Back to the Waking Life

Hurrah! I have survived my two weeks on night float. Everytime I tell someone that, they all sort of imply that it's amongst the worse things you'll have to do as an intern. My experience really wasn't that bad, overall. Perhaps some of that was luck, in that nobody died unexpectedly or suffered because of a massive mistake I had made. Or maybe I just had really decent nurses in the ICU who had my back.

My last two nights, unfortunately, were hell. I realize now that some of that was my own fault, for not knowing when to ask for help in managing tasks. (I also didn't know that I had the right to insist that my senior medical resident physically come down to help me when I needed it for complicated patient problems.) Both nights, my pager exploded at 7 pm with things to do, and many tasks were pushed aside because of acute patients in danger of hemodynamic compromise. As a result, I managed to piss off nurses in the telemetry / step down unit, upset a family because I wasn't able to call them when their family member passed away in the hospice unit two hours before, embarrass myself in front of the surgery team because my medical senior resident had foisted a bogus request onto me, and basically run around as though I was not in any kind of control whatsoever.

When I read back on that, it seems a lot calmer a description than what I went through. After the first busy night, I had a mini-crackdown because I found it so upsetting that everyone was looking to me as if I had answers that I clearly couldn't possibly have because I am just too dumb to be a real doctor. I was upset because someone was rude to me, something I should have been able to handle but instead took as a sign that I was totally on my own. I was glad to have made it through that first night, and was so sure that the evening after would be calm and quiet. Of course, it was just as much madness and it seemed like there was just no respite. On top of having an even more acute patient and multiple other pages come in, a nurse informed me 30 minutes before signouts in the morning that a patient had not received any fluids or food for a full day, and was now reporting severe dehydration. Of course, this patient was also scheduled for surgery, and when I asked them for help with a central line, I got yelled at for not bringing the matter to their attention sooner, and was stuck staying an extra 2 hours longer trying to rectify the many complications associated with the situation.

In fairness, I deserved that reaming. Looking back over the past 2 weeks, there were a lot of things that I overlooked or didn't consider, many fevers I didn't investigate fully, many calls for help I should have made but didn't. Everyday, I felt like the bar was higher, always unreachable. And after those two days, I drove home asking myself if this was what I really wanted. I don't like missing sleep, I don't like feeling gross and messy, I don't like feeling like I've messed up, and I don't like getting yelled at.

But after a few days of getting back to a normal sleep schedule, I remembered that I always doubt whether I want to do surgery when I'm post-call. I always hate getting pushed around or failing. And I love it that much more when I brush myself off and finally win. I love surgery, and I love that it's hard, and I love that it's not something everyone can do. I love getting asked something and realizing that I learned the answer without even realizing it. And ultimately, I chose this. So I've jumped off the cliff, and all I can do is hope for a soft landing.

Singing the Pager Blues

It breaks my heart to say this, but my pager and I are not doing so well. Perhaps I should modify that - my pager and I are a team, but everyone seems to hate us.

Two nights running, now, I haven't been receiving pages. The first night, it was one of the regular floors that kept paging, and then went to the operator when they couldn't reach me. But the odd thing is, the operator's page went through right away. Near the very end of my shift, I got paged by my senior to ask why I wasn't responding to pages from the ICU. Irritatingly, I was sitting at a computer 15 feet from the ICU, checking labs, and hadn't received the page. Last night, I missed a code, although at least that one had an explanation - the operator (who was new) thought that only the intern covering that patient needed to get paged, when in fact ALL interns have to go to the bedside.

Now, most pages you get in the middle of the night are not emergent. Most often, it's just for something small, like renewal of a medication or an order that wasn't written correctly. Occasionally, there's a problem where you do need to go down and check the patient out in person, like blood pressure issues or chest pain concerns. Naturally, in such a scenario, the nurse wants to reach you. But twice now, instead of trying me via the operator, they went straight to contacting my senior resident, which makes me look like The Lazy Intern Who Ignores Pages and Can't Be Trusted. What kills me is that I really do want to go to all of these pages, because I'm still learning as I go and I certainly don't want to miss something important like a heart attack or stroke.

I don't like to complain about technological pitfalls in hospitals, because the fact remains that only 10% of all hospitals in the United States even have EMR systems, and I picked residencies based in poorer inner-city areas because I wanted the experience. But it seems to me that the whole pager system is shockingly inefficient and cost-ineffective. I once did an ob-gyn rotation at a hospital in New Jersey where, instead of pagers, they had in-house cell-phones. They were pretty big and bulky, more like cordless phones, but they worked great because anyone trying to reach you didn't have to wait for you to call-back. There was no question of receiving a page with a hospital extension that didn't exist (I once got paged to the 5th floor, and we don't have one), or trying to call someone back only to find that they had walked away from the phone. If you were busy and running around the hospital, a person trying to reach you didn't have to wait for you to get to a nursing station with a phone not in use. Also, for anyone in a surgical or ob-gyn residency, if you were scrubbed into a case, the circulating nurse could pick up for you and relay the message right away, or even hold the phone to your ear if necessary. It made getting the work done easier for everyone, nurses and residents alike.

