I am sorry to not have kept up with the blog, here are more posts.

The vascular service rotation went by quickly, being only 3 weeks. We were on call every third night. Post-call, the following day we stayed until early evening when Marie let us go. This was the expected routine on every surgical service in the hospital and no-one questioned it. Spending so many hours in the hospital taking care of sick patients functioned as a way to shorten the learning curve. The continuity of seeing everything that happened to a given patient was also invaluable, both for the intern experience and the patient care: there was no dropping the ball: since everyone was there almost all the time, everyone knew all of the essential details of what was happening with even the most complicated patients.

One way in which we, as interns, were clearly abused was in that we were expected to perform tasks that were nursing, clerical, or that should have been done on an outpatient basis. One example of a nursing task was the discharge paperwork. The rule was, the intern had to fill out a discharge instruction sheet with follow-up instructions, a list of medications, contact numbers, etc., and we had to give it to the patient, explain it to them, and answer any questions. This is a task performed by nurses at private hospitals. If a patient needed a study such as a chest x-ray, we had to write the order in the chart and fill out a special radiology order form. The filling out of such forms is done by a ward clerk (or is bypassed altogether and just the doctor's order suffices) in private hospitals. There were many such examples of requiring physicians-in-training to perform non-physician tasks both at the University Hospital and other academic centers at which I have worked. Finally, specific to the Vascular service, there was the inpatient work-up. This required us to arrange for and follow-up on a complete pre-op work-up on the incoming patients who were being admitted for elective vascular procedures. This work-up consisted of ordering, filling out the forms for, then bird-dogging the results of the EKG, chest x-ray, cardiology clearance, bloodwork, and even in many cases the angiogram. (Insurance companies will not pay for inpatient admission to do what is an outpatient workup these days, so I doubt this last intern task exists any more.)

We had to prioritize all of these nursing, clerical and pre-op tasks while still addressing urgent and emergent issues with our patients, or assisting in the OR. When there are only 24 hours in a day, and you have a long list of tasks with frequent interruptions for patient questions and issues that come up all day and night, personal necessities such as sleep and meals fall by the wayside.

On my second day of internship, a nurse rushed up to me and exclaimed that Miss Carver in bed 24 had suddenly experienced slurred speech and weakness on her right side. Miss Carver had just undergone repair of a carotid artery injury the day before.   I rushed into the patient's room with the nurse, and asked the first question that popped into my head: "what's her blood pressure?"  I examined her: she was awake and seemed OK but was anxious.  The episode had cleared up, and her BP was fine.  I had no clue what to do so I quickley contacted the vascular fellow, who came to see her.  It never was clear to me what had happened with her, as I was then swept up with the endless stream of multitasking as the day continued on.  It was somewhat unnerving to be faced with a situation I had no idea how to handle when I had just been doing this a day, but I really had no time to ponder this.  

Another shock occurred when I found the need to order Tylenol: after all of the pharmacology we learned in medical school, I didn't even know what the dose was!  It was the first thing I wrote on my little pocket pharmacopia once I looked it up.

We did go to the OR on a regular basis, despite the general complaint amongst the surgery interns that our lives were spent as scut monkeys who never got to operate.  I assisted on vascular cases, watching as the attendings and fellows skillfully sewed grafts into place with fine prolene suture.  You have to be  fast yet precise as a vascular surgeon, because you are operating on arteries through which blood is rushing.  I got to do a couple of cases, but unfortunately the only intern-level cases in vascular surgery are amputations, which I did not like.  

