A Time For Thanks

Image courtesy of: http://chocolateonmycranium.blogspot.com/2008/10/thanks-and-giving.html

Last night, I had the pleasure of enjoying dinner on behalf of my patient's family. Yes, the one I blogged about a while back. The one that means so much to me. His family has become more than just the loved ones of someone I was able to help, but dear friends of mine. Their friends treated me (and my date!) to a fantastic dinner at Lemongrass in Deep Ellum. For you Dallasites, I highly recommend it. Fantastic Vietnamese--and they even kept things peanut free at my request! I'll keep this post short and to the point. My boyfriend (yes, I said it!) and I had a terrific time catching up with the family and friends that I've spent so much time getting to know as their son recovers. I have so much to be thankful for this Thanksgiving season, but nearing the top of the list is my patient's recovery, the new friends I've made because of his course, and the meaning which it gives me for my career. Thank you again to those of you who were so gracious in spending your evening with me. You know who you are. :)

Where I'm Coming From

While looking into moving to New England, it's only fair to compare it to "where I come from", i.e. Amarillo and as of late, Dallas. Essentially, these are the only places in Texas I'd want to live if I stuck around.

Amarillo

www.redwingaerials.com/amarillo.html

The Place

Location: Panhandle of Texas

The People:

Population Metro: 249,881

Population City: 189,389 (July 2009)

Ethnicity: 62% Caucasian, 27% Hispanic, 7% African-American, 2% Asian

Median Resident Age: 33.5

Crime Index: 533.0
Politics: 56% Republican, 44% Democrat (2008 Results)

The Weather:

Annual Rainfall: 19.6 inches

Annual Snowfall: 15.5 inches
Days with Precip: 72
Days with Snow: 12
Sunshine Hours: 3299/yr

Average High Jan/July: 50/91

Average Low Jan/July: 23/65

The Money:
Median Household Income: $41,759

Unemployment Rate: 5.3%

Cost of Living Index: 84.4
State Income Tax: 0%

The Homes:
Median House/Condo Value: $102,800

Average Home Price in 2009: $121,401

Median Rent: $657

The Medicine:
Average Medical Liability Premium: $20,000 to $107,000
# of physicians/100,000: 214
Average # of disciplinary actions of boards/1,000: 2.6

Dallas

Dallas Convention and Visitors Bureau

The Place

Location: "North" Texas

The People:

Population Metro: 6 million

Population City: 1,299,543 (July 2009)

Ethnicity: 43% Hispanic, 31% Caucasian, 22% African American, 3% Asian

Median Resident Age: 30.5

Crime Index: 546.2 (US average 319.2)
Politics: 35% Republican, 65% Democrat (2008 Results)

The Weather:

Annual Rainfall: 33.3 inches

Annual Snowfall: 2.5 inches
Days with Precip: 79.2
Days with Snow: 1.9
Sunshine Hours: 2849/yr

Average High Jan/July: 55/96

Average Low Jan/July: 36/77

The Money:
Median Household Income: $39,829

Unemployment Rate: 8.6%

Cost of Living Index: 94.4

State Income Tax: 0%

The Homes:
Median House/Condo Value: $135,600

Average Home Price in 2009: $210,881

Median Rent: $784

The Medicine:
Average Medical Liability Premium: $20,000 to $107,000
# of physicians/100,000: 214
Average # of disciplinary actions of boards/1,000: 2.6

Getting Home:

Distance to Amarillo: 363 miles (Southwest, American Airlines direct flights 1 hour)

Oh The Places You Will Go

So, until I know I won't ever be liable for HIPAA stuff, I don't want to mention my patient's name on my blog...even though it has been referenced on their Caring Bridge website. But I know many of you are wondering how he's doing these days...he is now 70 days out from the crash. I also know many of you know all the details of his days with his mom at his side. She is a great writer herself.

He was transferred from the skilled nursing facility to the rehab facility right before I went on vacation. Since that time he has made DRASTIC improvements.

