pediatrics.

Following my first vacation week of the year, I embarked upon a three week stint with the pediatric surgery service. Unlike pancreas/surgical oncology where the team consisted of a fellow and myself, this service was run more like the trauma service. There were 2-3 fellows, 1 chief resident, 2 second year residents, 1 international fellow who functioned as a junior resident, 2 interns, and 2 third year medical students. Between the lot of us, we managed all the general surgery patients in the hospital, consisting of general surgery, trauma, PICU, NICU, and off-service consults. Like trauma, a different attending was present each day.

This was the least thought intensive yet most frustrating rotation of the first third of intern year. Call days meant pickle phone of death, trauma pager, floor pager, and writing more notes than any other day as a result of rounding on the primary floor. As an aside, the terms "kiddo", "peanut", and "pumpkin" in reference to patients ought to be made taboo when speaking with surgeons. Non-call days meant rounding on the usually small number of off floor patients or helping the on-call or post-call people on their rounds. This was followed by a long day of not knowing what to do and, for interns, not going to the OR. An unfortunate side effect of the second years requiring X number of cases is that interns are actively shunted away from the OR. Often, the intern also ends up taking the daytime call responsibilities when the on-call second year is summoned to operate. Even more unfortunately, we were not told until the second to last week on service that an attending actually does round on the patients every day and that we are allowed to tag along. Surprisingly, this made the non-call days much more enjoyable as some teaching could potentially take place during these times, depending on which attending you were with. The highlight of intern year was my second to last day on service when I spent the day neglecting discharge summaries and rounding with the attending, who then invited me to go to the OR, and I had an opportunity to first assist for the first time all year. This was followed by a somewhat sad realization that this would likely be the last time I would ever be exposed to intra-abdominal surgery as my remaining general surgery rotations include only plastics, thoracic, and vascular.

Thanks to the plethora of free time while not on-call, however, a number of interesting facts were learned.

1. A surgical abdomen, according to an ED resident, is an abdomen that has been operated on

2. You may receive a consult for an abscess from someone who does not know the definition of fluctuance

3. Draining pus spawns many great stories

4. Nurses cannot take verbal orders, but can give the patient liquid roxicet instead of the percocet they were ordered without informing the MD because "it's the same thing"

5. Junior residents must prescribe tylenol for fevers of known origin to asymptomatic patients or the nurse will call your chief in the middle of the night

6. 5:45pm is a popular time to receive consults from the ED and the floor, especially when your shift ends at 6:00pm

7. People are unscrupulous and will steal stethoscopes out of white coats hanging in a private room on the floor

8. The people you work with truly make or break your experience

oncology.

Deja vu. I was plucked from one hospital and dropped in another with the same attendings and even a few of the same patients. Upon arrival, I was informed that I would be taking floor calls, ICU calls, and consults for the 3 surgical oncology teams, the vascular surgery service, and the thoracic surgery service that day. Thus began my second month on pancreas surgery/surgical oncology. The acuity of the patients seemed higher at this hospital, and there was the added joy (also known as pain) of HIPECs. This is an odd, yet beneficial, procedure in which hot chemotherapy is run through the abdomen of a patient with carcinomatosis for 100 minutes. For 100 minutes, therefore, the lucky intern's job is to stand at the patient's side and literally rock the abdomen back and forth. In a large patient, one needs only to rock the belly. In a skinny patient, one must essentially rock the entire patient. Surprisingly, it is more tiring to rock a small patient than an obese one. The hospital also rolled out a new electronic discharge system that month, and I nearly blew an aneurysm the first day this went into effect. I learned on this rotation a clever way of shirking intern work restrictions. In this hospital, interns on the surgical services are allowed to take in-house overnight call alone while receiving "direct supervision" from the in-house ICU attending. Consults and floor issues continue to be precepted to the chiefs/fellows of each service, who are at home. Codes, I suppose, may be attended by the ICU attending. Thanks to my overnight call, however, resulting in fewer net hours for the last week, I did indeed manage to sneak just under the 80 hour mark (discounting discharge summaries that were done after leaving the hospital, of course). Having escaped several potential HIPECs also contributed greatly to that achievement.

pancreas.

Second rotation of the year: pancreatobiliary surgery = pancreas cancer. This service had been part of the larger GI surgery service when I was a third year medical student and was actually one of my favorite rotations in medical school. My experience as an intern was quite a bit more frightening, particularly when rounding alone with one certain attending. Unlike trauma, this is a small service with a relatively small number of patients whom we come to know very well. I tend to prefer rotations on which I can develop relationships with patients, so this was a welcome change from the high turnover trauma service. Learning to manage medically complex patients was another challenge on this rotation, made easier by the fact that fellows/chiefs typically give you the plan without necessarily asking for your opinion on management. However, there were a few times when I, being the only person on the floor, had an opportunity to try some minor interventions. Although I was rather traumatized by solo rounding with a particular attending in my first week on service, my kind fellow and chief shielded me rather well the rest of the month from that particular stresser. Number of times I went to the OR? Zero. Not much for the intern to do on robotic procedures. Then again, number of times I was forced to go to clinic? Zero. You win some, you lose some.

trauma.

My first rotation, general surgery trauma, is in the middle of trauma season - aka July when the masses tend to be free from school, work, and other responsibilities. This rotation has made me a believer in the full moon effect. The best way to start intern year, I suppose, is to throw oneself into the fire. Night shift + 3 teams' worth of floor calls + pickle phone of death + trauma pager = fire. No trauma experience would be complete without a few ridiculous injuries, but on the whole, it was a rather tame month. The new intern work hour restrictions went into effect the second week of the rotation and were very nearly met with some tweaking of the schedule by the trauma director. This was actually quite impressive to me. High point of the rotation was definitely working with terrific people from med students to co-interns to the chiefs. Negatives included attempting to close on my condo while changing from night to day shifts every week and only going to the OR once for the purpose of transporting a patient. At one point, we almost had a floor census of 3, but this was negated by a mass exodus from the ICU. Although I nearly had an MI when I received my schedule and saw this rotation at the top of the list, it turned out to be quite an effective introduction to intern year.

restart.

