Sterile Field

Chief Resident

2010-07-05T15:54:00.001-07:00

I finally made it to the Chief year of my surgical residency. There weren't any moments where I didn't think I could make it through, but it's been the toughest job I've ever had. I've learned a lot, grown as a person, and become a better doctor through it all. Don't get me wrong - I don't think I'm the world's gift to surgery, but the residency process brings about a unique transformation from medical student to surgeon. However, it is a little bit of a hazing ritual to see how much work a doctor can take. The hours are much better than the old days, but it's still a grueling process.

On the night before my chief year began, I stayed all night in the hospital. I was about to go home at around 7PM and read about Pediatric Surgery (my first chief rotation.) The last thing I was going to do was check up on a patient in the recovery unit. He was hypotensive and tachycardic and his labs made us think he was bleeding. I hung out in the recovery unit and resuscitated him, but his labs and vitals worsened and I posted him for a takeback, then spent about one hour trying to convince my attending we had to take him back. It took two calls, but we took him back and found 2 liters of blood in his abdomen. We identified a small area of bleeding (who knows if it was the cause) and he was much more stable after. Still though, I spent the night in the hospital continuing to resuscitate the patient.

When the morning came, I switched gears, handed the patient off to the new chief of the service, and went to the children's hospital to round on the pediatric surgery service. We had about 30 patients to see and it was a whirlwind to see them all in 1.5 hours since they were all new to me. Both interns were brand new, but thanks to the medical students (who were on their last day of their 3rd year of school and knew the patients) we made it through rounds.

During my intern year, I posted a lot on this blog and got some comments (mostly from my dad) but I got too busy to post midway through the year. My wife blogs a lot and I think there has been something about the blogging process that makes her a more self-aware person. Whether it's the self reflection that comes with writing or accountability to the unknown people who may be reading the blog it seems to work! So I decided that I'd try to do the same thing for my chief year of residency. I'm not sure about the frequency that I'll blog, but we'll see.

I just spent some time looking over the various reviews through each year of my residency and in summary it seems:

Attendings think I'm a hard worker who pays attention to detail.
Medical students like working with me.
Initially, I got comments that I was technically behind other residents at my level, but lately I've been getting comments that I've been improving and it's been less of an issue.
Efficiency has always been something I should work on, but now this is less of an issue but it has translated into a new one: I need to delegate better.

For the upcoming year, as a chief resident, I'd like to be a good leader and I thought about several ways to do this.

Set expectations: I wrote out a list of things that each person on my team should know when we work together. I have a card for med students, interns, and junior residents. I had been doing this informally for med students and it turns out that most of them really appreciate this (at least according to the comments they send about me.)
Seek feedback: In the past, I didn't really care about what people thought about me. I knew I was trying hard. I've been paying attention to the criticism attendings write about me in annual reviews, and trying to address things they've pointed out. However, I need to schedule meetings with my attendings 2-3 weeks into a rotation and seek their feedback on what I can do better. I also need to seek feedback from the junior residents and interns and try to meet their expectations for myself as a leader.
Be nicer: In the past, I've tended to lose my patience especially around 3AM when up all night. From now on, I'm going to try to take a deep breath every time I get a page that bothers me, and return the call with class. Also, at the end of last year, I lost my patience with some of the OR staff. The specific thing that bothered me is when OR nurses treat me like a novice / newbie. I've been a resident for 4 years and I know how to do things in the OR, and I'd lose my patience when they didn't respect that. So I have to just ignore it when it happens. However, it seems that most of the OR staff have started treating me better in the last two weeks once they realized it's my last year of training.
Lead: The role of chief resident should be one that people look up to. I should also be training junior residents and interns how to be better doctors. I need to project the image of unflappability and professionalism. I need to delegate better and focus on that. I will try to make all the social and recruiting events which I've tended to blow off in the past.
Read: I'll be taking the boards at the end of the year and starting a vascular surgery fellowship, so I need to step up the literature review. I've been doing a good job recently in terms of preparing for cases and reading, and I need to continue. I need to set a board prep and fellowship prep reading list and stick to it!

We'll see how the above works out in the posts to come.

A humbling experience

2010-02-06T11:41:00.001-08:00

Last wednesday night we got a call from the geriatrics team that one of their patients, and octogenarian, was admitted from clinic with abdominal pain and had a CT scan that showed one area of small bowel with pneumatosis (air in the bowel wall, usually an indication of dead bowel.) However, the person calling the consult said that the patient was stable, didn't have abdominal pain, and that the consult was a formality. They hadn't even ordered labs yet on the patient. We said we'd be by later in the evening to check her out as we were busy with other, seemingly more pressing consults.

Two hours later we got a frantic call from another resident on the team. Why hadn't we come by yet? Why weren't we rushing the patient to surgery? In the meantime, the medicine team got labs on the patient and they were stone cold normal. We came up to see the patient, a very pleasant woman who had traveled the world in her line of work as a diplomat who had retired to live in our communinity near her daughter. Her abdominal pain had been present for the last month, but now was gone and she was without abdominal pain and had a benign abdominal exam. The CT scan from earlier showed one area of compromised small bowel that was about 1 cm long. However, putting everything together and seeing the patient I decided that we operate on patients, not on radiological findings. The patient did not match up with her CT scan. I told the medicine team that we would keep a close eye on the patient, but that we didn't need to rush her to surgery.

I called my attending and ran the patient by him. He said he'd take a look at the CT scan from home. He called me back an hour later and said we should probably just take a look with a laparoscope to try to figure out if there was something bad going on inside. The patient and her daughter were understanding and agreeable to an operation. At laparoscopy, we saw a piece of compromised small bowel and converted to an open operation. We ended up finding a small piece of bowel that did appear to be necrotic, but it had not perforated and amazingly, the surrounding bowel and mesentary had done a great job of sealing off the compromised bowel. However, we ended up removing 100 cm of bowel that was inflamed. The patient now had about 120 cm of small bowel left, which is just about the minimum one can have and still be able to absorb food.

It was a humbling experience. I went to see the patient and felt like I had a good exam which was non-surgical and that meant that you don't operate. However, we ended up removing 100 cm of bowel. I'll never know if she would have done OK and healed her injury with or without surgery, but it was a humbling experience.

In other news, here is a great and pity article about universal health insurance by James Surowiecki from January 2010 in the New Yorker:

Fifth Wheel

life and death

2010-01-19T23:13:00.001-08:00

the other morning a teenager came into the ER in the early hours with a horrible stab wound. she had already been coded three times en route, transfused with multiple blood products, and basically came into the ER and lost all signs of life. we took her to the OR to try to stop the bleeding but after about forty-five minutes of exploring the wound we finally got it to stop bleeding. at that point, it was about 1.5 hours of coding her and she had no signs of life. in retrospect i'm not sure that there was anything we could have done surgically to save her when she arrived in the ER without a pulse.

i had to sit down in a room and tell her family that she died. her 11 year-old brother freaked out and ran out of the room and we had to go and chase him down and find where he ran off too. eventually i tried to get the family members to focus on helping their other family member (also stabbed but survived) get through the hospitalization.

night float is like one of those experiences like when they take astronauts or pilots up to high altitudes and take away some of the oxygen. you start to have trouble thinking - the sheer horror and urgency of some of our situations in the setting of anti-physiological sleep patterns (awake at night and sleeping by day) tends to make feeling emotions an abstract concept. and then sometimes i have an experience like the one that i describe above and i didn't even have time to process it. i had to run up to the icu and do an emergency procedure right after telling that girl's family about her death.

surgical miracle

2010-01-19T22:12:00.000-08:00

on friday morning early i was between emergency consults when i finally got up to the neonatal ICU to see a 6 month old former 25 week premie who was billed as a non-urgent consult for abd distention. she looked sick, febrile, and tachycardic and had a bowel obstruction on xray. we posted her for the OR and found an adhesion from a prior surgery caused a small bowel malrotation. we fixed it and didn't have to resect any bowel thank goodness and the baby started looking much better and more stable. the circulating nurse asked my attending what the name of the procedure that we performed and he said, just put down "surgical miracle."

he was totally joking, and he didn't say it in an egotistical way or anything. he went on to say some good things about how we got the baby to surgery and said some good things about me. the whole time i kept thinking how crazy it to say those things was because i always second guess myself five-hundred times when i say it's time to take a patient to the OR. i wish i could be more decisive about these things which i suppose will come with time.

Night float can be slow

2010-01-14T00:13:00.000-08:00

The past two nights not much has been going on. It's been pretty slow. Even with that, two nights ago we had a pretty cool case - I walked into work and got an intraoperative consult from the Gyn service who was doing a myomectomy for fibroids and they randomly came across a appendiceal tip mass. I got to do an open appy as an intraoperative consult... I wouldn't have known how to do the case properly (I would have figured something out) except the previous night we had a patient with appendicitis and we did it open at the patient's request for a "tougher" scar. See one, do one, teach one is what they say in surgery so now I'm ready to teach someone how to do an open appendectomy.

night float

2010-01-11T21:55:00.000-08:00

ok.
i'm back to blogging.
we'll see how long this lasts.

i'm PGY-4 now, and have finished transplant surgery, vascular surgery, and wake med (trauma at the community hospital) rotations.

now i'm on the night float service. i come to work at 5pm and stay until 6am. all surgery consults go through me: peds surgery, vascular surgery, general surgery, etc. there are tons of trips to the emergency room at 4 am.

speaking of 4am, one of the craziest cases i did was on a wed morning at 4am. a guy came in with three bullet holes in his legs and two bullet holes in his abdomen and an xray with a bullet in his femur. one bullet went through and through his abd wall (but a graze wound) and one bullet when through his left leg (missing his femur) and lodged inthe right leg femur.

we took him to the OR and did an angiogram which was negative for injury, and washed out his abdomen. we rolled him back to the SICU intubated and noticed his right leg was bleeding. i held pressure and when we got him back to the room i took a look at the leg. blood was *pouring* out. i've never done this before, but i climbed back up on the bed and held pressure while we rolled the patient back to the OR (with me still on the bed.) we had to filet open his leg to find a bleeding vein at the base of the gunshot wound.

Winning the game, more night livers, and moving on...

2009-09-01T07:47:00.001-07:00

We won the game last week. In residency, that means we discharged all of our patients on the service and didn't have to come early to round since there was no one to round on. It's a pretty rare event for this to happen, and it was erie. Everyone on the service felt uneasy, like we were supposed to be doing something but there was nothing to do. We gave the intern on the service Friday and Saturday off. I came in on Saturday to round on a consult patient and we actually did get one admission. I almost gave him Sunday off and he said "are you sure?"

In the end, I asked the intern to come in on Sunday and I'm glad I did because we got two admissions for transplant. One kidney transplant and one liver transplant. The liver transplant went first at 1AM on Monday morning, and we finished around 7AM. The patient did well but like all liver patients bled intra-abdominally on the first post-op day. I spent the day resuscitating him and we almost had to take the patient back to the OR for exploration but he stabilized out in the end.

Moving on, I started as Vascular Surgery senior resident on Wednesday. Vascular is the field that I am likely going into, but the service itself is miserable. I love the cases and like the patients themselves, but every day is a 6AM to 10PM affair. We always think that there is an end in sight for the day, but something always comes up, there are unanticipated admissions, extra cases that need to come up, anesthesia delays, oh my.

