A Week of Emergencies

I spent this last week working in the emergency room at Los Angeles County Hospital. It’s one of the busiest emergency departments in the country, seeing an average of 465 patients per day. The average patient wait time is 7 hours. I was nervous going into it—at the start of the week, I thought it 70% likely that emergency would end up being my specialty. I really wanted to love it. I worked five 12+ hour shifts in six days, one of which was at night.

Day 1 – North Wing: emergency department (ED) for patients with mostly internal complaints (abdominal pain, cancer, chest pain, stroke symptoms, cough, etc).

The emergency department has very few doors. Each wing has a couple central stations for doctors and nurses with desks and computers, and the patient areas line the perimeter of each wing. The rooms have curtains that don’t close all the way, so as you walk around you can peek into any room and see what’s going on.

I got introduced to the grind. In emergency, the patients never stop. Every time a room empties, the next time you look into it there’s a new patient in the bed, waiting for you. I followed my resident for the first few hours as she walked room to room, sitting down every once in a while to write imaging or prescription orders. Soon she gave me my own patients to see, and I’d come out to present my thoughts and findings to the attending. When my stomach was rumbling around 1:30 pm, I asked if I could grab lunch. She said, “Definitely. Just go eyeball your next patient around the curtain really quick and see if she looks like she’s stable. If she looks ok you can go eat.” That was the moment I realized that in emergency, you have to deal with this nagging feeling that no matter how fast you move, how many breaks you take or don’t take, your patients are still lined up and waiting for you.

In the evening, I walked through the resuscitation wing to discover a horrifying scene—a ten year old boy who had just been run over and dragged by a truck, his chest splayed open on the table. The senior surgery resident was doing internal cardiac massage. Someone exclaimed that the boy’s mother was coming into the ED. “Close the curtain! Quick, someone throw a blanket on his chest while we take him up to the OR so his mom doesn’t see.” They rushed him up to the operating room, but he didn’t make it.

Day 2 – overnight shift during Halloween weekend in the resuscitation (“resus”) department. This is the ED for critically injured or ill patients.

A couple women in costume arrived wrapped in bloody towels. They had been stabbed by a stranger in the face, arm, and back while celebrating Halloween at a bar. They had copious amounts of costume blood and real blood on themselves. 20 minutes later, their assailant was also wheeled into resus, agitated and strung out and with a swollen ankle. Ultrasound showed that one of the women had blood in the space around her lung, so the second year resident put a chest tube into the space, through her back.

A teenage boy came in, also the victim of a brutal stabbing. His bowels were protruding from his abdomen. He was rushed up to surgery.

I put a few staples in some guy’s head.

I got to sew up multiple stab wounds. I have a feeling if I were at another hospital, somebody besides a third year medical student would have sutured a facial laceration, but there I was. I did my best and I was proud of the way it looked.

Why are there so many stabbings?

In the early morning, I walked out of the hospital, exhausted. I looked down at the blood on my sleeve and couldn’t match it to a patient’s face. All I remember is that sometime in the night during a chaotic trauma team activation, I looked down at my arm as I was bracing someone’s neck and realized it was all bloody.

Day 3 – more resus

A yelling man gets wheeled in, strapped to the bed, a spit mask over his face. A spit mask is like a mosquito net that goes over your face, with an opaque sock-like part that covers your eyes. It keeps you from seeing anything, and prevents your defiant spit attacks from reaching anyone. I get assigned to one of his legs, and I do my best to hold it down while he gets jabbed with some meds for his agitation. Who knew I’d be using all my CrossFit strength to hold down patients every day. I chuckle as I remember one of the core CrossFit mottos: “Training for Life.”

They take his mask off, and he’s bucking his whole body, trying to get off the bed. “Let go of my leg, you fucking bitch. I swear when I get out of here I’m going to go get my gun and come back and kill you all.” Earlier this year I think this kind of thing would have bothered me, but it’s amazing how quickly you can just stop caring about it.

A very sick patient is quickly crashing and needs to be intubated. The attending yells to the second year resident, “How confident are you that you can get this intubation? You’re only going to have about 30 seconds.” The resident takes a deep breath and says he feels pretty confident. He nails it, and everyone in the room cheers and slaps him on the back.

I realize that these are the moments that emergency residents live for. They are total adrenaline junkies. They wait for these moments when they are asked whether they are willing to bet a patient’s life on their procedural skills. I will never be a person who craves this moment. I am not a thrill-seeker. Maybe this is not for me.

