Closing The Gap

Yes, yes, I know, I have been inconsistent yet again.  But I'm baaaaaaaaaaaaack!!  (Hmm.  Creepy.)

I've spent the past month at Medium Class Shmanhattan Hospital, which is an outside rotation that my program arranges for us to attend a few months each year.  I state that it is Medium Class so as to avoid confusion with those Super Duper Fancy Shmancy Manhattan hospitals, which of course, I will not get to go through.  But for me, it is in fact SUPER DUPER because nearly anything looks brand spanking new next to my home base hospital.  (But I love oldies!  OLDY BUT GOODY!!)

It's a place that many of my senior residents wax poetic about, because it has things like an EMR and several operating rooms and lots of cases.  And overall, I had a pretty good time rotating there, from a surgical standpoint.  But it wasn't quite what I expected.  For starters, at my base hospital, being on call is busy, sometimes overwhelmingly so.   But the other interns don't chill out while you're working your ass off - they help, because we're The Team.  In contrast, I was only on call a few times for the month at MCSH, but each call was more or less torture.  The pager just explodes with consults and clarifications and so on, and you are fielding all of them while also running the patient list and trying to discharge people.  You hope that the many other surgical residents milling around will help you, but unfortunately, they don't always.  You have an army of students to help you, but not all of them are motivated to stick around in case you need a spare hand to grab paperwork or help patients walk after a procedure.  The nurses were shockingly worse than at my home base hospital - I actually got called several times because I had ordered a medication or a blood test, and the nurse wanted to know if I wanted it.  One could make the argument that this is just an example of a nurse wanting to be thorough, but when it happens 18 times in a day (literally), it gets a little old.  Read the fine print, lady, I want what I want.

I also drew the short straw and rotated during the holidays, during which there were noticeably less patients and cases to see.  The 40-50 cases my co-interns were seeing wound up being more like 20 for me.  Of course, being an intern, it doesn't really matter as much, but it still would have been nice to Do A Fricking Appendectomy like my co-intern did, or scrub on any case bigger than an elective hernia procedure (like an exploratory laparotomy), like others did while on call.  Of course, getting to assist in small cases is good for an intern, it's how you get your feet wet.  But there were days where I didn't get a single case at all, and other interns got 3.  By the end of the rotation, I started getting a little grumbly about a lack of equity when it came to case division, and finally got fed up when I had a bad night on call during which some residents refused to help me divy up the work.

So, I'm done now.  Because of a complicated issue involving intern supply at another outside rotation hospital, I have been switched off of my upcoming rotation with surgery at the home base to do two weeks of surgery at a large Queens hospital, a place that no intern from my year is assigned to.  Onwards and upwards to the next new thing, I suppose.

Hmm.  Now I need a name for the Queens hospital.  Maybe it'll be Shmeens.

Baby's First Chest Tube

Well, I finally finished medicine.  I can't help but shout a good and proper WOOHOO!!  because I really was getting pretty tired of it, after so long.  Don't get me wrong, internal medicine is important, and of course I have to know how to manage a heart attack or a stroke or blah blah blah.  But honestly, so much of medicine is simple paper pushing, or dealing with "soft admissions" (someone who really didn't need to be admitted but we did it anyways to cover our asses), or patients trying to get out of work, or whining about pain.  I exclude the ICU from this criticism, because I feel like I learned so much from my two weeks on ICU.  Those patients are actually sick, and because there are less of them but with more problems, you can really dig into the physiology aspects of all of the disease processes and get a bigger picture of sepsis, end stage renal disease, end stage cancer and post-operative management.  I have two more weeks on ICU coming up that I am really looking forward to, but I just wish that my surgical program required us to do two months of ICU, instead of forcing us into a month of medicine.

My last day of medicine included a 24 hour call.  In our hospital, the night shift manages the patients for 6 nights a week, which means that their night off must be covered by a 24 hour call.  It's not so bad, but they only put two interns to cover a fully functional hospital, which includes things like discharges, transfers, writing daily progress notes and taking in lots of new admissions.  Our census was especially full this weekend, and my co-intern and I could see that things were going to be somewhat nasty.  I agreed to take step-down / telemetry (boo!) so that I could also get the ICU, gambling on not too much drama happening in the ICU, allowing me to focus on the extra-packed telemetry unit.

Boy, was that a stupid mistake.  The previous night, a young guy came in after not being able to breathe for a long time.  Because he was young and healthy, his heart came back after several rounds of cardiopulmonary resuscitation, but the damage was already done and his brain had suffered from lack of oxygen.  It was a very sad case, made worse by the fact that his family was so calm and quiet through the whole thing.  I spent the whole day fighting back tears and thinking of my parents, and how awful it must be to suddenly lose someone so precious to you.  (This was made worse by the fact that this patient was SMOKING HOT, which I know shouldn't matter, but it was like God gave a gift to women and then selfishly took it away.  Just wrong.)  So I spent the morning accompanying him to the CT machine so that we could evaluate the extent of damage, then talking to the family about options for transfer.

The sanitized version of putting in a chest tube.

I had not yet been able to write a single progress note on a patient when E, one of my favorite surgical residents, mentioned a patient of mine on telemetry who seemed to have fluid building up in the space around her lung.  This patient had just undergone a very minor and routine surgical procedure the day before, and her chest x-rays were getting progressively worse.  E paged me to say that it looked bad, and since her oxygen saturation was dropping and she looked pale, we would have to place a chest tube and try to drain whatever was accumulating.  We were all hoping it would be pus or some other fluid, and not blood, but the odds didn't look so hot.  E generously offered me the chance to put the chest tube in, which I jumped at, because I had never done one myself and I knew I would have to when I rotated at an outside hospital.

There are times where the human aspect of medicine collides with the surgical aspect of medicine, and it's frustrating because it's so easy to just dismiss the human part.  This patient spoke very little English, and she and her husband were both frail elderly people.  We explained multiple times, with a translator, the emergent need for the tube, why we needed fresh blood samples, and why it would be better if everyone stepped out of the room for the procedure.  But it was hard to stay patient with them as they struggled to understand - all they could see was that we kept sticking her with needles for blood, and why weren't those samples good enough?  And why can't our daughter come in, and our son-in-law, since they all speak English?  And why is this so serious?  And where is the attending who did the procedure yesterday?

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.

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.

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.