Hurricane Jill

Surprises

Have you ever had one of those days where you encounter one new little piece of information, and have to rearrange the entire way you think about a situation?

Yesterday was a day like that for me. Continue Reading Surprises…

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.

After the storm

I am inexplicably happy this evening, and I can’t figure out why. There are so many reasons NOT to be happy today: I was in clinic all day, I still don’t have a job next year and I can’t get anyone to even answer my emails about finding one. I hardly ever see the sun, and I haven’t swam in weeks. And there’s certainly no new man in my life to explain it.

Nonetheless.

Maybe it had something to do with scrubbing in on a pericardial window this evening, which I’d never seen before. Or maybe it’s because I finally found a set of gloves that fit my arachnodactylic hands, and it was instantly ten times easier to tie knots. Or maybe it’s just that I have the weekend off.

I’m basically a happy person, and have been all my life. There has to be a lot of shit going on to get me down. Which means there’s been an awful lot of it these last few years, because it’s been a while since the balance tipped toward the happy side when I wasn’t on a neurosurgery rotation.

So I can’t explain it–I just feel like my old self again. And boy did I miss me.

And counting

20 days plus two weekend calls left of internship. Onward to vascular and thoracic surgery.

Damn you, Camus

Ugh! I’m sick today. Actually I was sick yesterday too, but I was on call. And I was still ambulatory and mostly functional, so in I went.

The elevators at my hospital have these signs saying to stay home when you’re sick. I look at them every day and try to remember what it’s like to have the luxury of doing that. Then yesterday it occurred to me that clearly the rest of the hospital is not running at maximum efficiency, if they can spare people like that. We, on the other hand, are the pack animals without which patient care would grind to a halt. We don’t chart the course, we just carry the load. So even a lame pack animal is better than none at all.

It also occurred to me yesterday that it really doesn’t matter how good an intern you are. If you carry the load from point A to point B (i.e. July to July) without it crushing you, then you’ve succeeded. Even if you’re the best intern in the world, the patients keep coming, the bureaucracy gets more elaborate on a daily basis, and it’s always your fault when something goes wrong. And even if it’s someone else’s fault, you’re the one who’s supposed to go the extra mile to make up for it.

Dear lungs:

You are the only reason my patients ever die. Please cease and desist from all activities which detract from your primary duty of oxygenating blood and excreting the acidic end products of glucose breakdown.

Sincerely,

Your patient’s intern

Oh my God I’m so sick of dealing with anything non-neurological. I seriously don’t know how I’m going to make it through two and a half more weeks of this. Not to mention that it’s killing my good record for not readmitting patients to the ICU.

I have two patients who keep getting better, then worse, then better, and so on. There were three, but over the last three days, each of them has successively crashed, and yesterday one had to be readmitted to the ICU. He was within a day or two of discharge, and we had consulted ID for recs on outpatient antibiotic therapy. The ID service had requested a thoracentesis on the guy’s pleural effusion, to make sure it wasn’t an untreated source of infection. I’m a little pissed off that they even asked for it, because clearly the guy was clinically improving, and we were asking them for simple recs on an infection we had already identified and were evidently treating appropriately. We were not asking them to go hunting for an occult infection, nor was there any indication to do so. But we can’t ignore a request like that, when the guy clearly does have a pleural effusion that hadn’t been fully investigated.

So our chief did it, and the patient was fine immediately after the procedure. But then an hour later I went to check on him and found him in respiratory distress. Paged the chief, called a rapid response, recruited a couple of nurses for vitals, O2 and an EKG, and got set up for an ABG. He was tachycardic and tachypneic, but with palpable radial pulses. He’d gotten his post-thoracentesis chest x-ray moments before I arrived, which looked like a pneumothorax but not a tension pneumo. Most of the lower lung fields were whited out, a big change in comparison to the pre-thoracentesis image. He obviously needed a chest tube, but what kind and where to place it was not clear. So I called the radiologist, and he read it as a hydropneumothorax. I’m sure I could have placed it myself, but at this hospital chest tubes are the province of thoracic surgery. But they were busy, so the R2 ended up putting it in. Initial output was about a liter, and his hematocrit dropped significantly, so he went to the ICU for closer monitoring. I was so pissed off at the whole ridiculous sequence of events. One stupid, overly cautious consult rec, and now the guy has to spend an extra two weeks in the hospital.

