The second three weeks of my surgery rotation were spent on the acute care service, ACS. Acute care surgery is split into two categories: non-trauma (person needs surgery in the next 48 hours) and trauma (person has just been in some sort of catastrophe). ACS is known to be the most demanding stint of the third year of medical school, feared because of its 30 hour shifts.
Wait, 30 hours? As in, you want me to work for 30 hours in a row, without any designated time for sleeping…?
The schedule for ACS runs in four day cycles. Say you start work on Monday morning. You work for 30 hours that day, then come home Tuesday early afternoon. You have the rest of Tuesday off, but then come in for a 12 hour day on Wednesday. Thursday you have off, then you start the cycle over. So one unbearably long day, one afternoon to take a nap, one regular work day, and one day off.
I wondered what on earth I would be doing for such a long time at work. I had no choice but to find out. It went something like this.
5 am. “Getting numbers.” This entails making a printout of all the patients and writing in by hand their lab values, new imaging results, and overnight events. One of the residents is drinking a 24 oz Monster energy drink. I joke, “Hey man, aren’t you afraid you’re going to peak a bit early after drinking that? You’ve got a lot of hours ahead of you.”
He looks at me, completely expressionless. “So? If I get thirsty I’ll just drink another one.” He is not amused.
6 – 7:27 am. Rounds. As a team that includes four medical students, two second year residents, and our fourth year resident (our “senior”), we visit about 30 patients, scattered on six floors of the hospital. Each patient visit lasts 1 – 2 minutes. The medical students’ job is to bring a duffel bag stuffed full of supplies, mostly to re-dress wounds, and to be ready to whip them out and give them to the residents. When we run out of a certain type of bandage or solution or tape or gauze, one of us runs out of the room and tries to find it from a supply closet. This person invariably gets left behind, and spends the next ten minutes trying to find the group again. I am a sprinting handbag. My white coat pockets are so full of supplies that I cannot put my arms down at my sides.
7:30 – 8:30 am. “Pass ons.” A meeting that includes all of the doctors from the four surgery teams, as well as the attendings (the big bosses) and the medical students. Topics discussed: surgeries performed overnight, trauma cases that came in overnight, surgical consults that other services requested, and surgeries planned for that day. I am handed the trauma pager by the medical student who has been carrying it for the last 24 hours. It’s my turn to hold it until I pass it on tomorrow at this meeting.
8:30 – 8:50. Breakfast in the cafeteria.
8:55 – 9:30. Seeing patients, writing progress notes.
9:30 – 10:30. Teaching for medical students. This is a session with 8 students and one attending. We stand in the middle of an arbitrary hallway in the hospital and discuss a trauma case that came in the night before.
10:30 – 12:00. Writing more patient progress notes and doing random tasks.
12 – 1 pm. “Running the list” in the cafeteria over lunch with the team. Running the list means giving any updates on patients, discussing plans and things that need to get done for them, and deciding who will take responsibility for those tasks.
1 – 2:45 pm. Doing said tasks and other random tasks.
3 – 5 pm. Lecture. Today’s topic was Fundamentals of Trauma Surgery.
4:59 pm. My TTA (trauma team activation) pager starts beeping, incessantly and loudly, kind of like a smoke detector. Panic sets in. You have five minutes to get to the resuscitation emergency department (“resus”) before you’re late. We run/walk back to the new hospital from the old county hospital where our lecture is. A crowd of 20 people has assembled. The attending surgeon takes me and my buddy up to the helipad to watch the trauma patient arrive. Man found down in a bloody driveway with stab wounds, we’re told. A helicopter appears in the sky. It lands on the helipad, and the paramedics jump out. Quick, but careful. They aren’t running. I remember a doctor told me once that you aren’t supposed to run to a code. You’re supposed to be quick and precise, but calm. They bring him into the hospital and into the elevator. In the trauma bay, the doctors get to work. My top job is to fill out the trauma form (medical school is so glamorous), so I stand in the corner of the trauma bay and listen to all the shouting doctors. I try to take down everything they are saying. They intubate the patient, check him out, and take him to the CT scanner.
A doctor yells for someone to get an ABG (arterial blood gas—a sampling of blood from an artery in the wrist to measure the pH, oxygen status, and carbon dioxide status of the arterial blood), and my fellow (fellow is a more senior doctor than a resident) motions at me to come do it. I’ve never done one before. I try three or four times and fail. He’s very patient with me. He says he usually uses an ultrasound machine while he does it so he can see right where the artery is. He pulls over the ultrasound and shows me how it’s done.
The TTA pager goes off again in the middle of the first TTA. Some doctors leave the room and go into another trauma bay. Man coming in with gunshots to the head and chest, someone yells. I stay at the first TTA, and eventually the doctors who left come back. Dead, they say. They did an emergency thoracotomy and tried to sew up his heart, but he died anyway.
7:35 – 7:55 pm. Dinner. I’m exhausted already.
8 – 9 pm. Team meeting to discuss the surgeries we will be performing overnight and rank them in order of urgency. Cholecystectomy (gallbladder removal), appendectomy (appendix removal), abdominal washout (clean out giant gaping abdominal wound and sew the edges together), tracheostomy (make a hole in the trachea and stick a breathing tube in).
