What is it that we do in medicine?

There are mornings after a night of weekend call, that I find myself thinking about what I actually “do” when it comes to the practice of medicine. My first encounter with a patient on a call night is usually in the Emergency Department after one of the interns or Emergency Room physicians has asked for a surgical evaluation. Many times, especially if the patient presents in a complicated manner, the Emergency Room resident or attending will call me directly and bypass the junior resident. This is not because the junior resident is incapable of making an evaluation, but largely to save time.

When I get one of these calls, I usually beep the junior resident and we see the patient together with the junior resident taking the lead. It the junior is in the middle of something else, I will start the evaluation and fill them in when they break free of what is demanding their attention at the time. In general, I have no problem “picking up the slack” when a patient needs to be seen earlier rather than later. I also try to pull a medical student or two if there is something of an educational note (definitely in these cases) that I believe will contribute to their learning.

I generally will introduce myself to the patient and begin to ask questions. Last night, I found myself face to face with a gentleman who had a cold right leg. “Mr J, how long has your leg been like this?”. “I don’t know doc, I think since this morning. It started turning color about four hours ago”. “Doc, I don’t want to lose my leg.” He began to plead with me not to “cut off” his leg. At this point, I begin to set in motion a series of orders to get anticoagulation underway for this gentleman. I also phone my vascular surgery attending who is heading in to the hospital. The interventional radiology fellow has the angio suite ready to go in case we need his services but a thorough examination of this gentleman spoke OR to me rather than angio. I quickly thought about my surgical approach and how I would do the embolectomy (removal of a blood clot) from a branch of the femoral artery by common femoral artery approach.

I reassure Mr J, that we are going to do everything possible to attempt to get some blood flow to his leg. I also explain the procedures and strategy which he accepts and understands. I am careful to explain that we have a very short window of time which may have already passed since he does not know how long his leg has been without blood flow. In cases like these, we treat aggressively unless we are sure that the time span is too long to be successful in the prevention of irreversible injury. Since nerves are the most susceptible to ischemic injury, level of pain is a fairly good indicator of injury. This gentleman had a fair amount of pain but not an overwhelming amount of pain.

As the patient was being prepped and anesthetized, I spoke with his wife who had now arrived and was in the surgical waiting room with the couple’s son. She was certain that this problem had occurred no more than three hours ago (more encouraging for me) and that they had taken the time to speak with their primary care physician who encouraged them to call EMS and get to the hospital as soon as possible. I made a mental note to notify the primary care physician as soon as we were done with this case.

Back in the OR, my attending and I scrubbed and examined our operating field. I had asked the surgical technicians to “prep” the entire extremity as minimally, we would remove the clot but we might need to do more. The angio fellow stood by as we would assess our blood flow by intra-operative angiography. I made my incision and carefully threaded a Fogarty catheter into the vessel. I inflated the balloon and withdrew removing several large clumps of clot at the same time. Upon removal of the clot, there was a rush of fresh arterial blood which we promptly controlled. I continued to pass the catheter down both the superficial and profunda femoral arteries until we obtained a strong pulse at both the dorsalis pedis and posterior tibial areas. I also had good backbleeding too.

We shot a quick angiogram which showed both vessels to be open and I closed the arterotomy in the common femoral artery and closed the small incision that I had made to gain access to the artery. The patient would continue to receive heparin anticoagulant therapy and we would watch for signs of re-ischemia and reperfusion injury. The patient was transferred to the vascular intensive care unit.

I spoke with his wife and spoke with the patient’s primary care physician. We would closely monitor this gentleman for signs of reperfusion injury. He might need additional angiographic studies once this immediate threat to limb had passed. I left him early this morning in the hands of the vascular service as I rounded on my patients and headed home. I have called the unit a couple of times and the patient’s pulses are strong. It looks like this gentleman will go home with two legs.

What do we do? I performed an intervention that restored blood flow to a gentleman’s leg. In the back of my mind, I remembered this man pleading with me to save his leg. I was also very careful to explain that even with the surgery, he might lose this leg at a later date. The fact that we were able to restore blood flow is a great sign that all will go well. In this gentleman’s case, the loss of blood flow to his leg was sudden but because of his age (early 70s) he is likely to have some degree of atherosclerotic vessel disease that may need further intervention.

You see a patient in the emergency room and in many cases, you become a significant part of their lives. Your evaluation skills, your procedural skills and your experience immediately kick in and you do what you have been trained to do. The process is almost gradual and you do not realize that it is even happening. That process comes with seeing hundreds of patients and learning the best course of therapy for their problems. The process comes from hours of reading about the pathology of your patient and why you would choose a particular intervention.

I have a very strong interest in vascular surgery. To me, it is a wonderful branch of surgery with many elegant procedures and cases. I also love the patient population that is likely to come in contact with a vascular surgery (middle-aged to elderly gentleman with atherosclerotic vessel disease). These patient generally have multiple medical problems including hypertension, diabetes and some degree of lung disease (former smokers).

When a patient squeezes your hand, looks you in the eye and asks you to save a foot or leg, you know that you are going to do everything possible to do just that. Most of my best vascular cases have taken place in the Veteran’s Hospital where vascular disease abounds. There just isn’t a better population of patients that need the best care than veterans. This is what I “do” in medicine.

Internship or PGY-1

After graduation was complete and I had finished filling out all of those thank-you notes for presents and good thoughts, I turned my attention to making preparations for my move to my residency location. Over my four years of medical school, I had accumulated loads of books and papers. The first thing that I did was toss out any papers that would not be helpful to my little sibs back at medical school. The next thing I did was get rid of the rest of my books and USMLE Prep materials. My little sibs split the lot of them.

