Once again I am writing this post in an airport. I’m currently on my way to Santo Domingo, in the Dominican Republic for a 10 day mission trip. There is a hospital there dedicated primarily to pediatric orthopaedics, and my mentor from Loma Linda as well as a great peds orthopod from Ohio will be there to show me what missionary life overseas can be like. Of course I’ve gone on multiple missions before, but never from a true medical/orthopaedic standpoint. I’m really excited to meet the patients, I’m excited to see their lives changed after their limbs are fixed, and I hopeful that I might make good contacts so that I can return when I am done with my training.
So it would seem that I only decide to blog when I’m flying to a conference…perhaps that is true. Right now I am on the plane (courtesy of Southwests $8 WIFI) on my way to the POSNA meeting in Hollywood, CA. This will be the the first POSNA meeting I have been to and the last POSNA meeting I will be able to attend before I attempt to match into a Pediatric Orthopaedic fellowship position in April 2015. By this time next year I would have already known where I will be spending year of fellowship at. This is why I really wanted to attend this year in order to meet some of the giants in the field and hopefully get my name out there and just learn what new and exciting things are being researched in the peds ortho world. It doesn’t help that I get to do this in the sunny 80 degree California weather.
I have spoken in the past about my fears of doing academic medicine and trying to find that balance of advancing my career and maintaining the bond with my wife and kids that I love so much. Since then I have sought much counsel (Proverbs 12:15) and my views of academics have certainly changed. Just like anything in life, you can make academics what you want it to be. You can be the guy who is at the hospital at 4 am everyday who publishes 10 papers a year and becomes a full professor in 8 years. Or you can be the guy who publishes similarly relevant data but prioritizes his family and the time he/she spends with them and eventually will contribute enough to the field to be advanced academically. Being advanced also is probably the wrong goal to have. After talking with a couple of full professors we have here at Hopkins, they stressed that the goal should be to take care of your patient, first. After that comes research, and if you do good research (not necessarily a bunch of research), then you will be progressed. This is comforting to me as choosing to do Peds Ortho mostly directs me towards an academic career.
What has been more pressing on my mind is the apparent conflict between doing academic medicine and going overseas to do missionary work as part of the Deferred Mission Appointee program that my wife and I joined while in medical school at Loma Linda University. It takes time to build a successful orthopedic practice in the U.S. (probably about 4 years), and leaving during or right after those 4 years will basically destroy the practice you built, especially if you are gone for 1 year +. But I also have to ask myself, when God comes again take us back to heaven with Him, what will he put more emphasis on, my academic productivity or my productivity in things spiritual and altruistic. I have to believe it is the latter. But I want to do both equally well; I want to be an academic surgeon who teachers and writes, and I also want to help overseas. I don’t know how set I am in doing a full 3-5 overseas stay. I will have to get more guidance from God on how to proceed when the time comes.
Switching gears (as I don’t know when I will be blogging next), I tend to be incredibly neurotic when it comes to applying for the next academic position in life. So to go along with that, I’ve already chosen a handful of programs that I will likely apply to for my peds ortho fellowship. I may add more, but here is the tentative list:
Pediatric Orthopaedic Fellowship Program
Children’s Hospital Los Angeles
Director: David L Skaggs, MD
# of Positions: 2
ACGME Accredited: No
Rady Children’s Hospital San Diego/University of California San Diego Pediatric Orthopedic and Scoliosis Fellowship
Director: Dennis R Wenger, MD
# of Positions: 4
ACGME Accredited: No
TJU/ A.I. duPont Hospital for Children-Pediatric Fellowship Program
Director: Suken A Shah, MD
# of Positions: 3
ACGME Accredited: Yes
Children’s Healthcare Of Atlanta at Scottish Rite Hospital
Director: Michael T Busch, MD
# of Positions: 2
ACGME Accredited: Yes
Johns Hopkins Bloomberg Childrens’ Hospital Fellowship in Orthopaedic
Director: Paul D Sponseller, MD
# of Positions: 1
ACGME Accredited: No
Pediatric Orthopaedic Fellowship
Boston Children’s Hospital/Harvard Medical School
Director: Young-Jo Kim, MD
# of Positions: 3
ACGME Accredited: Yes
Pediatric Orthopaedic, University of Minnesota Program, University of Minnesota Medical School/Gillette Children’s Specialty Healthcare
Director: Kevin Walker, MD
# of Positions: 1
ACGME Accredited: Yes
Children’s Hospital of Philadelphia Orthopaedic Clinical Fellowship
Director: John P Dormans, MD
# of Positions: 4
ACGME Accredited: Yes
Dorothy & Bryant Edwards Fellowship in Pediatric Orthopaedics and Scoliosis
Director: Daniel J Sucato, MD, MS
# of Positions: 5
ACGME Accredited: Yes
Director: Unni Narayanan, MD
# of Positions: 2
ACGME Accredited: No
The application season opens up in September 2014 and interview time is usually from November to March. I will keep you posted on how the process is going.
