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.