The Making of a Surgeon in the 21st Century
The Making of a Surgeon in the 21st Century is a highly personalized description of one individual's experiences during a five-year residency in general surgery at a major university hospital. It describes the personal challenges and rewards, the drama of triumph and tragedy, the agony of indecision and the thrill of success. Residency is the most profoundly life-altering sequence of events in a surgeon's life.
What does it take to make a surgeon?
It takes a college degree and a medical school education, followed by a residency. And it takes a willingness to subordinate one's personal life to acquiring the skills and knowledge which a surgeon must possess. This sacrifice takes its toll - on families, on mental health, on life-style. A surgical trainee may not get out on his own until well in his thirties - living, in the meantime, a meager existence at best.
Post-graduate training in surgery is longer than that of any other medical specialty, five years at least. Tortuous on-call schedules often demand exceedingly long work hours - 100-hour work weeks being the norm. Compounding the problem are very high stress levels, the burdens shouldered by the resident's family in his frequent absence and often an enormous educational debt.
Nevertheless, every year hundreds of fresh medical school graduates compete for the few available positions. They are consistently the very best of their classes.
Why would otherwise intelligent, highly motivated individuals actively seek such a miserable existence?
Surgeons have, of course, been glorified in the mass media as the swaggering, brilliant, fiercely independent cowboys of the medical profession. Their compensation has also been great. But beyond this is a personal quality best defined as decisiveness. They want to make the difference, in no uncertain terms. In surgery, when the patient enters the operating room he is suffering from disease. Thanks to the surgeon, he may be wheeled out cured. It doesn't happen every time, of course, but the possibility is there (in other disciplines of medicine "cure" is, unfortunately, an unusual event). Who wouldn't want to be such a healer, making a palpable, tangible difference?
"Honest, hard-hitting and tremendously entertaining ... an unvarnished look at surgery residency." Louis M. Messina, M.D., Professor of Surgery, University of California, San Francisco
"Terrific stories ... we [surgeons] live through this every day but it hardly ever comes out like this ... [Dr. Miller] got it right." Phillip Caushaj, M.D., Chief of Surgery, The Western Pennsylvania Hospital
Table of Contents
1. The Internship Year-Batten the Hatches
2. The Internship Year-See the Man Run
3. The Internship Year-A Little Knowledge...
4. The Second Year-Perchance to Sleep
5. The Second Year-Don't Do Nothin' Dumb
6. The Second Year-Plastic People
7. Strange Problems
8. The O.R. Team
9. Hands and Hans
11. Publish or Perish
12. The Third Year-On the Hot Seat
13. The Third Year-Chops
14. The Senior Year-Little Problems
15. The Senior Year-Glorified Plumber
16. M&M-The Crucible
19. Trauma: Life in the Big City
20. Chief Resident
22. The Making of a Surgeon
Mr. Colson was in trouble.
Bathed in sweat, he was lurching about on his hospital bed, wracked with waves of nausea and intermittently vomiting up pints of partially-digested blood from what seemed to be an inexhaustible supply. The bloody vomit covered Mr. Colson, his bedclothes and most of the room-including his panicked nurse, whose page had summoned me to the scene. I stood transfixed, alternately trying to gather my wits and dodge the brick-red plumes which spewed from Mr. Colson. What should I do?
It was the evening of July 1, 1994, and my first day of surgical residency was drawing to a close. My first night on call was just beginning....
In the United States-and most industrialized nations-medical school graduates must complete a post-graduate training program in the specialty of their choice before they may practice medicine independently. This training program is called "residency," a term dating from the nineteenth century when the trainee would literally live within the hospital in which he was treating patients and being educated. In contrast to medical school, where the large majority of learning comes from lectures, books and (more recently) electronic media, in residency the journeyman physician learns his profession from actually performing the duties of a doctor on a day-to-day basis. Residency is on-the-job training, in a sense....
My first day of residency actually began the night before. I had opted to visit the wards a little early to learn about the patients on my service and acquaint myself with the nuts and bolts of the hospital. Knowing from the rotation schedule that my first tour of duty would be on a service called Surgery 2, I read through all the patient charts bearing that notation. Manila computer cards were ubiquitous on the inpatient units and I grabbed a handful, jotting down obscenely long and detailed notes to myself. In a way I still had the mentality of the interviewee, trying to outdo everyone, but I genuinely wanted to be the best resident I could possibly be-and I knew that meant being familiar with all aspects of the patient's care....
I swiftly made some "pre-rounds," checking the patient's vital signs and so forth. Poking my head gingerly into the rooms, I silently cross-referenced the sleeping faces with the diagnoses I had compiled on my obsessive-compulsive manila cards. Surg 2 was a straightforward general surgery service, with a particular emphasis on colorectal problems.
Around 6:30 am the rest of the team arrived.
