Why I chose urology

A little background...

Its 7pm. I pick up the phone. I dial the number. The phone rings once, I panick and hang up.

I stare at my phone. Can I do this?

I'm lost in one of those infinite moments, where you think a lifetime of thoughts and scenarios in the span of seconds. What will I say? How will they react?  

My phone rings, the harsh tones startling me out of my revelry. They are calling back... 

I'm about to do the hardest thing I have every done. 

I am about to tell my parents I want to be a urologist...

Ok sorry for the overdramatization, it really wasn't that suspenseful. But is sure as hell felt like it. My parents are traditional more blue collar people. We are first generation immigrants, no-one in my family is a doctor.  So for my parents it was a big deal when I got into med school, and they were super excited to tell our family and friends that their son was a cardiologist, an emergency room doctor, etc.

So when I finally built up the nerve and told them, they weren't exactly thrilled. They didn't fully understand what it meant to be a urologist. Their impression was that urologists were essentially gynecologists for males.

But really, urology is an amazing field. First and foremost - urology is a surgical subspecialty. You have to love surgery. And I love being in the OR. As I detailed in a previous post, for me nothing beats being in the operating room. Urology affords me that opportunity.

But additionally,  their are some specific things I love about urology.

Anatomy
I like the anatomy. I like the abdomen and pelvis, I like working the abdomen. I like being the master of all things urological (kidney/bladder/ureter/scrotum). We do our own ultrasounds, we read our own CT's, we do our own retrogrades in the OR. We are better at radiology in that sense.

Ownership
What do I mean by this? I think an example is best. A colorectal surgeon will get referred all his cases. GI treats the inflammatory bowel patients, when they fail medical management send them to the surgeon, he chops it out and sends them back to GI. Same thing with cancer.

But urology, we own our patients in a unique way. Sure we have the cancer referrals that we operate on and then lose. But we also have a huge population of patients that we manage. We are men's health doctors. We do annual exams, treat men for their ED, follow patients BPH (big prostate) voiding issues. Right now when I'm in clinic with my attendings, almost on a daily basis we take care of patients that he has been seeing for 10+ years. He's operated on them, managed them medically, and really know them. I like that about urology, we build very long relationships with our patients.

Master of our domain
We are masters of our domain (does anyone know that reference from Seinfeld??)
We medically AND surgically manage diseases of urological organs. We take care of BPH, recurrent UTI's, and stones, along with multiple others. I like being the guy that does that. I like to go to a patient and say well you have a stone, we can try medical or surgical management, but either way I'll be taking care of you. This ties in with anatomy and ownership, we really do take care of our patients from start to finish.

Hours:
I can honestly tell you that everyone for everyone who goes into urology, this is a factor. Urology is a surgical subspecialty, but we have far better hours than our general surgery brethren. Theirs are significantly fewer urological emergencies. Plus urology is alot less baby sitting, and we don't take care of the painful trauma bombs. Sure emergencies can be fun and exciting, but in thirty years will I still want to be doing that? Its kind of nice to have fewer emergencies, have a better schedule and more control over your life. Also our residency, while still grueling, is nowhere near as bad as our general surgery colleagues have it.

Diversity
I love this about urology. We do big open abdominal surgeries. We do a ton of laparoscopic surgery. We use the robot more than any other specialty, and have a good reason for using it. Our bread and butter is endoscopic surgery. Our pediatric surgeons are essentially plastic surgeons. The variety is huge.

People:
Urologists have a unique personality. First and foremost urology is a surgical subspecialty, so it attracts driven, intelligent, hard working type A personalities. At the same time though, almost paradoxically, we are some of the laid back, relaxed and funny people in the hospital. Jokes fly all the time in the OR, and in general we all have fun and don't take ourselves to seriously.

Theirs a reason that urology is so competitive these days, and I think the above outlines it. Its a fantastic field, full of people who love their job. When you love your job, you work harder to be better at it, and it just furthers the field.

AsConfucius said “Choose a job you love, and you will never have to work a day in your life.” 

Trauma call

For the past month I've been on trauma nights. In our residency we do two months of nights, my first month was in the beginning of residency as I've talked about, and I'm doing my second month now. Before I was a med student, before  I was a resident if someone told me "trauma nights" I would think it was the coolest thing in the world. In fact that happened recently, we had a bunch of friends over one Sunday, and as I got ready to go to work on Sunday evening everyone was saying how awesome it must be to be on trauma. I tried to explain how depressing it is, but stopped before I said anything stupid. Grey's anatomy, House, Scrubs - they've all made life as a doctor and surgeon out to be something it isn't. In those shows, the terrible traumas come in, but in the end everything works out. Shit isn't real. But it hits in you in trauma nights how real things are.