Not to mention that, this entire year, I’ve never walked in on a patient that sick who wasn’t already being tended to by the nurse or the rapid response team. Seriously, if I hadn’t happened to walk in right then, that guy would likely have died before anyone else came in to check. And what’s up with getting a chest x-ray just moments before? How can you come in, blithely shoot your x-ray (for which, by the way, you have to ask the patient to take a deep breath), and leave without noticing that the patient looks like he’s asphyxiating? This guy’s distress was so obvious that it needed no medical training whatsoever to see.

Ironically, the very fact that I’ve never had to deal with this before as an intern is a testament to how good the hospitals are at which I work. But I was still pretty shaken by the whole series of events.

I remember vividly the last time I had a patient get that sick on me. I was a third year med student, on my medicine rotation at the VA. It was a spinal cord injury patient who had come in for shortness of breath. We worked him up in the ER and found post-obstructive pneumonia from advanced lung cancer, previously undiagnosed. The guy had been a nonsmoker all his life. A couple days into his hospital stay, I had promised him I would come talk to him about what was going on. There had been some discussion that day about making him DNAR, but no paperwork had been filled out. I had forgotten to stop by that afternoon before going home, but it had been impressed upon us the importance of keeping the promises we make to patients. Plus, the guy was dying, and had been such a shit to his family that they refused to have anything to do with him no matter how he’d turned his life around. I mean, can you think of a worse way to die?

So I came back after dinner to talk to him, thinking I would just sneak in and out to keep my promise without making the other students look like slackers. But I found him in respiratory distress with an O2 sat in the 60’s. He already knew his diagnosis was terminal, so I asked him if he wanted me to try and do everything possible to help him live right now, and he nodded. So I checked the chart for DNAR paperwork, and finding none, went to get the nurse to call a code. He died in the code, and the senior resident wasn’t too happy that I had called one, since his diagnosis was terminal. Not to mention, what the hell was I doing at the hospital at nine o’clock at night when I wasn’t on call? My explanation sounded unbelievably lame, even to me. I could just hear them all thinking “what a f-ing gunner.”

Except I’m pretty much the opposite of a gunner: I try not to look like I’m working harder than the other people in my group, while still getting all my work done thoroughly and well. But that whole medicine rotation, my patient list was like a cancer ward. Plus I had a bunch of super-complicated patients with obscure diagnoses. Meanwhile my fellow students’ patients were all pretty much SNF candidates, waiting on placement. It’s funny how the luck of the draw (which it totally was) can still lead to such a skewed distribution.

So I had a few patients die on that rotation. But it’s funny, I never cried over a patient’s actual death. I only cried about the things we did wrong that hastened it. Which I guess is a good thing in a neurosurgeon. There’s too much death to function adequately, if you find even inevitable death seriously disturbing. But it should be very upsetting to have made it happen sooner.

In other news, I have an interview back in hurricane country next week. It’s a solid program with pretty much all the things I’m looking for, so hopefully they’ll offer me the spot. The one intern there that I know from the trail is a good guy. But it’s literally the opposite corner of the country from here, so I’m spending twelve plus hours traveling for five or so hours of interviewing. Kind of crazy.

If I don’t end up getting that position, it’s unclear what I’ll be doing next year. What I had thought was a solid backup plan is no longer a sure thing. 47 more days to figure it out.

Can’t stop the clock

53 days of internship remaining…

Back on General Surgery this month. The first day on service was incredibly painful. Not only was I taking over for an intern who was actually a mostly-trained general surgeon in another country (and thus finds everything in general surgery easy and straightforward, unlike me), but I also had a schedule that day which literally required me to be in two places at once for most of the day.

In any event, things calmed down after the first day. Part of the problem was that I’d never really had to pre-round on a general surgery service since the point at which all the vitals and allied health notes were switched over to the new computer system. So the first day, I was completely unable to find large chunks of the info I was expected to have available on rounds. I know exactly where to find it on the old system, but that knowledge is now useless.

On a side note, it sucks to be an intern during your hospital’s changeover from one EMR system to another that’s completely different. You have to know all the details, and when they’re suddenly somewhere else, and buried in a non-physician-friendly format on a program that loads information slowly (this is a key point), patient care can easily be compromised.

The slow-loading program is what’s currently pissing me off. It takes twice as long as it should to collect the data I need in the morning, and most of my time is spent waiting for pages to load and display information. And the pages purporting to provide an “MD Summary” are frustratingly incomplete, superficial and completely un-tailored to the patient’s primary service. The programmers were clearly lacking sufficient breadth of physician input.

