An education in contrast

I've spent the last week in a small private hospital with a plastic surgery group attached to it. Being over there is like a night and day comparison with hell-hole of a University Medical Center where I spent the previous 6 weeks. Sure the Academic Mecca is great if you want to be the 15th person scrubbed in on a surgery on a patient who is one of 19 people IN THE WORLD to have their specific kind of cancer (true story!), but you could go 2 months without seeing an uncomplicated lap choley in an otherwise healthy individual.

Case in point (which I referred to in my last post): Woman in her 60's with an acute abdomen that hits you over the head with the stigmata of acute appendicitis...CT evidence to back it up. Can't do it laparscopically because she's had 5 previous abdominal surgeries and now has a ventral hernia the size of my head. Try to do it with a LLQ incision...oh wait, there's no way to get the appendix exposed because of the adhesions. Midline incision leads to 2 hours of cutting adhesions, the finding that the cecum and terminal ileum are gangrenous. So a bowel resection, reanastamosis, and ventral hernia repair later, what should have been a 30 minute case turned into 5 hours.

On the other hand, private practice is where I saw my first childish temper tantrum be thrown at the private hospital...hundreds of dollars of instruments were thrown across the room onto the floor to make a point, curses were aimed at the cowering scrub nurses and circulators, stories were told for days afterwards...all because 2 minutes of waiting eats into the bottom line. The cases are more simple, and it's straight forward treatment delivered to the average patient. I feel like that is what has been missing after 6 weeks at the academic Mecca, however now I'm missing the intellectual stimulation and the feeling of being part of something larger.

Oh, Plastic Surgery, you are so glorious.

No one is sick, no one is dying, no one is grumpy. I get to watch boobs change size, tummies get tucked, big sticky-out ears get pulled back saving years of therapy down the line, and bumpy, crooked noses made straight and feminine. Everyone is there under their own will, everyone is pleasant to work with, no one has scutted me out in a week...I haven't even had to write a note! Oh and I get to leave when cases are over...usually around 3 PM...and cases start at 7:30. Sleep is so awesome.

But it feels like something is missing. I have no sense of urgency in my days, no need to get everything done 10 minutes ago because Dr. So-and-so wants to round. I'm not part of a team delivering health care, there are no decisions to be made. Everything runs on autopilot. There is no physiological medical purpose to the majority of these surgeries (except breast reductions) that I have seen, absolutely no pathology to eliminate besides the overly self-critical psyche. Plastics seems, in essence, an exercise in feel-good, preventative psychiatry.

Oh well, one more week until the shelf to go. I started making my first forays back into the library since the boards and I don't miss it very much. I'll take the narsty wound infection smell of the surgical floor at 5AM over that damned carrel any day. I'll be pounding through NMS casefiles, Surgical Recall, Pre-Test Surgery and whatever else I can find. I'm not too sure how the shelf questions are going to be asked, but I'm sure that it won't be too bad. Hope it goes well, until then


Surgery Experience Redux

As you're all aware, dearest readers, I've pretty much stopped writing over the past 6 weeks because of my awesome surgery schedule, lack of time to do anything but be in the hospital, sleep and read for the next day's cases/rounds. I apologize for the absence, but I am not on a Breast/Plastics 2 weeks that promises to be quite relaxed. Anyway, here comes the post:

On a number of occasions since the beginning of third year, I have attempted to piece together something coherent enough to post in my very limited free time. When I go back and look at those drafts, they reflect what had happened in the previous 12-24 hours, don't really have any direction behind them, and generally are just bad. Now that I'm post 24 hour call for my last time until January and looking back on the bulk of my rotation, I can properly analyze it...I hope.

What I liked:
To be completely honest, I enjoyed Surgery quite a bit despite the downtrodden tone that I adopted when writing about it. I know it's going to sound cliche, but I like the idea of being able to directly intervene in, and usually alter, the course of a patient's illness by surgical management. It was satisfying to see the patients come in sick, get surgery and leave the hospital in a better state! While that's not universally true, it did happen in the majority of cases. I like the fact that there is a continuum of patient care from admission, through discharge for the disease without the 5 hours of teaching rounds per day...just get shit done instead of mentally masturbating over potassium changes of 0.1 while the patient circles the drain. As a surgeon, you're a complete physician who can manage most medical problems on your own without having to have someone talk you down from the roof of the hospital when something isn't going quite right in one of your patients. I like being independent!