I’m currently sitting in the airport in New Orleans after the 2014 AAOS Annual Meeting and I must admit that I’m entering a better stage of clarity in regards to what I want to do and be when I grow up. One of the main questions that need to be answered as a resident first is what sub-specialty are you interested in and next and equally important is whether you want to go into private or academics. I’m currently on my Foot and Ankle rotation at Union Memorial Hospital and its very cool. I can honestly say that I’m finally understanding the biomechanics of the foot and ankle and the various tendons that run through it. A significant amount of our residents have decided to pursue Foot & Ankle for fellowship due to the combination of the great teachers we have in residency, the nice lifestyle, and the great compensation. I could possibly see myself doing Foot & Ankle, but I don’t like the idea of being limited to one area of the body, and I also don’t like diabetic feet. So I have basically been between Spine and Peds, and I’m pretty comfortable now with the concept of doing Peds Ortho with a emphasis on Peds Spine. When I consider taking care of kids it just plain make me more happy, and thats what matters it the end. And if I do Peds I still get to do Foot and Ankle procedures, I still get to work on the hip, I still get to work on the pelvis, I still get to do trauma, I still get a little long term follow-up, etc. Its just seems perfect. I’m happy to know what I will hopefully be when I grow up and now efforts need to be focused on applying for fellowship and successfully matching. The madness never stops!
I am typing this on the plane to San Diego for the AO Basic Fracture course. This is a course hosted by the AO Foundation to teach residents the fundamentals of fracture fixation. Most orthopaedic residents go to this course during this PGY-2 year, but at Hopkins we have very little free time to do anything but work, piss, and sleep during our second year, so my whole class is going during our PGY-3 year. Its actually kind of cool this way because I have already done a significant amount of trauma, so most of what I go over in this course will hopefully be tips and tricks to tighten up my skills and knowledge. Or I could be totally wrong and end up learning all new stuff.
In terms of work, I am currently at the Bayview Hospital which is comprised of mostly Joints and Trauma. My joints attending runs two rooms and once he is confident that you know what you are doing, he lets you do much of the case. He likes doing the anterior approach for his total hips which has pretty cool anatomy. After about 5 weeks now on the Joints service I can confidently say that I do not want to be a Joints guy. Here are my pros and cons:
|Very regimented and predictable||Not enough variety. Every day I know that I either going to do a knee or a hip and I’m going to do it the same way I did it yesterday and the day before|
|Patients do extremely well often postop||Reimbursement not rising, meaning you have to do more cases to maintain salary|
|Growing patient base as babyboomers retire||When joints get infected that really sucks|
|Pretty good lifestyle as often times you can be done with 5-6 cases by 5pm (good for family)||You don’t get to operate on kids usually. Everyone is old|
What I can say that I have taken away from my time on joints is really solidifying my approaches to the hip. I’ve become quite comfortable with the anterior and posterior approach and I am starting to cozy up to the lateral approach. Knowing this approach and anatomy well will aid in a variety of cases that I might do in the future, even if I’m not putting in a total joint.