1. He no longer has a wound VAC on his abdominal wound.
2. His cervical collar for his neck fractures is OFF.
3. His tracheostomy tube is out and the hole it left behind is healing well.
4. He spends a vast amount of his time in a wheelchair, not the bed.
5. He is working on the treadmill with physical therapy.
6. He has to have his achilles tendon released on the left side so that he can start walking a bit better. This will happen tomorrow or early next week.
7. He can feed himself and will likely have his diet advanced from pureed to ground/chopped foods in the next couple of days!
8. He is talking more and more clearly every day.
9. He says "thank you" all the time. If you listen to him intently enough you can catch him say things like "thank you" (which he has already said to this person a number of times) followed by "thank you for everything".
10. He's reading as well. His mom finally had the chance to introduce us earlier this week, and she introduced us again today. As I was standing there talking to him, at one point we heard him say "Brittney" and asked what he said and he repeated it. He was reading my name tag!
11. I'm not quite sure how many shirts he has now, but the surrounding fire departments have been amazing in getting him shirts from each of the departments in his county (and beyond). Yes, he's training to  be an EMT and finished fire school in May. That's why his bracelets say "Keep Fighting".

I can go on and on about how cool it is to watch him. I always try to go say hi and plan on a quick 30 minute visit or so. I used to stick around to talk to his family for hours, now I stick around to watch him progress. We rarely get to see this side of it. The recovery, the therapy, the going home. I've been given a great opportunity to see what it's like once they are discharged from the hospital and what the long road to recovery really means.

Besides the outstanding amount of support that's showered upon him and his family, I think I'm most impressed by his family's strength. I know they have their weak moments, sometimes I'm there to witness them and sometimes I'm not. It makes my heart hurt to see them worry (especially his granddad), but I can always feel the love between all of them. His mom has dedicated so much time and effort to his recovery and making sure he's always on schedule, keeping nurses on their toes, and helping him to understand the process of what he's going through. I know everyone around him is doing the same, but his mom is the person I see the most. (And somehow she's still managing to get some work accomplished during all this too.) I constantly compare this to watching grass grow. If you stand there and try to watch your grass grow, you'll never notice any difference. Even if you check on it every day, it doesn't seem to make much progress from one day to the next. But if you leave for four days and come back, it's grown like a weed! I used to be the one checking on him every day, then he was transferred to the SNF. Now I check on him once or twice a week depending on my own work load. I imagine if I was still seeing him every day it would be hard to really notice the big improvements, but it is so amazing to see how much he progresses in the span of only 3 to 4 days. His words are clearer, his motions more controlled, his thoughts more coherent, his memory improving, his weight gain, all of it. I admire that his family can see him every day and still notice the progress he's making.

I can only imagine what it feels like for them 70 days out. He's come so far. He obviously still has a long ways to go, but some of the biggest hurdles have already been jumped. Soon enough, he'll be doing too well for rehab and he'll be off the next place which I'm fairly certain isn't a place that's going to be easy for me to keep checking in...at least not in person. But the pictures and texts from his mom, his Caring Bridge, and his spirit will keep me updated I'm certain.

Keep Fighting

So, I'm going to avoid any HIPAA violations and not mention anything personal about my patient that you've read about for 3 days. But here are the sweet moments of his stay with me.

1. Hugs from the family about a week into everything
2. Being asked for by name by his family members
3. Chocolate chip walnut homemade cookies brought by his family
4. The patient's mom's ensuring my AC gets fixed or else she's sending someone out to do it herself
5. Having the neurosurgeon tell me he's going to wake up, that he can survive
6. Knowing he never even got a whiff of a pressor
7. The bracelets his friends made for support and being provided one to wear proudly myself (see above, they mention his name but that would be poor HIPAA form)
8. When he tolerated tube feeds
9. When he looked me in the eye for the first time
10. When he tried to stop me while I was changing his gastrostomy tube
11. When his grandpa told me "I know you won't bullshit me. But you'll still be upbeat."
12. Making it off the ventilator
13. Fist bumps with his Dad when I had good news, or met goals I had set for us (like his TBili being less than 1.5...it was 1.4 on the day he left)
14. Sweet elbow bumps and waves from them as they walked by when I was working on notes
15. Visits with his family in the waiting room (about my own personal life too)
16. Having an attending stand up for him in conference by saying he wouldn't be a vegetable and that he would wake up (I wasn't the only one that believed!)
17. Presenting him in trauma conference and OWNING him as my patient and being proud of my management
18. Giving updates to the OR staff on his condition/disposition (especially calling to tell them he had been transferred out!)
19. Lingering in his room a bit longer to catch more Looney Tunes while I was working with him