As a result, I haven't been able to spend much time with my wife who is usually asleep when I get home and waking up as I leave, but I do have this weekend off. I am looking forward to seeing my wife and we are going on a date to see a Tenessee Williams play at a local theater.

Night-time livers

2009-08-18T06:10:00.000-07:00

I've been inspired to blog a little more both from my wife, who has a semi-professional blog that she actually gets paid for writing (based on ad-revenue stream of visitors) and another surgery resident whose blog I started following.

I've been meaning to blog on the day after being up all night or after an interesting case. Last Monday night on August 11th, we did a liver transplant. Actually, the case started at 1AM on Tuesday August 12th and finished around 7AM. The guy was a very sick frail gentleman who "appeared much older than his stated age" of 60 years old with end-stage liver disease from hepatitis C. He had around 6 liters of ascites in his belly and the case was pretty bloody. I was a good first assistant in a pretty big case and I sewed half of the portal vein anastamosis and half of the biliary duct anastamosis. I've scrubbed in liver transplants before where I've been able to do more of the case, and I feel pretty comfortable with the case and feel I could do more of it, but working with different attendings I just take what I can get.

More importantly, I think we did a great job of managing a pretty frail old guy post-operatively. We did a gentle management and now one week later he is on the floor and ready to go to rehab.

Not much else is going on. The service is pretty slow right now and we discharged most of the other patients and our census is now 3 patients and one is going home today. I thought we might "win the game" in discharging all of our patients today and thus wouldn't have to come in for rounds on Wednesday, but now I don't think that will happen.

Transplant Surgery

2009-08-02T10:33:00.000-07:00

Well, I'm back for a post. We'll see how long this last.

This blog lasted throughout the majority of my intern year and a brief one month period during my third year. Now I'm about 1+ month through my fourth year of training. I started the year on transplant surgery, which is a cool specialty. We basically do two operations: liver transplants and kidney transplants. Kidney transplants are more frequent and are pretty straightforward in terms of the operation itself and the post-op recovery. The liver transplants are less frequent, are almost epic in their scope and post-op recovery.

On Thursday, I came into work a little early. I got paged at around 5 AM that a patient who we were following (on the waiting list for a combined liver-kidney transplant) was in the ER with an incarcerated hernia. I showed up to the hospital at 5:45 AM and scrubbed into the case. We had two scheduled cases that day, a laparoscopic cholecystectomy and a revision of dialysis fistula which I did next. During these cases, I found out that we were posting both a kidney and a liver transplant. We did the kidney transplant and next the liver transplant.

In summary, I scrubbed into a case at 6 AM and didn't finish with surgeries until 7 AM THE NEXT DAY. 25 hours of surgery! I was a little tired during the liver surgery, which was the last one. I was scrubbed in the 2nd assistant position and I actually did a lot from that position as there is a new fellow who is sort-of new at the transplant business, but there were parts of the surgery where I wasn't doing much and I FELL ASLEEP STANDING UP. However, at the end of the day, it was a pretty amazing day of surgery.

Vacation!

2009-01-19T08:27:00.000-08:00

Whew. Finally made it to vacation. It's been good so far - going out for dinner at a very nice restaurant post-call to celebrate and spending the day with my wife on Sunday. Unfortunately, I'm not doing very much over the vacation other than catching up on Things That Need To Be Taken Care Of, like taking USMLE Step 3 and finishing cleaning out our old house which finally is under contract after one year on the market.

I had two calls, on Monday, Jan 12th and Friday, Jan 16th. Monday's call was probably easier, with 43 pages, 14 consults, and 4 cases (I&D buttock, lap chole, and 2 lap appy.) Friday's call had 64 pages, 16 consults, and 4 cases (lap chole, washout and closure of knife wounds, a grueling 6 hour long common bile duct exploration, and a lap appy.) Then on Saturday morning, we did a 2 hour long lap chole for acute cholecystitis on someone who came in the day before. The gallbladder was about 8 inches long by 3 inches wide and filled with huge gallstones. Normally, the resident on-call on Saturday is supposed to do the case, but I like doing that case and it was someone who I had admitted, so I scrubbed.

I think I need a vacation - my last one was in July.

Cannot... Wait... For... Vacation...

2009-01-11T18:10:00.000-08:00

Well, I made it through two more call nights. The first was Jan 5th and the second was Jan 8th. It was nice having four days off from Jan 1st through 4th, but it seems like all I do is call these days. I'm on vacation after this upcoming week and I can't wait. I have three major goals during vacation: 1) get my life in order 2) study for ABSITE and 3) take my USMLE Step 3 exam. Not necessarily in that order.

I've been keeping stats on the calls, and now it's kind of funny that my co-residents and attendings ask me how many pages I got on the morning after call. I know it's geeky to keep track, but still I keep doing it. I had 72 pages on Jan 5th and 69 pages on Jan 8th. On Jan 5th I had 18 new patients and on Jan 8th I had 12 new patients.

The highlight of the two calls was doing a case at 6:30 AM on Jan 6th for perforated appendicitis. My attending kept thinking we were going to have to open but I managed do the case without attending help and kept it laparoscopic instead of open. The guy left the hospital on post-op day #3 and did very well. I hope he doesn't come back with an abscess.

Next calls: Monday, Jan 12th and Friday, Jan 16th.

Can't wait for vacation.

Merry Christmas...

2009-01-04T13:40:00.000-08:00

Just got back from New Year's break. We had 4 days off, and in order to make this happen I had to work three calls in a row. I'm not sure if it was worth it, although I had a great time visiting my parents in Miami Beach, FL. My sister lives there with her family and on New Year's day my brother and his family flew in. It was great spending time with everyone and especially with my niece and nephew who are 2 years old and 15 months old respectively.

I had overnight call on Dec 22nd, Dec 25th, Dec 27th, and Dec 30th. It was a brutal series of days spent at the hospital and I worked for 97 hours over the week (a generous estimation, it was probably more.) I survived. I guess the hours are what it used to be like for surgery residents before the implementation of the 80 hour work week, but let me write down some statistics about the call in order to compare.

Number of pages per call: Average 71.25 (37, 64, 81, and 103 listed by call)
Number of consults seen: Average 14.25 (6, 12, 26, and 13 listed by call)
Number of cases scrubbed: Average 2.75 (1, 1, 4, and 5 listed by call)

It was a toss-up between Dec 27th and Dec 30th as to which was a tougher call. We had 26 consults on the 27th, but there were less pages. We only had 13 consults on the 30th, but there was 103 nursing calls and 5 long cases. I almost lost it at the end, but appreciated the days off. I'm starting out the first day back with a call, but look forward to one week off for vacation later in the month...

Next call: Jan 5.

Long time...

2008-12-21T12:47:00.000-08:00

It's been a long time since I wrote on this blog. I think I got overwhelmed with intern year and was too tired out to blog. In the last two years since I've written a lot has happened. Professionally, in my intern year I finished the year strong, winning two awards, one given by the nursing staff and one given by the medical students. My second year of training didn't go as well though. In retrospect, my weaknesses stemmed from lack of confidence in the operating room and lack of efficiency in seeing consults, etc. The third year of training is going better in my opinion, but I haven't had my annual review yet. I have gotten more efficient and I think that I am more confident in the operating room these days. I truly enjoy being in the operating room and I am now comfortable working with many of the attending surgeons where I used to be nervous around them...

Currently, I am doing a rotation at a community hospital in a city 30 minutes away from where I live. We rotate through this hospital for a month as interns and then we spend half of our third year of training at the hospital. It's an amazing experience this year but very tough. We are on overnight call every 4th night and we get tons of consults and operative experience. The hospital is also a level one trauma center and we get multiple trauma admissions every day. Thank goodness we have a lot of help from Physicians Assistants, who work with the surgical residents in rounding and taking care of all the trauma patients.

I was last on call on Friday, Dec 19th. I started tracking how many pages I got on this rotation while on call and on Friday I got 58 pages during the day. The most pages I ever got was 110 pages in a 24 hour period, so this wasn't bad. I also did 5 surgeries during call, including two surgeries that I'd never done before (surprisingly) which were debridement of necrotizing fasciitis and a trauma splenectomy. The most memorable moment of the night was when I performed a rectal exam on a totally drunk guy who had been hit by a car. After the exam he started yelling:

"Someone just violated my anal butt!"
"Whoever just did that is going to pay for it! 100%!"

The entire trauma team was giggling for the next hour about it...

Look for another post some time after my next call.

Next call: Monday, Dec 22nd.

#47: Last call...

2007-01-14T07:05:00.000-08:00

This is a retrospective post. My last call night on Surgery Oncology wasn't too bad. I slept for about 1.5 hours but there was a really sick guy that I inherited by cross-covering a service. He was an 80 pound cancer patient that had just had a minor operation and had the normal amount of post-op fluid resuscitation, but he was so low on protein in his blood that he leaked all the fluid into and around his lungs. He had an increased O2 requirement all of a sudden his lungs sounded like he was underwater. I gave him about 60 mg of Lasix (a diuretic) but he didn't get better and so he ended up getting transferred to the ICU to give him more O2 than was allowed on the floor. He got a CT scan because there was a concern for a blood clot that might have broken off and gone to his lungs but it turned out that he just had a lot of fluid around his lungs.

In the morning, I called my chief just as I thought she might be waking up because I was worried about another patient in the ICU. I asked if she might have any ideas that I might try before she came in but she said that she wouldn't be rounding in the morning because she had to go straight to the OR. So it ended up being the medical student and me who went around rounding on the patients. It took longer than it would have taken had the chief been there, but I went down to the OR and it turned out that I came up with some decent plans for the patients without my chief, so I was pretty proud of myself. About one hour later, I was post-call and my chief sent me home even though there were still things to do. She said "have a good vacation" so I left... Thank you Chief!

Last call night: Friday January 12th
Amount of sleep: 1.5 hours
Currently reading: Heat.
Currently watching: An important basketball game between two rival schools.
Currently listening to: The sound of silence (unfortunately my wife is in the ER on her rotation with an evening shift.)
Next call night: Tuesday January 30th (after vacation!)

#45 / #46: Double shift / Seizure

2007-01-09T07:04:00.000-08:00

I don't know whose idea it was to for me to do a back-to-back shift on Saturday call followed by a Monday call but it was a bad idea. Firstly, let me say that something went wrong because in the month of January most interns have 6 nights of call. I am on two weeks of vacation (half of the month) and I have 5 nights of call. You do the math. It's not really "fair." Not that I got mad or anything - I typically will do whatever anyone asks me to do with a smile.

However, I found that the second consecutive night of call made me incredibly grouchy which had some good (and bad) repercussions. I get signout from three other services in addition to my own on call and one of the interns is post-call so there are usually a lot of unresolved nursing questions that I can't easily answer if the post-call intern doesn't touch base with me before they leave (which was the case on Monday.) Secondly, the other intern who usually helps out with the post-call intern's work had some weird event where he fainted and cracked his head on the operating room floor, so they asked me to cover his service too for the day.

Finally, around 6 PM I started getting slammed with admissions and nursing questions that I felt like I couldn't really quickly resolve. So I went to the head nurse and said: "I'm sorry but I'm a little overworked right now and I can't answer all these questions. Please tell everyone to call me only if a patient is actually sick.." It worked. I stopped getting nuisance calls and only heard about things that actually were important. Wow. Still, I was up until all hours of the morning doing several post-op checks. There was one inappropriate call: the nurse who asked me to prescribe colace (a stool softener) for her patient at midnight. I told her that even though she was calling at midnight that this probably didn't qualify as an emergency and the patient would probably have to wait until either she or I had a free moment to enter in the medicine into the computer.