If it’s going to be that slow to load, there should be some way for me to create a tab for myself that automatically loads all the information I need, as a surgery intern, and allows me to add or delete things as my data collection needs change on various services and with various supervising residents and attendings. Man, if I could do that, I’d be Super-Intern. There would need to be a huge variety of things I could pull into my tab, and I’d have to be able to control the format to a reasonable extent, but I know it can be done. It’s just a matter of institutional will to make it happen.

Theoretically, it’s possible to do that with notes. But I find the process to be prohibitively difficult and the options on formatting and information retrieval limited. It’s OK for attendings, whose formatting needs don’t change every month. But for residents, and particularly interns, on whom the brunt of data gathering and documentation rests, it’s actually more efficient just to wait for the pages to load. Seriously.

Anyway, when I had initially looked at the schedule for this rotation, it appeared that I would be in clinic nearly every day. Thankfully, that has turned out not to be the case. I have dedicated clinic time on Tuesday and Friday afternoons, and occasional duties at other times when the load is particularly heavy. And the clinic I work is a vascular service, with an attending who mostly does research, and loves to teach.

So it’s not as bad as I expected. Although it seems that most of what I learned about vascular disease in medical school is wrong. I don’t know what kind of vascular program Tulane had–I don’t recall meeting any faculty who were vascular surgeons, but it’s possible I did and just forgot. I did see some truly horrendous vascular disease in New Orleans, but I don’t recall seeing any that had been surgically treated. It’s a real gap in my education, and the subject is interesting enough that some remediation is welcome at this point.

But the hospital I’m at is notorious for its bureaucracy, which makes any rotation here just that much more painful. The joke is that JCAHO ran screaming from the building when they came to accredit this hospital, because we have more policies, procedures and forms to fill out than even they want to deal with. And the internal culture is such that everyone seems more concerned about getting the proper form filled out than anything else related to patient care. Also, if you like having some autonomy as a junior, you won’t get it here. The sphincter tone is substantially higher at this hospital, no matter how competent a resident you are. I don’t know if patient care is any better, but the leash is definitely shorter. It’s kind of funny – I had more autonomy my first three months as an intern than I do now in my second to last.

I figure if I just pretend I’m a med student again–albeit one with order-writing authority and twice as many patients–I should get through this rotation without running afoul of anyone. I was frustrated then at not having authority to make even low-level intern decisions. That’s all I get to make on this service, so that should be just about right.

Anyway, in less than two months it’ll be all neurosurgery, all the time. So things are about to get a whole lot more interesting. And two rotations is nothing, compared to the eleven I’ve already done.

Schadenfreude

It’s been a fun couple of days in the ER. Exhausting, but definitely interesting. Yesterday we had a guy come in with an extremely large and deep neck laceration that miraculously missed every major nerve and vessel. So the task of sewing it up fell to me, the intern.

It was not a simple task. The laceration was Y-shaped and ran at a 30 degree or so angle to the plane of the overlying skin, with a dog ear at one end. Last July I wouldn’t have had a clue how to approach the problem, but now it seems easy. That’s what three months of plastics will do for you. The scar won’t be as pretty as I could have made it–he’s a guy, and he wanted bragging rights for the most stitches among his buddies. So I obliged, and closed it with closely spaced interrupted sutures instead of the running subq I’d have done otherwise.

We’d had a patient the previous evening who’d taken a pretty bad beating to the head, and had a multitude of 1-2cm lacerations across his occiput that were bleeding profusely, along with some facial fractures. Not coincidentally, he was also drunk and high on a number of illicit substances. He’d been talking on and on to me about how he was a God-fearing man, and had lost his woman, and loved her so much and wanted her back, etc. etc. All the while I was injecting lidocaine in his scalp in order to irrigate his wounds and staple them up, which was taking some time because they were all under his C-collar and he wasn’t really cooperating. But then the craniofacial intern came down to see him. For some reason, the patient took an instant dislike to said intern, and stood up on the bed, pulled off his IV and started cursing at all of us. For a moment, the patient and I made eye contact, and I thought for sure he was going to launch himself off the bed at me. So I very slowly backed up a few steps and walked behind the curtain. And like an infant with no sense of object permanence, he forgot I existed, instead launching himself out the door of Resus 1 and toward the back desk of the ER.