Maddeningly, I have tested and re-tested my pager a million times, and it is working just great. Of course, I could just trade the sucker in for a new one, but then I would lose my Hawaii Five-O theme song ringtone. Fortunately, the important nurses (covering the critically ill patients in the ICU) know that I'm serious about wanting to come and help, and aren't angry at me. Last night, I averted the situation by physically going to each floor and making them page me to prove that it was working, and that I did want to come down for anything important. I also made sure they all had the phone number for the girls' call room phone, just in case something didn't go through. But the nurses on the floor are a little bit less invested in making a real effort all of the time, and the last thing I need is talk spreading all over the hospital that I'm the surgical intern who doesn't give a crap.

A Subject Close To My Heart

I don't want to beat anybody over the head in either direction. But the NY Times has a terrific article coming up this weekend on abortion provision in our country, and how shifts in medical education and training for ob-gyn residency has changed our attitudes and ability to access decent care.

NY Times: The New Abortion Providers

My only point is this: it's legal, and women deserve reasonable access to safe procedures without risk of being hassled (either as abortion providers, nurses or patients). We don't hassle transplant surgeons for giving new livers to recovering alcoholics, and we don't hassle psychiatrists for treating sex offenders. Let doctors learn, train and do their jobs without the politics. We all have a responsibility to treat our patients to the very best of our ability, and that means knowing how abortion procedures work and how to manage the care and complications, even if one doesn't plan on providing them in practice. If you don't want people in your community to terminate their unwanted pregnancies, let's all work together on ways to prevent them from happening in the first place.

Things I Learned From Night Float

1) Having my beeper set to the tune of the Hawaii Five-O theme song really does make getting paged multiple times at 3 in the morning less painful.

2) Bring lots of water bottles because yours will get thrown out.

3) The residency hierarchy is alive and kicking. The intern call room looks like a crack den, but the surgical suite has plush couches and a big screen tv. Oh, and a working phone and computer to check labs on.

4) The stroke floor is where I will go to hide, because the nurses are so nice that they give you Vitamin Water and help you do the labs.

5) I don't need to call The Wake-Up Squad after all. It turns out that there is an easier way to stay up when you need to.

Definitely Not an I-Banker

Not that it needs repeating, but it is depressing to be home on a Saturday night when all of your friends at home are out for the weekend, tubing and catching up with out-of-towners and just generally enjoying their summer.

Here's what I'm reading:



The sad part is that I am trying very hard to actually remember all of the important topics I am learning about in surgery and for Step III. Unfortunately, all of my brain space is occupied, because I have the entire Harry Potter series memorized. Blood supply to the gallbladder? Umm, I think it involves the celiac trunk, somewhere. Etymology of the name "Dumbledore"? It originates from the Old English word used to describe a buzzing sound, most often associated with bumblebees.

To make things worse, here is my desk setup:


And here is my actual desk, parked in front of the tv:



At least I am trying, though. In my chapter on wound healing, I was losing focus, only to find references to cutting-edge research being done in Princeton and Plainsboro and other parts of central NJ, where I am from. So don't go talking shiz-nit about my state, yo. JERSEY PRIDE!!!

Sesame Street, it ain't

There are so many aspects of medicine and hospitals that you forget over time, until something reminds you. I did radiology as my last rotation, followed by vacation, so to some extent I had forgotten how to examine a patient thoroughly and write a basic note. I had forgotten how the smell of electrocautery (burning flesh) in the operating room wakes me up like coffee, and how looking at abdominal fat makes me crave cheeseburgers. I had forgotten how much I like talking to patients and finding out how they are doing, and watching them get better with time.

I also forgot how political and territorial medicine can be. I had a very minor yet unwelcome reminder this week, as I finished up my gynecology rotation. We finally had a case booked, a simple hysterectomy, and I read up the night before on pelvic anatomy and practiced my two-handed knot tying.






On our service, the gynecology intern has a family practice senior resident to call if there are any issues or questions which are too menial for the Ob-Gyn attending. I called to let her know that there would be a case, and she stated an interest to come. I didn't think anything of it, but the next morning, I discovered that the case was actually a tag-team case involving general surgery as well. This meant that I now had a more direct educational stake in the procedure, especially since it was something I had never seen before, an abdominoplasty.



Since both attendings were scrubbing the case, they said they only wanted one resident at a time scrubbing to assist. I deferred to my senior resident, thinking that the senior had "seniority" for the case (ie, more right to scrub than I did, as intern). I didn't think too much of it, although I was disappointed not to scrub into the case. But after the case was done, multiple general surgery residents approached me to find out why I had not joined the case. When I said that my senior resident had scrubbed instead, suddenly everyone was not happy.

As it turned out, the gynecology intern is supposed to scrub all cases, and the senior resident is just there to help out on the floor as needed. Especially because I was a surgery intern, my surgery seniors felt that I had the right to be there while my senior family practice resident did not. Unbeknown st to me, this particular resident had previously expressed an interest to join surgery and was not accepted, and so her actions were interpreted by the surgery residents as trying to get into where she did not belong. The surgery chief resident discussed the situation with her, for future clarification, and the whole thing was resolved relatively painlessly.