I thought understood the need for continuity of care on an intellectual level before this rotation, but to see the management of patients with a night float system is somewhat horrifying. You could get legitimately sick overnight/weekend and no one would fully understand your entire clinical picture and some 26 year old kid with an MD comes to the rescue and has no idea what to do because they have a 10 word blurb on what's going on with you on a sheet of paper with 40-90+ other patients. Medications fall off the list because they're not renewed, innocent nurses call about seemingly emergent issues that are trivial, seemingly trivial events go unnoticed despite their far-reaching implications. So while the hours are inhumane, they are necessary to actually ensure proper care for sick patients overnight so that they not just stuffed in the corner to heal on their own accord/die!

Of all of the specialties that I had the opportunity to see, I think Trauma/Critical Care appealed to me the most.

For Trauma: patients come in the door with whatever is going on and very limited information, you figure it out with a very logical algorithm and intervene by addressing threats to life and everything after that. If they need surgery they're in the OR ASAP, if they don't you manage them conservatively. The patients generally tend to be younger healthy people with fewer comorbidities than the general patient census, from all walks of life and they generally appreciate the fact that you have helped them.

For the Critical Care end of things: the approach is very evidence/data based, which appeals to the repressed scientist in me...everything is based on trends in the patient's physiologic functions (which are continuously monitored) and directly acted upon in a monitored fashion. Instant results that usually make the patient better!!! Everything is continuously monitored, the staff is extremely competent in dealing with VERY sick patients, there are lots of other docs around to talk your plans over with before you implement them...it's the safest place in the world next to the OR. What could be more satisfying???

What I disliked:
The hours/isolation: I can now honestly say that I have worked 114 hours in one week, albeit in the capacity of a medical student with only 4-5 patients to follow in an ultra-supervised manner. The sleep deprivation isn't that bad once you get used to it. My problem comes in that I have had no semblance of a life outside the hospital for the past 7 days save one quick dinner outing with a friend who happened to be around.

If I had someone to come home to and to assist in keeping my home life somewhat on track and to talk about non-surgical issues with every night before I became unconscious, I feel like I could make a 110 hour week work for me. But to go through this endeavour alone would be the most isolating experience ever. The other issue that I'm coming across is that I couldn't imagine putting children through life with their father not being around on a consistent basis to do normal family things. Running can be squeezed in around shifts, hiking/skiing/outdoorsy stuff can be crammed into vacation months...raising kids takes a lot of work and time that I wouldn't have as a surgeon...something to think about.

The people:
Surgeons are a unique breed: cantankerous and crotchety on a good day, downright malignant and vindictive on a bad. There is not a whole lot of respect for anything not going according to plan, and when there is a SNAFU everyone knows about it from the temper tantrum. That's not me! I'm too laid back to be like that...I don't know if I could deal with people like that 24/7 for the rest of my life.

Altering my life plan:
I guess that I never really saw myself as surgeon in the past. I have always loved my life outside of medicine so much more than my life within it. The thought of working 80+ hours a week for the rest of my life makes me sad for the plans I once had in my life. I like going to the beach on weekends, meeting up with friends for drinks/dinner randomly and spending my free time doing absoutely nothing at all of purpose. I met up with one of my good friends a few weeks ago to hit up the rock climbing gym and I had forgotten how good it felt to do something with absolutely no real purpose other than fun. I'm not sure that I can/am willing to live my life that way for the 7 years following medical school and to wake up and suddenly be 35 before making my first paycheck and holding a real job.

