Chief Resident

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

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

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

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

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.