Friday, March 4, 2016

3rd Year Chronicles: Surgery


The unrelenting wail of my pager cut through the heaviness of my dreamless sleep. I opened my eyes and fumbled to turn it off before it woke the person trying to sleep a couple of bunks over from me in the call room. It was a text page.
Someone is eager to retract...

"Come to CT in the ED."

It was almost 1 am on a Friday night. I was on trauma call at Loyola at the end of my third of eight weeks on my surgery rotation. For the first half of the rotation, my days had been spent on the vascular surgery service at the nearby VA hospital.

The days were long - I usually was there around 4:30 am to prepare the patient list, round on my post-operative patients, and write my notes before rounding again with the team around 6 am or so. After rounding, our usual two or three cases would keep us in the OR from anytime until noon on a short day to 4 pm or later on a longer one. After a few hours of taking care of miscellaneous tasks throughout the hospital, seeing consults, attending lectures, and checking on our patients in the afternoon I was usually able to finally leave the hospital anywhere from 5 pm on a good day to 8 pm or so on a longer one.

When I came home, I was pulled between needing to read up on the next day's cases, trying to get some general studying in for our surgery shelf exam at the end of the rotation, preparing any presentations that I had been asked to give, taking care of what felt like a million different miscellaneous things that needed to be squared away before fourth year and residency applications began, and – most importantly – spending as much time as possible with my wife and son. Sleeping was usually on the list in there somewhere, too.

After a few weeks on that merry-go-round, I was exhausted. During the days, it was difficult to find time to eat, drink, or use the bathroom. When I finally got home at the end of the day, I really just wanted to sit down with my family in front of the electric heater in our living room – the older house we are renting doesn't stay very warm when it is in the single digits outside – and just relax with them, chase my son around the house, and spend time with my wife.

But there was no going home tonight. Fridays were busy days anyway at the VA. In the mornings, we rounded as usual and then went to several hours of conference. After taking care of any miscellaneous tasks on the floors, we then went to clinic. Technically, it was scheduled for three hours. But since they routinely tried to squeeze in 40-45 patients in that time span, it was something we all dreaded each week. The clinic was always ridiculously crazy and fast-paced, and by the time we were getting to the end of the afternoon – several hours behind schedule at that point – the patients were almost all (understandably) peeved about having to wait so long.
Of course, that made things even more enjoyable. Once the patients were all seen, we would breathe a sigh of relief and start writing our notes – which would usually take up the next couple hours – and finishing up things on the floors for the day. After that, we finally would go home.

Tonight, though, was different. After finishing clinic, but before getting a chance to write my notes for that day, I headed over to Loyola to start my overnight trauma call. After meeting up with my resident for the night, we spent the next few hours seeing random consults and admissions throughout the hospital. Finally, around 9 or 10 pm, things started to slow down a bit. I went to the call room to try get a little bit of studying in, but that didn’t last long. I quickly fell into a deep, empty sleep. That, apparently, wasn't how I was going to spend the rest of the night.

After I found my shoes, threw on my white coat, and tried to quietly fumble my way out of the call room, I headed downstairs to the emergency department and found the imaging room. A small group was huddled around the screens displaying images that were just being taken of the patient lying on the table in the CT machine beyond the glass pane. They weren't very promising images, either.

The story we initially heard was that a teenager was found by friends after he had slipped on ice and hit his head. We'll call him Peter. EMS arrived about 15 minutes later and he was brought to the ED, where he was intubated and sedated since he had a significantly decreased level of consciousness and was agitated on arrival.

The images we saw, though, suggested someone wasn't telling the whole story. This kid had two different skull fractures and bleeding all throughout the brain. His brain was swelling in response to the injury and essentially trying to escape through the hole in the bottom of the cranial vault and his pupils were fixed and dilated – a very bad sign of neurological injury. Had this been anyone else – anyone other than a young kid - it more than likely would have been deemed that any significant intervention wouldn't change the prognosis, which was very poor. Since Peter was younger, though, they had to at least try. Nevertheless, the odds of him surviving were grim.

After some further imaging, neurosurgery placed an external ventricular drain – basically something that amounts to a catheter inserted through a hole they drill in the skull to drain some of the fluid that normally circulates throughout the brain to reduce intracranial pressures. If the increased pressures continued, they would kill him.

Normally when the drain is inserted, the clear fluid normally dribbles out the end of the catheter. In his case, though, the fluid was spurting out the end of it like water does when you put your finger over the end of a hose. Not a good sign.