And my most favorite:
The day he was transferred out, I had worn bumble bee earrings. Most of you know, I collect bee things. (Mom and Dad always called me Miss B...which turned into Miss Bee...Dr. Bee...and a love for bee stuff). I hadn't worn bee earrings in at least a month. One of the ICU nurses commented on them, and then Dad's eyes started to well up. Apparently, there is a motivational speaker out there (I couldn't repeat her name even if I tried) that uses the bumble bee analogy that I used for a previous blog post title. She speaks to the fact that aerodynamically speaking, a bumble bee should not be able to fly. Yet, they go on flying anyway. I've always enjoyed that little fact about bees myself. It's part of the reason I've never been hesitant to adopt them as my personal "symbol". On August 30 (the day I put those earrings on for my last call on the rotation), this motivational speaker had called the patient's mom with full knowledge of the situation and to offer support--out of the clear blue. And my precious little Kate Spade bumble bee earrings served as a reminder of that we can overcome things that shouldn't be possible. Maybe my patient shouldn't be alive, but he goes on living anyway. And maybe he shouldn't be doing as well as he is, but he keeps on doing it. That makes me proud. Proud of my patient, and proud to be Dr. Bee.

Sweet Escape

With the help of attendings, ICU nurses and ancillary staff, ICU interns, and the patient's family, he kept improving. He was tolerating more and more tube feeds all the time. His blood pressure was better controlled. We were weaning off pain meds. We were even weaning off the vent, to the point that he didn't even need the ventilator during the day!

We were doing less, and HE was doing more.

Finally, three weeks to the day, my patient was transferred to a skilled nursing facility! Yep, that means he had improved enough that he no longer needed our ICU. He still needed very close monitoring and still has some issues being addressed (but not life-threatening). But he's better, and he's alive, and he's got a long (but likely successful) road ahead!

On August 31, he was discharged. And on August 31, my current rotation at the hospital was over. I had succeeded. HE had succeeded. I had saved a life! I don't think I really took credit for it until I spoke with the accepting physician at the new facility. The day prior to his leaving, I discussed all of his injuries, current treatments, etc with his soon-to-be primary physician.

I had to relinquish care! If you only knew how territorial I had become! I even told my chief when I had my days off to avoid messing with him too much. This was MY patient. My chief never had to see him until four days into his stay, and only saw him a couple more times while he was in our hospital. Otherwise, it was me and the ICU team (attendings, interns, consultants, RTs, RNs, etc) getting this guy through.

After relaying all of his primary injuries and findings during our initial visit to the operating room, her response was "So basically, he should have died?". At that moment, I realized, had we not intervened on time, had my attending not helped me through his first ex lap, had neurosurgery not placed the bolt, had we not watched him like a hawk night and day...he would have died. He could have died. But, the only thing I'll correct about what the new physician said, is that he certainly SHOULDN'T have died. And he didn't. Personally, I count this as MY first big save (obviously not something I could do by myself but you get the gist). I feel proud. Most of all, I'm reminded why I gave up a life in dermatology (working maybe 40 hours a week with minimal call) for surgery (working 60 hours a week plus with frequent, stressful call). It's those moments that your patient's father's eyes well up with tears and all the ICU nurses come by to say their goodbyes as your patient leaves for the next step. That's why I became a surgeon.

Bumble Bees Shouldn't Be Able To Fly, Technically

There he was in the ICU. Pressures good. Heart beating away. On a ventilator. An open belly. And a heart of gold. His drug screen was negative. Not a drop of alcohol in his system. New lab results coming back that I was extremely happy with--considering. So we scanned him. Had we just done a big time surgery to find out he had a devastating head injury?

A list of his injuries:
1. Intraparenchymal cerebral hemorrhages (multiple and terrible looking)
2. Large scalp laceration
3. Left clavicle fracture
4. Bilateral pulmonary contusions
5. Left hemothorax
6. Left diaphragm injury
7. Shattered spleen
8. Grade IV liver laceration
9. Left retroperitoneal hematoma
10. Left acetabulum fracture
11. Left pubic ramus fracture
12. Left sacral ala fracture
13. L1-L4 left transverse process fractures of spine
14. C2 fracture of neck
15. Large amount of pneumomediastinum

Then I spoke to his granddad. Sweetest man ever and obviously aching over his prized grandson. And grandma, the smallest, cutest, and soft spoken woman doing her best to maintain a hopeful smile. And Dad, the most fit middle aged man I've seen, doing his best to act as the backbone for the group when deep down he could use just a moment to have his own breakdown. And Mom, energetic, outgoing, and totally in love with her son. Then the girlfriend, they've been dating for 3 years and this was going to be the biggest growth spurt they could ever take as a couple--you could see she was up for the challenge. And girlfriend's mom who obviously cared for him like her own son. I remember telling Dad, "I just want to meet one mean person in the family. Then I know he'll walk out of here in a week." No such luck.

