It’s Saturday afternoon on call…

Well, it a S-L-O-W call day even though it’s a Saturday. Please note that I spell that word and don’t write it or (gulp) say it. As soon as I say or write that word, all he– will break loose and the trauma bay will fill up. I do love a good trauma but I am sitting here after a nice lunch of Pho (Vietnamese beef noodle soup) and there’ s a little food coma about to set in. I mused with turning on the TV to see if I could catch an Orioles’ game but I just don’t want to wrap my head around anything. It would be cool to just nap for 20 minutes and then check a couple of patients.

My junior residents are not busy so I don’t feel obligated to micromanage them. All of my senior residents have signed out to me and our services are Q-U-I-E-T (another word I don’t say write). My attending on call, has just checked in to say that he’s going to afternoon lunch with his wife and would like to let me know that he is on Mobile. I love it when they do that. It saves me the trouble of paging and waiting for a call back. I can go right to the source.

So far, I have rounded on my service and discharged just about everyone who could go. I elected to keep one gentleman over the weekend because no one is home to be with him and he is a 75-year-old recovering from a sigmoid resection. His daughter will arrive on Sunday night and he can go home Monday morning. Besides, a couple of extra days of watching especially since I am not happy with his food intake will be good for his recovery. My attending agreed with my assessment.

I am also contemplating doing a stairwell walk to get some exercise. When I start to feel the afternoon slump, I walk up the 10-stories from basement to top floor and back to my digs on the fifth floor. Then I look for a fresh cup of coffee or grab a diet Pepsi. There are fountain soft drinks on every floor at the nursing station that feature, colas, iced tea, lemonade and water. The coffee has to come from the coffee bar that is in the cafeteria. Since Saturday lunches are usually not too great, I had my fiance bring in some Pho so that I wasn’t drowning in grease this afternoon. The bad thing is that I can be pretty hungry around 5pm so I need a good protein dinner.

I am also thinking about the logistics of getting to the White Coat Ceremony that my medical school will be having for the incoming medical students. There is usually a nationally recognized speaker and then the name of each incoming student is called. A member of the physician graduates will then cloak the incoming student. We all take the Hippocratic Oath again just to remind us of what being a physician is all about. It’s a great day and loads of fun to see the newest class and catch up with some of my classmates and professors. It’s always a good time. This year, I am going to be buff so I really want to go. The bad news is that I will be making the schedule so I have to be totally fair with time off, if I leave town.

I spent an hour this morning preparing one of my pathology review lectures. I am amazed at the depth of information that I can burn out in a PowerPoint in about 60 minutes. My teaching experience has really helped me in putting together presentations. I am hoping to have all of my lectures done just in case something comes up and I am not able to teach n the days that I have been scheduled. Sometimes a case can run later or a complication will develop and thus, I have my work ready to go.

One of my junior residents just beeped me to ask about making a patient NPO (nothing by mouth). Since this patient is low-risk for surgery today, I opted for “sips and chips” meaning sips of clear liquids (no carbonation and limited to 30 ccs per hour) plus ice chips. If we do end up operating emergently, we can do so after “sips and chips”. One of my attendings allows hard candy with “sips and chips” but I leave this up to the patient. If there is any hint of nausea or vomiting, back to NPO and I will increase the IV rate.

Well, that’s a glimpse of my world at present. I have to get back to studying for my board exams. I have a strict reading schedule that I am adhering to complete with check offs. I may yet do the stairs and take a nice hot shower before the evening rush. On a Saturday night, I can expect some trauma work.

I just gotta have it!!!

I have been reading Brian Ambrozy’s review on Short Media about the Sumo-Omni http://www.short-media.com/articles/sumo_omni chair/lounge/i-don’t-know-what-to-call-it/thing and I must have one. As one of his children describes it, this is a “nest” that can be tossed from place to place with impunity. I just have to get one of these to fall into after a long day in the hospital. Take a minute and read Mr. Ambrozy’s review and savor the possibilities???

