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.


Albinoblackbear said...

Amazing what a few hours of sleep will do for cogent writing! :)

Have you done an ED rotation yet? Some of the things you seem to like about surg are evident there as well (except the continuity of care).

Oh, and the "making most people better" part. Welllll depending on your demographic that can be the case or not. Work in Silver Tsunami, not so much. Work in ED at the bottom of a ski hill and it's no-meds-no-allergies-here's your-versed-snap-crackle-pop-goodbye-happy-athelete all day long.

But the sweetness is at the end of the day you're not on call. The doors close behind you and it's dinner time with no pager. Or breakfast. Whatev. No responsibilites. Play with your babies, go skiing with your wife.

Enjoy the scotch and the navel gazing!

Albinoblackbear said...

And by "goodbye-happy-athelete" I meant that they go home not *points upward*.

Okay except for the skier vs boulder ones or the biker vs tree when it's an exciting trauma, rife with fun filled instant gratification interventions.

Have I sold you yet? hahah

Bostonian in NY said...

No need to sell it to me. For a little background, I resurrected my school's EM club last year and I'm now the school rep to EMRA/ACEP med student branch. I was about 95% sold on EM until I got to see what they actually do all day, how everyone else in the hospital shits on the ED docs and the amount of anti-litigation medicine that goes on...hence the current navel gazing.

Then again, I've only seen the weak clock puncher practice at my hospital be completely put in it's place by a stronger academic trauma program. Real life will be different wherever I practice, I just need a glimpse of that real life BEFORE I commit my career to it.

The Lone Coyote said...

Glad to hear you did find some redeeming features of Surgery. It does give you that satisfaction that you "did something" and really helped someone. For me all the other bad parts of it outweighed that by far, so it was a no-brainer to immediately cross it off my list. Critical Care might be one to think about when you are navel gazing... lots of procedures, management, and shift work at most places it seems once you are an attending. Of course you'd have to survive a Medicine residency first and all of those hours of rounding and discussing electrolytes.