醫學生日記2016年5月12日

醫學生日記2016年5月12日

阿山 （龐靜翻譯）

 

我正處於手術見習的最後階段。我在藍隊，這個隊的專長是直腸結腸手術。他們治療很多直腸癌的病患。直腸癌是美國位居第二的癌症。所以，我們是醫院最忙的部門。對於我來說，這是見習以來壓力最大要求最高的階段，同時，我感到更興奮，激發了更多的能量。但是也有情緒低落的時候。這是我在藍隊三周中的第二周。我要回顧一下這一周，主要集中於我自己的情緒波動，而不是醫療方麵的。

 

星期一 早晨5:30 – 傍晚6:30

 

很奇怪，這麽長時間，卻是我這星期最容易的一天。這天沒安排手術，大家都在門診忙。我們早晨從預查房開始，就是檢查住院病人。等整個藍隊一起查房時，我們要匯報病人的情況。我一早來了，把我的六個病人的事情準備好了（記錄，據前一個在這見習的同學說，其中有五個病人很難辦。但是我不怕。）還有另外兩個同學也在藍隊。同學A隻有兩個病人。同學B，他是第四年的學生，這是他ACE的第一天（ACE， Advanced Clinic Elective， 他想做手術住院醫，所以他這個月參加藍隊，體驗一下）。我們在藍隊見習的第一天，住院醫頭兒就明確告訴我們應該用什麽樣的內容和方式匯報病人的情況。我覺得這很直接了當，我可以從容地匯報我的六個病人的情況。查房結束時，住院醫頭兒說：“這兒用不著我了。” 他同意我對病人的全部論斷和處理方法。比起同學A，當他匯報他的倆個病人時，住院醫頭兒多次打斷他，說他匯報的內容順序不對，說他把昨天和今天的化驗結果搞混了，說他的匯報太囉嗦，摻了很多沒必要的細節。

 

查房之後，同學B，那個四年級同學請一個第一年的住院醫跟他一起看一下病人名單。我可以看出來她驚訝地轉眼球。她第一天跟我們見麵時就告訴我們不要問她問題，什麽都可以自己去找。現在呢，這樣一個高年級的學生，我們查房時都討論過並記錄到電腦裏的信息，他居然要求她一起再複習一遍。考慮到同學B不太清楚藍隊的要求，我自願和他一起複習所有查房的內容，也可以替那個第一年住院醫省點時間。如果從手術見習中我學到了什麽，我知道了手術醫生們最恨沒必要的重複和沒效率。盡管從名單上我跟了六個病人，但是一星期以來我已經熟悉了我們藍隊的所有病人，也了解對他們的治療。之後，同學B問我“憑什麽你都知道這些？”

 

這一天早晨的情形決定了這一星期藍隊以怎樣的動態進行一周的工作。

 

星期二 早晨5:30 – 晚9:30

 

今天早晨我還是有六個病人。昨天的一個病人可以回家了。我在門診接了個新病人，我建議的收她住院。當時在場的手術醫生同意了，昨天直接把她從樓下門診部轉到了住院區。（這裏記兩件有趣的事情 — 1. 一般來說，在手術見習的學生跟著的病人都是我們見習手術的病人或已經住院的病人。2. “肉眼觀察”在醫學上非常重要。部分是因為我們的訓練使我們能看一眼病人就能決定他們是不是應該上醫院，是不是需要手術，如果不馬上治療會不會有生命危險。首先得熟練掌握肉眼觀察，其次得能用醫學術語把肉眼觀察的發現說清楚。）再回來說查房，同學A隻有一個病人。同學B說他還需要一天才能搞清狀況。我想強調的是這邊一般都有12到20個病人，如果他們真是很在意，他們有足夠的機會跟著新病人。

 

星期二是一個大手術的天。整個藍隊都在手術室。做為學生，我們頭天晚上就拿到了手術室的時間安排。我學乖的另一件事就是不要相信事先的安排。手術這個領域，病人的情況一直在變，總有新的緊急狀況。我們學生自己決定跟哪個手術，但是我有一個規則，由於不知道會有什麽變化，我把計劃內安排的每一個手術都做了準備。星期二就是一個很好的例子：計劃中有四個手術，根據每個手術所用時間，當時我們幾個同學把這幾個手術平均分了。第二天早晨，有兩個緊急情況加進來了。我決定隻要住院醫或在場手術醫生談論病人的病情，我就得在附近，聽得到他們說什麽。這是一個很棒的學習方法，還能知道大多數病人的最新治療方案。所以今天，我們幾個學生先前的計劃就沒用了，我試著給我同學講明計劃變更，但是他們沒有及時地出現在該在的地方，我也犯不著離開我的崗位，出去找他們，告訴他們做什麽。我首要任務是幫助住院醫，他們經常需要一個學生做一些文案事情，幫助轉送病人，幫助病人做手術準備，幫助手術室做手術前的準備；總之有很多事他們沒時間也不想做。我覺得這是一個很好的機會，既可以幫了人家，又可以得到一些學習的經驗。還有一個後果，如果手術醫生馬上要開始手術，那個學生又不在旁邊（計劃上的時間從來不準，這是我學到的又一課。要想準時的唯一方法就是你自己隨時警覺。），手術團隊不希望在場的見習生離開手術室去找他的同學，造成不必要的延遲。所以，事先有準備就很有幫助了。