The next day, his pneumomediastinum appeared to be increasing. So an emergent bedside tracheostomy was placed with significant improvement. Neurosurgery and orthopedics came by. A "bolt" to monitor intracranial pressure was placed. He was started on medications to keep his blood pressure down and to keep fluid off his brain.

A couple days later, he returned to the OR. The sponges were removed and everything appeared ok. No more bleeding. So his belly was closed and he was again sent back to the ICU.

Over the next few days, he remained status quo. Multiple EEGs were done to examine brain function with no devastating (but really not hopeful either) results.

We started tube feeds and the next day we was noted to have what looked like gastric contents coming out from around his trach. More concern for a possible esophageal injury arose. The following day, we took him to the operating again. With a scope, we confirmed that no esophageal injury. We opened his belly again and placed a gastrostomy tube. We placed an IVC filter for prophylaxis, in hopes of avoiding any kind of clot traveling to his lungs. And we closed his belly again.

Over the next few days, he didn't tolerate tube feeds too well. So he stayed on TPN and we watched as his liver function tests and his pancreatic enzymes trended down as his pancreatitis improved. He remained on antibiotics for pneumonia. But otherwise, he wasn't deteriorating but things weren't moving rapidly either.

Then his bolt was removed! No more prongs sticking out of the head making us anxious with roller coaster like numbers. After that, things really started changing. He was overbreathing the vent. He was moving his arms more. Each day, something more happened. His eyes were open wider. He had purposeful movement. He was tracking with his eyes. And on occasion, many of us swear he was following commands. On a number of neurostimulants, he was coming around. Just as I felt he would. With love and age on his side, he was going to get out of here.

To Be Continued...

How to Save a Life

It's not everyday that we get reminders of why we agreed to work 80 hours a week and 30 hour shifts to "someday" have a better paying job with more freedom. Like most residents, I'm pretty jaded. Most days I'm convinced that 75% of our patients are really just a drain on the system rather than real people needing real help. When it comes to trauma, the rule seems to be dealing with jerks who were legally shot by Texas homeowners during attempted break-ins. On top of that, they throw out four letter word after four letter word in the trauma bay and then go on to treat our nurses like another four letter word. It's annoying and disheartening. One easily loses their faith in people. And just when you think these jackasses make residency completely worthless, something amazing happens to reel you back in and convince you to keep going.

On August 10, I was on call. My chief resident and I were in the middle of a case when the trauma pager went off letting us know a Level 1 (the most serious kind of trauma requiring a response from the team within 15 minutes) was coming in the door. My chief looked up and told me to go down to the trauma while he went on with a grueling ventral hernia repair. I scrubbed out and ran downstairs to the ER.

EMS relays the story. This was a young male found down at the scene after a wreck. He had been t-boned on the driver's side and was unresponsive at the scene. EMS intubated him before bringing him to us. He never lost vital signs, but his blood pressure had been persistently low--an ominous sign in trauma. I ran through my ABCs, his endotracheal tube was in good position, confirmed in multiple ways. He had good breath sounds on both sides. His chest xray showed some significant bruising to both lungs and a fracture of his left collar bone. He had a large, deep, bloody scalp laceration on which we placed a gauze dressing. On FAST scan, he had a small amount of fluid around his spleen. He had a small pelvic fracture on xray too. After 2 liters of IV fluids and 2 units of blood, my attending decided if his next blood pressure wasn't more than 100, we were going to the OR. I watched as his belly grew, bloody urine filled his foley catheter tubing, and his reading came back...still in the 90s. More blood was hung on the IV pole and off to the OR we went for an ex lap.

When we got upstairs, my attending and I stopped in OR 8 to tell my chief we were now in OR 12 with the trauma. While putting on our shoe covers, he jokingly asked, "You wanna go scrub him out and finish that ventral hernia so he can come do this?" I laughed and said "Heck no. He can join us later."

Prepped and draped, my attending and I opened him up--a long midline incision from his chest bone down to his pubic bone. Once we got "in", at least four liters of blood poured out. We cleaned up the blood and in typical trauma fashion and packed all four quadrants. Then we went exploring. His spleen was shattered. Out that came. His left side had a large hematoma surrounding his kidney and retroperitoneum that was controlled with more packing. We looked in his pelvis. Thankfully, his pelvic fracture wasn't causing much bleeding. Then we looked at his liver. The capsule was torn in at least 7 places, he had a large hematoma on the left lobe, and two deeper lacerations towards his back. We used the argon laser to help control the bleeding. He continued to ooze so we packed the liver with laparotomy sponges. Still oozing. At this point, I noticed a hole in the left side of his diaphragm. He was somewhat stable at this point, so we repaired that. The bleeding seemed to be controlled for the time being. We placed a wound VAC and got out of the belly. My attending went to the head of the bed and repaired his scalp lac while I put chest tubes in on both sides. Stabilized, we sent him to the ICU. He received 27 units of blood and an additional 37 units of other blood products by the time he got there. And one whopping dose of factor VII. The best part is that anesthesia had done a fantastic job of helping to resuscitate him so he NEVER received one dose of a pressor.