We started packing on a small scale but quickly realized that we still had too much “junk”. I even had boxes of things that I had accumulated and had left unpacked for my previous move that had taken place at the beginning of my third year of medical school. I had moved to be located closer to the clinical affiliated hospitals to shorten my commute. A forty-five minute commute was OK for medical school because I could study on the subway but I wanted to spend no more than 20 minutes if I was going to drive.

I made a couple of trips to the location of my residency. I took one of my best friends so that we could scout out some great places to live. She helped me pick out a wonderful three-bedroom home that was located in a wooded area with plenty of jogging and bike trails. Since I have a couple of dogs, I wanted a spot where they could get some exercise and I could get outside. I found the perfect place and I loved living about 1,000 feet from a beautiful lake with woods and streams all around.

After the move, I had one day to get to orientation. I was still in the midst to unpacking on orientation day. I had completed my criminal background check and drug testing. I had also finished completing the materials for my license and smooth move to the local medical society. Orientation started early with mugs of strong coffee and plenty of folks who looked as scared as I was. We received our pagers, our lab coats and our directories. The second day of orientation is where we received our departmental information including our rotation schedule.

I started with Vascular Surgery. These patients are among the sickest in the hospital. I quickly got into the routine of rounding in the early morning (0400h), getting my notes written and then getting ready for rounding with the team. The team, which consisted of the fellows, the surgical chief resident, a mid-level resident, two interns and four medical students would then round. It was the duty of the interns to write every order and plan after we presented our pre-round findings to the fellow and chief.

The residents and students would head off to the operating room while the interns would get orders and discharges done. We would follow up on all labs and studies and then get the discharges completed. I quickly learned to “pre-discharge”, get the orders ready and then make one click to send them to the computer. The computer would print all instructions and prescriptions for me to sign. My dictations would be done at that time too.

Once the daily ward work was underway, one of us would try to get some OR cases while the other intern waited for new admissions and post-ops back from the OR. We would also follow up on all information that came from consultants and all studies as the patients returned. When the patients came back from the OR, it was my job to get them settled in and follow up on what had taken place during surgery. I would look at the OR reports, anesthesia notes and any history and physical information. I would also start a note sheet for tomorrow’s note and check all orders.

By the evening, the fellow would leave and I would report all studies and findings to the chief resident. He or she would add orders or give me the plans for the next day. If anyone was headed for surgery, they would need to have preoperative orders placed for things like nothing by mouth after midnight. Periodically during the day, I would visit each room and find out how the patient was getting along. I would also do things like debride (clean off dead tissue) wounds and follow vital signs and labs. If I was not on call, I would leave the hospital around 6pm after reporting to the on-call intern. If I was on-call, I would receive report from the services that I covered.

I had the unique opportunity of covering cardiac, thoracic and vascular when I was on call. The other interns only covered one other service and their own. At first, the cardiac patients were scary but later, I fell into taking care of them just as I took care of my own vascular patients. My patients were the sickest patients on the three services and I knew them best.

After vascular, I rotated as intern through surgical oncology and colo-rectal surgery. My program director was very impressed with my work so he decided to change my schedule to include a month as Surgical Intensive Care Unit resident. Usually, this rotation would go to a second year resident but a couple of interns managed to get this rotation. I was fortunate because the other two residents on this rotation with me were second year anesthesia residents. They taught me how to place internal jugular central lines and to float Swan-Ganz catheters. The nephrology fellow taught me to place temporary hemodialysis catheters and how to calculate fluid balance. I already know loads about mechanical ventilation but I learned even more from the critical care specialists. It was a great month for me.

I was then invited to spend a couple of months at the Veterans hospital. This was an away rotation that was totally awesome because there was so much operative experience. I honed my surgical skills and could hold my own in the ICU. My chief resident was very comfortable with my work and left me in charge of the service (as an intern no less) when he needed to go out of town. At first, it was scary but I learned that I could trust my instincts. My attending physicians were great teachers and things hummed along for me.

I went through another rotation on Vascular and then Thoracic. I made a deal with the other interns in that I would do all of the dictations and discharges if they would pull chest tubes and work out discharge planning. They hated to dictate and I had become very efficient at getting these things taken care of thanks to the VA hospital. My fellows were great to work with also. I was very comfortable calling them at home and updating. One of the most demanding fellows turned out to be one of my best teachers. He showed me how to sew down grafts.

I finished my year as Night Float intern. I covered all of the General surgery patients. There was an intern for Trauma who took care of the Trauma patients and did all admissions. If he or she was busy, I would admit patients and follow up on studies. I learned to anticipate problems and get them taken care of. I also learned to do make things happen that needed to happen. I made great friends with the night radiography technicians who would get studies completed for me and placed in front of the radiologists before I could get down to the department. They were great folks to work with.

As I headed into second year, I knew that second year would be my worst year. As a more senior resident, I would expected to play bigger role in keeping the service running. Since I would still somewhat junior, I still had a huge learning curve too. All in all, my intern year was great. Some of my chief residents and fellows were very difficult to work with but I always stepped up to the plate and got the job done.

Being a good intern is being anal about every detail of your patient’s care. It took a few months to learn the “ins and outs” of good patient care but I took careful notes and operated every chance that I could. The nursing staff also gave me high marks for getting things done and keeping the services under control. The hours are long and sometimes the work seemed endless but there was a learning point to every task. Intern year went quickly but I felt in control of my learning.