As I see it, I can survey the X-Box 360 from my Sumo-Omni or just park it in front of my patio door (removing a couple of beagles) and enjoy the afternoon sun on a lazy Saturday. I am also expecting that I will spend a fair amount of time removing the beagles from the Sumo-Omni so that I can hang out in this thing. Likely, I will end up buying one for them and one for me. In short, I am about to spend $260 on a couple of beanbags but as I see it, a great investment in getting myself “back to the womb”.

Why am I mentioning this? Because one of the greatest lessons that I have learned is that after spending days in the hospital, coming home and tossing myself into a Sumo-Omni with abandon is just my idea of heaven. Keeping some sanity in this profession is all about doing little “nice things” for yourself regularly. This is a $130 daily vacation complete with sunlight on the weekend. Who know? I might have to import this thing into the Chiefs Den for catching a nap between cases.

Typical Day on Pediatric Surgery

When I was a PGY-3 general surgery resident, I was one of four senior residents on an away pediatric surgery rotation. The pediatric hospital where I rotated for peds surgery was located away from my base hospital. It was a large tertiary referral center for the sickest children from a tri-state area. General Surgery residents from other hospitals and programs rotated with me. This hospital had a burn unit, that was managed by surgery, in addition to all of the other things that a very strong pediatric surgery department would cover like trauma and surgical emergencies.

Pediatric surgery is the one surgical subspecialty that covers every surgical aspect of their population. Pediatric surgeons create fistulas for hemodialysis access in the pediatric population. A pediatric surgeon will ligate a patent ductus arteriosus (persist vessel between the pulmonary artery and aorta). A pediatric surgeon will perform hepatic resections and resections of choledochal cysts in addition to removing lung tumors and repairing chest wall abnormalities. Pediatric surgeons will also remove thyroglossal cysts and cystic hygromas (neck malformations). Pediatric surgeons will perform skin grafts, tracheotomies and transplants in infants and children. In short, pediatric surgeons perform procedures in children that would be performed by surgical subspecialists in adults.

A pediatric surgeon first completes five years of a General Surgical residency. Most complete two years of dedicated research in addition to the five years of residency making a total of seven years of training just to get to the pediatric surgical fellowship. In addition, the fellowship is two additional years making a total of 7-9 years of training beyond medical school to enter pediatric surgery.

Landing a pediatric surgical fellowship is no easy task either. There are presently about 23 fellowships nationally which means that applicants for pediatric surgical fellowship will apply to all fellowship programs and hope for enough interviews to be able to land a fellowship. Criteria for selection are scores on the American Board of Surgery In-Traning Examination (ABSITE) and a high level of performance in general surgical residency. The small number of fellowships nationwide in addition to the fairly large candidate population makes obtaining a pediatric surgical fellowship one of the most competitive if not the most competitive that any physician can obtain. In short, pediatric surgeons are the elite among all surgeons.

My pediatric surgery attendings fit the mold of pediatric surgeons completely. All four did fellowship in top programs in the United States and Canada. They all were extraordinary teachers and all had amazing surgical technique. It was a joy to stand across the table and see not a single wasted motion or miscue. They were equally gifted in teaching both the craft and the art of all aspects of surgery not to mention being some of the most professional folks to work with in the operating room. They treated the OR staff and the resident staff with great respect and made learning quite enjoyable. Here were four individuals who were the absolute best of the best among surgeons and they were just wonderful to learn from and work with and were the “least malignant” personalities I have ever met. Some of my best times in the OR were on the pediatric surgery service as both intern and chief resident.

On a typical day, after finishing up cases in the OR (around 4pm) I would receive sign-out from the folks who were not on call. I would be responsible for checking all post operative patients to make sure that they did not have problems urinating or had adequate pain control. I also carefully checked all vital signs and dressings to make sure that there were no problems that needed to be taken back to the OR. In addition, the attending surgeon that was on call with me would check in before he left for the day, just to make sure that the house was good for the night. If there was an impending admission, he would let me know when the patient would arrive.