A little background on trauma. The ED handles the vast majority of simple trauma without activating the trauma pager. IE you have a car accident, you hurt your hand, no other injuries - that won't be a trauma. But, if its a bad accident, essentially any thought that surgery needs to be involved then the trauma pager is activated. You gotta remember, if someone unstable after a trauma, they are tanking in the field, an ED doctor can't do all that much other than acutely stabilize the patient. You need a surgeon, and its best to have the surgery team at the bedside waiting for you so as soon as you get in we're ready to roll. So when that trauma pager goes off, we haul ass down the trauma bay and get ready. We always expect the worst. We are notified whether its a level 1 or 2 trauma. Level 2 are generally stable, still a significant enough impact to activate a trauma but generally not someone who you expect to die any second (but you never know). A level 1 is serious, you have no idea what you're going to get but its generally bad. For level 1 traumas we expect to immediately intubate (breathing tube), line them up with central lines, chest tube/thoracotomy trays ready. You just never know. Its better to have a trauma surgeon and the team available then not. One of the memorable traumas: (identifying details obviously changed)

Its 7PM, Tuesday night. I'm running around the hospital, answering pages, doing post op checks. I was hoping for a quiet night, the thing with trauma nights is that if their are no traumas, by midnight you can be done with all your work and get some good rest as long as no floor patients are crapping out.  So anyways I'm on the floor when the trauma pager goes off. The sound of that pager always gets my HR going, scares the hell out of me. Its a level 2, so me and my med student head down the trauma bay right away. All I'm thinking of is the work that I have to do, and hoping this trauma isn't too bad.

I get my lead on (we always take xrays in the trauma bay and as the intern, I stay with the patient during the xray), throw on some gloves and wait to hear whats coming in. The ED nurse tells us its a pedestrian hit by car. This is one of the most common traumas we get. Me, my chief resident and the ED attending are just hanging out in the trauma bay waiting, joking around. Finally about 10 minutes later the ED doors bang open and paramedics are rolling the trauma in. They yell "22 year old female, jogging, struck by car ~20 mph". We transfer her to the trauma bed and get to work. We are a well oiled machine, consisting of the chief resident, junior resident, and myself (the intern). The junior resident starts with the ABC (if you remember from CPR, just make sure their breathing and airway is intact), while I help the nurses get the BP cuff/EKG leads on for our first set of vitals. While the junior completes the head to toe assessment I start cutting off all the patients clothes. Trust me - you never want to be a trauma, no privacy, no dignity. We cut everything off.

Her vitals were stable, she was alert and oriented with no obvious life threatening injury so we all slow down a bit. We do a FAST abdominal ultrasound exam, which tells us if their is a large amount of free fluid in the abdomen which would imply an urgent trip to the operating room. Its negative. Because she lost consciousness in the field, we decide to get a CT of the head and cspine just to be safe. We roll her over to CT, grab a seat and wait for the scans. This is what we see:

She had a huge epidural hematoma (brain bleed). As med students we see these pictures a hundred times, and I had seen a couple of subtle ones on traumas before. This one wasn't subtle (Obviously that picture is not her, its from google, but it was that big). She had midline shift and everything, yet her neuro exam was perfect. We call neurosurg right away, they come down, evaluate her, and recommend sending her to the neurosurgery ICU and watch her closely.

Why did this trauma stick out in my head? Well after the CT, but before she went to the neurosurg ICU she had a bunch of lacerations that needs to be sutured in the trauma bay, nothing unusual and the task usually falls to the intern. We also had some time where I had to stay with her while the transfer to the ICU was being sorted out; the team didn't want to leave her alone unmonitored. So we start talking, and it kinda hit me how completely normal she was. Its this 22 year old girl from Europe who came to LA to work in fashion. She was just out for a jog and thinking about her weekend plans.

Working in this field, seeing all the trauma's roll in one after another you lose a sense of the human connection. The traumas, the patients are just work. We don't even assign them real names, they have trauma code words (oftentimes traumas who come in don't have ID and we can't ask them their name, so by default all traumas get assigned a code word). You lose empathy, start to identify the patients by their disease process. We don't say "how is mr jones doing", we say "how's the old guy who had the splenectomy doing".

But talking to that girl I saw how scared she was, she kept on thanking us but she as clearly in shock at what was happening. We never stay with out patients long enough to talk to them about anything but the acute medical/surgical problems; the social workers/nurses/therapists/case managers are the ones who figure the "other stuff" out. She had emergent surgery that night to evacuate the hematoma, she was going to have a serious scar and probably a long recovery.