And that's all in the first couple of hours. To be continued...

Yes, It is All About Me, B****

Just about once every three to four months I actually take the time to read through my evaluations for residency. In one year, I had 37 evaluations. That's a pretty good turnout. Evaluations come from attendings, chief residents, and occasional nurses, and they are all anonymous. Altough sometimes it's pretty easy to figure out who said what (and sometimes the attendings put names on them). Today, I reviewed all of my evaluations for my 2nd year of residency. I was very happy with all but one of them. This one in particular pisses me off beyond any doubt...

Please recall that my parents' home burned down when I was on call on May 29th. That means I was post call on May 30th when it was confirmed that this was true. I had attendings helping me find flights home for that afternoon and telling me that I shouldn't bother showing up for my next call because family comes first. One even went so far to say that he'd be disappointed if he saw me in the hospital at all for the rest of the week. I'm thinking, "thank goodness I found that kind of residency"!

Anyhow, I finished my rounds post call on the 30th and came home to pack. I then proceeded to make sure that my next call would be covered by someone (on June 3rd). Once that was done, I let his chief and my chief (for June) know the call situation. I was already scheduled to be off on June 2nd. That meant that I would really only be gone on May 31st and June 1st. We switch rotations on the 1st of every month, so I had only ONE more day on my rotation for May. I called my chief for May to let her know that I was planning on catching a flight home to be with my parents as soon as possible (a flight that my attending had helped me find). For the following day, there were three cases with a really great attending that I had originally been scheduled to cover. These were the ONLY cases scheduled for our whole team. When I didn't hear back from my May chief immediately, I started calling other people that I knew would be around to see if they had any availability (chiefs, other 2nd year residents, etc) to cover the cases I was supposed to cover. I found someone that could help me cover at least one or two of my cases. I then sent a text to my May chief again explaining the situation and telling her that I had done my best to get my work for the 31st covered. I was now EXHAUSTED post call doing all of this and when I hadn't heard back from my chief, I cancelled my flight and rescheduled for the afternoon of May 31st. My June chief had already sent me a text saying that taking the 1st off was no big deal and that he would see me back when the weekend was up.

Later that night, I end up getting a slew of rude text messages from my May chief saying that she fully expected me to come in to round on my patients on the 31st. Good thing I had already rescheduled my flight. I showed up the next morning to round on my 12 patients. I saw all of them except my ICU patients who I knew would be seen by the ICU resident and my attending long before I got to them. My flight was scheduled to leave at noon. I figured if I left the hospital by 11am, I could make it. At 10am, I received a voicemail from my May chief on rounds that was absolutely heartless and rude. She demanded I tell her who all I had seen so that she "could see the rest of my list" and then went on some tirade about how "bad things happen in residency" and she "just couldn't believe this" and that she would "talk to me when I get back". All ending with a loud "UUGGH!" and then hanging up. "What an f***ing b****!" I thought. THIS, coming from a girl that left early on other rotations to take her dogs to get their yearly shots instead of using a day off! (And I'm a veterinarian's daughter so I can sympathize, an ability she obviously doesn't share.) By this point, I was finishing up rounds on my floor patients and had actually been in the process of checking out with my attendings to ensure they were ok with my not seeing my ICU patients for the day, etc. They were, in fact, upset that I had even come in to round at all. I tied up a few things and then left the hospital just before 11am and luckily walked right on to my flight at the airport to make it "home"...only to see the rubble and ashes that was once my childhood home, the place my parents had poured their heart and soul into for 30 whole years...

So back to my evaluation: this chief is the ONLY bad mark I received the entire year. When asked if the resident is dependable (with answers ranging from poor to excellent), she marked poor. This was followed by the comment: "She has a problem with passing work off to other residents as well as not always working well with her team. She has a very "me" attitude."