I could generally grab a bit of dinner from the cafe and then head off to check the burn unit and emergency department. I would also check for any patient who might need pre-operative orders. Most surgical patients were either emergency admissions, who would go to surgery that night or AM admissions who were still at home. Many nights, trauma patients would be flown in by helicopter from neighboring counties and thus would have to be cared for by my service (me alone after 5pm). The best thing was that most children are not out after 10 pm so traumas after 10pm were rare in pediatric hospitals and more common in adult hospitals.

By midnight, I would be napping in the call room. My naps would be punctuated by calls and questions from the nursing staff. In general, few things needed my presence at bedside if I had done my post op checks thoroughly. Usually, questions would be renewals of orders or an extra pain medication dose. I usually covered my post operative patients with something for nausea with a call to me before it was administered.

Often a first-year pediatric resident and a couple of medical students would take call with me. It was my duty to be sure that this resident and the medical students got the best experience. If I received a routine call from the emergency department, I generally didn’t awaken my staff unless there was something that was going to the OR that night. I preferred to perform my own history and physical exams but I always gave the students a chance to check and observe the incoming pathology.

Patients who had been burned would be sent directly to the Burn Triage area and would not stop in the Emergency Department. Usually the Burn Triage nurse would let me know if a patient was coming. I would check over the burns, write the necessary orders and the nurses would take care of the patients. Again, adequate pain management was usually the most important aspect of burn care along with very strict attention to wound care.

My most memorable case was placing a newborn on Extra Corporeal Membrane Oxygenation or ECMO. This patient had been born with a diaphragmatic hernia that allowed abdominal organs to form in the chest cavity causing the patient’s lungs not to develop properly. When these children are born, ECMO allows the hypoplastic lung to grow and takes over oxygenation for the child. Two large bore vascular catheters are placed in a neck vein and artery. I jumped at the chance to participate in this procedure because ECMO is rarely used. It had been 2 years before that ECMO had been done at this hospital. The resident that was on call had no interest in the procedure but I was thrilled to do this. Later I participated in the definitive repair of the hernia with a good recovery from a potentially lethal congenital defect. It was awesome.

I also participated in a liver resection in an 8-month old with cancer. Again, I had a chance to participate in a fairly rare case with very interesting pathology. This patient also did well after a week-long stay in the Pediatric Intensive Care Unit. The power of regeneration in the liver is nothing short of remarkable. In a pediatric patient, the physiology of these cases are amazing. Liver anatomy is also very interesting as are the techniques used in liver surgery. My favorite surgical instrument is the Argon Bean Coagulator which is used to coagulate the raw edge of the resected liver. This is literally a plasma scalpel.

By 4am, I am usually up, showered and making my early AM rounds. I try to get my notes written so that work rounds are not rushed before we start AM cases. I am required to be out of the hospital by 12 noon on my post-call day but usually, I am done by 9am. I try to make sure that my patients are taken care so that the incoming call resident is not weighted down carrying my patient load and his. For me, it’s all about planning. I usually give a very complete signout with anything that needs to be watched and what I would do if there is a problem. The on-call resident only has to look at my sheet to be able to jump in and do what may be needed.

Another interesting aspect of pediatric surgery is seeing the patients in clinic. In general, the attending who is on call is in office while I am on call at the hospital. This made getting over to clinic more difficult but I did get some clinic time. It is good to see the patient in clinic, do the work-up, perform the surgery and post-op care and then see the patient back in clinic. I love to see how my closures worked and the patient pain-free. Clinic was always interesting.

I thoroughly enjoyed my pediatric surgery rotation because the patients are great fun to take care of and because peds surgery pushes the limits of a surgeon’s diagnostic capability. A surgical abdominal problem in a pediatric patient present far differently than in an adult patient. Even hernia repairs in pediatric patients are more fun than adults because the anatomy is seldom distorted.

I also always keep in mind two quotes: One from Alfred Blalock, the late chairman of surgery at Johns Hopkins. He said, “It’s takes arrogance to cut open a human being.” and the other from one of my pediatric surgical attendings who said, “You wouldn’t hand the keys of your car to a total stranger, yet these parents hand over their child to you, the total stranger. You have been given a great trust.”