One evening, I was post-call, having gotten very little sleep the night before, when Marie came up to me and told me apologetically that she could not let me go yet, I was needed to assist with an axillary artery injury that was being rushed to the OR.  I told her I would be there right away (not that I had any choice).  The patient was a young man who had been in an accident and had somehow lacerated the large artery in his upper arm; if it was not repaired immediately he could hemorrhage to death or lose his arm.  The attending, Marie and I worked swiftly to isolate the briskly bleeding artery and repair the damage.  The surgeon needed to be swift and precise, and someone had to keep the surgical field dry, so this could only be done with two surgical assistants.  The attending vascular surgeon was highly skilled, and the patient kept both his arm and his life.  I wonder how situations like this are handled nowadays, with the work hour restrictions.  Would the residents just say "sorry, but I have worked my hourly limit already" and walk away, leaving the attending to cope as best he could?  

One day a nurse rushed up to me yelling "Mr. Starkey is bleeding from his graft!"  Mr. Starkey was being treated for an infection of his femoral artery bypass graft.  I went into his room to find arterial blood gushing from his right groin area.  The infected graft had weakened and ruptured.   The nurse threw me gloves and a wad of dressings, and I applied pressure.  Meanwhile, the charge nurse had notified the vascular fellow, and arrangements were being made to rush Mr. Starkey to the OR.  I climbed on to his bed to get into a better position to hold pressure, and stayed there as the nurses wheeled the bed down to the operating room.  We were then wheeled right in to the sterile vascular surgery OR where the surgical team awaited.  The fellow relieved me from holding pressure and I left the room immediately, as I was not wearing a hat or mask.  Mr. Starkey got a new graft on an emergent basis and did well.  

Not too long after that, a nurse informed me that the gentleman in the room right across from the nursing station was nauseated.  I went in to evaluate him.  "Mr. Courtney", I inquired, "what is bothering you?"  After determining that he was very nauseated and diaphoretic, but not having any chest pain or shortness of breath, I ordered STAT cardiac labs, EKG, and chest xray.  Most of these vacular patients were very ill, and usually had cardiac disease as well as peripheral vascular disease, not to mention diabetes, which can be associated wirth "silent" myocardial infarctions.  His EKG did show some cardiac ischemia, so I paged Marie and informed her I was sending the patient to the cardiac care unit and calling a STAT cardiology consult.  I was somewhat surprised when she rushed up to the floor, agitated that I had not immediately informed her when I was supicious that Mr. Courtney was having cardiac symptoms.  However, I had clearly done the right thing in ordering a STAT ROMI (rule-out myocardial infarction) despite the fact that he had no chest pain, and she didn't stay mad at me for long.  

There was camaraderie amongst our little vascular surgery team for the brief time we were together, and we had dinner and drinks one night at the vascular fellow's apartment.  The attendings, however, were quite distant with us interns, as you would expect.  As interns, we were beneath their notice for the most part.  Any positive or negative feedback was communicated by the senior resident and fellow, never directly.  We did receive an evaluation at the end of every rotation.  This was really the only means we had of knowing how we were progressing. A somewhat more overt and structured feedback mechanism would have been helpful.  After all, we were there to learn how to become competent, independent surgeons.  In the rigorous daily routine, the focus was on being on top of everything that was going on with the patients, from their morning labs to the condition of their surgical incisions.  This sort of attention to detail really makes up the nuts and bolts of making sure the patient does well during thier hospital stay and goes home in good condition, and so is an essential part of the evolution of a good surgeon.  The surgery residency culture at the time was that we were more or less left to assess our own progress.  I didn't really think about this at the time.  We were all focussed on day-to-day survival for both ourselves and our patients.

The first morning, I walked up the drive to the almost overwhelmingly large University Hospital anticipating  the days and weeks ahead of me as intern on the Vascular Surgery service.  I felt as prepared as I could possibly be, having reviewed the patients I was picking up.  It was an exciting, yet somewhat terrifying, morning.  I met my co-intern, Dean, who was going into Urology.  He would have to do two years of General Surgery as part of his residency, unlike me, who would be able to go right to my specialty, Neurosurgery, after the internship year.  We met the senior resident, Marie, with whom we would be working the closest.  She was a tough, no-nonsense surgery resident who exuded confidence and experience.  She knew we were essentially green medical students, and she carefully explained our responsibilities and priorities.  She would spend most of her time assisting in the OR, taking care of the ICU patients and seeing consults; we were to take care of the floor patients and do the admissions, pre-ops and discharges.  We would also assist in the OR when needed.  