You know what? Screw her. I don't have a "me" attitude, and obviously the other 36 evaluators didn't feel that way. I rarely, if ever, pass off work unless someone asks me to or I absolutely have to based on work hour restrictions. I didn't like having crap passed off to me, so I try to keep it off others when I can. Other than the vacation I had taken that month (as scheduled almost a year prior) and my scheduled days off, no one ever had to see my patients for me.  In that moment, I (and any one else in that situation) SHOULD have a "me" or "my family first" attitude. If they didn't, I, personally, would think less of them as a physician, as a family member, as a human being--much as I do her.

The really awkward part was running into her at a dinner a week ago as she is all smiles with everyone and acting her usual loud, perky, Texan-drawl self. All I could think at dinner that night was "What a fake bitch." Now that she's done with residency and out in practice (and I thankfully can keep my encounters to a minimum), I'm just hoping nothing terrible ever happens to the poor bitch during her career, because IF what goes around really does come around, no one is going to be willing to step up and help her out while her parents or her husband or her kids or her childhood home dies.

Found Out

Yikes! I've been found out! Isn't that what bloggers want? Of course it is. But I have to admit, I got a little scared. I'm thinking twice about what all I post here...even more than I was. A couple days ago, an ICU nurse (who shall remain nameless in hopes of not embarrassing her) said "I hope you don't think I'm a creeper, but I totally read your blog!" I couldn't help but laugh, and then part of me cringed, wondering what the hell I've written on this thing. Come to find out, she learned about my blog from ANOTHER ICU nurse. Well crap. Now I have a following from people I work with--not just my very supportive, blog enthusiast friends, but people I am in contact with every day. That means I'm really being held accountable for updating this thing now. So I guess there's no more getting by with the occasional post saying hello from the pups. It's back to rants about work and fun posts about decorating...which is really the only other thing I'd be doing other than surgery for a career. Now if I only I can fit in this book I want to write...

Thanks "Peter" girls for holding me accountable! I'll do my best to avoid disappointment from here on out. :)

The Doc Will Not See You Right Now

First of all, if any well versed social media docs read this, please advise me on how to protect myself from scrutiny from my own institution (not so social media friendly) and the rules that I mention.

Secondly, I apologize to any readers that don't care about medicine/surgery/residency. This is a long rant on how my world is changing. Feel free to read on, I provide a lot of background information for you to attempt to empathize, if you dare to try.

This morning, during M and M conference, I tweeted about my frustrations with the new intern hours and promised a later blog. I have cooled off for now, but that won't last long.

Some background information:

I am a second year in general surgery residency in a community-based program. I work anywhere from 60-80 hours a week depending on how many days off fall in that week. The current rules state:

• Maximum 80 hours worked per week (averaged over 4 weeks)
• In house call shall not exceed an average of every 3rd night (averaged over 4 weeks)
• Must have one day off per week, a full 24 hours without duty (averaged over 4 weeks)
• Can only see new patients for a maximum of 24 hours
• Maximum of 6 hours "post-call" to wrap up and get out of there basically
• That means our maximum shift is 30 hours long which must be followed by a 10 hour break of absolutely no duty...not including driving time.

I will admit that there are a few occasions where I have worked well beyond the 80 hour limit, but averaged over 4 weeks I think the worst it's ever been is 79 hours. (And I, unlike many residents around the country, don't lie about my hours because I'm sort of interested in what they actually are.) I typically arrive between 5:30 and 7am depending on the rotation. Some days I leave at 3pm, some days 5 or 6pm, and other days later. Post call I usually plan on being there until noon, period. It's not THAT bad. Granted, our social lives still suffer (not to the extent that they did prior to the work hour restrictions). That's right, there used to be absolutely no work hour restrictions for resident physicians. It was common practice for one to work for 24 hours, be off for anywhere from 5-24 hours and be back on for 24 hours with no true days off. Believe me, MOST post call days don't feel like a day off--certainly not when you've been up all night.

Yes, I have fallen ill of the victim mentality on more than one occasion. I get sad that I can't enjoy Sunday brunch EVERY weekend, or that I can't just join the girls for lunch on any given day, or that I can't stay up late tonight because I am on call tomorrow, or that I can't enjoy happy hour on more than the very rare occasion. However, those are small sacrifices for the education I am receiving to be able to adequately and competently take care of my patients on my own when I'm done after five years--and with good technical skills to boot.

In our program, we average around 1000-1100 cases when we are finished with five years. That's a great number! Only 750 are required to qualify for the board examination. So in other words, we operate A LOT. This was a huge part of my placing this program at the top of my list. I wanted to know that I would be comfortable in an OR alone after five years without the NEED for a fellowship. I didn't want a program stuck in the old hierarchial system that prevents most lower level residents from seeing the OR. I wanted a full five years of surgical training, not four and certainly not three.