He was tackled by security, and eventually sedated and restrained, and the other intern and I continued with our respective tasks. It’s so much easier to irrigate and staple lacerations when the patient is snowed. If he hadn’t gone nuts on us, I’m not sure I could have done it.

Then today I put in a chest tube on my own, with correct placement and without complications. And then I did my first femoral arterial stick for a trauma code, and got it on the first try. And all shift I was getting lines and blood draws when other people couldn’t. In fact, we had a patient with exactly the same invisible roly-poly little veins as my 2nd year classmate/blood draw victim, and I got a line on my first try. Now that’s a milestone.

Now if I could just get an opportunity to put in a central line…

Hema-tomato

Alright, I’m still alive. If a bit loopy. My head still hurts, but after some Tylenol it was much better. In retrospect, we probably should have scanned my head. I take two different drugs that affect platelet function. Neither of them are common enough to send up an immediate red flag in most surgeons, so I don’t fault anyone for not picking up on it, but I knew better. In any event, no harm done.

And I have one more thing to say about the whole being a trauma patient thing: that backboard? Not uncomfortable at all. Seriously, my empathy is gone. Unless you actually broke something, in which case I still feel for you.

As for my minimally injured self, I’m now more worried about my knee, which has developed a pretty impressive hematoma. It’s actually a distinct pool of blood in the subcutaneous tissue. I know that has a different name, but I can’t remember it. I’ve gotten one before, and it took weeks to resolve. Although that one wasn’t over a joint, so there wasn’t the ongoing trauma that’s happening everytime I bend my knee now. It’s very uncomfortable. Although not painful, and the knee itself works just fine.

Fortunately this occurred on the last of my four shifts in a row, so I have a couple of days off to recover.

Hardheaded

I guess I’m not quite as much of an old lady as I thought. I had my own little GLF today (that’s ground level fall, for you non-medical types) in the ER. I tripped over a cord that was suspended about 5 inches above the ground between a patient bed and the wall. I had nothing to grab and catch my balance, so down I went. I hit my forehead, the side of my nose and my left cheek right on the zygomatic arch. Given the number of years I took prednisone, I ought to have broken something. But no, all I had was a piddling 1cm laceration in the middle of my forehead. It bled profusely enough to freak everyone out, but turned out to be very superficial.

If I had been a real old lady, I would have had some significant facial fractures, and possibly a subdural hematoma. I guess I could still have the latter, but it’s probably just a concussion. We didn’t CT my head, so who knows? But there was no loss of consciousness, and I remember the fall in detail, so anything worse than a concussion is very unlikely.

Strictly speaking, the laceration didn’t even need sutures. We could have dermabonded it, and it would have been fine. But I’m just vain enough to want the smallest scar possible, and dermabond wouldn’t have approximated it as well. So our trauma doc, who also happens to be a plastic surgery resident, put in a couple of tiny sutures, and I got a nifty Bugs Bunny bandaid on top. I figured the sutures would be a lesson in empathy for my patients.

Nothing could be further from the truth.

Seriously. I warn people about the burning sensation with lidocaine infiltration, and still they yell and curse because it “hurts so bad.” Please, people, get a grip. It’s not that bad. Also, it doesn’t take 5 minutes to work. I was numb within the amount of time it took her to open the suture tray and put sterile gloves on. Also, if you just drip lidocaine on intact skin, that’s pretty much enough to numb the epidermis. Granted, it was a tiny and superficial laceration. But still. People who think it hurts have clearly never experienced any real pain.

Afterward, I finished up my paperwork and was sent home. Now I’m just trying to stay awake so that I’ll hear the phone when it rings. I’ve assigned some people to call me throughout the morning to make sure I’m not dead or comatose from an epidural bleed. It’s a little dramatic, but, doctor’s orders. Although I’d probably know already if one were present. And a mid-forehead bonk doesn’t seem a likely mechanism to me.

As with most things, either it is or it isn’t going to happen. But ouch, my head sure does ache. I guess that’s what I get for having such a hard head.

Are the other interns not operating AT ALL?

Yesterday the case numbers for the intern class were sent out to all of us. I was surprised to see that I actually have more cases than just about any other non-categorical intern. I’m actually on par with most of the categoricals.

I find that very hard to believe. From my perspective, it seems like I hardly operate at all. It’s got to be that the other interns just aren’t entering all their cases.