The chief resident, Ramya Singh, was a diminutive Indian woman with a surprising, wry Kentucky cackle for a voice. She was accompanied by a third-year resident, Paul Striker. He was a red-haired, ruddy-faced Chicagoan in the plastic surgery residency who immediately expressed nothing but disdain and disinterest in anything related to general surgery. Bringing up the rear were two medical students who had begun their training in clinical medicine the day before. After the introductions were complete, we started to round. At the first patient's door I produced the appropriate card and began to spew forth information:
"This is Mrs. Jackson. She is post-op day three from a right hemicolectomy for adenocarcinoma. Her vital signs are stable, she's been afebrile overnight, and her I's and O's are 2.5 liters over 2.3. She's currently on a clear liquid diet.."
I droned on for several minutes. The chief listened patiently while I delivered my soliloquy, then glanced at Striker.
"He's one of them," she said with a bemused grimace, slipping by me into Jackson's room.
Dr. Singh was remarkably low-key, not nearly as frenetic and nerve-worn as the Ohio State residents I had remembered from my med school days. By "one of them," I understood her to mean that I was being lumped into the category of quasi-military, anal-retentive surgical hard asses that peppered the resident-and attending-ranks. Of course that wasn't my nature at all, but I imagined that there were worse first impressions to give, so I kept it up through the rest of rounds. Singh would listen to my spiel, then examine and question the patient. After a brief pause she would give me the orders pertaining to the care of the patient that day and we would move on.
We came to Frank Colson's room. Mr. Colson had undergone a stomach stapling and bypass procedure, called a Roux-en-Y Gastric Bypass, in an effort to reverse his morbid obesity. The severely overweight suffer from numerous significant medical conditions stemming from their size, far beyond the stigma that society places on their appearance. They develop diabetes, have joint degeneration, metabolic disturbances, sleep apnea-a whole host of problems directly attributable to their obesity. Dietary programs are almost universally unsuccessful as a long-term solution. One treatment for this disease of "clinically severe obesity" that has gained credence in recent years is a combined surgical procedure wherein a segment of the intestine is bypassed while the stomach is stapled. This will produce a sensation of satiety, "feeling full," after even small meals, and also avoid exposure of a long segment of the intestine-which does the absorbing-to the stream of food. This was the procedure that Mr. Colson had undergone two days earlier.
After my presentation we walked into Colson's room. Immediately Dr. Singh stopped in her tracks.
"What happened to your NG tube?" she asked the patient.
"Oh, did you miss Dr. Fleischman?"-Fleischman was the attending-"He was just here. He pulled it out."
Singh said nothing and examined Mr. Colson's vast expanse of an abdomen, listening with her stethoscope and then palpating gently. After proffering a few comforting words to the patient, she led us out of the room.
"That idiot Fleischman!"
She was furious.
"He forgot that Colson's only post-op day two. Craig, watch him like a hawk today. If he gets bloated or nauseous, let me know right away."
The problem was that the stomach and bowels do not function-do not push food along-for several days after an abdominal operation, a poorly-understood but well-documented phenomenon which goes by the name "ileus." For this reason, patients undergoing such abdominal procedures generally must endure a nasogastric suction tube-an "NG"-until their gut is functioning more normally, typically after three to five days. Compounding the concern in Colson's case was the fact that his stomach had been stapled across, creating a little pouch. The NG tube had been deliberately placed in this pouch in order to keep it from distending-due to gas or secretions-and blowing out the staple line. The pattern which had been established in this relatively new operation was to get an x-ray study of the pouch-to prove it and the other reconstructions were intact-before pulling the NG. This was almost always done on the third postoperative day. Fleischman had apparently forgotten what day it was and had taken the tube out before there was any suggestion that Colson's intestines were working. Because of the staple lines at the pouch, we couldn't even replace the NG safely. So the waiting game began. If Mr. Colson didn't get nauseous or distended, it meant that somehow the gas and secretions which form in the gut even in the absence of food-and we weren't about to let him even smell food-were passing through. If he did get sick, we'd have our hands full.
The rest of the patients were, mercifully, straightforward cases of postoperative management. Singh and Striker vanished after the last patient had been seen, taking with them the two students. This irritated me, because I had already been mentally assigning these med students various tasks of the sort that I had performed at their stage. Now they were all off to the operating rooms, and I was left alone on the floor to do the work....
After the day's surgery was over, the team reconvened for evening rounds. Again we traveled from room to room, this time with my relating the day's events for each patient and reporting the results of various tests and so forth which had been ordered. We spent the longest time in Colson's room. He said he was doing fine and, truthfully, he looked all right to all of our eyes. Fleischman never checked in on him the whole day.
When rounds were over, I checked the "post-ops"-the patients who had had surgery that day-then wandered down to the cafeteria to get some dinner. There had been so much work to do that I'd actually forgotten to eat lunch, so I was pretty hungry. After wolfing down a breaded fish sandwich and some fries (this is served in a hospital? I thought), I headed to my call room. Within a few minutes the other interns had "checked out" their services to me. This entailed providing me with a printed list of all their patients, with a military-style briefing as to the vital aspects of their cases. Three other services were covered at a time: Surg 1 (another General Surgery service), Surg 3 (Surgical Oncology) and Surg 6 (Trauma). The man or woman covering this call was said to be "in the box."