My next block is my first research block and I am so freaking pumped!!!! At Hopkins, Orthopaedics is the only surgical department that doesn’t require 1-2 years of research as part of residency. This is great in that I can go right into practice or fellowship after 5 years, but it is not great in that they still expect you to be productive academically. So in reality, much of our research is actually done when we get home on any normal night and then we really hit it hard during our research block. I really like the academic environment in that it keeps you on your toes as you are constantly challenged with tough cases or by questions from your residents or medical students. Like I have said before, I have had so many amazing mentors who have brought me to my current position, that I feel an obligation to follow the same path, particularly for minorities who may not have any attendings who look like them and understand their world view.
I have about 4 projects that I’m actively working on. My hope is that by the time I graduate I would have about 6-7 publications, with about 4 being first author. Some residents in my class are much more diligent with research and will likely graduate with 20 publications. Initially I was really perplexed by this and felt inadequate, but just recently actually I came to realize that for what I want to do I can’t look to others or else I will always come up short. I have 2 young kids and a wife who is also a resident. When I come home there is no silence; I am constantly pulled in multiple directions whether it be pillow talk with my wife (which I want to do), reading to my kids, playing with my kids, studying for cases the next day, reading articles for journal club, working on research projects, taking out the trash, etc. Which one of these activities do I do first when I get home? I really envy the single guys who can come home to relative silence and just read or knock out another paper. I suppose the grass is always greener and some single residents would prefer to come home to a full house, but there is no question that from a residency standpoint you have the capability to be extremely productive academically if you are single. Us married guys do our best to keep up, and folks with kids have to try even harder. My hope is that whatever I get done will be enough to give me a strong CV by the time I apply during my PGY-4 to fellowships.
The fact that I’m even mentioning fellowship is crazy to me, but by this time next year I would have already submitted my applications for whatever subspecialty I decide on. It was just yesterday that I was jazzed about having a long white coat for the first time, lol. When people ask what I want to specialize in I still say that I’m between spine and peds. I’m hoping that by the end of this year, when I have done a little Hand and a little Foot and Ankle and a little bread and butter Spine I will have a good Idea of what I want to be when I grow up.
Gifted hands with an unbelievably ungifted mouth. I don’t even think Palin could have made a statement so unintelligent. One day he is going to wake up and realize that the tea party and Fox news really don’t speak for most of moderate Americans. My respect is gone.
Note to self, Steinman pins shouldn’t impale your hand.
To make a long story short. While helping a junior resident put in a femoral traction pin, it ended up going through my 2nd web space through and through. Thank goodness he didn’t have Hep C or HIV, and thank God it didn’t get one of my digital nerves or fracture my proximal phalanx. Ortho can be rough some times, lol.
There are not many ways to describe what getting killed on call feels like, but if you are a resident at Hopkins long enough you will find out. On this past Sunday I truly learned the definition when I received 20…yes I mean 20 NEW CONSULTS. It got so bad that the pediatric ER physicians who kept consulting me started to offer me food and caffeine because they realized that it was just me and there were like 15 kids alone waiting to be seen. This actually is not a very common occurrence at Hopkins; usually a good call night is about 10 consults which still keeps you busy because you are also attending to the other patients who are actually on the floor. We used to have a physician’s assistant helping to handle the floor stuff, but now we don’t…and being alone just plain sucks. But the call is over, and the only said part of it all is that I didn’t even beat the record which was 23 consults. Once you hit the 20s, 3 more doesn’t feel as painful.
Every time I log onto my computer I feel guilty at not blogging. There is just so much that occurs each day, and so little time to discuss it. From what I can tell, I may be the only blogger out there who is in orthopaedics residency that blogs with some consistency, besides my old classmate from Loma Linda who has a blog which is much more entertaining than mine: http://orthopedicresidency.blogspot.com. So because of that I feel some responsibility to keep it going, but with two kids, a wife, the orthopaedic intraining examination (OITE), research projects, etc. going on, its hard to find the right balance. Okay so hopefully that serves as an adequate apology Dr. Richard Hinds, lol.
