12.28.2003

Stint in anesthesia

Before I was smart enough to realize that EM is the best specialty ever...I actually thought anesthesia was cool.

When I started my anesthesia residency as a CA-1 after my internship I was so excited. To not be the intern would be fun. To not be running around crazy on the medicine wards would be a pleasant change.

Prior to starting the residency we took an anesthesia ‘board-like’ test, just to help us start thinking about, and preparing for the board exam. It was one of those exams that, in the beginning you try very hard and think through every possible answer, using your test taking techniques to eliminate obviously wrong answers, etc. By the middle of the exam, I realized that I really didn’t have a clue. Really. I couldn’t even eliminate ‘unreasonable’ answers. This was one of those exams that’s just insanely difficult (especially when you know nothing about the subject matter). One of those exams that you can’t even have a discussion afterwards, for lack of understanding of the material.

For the first few weeks we were paired with more senior anesthesia residents. So much to learn, and in medical school you get almost no exposure to anesthesia unless you choose to do a rotation. The anesthesia machine…the patient-machine interface…the compliance of the tubing, the pressure of the gases… I was intrigued. Granted, I didn’t feel like ‘a doctor,’ but I could suck it up and give it my best effort. When I was a girl I had a mental picture of what ‘a doctor’ was, and anesthesiologist didn’t fit that mental picture (at all). But, there are some advantages of being an anesthesiologist. For one, it was a very easy specialty to get into. Not a whole lot of butt kissing involved. The salary was great. The job market, wide-open. It was known as a ‘life-style’ specialty, which allowed time to enjoy life outside of medicine, and that appealed to me. Anesthesiologist only deal with one patient at a time, and they sit all day (and read magazines) behind the curtain. What a life!!

At my (ex) program, there’s lots of emergency surgery (therefore emergency anesthesia). One day, as call was just beginning, there was an RB (‘red blanket’ which is an incoming trauma). Up from the emergency department there was this guy, young Hispanic guy, with multiple gun-shot wounds to the abdomen and thorax. He was awake, but agitated…and dying quickly. As the surgeons poured betadine (from the bottle) on his belly, we quickly put the patient to sleep (i.e induced a state of unconsciousness, and paralyzed him, thereby completely taking over the most basic bodily functions for him). We stuck needles in his neck for intravenous access. We stuck needles in his arteries for monitoring of blood pressure. We collected his blood as he was bleeding out, and transfused it back into his body. We gave him drugs to keep his blood pressure up. It took 4 anesthesiologists to perform these different tasks. It was unbelievable to see how this whole trauma resuscitation worked (from the top of the curtain). The trauma surgeons cut his belly from top to bottom, avoiding his belly-button. They tried to stop the bleeding, packing his belly with gauze. But, what was keeping this guy alive was what *we* were doing!! Amazing.

Most cases were not so exciting, however. They say anesthesia is 90% boring, and 10% super crazy. So, typically, the first year anesthesia residents did the ‘easy’ (i.e. boring) cases. Those cases where you sit for 4 hours while the surgical resident learns to take out a gallbladder. Or the straight forward appendectomy that they attempt to do laparoscopically, eventhough it takes them 3 times longer to perform (and the patient ends up with 3 small scars instead of one), for practice using the laparoscope. And your only opportunity to talk to someone is in response to the surgeon request.

“Table up, please.” The surgeon requests.

“Is that high enough? Great. Would you like more trendelenburg?” You ask, delighted to be acknowledged.

The surgeon ignores you.

“How much longer?” you ask. This is vital information because it’s expected that the patient wakes up the instant the last piece of tape is applied to the dressing.

“Oh, 15 minutes.” I don’t know why we bother to even ask. The case never ends in the standard ’15 minute’ timeframe. More like 45 minutes.

At this program, the CRNAs were so much more willing to teach than the attending staff. They were so sweet, and patient. The attendings, on the other hand, were a very vindictive bunch. One time, I asked the attending if *I* could attempt intubation this time, since he always took my procedures from me. Oh, man, that was the wrong thing to say. If I had my afore mentioned ‘handbook’ I would have known better. I would have kept my head down, careful not to look at them in the eye. I would have walked 10 steps behind them, and said nothing…ever!! I quickly found myself on the ‘wrong side of the political fence.’ Actually, most of the American residents ended up on the same (wrong) side of the fence.

We always presented our cases to the attendings prior to the scheduled surgery (preferably the night before). Usually this went without incident. Sometimes the attending would pimp me about the upcoming case. But many times the discussion ended with me feeling quite disrespected or embarrassed for one reason or another.

“Ms. Aleman is a 25 year-old African-American female – “

-interruption by attending-
“Aleman? Why would a Black person have a name like that?”

Back to me. “ –with no past medical history, but does have a history of drug abuse – “

-interruption by attending-
“They all do. They all have a history of using crack.”

What? I can’t believe this asshole just said that?

