Friday, November 26, 2010

Level Up! (continued)

There are days during residency whether by fault of your own or indiscriminate criticism by an attending you'll feel like an incompetent failure. Sure, when you leave the hospital you're "the neurosurgeon," but how often does that actually happen? For the most part, day in day out we're with other neurosurgeons, and at this stage in the game are the moss that grows on the log that the frog sits on. This particular day I was pulled into a senior level case because we were once again short residents to staff the complex cases for the day. Maybe he was just frustrated to have a junior resident, but for whatever reason I just couldn't make him happy that day. I left the 8 hour case feeling like I didn't know anything, that my operating technique was primate-like, and that I should really work harder to learn everything there was to know about neurosurgery this year to avoid such moments of smallness again. Unreasonable goals set to appease the bruised self-esteem, squelching the fear that such a feeling will recur because you have a plan, which seems feasible in your sleep deprived emotionally battered state.

I stuck around for the red line that was about to go because it was my operative day after all. This attending guided me through the beginning half of the case and let me make the skin incision, cut down the muscle, drill off the bone flap, cut the dura, and buzz the brain and make the first cortical incision. I never actually had a chance to do the last couple of steps, so this experience was huge for me. Suddenly I was more than just a burdensome junior resident, but the primary surgeon on a complex vascular surgery. Shortly after my chief resident cut in and took over, but even getting there was more than I could have asked for.

The challenge of being a resident learning how to operate is that the only real time we have to practice or refine our skills are in the OR itself. But the attendings don't know what we've done to date, or how much experience we've had with one tool or the other. Each time I'm in the OR it seems I get a little more experience with a new tool, a new skill set. So we learn, but consequently always seem like we're just beginning. That day I frequented 3 new surgical instruments, a new tool set to add to my armament of operative techniques. I left the hospital a little after midnight with only hours before I had to come in to take my overnight call, but it didn't matter, I felt awesome.

Wednesday, November 24, 2010

Level Up!

Just spent about 18 hours in the OR today operating.

I got lucky again and got to do some really senior level cases. Got to slice and dice normal brain and everything.

I need to wake up in 4 hours to start call.

Must sleep.

Monday, November 22, 2010

Starting up again

Sorry for the blogging hiatus. I was on vacation last week, and spent the time away from the computer and hospital.

There's an interesting phenomenon that occurs when R2s take that week of vacation. Being plucked from the gears of the neurosurgery team for servicing and repairs, we go from the finely tuned, well oiled machine of 3 residents to a piece meal collection of pinch hitters as our seniors cover for us and take call. Suffice it to say there aren't any great disasters, but one does miss the familiar team work that has become as second nature as the beating of our hearts or breaths we unconsciously take.

The most jarring sensation of disconnect is felt, however, when it's time to return from vacation. Rested, revitalized, and ready to take on another stretch of never ending 30hour shifts, you feel like the refurbished part being thrown back into the gears of the service. You're slow at first, the freshly applied oil still cold compared to the racing fever of the neurosurgery machine. You miss scans, have to think about the landmarks on a ventriculostomy, and forget that you can't just sleep when you're tired. But just as only a few days prior you realized all you knew was neurosurgery, that the happenings of daily living were somewhat overwhelming in their lack of structure and intensity, you find you're back at home.

Call yesterday felt like another house of falling cards. I started the day with a red-line, a hemicraniectomy for a stroke patient (procedure where you take off half the patient's skull to give their dying/dead brain room to swell following cell death). I love to operate, but operating when you're on call is painful. Every minute you're in the OR you know the work is piling up around you. The consults still come, attendings still call. It was only a 3 hour case, but by the time I was done I was three hours, 2 consults, and 25 tasks behind. But still, it felt different. Despite the 5 admissions, acute intracranial hemorrhage causing herniation (no bueno), and two bedside procedures, there was never really any moment of panic or helplessness. Tired, yes; overwhelmed, no.

It was when I was placing bilateral subdural hematoma drains at bedside that it really felt like I was making progress. If you recall, my first bedside subdural hematoma drain was a disaster. An hour of futzing around with not much success, and having to call in my senior to help me out with an audience of nursing students watching me flail. Boo. This time, I placed both drains, one on either side of the head, within 30 minutes. The CT showed awesome placement. It almost made up for the 4 CT scans I forgot to show on radiology rounds... gah.

