医学生日记2016年5月12日

医学生日记2016年5月12日

阿山 （庞静翻译）

我正处于手术见习的最后阶段。我在蓝队，这个队的专长是直肠结肠手术。他们治疗很多直肠癌的病患。直肠癌是美国位居第二的癌症。所以，我们是医院最忙的部门。对于我来说，这是见习以来压力最大要求最高的阶段，同时，我感到更兴奋，激发了更多的能量。但是也有情绪低落的时候。这是我在蓝队三周中的第二周。我要回顾一下这一周，主要集中于我自己的情绪波动，而不是医疗方面的。

星期一 早晨5:30 – 傍晚6:30

很奇怪，这么长时间，却是我这星期最容易的一天。这天没安排手术，大家都在门诊忙。我们早晨从预查房开始，就是检查住院病人。等整个蓝队一起查房时，我们要汇报病人的情况。我一早来了，把我的六个病人的事情准备好了（记录，据前一个在这见习的同学说，其中有五个病人很难办。但是我不怕。）还有另外两个同学也在蓝队。同学A只有两个病人。同学B，他是第四年的学生，这是他ACE的第一天（ACE， Advanced Clinic Elective， 他想做手术住院医，所以他这个月参加蓝队，体验一下）。我们在蓝队见习的第一天，住院医头儿就明确告诉我们应该用什么样的内容和方式汇报病人的情况。我觉得这很直接了当，我可以从容地汇报我的六个病人的情况。查房结束时，住院医头儿说：“这儿用不着我了。” 他同意我对病人的全部论断和处理方法。比起同学A，当他汇报他的俩个病人时，住院医头儿多次打断他，说他汇报的内容顺序不对，说他把昨天和今天的化验结果搞混了，说他的汇报太啰嗦，掺了很多没必要的细节。

查房之后，同学B，那个四年级同学请一个第一年的住院医跟他一起看一下病人名单。我可以看出来她惊讶地转眼球。她第一天跟我们见面时就告诉我们不要问她问题，什么都可以自己去找。现在呢，这样一个高年级的学生，我们查房时都讨论过并记录到电脑里的信息，他居然要求她一起再复习一遍。考虑到同学B不太清楚蓝队的要求，我自愿和他一起复习所有查房的内容，也可以替那个第一年住院医省点时间。如果从手术见习中我学到了什么，我知道了手术医生们最恨没必要的重复和没效率。尽管从名单上我跟了六个病人，但是一星期以来我已经熟悉了我们蓝队的所有病人，也了解对他们的治疗。之后，同学B问我“凭什么你都知道这些？”

这一天早晨的情形决定了这一星期蓝队以怎样的动态进行一周的工作。

星期二 早晨5:30 – 晚9:30

今天早晨我还是有六个病人。昨天的一个病人可以回家了。我在门诊接了个新病人，我建议的收她住院。当时在场的手术医生同意了，昨天直接把她从楼下门诊部转到了住院区。（这里记两件有趣的事情 — 1. 一般来说，在手术见习的学生跟着的病人都是我们见习手术的病人或已经住院的病人。2. “肉眼观察”在医学上非常重要。部分是因为我们的训练使我们能看一眼病人就能决定他们是不是应该上医院，是不是需要手术，如果不马上治疗会不会有生命危险。首先得熟练掌握肉眼观察，其次得能用医学术语把肉眼观察的发现说清楚。）再回来说查房，同学A只有一个病人。同学B说他还需要一天才能搞清状况。我想强调的是这边一般都有12到20个病人，如果他们真是很在意，他们有足够的机会跟着新病人。

星期二是一个大手术的天。整个蓝队都在手术室。做为学生，我们头天晚上就拿到了手术室的时间安排。我学乖的另一件事就是不要相信事先的安排。手术这个领域，病人的情况一直在变，总有新的紧急状况。我们学生自己决定跟哪个手术，但是我有一个规则，由于不知道会有什么变化，我把计划内安排的每一个手术都做了准备。星期二就是一个很好的例子：计划中有四个手术，根据每个手术所用时间，当时我们几个同学把这几个手术平均分了。第二天早晨，有两个紧急情况加进来了。我决定只要住院医或在场手术医生谈论病人的病情，我就得在附近，听得到他们说什么。这是一个很棒的学习方法，还能知道大多数病人的最新治疗方案。所以今天，我们几个学生先前的计划就没用了，我试着给我同学讲明计划变更，但是他们没有及时地出现在该在的地方，我也犯不着离开我的岗位，出去找他们，告诉他们做什么。我首要任务是帮助住院医，他们经常需要一个学生做一些文案事情，帮助转送病人，帮助病人做手术准备，帮助手术室做手术前的准备；总之有很多事他们没时间也不想做。我觉得这是一个很好的机会，既可以帮了人家，又可以得到一些学习的经验。还有一个后果，如果手术医生马上要开始手术，那个学生又不在旁边（计划上的时间从来不准，这是我学到的又一课。要想准时的唯一方法就是你自己随时警觉。），手术团队不希望在场的见习生离开手术室去找他的同学，造成不必要的延迟。所以，事先有准备就很有帮助了。