There was an actual emergency on Saturday night. I got called about a 7-year-old kid who was status-post liver transplant who "had a seizure." Let me tell you, I don't know that much about treating seizures and I was on the complete opposite side of the hospital so I tried to get as much information over the phone as I could, only the nurse who was calling me was the charge nurse and she really didn't know anything about the kid, but she sounded really frantic. I skimmed the chapter in the "Surgery-on-call" book about seizures (not very helpful) and headed over. I got the kid's room and there was no one from nursing around. Pretty weird for how frantic everyone sounded on the phone.

I walked into the room and the kid started seizing again right in front of me. I moved the kid to the center of his bed so he'd avoid smashing his head on anything. Meanwhile, I'm trying as hard as I could to think of what to do in the situation. This was the first time I've ever seen anyone have a seizure, let alone try to treat a pediatric patient. So I called over the call bell (finally four nurses came running) and I remembered that you're supposed to give Ativan to break a seizure if the patient isn't breathing. So with one hand I'm holding onto the kid's shoulder to prevent him from falling down and with the other hand I'm pulling out my "pediatric cheat sheet" to figure out the Ativan dose. By the time I calculated out the dose the kid had stopped seizing. It ended up with a full-scale medical evaluation of the kid - with the chief resident coming in from the department party in a red dress to the neurology resident coming in from home to a stat CT scan. It all turned out fine and the kid didn't have any more seizures after we stopped one of his antibiotics that lowers the seizure threshold.

Last call night: Saturday January 6th / Monday January 8th
Amount of sleep: I don't remember.
Currently reading: ABSITE Review.
Currently watching: youtube.com
Currently listening to: The wind blowing the wind charms outside.
Next call night: Friday January 12th.

#44: Back to work / New Year's resolutions

2007-01-03T07:04:00.000-08:00

Yes, yes. I know I have become the world's worst blogger lately. I had two crazy weeks of a new rotation in early January and have been on vacation for a week now. I was supposed to write this blog two weeks ago in which I meant to write about my New Year's Resolutions which included:

1) Blog in a more timely manner.
2) Work out on non-call days.
3) Clean up the house better.

So far none of items #1 through #3 have been accomplished. Oh well.

The first night of call after New Year's wasn't too bad. I started on a new (old) service which is Surgery Oncology, which I previously rotated through in the second month of internship. This time around it's a lot easier because I am working with another intern where I had previously worked by myself. However, it is a little harder in a sense because there are three 4th year residents who are out of work right now for various reasons and that includes the resident that should be working on our service. As a result, the other intern and I are scrambling around trying to do all the floor work as well as covering some of the cases.

This is great because it means that we get much more operative experience, however, we feel like every other second some one is calling us to help out somewhere yet we can't fill every request. So we've learned to prioritize responsibilities.

Look for more blogs in the upcoming days as I continue to be on vacation.

Last call night: Tuesday January 2nd
Amount of sleep: I don't remember.
Currently reading: ABSITE Review.
Currently watching: Miami Heat versus New York Knicks (live at the Heat Arena!)
Currently listenintg to: My wife playing piano.
Next call night: Saturday January 6nd.

#42 / #43: Christmas Eve Call and more

2007-01-01T10:27:00.000-08:00

Happy New Year!

I took call on Christmas Eve, which wasn't so bad because we normally don't celebrate Christmas. Growing up Jewish, my family and I used to celebrate Christmas by going to see a movie and getting Chinese take-out. When my wife and I started dating, I've spent every Christmas (up until this year) at her parent's house in Pennsylvania. Since she and her parents are Jewish as well (but secular) they don't celebrate Christmas either and instead we have been renting a movie and getting take-out Indian food. Don't feel bad for us for missing out on the Christmas tradition that everyone experiences - we have a great time.

Christmas Eve call was pretty cool because there were three cases that I got to scrub on. The first was a really disgusting case in which someone was so fat that she got skin infections all over her body, and we debrided those areas of skin and put a wound vac on her (the wound vac sucks out all the fluid out of the wound and allows it to heal faster and better.) The second case was a splenectomy. The third case was an abdominal closure on someone who was brain-dead and his family withdrew life support later in the evening.

So the day itself was pretty busy, but the evening was not. My wife came to visit and we hung out for a while around the hospital. I got a series of calls throughout the night that I could basically ignore (I didn't have to physically do anything.) and I got about 6 hours of sleep.

The next call night was on Wednesday, the day before my four days off over New Years. This call night was not very busy but I was covering about 6 pediatric surgery patients and each of the patient's nurses called me incessantly from 4 PM to 11 PM. The majority of the calls were totally not important at all. Once I finished tidying up the pediatric surgery service, I watched some TV until 1 AM and went to bed. However, I got woken up by a semi emergency. One of our patients who we knew had aspiration pneumonia had low oxygen levels all of a sudden. I spent some time working her up and ended up transferring her downstairs to the intermediate care unit. By the time all of that happened it wasn't worth going back to sleep and so I just started pre-rounding for the next day. I was pretty tired, but I had the next four days off so I didn't care!

Last call night: Sunday December 24th / Wednesday December 27th.
Amount of sleep: 6 hours / 1 hour
Currently reading: Starting serious review for ABSITE exam.
Currently watching: Miami Hurricanes versus Nevada (in HD) Go Canes!
Currently listenintg to: Sufjan Stevens.
Next call night: Tuesday January 2nd.

#41: Hired gun

2006-12-29T09:30:00.000-08:00

Vacation was very needed. I got back from a week off in which I spent some time doing a whole lot of nothing, visiting a nearby college town so my wife could interview for residencies, and visiting my parents in Florida. It was tough to go back to work after all of that but I had no choice.

I started the week back at work as a "hired gun". I had previously been scheduled to be on trauma but the Surgical Oncology service was short a senior resident and they asked me to help out the team as an extra body. The first day I was on the service our chief resident was post-call so he went home early and the other intern on the team decided that since I was now on the team that she could leave early as well - even though I didn't really know the patients all that well. That left me as the only resident to round on all the patients in the evening. That was all fine by me, but even though I had switched to another service I was still covering the evening call pool of the previous service, so three services signed out their patients to me in the evening while I was trying to round. To make matters worse, I had to do a procedure on one of my new service's patients by midnight or the guy wouldn't be able to get any nutrition via his central line. So I felt slightly rushed, but the evening turned out to be tolerable in the end - even though I was waking up every hour or so to go check on a patient with low urine output who was in the pediatric intensive care unit (across the hospital from the call room!)

In real time, I have four days off now over the holidays, but I have two more call nights to chronicle in the next two days so look out for some new posts!

Last call night: Monday December 18th.
Amount of sleep: 2.5 hours (in spurts.)
Currently reading: Rolling Stone's Year in Review magazine.
Currently watching: Sound of Music in HD. It is such an awesome movie.
Currently listenintg to: Sufjan Stevens.
Next call night: Sunday December 24th.

#39 / #40: Trauma-rama

2006-12-13T05:36:00.000-08:00

I started a new service: Trauma Surgery.

However, I was only on the service for one week because... I am on vacation this week!!! Thank goodness, too, because I was getting a little burned out. The Trauma service is a lot busier than the previous services I've been on. We have three interns for the service - there are routinely 30+ patients on the service and at least 10 of them are intensive care status. For some reason however, during the first three days of the month I was the only intern working (due to vacation and weekend coverage) and so I was running my butt around the hospital desperate as could be. Every time I thought I'd get something under control another "red trauma" would come into the hospital. A red trauma is a level one trauma - or the highest acuity that a trauma could be. There was one trauma on my first night on call where a guy came after crashing his motorcycle and the ER resident couldn't intubate the patient so my senior resident did an emergency surgical airway in the ER bay! That was a crazy moment.

SENIOR RESIDENT (reaching his hand back): Give me the trach hook!
ME (internal): What the hell is a trach hook? Well, this thing looks like it might be a trach hook. (Hands the tool to Senior Resident)

I guess I picked the right hook because he didn't say anything else after that. We got the airway secured and the trauma work-up continued. I haven't gotten to do that much in the way of procedures or OR time yet. The floor is keeping me busy but I've been told that I can get in on putting in chest tubes or central lines - we'll see as I have two or three call nights left in the month.

My second night on call was ON MY BIRTHDAY. Talk about a terrible birthday present from my program. Oh well. My wife came to the hospital at around 11 PM and brought me cupcakes. I can't say how much that made my night. The call night itself was pretty uneventful - if it hadn't been for checking up on a 5 year old kid's urine output after a nephrectomy I could have gotten around 6 hours of sleep - instead I slept for 2.5 years.

Anyway, vacation has been nice - to catch up on sleep and catch up on my life outside the hospital. Right now I'm in another city (a college town) while my wife interviews for a pediatric residency. Since I'll be at my current surgery training program for another 4 years she's planning to list only the programs in our hometown, but her advisor told her to interview at some other programs as an insurance policy in case something goes terribly wrong with the match. I'm about to walk over to the coffee shop and grab a late breakfast - vacation is awesome!

Last call night: Saturday December 2nd and Friday December 8th.
Amount of sleep: 1 hour and 2.5 hours (in spurts.)
Currently reading: Harper's Magazine.
Currently watching: Jackie Brown. Catching up on some Netflix as well.
Currently listenintg to: Fountains of Wayne.
Next call night: Monday December 18th after vacation.

#37 / #38: Sayonara neurosurgery suckas

2006-12-12T06:43:00.000-08:00

The last two call nights for neurosurgery weren't too bad although I am still frustrated with the whole experience of working my butt off for senior residents who don't care at all about anything else but whether I discsharge patients from the service or not. They don't even go into the rooms of the patients. They don't care about the patients.

Case in point: On one of the last nights on the service I was taking care of a patient who was on our service because he had metastatic cancer to his spine and we had taken a biopsy of the mass. The patient was a fifty-something year old self professed "country boy" - a former mechanic who now weighed 90+ pounds and was wasting away from his disease. The patient had been on our service for at least three weeks because we just couldn't find a nursing home that would take care of the patient. I had a good relationship with the patient and his family because when he first came into the hospital he had been somewhat demanding and I spent an evening calming him down and in the end we ended up having a joking relationship... In any case, over the previous two days the patient had been very sleepy on morning rounds but in the afternnoon he started having trouble breathing. I worked him up with a blood gas and a chest x-ray. The gas showed that there was something wrong with his breathing and when we pulled up his chest xray it showed a completely white left lung showing a likely effusion (fluid between the lung and the ribcage.) What this meant was that his cancer had likely spread to his lungs. I told my senior resident and he told me this:

"Go up the patient's room and call a medicine consult. If the medicine consult won't see the patient then call a code so someone else (besides me) will take care of the patient."

What was I supposed to do? I called the medicine consult and without threatening the above I got the medicine resident come help me take care of the patient. We were going to do a thoracentesis (drain the fluid off the outside of the lung) but then I realized that we shouldn't do that up on the floor during change of nursing shift (and the night shift on this floor is essentially like having no nursing care at all) so I suggested we transfer the patient to the stepdown unit first. The medicine resident decided to transfer the patient to the oncology service, which was the appropriate thing to do. We (neurosurgeons) should not be taking care of end-of-life oncology patients, but the next thing that happened was really upsetting. The medicine resident called my senior resident to discuss the care of my patient and my senior resident was really insulting towards the medicine resident and said that medicine had to take the patient and if they didn't, the neurosurgery service "would neglect the patient." I don't understand why this had to happen. Medicine had already decided to take the patient and there was no need to make them feel like chumps about it.