A mother comes in screaming, holding her 3 year old daughter to her chest. They lay the kid on the bed, a gaping stab wound extending halfway across her chest, and another across her back. The trauma team rushed the girl up to the OR, but she died. I will never forget the look on her mother’s face, standing there in the resus hallway, sobbing and shaking, her white T-shirt completely drenched in her daughter’s blood.

Day 4 – Jail ED

The jail ED is a bizarre place. There are a few patient areas—a row of private rooms with curtains for the sicker patients, a big room filled with 12 hospital beds, a row of chairs in the hallway, and a couple isolation cells with heavy metal doors. There are guards in uniform everywhere. There is pop music playing. All the patients are handcuffed to their hospital beds, or they are sitting in the hallway, handcuffed to the bench.

One patient had attempted suicide by taking a stash of meds he had been accumulating, day by day.

Another was brought in for a medical evaluation after filing a claim that officers had used physical force against him. He gave official videotaped testimony, showing his injuries to the camera, right there from his hospital bed. The guards were standing all around him, questioning and recording him.

In the afternoon, we could hear a patient coughing and yelling up a storm in the hallway. Pepper spray had been used on him, the report said. They took him to the isolation cell, and five of us went in there to physically subdue him in order to inject him with some meds. As soon as we entered the cell, I could taste the pepper. All five of us started coughing. We held our breaths as we restrained him so the nurse could give him a quick jab. A few seconds later when we tried to open the door, we realized that it was locked. Now we were the ones coughing on pepper spray fumes and banging on the cell door and yelling. It was probably only 20 seconds before we were let out by a guard. Oh, jail.

Day 5 – West Wing: ED for people with mostly arm, leg, back, eye, breast, and vaginal complaints. No one is actively dying.

I learned how to ultrasound an eyeball. Watched my intern use a power tool to cut a ring off of a guy’s swollen finger. Watched my resident cut open a guy’s infected toe to search for a piece of the stick that he had stepped on a month ago at the beach. Watched an ultrasound on a pregnant woman with abdominal pain who was concerned about her pregnancy. Regular emergency room stuff, basically.

Conclusions

I can’t believe how much I saw in five days. The patients kept coming and coming and coming. The emergency doctors know how to manage any condition acutely, and also do a lot of procedures every day. I have tremendous respect for the breadth of the specialty.

I feel anxious about my own impending residency, no matter which kind I decide to sign up for. These people work so hard every minute of the day for about 13 hours in a row, with maybe a 30 minute lunch break. The second year resident was telling me that on her ‘day off’ tomorrow she has four hours of lecture, then the next day she will start back in the hospital for eight days in a row. ED residents get 4 – 7 days off per month, and alternate every two weeks between day shifts and night shifts, for the duration of the four year residency. How on earth am I going to make it through four years of residency when I am so tired after one week?

Even though I found the residents to be wonderful teachers who are easy to get along with, and the content of emergency medicine to be absolutely fascinating, I’m not a thrill-seeker at heart. These residents not only thrive under pressure, it’s what gives them true joy. They are their happiest when they are doing critical procedures, sprinting through the hospital when an airway code is called, and actively stabilizing people who are on the edge. If I was 70% sure that this would be my specialty at the beginning of this week, I am now 55%.

But for now, I have a golden weekend (a golden weekend is when you have both Saturday and Sunday off). It feels sacred. I shall treasure it by just lying here perfectly still in my bed for the rest of the day.

Marry Me

“Do you think we have to wear rings to this thing?” Jono asked me.

“Ehh probably not, who knows,” I replied.

It was the morning of our wedding. We had convinced ourselves that our impending marriage was more of a formality than anything. Jono’s 90 day fiance visa had finally gotten him to America, and we had 90 days (but really more like 60 because of paperwork processing time) to tie the knot in exchange for his green card.

Getting married for a green card is a bit awkward. We didn’t feel like getting real married was appropriate—we had been dating for a year and a half, most of which was international long distance; we had never lived together, we didn’t know if Jono would even like America, neither of us fully buys the idea that you can promise somebody forever, and on and on. We joked that getting married despite the fact that neither of us wanted to was real proof of our love for each other.

We arrived at the East Los Angeles Courthouse three weeks after Jono landed at LAX. It was sweltering. We stood outside at the end of a long line of people for a few minutes, then a worker managing the line looked at my white sun dress and yelled over, “Are you getting married? Do you have an appointment? Ok, come this way.”