But the main point here I think is that I understand why we don't try and connect with our patients. It would destroy you. We get so many drunk people who come in after doing something stupid - hell not too many years ago that could have easily been me or my friends. We never empathize with them, we call em drunken idiots and try to get em out of the ED as soon as possible. For all the terrible motor vehicle traumas we see and don't think about, man we all drive to work. That could be our family, our friends, us. We never think like that; its just a job. And it has to be like that because like any other thing in life sometimes things don't go well, bad things happen that are out of your control. And sometimes bad things happen because you or someone on your team screwed up. And if you treat this like more than a job, if you stop and actually put yourself in the patients shoes or if you try to treat everyone like you would treat your mom or dad I really think you will lose your mind. If you thought about the consequences your actions had on peoples lives, I don't think I could bear it.

And that sobering thought, the idea that I treat work like work I think has really defined my intern year. I know lots of people think that we become doctors for women, power, and money - but really thats not what drove me and most people I know to do medicine. I worked in tons of menial jobs in high school and college, and what made me want to do medicine was the idea that I could get paid, my career would be doing something intellectually stimulating, interesting, and I'd be helping people. I like to think I'm a genuinely nice guy who cares about others. I've always been that way. I remember as a medical student spending hours with patients, talking to them. I really empathized, and I couldn't understand why residents and attendings were so callous, so rushed (their will actually be another post about a patient from my third year of medical student that really changed me). I remember thinking I'd never be like that...

And then I think of how am I know. I'm just 8 months into my residency, and already I'm losing that emotional touch. I just want to get through the day. When the trauma pager goes off, my mindset isn't f**k someone may be badly injured, its f**k I hope its not too bad so MY day isn't ruined by this. It sucks, and its just not surgery its all specialties. We all try and dump patients on other services. No-one wants to sit down and figure out the social situation, the background, we want to just get on with our day. We have the same mentality with the hospital that virtually everyone has with their  daily job. The  only difference is instead of have that attitude towards meetings, the bottom line, clients, customers etc that is completely acceptable in any other profession we have that attitude towards sick human beings who are coming to us for help.

Every once in a while something reminds me of how I used to be, how much I used to empathize. And please don't get me wrong, myself and most people in our field are genuinely good people. We do want whats best for our patient. Thats the underlying sentiment, thats what drives us. But this damn system, you are so overworked, so tired, so stressed that sometimes you lose sight of the big picture. I work in an era where work hours are significantly improved from where they used to be, but its still nothing like 99% of the population will ever experience. I easily hit 40 hours by Wed afternoon. I go the entire year averaging about 80 hours a week of work. I get one day off a week, and its sometimes in the middle of the week. We don't get many holidays, and tend to be on call for most of them anyways. But the point of this post isn't to complain, because honestly I still think I'm blessed to be in the position I'm in and wouldn't trade it for anything. But this system changes you, and not for the better. I know I'm still that person that cares, that I would do anything for my patient. I just need to remind myself of that sometimes...

My first case as a resident

So as I mentioned, this intern year has been a year of highs and lows. I think as a surgical resident, or any resident in general, this is an adaption we get used to.

My first high came during my first week of nightfloat. I mentioned in my previous post the feeling of just being crushed by nightfloat. Another downside is their is very little to no operating experiences for interns on nights. The senior residents do most of the cases and traumas while we interns run the floor. But one night, I think it was my third or fourth night in, I get a text that one of our pediatric urologists has a 7AM case that is going uncovered - ie no resident would be free to do it. It was mine if I wanted to stay. I was euphoric.

You have to understand, the most frustrating period in medical school is that point when you realize you want to be a surgeon, but you are still a med student. At most, you get to close skin. You'll spend hours literally inches from the surgery, but never do anything. I was itching to use the bovie, to use the scalpel. As a fourth year you get slightly more responsibility, but still its nowhere near the same. Your third string, behind the attending and the resident. I was so pumped about this, after a few hellish nights of running around the floors I was going to get to operate!

The night went by hectic, as always. Finally at six in the morning I finish signing out the night events to the day interns, I go to the call room and read about the procedure for an hour. We would be doing an orchiopexy on a 6 month old baby. Essentially, one of his testicles had not descended, it was stuck in an area near the groin called the inguinal canal. Our job was to release it, bring it down, and sew it in place so it wouldn't go back up again.

The case itself was amazing. Its hard to describe the high I get when operating. Time flies by. My family and friends always ask how can we be comfortable while we're sterile. You're wearing a mask, gown, gloves; you can't itch or scratch, can't leave or take breaks. You're standing, operating. But all your focus is on the task at hand. Nothing else matters, I really lose myself. A two hour case feels like 20 minutes. Its the greatest feeling, and that morning reminded me that, despite all the crap of intern year, it'll be worth it in the end. Even 8 months into intern year, nothing has changed. I still can't believe I get paid to do this. I hope that feeling never goes away.

First day of residency

Every year around the end of June/early July, new interns get ready to tackle the job of being a "real doctor". For you non-medical people, I don't think theirs any way to convey the fear that goes into this. We go from being a medical student, which is essentially a role where you have no responsibility, to being a doctor. The truth is, 4 years of medical school do NOT prepare you for residency.