因此，今天的两个大手术我都在场。第一个从早7:30到中午。第二个从下午1:00到晚上9:00，还出现了几个手术中的大的复杂情况。当手术中大部分手术工作完成之后，主刀医生8:30离开时，我们开始缝合切口。主刀医生说这么磨人的手术太累了。住院医头儿缝完最深的一层切口后，给了我结束手术的具体指示，8:40也走了。他老婆两小时前进了产房。所以，现在就是我的好机会了，我可以缝上最表层的切口。更棒的是，我是现场唯一的手术团队成员，我有机会指导护理人员把病人从手术室转到住院处的恢复室。这就逼着我把病人的情况和手术中的复杂变化，以及术后护理对麻醉医生和护士们说清楚。根据规定，这是主刀医生或住院医的活。住院医头儿违反了这个规定，没有给我讲解帮助就把这个机会给了我，可见他多信任我。

星期三 第一段 早晨4:30 – 下午6:30

我头天离开医院还不到七个小时，大约只睡了四个小时。这已经是公开违反工作时数的规定了。学生A很严格地遵守工作时数的规定，为了符合规定，有时候来的比较晚。管理部门鼓励大家这么做。但是，住院医们直言他们嘲笑这样守规矩的学生，因为他们自己一直在违反规定，很简单地就是因为工作需要，他们认为医学院的学生工作难度只相当于他们工作难度的一部分。我知道同学A知道我在违反规定，但他一直遵守规定，但我们俩彼此之间不谈这个。

查房没什么特殊的。星期三是忙碌的门诊天。不管怎么说，星期三的头一段还算顺利。

星期三 第二段 下午6:30 – 第二天早晨7:00

这一夜我值班。完成了蓝队工作之后，我小息一下，吃了晚餐。然后我去见当夜资深手术住院医，他问我，“从值夜班中你想碰到什么状况？你想学到什么？” 他用一句话说明了他有资格这么问我，他要根据我的回答决定是让我先去睡觉还是根据我的兴趣提高他的要求。我回答“我想当儿医，但是今晚我想有真正的挑战。”

结果这一夜很忙。来了四个创伤病人，病人1从急诊转到手术室，病人2的出血失控。还有两个很变态的病人在急诊征求手术意见。两个病人落入我的肉眼观察。事实上，病人X由于酗酒和疾病性营养不良非常瘦弱，他基本上就是一具骷髅，还在挣扎着保持知觉。很明显，他们根本没有多余的体力可以支撑手术，他们的疾病正在杀死他们。病人Y情形和X差不多，但是她到了这样的境地是因为癌症。

星期四 早晨7:00 – 7:30

这个早晨我倍受挫折。我值完夜班自我感觉很好。一早同学A和B就走到我面前说他们要跟我谈谈。同学B（四年级学生）说我做为一个三年级学生不应该比他表现好，他要增加他的病人，要求把我的一个病人转到他名下。同学A说我们病人的数目应该分配均匀。他说现在这样不公平，他的学习机会少了。如果我没这么累，当时我一定很生气。对于同学B，如果他真想表现出一个住院医的水平，他就不会要求一个比他还菜鸟的同学往后稍，好让他显得棒一点。另外，我对我的病人负责，我知道他们的情况，每天看他们，管理他们的病历，他想让我把这些给他，让他得功劳。我没那么高尚，为了让他高兴而按他的要求办。尽管如此，我还是很不情愿地给了他一个昨夜从急诊室转来的病人。至于同学A，老师们反复教我们要积极抓住学习的机会，参与病人的治疗。我一直积极并且随时努力为自己创造机会。我确实相信，对于他，这里也有很多机会。但是他却在要求别人把机会让给他。说实在的，尽管我们是同年级学生，要求也一样，刻薄地说他跟我在一块就不舒服。

很幸运，我离开之前得到了几句比较好听的话。我们的住院医对我们一半期间的表现做了一对一的点评。她的话代表整个蓝队，她很肯定我的表现，让我继续努力。她说我不用太在意其他同学的感觉，因为我的首要目标是让今后当住院医的日子容易一些。就这样，我开车回家，休息一天，为很长的星期五做好准备。

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.