The origin of this term, "the box," is obscure, at least to me. Some said it referred to the tiny six feet by ten feet call room to which we were assigned. Others were sure that it referred to the fact that we were covering four services at a time, and that they had appeared on some ancient schedule in the shape of a box. There was no consensus. Whatever the origin of the phrase, I was in the box that night.
I called my girlfriend to let her know how things were going. She wished me luck and I told her I'd see her the next evening. It was about 9 pm.
The calls started at about 9:05.
When I say calls I really mean pages: the nurses may or may not have known where the call room was, and what the corresponding phone number was, but there's no question that it was far easier for them to page me than to dial a number and wait for an answer. Who knew, I might be on the other side of the hospital, putting out some figurative fire? Plus, by paging me they could go on about their work until I called back. Many times during residency I wondered how hospitals ever got along before the paging technology arose (one old-timer said that in years past, when nurses wanted to summon residents who had wandered over to the nearby stadium to watch the Ohio State Buckeyes play football, they hung bed sheets from the windows of the upper floors with the docs' names written on them)....
I was happily playing my utterly-involved bad-ass role when I got the first really scary page of the night. It was from 10 East Doan, my home floor. Sure enough, it was Frank Colson's nurse. He was vomiting. A lot.
When I sprinted into Colson's room I nearly slipped and fell on the blood and puke. The nurse, a very experienced sort, had a look of disappointed resignation on her face, as if the horse she always lost money on had come up short again. A young student nurse standing alongside the bed had a more animated appearance: clutching a hopelessly-overmatched vomit basin, her once-white uniform dripping with the bloody gastrointestinal secretions of the mammoth (and still-erupting) Mr. Colson, she had a look on her face as if a scene from The Exorcist had come to life before her eyes. In truth, nothing in that film came close to matching this tableau for pure stomach-turning gruesomeness. And you can't smell a movie, either. The overwhelming stench of partially digested blood really has to be experienced first-hand to be appreciated: descriptions just don't do it justice.
Mr. Colson himself was unquestionably, at that point in time, the most miserable human being I had ever seen. He was throwing up with such frequency and violence that he could barely catch his breath.
Ever since Dr. Singh's early-morning alert outside Colson's room I had been dreading the possibility of having to cope with the after-effects of the rash decision to pull the NG. Now here I was, and the problem was much worse than I could have anticipated.
There was a cardinal rule of internship at Ohio State: "The intern who has made a decision has made a mistake." I hadn't heard that rule yet, as it happened, yet I realized that the input of more experienced individuals was going to be of considerable importance here.
Before calling the junior resident for help, though, I reflected on my choices. Only two really came to mind right away.
The first option was to try powerful IV "anti-emetic" drugs to suppress the nausea and vomiting. But no, the nurse had done that before even calling me.
My second thought was to try to be the hero and blindly pass an NG tube, unsupervised. In that case, if I was successful, the patient would be happy, the nurse would be ecstatic, and the student nurse would get an opportunity to take a well-needed shower. However, if I perforated the staple line the patient might die from peritonitis-even if we did get him to the operating room in time to fix the damage I'd have caused. No, that brand of heroism seemed a little too close to stupidity for my comfort.
I paged the third-year resident in-house that night and described the problem. She arrived and we debated the possibilities. By now another consideration was arising: what were all this vigorous retching and general gastrointestinal upheaval doing to Colson's staple lines? It couldn't be good. We had to act fast.
We came up with a plan and phoned Singh to tell her about it. After she approved (with a few more choice words for Fleischman) we brought Mr. Colson down to the X-ray suite. There, we sat him upright on the fluoroscopy table ("fluoro" is a kind of real-time live-action x-ray). Then we inserted the NG tube in the patient's nostril and guided it down his esophagus into his stomach. This was dangerous work for us, too, because we were still intermittently dodging the copious projections which Colson was continuing to spew. When we got the tip of the NG close to the stomach we shot some contrast material-which would show up dramatically on the fluoro screen-through the tube. Perfect! The little gastric pouch was still intact, and it was clearly delineated by the contrast material. We gently slid the tip of the NG into the pouch and secured the tube to Mr. Colson's nose with about six rolls of adhesive tape.
When we hooked the end of the NG to suction, literally gallons of secretions poured out and into the affixed canister. Mr. Colson looked utterly exhausted, but he actually managed to coax some humor out of the horrid experience, drawing in enough breath to say, gratefully, "Who should I kiss first?"
Given his less-than-appealing appearance and highly pungent scent, we opted to forego any physical expressions of affection.
Blue Dolphin Publishing, 2004
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