9:15 pm. TTA. Bicyclist coming in with injury to the trachea after hitting a parked car. Intubation fails, so my senior resident does an emergency cricothyroidotomy. All 20 sets of eyes are on her, and the moment is tense. The attending is yelling at her, guiding her. She nails it. They call for an ABG again and I step up for my next attempt. I nail it. I feel good about myself. They stabilize him and the whole crowd moves over to the CT scanner. I keep filling out the form.
Midnight. I take off my white coat and jump into a bunk in the call room for a nap, TTA pager and cell phone right by my head.
12:30 am. I am texted to come to the OR and assist with a cholecystectomy. I know it’s going to be a mess because I’ve never driven a laparoscopic camera before, and it is the role of the medical student to drive the camera. My inexperience makes the surgery miserable for everyone.
“Keep my tools in the center of the screen.” “Give me a 9 o’clock view. No, 9 O’CLOCK.” “Change the port for a different view.” “Show me the bowel.” “Anticipate my movement.” “Zoom out.” “Center me.” “Anticipate my movement.” “If you don’t keep me in the center I can’t see what I’m doing.” “Clean the camera.”
I take the camera out and wipe it on a dry white pad, then rub it on the anti-fog sponge. “1, 2, 3,” the surgeon says to me. I have no idea what this command means. “ONE, TWO, THREE.” I see a little gray sponge near the anti-fog one, so I guess that she is telling me to rub the camera on that one next. I get about 1 mm away from putting the camera onto it. “NOOOO!!!!!!” shout three people at once. It turns out that the gray square is basically like sandpaper and is used to scrape the char off of the cautery device. I would have ruined the camera. “1, 2, 3. WHITE, GREEN, WHITE. EVERY TIME, ALWAYS,” she says urgently, losing her patience.
Can this please end.
3 am. Directed by text message go to the emergency department (ED) and see a trauma consult. Man in a single-party motorcycle accident, helmet found at the scene on the ground next to him. When I get there, he’s already intubated and sedated. CT scans show subdural and subarachnoid hemorrhages (brain bleeds), neck fracture, and various rib fractures. I introduce myself to his terrified family as the medical student from his surgical team. I do a preliminary exam, get more of the story from the ED resident, and read up on his scans so I can be ready to report to my team. His family looks at me like I’m his doctor.
*If this is when the day could end, I would be less miserable. Trauma surgery is fascinating to be involved in. I have seen some crazy, exciting, miraculous things happen, and I have learned a ton from the experience. Some of this is good.
4:25 am. Starving. I eat two bananas and two energy bars.
4:30 am. Time to start the day over again, getting numbers. The simple task of copying numbers from the computer screen onto a sheet of paper feels difficult. I start preparing for the presentation I will give at 9:30, along with another medical student on my team. Every day at 9:30, the post-call (that’s what the day is called when you’re still in the hospital from the day before) students present a trauma case that came in. We decide to present the guy who died. When I first started surgery, I was shocked at how callous everyone was, about how casually everyone treated death and dying. It only took a couple weeks for me to realize though that when you are confronted with death on a near-daily basis, when death becomes a part of work, it’s not that shocking. People just die. It’s the middle of the night and you’re exhausted and you have more work to do. People just die.
6:00 – 7:28 am. Rounds again.
7:30 – 8:30. Pass ons. Relieved to hand the TTA pager over. I nudge my buddy in the thigh to stop him from snoring.
8:30 – 9:25. Running the list with the team.
9:30 – 10:30. Teaching rounds. We present the dead guy. There was nothing anyone could have done for him. My friends sutured his giant chest wound closed at the end though. The attending high-fived them on a job well done.
10:30. Text from our resident saying that we need to go examine four patients each and write their progress notes for the day, then we can go home. I’m so tired. My eyelid has been twitching for three weeks. I feel like I’m dying. I go see my patients. When one of them isn’t in her room, I curse. I don’t have time for this. Where is she. Doesn’t she know that my ability to escape from here, to ever sleep again, depends on her presence in that room?!
Another of my patients is in the basement, in the jail ward. I’m so tired it’s hard not to get lost finding his cell. I wait behind the giant set of bars as the lineup of inmates walks by, chained to each other in sets of three. I avert their eyes. I am not in the mood for comments right now. After they go by and the bars slide open for me, I find my patient’s room and ask the guard if I can go in. He escorts me into the room and stays in the doorway during my exam. My patient has a colostomy bag because he ate an entire set of silverware in jail, which caused life-threatening sepsis and a lot of intestinal problems. Some days I want to ask him why he did it. Other days I don’t really care.
It’s been 29.5 hours. It’s time to write my notes. I usually take pride in my work and do a thorough job, but right now I can’t. I used to be so disgusted by doctors who appeared not to care about their patients, but I’m starting to understand. I will do anything to get out of this hospital right now.
12:00. Done. I feel broken. Existing is such an effort. It’s really sunny out. Going to go home and take a nap, then probably go back to sleep so I can wake up really early tomorrow and come back for a 12 hour day. At least tomorrow I can leave work the same day I arrive.