He led me, Jono, my mom, and Dan inside, to the bride holding room. The room had about four brides in white dresses, plus their partners and a few guests. Every fifteen minutes, a couple would be called into the next room to get married.

They called our names, and we were greeted by a familiar face—Maria, the woman who had helped us fill out our marriage license paperwork at the courthouse a week before. She explained that the person who usually performs the wedding ceremonies was gone for the day, so she’d be doing the honor. She unfolded a black nylon cape, just like the ones they use at the hairdresser, and slipped it over her T-shirt, jeans, and running shoes.

She led us into the next room. It was a windowless room with rows of plastic chairs, a wooden podium at the front, and an archway decorated with plastic flowers. She explained that the entire room was going to be ours for these 15 minutes, so we could feel free to move around and take photos. I told my mom to send a 10 second snapchat video during the ceremony.

Dan was walking around the room, taking photos, and my mom gestured at him to stop making such a ruckus. Maria interjected, “No no, it’s fine, let him take as many photos as he wants. Alexa and Jono can show these photos to their kids!”

Jono and I cracked up and rolled our eyes at each other.

“What?” Maria protested, “You don’t want kids? I swear, all the young people these days are just doing their own thing and not having kids. So, which one of you is it that doesn’t want kids, and why?”

We pushed through a few more minutes’ worth of ceremony, including some vows, then Maria gave us an opportunity to freestyle. “What else would you like to add, Alexa?”

“Well, Jono, I’m really glad you made it here and I’m very excited to be together.”

“And…?” Maria prompted. “How about ‘I love you’?”

“Oh yes, of course. I love you.” We were both trying so hard not to crack up.

After we were dismissed, Jono and I went out for a boba and some popcorn chicken from our favorite Chinese cafe. We blasted Taylor Swift’s Bad Blood on the radio and decided that it would be our wedding song.

In the evening we went to dinner with my mom and Dan and some close friends. They pooled together and bought us a gorgeous cold brew coffee dripping tower. We were touched.

It’s already been more than a year since that day. I feel happy and relieved. I was scared that Jono would move here and not like it, or that I’d be too busy with school, or that he wouldn’t be able to make friends, or that he wouldn’t be able to find a job, or that we would argue about money, or that I would end up wishing for more time alone, or that he would ruin my perfect bedtime track record, or that he would be sad that I wasn’t the carefree girl he met in Wellington during our Tinder love story. 

But it turns out that none of my fears came to life. We have so much fun together, every day. We laugh about our quirks and make fun of everyone else’s. Living together is the best. Indeed, Maria, I am very much in love with him.

I feel lucky that we were able to get Jono’s green card, and I acknowledge that it wouldn’t have been possible from a lower social status. If he were from China or India, the visa would have been significantly harder to get. If we didn’t have the thousands of dollars we had to spend on visa filing fees and our visa lawyer, as well as proof of more money in the bank, it wouldn’t have worked. If we weren’t as well-educated and willing to spend hours meticulously poring over complicated guides and forms, our application could have easily been denied. I maintain that getting Jono’s green card, in the end, was as difficult and painful as applying to medical school.

 
Marriage, like life, is what you make it. I finally started calling Jono my husband, after a year of introducing him as my boyfriend and responding to the skeptical raised eyebrows with a rushed, “oh yes well we did get married but not really.” It’s easier for him to be my husband. And these days it’s more and more natural, too.

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Open Your Eyes

It was the early morning of my first day on neurology, and I awoke in the dark in a panic. I don’t know how to do a neurological exam in Spanish, I realized.

The thing about Los Angeles County Hospital is that a giant proportion of the patients (half, or more?) are Spanish-only speaking. So not only am I a third year medical student, fumbling while trying to sound fluent in my new language of medicine, but I also do not speak Spanish, the primary language of my patients. Talk about an uphill battle. So far, I have managed to get by with the most basic Spanish phrases, scribbled on the back flap of my notebook.

“How are you feeling today? How much pain do you have? Nausea / vomiting / constipation / diarrhea / fever / chills / chest pain / cough? Are you eating? Are you pooping? Are you walking around? Ok perfect, see you later!”

I went over to my bookshelf and stuffed my three medical Spanish phrasebooks into my white coat pocket. I printed out a Spanish copy of the MOCA, a standardized set of cognitive tests. I shoved my neuro exam tools—tuning forks, pen light, ophthalmoscope, tongue blades, eye chart, reflex hammer—in my pockets.

I headed to the hospital to go find my first neurology patient, a 75 year old man with AIDS. I knocked on his door and turned on the light. “Hola, senor!”