So I stumble through the rest of my presentation. At the recommendation of a more senior resident in the program, I said nothing. She detailed to me what has happened to “those who tell.” The ‘handbook’ clearly states, if you want to be granted permission to sit for your boards after you’ve completed the residency, you will say nothing. No one can help you. You will only hurt yourself.

In the cafeteria I expected a reprive from the inappropriate comments by the attendings. Sitting at a table near 2 fellow residents, I overheard one talking about her husband. Perhaps she was frustrated with the lack of time they had together, and said something to that effect. Well, the attending walks by, overhears a few words, and says “He’s probably with other women…you know how you people from the middle east have multiple wives…”

Rumor has it that those two women attempted a lawsuit, but being in a vulnerable position, eventually dropped it. I guess they opted to just “get finished and get outta there.” As a medical student, I did a rotation through the anesthesia department at this institution, and of course you don’t get the full story. I was warned not to go to there, but I was also told that the Department was improving every day, and in two years it was expected to be a great place to train. A new Chairman was hired. And after losing ACGME accreditation a few years prior, things were on the right track.

I was very unhappy. I wasn’t sure if it was the anesthesia department, who obviously didn’t like me, or anyone who looked like me, or anyone from this coutry. This sentiment was shared by the overwhelming majority of the American medical school grads. I considered that perhaps I just didn’t like anesthesia, period. It’s very difficult to differentiate between the two when everything is horrible. Initially I worked very hard to prove myself. When I complained to the Chairman that I was being unfairly evaluated, he himself came into the OR with me, to evaluate me, to teach me. We both agreed that I did well.

But the torture continued. Everyday, dealing with attendings that were not present in the OR. Attendings that did no teaching. Attendings who made inappropriate comments. Apart of a system where little could be done to remedy the problems. Between the (apparent) inability of the chairman to fire staff that was problematic, to the ACGME who encouraged residents to report problems, but could do little to protect the resident in the long-run, I had to get out. The OR walls started closing in on me. No windows, sitting in a little 6x6 foot area, with on one to talk to. Taking crap from the surgeons. Listening to that annoying beep of the monitor (a sound it took months to get out of my head). And not feeling like ‘a real doctor.’

There were a few great attendings. There was one in particular, who was like a ray of sun through a rain cloud. He would look on, sympathetically. He was like a big brother in a violent household. The kind of ‘guardian’ who was sophisticated, yet sly, enough to protect us residents while following the ‘handbook’ guidelines. When I hesitantly told him I was thinking about switching out of anesthesia and into emergency medicine, he immediately offered to write me a great letter of recommendation.

4.28.2003

The "handbook"

As an intern you’re constantly reminded of how dumb you are. No matter how much you read about a particular patient’s disease, on rounds the attending will most certainly ask you the *one* question you don’t know the answer to.

“This is Ms. Sanchez, she’s a 21 year old Hispanic female who presented to the ED last night complaining of right upper quadrant abdominal pain. This is the second such episode…”

Attending interrupts my perfect, well-rehearsed presentation “so what is your differential diagnosis?”

Huh? What about the rest of the history? Don’t you want to hear my very focused physical exam? And there are lab results to report. I worked *all night* preparing this damn presentation, and he wants to skip all the way down to the differential?

After reciting my (memorized) list of possible diagnoses, he decides to pimp us. I think it made him feel special to demonstrate in front of a group how much more he knows than the rest of us. After a 30 minute discussion, we agree that the patient probably has gallstones. I’m now feeling quite proud, ahead of the game, because I stayed up *all night* reading about cholelithiasis (gallstones) and can basically recite everything there is to know about this disease. I’m gonna show all my fellow interns that I’m smart, that I know my stuff.

“So, Dr. Gilman…,” (bring it on) “can you tell me the name of the person who had the world’s first gallstone?” the attending asks.

What?! You’ve got to be kidding me. Who knows the answer to that, and why is it relevant?

I stare back blankly.

“Anyone?....This is a very basic question. You guys should know this. You call yourselves doctors? How are you gonna effectively treat this disease if you don’t know basic information about the disease?”

Of course there’s some goody-two-shoes intern that actually *does* know the answer…and I end up looking like an ass. On to the next patient (not mine). As were walking down the hall (interns behind the residents, but in front of the medical students) my resident slows down a bit and whispers to me “I should have told you that, he *always* asks the interns that question on rounds.”

Note to self: get a copy of the ‘what the attendings love to ask interns’ handbook. All the reading I did, and all of the *relevant* information I learned went unrecognized because I didn’t have a copy of that handbook.

I was to discover that there were many “handbooks” during residency. Some were more important to have than others.

4.18.2003

Me, a doctor?

(note: my name isn't really Dr. Gilman)

“Dr. Gilman?...Dr. Gilman?!!” I glanced around and casually caught the eye of one of the nurses sitting at the nurses station.

“Are you Dr. Gilman?” she asked me.

Me? Oh me!! “Yes, I am Doctor Gilman.”

Starting my internship was a very exciting time. Not only did I get the privilege of wearing the *long* white coat and carrying a pager, I was finally ‘the doctor.’ I think the most difficult part of the transition from sub-I to intern was being called “doctor.” Suddenly you go from lowly medical student…who can’t even get an order carried out by the nurses without a co-signature, to being the first to be called in a full arrest…overnight, literally!!