But the divisiveness of the whole thing surprised me. Suddenly, I was "team surgery", so to speak, and my seniors were looking out for me even though I am not to join surgery service for several weeks. The other residencies in our hospital were "they" or "them", with guesses as to motivations, wants and needs. It was nice to have someone stand up for me and my education. It was my only case for the entire gyn service, and I actually enjoy gyn, so I would have liked to be a part of the case and maybe even get to help. But I felt a little bad that it was at the exclusion of someone else. It just wasn't very warm and fuzzy.

On the other hand, last year I was so aggressive with my showcasing for surgery that I would actively kick lowly third-year students out of good cases so that I could use the few weeks I had on service to demonstrate my skills to attendings and hopefully score an interview. One student even called me a b**** and tried to complain to a resident, only to get smacked down for disrespecting my seniority. I'm not exactly Fozzie Bear myself.

Douchebag O' The Day

It's hard to see here, but he also had BMW decals next to his BMW rear styling. And, as icing on the cake, he had gel-spiked hair, a tan darker than me, and a popped collar. A fist-pump to you, dude.

Edit on 7/9/10: While driving from my hospital towards the bridge, I saw THE EXACT SAME CAR. If this guy shows up as my surgical patient, I may die. Or maybe I'll just ask him if he wants "BMW" cauterized onto his ass.

the end of a week of torture

....because I now FINALLY have internet in my apartment! YEAAAAAAA!!!!

PS - Right after I wrote so glowingly about missing my parents, they both turned into royal paranoid neverending messes. My dad decided that ANY POLICEMAN ANYWHERE can pull him over and arrest him if he can't provide immediate proof of citizenship, and therefore we must all blow $45 on the stupid new passport cards. Dude, this is the NYC area, not Arizona. Also, you're a pillar of the community, and it would be national headlines if the central NJ police were stupid enough to arrest you without warrant or cause. And my mom just decided to keep talking and stop listening. Because her voice is so beautiful to hear, I'm sure.

Bah.

Not So Much a Throwdown as a Slowdown

A corollary to go with my bad-luck-turns-into-good-luck theme is that things are almost never what I expect. I've been sweating and dreaming (nightmare-ing, really) and just worrying myself into a hole about the start of residency for weeks now. I've been dreading the responsibility and feeling excited for the importance of it all, and just generally expecting that it was going to be a big huge change.

Predictably, it is boring and easy and anti-climactic.

I've been assigned to start on gynecology, and I had no complaints about that because I really do love the field. This particular hospital doesn't have any obstetrics, unfortunately, but I still enjoy things like clinic care and hysterectomies and such, so I really didn't change my expectations going in. The attending is super nice and a great teacher, and it is really a pleasure to be around attendings who let you do things but don't pressure you if you're not sure which way to go when you're starting out.

But my god, the boredom. It turns out they only have 2 half-days of clinic a week, and nobody scheduled cases because they didn't want patients post-op over the holiday weekend. And the following week, even clinic is cancelled. So basically, my job is to wait for consults, and I have not had that many so far. (I did have one very young teenager miscarry her pregnancy, and then go 10 rounds with me on starting a reliable birth control method while showing no indication that she would change her 3-partners-in-2-months pattern, but that's ureters under the ovarian arteries. Ha! Water under the bridge! Gyn humor! HA HA!!!)

I've been so relaxed on this rotation, people keep coming up to me and saying that I look too happy to be an intern. The program director for surgery keeps asking me why I'm wearing an actual skirt instead of wrinkled scrubs. My co-intern teased me about the audacity of wearing dusty pink peektoe heels. And everyone keeps checking their schedule to see when they get to go on gyn.

In other news, my parents are leaving relatively soon for a massive trip to Asia which will include attending my sister's MBA graduation and hanging with my expat cousins in Shanghai. Needless to say, I am super jealous and wish badly that I could go, but I'm also having an odd feeling of dread. They'll be gone for quite awhile, and I can already tell that I'm going to really miss having them to call and complain to and get scolded by. Which always surprises me, because I am the average Indian twenty-something-treated-like-she's-16 and every time I come home I get scolded and nagged for this and that, and I hate it. HAAATE it. But I know that when they go, they're going to have such a good time that they'll do what they usually do, which is out of sight, out of mind, and not worry about me at all. The last time my whole family was on a trip together without me, my mom kept hanging up on me because she had parties to get back to. Parties. The time before that, my parents went on a cruise with my British aunt and uncle in the Caribbean. I was studying for finals during winter quarter in college, and feeling stressed and depressed and lonely. I got a call from them while studying on my birthday, and they sounded too relaxed and semi-boozed to talk me off the ledge (mind, it takes like 1 rum drink to do that to my mom).

So I will be free, soon, and irritatingly, I'm not looking forward to it. It's going to be very lonesome.