He lay there, his eyes closed and breath raspy. His whole body was shivering, his face twitching every once in a while. His wrists were strapped to the bed with padded restraints. I deployed some of my Spanish stock phrases on him.

“Hello, sir! Good morning! Hello? My name is Alexa, I’m a medical student. How are you feeling today? Open your eyes. Open your eyes!”

But no amount of my bad Spanish could wake him. That was the moment I realized I wouldn’t be needing all my phrasebooks for this rotation. In neurology, it turns out, the patients don’t speak Spanish. They’re comatose.

[They aren’t actually all comatose.]

So every morning, I say a few phrases in Spanish to my patients, just to see if I can wake them up. Inevitably they say nothing, so I proceed with the coma exam. The point of the coma exam is to assess basic reflexes and brainstem responses. I yell at them to open their eyes, and to squeeze my fingers. I pry their eyes open and shine a light inside, checking to see if their pupils constrict. I touch their eyeballs to see if they blink. I wiggle their breathing tubes to see if they cough or gag. Then the rubbing and the pinching. Each limb needs to be assessed to see if it moves in response to pain. I press the side of a pen into their nail beds (it hurts a lot), seeing if they move their arms or legs in response, or if they try to move the pen away using the other hand (reaching towards the painful stimulus to try and remove it gets a higher score than withdrawing away from it). I check their spinal cord reflexes with my hammer. I scratch the soles of their feet and watch to see which way their toes curl. I say thank you and tell them I’ll be back later. If they can hear me, if they know me, they must hate me.

And then there are the families. I have never been so consistently exposed to so much misery. They sit at bedside, crying, praying, pleading for their loved ones to wake up. They decorate the rooms, put relatives on speakerphone, write cards and poems.

Often it takes a long time for something so catastrophic to sink in. Every morning I examine Scott, a 21 year old guy who was in a motorcycle accident last week (it’s always the goddamn motorcycles) and suffered multiple brain bleeds and severe brain swelling (flashback to all those TTAs). He’s now in a coma. His oldest brother is my age, and he’s always sitting at bedside, day and night. Every day he asks me if there is anything he can do, if there is anything new that I know, if I think his brother will ever be Scott again. I tell him the same thing every day—that it really is too early to know. Right now he’s in bad shape, but stable. It could be a long time before we know if he is ever going to get better. Unless he gets a lot worse really fast, or he starts being more responsive, we’re going to be stuck in this gray zone. My attending thinks it will take a full year before we can make an assessment as to whether he will ever recover. I tell Scott’s brother to go and get some rest, and that he has to take care of himself, too. I tell him it’s my team’s job to take care of his brother, that 24 hours a day there is a doctor from my team present on this floor. Teary-eyed, he just puts his head in his hands and says he’ll stay a few more hours.

 
Seeing all the helpless beings in comas, and their helpless families who don’t even know what to hope for, makes me appreciate the people in my life. It makes me hug them for a split-second longer. To be awake and alert and alive, really alive, is something that can be smeared across the pavement and lost forever. It just takes two seconds.

Alligator Hands

(In case you need some context about my life in surgery: Welcome to Surgery and The Longest Day)

It’s the middle of the night, and my TTA (trauma team activation) pager goes off. This could be it, I think. It’s my last ACS call shift tonight, and I came to work with one goal today: to see an emergency department (ED) thoracotomy.

A thoracotomy is one of the most dramatic things that can happen in the emergency room. Basically, it’s a desperate effort to save someone who has sustained penetrating trauma to the chest, such as a stab wound or a gunshot wound. If there really is no time to spare, the procedure can be performed immediately when the patient arrives in the emergency department, which means that no one has to scrub in and the surgical environment is not sterile. It means that there are more people crammed in the room than there would be in a typical operating room, so the environment is more chaotic.

The goal of the procedure is to access the heart and surrounding structures as quickly as possible, so that the surgeon can manually repair the damages, cross-clamp the aorta so that blood preferentially flows to the brain instead of the body, manually beat the heart with her hands (called internal cardiac massage), or put defibrillator paddles directly on the heart and try to shock it back into rhythm.

The mortality rate of the procedure is about 95%. In other words, without the procedure, the patient has a 0% chance of survival; with the procedure, the patient has a 5% chance of survival. Los Angeles County Hospital is a busy trauma center, where ED thoracotomy is performed multiple times per week.