The medicine consult resident ended up staying late after she was supposed to go home so I decided to stay late as well. Our patient was clearly out of it mentally at this point so we ended up talking to his sister. Reading the above story it may be obvious that the patient was nearing the end of his disease course, but when we started talking about this fact to his sister she said that no one had ever talked to her about the fact that her brother was nearing the end of his life and she started crying. We spent a lot of time with the sister and talking about what would happen next.

The next morning none of the neurosurgeons even noticed that the patient was off of our rounding census and no one asked me what happened to him.

Later the next day I stopped by my patient's room and they had decided to stop all medicines and let the patient go home to spend time with his family at the end of his life. His whole family was in the room and the patient was delirious - thinking he was still in his garage. I said goodbye to him and spoke to the family outside his room. They were upset about the fact that their relative was delirious and dying but had dealt with similar situations with other family members recently and therefore were coping well. They were reminiscing about their relative and told me the following story:

My patient, the self-professed "country boy" mechanic used to own his own garage. He drove a golden colored Corvette and used to chauffer his pet white poodle around in it. He'd always leave the poodle in the car when he went out to dinner with friends and he'd bring a doggy bag back to the car and feed his dog while tearing it up down the road. It was such a nice image, and I thanked the family for sharing it and wished them luck as I headed out of the hospital for the evening.

Last call night Saturday November 25th and Wednesday November 29th.
Amount of sleep I don't remember.
Currently reading: Heat. A novel about a writer who works in Mario Batali's restaurant (aka Multi-Mario)
Currently watching: Monday Night Football on HDTV. I made the splurge and it's great.
Next call night: Saturday December 2nd after switching to Trauma Surgery.

#36: Thanksgiving

2006-12-12T06:40:00.000-08:00

I just got back from Thanksgiving vacation; it was great to visit with family and to meet my new niece! My brother and his wife are new parents to a baby girl now barely over one week old and as cute as could be. The new generation of Maturins has just begun!

However, in order to take vacation I had to take call the day before Thanksgiving and then take call on the Saturday night after Thanksgiving. The good news is that Saturday night call the weekend of Thanksgiving seems to be a pretty quiet night. There is really nothing for me to do other than watch Kevin Costner movies on TV and you know you have to be bored out of your mind to do that.

Call on Tuesday night before Thanksgiving was pretty cool. I had one easy admission at 7 PM and I assisted on a short case at around 10 PM. Despite that, I was still busy until 2 AM so I didn't get much sleep. We'll see how much sleep I can get tonight - the intern on last night claims to have slept for 5 uninterrupted hours.

Last call night Tuesday November 21st.
Amount of sleep 2 hours.
Currently reading: Stiff (a novel about corpses - really it's a lot more interesting and less macabre than it sounds.)
Currently watching: Dances with Wolves AND Robin Hood. I can't believe there are two Kevin Costner movies on at once.
Next call night: Saturday November 25st.

A little moderation

2006-12-11T13:37:00.000-08:00

Apparently someone used my blog comment to advertise how much he loves Jesus Christ instead of commenting on my blog itself. Furthermore, he went on for 3 pages on how much he loves Jesus Christ, therefore Therefore from now on the comments on my blog will be moderated meaning that I have to click on an "approve" or "reject" button for each comment. Sorry loyal (six) readers, but I am going to delete the comments from my last blog entry (as I can't delete individual comments.)

Comments from the previous post were:

Dr. WhoAmI said...
I love Jesus Christ (for 3 pages long)

sarah said...
ahhh your last comment = so scary! i miss youuuuuuuuuuuuuuuuuuuuuuuuuu so guess who this is. . . .

Sun Nov 26, 04:49:32 PM 2006

vickie said...
yeah, i don't know about that. weird.

Mon Nov 27, 05:28:48 PM 2006

atilla said...
dr whoami is not exactly succinct...i'd lump him into the dangers of the internet...also an advantage... you'll never be in the same room with him

Sun Dec 03, 09:01:06 AM 2006

#31 / #32 / #33 / #34 / #35: Neuroslavery

2006-11-07T16:09:00.000-08:00

Yes, yes. I know it's a big cop-out to bundle up 5 nights of call action into one blog post. It was interesting to hear everyone's perspective on how days in the hospital and office life have "themes."

Most recently I started on a new service: Neurosurgery. I call it Neuroslavery because I've never been treated so much like a gopher by senior residents on any other service. The neurosurgery program at my hospital is pretty small - there is only one resident in neurosurgery per year of training - and they all work on the same service together all year round. The intern, or member of the team with the least amount of training (ie. me), is NOT in the neurosurgery program. Since all of these people work all year round together, I don't feel like part of the team since they were such a close-knit group. Furthermore, I think they think of me as free labor. They expect me to do all of the dirty work like seeing all the patients, writing daily notes, writing orders on all of the patients. Then, they don't look at any of the studies that we order during the day - they expect me to look up and know all of the results (which I do) but when I discuss the results on rounds half the time they have forgotten what the results are by the next morning and they ask again. Furthermore, they ask me to consult other services to ask some of the most ridiculous questions I've ever heard. For example, the other day a woman was coughing (no fever) and we started her on cough drops and sent a test that ruled out strep throat in the woman. Yet still, my senior resident asked me to consult the Internal Medicine service to ask them about the best management of sore throat and coughing. I felt like the biggest jerk paging the Internal Medicine people and asking for their help. Finally, there is a nurse practitioner in the neurosurgery clinic who calls all day long and asks me to go to clinic to write pre-operative notes. This is totally ridiculous because she was hired by the clinic in order to do the very job that she asks me to do, yet somehow they want me to hike across the hospital (5 minutes) in order to interview the patient (10 minutes) and fill out a pre-op sheet (5 minutes) and then walk back to the wards (5 minutes.) In total, it's 25 minutes of my time in order to save the nurse 5 minutes of her time.

No, I'm not bitter about the month at all...

The only saving grace about the rotation is that call nights aren't as difficult. I cover Ear, Nose, and Throat patients, Plastic Surgery patients, and Thoracic Surgery patients. The Thoracic Surgery patients can get very sick - like the other night I was on call a guy was bleeding into his lung after surgery - but overall I've gotten more sleep and had less admission work-ups at 3 AM than on my first few rotations...

Last call nights/amount of sleep
Wednesday November 1st (3 hrs)
Saturday November 4th (30 min)
Thursday November 9th (3 hrs)
Monday November 13th (4 hrs)
Friday November 17th (1.5 hrs)
Currently reading: Just got my first Journal of American College of Surgeons.
Currently watching: HBO's Rome. Seems like a pretty cool series so far.
Next call night: Tuesday November 21st.

#29 / #30: Saying goodbye to the private world

2006-11-07T16:02:00.000-08:00

Somehow my schedule got the best of me and I haven't been updating the blog. I know that all six of you who read my blog were disappointed, but I'm encouraged that the number of readers has grown from four to six.

I finished up the last two nights on call at the private hospital and they were all good experiences:

Call #29: Theme of appendicitis! I did a pediatric laparascopic appendectomy and assisted (held the camera) on two adult laparascopic appendectomies.

Call #30: Theme of falling. Two mexicans injured in separate incidents by falling from at least 20 feet in both cases. They both arrived at 10 minutes from each other in the ER.

I started a new rotation back at the university hospital on neurosurgery. I'll write about that later tonight.

Last call nights Sunday October 22nd and Thursday October 26th.
Amount of sleep last call night: I don't remember.
Currently reading: Rereading Ender's Game.
Currently watching: Borat. Hysterical.
Next call night: Wednesday November 1st.

#27 / # 28: Another tale of two patients

2006-10-21T12:59:00.000-07:00

Compare this essay to a previous post comparing two patients.

The trauma experience continues at the private hospital. I've seen and taken care of several patients lately who have been involved in some serious traumas. My last call day started out at 7:15 AM when a patient came in from a high speed collision and they overhead paged saying that a patient had just arrived in the ER. She was in an accident and being transported to the hospital when suddenly she lost consciousness and the ambulance crew couldn't find any pulse and in the ensuing chaos the ambulance never notified the hospital that they were bringing in the patient. She was intubated and stabilized in the emergency room and transferred to the operating room where we explored her abdomen for a source of bleeding (none was found) and her chest was opened because her heart rate dropped precipitously but her heart stopped and she never made it out of the operating room (we were going to send her to interventional radiology to see if she was bleeding into her broken pelvis.)

It was a strange feeling to see a patient lose her life without having any personal connection to the patient. I never even knew her real name - she was just "Trauma Female" on her charts. I wasn't scrubbed on the case so I didn't have a personal connection - just a peripheral involvement as I got paged from 10 minutes into the trauma saying that I should go to conference even though there was a trauma because there weren't enough people in conference. After conference, I went to the operating room where we were losing the patient and I made a few calls trying to get the patient to interventional radiology but she crashed during my calls. It was a frightening chaotic experience but in the end my level of involvement in the case made it feel for the patient just about as much as if I had seen the whole experience in a movie.

On the other hand, I have a really strong connection to another patient who I met in clinic for treatment for a diabetic foot ulcer. The patient was in his mid-twenties and has type 1 diabetes for more than 10 years (poorly controlled) and as soon as I walked into the clinic room I knew he was going to lose his foot based on the smell alone. We admitted him, took him to surgery the next day for a toe amputation, and he's been recovering and working with physical therapy the past few days. I keep going by and trying to give him pep talks on how to better control his diabetes. He seems extremely motivated to do so after this recent complication and we've managed to get his sugars under control in the hospital so we'll see. He's broken down and cried twice this hospitalization: once when we were talking to him about the possibility of an amputation and the other time when I was first changing his dressings and he started thinking about his cousin who recently died in the hospital.

Last call nights Sunday October 15th and Thursday October 19.
Amount of sleep last call night: 1 hour and 2 hours.
Currently reading: Greenfield's Chapters on Trauma.
Currently watching: Arrested Development. Not as good as Six Feet Under.
Next call night: Sunday October 21st.

#26: Trauma One ETA 5 minutes

2006-10-11T19:02:00.000-07:00

Nowadays I get pages like "Trauma One 18 year old with multiple stab wounds to chest, difficulty breathing, ETA 5 minutes." (ETA=estimated time of arrival) That was the page I got just as I was sitting down to lunch yesterday. Since I was on call, it was my job to run to the trauma bay to staff the patient. We evaluated the patient, who had "5 beers and 3 shots" and whose urine tested positive for cocaine and marijuana. He had two stab wounds, one under his arm and one in his abdomen. On CAT scan he had blood pooling around his lungs, compressing half of his right lung, and I volunteered to put in a chest tube. (The only other time I'd put in a chest tube was in the operating room when the patient was intubated and sedated.) Right as we were prepping the table for the chest tube insertion, the patient's heart rate started drifting downwards and he started dry heaving, evidence that the blood collection was at the very least irritating his heart if not compressing his heart and lungs. I dissected through his chest wall, got into the lung space (blood came pouring out) and put in the chest tube and his heart rate came back to normal!