Seriously, I’ve done most of the rotations where the intern gets operative time: burns, plastics, and formerly, trauma (not so much now that they’ve reconfigured the intern assignments). And I know that a number of my fellow interns have done those rotations as well. Since that time I’ve done anywhere from 2 to 10 cases per rotation–significantly less than I hear other interns are doing on the rotations in question. Yet their case numbers are one-half to one-third of mine.

It’s true that I am very meticulous about recording my cases. More so, I’m sure, than most interns. I’ve recorded nearly all my cases since the beginning of my core surgery rotation in medical school (however, only my cases as an intern are logged in the database). So it’s pretty much second nature to collect an ID label for every patient I operate or assist on. And probably the prelims for other specialties are tracking their cases in specialty-specific databases. But I have more cases than all but one of the undesignated prelims, and by a long shot. And they should definitely be recording their cases in the same database as me.

This can’t be right.

Out of season

I finally feel human again after yesterday’s ER shift. The previous night’s crew started getting hammered with traumas at about 4am, and when we came in at 7am, every bed was full on the trauma side. Five patients whose charts contained only their story and an incomplete physical exam were signed out to me by the prior night’s intern (who is a friend of mine, so I told him I’d do his neuro exams if he’d do the ABIs. Except then I had to teach him how to do ABIs, so it didn’t actually save me any time. But no big deal.)

This wouldn’t have been any kind of problem, except that the traumas kept coming, and coming, and coming. We would only just be done with the primary survey and maybe trauma films when the next trauma would roll in and overhead we’d hear the dreaded words “Trauma doc! New patient in Resus 2.” At one point it got so ridiculous I just starting laughing hysterically (and inappropriately) whenever I heard it. By noon the whole team had this dazed, punch-drunk look on their faces. It finally slowed down at about 2pm that afternoon.

But it didn’t really end. Instead, it transformed into a steady stream of garden-variety trauma punctuated every hour or two by major, attending-level, multi-line-and-tube, open chest, headed to the OR ASAP injuries.

Amazingly, none of them died in the ER. Possibly one was brain dead before arrival, but no one left the ER without a pulse on our watch. And I got to put in a chest tube, hooray! But then they opened the chest, which kind of defeats the purpose of a chest tube. Oh well. I’d never seen an ER thoracotomy before, and yesterday I saw two. One was even a clamshell (a bilateral thoracotomy, which basically lifts the entire chest wall up off the heart and lungs). It was funny, because we’d just been talking about that earlier in the day.

I guess, after watching all of that, I can see how general surgery would appeal to people. The gen surg chiefs and fellows and attending basically swooped in and got the patient’s heart working again, and whooshed him off to the OR in heroic fashion.

But I’m sure that every field has cool and exciting things about it. And if you consider only that, there are a number of fields that look interesting and rewarding. But I think you really have to like the mundane stuff as well, because that’s at least 95% of the job. And that’s where neurosurgery wins the game, for me. Operating is fun, at some level, regardless of the body part. But it’s all the other stuff that makes the difference.

Anyway, it took me until 4pm just to dig myself out from under the charts that had been signed out to me that morning. But then my own charts were much easier to finish, and surprisingly, the major trauma chart was easiest of all. It was just a chronology of events and exam findings, and since the patient was only in the ER for half an hour, and I was at the bedside the entire time, it was easy to document what happened, when and why.

But I was totally wiped out when I got home.

Rumble in the fishbowl

If you’ve ever worked in an ER, you’ve probably noticed how each day seems to have its own theme with regard to the presenting complaints. For example, last Sunday’s theme was kid trauma, and particularly kids falling out of windows.

Sometimes you know going in what the theme of the day will be. On the 4th of July, it’s obviously going to be firework injuries. On New Year’s Eve, MVCs involving drunk drivers. But for most days, it’s the proverbial box of chocolates. You don’t really know the theme until late in the day when someone finally says, “good lord! what is it with all the {insert diagnosis} today?!”

So today was head bleed day in the ER. Both the medicine and the trauma sides had more than the usual share of them. Unfortunately for the neurosurgery service, they get consulted no matter which side the bleed gets triaged to. The poor neurosurg resident on call was running around like crazy trying to keep up with all of them.