—-

I speed walk to the emergency department, and by the time I arrive, a cluster of doctors is starting to form. Someone shouts that the patient is a man with gunshot wounds to the chest, without pulses, chest compressions have been done for eight minutes so far.

“Prepare for thoracotomy,” the trauma attending shouts. “Two minutes until he arrives.”

Twenty people start gearing up for battle. Gloves, caps, shoe covers, gowns, face masks. The crowd is a sea of blue. My TTA pager goes off again. I ask my resident what to do, and she says I should stay here and come to the next TTA as soon as I’m done with this one.

The patient is rushed in on the gurney, a paramedic riding on the rails doing chest compressions.

Within 30 seconds, my resident takes a scalpel and makes a deep horizontal cut through his left chest, right over his heart, about a foot long. The fellow inserts a giant metal retractor with a crank and cranks the ribs apart to expose the heart. She cuts into the pericardium, the sac that contains the heart.

Immediately, blood rushes out. A fountain of blood. It’s flowing out as fast as if you were to take the top off of a gallon of milk and tip it on it’s side. It’s gushing. Onto the bed, onto the floor, onto our shoes, onto my face mask.

The bullet tore a hole in the heart. The fellow has both her hands on the heart, trying to feel for the hole. Blood continues to gush, so fast that she can’t see what she’s doing at all. She tries for another minute, and just like that, it’s over.

The attending tells everyone to stop, and calls time of death. The patient has lost too much blood, he says.

The fellow takes her hands out. There is blood all over her gown, covering her arms up past her elbows. The pool of blood on the ground is so big that I can see my reflection.

“Damn it,” the attending exclaims, pulling his beeping pager from his waist. “I need to go check on another dying guy. Nobody move. Stay right here. Nobody leave this room.”

About fifteen of us just stand there silently, blood still dripping onto the ground. A rather morbid reflecting pool, I think.

In a couple minutes the attending comes back. He tells us that we will be discussing thoracotomy and proper technique for internal cardiac massage. He demonstrates the motion—palms facing each other, connected at the wrist. The wrist is a hinge, like an alligator mouth, he says. Fingers straight, never curved or you may pierce the heart. Alligator hands. If the heart is still, you manually beat it like this. If it is beating feebly or chaotically, you wait until you feel it fill, then you compress it with its natural rhythm to help the blood exit.

“Ok now get in a single-file line. It’s time to practice.”

Someone lays a towel on the ground to create a path to the body, so that everyone’s shoes won’t get more bloody. One by one, we reach into the body and practice beating the heart.

His body is still warm. His insides are warm. His eyes are open, blood splattered on his face, an airway tube in his mouth. Today he was alive. Thirty minutes ago he was alive.

After we finish, the crowd scatters. I rip off my outer layer and walk down the hall to join the TTA that had started in the middle of this one—a middle-aged man with 15 stab wounds to the torso. On to the next.

 

I don’t know exactly what I was wishing for this morning, but I think I got it. I am reminded of a line from some pop song I heard on the radio: I was so much younger yesterday.

The Longest Day

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.

 

Welcome to Surgery

“Commence,” barks the senior resident at the head of the table. Within ten seconds, the meeting has officially started as another resident starts presenting the patients that were admitted overnight. This meeting happens at 7 am sharp, seven days per week, always in the same conference room. In order to be ready to present at this meeting, my team starts morning rounds at 6 am, and starts reviewing and recording lab values at 5 am. Medical students pre-round on their patients at 4:30 am.

I asked my resident (residents are in their first four years of being a doctor; they are the ones in charge of the students’ day-to-day lives) if I should wake my patients up at 4:30 to talk to them and examine them. It just seemed kind of cruel since I’d be back to examine them again with the team in another couple hours. Stupid question. He smirked as he said to me, “The hospital is not for sleeping.”

And that was my warm welcome to the land of surgery. In this land, 3:30 am is the standard wake up time, meals are consumed in less than four minutes, the words hello, goodbye, and thank you do not exist, and those who do not wear running shoes have no chance of keeping up.

All in all, my six-week rotation in surgery has nearly destroyed me. Before I go on to relentlessly bash surgery and surgeons and the whole surrounding culture though, I would like to acknowledge that not all of the surgeons are evil robot monsters. In fact, I came across a fair number who went out of their way to help me, to encourage me, to teach me. I am thankful for those people, and those experiences stick with me as highlights of the rotation.

I would also like to acknowledge my good friends in medical school who will go on to become surgeons. I respect the work and the drive, and have now seen firsthand that surgery as a field is inarguably and immediately life-saving. I know you will go on to be excellent, and I don’t want you to think I have anything against you or your career choices. I do not have the strength required to survive the residency you will.