What a great feeling to be able to make a difference! However, what I didn't say above was that it took me about 10-15 minutes to be able to dissect down into the lung and it was hard for me to get the chest tube into the space. The whole process should have taken me 2-5 minutes if not faster. Also I got some blood on the floor (well, that part was pretty cool - made me feel like a trauma surgeon - and don't worry mom we wear all sorts of protective gear so no contamination.) Finally, what difference does it really make in the world to perform therapeutic interventions on cracked out drunk teenagers who get into knife fights at 1 PM on a Wednesday?

Yesterday's call had a theme: motorcycle accidents. We had three patients who came in after motorcycle accidents with serious broken bones. One guy was a college student who lost control of his motorcycle - he was this tough looking 6'4" muscular guy who was literally crying and begging for pain relief all afternoon long waiting for an operating room to open up so his leg and arm could be screwed back together. I had never had the desire to ride a motorcycle but this was a new experience. I am sure I will tell my kids about the patients I've seen with these sorts of accidents, but it never really hits home or becomes real until seeing the patients in person.

Last call nights Tuesday October 10th.
Amount of sleep last call night: 2 hours.
Currently reading: Greenfield's Chapter on Diverticular Disease.
Currently watching: Goodbye Lenin.
Next call night: Sunday October 15th.

#24 / #25: University versus Private

2006-10-08T13:11:00.000-07:00

On Monday I started a month-long rotation at a new private. The hospital where I spend the other 11 months of the year is a University hospital located in a college town while this new hospital is the only Level 1 trauma center in a nearby city with population 275,000 people. There are a lot of really cool benefits of working in the new private hospital:

1) The structure of the rotation is greared so that there are four more senior residents and only one intern. This is the first time that these residents are allowed to manage patients on their own and they don't like letting the intern (me) make a lot of decisions. That translates into very few pages during the day for me and a lot less work directed towards the intern.

2) As a result, I get to be the first assistant on several cases during the day without interruption. True, the cases I get (hernia repairs, hemorrhoidectomies) are not as glamorous as the cases that the senior residents assist on, but it's great experience for me to get to the operating room.

3) There is free lunch every day and free breakfast three days out of the week for surgeons.

4) Call nights at the University hospital are characterized by a seemingly endless stream of calls from nurses. Many of the calls translate into "Please do my job for me." At the private hospital, I don't get any of these calls because for some reason all of those calls go to the senior resident on call. Instead, my responsibilities are to see consults and to go to traumas that arrive in the emergency room. As a result it's a much more intellectual exercise for me.

The trauma experience at the new hospital is really interesting and exciting. However, I don't have much experience with traumas so I have a lot to learn. Still, there's nothing like being the first people to evaluate gunshot wounds and knife wounds and car crash patients - both terrifying and exhilarating at the same time. I've also had the chance to assist on several good operations like a laparoscopic removal of gallbladder and laparoscopic removal of appendix. One of the attending physicians lets me do a lot of the operation by myself which is totally amazing.

Last call night I met a patient at 2:30 AM. The guy had appendicitis and he was shivering, in pain, and vomiting all day long. We took him to the operating room at 5 AM (when it was available) and my attending let me do a lot of the operation. I saw the patient at 11 AM and he was without pain, comfortable, and we had curing his disease. It was such a great feeling to be able to cure the patient and a great feeling to have more responsibility in taking care of patients in the new hospital.

Last call nights Monday October 2nd and Friday October 6th.
Amount of sleep last call night: 2.5 hours and 1.5 hours.
Currently reading: Greenfield's Chapter on Anorectal Disorders.
Currently watching: Enterage Season 2.
Next call night: Tuesday October 10th.

#23: 25% done

2006-09-30T12:00:00.000-07:00

Last call night was my 23rd call night and it was the last call night after three straight months of call on the same general surgery service. Since I've rotated through 3 of the 4 services that share the same call pool I've really gotten to know most of the patients that I cover on call. Also, with three months of intern year finished, I'm 25% of the way through intern year! When I think back to all of the days and nights that I've spent in the hospital it's completely amazing how much I've learned and the amount of confidence I've gained in taking care of patients in the hospital.

Still, there is so much more to learn - I started helping to take care of a really sick patient in the intensive care unit this week. I was totally terrified the other day when my chief resident told me to leave our pre-operative planning conference to go take care of the patient while he finished presenting patients for the conference. I went over the ICU and the patient's heart rate was racing, his blood pressure was falling, and all of the nurses were asking me what to do. I really didn't know what to do - what medicine to hang for him - because every medicine drip that we adjusted changed the patient's heart rate and blood pressure. I felt like we were walking this very fine line between keeping the patient going and watching him crash. I have a lot to learn about how to manage really sick patients like this one. Thankfully, my chief showed up after a while just as the patient was starting to stabilize and I felt a lot of relief.

I ran out of moeny on my meal card on my last call night so I could buy coffee at midnight like I usually do. As a result, it took me until 4 am to finish the amount of work that I would normally finish by 3 am and as a result I only got 60 minutes of sleep before the 5 am pages started rolling in.

Next month I'll be working at a private hospital affiliated with our university hospital. Everyone who works there says it's such a nicer experience and as interns we actually get to operate all day and call nights are not a rough as there are less pages and less acute problems. It'll be a nice change.

Last call nights Wednesday, September 27rd
Amount of sleep last call night: 60 minutes, .
Currently reading: Greenfield's Chapter on Ulcerative Colitis
Currently watching: Heroes Premier Episode (recorded) I've always wanted to have super powers.
Next call night: Monday, October 2nd.

#22: My heart beat a little faster

2006-09-30T11:39:00.000-07:00

I'm starting to see different themes to my call nights. The previous call night was characterized by fever work-ups, and Saturday's call was characterized by cardiac arrhythmias. The first one happened when I was talking on the phone and I heard out of the corner of my consciousness: "Anesthesia to the CCU." I thought about it for a second because we had a patient in the CCU but that patient was already intubated so I didn't think that patient would have an acute event. The next thing I heard was "Stephen Maturin report to the CCU." Holy crap! Did I just get overhead paged on the hospital-wide overhead? I ran down to the CCU and it turned out that my chief resident had paged me because we had worked a code on the same patient two weeks ago - the last time we shocked the patient but this time she had a implanted defibrillator so she probably got shocked again.

The next second I got paged to another patient's room for rapid heart rate. The patient had an extensive history of cardiac disease and so we hooked up the defibrillator to his chest but by the time we hooked it up to his chest he had gotten out of the arrhythmia. Luckily my senior resident stopped by the room and her previous plan was to start a new medication in case this patient had the arrhythmia again (he had previously had several episodes) and so I didn't have to figure out what to do to treat the patient.

I've been pretty confident in what to do in most situations as an intern on call but it turns out that I don't really know what to do in the case of cardiac problems. It's a pretty terrifying experience and I really need to read a little this weekend about what to do in these sorts of situations.

Last call nights Saturday, September 23rd
Amount of sleep last call night: 90 minutes.
Currently reading: Greenfield's Chapter on Crohn's Disease (still)
Currently watching: America's Test Kitchen "BBQ Pulled Pork".
Next call night: Wednesday, September 27th.

#21: Tuesday Night Fever

2006-09-21T16:49:00.000-07:00

Tuesday night's call had a theme to it: fever. There were five patients with new fevers that I worked up. One of them was really scary: a lttle old woman who started shivering and became unresponsive before my eyes. Her pulse was around 130 beats per minute and they couldn't read her blood pressure. That's what happened the first minute I walked into the room. I wasn't quite sure what to do since she had just come back from a procedure earlier in the day AND she had her bladder catheter taken out a few hours before. It turned out that her blood pressure was normal when I checked it manually, but she still had the elevated heart rate and wasn't talking to me. We put her bladder catheter in, a bunch of urine came out, and within 2 minutes she woke up and her heart rate came back to normal. Who knows what happened, but we transferred her to a nursing unit with closer supervision. She was the first patient I've seen who deteriorated right before my eyes and it was pretty scary.

There were four other fevers to work-up that night and one admission that came at midnight and another that came at 3 AM. In the end, I didn't get much sleep and I was pretty worthless the next morning. I spilled my coffee all over the floor and fell asleep in grand rounds. Thankfully, today is an easy day and I got home at 7:30 PM and get to spend time with my wife!

Last call nights Tuesday, September 19th
Amount of sleep last call nights: 30 minutes, with my head on the desk.
Currently reading: Greenfield's Chapter on Crohn's Disease
Currently watching: The new season of Gray's Anatomy.
Next call night: Saturday, September 23rd

#18 / #19 / #20: The Program Director's service is kicking my butt

2006-09-17T14:35:00.000-07:00

Well, it was nice to hear from several of my friends and family that they missed my blog this past week. I was absent from the "blogosphere" because, contrary to my previous post, the Program Director's service is NOT easy. In fact the service is the hardest one I've done so far. We have two operative days per week in which we run two operating rooms each day. Most of the patients are ones who had several failed operations by other surgeons and my attending fixes up everything and connects it so their gastrointestinal tract finally works. These patients had lived with a lot of pain prior to their operations and they are often on chronic pain medicine. What this translates into is a bunch of patients to take care of after surgery and their post-operative course is difficult and protracted. Or stated another way, there is a lot of shit to deal with (both literally and figuratively.)

The last three call nights have been very busy. Thursday night I was in the operating room for the first part of the call, so I was very behind and all the other interns signed out a bunch of post-operative patient checks for me to do. Then there were two patient admissions at 3 AM and 5 AM and therefore I didn't get any sleep at all! I don't even remember what Monday night's call was like. On Friday night, there was some really poor nursing, and I got a bunch of pages from those nurses. Each of the pages could have been translated into: "Please do my job for me." There was the time that I had to go into the room of a patient with a nurse and had to talk to the patient in order to convince them to take their medicine (her nurse should have been able to do this.)

Then there was the time that the patient had a fever of 102 degrees on the night just after they had surgery. The #1, #2, and #3 cause of post-op fever is when patients don't breathe correctly. I asked the nurse whether the patient was using their incentive spirometer (a breathing machine) and she said, "What is an incentive spirometer?" Then she called me back two hours later (at 5 AM) and said that the patient WAS using the incentive spirometer but he still had a fever. I went to the patient's room and she had taught the patient to use the breathing machine UPSIDE DOWN and EXHALING instead of INHALING. I sat in the patient's room and taught him how to use the machine and in 2 minutes he no longer had a fever.

I'm going to start calling up my attendings every day every time I get paged and say "Please do my job for me."

Last call nights Thursday, September 8th / Monday, September 11th / Friday, September 15th
Amount of sleep last call nights: 1 hour / 1 hour / 2 hours.
Currently reading: The News and Observer Weekend Paper!
Currently watching: Miami Football (Hurricanes and Dolphins) - neither team is doing so well these days.
Next call night: Tuesday, September 19th

#17: The Program Director's service is easy

2006-09-09T13:28:00.000-07:00

This is a retrospective post from Sunday night's call. My actual last call was Thursday night, which means that this weekend is my GOLDEN WEEKEND! Look for a post tomorrow about Thursday night's call, which was pretty uneventful.