I am currently on my Pediatric Orthopaedic rotation, which is by far our busiest service primarily because of Dr. Sponseller who doesn’t receive his sustenance from food or sleep by operating. He is a machine and has been unbelievable successful in his career. Every time I operate with him I want to be more like him, but know that I likely never will, but being at least close will be better than most everyone else. The only reason why I have time to blog today is because he is on vacation this week; next week when he returns we will get very busy again so I will likely be a bit silent.
So far, I have really been enjoying my pediatric orthopaedic rotation. One day we could be pinning a supracondylar humerus fracture, the next case we could be performing a pelvic osteotomy for hip dysplasia, and the next day we could be doing a 15 level posterior spinal fusion down to the pelvis. Its the mix of trauma cases and spine that really draw me in; as well as the patients (kids) are pretty fun once you get past some of the neurotic kids. For instance, 2 weeks ago, I was on call and I got a consult for a hand laceration in a in a little girl after she dropped a glass bowel which shattered. The Pediatric ER wanted me to rule out a flexor tendon laceration, but in truth they are just afraid of stitching lacerations. So I saw the little girl, and to make her feel more calm I honed in on her Dr. McStuffins sticker and asked her whether she had seen the show. We talked about Dr. McStuffins for like 2 minutes and then she let me examine her hand. I looked at her hand with my loupes and found that she just had a laceration to her skin and subcutaneous tissue. Under conscious sedation I washed her hand out, stitched it up and placed her in a bulky mit with a volar slab splint. Well one week later when, they returned to my hand attending for a wound check, apparently they were so pleased with the interaction that they left me a card, which I will cherish forever. You can see it below:
I still have 4 more weeks on Peds to make my decision between this sub-specialty and spine so we will see what happens. On other news, my son turned 1 years old 2 weeks ago. He is walking, running, climbing on top of the table, etc. It is such a blessing from God to see him grow up like this. Every time I get discouraged with residency and feel inadequate as a doctor or a surgeon I think of them and realize what its all for. I praise God for my wife too. As smart as she is, and despite what her actions might mean for her “career” as a physician, she has made it her priority to make sure that our kids and our household are where God would have it to be. If I was married to someone more like myself, my kids would likely suffer because there would be no one smart enough to realize what their work ethic was doing to their family. Finding a spouse that fills in your weaknesses is an amazing thing.
Well I have to wake up tomorrow morning to round. I will hopefully blog a bit later.
I was notified by one of the nurses at Johns Hopkins Bayview that I was on their website. I don’t ever remember a picture being taken of me so I joked and said that she needs to stop getting all of us black people mixed up. Well low and behold, she emailed me to URL and I am on their website, doing what I always do, working on my iPad mini. I don’t even remember a camera man being on the floor. Hopefully I will be receiving a cut of the profits that this picture is sure to bring lol.
Now that I am a PGY 3, I have more time to actually breath. I hope to blog much more than last year and hopefully in my next post I will be able to talk a bit about the hell of my just finished PGY2 year.
Today marks my last in-house call as a PGY-2 at the downtown hospital!!! Only a PGY-2 would understand what it is like to be done with in house calls at your main hospital. I know many will think, “But wait, it’s still April, how can he be done with in-house call?” You would be correct in saying that I can’t truly be done with ALL in-house call yet, but I’m done with the really stressful part. Like most academic ortho programs you have your main hospital like Johns Hopkins, Emory University Hospital, UCLA Hospital, etc which is where you do most of your call as a PGY-2. But all of these academic programs also have their residents usually rotating at surrounding hospitals where you get to operate with a lot more autonomy, the attendings are happier, and it’s not a Level 1 trauma center so that call is more manageable. At my program that “other” hospital is called Johns Hopkins Bayview, and it’s about 15 minutes away from Johns Hopkins Downtown (the historic hospital where Halsted and Osler practiced). The atmosphere between the two hospitals is like night and day; when you walk into the downtown hospital everything and everyone is high stress, darting to and fro, not smiling much. At Bayview, the security guard always greets you with a smile and a good morning, the cafe food is actually edible, the OR runs more smoothly, the Boards in the morning after you are on call is not a reenactment of the Spanish Inquisition, etc. So yes, today I am done with my last Johns Hopkins Downtown call as a PGY-2, and next month I move on Johns Hopkins Bayview…I can’t wait!!!