As the days went by it quickly became clear that we were basically glorified ward clerks.  Somehow, the service was able to admit patients pre-op for their entire workup, something that would be impossible nowadays because insurance simply would not pay for it.  Our daily routine, after morning rounds, consisted of admitting patients, taking a history and doing a physical exam, and ordering all of the preop studies, including angiograms.  All of this could have theoretically been done on an outpatient basis, but since we were there, the patients were simply admitted, and we did all of the work.    

Meanwhile, we experienced getting task after task assigned to us, compelling us to shuffle the tasks around in order of priority, and to multi-task whenever possible.  One might find oneself at the end of rounds tasked with 3 discharges, 2 admissions and preop workups, 2 central lines to pull, 5 consults to call in, a handful of xrays, cat scans and labs to be ordered, and a diabetic foot ulcer debridement to be done at the bedside.  One also had to check labs, x-rays and any other studies that had been done.  One had to check consult notes, to see what the consulting service was advising us to do.  As one went about these tasks as swiftly as possible, one would have to field questions from the floor nurses, pages from interns on other services regarding patients the Vascular Surgery service was consulted on, and pages from the senior resident in the OR with new tasks to be done.  In the middle of all this, one might be called to go assist on a case on the OR.  Basically all of the tasks were expected to be completed by pm rounds, the time of which varied from late afternoon to mid-evening, depending on when the senior resident was done in the OR. 

To make life more interesting, it turned out that the patients on the Vascular Surgery service were the sickest in the hospital.

June 30

The day before the first day of surgery internship at Chicago University Hospital, I went in to meet with the Vascular Surgery intern whose place I would be taking the following day.  She was a plump, tired looking woman with stringy blond hair.  She was at the nursing station on the vasc surg floor, working.  She had been working overnight until 1 am that am, and had returned to work maybe 5 hours later.  She related to me the basics of running the service, and who my supervising residents would be.  I reviewed the charts of the patients I would be picking up and made a list of them, their problems, and their meds.  Then I went home, vaguely terrified, yet elated at the prospect of beginning my internship.

I was luckier than my predecessor on the vasc surg service, in that I shared the service with another intern, making it more likely I would actually get some decent sleep on the nights I was not on call.  

First post: Forward/med school

I write this as a memoir of my journey through a surgical residency.  I am finished now, and have been in practice for several years.  I have always wanted to record my story: this is a good forum. 

The timeline for this narrative is irrelevant: suffice it to say these events occurred some time during the 1990s.

All of the events and people herein are real. I have altered the locations and names to obscure the true identities of where and with whom I worked.  I also endeavor to be as objective as possible, realizing that I will not be able to avoid injecting my own personal bias into these events: at the same time, these events did happen to me, and no one else experienced my perspective of these events.  

I had a great time in med school, and was encouraged to apply for a very competitive residency: neurosurgery.  I did run into one detractor, however.  The residency program director at my med school once told me: "you will never get into a neurosurgery residency, because you are female."  My gender had never been an issue before in med school.  At that time,  a shift was occurring in the makeup of the med school class.  Each incoming class had a slightly higher percentage of women than the previous one, and my class was almost 50% women.  I never felt, nor did I feel other women med students were, subject to differential treatment.  

Once I was in residency, in general it never occurred to me that I would be treated differently due to my gender, although in retrospect this may have occurred.  It certainly was not something that was even on my radar at the time, and I will try not to attribute events that occurred during my residency to gender discrimination, although, for some events, this may have been the case. 

The purpose of this blog is to record and share my experiences during my residency. Every word is true, and you can take whatever lesson or message you chose to about the nature of surgical residency training.