Sunday was notable for one of my patients coding. It was a patient I was cross-covering, and I heard the "Code Blue Transplant Floor" and I was like "Holy crap! That's one of my patients!" I ran up to the floor and compressions were just started. Luckily, the transplant attending was on the floor and therefore I was the fouth or fifth physician to arrive so there was a very fast response. We shocked and intubated and the patient regained a rhythm and then got transferred to the Surgical ICU. Score one for advance cardiac life support - so far I've been to three codes and two of the patients regained a rhythm afterwards, which I think is probably above normal percentages. On Sunday I tired to go to sleep at around 1 AM and finding out that there was a new patient who all of a sudden just showed up on the floor transferred from another hospital without any information about why they were being transferred. Furthermore, the patient was Spanish-speaking only and even though I speak a little Spanish there is no way that I could figure out anything more complicated than whether or not a patient has pain in their abdomen or if they have flatus or bowel movements and therefore I had to call a Spanish Interpreter at 1 AM. According to law, patients being transferred should come with a discharge summary but this one didn't and therefore their transferring hospital COULD be fined $10,000 but I guess that road is never pursued.

I started on a new service which is GI Surgery (my second month since I also did GI Surgery in July.) However, this new service has only one attending, who happens to be the Program Director. So far the service has been pretty easy, but that's because the Program Director was on vacation this past week. His service is typically very busy and next weeks looks to be pretty tough!

Last call night Sunday, September 3rd.
Amount of sleep last call night: 1 hour.
Currently reading: The News and Observer Weekend Paper!
Currently watching: He Got Game. Denzel and Spike Lee are awesome. Ray Allen is too, but he's not the best actor.
Next call night: Thursday, September 7th

#16: Adhesions

2006-08-30T16:17:00.000-07:00

I've been continuing to bust my butt getting floor work done and have been getting to the operating room a fair amount. Yesterday I assisted for a serious abdominal operation for about 1.5 hours. They've been calling me down to the OR a lot - to help close cases - to help open cases - to do minor cases - etc... It's pretty hard to do all the operating and do the floor work and by the end of the day I get sort of stressed out - my chief resident asked me last night on rounds why I kept sighing every time she asked me to do something else that night. It was because it was 8 PM and every time she asked me to do something it meant it would be even later before I could get something to eat and I hadn't eaten anything since breakfast. I said I was sorry and I stopped sighing. It wasn't until 12:30 AM or 1 AM until I got anything real to eat and it was a sad lunch: a grilled turkey and cheese from the grill (the only food option available.)

Anyway, back to the operation - a 90 pound woman with multiple operations in the past for bowel obstructions presented with another bowel obstruction. We opened her abdomen and began the process of trying to figure out where her bowel was obstruction, which meant about 2 hours worth of dissecting through adhesions. It was pretty cool to assist on this operation - I learned a lot about how to dissect through all the old scars intrabdominally - sort of gross but cool in the same way - I'll be even more invested in the patients post-op recovery now that I helped out with the operation.

Last call night: Tuesday, August 29th.
Amount of sleep last call night: 1.5 hours.
Currently reading: My wife's blog.
Currently watching: Six Feet Under Season 5.
Next call night: Sunday, September 3rd (that's 5 days between call nights - for the first time in a long string of call every 4 nights!)

#15: Friday night is the worst night for call

2006-08-27T15:38:00.000-07:00

Friday night is probably the worst night to be on call because everyone wants to get out of the hospital for the weekend and they sign out a lot of work for the on-call intern. Then, on Saturday morning, no one else is around to help round. Adding to this, one of the senior residents on our service was out of town and the attendings and other residents kept asking me to come down to the operating room to assist with cases. This is great because I love to be in the operating room, but all the other residents only have to operate all day long and I have to do all this work on the floor for the other patients during the day in addition to operating!

So I went into call with several daily notes still left to write and several other tasks to do for the evening, and I was hit with several tasks that got signed out to me. There were three unplanned admissions (our service wasn't even on call) and taken together all this added up to me not getting everything done. I did most of the major stuff and I was running back and forth between two ends of the hospital taking care of two patients throughout the night, and I feel like I did a decent job: one patient got a full work-up for heart attack and evaluation for pulmonary embolism and the other patient went to back to the operating room the next morning, and I think I got both patients through their work-up as expediciously as possible. However, I got no sleep.

Friday night is the worst night for call.

Last call night: Friday, August 21st.
Amount of sleep last call night: None.
Currently reading: The Sunday Paper.
Currently watching: America's Test Kitchen on PBS.
Next call night: Tuesday, August 29th.

#14: Operative experience

2006-08-26T17:08:00.000-07:00

This month has been really great in terms of getting operative experience. Every Tuesday and Friday as I mentioned I am the assistant for minor cases for this one relatively young and intense attending surgeon who specializes in surgical oncology. The cases are usually excisions of melanomas/other skin lesions and excisional biopsies of breast masses. As I mentioned before, my job is to prepare the patient for the procedure by setting up a sterile field before my attending arrives in the room. The first week that I worked with him I was running around the hospital discharging patients and I would get a page from the procedure room saying the patient was ready and I'd drop everything and go running over to the room to start the preparations only to find my attending show up 2 minutes later so obviously the patient would not be prepped for him.

Outside while we were scrubbing for the case he said to me, "Stephen, you don't have to hang out here in the procedure room all day but you need to figure out a way to get the patient prepped before I show up." That would have been fine, but he then added: "You are acting more like a medical student and I need a MD." Well that really made me mad because all I was doing all day was busting my butt for the service getting patients discharged (and doing a decent job at that!) I would run over as soon as I was notified and this was the thanks I get! All I said was "OK."

In the subsequent weeks I figured out how to beat my attending over to the room and prep the patient and in return my attending has been giving me tips on technique and whatnot. I've worked with several attendings and this particular one is really gifted in technique. He's not overly fast with his hands but he's very deliberate and does things exactly the same way every time and in the end our cases end up taking much less time than the other attendings. I don't think I'd like to be like my attending in terms of personality, but I'd definitely want to be much like him in terms of technique.

Last call night: Monday, August 21st.
Amount of sleep last call night: 90 minutes.
Currently reading: The Sunday Paper.
Currently watching: Gray's Anatomy.
Next call night: Friday, August 25st.

#13: Swamped

2006-08-19T11:11:00.000-07:00

I was so wiped out after Thursday night's call that I took a 3 hour nap at work in the call room before I drove home. I drive about 30 minutes door to door at 6 AM and 45 minutes door to door at 5 PM and I've been having trouble with falling asleep at the end of my drive home so I opted for the nap.

The last call night wasn't overly busy but I had been assigned several tasks that I knew I would not be able to complete in the time that I had. I had to prepare 6 cases for discussion in morning conference, get four discharges set up for the next day, and dictate several past discharge summaries before the patients came to clinic the next day. Add to that the three post-op checks that were signed out to me and the patient who showed up on the floor at 1 AM as a transfer from an outside hospital without any documentation about why he was transferred and understandably I didn't get any sleep.

I've been more in volved in teaching the medical students lately. The medical students like to hang out with me during the day and during call because I keep a running conversation going about why I am doing what I'm doing and I let them try things like drawing blood on patients and whatnot. I really enjoy teaching medical students, and when I've taught them a few things they can really help me out when they offer to pull drains, remove surgical staples, and other various jobs. I don't think they mind doing the scutwork because I always try to make it worthwhile for them by teaching them little intern tricks I know in return...

Last call night: Thursday, August 17th.
Amount of sleep last call night: 10 minutes in 2 periods of 5 minute naps.
Currently reading: Greenfield's chapter on Hepatic Neoplasms.
Currently watching: We are going to see Little Miss Sunshine tonight.
Next call night: Monday, August 21st.

#12: Code Blue

2006-08-16T16:09:00.000-07:00

I only slept for 1 hour on my last call night, which was unusual because it was on a Sunday night. Usually not much is going on Sunday night but at 2 AM there was one patient who had a minute-long run of a cardiac arrhythmia and I went to the Cardiac Intensive Care Unit in order to ask for some advice about what to do. As I walked in, I heard over the hospital-wide loudspeakers "Code Blue Cardiac ICU" and I was like, "Holy crap, that's right here!" I walk around the corner and there was a full-blown code going on with chest compressions and shocking and all. I went up to the person who was running the code, introduced myself as a surgical intern, and asked if she needed a central line. I put in a femoral line even though I couldn't feel a pulse in the guys leg but somehow it worked. It wasn't the first code that I've been in, but it was weird because I didn't even know the patient at all. I felt very detatched from the whole situation almost like I was acting on autopilot and didn't know why I was doing the things I was doing. I would have felt much better about the situation except the guy didn't make it through the code.

Last call night: Sunday, August 13th.
Patients covered last call night: 40+.
Amount of sleep last call night: 1 hour.
Currently reading: Greenfield's chapter on Colon Cancer (still).
Currently watching: I came home early today (around 4 PM, trying to cut down on hours) and fell asleep watching Arthur and Friends.
Next call night: Thursday, August 17th.

#11: Mesenteric Ischemia

2006-08-12T10:19:00.000-07:00

I've been really busy at work lately. Though we've managed to get the service size down to a managable number of patients. I'm not sure if this is true or not but I think it's because I'm doing a decent job as an intern. The job of an intern is to discharge a patient once the team decides that he or she is fit for discharge. However, there are usually a number of obstacles preventing a patient from going home which include setting up appropriate home health, getting the patient's nurses to teach the patient about wound care or glucose testing, and any number of unanticipated things. Finally, just as a patient is going out the door do they realize that they want a prescription for this that or another. Once someone tells me to discharge a patient I work as hard as I can in order to make it happen because it translates into less work for me the next day because I don't have to write a daily note on the patient or put in orders if the patient has been discharged. The maximum number of patients that I've discharged is 6 in one day and I almost reached this number yesterday (I discharged 5 and had the last discharge paperwork all completed) but this one patient refused to go home even though we were doing nothing for the patient in the hospital.

My last call night left me super tired the next day. Usually around 2 or 3 AM things wind down and I'm able to grab an hour or so rest, but this night at 2 AM our patient who we suspected had mesenteric ischemia (sort of like a heart attack but affecting the small intestine and stomach instead of the heart) suddenly became symptomatic. All of a sudden she started dry heaving and feeling horrible and she was in a lot of abdominal pain, yet when I pressed on her belly it didn't cause any pain. This sort of "pain out of proportion to exam" is classic for mesenteric ischemia. I called my chief and he came in from home at 3:30 AM which really impressed me and we got labs on the patient and he and I physically pushed the patient down to Vascular Interventional Radiology so we could shoot an arteriogram (look at her mesenteric blood vessels.) The nurses and I were feeling pretty good about things because it was about 2 hours from the time the patient became symptomatic until she was on the table getting a diagnostic procedure. However, now two days later the patient is in trouble (the intervention we got her didn't work, and she's even sicker than before.) My mind is constantly trying to figure out what we should have done differently.

Last call night: Wednesday, August 9th.
Patients covered last call night: 40+, 5 post-op checks.
Amount of sleep last call night: 10 minutes.
Currently reading: Greenfield's chapter on Colon Cancer.
Currently watching: We are going to see Talladegha Nights: The Ballad of Ricky Bobby tonight.
Next call night: Sunday, August 13th.

#10: Verbal sparring

2006-08-10T19:58:00.000-07:00

Sorry I've been absent - surgical oncology really is a difficult rotation compared to my last rotation. I'm writing this entry post-call while I still have two dictations to do and I have to prepare three cases to present at conference tomorrow morning. Also, I didn't get much sleep last night because I was standing at the bedside of a really sick patient all night.