A bit of background for people who don't have a background into the training system in our country:

Residency is where you learn the skills to practice the specialty you want to do for the rest of your career. Most people go into internal medicine or one of its subspecialties, forming your general practioners, cardiologists, gastroenterologists, etc. Others of us choose surgical subspecialties, and their are tons of other options as well. I chose urology, which is the surgical subspecialty for the urinary tract (kidney, ureter, bladder), along with male specific organs (prostate penis and testicle). Urology is a great field, laid back people, and awesome cases (I'll have a post on this later). But I digress, back to the main point which is as surgeons training is 5 years at a minimum. During these 5 years yes we are doctors but their is precious little we can do without consulting first with our attendings. Essentially its an apprenticeship. The keys here - we work like dogs and get paid shit. I - no joke - with the hours I work weekly make about 11 dollars an hour (the frustration about that will be a separate post don't you worry). Anyways I am currently in my first year of residency, also called internship, which is the by far the worst year as you are on the bottom of the totem pole. 

Anyways, back to my point. So the residency I am at has switched to a night float system as interns are not allowed to take 24 hour call anymore. Essentially every month 2 interns cover the hospital at night, taking care of the patients (with help of course). We work from 5:30PM to around 6:30AM, with one night off (sat) a week. Its a tough rotation, as you have to cover around 100 patients on whom you really don't know much about. You can imagine my joy when I found out that my program decided to put me on night float as the  very first rotation I would ever do as intern year. It was terrifying.

So flash forward to June 26th, a night that will live in infamy (ok I'm being a little dramatic). Shift started at 5:30, so I got my scrubs on, wore my brand new long white coat and went to work. I had no idea what I was getting myself into. As the "floor" surgical intern, I'm covering about 60-90 inhouse patients overnight. Patients whom I know really nothing about. We go through a signout procedure, but realistically all it is is saying nothing to do on the majority of people, and a few tasks for others. You don't really know anything about the patients you're covering. So I get my pagers, intern cell phone (so the rest of the team can get in contact with me at anytime) and get to work.

Let me tell you, it was terrifying. I got about 60 pages that night. The majority are small things (pain, nausea, home meds), some slightly scarier things (tachycardia, fevers, low UOP), and some downright scary things (hypotension). Some highlights from the night:

• A chronic pain patient was admitted, and I had to do admission orders for her. One of the things that they really stressed during orientation was not killing anyone by oversedating them with narcotics, so I gave this patient the standard Q4 doses of opioids. We're talking a maximum of 1mg of dilaudid every four hours for a patient who is on a fentanyl patch at home. Of course no surprise I get paged about her pain meds, and my solution was to give her .2mg pushes of dilaudid. It was like throwing a snowball at an inferno, it didn't do anything except drive the nurse and patient crazy. In retrospect I feel so bad for that nurse, I think she paged me about 5 times for 5 separate baby dilaudid pushes, I was just so scared to give any more pain meds.
• A thoracic patient who just had a VATS (video assisted thoracic surgery) complain of chest pain. Trying to be a superstar intern, I remembered how to work up chest pain. I got troponins, cxr, and EKG. Of course, the astute reader may questions - hey if this person just had THORACIC SURGERY maybe its ok for them to have a little bit of chest pain? Yeah, I didn't quite make that connection and got a 500 dollar workup anyway
• Calling my senior resident to ask if it was ok to give benadryl
• Calling my senior resident to ask if it was ok to give tylenol
• Calling my senior resident to ask if it was ok for someone to have a HR of 110
• Calling my senior resident...you get the idea she was a patient soul.

In anycase, I can't describe the stress of that night. I had a great team helping me out, but at the same time being the doctor in house, being the go to guy for the nurses to ask questions on all the inpatient surgical patients was an overwhelming experience. 

Seriously guys, don't go to a teaching hospital in July. Just don't do it.

Intro

Hey,

This is going to be my venue to let of some steam, maybe give people a glimpse into what life as a surgical resident is.

So about me - I'm currently doing my intern year in general surgery. This year has had some incredible highs and devastating lows that I've never experienced before. Its changed me as a person, and I'm only halfway done...

I have a ton of stories and thoughts to share from the first half of the year, and I'll sure I'll have more by the end of it.

A little bit about me, I went straight from undergrad/med school/residency, and picked surgery because I loved being in the OR and loved the definitive intervention. An 8 week med school rotation did not prepare me for this, but having said that I wouldn't trade what I do for anything. I'm actually doing urology, so life will get a hell of a lot better once this year is over. I'm a laid back guy, before this year never really yelled at anyone, and pretty low key/low stress.

Ok enough for now, pager going off...