Around this time, the family was starting to trickle in. We eventually learned from one of Peter's friends that he had actually hopped on top of the hood of a slow-moving car that the friend was driving. The friend was startled and quickly hit the brakes, throwing Peter off of the hood of the car and to the ground, where he hit his head.

Soon after the drain was inserted, the patient went back to the OR. There, the neurosurgeons essentially lifted up the left half of his scalp from his skull and then removed the exposed portion of the skull – the entire left side of his head. The whole time, the brain seemed like it was trying the escape the room. When they finally cut through the dura mater – a thick covering over the brain that normally protects and encloses it – it finally was allowed to swell without compressing itself on the inside of the skull.

By the time they got to this point, I was around maybe hour 25 or 26 of my shift. I was exhausted. Not only had the preceding week been incredibly busy and sleep been scarce, but I knew I still had at least a couple of hours of work ahead of me – before I left, I needed to go back to the VA to wrap up my notes from the prior day.

All throughout medical school, we had been warned about various studies demonstrating a decrease in the measured "humanity" or empathy of students that has been observed from when they start their first year as compared to when they finish. The steepest drop often happens in third year. So far, I felt like this hadn't been really been an issue. I've enjoyed most of my rotations so far, I've enjoyed my patients, and I've had a good time overall. I've even really enjoyed my surgery rotation. Taking part in patient care, being a part of the medical team, and learning "real medicine" has been very satisfying.

Tonight, though, was different. Tonight, as I was standing near the head of the bed, watching this young kid fight a losing battle for his life… I realized something.

I didn't care.

That wasn't entirely true. There was a small part of me, deep down, that was breaking for Peter and his family. We've all done stupid things before, but now this young man was paying for it with his life. But there was a bigger part of me, a more immediate and present part, that didn't feel any of that. A part of me that just wanted to go finish my notes and go to sleep for the next week.

I could easily explain this away as a bad day on my part. I could say that I was just exhausted, and that things would be better after a day off and decent night's sleep. And maybe all that is true. But the fact remained that I found myself that night experiencing something I never really thought I would – a distinct, undeniable feeling of indifference for a patient. Something that I would sometimes see in residents or attendings who were further down the road and swear to myself that I'd never become like that.

Peter survived the surgery and was transferred to the pediatric ICU, where he remained for almost a week in critical condition. His family slept at the hospital, staying at his bedside as much as they could. Pastoral care and social workers did their best to help the family manage their feelings and help them with all of the little things that need to be addressed when a loved one is critically ill. Peter's intracranial pressures actually slowly began to improve, but he then began to require mechanical ventilation to breath adequately. His hospital course was complicated by one of his lungs collapsing, a lung infection, a deadly respiratory distress syndrome that sometimes occurs after trauma, and eventually progressively worsening blood pressures.

Finally, late in the afternoon on what would be his last day in the hospital, Peter's status was continuing to worsen. After one final flurry of a failed resuscitation attempt, his father decided that it was time. One more round of drugs was given in a futile attempt to prolong his life until another family member could arrive, but Peter died around 6:30 pm that evening before they got to the hospital.

Several weeks later, I'm now nearing the end of my surgical rotation. After the end of the fourth week, we switched services and I was assigned to surgical oncology. This has been another busy service with some very sick patients, not all of whom have survived the surgeries that were meant to be a last attempt at a cure. Some of those who have survived still don't have long to live – maybe a couple of years at best.

I'm still tired. That seems to be a defining feature of this rotation and probably won't go away with the next one. But my experience that night at Peter's bedside has stuck with me. It taught me how easy it is to lose the "bright-eyed and bushy tailed" optimism that so many of us start third year with and gave me a little more understanding for those weary residents and attendings who, from my relatively rested point of view as a medical student, were maybe a bit shorter or seemingly uncaring with patients than I would like to think I would be. But for all I know, perhaps I'd be even worse if I was in their shoes. I hope not. To you, the reader, perhaps this all seems a bit silly and blown out of proportion. And perhaps you're not wrong. For my own part, though, my hope is that this experience serves as a reminder going forward to continue to reflect on my "spirit" as a medical professional and ensure that it doesn't get beaten down by the rigors of the path to come.

The Verdict

So will I go into surgery? Probably not. That being said, I really did enjoy the rotation. I think I would be happy in a surgical field, but then I’d be happy in most fields of medicine. There’s definitely an important distinction to be made between being satisfied with your career and being satisfied with your life in general – notably, the former doesn’t necessarily beget the latter.

I really enjoyed a lot of things about this rotation. I enjoy working with my hands. I enjoyed the (mostly) definitive fixes that we were able to offer patients most of the time. I would imagine that being the person who reached inside someone and fixed them is an immensely satisfying thing.