As an aside, I was talking with one of my old LLU SOM classmates who I respect a lot who matched into Ortho at an amazing program. We were both talking about how crazy this year is and what a toll it is talking our our families and more importantly, our spiritual lives. Now generally my friend’s spiritual life makes mine look like a total farse but he was relaying how difficult it was for him because not only was he dealing with the general stress of residency, but he had a wife and kid and no family around to help. As I look back, that is one thing that I am truly grateful God for, and that is living at least 40 min away from our parents on both sides. When you are a resident and you have a spouse and kids, you will not see them, much. You will also run into multiple situations where you thought you would be home at 7pm, but another consult came in and now you are coming home at 9 pm. Having a regular nanny would be impossible because you are usually at the hospital by 5am and you get home when ever the hospital prison guard decides to release you. My wife and I are blessed to have family who agreed to live with us and watch our children. With my wife being an OBGYN resident we have even less time for our kids and everything else. But after a rough week it is so wonderful to go to my arents house on the Sabbath, chill on the couch, and eat food that I nor my wife cooked, while my cousins play with our kids.
For those that are looking at future residency positions in ortho, don’t discount how important location can be. Matching into any ortho program is a huge achievement, but at the end of the day when you are super stressed you want to have those who you love and care about close by.
P.S.- that is of course not me jumping in the photo above as I have not exercised in 2 years due to residency. Hopefully PGY-3 yr is better.
The last 3 days gives you an idea of what it’s like to try to balance Orthopaedics and fatherhood and your spouse.
On Wednesday I got up and into work by about 6:30am. Which is great because as an intern i was was getting in much earlier. I printed out our patient list to see if any new people were admitted to our service overnight. I also started going through our EMR to make sure folks didn’t have any new PT notes or event notes written. Then I went down to “The Boards”.
The Boards is the official name for the presentation of all the inpatient and ER consults that came in overnight. It is held in our conference room in front of our orthopaedic trauma, pediatric, and hand attendings. At many institutions this is done more privately in front of a computer with the on call attending and the on call resident but at Hopkins we believe in pizazz, lol. No really, while it is more stressful to present in front of all of your attendings and fellow residents, I believe this process better prepares you for what you will experience during your oral boards. So what is a boards presentation like? Well I was taught that a boards presentation should be done all in one breath, and provide enough information to satisfy most attendings questions but not provide so much information that you portray that you know it all making you a target for very difficult questions. For example( this is made up and does not reflect a real patient I saw):
This is a 35 yo female who twisted her ankle while walking in snow and sustained this closed, neurovascularly intact L Weber B ankle fracture. Stress views were negative. She was closed reduced and placed in short leg Bulky Jones splint.
And of course while you are saying all of this you are showing your pre and post-reduction films to the audience. If you are lucky and presented clearly and your reduction looks good you won’t get further questions and you can present your next consult.
As an aside the board presentation should include all the aspects of a regular Orthopaedic presentation:
1. Age and pertinent PMH
2. HPI including mechanism of injury
3. Physical exam
6. Assessment/ Plan
Okay so back to my original post, I went to the board and heard all the consults that came in overnight. Since I was on call that day I grabbed the call pager from the previous on call resident and went to clinic. We had about 40 patients in clinic and so we got to work quickly. Of course I’m still holding the call pager so I would have to leave intermittently when a pressing consult came through. By 5 PM we were done with clinic and so I went to the floor to get sign out from the trauma, peds, spine, and hand teams so that they could go home. By 6.30 pm myself and the overnight PA had the pagers and we set out to take care of patients that were post op.