 

因此，今天的兩個大手術我都在場。第一個從早7:30到中午。第二個從下午1:00到晚上9:00，還出現了幾個手術中的大的複雜情況。當手術中大部分手術工作完成之後，主刀醫生8:30離開時，我們開始縫合切口。主刀醫生說這麽磨人的手術太累了。住院醫頭兒縫完最深的一層切口後，給了我結束手術的具體指示，8:40也走了。他老婆兩小時前進了產房。所以，現在就是我的好機會了，我可以縫上最表層的切口。更棒的是，我是現場唯一的手術團隊成員，我有機會指導護理人員把病人從手術室轉到住院處的恢複室。這就逼著我把病人的情況和手術中的複雜變化，以及術後護理對麻醉醫生和護士們說清楚。根據規定，這是主刀醫生或住院醫的活。住院醫頭兒違反了這個規定，沒有給我講解幫助就把這個機會給了我，可見他多信任我。

 

星期三 第一段 早晨4:30 – 下午6:30

 

我頭天離開醫院還不到七個小時，大約隻睡了四個小時。這已經是公開違反工作時數的規定了。學生A很嚴格地遵守工作時數的規定，為了符合規定，有時候來的比較晚。管理部門鼓勵大家這麽做。但是，住院醫們直言他們嘲笑這樣守規矩的學生，因為他們自己一直在違反規定，很簡單地就是因為工作需要，他們認為醫學院的學生工作難度隻相當於他們工作難度的一部分。我知道同學A知道我在違反規定，但他一直遵守規定，但我們倆彼此之間不談這個。

 

查房沒什麽特殊的。星期三是忙碌的門診天。不管怎麽說，星期三的頭一段還算順利。

 

星期三 第二段 下午6:30 – 第二天早晨7:00

 

這一夜我值班。完成了藍隊工作之後，我小息一下，吃了晚餐。然後我去見當夜資深手術住院醫，他問我，“從值夜班中你想碰到什麽狀況？你想學到什麽？” 他用一句話說明了他有資格這麽問我，他要根據我的回答決定是讓我先去睡覺還是根據我的興趣提高他的要求。我回答“我想當兒醫，但是今晚我想有真正的挑戰。”

 

結果這一夜很忙。來了四個創傷病人，病人1從急診轉到手術室，病人2的出血失控。還有兩個很變態的病人在急診征求手術意見。兩個病人落入我的肉眼觀察。事實上，病人X由於酗酒和疾病性營養不良非常瘦弱，他基本上就是一具骷髏，還在掙紮著保持知覺。很明顯，他們根本沒有多餘的體力可以支撐手術，他們的疾病正在殺死他們。病人Y情形和X差不多，但是她到了這樣的境地是因為癌症。

 

星期四 早晨7:00 – 7:30

 

這個早晨我倍受挫折。我值完夜班自我感覺很好。一早同學A和B就走到我麵前說他們要跟我談談。同學B（四年級學生）說我做為一個三年級學生不應該比他表現好，他要增加他的病人，要求把我的一個病人轉到他名下。同學A說我們病人的數目應該分配均勻。他說現在這樣不公平，他的學習機會少了。如果我沒這麽累，當時我一定很生氣。對於同學B，如果他真想表現出一個住院醫的水平，他就不會要求一個比他還菜鳥的同學往後稍，好讓他顯得棒一點。另外，我對我的病人負責，我知道他們的情況，每天看他們，管理他們的病曆，他想讓我把這些給他，讓他得功勞。我沒那麽高尚，為了讓他高興而按他的要求辦。盡管如此，我還是很不情願地給了他一個昨夜從急診室轉來的病人。至於同學A，老師們反複教我們要積極抓住學習的機會，參與病人的治療。我一直積極並且隨時努力為自己創造機會。我確實相信，對於他，這裏也有很多機會。但是他卻在要求別人把機會讓給他。說實在的，盡管我們是同年級學生，要求也一樣，刻薄地說他跟我在一塊就不舒服。

 

很幸運，我離開之前得到了幾句比較好聽的話。我們的住院醫對我們一半期間的表現做了一對一的點評。她的話代表整個藍隊，她很肯定我的表現，讓我繼續努力。她說我不用太在意其他同學的感覺，因為我的首要目標是讓今後當住院醫的日子容易一些。就這樣，我開車回家，休息一天，為很長的星期五做好準備。

Journal 20150512

I am currently at the midpoint of my very last surgery rotation. I’m on the Blue Surgery team, which specializes in colorectal surgery. The team takes care a lot of patients with colon cancer, which is the second most common cancer in America. Translation, this is one of the busiest services in the hospital. This has been an extremely stressful and demanding rotation so far, but somehow, this has made me feel invigorated and excited. However, there were also some low moments.  This will have been my second out of 3 weeks on service. I will recap the week here, mainly focusing on the interpersonal dynamics instead of the medicine.