Monday, November 08, 2010

Feeling more like a surgeon

The phone went off at 4:45AM. I had already been laying awake in bed for 10 minutes, wrestling with the idea of getting up and starting another day. It was day 7 of my 2 week stretch without a day off, the black stretch that the R2s have to go through once every month. I already knew what the phone call was before I picked up. Someone had bled into their brain on the neurosurgery service and had to be red-lined to the OR, they needed backup for getting set up for rounds and needed me in early. I was out the door in 10 minutes and driving over to UCLA. After setting up things for morning rounds I relieved my co-resident in the OR and flew through the surgery with the attending. The senior residents were called away for rounds, leaving me as first assist on a pretty awesome case. We cut down to skin, him on his side of the incision, me on mine. Scalp up, periosteum off, drilling down to bone with bone dust flying with the blood and irrigation in minutes. By the time we opened dura the brain was so tight it started to ooze out of our incision. We cut open the rest of the dura to relieve the pressure and started sucking down over the sick looking brain. We found the blood clot quickly, and sucked it out along with the tumor that had bled. Once we had stabilized the bleeding and removed the rest of the tumor, he took off because he had to drop off something for his son. It's a great feeling to be the primary surgeon in any case, being able to go at your own pace and doing things in what you feel is the best way of the various techniques you've been taught. I finished closing the dura, plated and screwed on the bone flap, and was closing skin by the time my senior residents popped their heads to see how things were going. They cracked a few jokes, complimented my work, and left again. It was a great way to start the day.

This is our lot it seems. There's never really ever going to be a day off. Even when you're off duty, you can be called in at any time if they're short staffed. Death respects no vacation days, and for our hospital there's about 10 neurosurgery attendings and 15 residents. The residents are split up amongst 4 different hospitals, and the attendings aren't always in town. We're always on pager in case something comes up, being woken up in the middle of the night or post-call because we may know some critical piece of history or information that wasn't passed on in the rush of morning rounds or sign out. Yea. I'm tired. Vacation is coming up though. Hopefully I'll be able to get some sleep.

Saturday, November 06, 2010

Trust No Finger Butt Thine Own

The neurologic exam is a critical part of our history and physical when we're assessing a patient. Be it for documentation purposes prior to a surgery, or determining whether or not a patient even needs surgery, the patient's neurologic status and the documentation thereof is paramount in both a medical-legal and treatment paradigm way. As such, although we would like to trust our colleagues on different services regarding their neuro exam, as a neurosurgeon we really have to perform it and document it ourselves. I mean really, what do they know about 4+ versus 4- strength or the bulbocavernosus reflex? One piece of information in particular that seems to be stressed is the digital rectal exam. I'm not sure how many times you need to have had your finger up ...


In any case, I was called recently to assess a patient with fecal incontinence. Per report there was no rectal tone. Getting a little bit of history made me suspicious that that wasn't entirely true. The guy was in pain, he didn't need another finger up his rear, and surely not right before dinner. But I had to be sure. And sure enough, there was tone. I really really really felt bad for the guy. When you're a patient you've got to wonder, "OK these docs REALLY got to talk to each other so they can COMMUNICATE what's going on up there." You don't get a CT scan everytime a different team wants to look at an image. They should make a portable rectal tone manometer so we'd only have to do it once and it can be objectively documented. But until then, as evidenced today, you can't trust the finger of anyone else's but your own.

Monday, November 01, 2010

One Third Done

We hit our 4 month mark today. It feels like I've been doing this job for a year. And if you calculate it, and of course we're duty hour compliant, but it turns out roughly to be 1440 hours that we've worked up to now in R2 year alone. An average 40hr a week job will work 1920 hours in a year. By the end of this month we'll have put in enough hours to bill for a year's labor, but sadly only have made $8.30 an hour. It's funny how the ACGME is all up in arms about us being sleep deprived and overworked, but never once filed complaints about us being underpaid.

That grievance being said, it's been a pretty smooth 4 months to date. Those still curious as to whether or not I'm still the "nice guy" who started this year, I would say yes. There have been times that I've wanted to tell someone they were being idiotic or yell at them for mismanaging a patient, but I'm sure I've been on the other side of mismanagement multiple times throughout my short career so far, and will be many times again in the future (hopefully only regarding non-neurosurgical issues). Everyone's only trying to do their job the best they can. But don't worry, the day I meet a doctor who shouldn't be a doctor because it's dangerous for patients, or are just blatantly negligent and irresponsible, I'll lay into them like there's no tomorrow.

One third done, 40 overnight calls completed, 73 overnight calls to go.


About Me

I'm a quixotic idealist that's readjusting to the reality of the world around him. An aesthetic at heart, willing to not shower a week at a time to go camping, exploring, hiking, etc. I love food, poker, and anything that can be turned into a competition.