I also hated the rest of my life during this rotation. Most everyone that I worked with seemed to not enjoy (or, perhaps more accurately – not be able to enjoy) their life outside of the hospital. I’m all for working hard, and there’s a small part of me that would go into surgery just because I like to do hard things. But most of those who go into surgery seem to have a rather unique mentality – the training demands that those who would wield the scalpel not only be willing to work themselves to the bone but enjoy doing so, and then come back and ask for more. It demands that those who aspire to be a surgeon give everything that they have to that end. It demands that surgery be the most important thing in their life, regardless of the cost to everything else they might value. At least, that’s what it seems to take to be a “good” surgeon. And while all of that sounds noble and good, it has a not-so-subtle dark side.

One resident that I worked with has a wife, a two year-old child, and one on the way – a similar situation to myself. I was trying to pick his brain about how this all worked during his busy residency. His response was, “It’s fine. My wife [she worked nights as a nurse] picks our kid up from daycare on her way to work in the evenings and drops her off at a friend’s house. I pick her up from there on my way home from work and put her to bed. In the morning, I’ll take her back to her friend’s house on my way to work, and then my wife will pick her up from there and drop her off at daycare for the day. We may not see each other for a couple of days, but that’s fine. It works.”

No. That’s not fine. At least not for me. Being a good doctor is important to me. It’s an incredible profession that demands a lot of its trainees, regardless of what field they go into – and rightly so. I’m more than willing to work hard. But there’s more to life that being the “best doctor ever” or proving to your colleagues that you can take endless amounts of abuse. I value my future career, but I also value being a good husband and father, one who can be present in and participate in my family’s lives. I have interests outside of medicine that are important to me as well.

There are certainly those who balance a surgical field with all of the above and do it well. But there are very real costs to such a path that need to be counted before one enters onto it. Particularly when you are entering a field where certain residency programs used to actually boast of divorce rates greater than 100%, you have to understand that you are fighting the tide when it comes to maintaining a healthy family life during your training. Sure, residency and fellowships are temporary, but that’s still five, six, seven years of your life. And most of the attendings that I worked with didn’t seem to slow down much themselves.

One piece of advice I’ve heard is, if you’re thinking about going into a field, try and identify someone in that field who is living the life you hope to live when you get to where they are. If you can’t find that person, it probably is for a good reason. For me, I was just trying to find someone who was able to spend enough time with his or her family. I had the opportunity to work with a pretty large number of attendings, but most of them either 1) had very young families (i.e. didn’t start a family until after most or all of their training was done and they were established in their career) 2) were single 3) saw their families “enough” for them (e.g. “I saw my kid once this week – that’s enough for me”) or 4) seemed like they were always working and bemoaning not being able to make it home for planned events or whatever.

Some people get into the OR and feel that they’ve found their home. That wasn’t my experience. As I said, I certainly enjoyed it. But I won’t really miss it all that much. And therein lies the important decision point – if surgery turned out to be “the one thing” in medicine that I truly enjoyed, then we would consider starting down that path. It would be difficult, but we would without a doubt come out the other side stronger for it. But the stuff that doesn’t kill you, while it makes you stronger, also leaves scars. Those scars can run deep, and at least for me and my family, they aren’t worth it.

I guess I’m writing all of this because I really had to think quite a bit about what I was hoping to get out of medicine and life in general during this rotation. There were a number of times where, after having the opportunity to do something “cool” or see some incredible anatomy that I could peer into the future and see myself doing this. But there were also plenty of times where I missed out on some special moment with my son or some quality time with my wife because I was at the hospital during all hours of the day (or night), and when I was at home I was exhausted and not truly there.

As I said, to some degree that’s just part of medical school and residency in general, and those features are by no means unique to my surgical rotation – I’ve experienced busyness and fatigue throughout third year. But the mentality of the field is different – in other rotations, working long hours or missing out on stuff happening outside the hospital was a begrudgingly accepted part of training. No one liked it, but it was acknowledged as being a necessary part of becoming a doctor. During this rotation, though, that type of stuff was almost worn as a badge of honor. That’s just not me.

I have a lot of respect for those who go into surgery, and I hope this post doesn’t dissuade anyone who truly is meant for that field (I doubt that it would). But for those who are reading this who might already have a family or are planning on starting one soon, I think it’s certainly worth taking a step back before plunging into the field and counting the cost. For some, it may be worth it – and rightly so. The field of surgery is varied and incredible. For those like me, though, who could have a satisfying career in many different areas of medicine, it might be worth thinking twice before committing yourself to that path.