As I near the end of the halcyon days before residency, I suddenly rediscovered my long forgotten blog. This probably is not the most opportune time to resume blogging, but perhaps I shall make an attempt.

Five years ago when I was about to enter medical school, I could not imagine myself actually being in medical school. It was just another goal I was relieved to have reached, but only because I had not discovered any other life paths in college. Despite what I may have said in interviews, I am not sure a passion for the study of medicine actually existed at that time. At least, the novelty of drinking from a fire hose wore off rather quickly, and I found myself, like so many others, questioning why I had aspired to come to medical school in the first place. Occasional patient contacts reminded me of the rewarding side of medicine while each miserable exam crushed my spirit once more. One step forward, two steps back. Sometime during third year, the rewards began to outweigh the desolation felt after each exam. But at the end of that year, I felt in no way ready to make a career decision and step forward toward residency. A year of bench research taught me two things: I do not like bench research, and I do like clinical medicine.

Upon returning as a fourth year medical student, I was undoubtedly dumber than I had been when I finished third year as far as general medical knowledge was concerned, but there was an inexplicable confidence that had settled in me. The most simple explanation is that fourth year of medical school essentially does away with standardized testing and thus only clinical application of knowledge is important. If given the choice between being pimped in the OR and taking a shelf, I will gladly take the former.

The one year hiatus had taught me nothing about medicine and yet, the transformation of my approach toward medical school was undeniable. When did I, a shy and self-doubting type my whole life, begin to enjoy working with patients and feel like perhaps I had something to offer them? When did histories and physicals become conversations and not checklists? How did morning rounds change from a time of nerve-wracking evaluation to an opportunity to discuss semi-intelligently how we could help this patient? When did attendings become teachers and mentors and not foes trying their best to tear me down? Was this merely the difference between a third and fourth year student? Or had I changed so drastically? How will I view the world, or more importantly the system of medical education, as an intern? Medical school was the rockiest road I encountered during my life, and just as it had become smooth, the road ended and I now embark on a new path.

fate.

I am currently toiling away on my psych rotation and decided to "explore" different fields of psych during this 5th week. This afternoon, I decided to spend 2 hours in the transplant clinic before heading off to a neuropath lecture. As it happens, the psych transplant team occupies the room next door to the liver surgery clinic, where I did my first surgical rotation. I went to say hello to the old team, and whose name do I see pulled up on the computer but that of my very first patient on the liver surgery service! He was the first patient I ever saw in that clinic, and he was the only surgery scheduled for the next day, and he just happened to be in for a 3 month post-op visit at the very same time that I arrived for my 2 hours of transplant psych. I'd had a very good relationship with this patient and his wife, so they were very special to me. Come to think of it, I even presented him in case conference because he'd had metastatic colon cancer and had undergone right portal vein embolization to beef up the puny left lobe, which was cancer free, before surgery. I chatted with them until the attending came in, at which point I slid out (sadly) to go to transplant psych (which I was late to). I was so happy that I had a chance to see them again, and they seemed to be excited to see me again, too. It's always a bonus when a patient actually remembers you after they leave the hospital. Of course, we're never really on service long enough to see post-ops so it's uncertain how many patients actually would remember you given the opportunity...at any rate, it was an amazing coincidence that only God could have arranged so perfectly.

high-functioning.

There are a number of people who seem to look with disdain upon the field of sports medicine. They criticize it because you're taking care of "high-functioning, healthy people" when you should be dedicating your medical education to the poor, helpless, or otherwise unfortunate. Obviously, I am not opposed to serving the poor, helpless, or otherwise unfortunate, but I think it is equally important to treat those who are high-functioning and healthy. Some may scoff and say that a knee injury in a college football player threatens neither one's morbidity nor mortality. Is it really fair, though, to condescend and say that fixing an injury that could ruin everything that person has worked for in their life is less important than saving that same person's life in a MVA? Sure, they'll continue living if their knee never gets treated, but "living" becomes a subjective assessment. Say they are from a poor, inner city family and football is what is getting them their college education. Imagine that football is the only thing they have going for them and they've poured all their efforts into it over the years. Is it worth any less than the high-functioning student from a middle class family who has worked their whole life to go to medical school and then suffers a brain injury that lowers their intelligence to a level that is compatible with life and happiness, but not an MD? Haven't both patients worked hard and then suffered a medical misfortune that threatens their dream? Don't both deserve to have their suffering treated with equal respect?

I've found over the past 2 weeks of this sports medicine elective that I really like the patient population. We see high school kids who play for love of the game and suffer an injury, but can be treated and returned to play. Maybe someday they will even earn a college scholarship. We see the weekend warriors who work hard to keep themselves fit. They are taking care of their bodies so that they don't become obese and end up with complications such as diabetes and heart disease. Are they any less important as patients than those who don't try to lose weight and inflict all types of medical misfortunes upon themselves? We see elderly people who have always been active, but now have arthritis because their joints have taken so much wear and tear. They, too, deserve the best treatment so they can continue to stay healthy and have the best quality of life. Could you really tell any of these people, "your joints are not as important as another patient's complications of metabolic syndrome" or "your sports medicine doctor should have gone into trauma so that they could be treating patients on death's door rather than you"? I think every single specialty has it's merits and is important to the field of medicine, and that includes the oft misunderstood specialty of sports medicine.