 

Monday 5:30am – 6:30pm

Shockingly, with hours like that, Monday was the easiest day of the week for me. There were no surgeries scheduled and the entire team would be working in clinic. We started the morning by showing up to pre-round. This means that we each would check up on the inpatients we were following in order to provide an update report for when the whole team rounded together. I showed up and got everything I needed for the 6 patients I was following (note, per previous students on the service, trying to carry 5 patients was already considered very difficult, but I was up for the challenge). There were 2 other students on the service with me. Student A was carrying 2 patients. Student B, was a 4th year starting his first day on Blue for his Advanced Clinical Elective (ACE – he was interested in surgery residency and this was his month to be really involved and impress the Blue surgical team, think of the ACE as a chance to audition as a resident). On Day 1 of this rotation, our Chief Resident had told us exactly what format and what information order he wanted us to present our patients with. I thought that made things extremely simple and I was able to cruise in putting together the presentations for all 6 patients I was following. At the end of rounds, the Chief Resident commented that “I was really on a roll and kicking ass” and he agreed with all my assessments and plans for the patients. This was contrasted with the Student A, who the Chief Resident interrupted multiple times in both his presentations, commenting on him reporting information in the wrong order, him making the mistake of misrepresenting yesterday’s lab values as new updated information, and presenting a plethora of unnecessary details.

 

After rounds, Student B, the new 4th year asked the first-year resident (intern) to review the patient list with him. I could see her suppressing the eye-roll. On her first day meeting us, she had requested us to never ask her anything we could look up ourselves. Here, supposedly an advanced student, requested her to review information that was all available in the electronic medical record after we had already reviewed it all once on rounds. Considering that Student B didn’t know the expectations of the Blue team, I volunteered to review everything with him instead and save our intern some time. If there’s one thing I learned on surgery, its that surgeons hate needless redundancy and inefficiency. Even though I was only following 6 patients on our list, I had been involved for a week and was already familiar with all of our patients and what we were doing for them. Afterwards, Student B asked me “how the hell do you know all of this?” 

 

This morning pretty much planted the seeds to how the team dynamic would work throughout the week.

 

Tuesday 5:30am – 9:30pm

This morning I had 6 patients again. One of mine from yesterday was able to go home. I saw my new patient and clinic and made the recommendation that she be admitted to the hospital. The attending surgeon agreed and she had gone from clinic downstairs straight to the inpatient floor yesterday. (Two interesting side notes here – 1. Among medical students on surgery services in general, it is expected that we follow the patients who we participated in their operation on or the ones we evaluate and admit to the hospital. 2. The “Eyeball Test” is extremely important in medicine. Part of our training is being able to take one look at a patient and decide if they need to be in the hospital, do they need surgery, are they in danger of dying if we don’t do something soon. First comes mastery of the Eyeball Test, then comes the mastery of the medical language to describe the Eyeball Test findings.) But back rounds, Student A had only 1 patient now. Student B said he wanted another day to get oriented. I want to emphasize, there are routinely between 12-20 patients on our service, there were plenty of chances for them to start following patients if they were concerned they weren’t carrying enough.

 

Tuesday was a big surgery day. The entire team would be in the operating rooms. As students, we receive the operating room schedule the night before. Another thing I learned, never trust the schedule. Surgery is a field in which patients’ statuses are constantly changing and there are new emergencies. We students decide who will follow which case, but as a rule, I prepare for every single case on the schedule because you never know what changes might happen to the schedule. Tuesday was a perfect example of this; there were 4 cases scheduled that we split evenly in terms of OR time. By the next morning, there were 2 more emergency cases added on to the schedule. I make it a point that whenever the residents or attending surgeons are talking, I am close by and paying attention to what they’re saying. This is a great way to learn and keep updated with all the most recent patient care plans. So today, our student plans were thrown a bit into chaos, I tried to update the other students on the plans, but if they weren’t immediately present in close vicinity, I wasn’t going out of my way to track them down to tell them what to do. My number one priority was helping out the residents, who often need a medical student simply to fill out and organize paperwork, help physically transport the patient, help prep the patient, help get the operating room set up; basically lots of busy work and labor that they don’t have the time and don’t want to do. I think it’s a great opportunity to help out and gain some learning experiences. But also as a consequence, if a surgery is about to start and the other student isn’t around (the times on the schedule are never close to accurate, another lesson learned. The only way to be on time is to be present and constantly vigilant), the operating room team would also prefer students to not leave the OR to track down another student, causing unnecessary delays. Hence, this is where being prepared for everything helps.