Now, let me tell you the top five reasons why I hate surgery.

Reason #1: no time for activities. Until now, I have never encountered a chapter in my life where I legitimately could not make time for regular exercise. In surgery though, every waking moment from 3:30 am until 5:30 or 6:30 pm is dedicated to surgery, with one day off per week. The days are so exhausting that I absolutely 100% need to sleep for 8 hours per night to get through them, so I have to be sleeping by 7:30 pm. On my day off, all I want or have the energy to do is work out, take a nap, study a little, get groceries and gas, do laundry, and go back to bed at 7:30 again. I blow off my friends over and over again because I am so exhausted. This does not feel like a balanced lifestyle.

Reason #2: surgery culture. To sum it up in one sentence, being a medical student in surgery is the repeated experience of people asking you to do things you don’t know how to do, then being annoyed when you don’t know how to do them. They act like giving me instructions in their heads is sufficient to convey to me how to correctly perform a new task.

I was scrubbed into a double mastectomy for a woman with breast cancer, and the operating table was raised so that the resident could work in a comfortable position. I was standing opposite the resident and the attending, with the patient between us. The operating table was tilted away from me. My job was to hold a retractor to display the inside of the breast to the surgeons. This is a common job for a medical student in surgery; basically, you just stand with your arm in a really awkward position for an undetermined amount of time and hold up a metal hook. After a while, the attending thrust the suction device at me without saying a word. At this point, I am propping open a body cavity that I cannot see into with a metal hook, while idly holding the suction in my other hand, unsure of how to suction blindly.

“Well, hurry and suction the smoke, before I asphyxiate.” I timidly move the suction towards the smoke created by the cautery device. “NO. Not in my line of vision. Never put your tools in my line of vision.” I timidly move the suction to the end of the incision, slowly circling the perimeter. “Hello?! Suction! Blood!” I stand on my tip toes, lean over the patient, and direct the suction towards the blood. “No. Don’t suction the pool of blood. Suction where the blood is coming from. Those two are not the same thing.” I cannot identify the source of the bleeding; blood just seems to be coming from everywhere. “Look, I know you can’t see in here, but I need you to do a better job.”

Eventually this torture ends, and it’s time to suture the incisions. Since this is a breast surgery, I assume they will not let me suture, since the cosmetic result seems important. Nevertheless, the attending hands me the needle, needle driver, and Adson (tweezer-like tool). I ask her what kind of sutures she would like me to tie. “I don’t care what you do, but it has to be water tight. Close the dermis, and hurry. You only have three minutes before I take over.”

I bend over to try and see what I’m doing. The string is clear nylon, after all. It’s basically invisible. “For fuck’s sake, stand up straight. You aren’t going to do better sutures just because you are closer. Stand up.” I straighten out and start to throw a stitch. “NO. Grab the needle at the end of the needle driver, always.” Just be calm, I tell myself. “No. Don’t grab it with the Adson. You can just let it go, it’s not going anywhere. See?” I don’t feel nervous, but I’m shaking. “No. Grab the needle driver palm down.” “STAND UP.” She grabs some scissors and holds them, pointy side up, about a foot away from my face. “Now you won’t be bending over even an inch, because you can’t, can you? Problem solved.” I felt no emotion. Maybe this is how surgery turns you into a robot.

Another day I scrubbed into a Whipple, a complicated procedure done for pancreatic cancer. I woke up extra early to study that day–I reviewed the anatomy, indications (situations in which you should do the procedure), critical steps, and complications, just like I was told to during surgery orientation. In the OR the attending started pimping me about the omentum. I couldn’t answer his questions, and he was frustrated. He was baffled as to how I could possibly not know how many layers of peritoneum cover it. He demanded that I list every single surgery I had ever scrubbed into, so that he could determine how pathetic it was that I did not know this information. Even when he concluded that this was indeed my first time in an open abdominal procedure, he was still annoyed. He briskly stepped to the side towards me and turned away from me, completely obstructing my view into the abdomen. And that’s how it went. I spent the next seven hours in surgery standing completely still, watching nothing but this attending’s back, because that’s all he wanted to let me see after proving myself unworthy one too many times at the beginning of surgery. Somewhere in the middle of the surgery he looked back at me and barked, “Are you listening? I don’t want you to just stand there and do nothing. I expect you to learn everything I am telling the residents. I’m not just talking for my own good.” I hated my life.