On the trauma side, though, the work was steady and not overwhelming. At one point in the afternoon, we were all sitting around doing nothing, and for some reason started talking about hyponatremia. Actually there was a reason–one of the head bleeds on our side was also hyponatremic. So at first it was serious, but then it rapidly degenerated into a mockery of medicine rounds, with each surgery resident trying to sound more intellectual and pedantic than the next. Of course, the medicine people were standing right there in the fishbowl with us, and started mocking us in return for all the dumb surgical clearance consults we send to them. It was all in fun, though, so hopefully nobody was offended.

I actually really like ERs that are set up like ours is. There’s a surgical side and a medical side, and patients are triaged to one or the other. Although here the surgical side is all trauma and emergent operative problems, while subacute but potentially surgical disease goes either to fast track or to medicine, with the appropriate surgical service merely consulted. So the experience we get from having to staff our side is a really valuable part of our training.

Interestingly, the attendings who serve as trauma doc when the R2’s are off, are all internal medicine-trained. It’s really odd, but it seems to work.

Laparoscopic brain surgery? I don’t think so.

Extremely slow day in the ER. Thank God. Yesterday was busy enough for two days. In fact, I think I’ve developed biceps. And perhaps lost a pound or two. Although I could be imagining either of those things.

I have vacation coming up, and I’m trying to decide where to go. Maybe Mexico. Definitely someplace warm and sunny. The problem is, I spent a large portion of my savings interviewing for PGY2 spots, and I don’t know if I can afford to go anywhere.

Wednesday a bunch of the interns, including me, have a training session on how to do a laparoscopic cholecystectomy. Now I ask you, my 3 or 4 faithful readers, when would I ever have occasion to actually do a lap chole? Would it not be a far better use of my time to attend neurosurgery grand rounds that morning instead? Not that I would mind playing around with the laparoscopic instruments on any other day, and I did beat all those general surgery gunners at one station of the laparoscopic skills competition on my surgery rotation in medical school (in fact, none of the winners were actually going into general surgery, if I recall correctly). But it bugs me that I’m required to learn how to do this operation at a time when I could be elsewhere, learning something I actually need to know.

This feels like work

Now I really know why they call it the Zoo. Oh my god, that ER is crazy. And yet I still haven’t seen it anywhere near the worst it gets.

I went to a school where we didn’t have to draw blood or place Foleys or insert IVs. I have placed a few Foleys, and art lines, and done bits and pieces of chest tube insertions. But aside from my mandatory blood drawing lesson back in 2nd year of med school (where I had the misfortune of trying to stick a classmate with tiny little roly-poly veins and a generous amount of subcutaneous fat, meanwhile she got to stick me with my supersize antecubital and thin skin), I’ve never actually had to place an IV or draw any labs. So I’ve learned a whole bunch of new skills in the last few days. And my arms are sore from rolling patients to check their backs.

It’s pretty fun, despite that. Although I’m glad I only have one month of it–I think it would get old after a while. I seem to spend most of my time trying to keep track of data, rather than diagnosing or treating anything, and trying not to let any of my patients languish too long without making any progress either upstairs or out the door. So far I’ve been able to keep up with my trauma sheets, and not get too far behind with writing down all the exam results. A few months ago, one of my fellow interns got stuck in the ER two whole hours after his shift ended, because he hadn’t kept up with his charting.

My goal is to be out the door by 7:15 at the latest.

The weird thing is, traumas here are handled completely differently than they were at the hospital where I did my trauma surgery rotation. Or maybe the med students there just weren’t as involved as they are here. Here they basically do what the interns do, the only difference is they have to have their charts and any medication orders cosigned. From a student perspective, it’s a much better experience.

So it’s been interesting and fun so far. But not a substitute for neurosurgery.

Unexpected kindness

Last night was the first quiet call night I’ve had at Children’s. All the consult calls came early, and there were no ER patients that had to be admitted to our service. Maybe it had something to do with the superbowl? I don’t know, but that seems weird, since all the calls came during the game.

It’s funny how small things can really make my day. Like the fact that the lady who cleans up our call rooms and makes the beds every day, put an extra pillow on the bed when she saw I was on call. And when I had gone into the supply room to get some dressing supplies, one of the nurses came in and said to me, “I know it’s unprofessional to say this, but I can’t believe that attending was being such a jackass. The way he was talking to you!” And then on a previous call day, the ER attending commented that I was the hardest working resident on our service. “Not that your department cares what I think,” he added.

They don’t, and but it’s still nice to know that someone notices.