I got in a fight with the transplant surgery nurses on my last call night, which was Saturday August 5th. The night had been going well as Saturdays are pretty chill call days since all the teams sign out to me around noon on Saturday and I have all day to get things under control. At 10 PM, one of the transplant nurses called me and wanted me to order Tylenol for patient who had a liver transplant a year or so ago. I know that we're not supposed to give Tylenol to patients in liver failure but that it's OK to give Tylenol to patients after they've had a liver transplant (they have a new liver after all.) However, this patient was in the hospital because his liver enzymes were elevated and the transplant team was trying to figure out why. So I sort of balked at the idea of giving Tylenol to the patient and had the nurse hold on the phone line while I looked up the patient's liver function tests on the computer. The tests were elevated, so I eventually decided on Motrin at a small dose for the patient's headache and I could tell that the nurse was annoyed at me for taking a long time to decide on this. Besides, Motrin is contraindicated in liver failure as well, but the patient had been getting Tylenol for several days so I thought maybe I'd switch it up. Regardless, the decision was really not that important in the grand scheme of things.

Still, two hours later at midnight the Charge Nurse for the floor paged me on behalf of the nurse taking care of the patient and said that the patient still had a headache and why hadn't I entered the order in the computer so she could give the medication to the patient. Now, I have a pretty easy-going personality but I've found that one thing that gets me mad in the hospital is when patients I am taking care of have pain that isn't addressed promptly by their nurses. Usually when I am on call and there is some medication that is as simple as Tylenol or Motrin the nurse enters the order into the computer herself, but this hadn't happened in this situation. So what this meant was that the original nurse had forgotten about her patient for 2 hours, hadn't given him medicine for his headache, and decided to blame me for her laziness and/or forgetfulness.

Me: Usually on your unit you guys take verbal orders for things like Tylenol or Motrin.
Charge Nurse: We can only take verbal orders in the case of an emergency.

If I entered in orders into the computer for every medicine I gave during a call night for all 45+ patients that I am covering I would not be able to do it. It simply takes too long and in order to do it I would have to spend all night putting in orders into the computer and I wouldn't be able to see patients in person.

Me (slightly sarcastic, slightly joking because usually I have that sort of relationship with the floor): Oh, so that's how it's running tonight...
Charge Nurse (accusatory): What do you mean by that kind of statement?
Me (backpedaling): Oh nothing, sorry. OK, I'll enter in the order into the computer.
Charge Nurse: So what medicine are you going to give?
Me: The same medicine I was going to give 2 hours ago, but I guess what you're saying is that you want to wait until it prints out on the computer to see it, right?
Charge Nurse: That's an incredibly immature statement and I'm going to have to discuss this with the team in the morning. (Hangs up.)

Me (calling right back to apologize and talking to a nurse that I usually work closely with on the floor): I'm really sorry I don't understand what just happened and I must have gotten caught at the wrong moment (blaming myself for the interaction, when in fact it seems like someone just picked a fight with me over nothing.)
Nurse: Yes, I don't understand either. Things have been hectic around here.

I go promptly up in person to the floor with the intention of apologizing. I can tell by the time I get there that they've been talking about me. It seems that the Charge Nurse had decided to pick a fight with me for some reason, perhaps because she thought it was the first night I've covered patients on her floor. I can tell that the nurse that I usually work with has told the Charge Nurse that I am a pretty nice guy, because we have a long conversation where we both apologize to each other. I see the patient in person and apologize for him not getting his Motrin for 2 hours while he has a headache.

A whole lot of hoopla over nothing. Also, I could have been sleeping during that whole hour.

Last call night: Saturday, August 5st.
Patients covered last call night: I don't remember but probably 40+.
Amount of sleep last call night: 3 hours!
Currently reading: Patient histories.
Currently watching: On Sunday post-call I watched the first few laps of the Indianapolis 500 with a patient who is a huge NASCAR fan.
Next call night: Wednesday, August 9th. I'll write another blog this Saturday about the call night, in which I get 10 minutes of sleep while taking care of a really sick patient who had mesenteric ischemia.

#9: Surgical Oncology

2006-08-07T08:09:00.000-07:00

Here it is on Monday morning and I just woke up 2 hours ago because I have the day off! Quite a change from the 4 to 5 AM wake-up times I've had for the past few days. I started a new service, Surgical Oncology, on Tuesday morning and it's been a lot more work than my previous service (Gastrointestinal, or GI, Surgery.) GI Surgery had two attendings but Surgical Oncology has three attendings so there are more patients that receive operations on my new service which translates into more patients that I have to take care of. Also, last month before I started on Surgical Oncology there were two interns who were doing the same amount of work that I am now doing by myself. I guess it's fair because last month was the first month in the training cycle and the service needed two interns since all of the interns were learning the system...

Now I also have the additional responsibility of running across the street from the hospital on Tuesdays and Fridays in order to assist in minor procedures like breast lumpectomies and melanoma/skin cancer excisions. My job is to show up in the procedure room and then race to get into a sterile gown and to prep and drape before my attending surgeon shows up (prep: sterilize the operative area with iodine and drape: put sterile drapes over the patient's body and secure them so only the steriled operative area is showing.) My attending surgeon is a pretty cool guy although I've heard he is pretty tough on interns. So far I've avoided any lectures or outbursts by getting the prep and drape done as fast as possible. The patients are awake for all of these procedures but they can't see what is going on so my attending shows me how to do parts of the procedure via hand motions. He'll do one part of the incision and then hand me the scapel and let me do the other half of the incision. It's pretty funny because once I did something wrong and got my hand slapped! Each procedure he lets me do more and more and now I'm at the point where I tie all of the knots except for the main midline knot. Also, he now trusts me to close the incision by myself so he'll leave the room before the procedure is over and lets me finish it up. We'll see what new responsibilities I have this coming week.

Last call night: Tuesday, August 1st.
Patients covered last call night:Around 45, including 18 on my own service on the first day that I met these patients.
Amount of sleep last call night: Around 90 minutes.
Currently reading: Greenfield's chapters on Breast Cancer and Skin Cancer.
Currently watching: I saw about 10 minutes of the Hall of Fame Game last night before falling fast asleep.
Next call night: Saturday, August 5th. I'll write another blog later today about this call night in which I got into a fight with two nurses.

#8: Did you really have to page me about this at 3 AM?

2006-07-30T08:55:00.000-07:00

There were a bunch of really crappy pages on Friday night call. There were multiple times when I would be paged to a phone number and I'd call back withiin 30 seconds and the person who paged me was not there anymore. After waiting for 3 minutes on the phone someone might pick up to ask: "Did you really mean to order Mr. So-and-So a diet?" Yes, I did. There was the time at 1 AM that a nurse paged me every 15 minutes for 45 minutes saying that Mr. Narcotic-Seeker wants the equivalent of 90 mg of morphine and that we'd only written him for the equivalent of 45 mg of morphine. I'd been ignoring this nurse since she'd cancelled a bunch of lab orders I'd requested earlier in the night and then she didn't tell me that she'd cancelled them. Yes, Nurse Ratchet, Mr. Narcotic-seeker doesn't get to have his 90 mg of morphine. Please see the clinic note on the computer saying that he is under a pain contract to only get 45 mg of morphine for the day and do you really believe he's in that much pain? She didn't page me any more after that...

Then there was the page at 3 AM:

Nurse: Mr. End-Stage Rectal Cancer has an extremely high blood pressure of 150/105!
Me: What is his pulse?
Nurse: Hold on, let me check... Just wait on the phone for 2 minutes doing nothing while I go do that.
Me (internal dialoge): Yes, heart rate is a very basic piece of information in order to interpret blood pressure - did you even stop to think for 5 milliseconds about why his blood pressure was so high? Do you think it might be because you forgot to hook up his pain medicine earlier in the evening?

The ultimate page at 5:30 AM was "Mrs. Small Bowel Obstruction has a low blood pressure of 85/50."

I return the page in person, showing up at the nurses station 30 seconds after being paged, only to find no one is anywhere to be found. I check the patient's chart, looking for how much urine output the patient had and how much fluid had been suctioned out of her nasogastric tube, only to find that no one had recorded any vitals in the patients chart so I have to track down the nursing assistant who is carrying around all the vital signs for the evening in his pocket.

Me: How should I try to figure out what is going on with this patient that you are paging me about if you don't record what is going on with the patient in the chart? Please hang half a liter of fluid in order to replace what we sucked out of her stomach.

I have an excellent relationship with most of the nurses that I work with, but all of the pages I got above were from nurses on the trauma floor, who are used to the doctors being mean to them. I am always extraordinarily nice and usually I try to make the nurses feel like they are doing all of the work for the patients and I try to involve them in the decision making process, but I feel like I got handed a load of crap from the trauma floor on Friday night (Saturday morning.)

Patients covered last call night: 45
Amount of sleep last call night: 90 minutes (from 4 AM to 5:30 AM)
Currently reading: Greenfield's chapter on Abdominal Wall Hernias
Currently watching: Miami Vice (we saw it last night and I thought it was a great movie! Michael Mann is on top of his game. I used to be a huge fan of the TV series as a kid and I own Seasons 1 and 2 on DVD.)
Next call night: Tuesday, August 2, 2006 (I am moving teams from the Gastrointestinal Surgery team to the Surgical Oncology team.)

#7: A Tale of Two Patients

2006-07-27T18:47:00.000-07:00

I know all four of you loyal readers were disappointed yesterday to learn that I didn't post about my last call night, but you'll be glad to see this entry. I'm feeling sort of overworked right now so today's installment will be brief. I'm continuing to get into the swing of things and the last call was pretty easy. However, this upcoming Friday's call (I'm q3, which means "every 3 days", this week) promises to be hard, as there are a bunch of patients coming out of the operating room on Friday and the other teams leave early, which translates into me doing some of their work. For today's installment, I present to you two interesting patients:

1) A gentleman, and I use the term loosely, who is a prisoner who felt that life was so bad in prison that he swallowed two razor blades "in order to go the hospital so I could get a decent meal." Unfortunately, we worked him up for about 4 days trying to find one of the razor blades. One exploratory laparotomy (we cut open his abdomen and tried to find the razor blade but failed) and two colonoscopies later and we finally got the razor blade. His prize: 3 days full of a liquid diet and one regular dinner and breakfast. Prison must really be terrible.

2) A blue collar guy who landed in the hospital with a rare gastrointestinal tumor and therefore had a part of his pancreas and gastrointestinal tract removed. He's had a rough post-operative recovery and he's on his third nasogastric tube (a tube placed down his nose and into his stomach, the process for which to place seems extremely unpleasant.) He's a former P.O.W. in Vietman, and we've been joking that now he is a P.O.H. (Prisoner Of Hospital.) I hope he gets out soon.

Until next time...

Patients covered last call night: 41
Amount of sleep:: 2 hours (in one hour increments - I had something figured out!)
Currently reading: Greenfield's chapter on Abdominal Wall Hernias
Currently watching: We saw Sketches of Gehry. I thought it would be better as a one-hour PBS program.
Next call night: Friday, July 28, 2006.