More background info: in our program, we take in house trauma/acute surgical call every fourth night for about 8 months a year (all the way through)! Chiefs occasionally have the opportunity for home call IF no one on their team is taking vacation. The only times we don't take q4 TRAUMA call (doesn't mean we aren't taking q4 in house call for something else) are:

• As an intern:
• Burns
• ICU
• Private hospital (without trauma) for two months
• Possibly an anesthesia month. 
• As a 2nd year: 
• ICU
• Private hospital (without trauma) for one or two months
• Pediatrics
• As a 3rd year
• Colorectal (home call)
• Cardiothoracic
• Pediatrics
• "Pre-call" at our county hospital. 
• As a 4th year
• Colorectal for two months
• Cardiothoracic 
• As a 5th year
• One or two months at the private hospital. 

Otherwise, we cover a regular service, usually comprised of either bread-and-butter general surgery, surgical oncology, or vascular surgery. We rotate at private hospital, TWO Level 1 trauma centers (top of the chain trauma centers), and a pediatrics hospital during our five years. Each rotation is one month long.

• "Main" hospital (also a Level 1 trauma center) 
• Five people on a team
• Chief
• PGY-4
• PGY-3 typically covers ICU at night
• PGY-2 typically covers ER
• PGY-1 usually a surgical intern covers floor at night
• Four teams
• Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
• County hospital (a Level 1 trauma center)
• Four people on a team
• Chief (PGY-4 or PGY-5)
• Junior (PGY-3 or PGY-2) typically covers ICU at night
• Interns (one surgical and one medicine/transitional/orthopedics intern) cover ER
• Four teams
• Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
• Private hospital 
• Four people on a team: Chief, a junior, and two interns
• Average Q4 call (home call as a junior or senior) rotates between the four, only one resident on call every night for floor/ER 
• A "closed" ICU for the most part
• Pediatrics
• Two residents at the pediatrics hospital
• Q4 in house call for floor and ER
• Colorectal service
• Two residents
• Home call for floor/ER
• Cardiothoracic
• One resident
• Home call for floor/ER
• Transplant
• One resident
• Home call
• Burns
• One resident (from our program), one 2nd year and 4th and one or two more interns from another program
• Q3-Q4 in house call for floor/ICU/ER, only one resident on call each night
• County hospital ICU
• One resident
• Takes Q4 in house call for the ICU
• "Main" hospital ICU
• One or two residents
• No call
•  County hospital "pre-call"
• One resident who covers "specialty" service cases during the day: vascular, breast, CT 
• No call
• Anesthesia
• One intern
• No call

So even though we have 8-9 residents a year, we get pretty spread out among services. Of note, we currently have no specific trauma/acute care service nor do we have a night float system.

The new rules coming up (and forgive me I don't know ALL of them):

• Interns (PGY-1) can work a maximum of 16 hours in a shift
• Interns must have 8 hours off between shifts
• Cannot exceed more than 80 hours per week
• Required full day (24 hours) off per week
• Interns cannot take more than three months a year of "night float" call
• All residents have a maximum of 4 hours post call (total max of 28 hours per shift)

How has our program decided to address this? (I'd love to know others' new plans too). Well, interns will just be working from 6am to 6pm. That's only 12 hours. I thought they were allowed a full 16??? Interns will not be taking night call, period.

That means:

• At the main hospital:
• After 6pm, the 2nd year covering the ER, the 3rd year covering the ICU, and the 4th year who is typically in the OR operating on all those patients the 2nd year has seen in the ER are all now required to make up for one whole person's amount of work. 
• Our chiefs will not be able to take home call. We will be spread too thin if they aren't there.
• When someone is on vacation, that means only THREE residents will be available as one will be long out of town and one won't be allowed to work. With ~40-45 residents in our program, you can almost plan that there are at least 3 weeks of every month (at the main hospital where we have the biggest team) where SOMEONE is on vacation. 
• Patients on the floor will not be responded to in such a timely manner because the other residents will all be busy in the ER, ICU, or OR and unable to leave their position immediately.
• Less OR time for everyone. Cases go uncovered. 
• At the county hospital:
• There is only one resident in the ER after 6pm--being someone that is not a resident actually trained by our program (or one that even cares about general surgery). 
• No extra intern to place lines, chest tubes, etc. requiring the junior level resident to stay out of the OR. 
• Consults will not be seen in a timely manner. We will likely be seeing consults well into our "post call" hours.
• Any elective cases will not go after 6pm. No more "clearing the board" and doing chole's at 1am UNLESS it's absolutely necessary because we simply don't have the man power to keep extra people in the OR and off the floor/out of the ER.
• The wheels will fall off. Less OR time for everyone. Cases DON'T go. Patient's don't get their operation.
• At the private hospital:
• Only two of the residents will be able to take call at night. Currently chief residents typically cover nights that we don't have attending staff on ER call. Therefore, this will become a home call situation and chiefs will not be able to take these 4 calls a month. 
• Interns will not be seeing patients at night to work them up to operate on them the next day. If they did, they would have to leave before their case went.
• Less OR time for interns but not more OR time for everyone else because they will already be working. 
• Also remember, we can't take more than q3 call, so we can't just take more calls as juniors or seniors.
• Transplant
• Interns can't take night call. No organ donations for you!
• Less OR time.
• Burns
• Interns can't take night call. Only two residents to cover call otherwise (and we can't be q2). 
• Possibly a shift work thing between interns here could work, but STILL not appropriate.
• Anesthesia
• No interns on anesthesia. We can't afford to lose the manpower.
• ICUs
• Interns can't take night call. They usually don't anyway. We have managed with this in the past. But interns on the basic services aren't around, this will be detrimental.
• "Pre-call"
• Possibly turns into a night float system to help teams out. However, this means one less resident around to cover cases during the day.
• Less OR time. Cases go uncovered.

Every time residents bring this up, we get brushed off. Even though we are the ones that do the work day in and day out, we are told by our administrators that this is how it will be--without lending an ear to concerns. We have often mentioned specific trauma services, a night float system (which I know from experience works very well for at least one other institution, with less residents). We have also mentioned having interns work 6a to 10p or 2p to 6a, or 6p to 12 noon--the full 16 hour shift. No matter what, "post call" no linger exists in an intern's vocabulary. I'm not sure anyone has the right answer, but just taking one or two residents out of play for 12 hours a day--the most terrible idea ever. Eyes glossing over and continued attempts at dismissal of the subject when we mention the so-called "plan" during the most appropriate time, i.e. when a majority of the residents, involved staff, and the department chair are all in the same room and have an hour to spend together, is also terrible.

All in all we fear everything will fall apart. Part of this is due to surgeons' egos and the fact that we all think we know a better way of doing this. Another thing is the culture of residency, especially surgical residency. One expects another to work. And work hard. There already exists a chasm between the physicians that trained without any work hour restrictions and those of us limited to 80 hours. This will provide yet another divide. Poor little interns are going to catch a lot of flack for something that isn't even their fault. A lot of this is fear of change. In my opinion, that is a well warranted fear.

If we don't have manpower, patients don't get seen, studies don't get ordered, drugs don't GED administered, and surgeries don't happen. In the worse case scenario, that means patients die. gloomy, cynical side of me coming out in full force. Concern for patient safety also coming out in full force.

So patients go unseen, and residents don't see them to learn from them. They operate less. They deal with less problems. They see less complications. They work up less patients. They lose out on valuable training time. That means residency has to be lengthened in terms of years. From my understanding, this is how it is done in Europe where many countries have 60 hour or less work week restrictions. Surgical residency is six years or more.

The other bad thing: how will these new docs function when they are faced with 24 hour call alone? I'll let you infer.

All of this in the name of sleep--the other side of the coin. If residents aren't well rested, they make more mistakes. True. Less mistakes to learn from and more opportunity for mistakes when they are faced with a sleepless night later and have never been forced to function under such circumstances.

Other sad fact, each year this will apply to more and more residents at different levels, not just interns. So you are less trained at EVERY level--not just one year.

Any honest 20-something can tell you that more free time away from work does not necessarily equate to sleep or even rest. It often means more dinners out, more happy hours, more brunch-time mimosas, more pick-up kickball games, more nights out with the family, more time visiting friends in other cities, etc. All of those things I miss. Yes, I miss sleep but I do sacrifice some to gain a life. It will be interesting to see if these residents rate their happiness any higher than those of us not subject to the new rules. I fear not. It will also be interesting to see how many of them sleep during those hours off, as opposed to taste the newest brew at the local bar or take the kids to the zoo.

Perhaps we are sacrificing manpower, time for patient care, and education for more time with family or the sandman. On the other hand, perhaps we are sacrificing manpower, time for patient care, and education for more mimosas.