’m not anywhere near the first person to wonder about the link between the techniques used at a particular place and the kinds of complications that tend to be prevalent there.

Good outcomes are something I care a great deal about. But I want to figure out and get right the details that matter, and not get caught up in worrying about the ones that don’t.

Angel of bad news

I don’t know how I get away it, but I really do say some outrageous things to patients. Not in the sense that they’re incorrect or unbelievable, but outrageous in that I’m expecting some shock and dismay in response. Really, I don’t pull any punches. Yet patients always take it fairly matter-of-factly and well, without even the slightest indication of trying to hold back their emotions.

It’s a mystery.