 

Because of all this, I ended up with the two biggest cases of the day. The first case ran from 7:30 to noon. The second case ran from 1:00pm to 9:00pm and had several big intra-operative complications. The attending surgeon left around 8:30 when the technical portions of the operation were finished and we were about to start closing the incisions. He openly admitted to being exhausted from such a excruciatingly difficult case. The chief resident finished closing the deep layers, told me the instructions to finish up, and bolted out at 8:40. His wife had actually gone into labor about 2 hours ago. So here was a great opportunity for me, I was able to close up the last bit of superficial skin. Even better, since I was the only member of the surgical team still there, I had the opportunity to take the lead and coordinate getting the patient from the operating room to the recovery unit to the inpatient floor. This forced me to debrief all the patient information, surgical complications, and instructions with the anesthesia and nursing teams. According to the rules, the resident or attendant surgeon was supposed to lead these debriefings. For the chief resident to violate these rules and give me this opportunity unsupervised, that spoke to me immensely of how much he trusted me.

 

Wednesday Part 1, 4:30am – 6:30pm

I had less than 7 hours away from the hospital overnight, and only about 4 hours sleep. This was

blatant work hour regulation violation. Student A was very strict about obeying work hour regulations and had come in late on a few occasions to stay in compliance. This was the route of action that the administration encouraged. However, the residents openly admitted they mocked the medical students who invoked these guidelines because they themselves personally were constantly violating these violations simply because of the work demand and they felt the medical students were only working a fraction as hard as the residents. I know Student A knows I’m violating hours regulations even though he was staying in compliance, but we both don’t acknowledge it.

 

Rounds were routine again. Wednesday was also a busy clinic day. But otherwise, the first part of Wednesday was fairly uneventful.

 

Wednesday Part 2, 6:30pm – 7:00am

This was my overnight call night. After I finished up Blue team primary duties and took a quick break to eat dinner. I met the senior overnight surgery resident and he asked me, “What do you want to go into and what did you want to get from this overnight experience?” He qualified this question with a statement about how he would either just send me off early to sleep or raise his expectations of me depending on my interest level. I responded with “I want to go into pediatrics, but I want to be really challenged tonight.”

 

The night turned out to be really busy. We had 4 trauma patients come in, 1 patient go emergently to the operating room, and 2 patients bleeding uncontrollably. We also had 2 very morbid cases come in for emergency surgery consult. Both of these patients failed my Eyeball Test. In fact, patient X was so emaciated from alcoholism and chronic malnourishment that he was essentially a skeleton draped in skin struggling to stay conscious. There was no way they had any physical reserve to survive surgery, and so their disease process was likely going to kill them. Patient Y had essentially the same Eyeball test, but she had arrived at that predicament because of cancer.

 

Thursday 7:00am – 7:30am

This was my infuriating morning. I was feeling really good from getting through my overnight call shift and getting to see and do so much. Student A and Student B came to me first thing in the morning and said they wanted to talk to me. Student B (the 4thyear) said that I as a 3rd year student should not be outperforming me, and that he was going to step up his patient load and he was just going to take one my patients. Student A said that he thought the patient numbers should be split up evenly because he claimed it was unfair he was getting less educational opportunities. If I hadn’t been so exhausted, I would have been much angrier at that moment. Regarding Student B, if he really wanted to show he could perform at the level of a resident, he should not be asking the junior medical student to step down so he could shine more. Plus, I had taken responsibility for my patients, learned all their information, seen them daily, handled their paperwork, and he was expecting me to just turn it over so he could get the credit for it. I’m not noble enough of a person to happily oblige to his request, though I did begrudgingly give him one of the new overnight admits that I had seen in the Emergency Department. And regarding Student A, we were repeatedly told to really be aggressive in taking our educational opportunities and participating in patient care. I was aggressive and prepared and tried to make the most of my opportunities. I fully believe there were plenty of opportunities for him too, but here he is, asking to be handed these opportunities. And truly, this is a thinly veiled way of saying he is uncomfortable with me outperforming him even though we are given similar expectations as junior medical students. 

 

Thankfully, I had some nicer words right before I left. Our intern was giving us quick personalized one-on-one feedback about our halfway performance. She was very positive and she spoke on behalf of the team that they wanted me to keep doing things the way I had been doing. She said I shouldn’t care as much about how I was making the other students feel because the most important priority was that I was making the residents’ lives easier. And on this good note, I drove home for my post-call day off, ready to start another long day on Friday.