Surgery is full of miserable people. They look like zombies. They can barely have a normal conversation, which is perhaps why they have become accustomed to chopping the beginnings and endings off of normal interactions with people—no pleasantries required. The surgeons say in all seriousness that if you don’t hate your life, you are not truly a surgical resident yet. And they mean it. They say my consistent smile is a poor prognostic indicator for my potential future career in surgery (thank god such a thing does not exist).

Reason #3: the lack of control. In surgery, there is no concept of a planned meal time. Thus, you only get to eat when or if time serendipitously allows. Surgeries vary in duration, and often last hours longer than they are supposed to. Many times, there was no opportunity for me to eat anything between the hours of 5 am and 3:30 pm. If you are scrubbed into a long case, this means you also will not get to use the bathroom for up to 7 hours at a time. To avoid having to pee and not being allowed to for multiple hours, I stopped drinking water and coffee until after surgery was over. Imagine not having your first cup of coffee until you’ve been awake for 12 hours.

Another rule in surgery is that when your superior summons you somewhere, you have to go immediately. On multiple occasions I inhaled lunch by myself or with my team in the cafeteria, standing next to the trash can, for one minute, until we had to throw the rest of our food away and go back up to find our fellow or attending. It’s called a minute lunch. You literally have 60 seconds to eat, then you have to throw the rest away so you don’t keep your boss waiting.

I feel like there are only two states in which I consume food anymore: either when I am not hungry at all and am forcing food down to prevent future hunger, or when I am so starving I think I might die. 

Reason #4: no questions allowed. Surgeons are chronically short on everything—short on time, on sleep, on patience, on energy. Even though they love putting students on the spot and grilling them to a level that sometimes feels like harassment, it’s not a two way street. One of my friends was informed by his resident that students should only ask questions every fourth day. After another friend walked out of the OR, he was taken aside by his resident and told that he had made a fool of himself, that after he had left the whole OR made fun of him for how stupid his questions were. He was explicitly told not to ask questions anymore. I’ve had a resident respond to my questions with, “Oh, you should look that up. Why don’t you do some research and present to us tomorrow morning?” I’m only allowed to learn when and what they decide I should learn. The power imbalance is excruciating.

Reason #5: no talking to patients. My current theory is that surgeons do not say goodbye to patients at the end of an encounter so that patients will not be prompted to ask questions. Instead, after gathering all of the desired information from the patient, the resident will just turn and head quickly towards the door. Once, a patient saw that the team was leaving his room and shouted towards us, “So am I allowed to have anything to eat today?”

The door swung shut behind the resident as we walked away, and he yelled back through the closed door without turning around, “No, you are probably having surgery. Nothing to eat.” And we moved on to the next room. I tried once to stay behind in a scenario like this, to talk with patient who had questions during rounds. When I emerged, it took me a long time to re-locate my team, and I got chastised for falling behind.

—-

After working with my team for a few weeks, I made an announcement at the end of our morning meeting. “Well, today is my last day before I switch teams, and I probably won’t get to say goodbye later in the day. I just wanted to say thank you for showing me the ropes. I feel like I’ve learned and seen a lot here, and I appreciate you teaching me.”

The chief resident looked at me, his expression neutral. He asked, “Have you decided to go into surgery?” I replied that I had not. He looked at someone else at the table and started talking about something else.

And that was goodbye. Good talk.

If I had to do my residency in general surgery after medical school, I would drop out today, without hesitation. 

 
More stories about misery and excitement in the land of surgery on the way.

MSIII: Bring Your Own Chair

Six weeks ago, I made my official entry into hospital life. I put on my short white coat, stethoscope around my neck, and headed into Children’s Hospital Los Angeles, having no idea what to expect. My first week was also the interns’ first week, so I got to witness firsthand the impossible transition between being a medical student one week and a doctor the next. Spoiler: there was not a day when no interns cried.

The first thing that stood out to me was the incredibly intense work culture. I didn’t know that so many people could act like it is completely normal to work for 12 hours at a time without so much as a ten minute break. I arrived each day at 5:30 am, and when I’d get dismissed around 5 or 6 pm, the interns would look at me longingly and tell me to enjoy seeing the sun. There is no such thing as a lunch break. Everybody works furiously until 1:30 or 2 pm, then we go and grab food from the cafeteria and bring it upstairs, right back up to our work stations.