The REALLY sick patients:
My training hospital is reknowned for how sick the patients are. Our beds have been shown to hold some of the sickest patients in the nation. What looks like a simple 20 minute open appendectomy on CT can turn into an overnight 5 hour suffer-fest (lysis of adhesions for 2 hours, exploratory laparotomy, resection of terminal ileum and cecum with reanastamosis, ventral hernia repair). There are some people that you can't do anything for...they're just going to die because their disease process is so advanced. It still makes me sad because I haven't had to deal with it directly, so I haven't become desensitized to it completely.

The really sick doctors:
I've felt like absolute crap for the past 5 days and nearly passed out in the OR a couple times, but I don't have a choice...I just have to keep on trucking through it. My residents have been sick to the point of needing to fluid resuscitate themselves, but they've stayed in the hospital through it and kept on working/operating. There are no sick days...

I guess what I'm getting at is that it's time for the Bostonian in NY to reassess his life and what he values within it...it should be a fun, whiskey/scotch sodden adventure full deep thought, navel gazing and long talks with the GF, friends and parents.


My next week will be AWESOME

Fortunately, there is no hour limit for medical students...otherwise my school might be in trouble:
-On for the next 7 days in a row
-42 hours of call (18 on Sunday, 24 next Saturday)
-70 hours of regular work week
-1 midway evaluation meeting with the clerkship director who will be getting an ear full about how disorganized his program, his residents and his secretary are, my 112 hour work week.
-1 sleepy Bostonian who is working nearly 3 normal person work weeks in the span of one and will be living off of nothing but caffeine, crappy cafeteria food and sarcasm come Friday evening.

By far, this may be the longest week of my life.

But, if I make it out alive I'm rewarded with 2 weeks at the Private-yuppie Hospital in the breast/plastics practice. Should be a nice change from the hellish County Hospital that has eroded my sanity/personal life/sleep hygiene for the past 5 weeks.

Catch ya'll on the flip side next week if I'm not in 4 point restraints by the end of the week.


Surgery Experience part deux

So far I've been in the hospital for 75 hours this week, and I still need to toss in another 18 this Sunday for a total of 93.

I have dreams about doing scut. I wake up ready to go do the scut, but then I realize that I'm in my room and go back to bed.

I have no life outside of the hospital except for consulting Dr. Google on my patients and ten minutes of talking to either mom and/or girlfriend before bed.

I still have about 5 people pulling me 5 different ways and I've reached the point where writing notes is no longer educational, just routine.

What have I learned thus far?
There is a hierarchy of surgery that revolves around the black hole of time known as the surgical floor.
Attendings: spend about an occasional hour rounding on their patients with a train of people paying attention to everything they say.
Chief Residents: Tell the senior residents to work their asses off and send everyone home or to another service, then go to surgery.
Senior Residents: Try to act like chiefs and spend as little time on the floor as possible
Middle Residents: Still occasionally help out and write notes.
Interns: Spend life on the floor taking care of everyone on the service 18-20 hours a day. Take care of everyone else when on call in addition.
Medical students: Stay out of the way, help where you can on your assigned patients, go to the OR when you finish, don't piss anyone off, make the chief look good during attending rounds and in the OR.

Ok so maybe it seems like I'm completely ruling out surgery from my life because it sucks. While it does suck, I have a deep respect for anyone that would sacrifice their life to that enterprise. But there is something about surgery that is appealing to me. You get to do something other than waiting for your patient to get better...you can intervene, change their course with a direct correction of the pathology. Anyway, Trauma/Critical Care/Burn has gone on my short list because of what I have seen in the residents/attendings. It's pretty far down the list because of life style/length of training. We'll see though

Anyway just wanted to toss up a post in my spare time because I haven't vented in a while. Peace out


25 years ago...

25 years ago, there was a child born in Massachusetts that would become the Bostonian in NY. 2lb, 8 oz of premature, grade A baby.

He promptly urinated on his new pediatrician within 5 seconds of birth...classy.

This year he's celebrating with a quarter life crisis-of-self: wondering why he's spending over 80 hours a week in the hospital doing NOTHING, why he has conceeded his entire third decade of life to medicine, and why he has lost all semblance of fun in his life for the past month.