#6: Ebb and Flow

2006-07-20T15:54:00.000-07:00

Call nights are getting easier as time goes on but fatigue is setting in as today was my 11th straight day at the hospital. It was a tough day because I showed up at the hospital yesterday morning expecting to round on only three patients, but instead I found two new admissions overnight to check up on, and there were five new patients that came up from the operating room during the day. In the end, our service went from three patients to ten patients in the course of 12 hours, which translates into more work for your friendly neighborhood intern.

Yet I was able to get into a pretty good groove last night with all the work. I went into overdrive, running around the hospital knocking out tasks as quick as could be and I had some help in the form of a really good medical student. However, at midnight I shut myself off of caffeine in the hopes that I could get a decent amount of sleep overnight. The unexpected side effect of this was that my energy level slowed down big-time and I got inefficient in the early hours of the morning and after rounds. Nevertheless, I got a decent amount of sleep and I only needed about an hour nap when I got home this afternoon.

Continuing my trend of butt operations, I had enough time last night to scrub on an incision and drainage of a gluteal abscess. There is one attending who has taken an interest in teaching me techniques, and he was nice enough to page me down to the OR to cover the case. There's nothing as glamorous as a butt operation at 10 PM in the evening.

Patients covered last night: 34
Amount of sleep last night: 90 minutes
Currently reading: Still working on Greenfield's Acute Pancreatitis (we even have a patient with this presentation!)
Currently watching: Munich (watched it post-call, interesting spy movie but overall very depressing.)
Next call night: Tuesday, July 25, 2006 (I have the entire weekend off!!!)

#5: Zen and the Art of Call

2006-07-16T17:59:00.000-07:00

I had my first good call night last night and I'm starting to get the hang of my new job responsibilities. My note-taking system is finally working and there are no tasks that are falling through the cracks thanks to the system. Certainly I made some minor mistakes and I know that I have a long way to go, but things were better last night. I learned a new sort of "calm" to adopt in stressful situations in order to analzye each situation rationally at all hours of the night while on call. There were three patients I evaluated last night that if I had just listened to what the patient's nurse wanted to do that I would have done the wrong thing. But I went into the patients room and even though the patient was acting loopy or crying or writhing in pain, I was able to detatch myself somehow and figure out what was going on and in each case I was able to correct the problem. It was a good feeling.

I know this feeling can't last forever and I know that there is my first code (medical emergency like a patient's heart stopping to beat) looming out there. I won't know exactly what to do in the situation, but I just have to trust in my training so far to be able to do my best.

My wife has been taking such great care of me: she's been making me dinner when I come home from the hospital and understanding when I pass out during the day post-call. Things will be tougher next month when she starts her "acting internship" in medical school and I hope I can return her TLC in kind...

My co-intern friend and I learned something new this week! We wanted to give his patient some aspirin because the patient was having chest pain and some cardiac symptoms, but the patient was not able to take medicines by mouth. Actual quote after my friend called the pharmacy for advice: "Oh! I didn't realize you could give aspirin up the butt!"

Patients covered on call last night: 44
Amount of sleep on call last night: 90 minutes
Currently reading: Greenfield's chapter on Acute Pancreatitis
Currently watching: 6 Feet Under 5th Season (I can't believe the 4th Season Finale!)
Next call night: Wednesday, July 19, 2006.

#4: Annoying

2006-07-12T16:01:00.000-07:00

If I had to categorize Monday night's call with one word it would be: "annoying". I'm worried that this blog may turn into a giant post-call bitch session on my part, but I got really frustrated with the way the system works last call night.

I got a call from the lab saying that one of the patients that I was covering (ie, not a patient that my team takes care of daily) had some critically low labs. I ran up to the patient's room and it seemed like he was doing OK but his vital signs were dropping to an almost critical value. So I tried to figure out what was wrong with him. However, looking at the patient' chart was no help because he had a blank chart (his primary team did not write out any sort of documentation about their plan for the patient.) Further detective work on my part found that the patient had been in the hospital for 10 hours and no one had done anything to treat the reason he came to hospital in the first place (ie extrardinarily low blood volume!) It was extraordinarily frustrating to try to get the poor guy some treatment.

ME: (10 hours after the patient should have gotten an IV.) "OK, now I'm going to start an IV on the patient."
NURSE: (Getting up from her lounge chair) "No doctor, let me do it."
ME: (1 hour later) "What is taking the blood so long to get here?"
NURSE: "I have to go get it from the blood bank."
ME: (15 minutes later and no blood.) "OK, now I'm going to get blood."
NURSE: (Getting up from her chair from which she hadn't moved for 15 minutes) "No doctor, let me do it."

We ended up transferring the patient to the ICU, and I pushed both the patient's bed AND IV pole. The lazy nurse came along and she actually physically GOT IN THE WAY of us moving the patient (ie, I had to continuously slam on the brakes of the bed in order to avoid hitting the nurse!) I really almost lost it with her.

Patients covered on last call night: Around 35.
Amount of sleep on last call night: 20 minutes.
Currently reading: Greenfield's chapter on Diseases of the Exocrine Pancreas.
Currently watching: Season finale for 6 Feet Under Season 4.
Next blog: Some time after my next call night which is Saturday July 15, 2006.

#3: Golden

2006-07-08T07:46:00.000-07:00

I'm sorry dear readers (of which there are only 3 confirmed!) that you all were left hanging until today when I said I'd write on Thursday night. Wednesday night's call started out innocuously enough. I got sign-out as usual and planned out my evening and it seemed manageable enough. Check up on labs/xray at 8 PM, round on a couple of patients by 9 PM, and two post-operative patient checks by 10 PM. Things were smooth, relaxed, efficient and I was thinking around midnight that I'd be able to get some sleep that night...

HOWEVER, around 12:15 PM I got a page saying that a patient was coming in to the hospital at around 4 AM for a liver transplant and that I had to post the case, write some pre-admission orders for the patient, and work her up when she came into the hospital. The person on the phone said it would be easy to do all this... Yet what she didn't realize is that all those steps were new to me, and I had to figure out each step of the way where to find the right info/etc, and what should have been an hours worth of work turned into 2.5 hours. For example, the computer program kept crashing whenever I put in the orders! In the end, I only slept 20 minutes that night and as a result was too tired to post an entry Thursday night.

In other news, I got to operate yesterday! The operation itself was NOT glamorous at all, and in fact if I wrote what type of operation it was I'm pretty sure everyone would be disgusted. Yet it was a pretty cool feeling when we started the case and my attending said, "Do you think you can finish the rest of this operation?" He then left the room and I was the only person left in the room to finish the case. Wierd feeling! The scrub nurse was humming a song and I correctly identified the song as "Gold Digger" to which she replied, "Dr. Maturin, you're not so bad!" Speaking of gold, this is my Golden Weekend which means I don't have to go to hospital on both Saturday AND Sunday. Not that I don't like being an intern, but it's nice to be off for two days in a row!

Patients covered last call night: Around 30.
Currently reading: Greenfield's Chronic Pancreatitis chapter.
Currently watching: Pirates of the Carribbean (tonight)
Next blog: Expected the evening of Tuesday July 11th after my fourth night of call.

#2: Hammer paging

2006-07-02T19:04:00.000-07:00

I've never experienced what it was like to be "hammer paged," which happened Friday night on call. Being hammer paged was when my pager went off and before I could even dial the number to return the page three new pages came through. Since I'm still new at taking call I didn't realize that some pages and questions could wait and so I got mentally bogged down by trying to treat all issues equally. However, I quickly learned that only about 5-10% of pages were really worth addressing right away. Like the page where I got called to evaluate a pretty sick patient that that was having trouble breathing after he had a procedure earlier in the day where needles were stuck in his chest. I was worried that he might have a hole in the lining around his lung that could cause air to be trapped in between his chest wall and his lung, and so after getting the appropriate tests we transferred him to an area of the hospital where he could be monitored more intensely. After all my worrying he turned out to be OK, so I was pretty relieved.

I'm still getting used to using the computer physician order entry program that we use at our hospital. Firstly, it's pretty slow and whenever I have to order a new thing, it takes me a while to find the area in the program to enter it. Yesterday I made a pretty funny mistake though. I was trying to order a suppository for a patient to help him move his bowels over the night. When I put in the order for the medication, the program kept trying to enter in the medication to be given every day. I couldn't figure out how to only give him the suppository ONCE, and the only way I could figure out how to do it was to order the item "stat." (Stat is typically reserved for emergency or high priority actions.) You can imagine the smack that I got from the nursing staff: "Quick! Get Mr. L some Dulcolax STAT!" I have since figured out the proper way to order this type of medication.

Patients I covered last call night: 48
Currently watching: The Devil Wears Prada (I went out with my wife and two of her girlfriends to watch it!)
Currently reading: Nothing, but planning to start studying surgery textbooks this week.
Next blog: Expected Thursday, July 6th, after my third night of call.

#1: At first I was afraid...

2006-06-26T17:01:00.000-07:00

As Gloria Gayner (and later Cake) sang, "at first I was afraid; I was petrified." Yet I survived my first night of overnight call! 30 hours in the hospital and I'm still alive (and more importantly so are my patients.) The transition from being a medical student to being an intern as I experienced last night was abrupt and HUGE! As a medical student I would rarely get paged by anyone during the day and last night I got "hammer paged," which means that I got a page on my beeper and just as I took my pager out to look at it another page (or two) would arrive. Even more importantly, as an intern I am now making medical decisions and implementing them in practice (prescribing medications, changing intravenous fluids, and discharging patients from the hospital) where as a medical student I never made any real decisions. It's amazing that just 2 months ago I had no "power" in the hospital (the common phrase I heard was "we need a MD to do that, not a medical student") and now all of a sudden it seems I had some magical transition in judgement to be able to make medical decisions.

There is a really humorous nurse on the fifth floor of the hospital who has been around for a while and is very good at her job as a floor nurse. She asked me to evaluate her patient, who was writhing with atypical chest pain and I decided (with the advice of my chief resident) to double the patient's pain medication because we thought he was too stoic to ask for the appropriate pain medication. The nurse said, in a somewhat angry tone, "Dr. Maturin, I totally DO NOT AGREE with that decision because that patient is too stubborn to use his pain button and he is just going to continue to be in pain." I was a little intimidated by this women, and I agreed in principle as well, and therefore I adjusted the pain medication further... It worked. Wow.

Currently Reading: Surgery On Call.
Currently Watching: I was too tired today to make it past 2 minutes of channel flipping before I fell asleep.
Next blog: Expected the evening of Saturday July 1st.

Frog transfiguration

2006-06-21T14:08:00.000-07:00

Welcome nonexistent readers to my new blog. I'm about to start a surgical internship (the first year of a surgical residency) in three days. Everyone says that this year is the most intense and the one in which a doctor learns the most about medicine out of any year of training. Therefore I thought it would be a good experience to chronicle via a blog! My plan is to write an entry the day after overnight call (24+ hours in the hospital) which right now will be every four or five nights.

Today we (the new surgical interns) learned how to use the hospital system for ordering labs and looking up lab values for patients. Of course, in order to practice we used a fake system and the patients names were all characters from Harry Potter. My patient was Ron Weasley, and I wrote a fake hospital admission note for him: "Patient is a 16 year old student who presents after accidental ingestion of potion causing frog transfiguration." Damn it, I've got to start acting more like a surgeon...

Currently reading: What to do in case of a code (medical emergency.)
Currently watching: NBA Finals (taped) Go Dwayne Wade and Miami Heat!
Next blog: Expected the evening of Monday June 26th.