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.

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