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.