“Dr. Gilman to CCU, STAT…Dr. Gilman to CCU, STAT!!” My name blared on the hosptialwide communication system.

What tha’ hell?? Why are they calling me?? What am *I* supposed to do? As I arrive to the CCU the (very excellent) RNs are already coding a young man who recently had an MI.

“Hi Doc!!” one of the older, seasoned nurses greeted me. “This guy just bradyed down on us…he’s already intubated, and we started ACLS. What do you want us to do?”

What do *I* want you to do?

Me: “Ahhh, just go ahead and do what you guys usually do…” I tried to sound ‘in control.’

Them: “What drugs do you wanna give? Is atropine okay? We’ve already given one epi.”

Whatever. Just do what you do. Pretend I’m not even here, I wanted to say.

Me: “Yeah, atropine is good. Where’s the resident?” Where the hell is my resident!! Why am I the one first called? I’m the least experienced, alone, in the middle of the night, with the sickest patients. What kind of a system is this? How is this advantageous to anyone that the most na├»ve doctor is the first one called to the unit?

I found that I’d frequently question the medical education system. I wouldn’t have wanted *me* as *my* doctor at that moment. Honestly, in retrospect, I wouldn’t have wanted the resident as my doctor either. Where was the attending? Shouldn’t he be there? You got a bunch of hacks up in the CCU…basically watching a patient die. The attendings? At home, where they typically are at night. If you dare, you can call him/her, wake her from sleep (or otherwise ‘interrupt’ their lives)…but you risk a virtual ass whupping if you do that. Not to mention being branded with a huge scarlet letter ‘S’ for stupid, to be permanently tattooed on your forehead.

It would go something like: “Oh, Dr. Gilman?...yeah…she’s one of our weaker residents…not very confident that girl…requires too much instruction…”

Thankfully the resident arrived seconds after I did…and ran the remainder of the code.

2.19.2003

A real life journal

There's a guy at work who, I think, is the only person who truly hates me. If there are others, I am unaware...blissfully. And you know, this guy actually has no reason to dislike me so much. Let me tell you what happened (and why I'm spending this mental energy on him).

I am finally a senior resident in emergency medicine. Emergency medicine still attracts young men with that "cowboy" mentality. And since most guys who grow up to become doctors weren't the coolest, most popular guys in high school...they tend to have "overcompensation" issues once they achieve MD status. And dealing with a man and his "overcompensation issues"...is (to say the least) frustrating.

At work we have this shady system of filling out our timecards. For starters we can't actually document the hours we work because the County only recognizes hours between 8 and 5, monday-friday. So, if you fail to place at least 40 of your hours per week during these times...you don't get your entire pay. And since the hospital is (obviously) open 24/7, and most of the time we're in the hospital in a given month may not fall within the "alloted" time frame...you have to lie and say you were there when you weren't. So you can see how this starts to become tricky once you start moonlighting, because that (separate) timecard must be accurate. So if you work Saturday and Sunday, and are off Monday and Tuesday...but decide to moonlight tuesday...on your (regular) timecard you're putting 8-5 M-F so you can get your salary. On your moonlighting timecard you must put tuesday (since that was the day you actually did the moonlighting). So now, when you consider the hours on both time cards, it looks like you're working once (tuesday) but getting paid twice (regular pay, plus the moonlighting). Suppose you decide to moonlight outside the program? Now it looks like you're 2 places at once. Crazy, huh? And with the newspaper following the docs around, taking pictures of them at their 'outside' workplaces, then writing a stories "exposing shady docs" by giving the appearance that the docs are lying, undercover criminals who are gypping the County as they are billing for hours they aren't actually there - puts people (me) on edge.

Another thing. The Hospital decides to only give out a limited number of overtime timecards. So, maybe 10 residents will get a timecard...but we have 20 residents who work overtime. How? you may wonder? Well, those without timecards work on the cards that are held by others. And, the thing is, you need 20 residents to cover all the moonlighting shifts that need to be covered. So, last year I had a timecard. This guy wanted to "work on" my timecard. I had reservations, but there's tremendous pressure and expectation from the residents (i.e. my colleagues) to "cooperate." He's one of these guys who works crazy long overtime (to save for that porche, to impress the girlies, to be a man). So he's want me to put 8 shifts a month on my card. We'll you can see how complicated that becomes...trying to find a way to record all of these hours with the above listed stipulations, without overlapping the required 8-5, M-F. Because if you overlap, and they catch it, they won't pay you the overtime.

Anyway, making a very long story much shorter...the situation became complicated and combative.

...and since then, he hasn't said two words to me. Outside of work, he barely looks at me.

The point of bringing him up? Yesterday I was browsing the internet, and on the computer I was using there was a journal he'd started just a week prior. Public, online, and kinda cool. I'm not so bold to publicize *all* of my thoughts, but I thought "what a great idea."

Hence the birth of this journal.