Every sixth day, I worked a 17-hour night shift. I felt very doctor-y, running around the hospital all night, admitting patients with my intern. For the patients I admitted, I was the first person to talk to them at length since they had arrived in the hospital, and I was the one waking them up every day before 6 in the morning to talk and examine them. When it came time for rounds at 9 am, I’d make a presentation to the medical team (nurse, three interns, senior resident, attending), patient, and patient’s parents. It was the first time I got to follow the same set of patients day after day. 

At 3 am one crazy night, after holding down a particularly squirmy, screaming toddler to jam a tongue depressor and a flashlight in his mouth to look at his throat until he threw up on me (out of defeat or protest, who knows), I stepped into the hallway with my intern. She looked at me and said, “Why am I here right now? I love kids, but I could have made so many other choices and been happy. I could have been a teacher. I’m so tired. I hate my life.”

Perhaps that will be me in two years. I really think working every sixth night indefinitely, and working from 5 am until 9 pm on all the other days, with an average of one day off per week (which means you could get stuck working 12 days in a row), will kill me, too. I understand why there are so many tears. I’m sure I would have cried trying to do all the work they had to do every day, knowing that getting tired will only slow you down, so you won’t get to leave until late at night, but no matter what time you leave you have to get up at 4 am and come back so you can start over the next day.

Before this gets too dark, I want you to know that some parts of it are good. My psychological state is much better than it was two months ago. Working with people in the hospital is far less depressing than silently studying alone for 10 hours in my room all day. An overwhelming majority of the pediatricians I have worked with have been nothing but supportive and eager to teach. It just seems that as a group of people, doctors have taken it upon themselves to remove all non-essential elements of human interaction. Thus, because I am a third year medical student and my value to the medical team is extremely low by definition, my presence is often ignored completely. It’s not personal.

Being a third year medical student is the most awkward thing I’ve ever experienced. Janhavi used to tell me that when you’re a third year, you become very aware that third years drag down the hospital, and that it’s no one’s fault, but that it sucks for everyone. I don’t know how to do anything, so I always have to be shown. My notes need to be proofread, my patient plans modified, my physical exams double-checked. It’s a giant amount of work to teach an MSIII (medical student III: that’s my title now) to be a doctor.

After my three weeks of inpatient life at CHLA, I transitioned to outpatient clinic life at the county hospital. I have a much less active role in clinic, often just shadowing. Sometimes even being the shadow of a doctor is difficult. More than once I lagged behind the group by ten seconds, taking off my disposable gown, mask, and gloves while saying goodbye to the patient, only to step into the hallway and realize that the entire team of doctors had evaporated. Poof.

I have become very good at looking busy while standing idly in the middle of a hallway. I’ll be with a couple residents, waiting for the attending, and they’ll sit down at computer stations to write their patient notes. There are no extra chairs, and I can’t go study somewhere else because no one would think to come grab me, so I just stand by, trying not to hover but not to get ditched either. I tally the minutes of awkward loitering I have accumulated over the past few weeks.

There is a palpable hierarchy. As medical students, we are advised to only answer questions that are asked directly to us, even if a question is posed to a small group. You don’t want to come off as a know-it-all, or to make the residents look bad. Quizzing medical students is everyone’s favorite activity. It’s called pimping. It makes up a large part of the interaction I have with doctors throughout the day. It can be used to assess a baseline level of knowledge on a subject, or just for the general entertainment of the doctors. I was in a lecture the other day, in a small conference room with about 15 doctors. I was sitting on the floor next to a bookshelf, since it is an unspoken rule that medical students are the first category of people to sit on the floor when the chairs run out. Halfway through the lecture, the professor pointed to the bookshelf and said, “I saw a medical student back there somewhere. Medical student! What is the molecular weight of albumin? This should be common knowledge.” I don’t know.

 
Finding somewhere to sit is one of my most frequent problems. In bigger conferences, the designated area for medical students is at the very back of the ballroom. Even though I arrive early, I look at the empty 50 seats and realize that there won’t be one for me. I put my stuff down and go chair hunting. When I find one that looks stealable, I start the trek back to the conference room, carrying my chair. People stream steadily into the conference, 2 minutes late, 5 minutes late, 10 minutes late. I can feel someone hovering right behind my chair at 8:15. I turn around and ask the doctor if she’d like my seat. “Sure, thank you,” she says. So I sit on the floor in the back of the ballroom, leaning against the wall, unable to see well. I find this ironic since I am the one who knows the least out of anyone in attendance, and I am in desperate need of teaching. Even if I had carried ten more chairs to this meeting though, I’d still be sitting right here.