The consults started rolling in around 8 pm the most concerning of which was a compartment syndrome of the hand with multiple phalanx fractures after a crush injury. This case had to be rushed to the OR immediately and so I was operating from 11pm to 3:30am with my hand attending. After I got out of the OR I saw a couple of other ER consults and them from 4:30am to 6 am I was writing consult notes based on what I had seen overnight. Then I rushed to get my board presentation with accompanying X-rays together for 6:45am. Boards went well and I then joined my normal trauma team for rounds from about 7:30 to 8 am. Afterwards I had to see more consults that had come in before the pager hand off time which was 7am. Afterwards we had grand rounds and teaching which went from 7am to 12 noon. You have no idea how hard it is to stay up for 4 hours of lecture while post call and not getting an ounce of sleep the whole night. So yeah my head was definitely bobbing through out lectures.
After lectures I went home and and my beautiful daughter and handsome son were playing in the living room. Honestly seeing them really makes everything worth it. I played with my kids for about 1 hr and ate some Jamaican bun and cheese that my grandma made for Easter. Then I went upstairs and collapsed in my bed, sleeping until 8pm. I woke up at 8 pm and talked with my wife about her day and helped her pack for our trip to Huntsville, AL for our college alumni weekend. She was leaving earlier with the kids because I had to work the next day until at least 5pm. So I helped her pack the suitcases and put the kids sleep. The next morning was our trauma team post-op conference which involves the PGY-2(me). In this conference the PGY2 gathers together the X-rays for every patient we operated on from last Friday to the next Thursday and presents them to the attendings in the standard format. We look at the preoperative films and the post operative films and discuss a variety of things including indications for surgery, nonop reduction techniques, approaches for getting down to the fracture in question, relevant anatomy, the various types of implants that were used, and what their post op plan is like weight bearing status, etc. As you can imagine this takes hours to get together and often times you end up reading about more than what the attendings pimp you about but it’s great to learn from.
After post op conference I went to the OR and we had a couple of cool cases like two weber B ankle fractures, a retrograde femoral IMN, one modification of a Taylor Spatial Frame, etc. They let me leave at 6 pm so I could get home earlier to pack for my trip to Huntsville. I jumped on the plane to Huntsville and arrived by midnight. The next day I went to church and enjoyed the alumni weekend festivities. On Sunday I went to the board meeting for a missionary group called NAPs (http://napsoc.org) and then I hopped on the plane back to Baltimore, again arriving back in Bmore at midnight.
I slept for 3 hours and got into work by 5 am because I was on call that day… Another 25+ hour shift.
I think I mentioned it before but my wife and I were part of a video series produced by the Loma Linda University School of Medicine on what it is like to go through 4 years of medical school there. This video is a snippet of the what the full video series entailed:
Wow it has really been a long time since I have had a second to post anything. When I was a college student I used to get really annoyed at reading the blogs of residents because they never seemed to update it enough. I just couldn’t understand why they would be so unreliable with their posts; of course now that I’ve become one of those residents I have a new found respect for folks that can keep up a steady blog, ready their material for their cases, take care of their family, do research, sleep, etc.
The last time I blogged, I was about to start my Pediatric Ortho rotation and I was pretty excited; well the rotation came and went and I really had a good time. Peds Ortho was the specialty I was automatically placed on when I was a Sub-I, so it was interesting returning again as a PGY-2 with new found responsibilities. Our Peds rotation is extremely well organized but also very busy. My day usually consisted of me getting to the hospital by 5 am and getting our patient list together. Some programs are lax with the list, but not Hopkins. The patient list is the holy grail of tediousness, and if there is a period missing then you have officially failed in your chief’s mind. After the list is done, then you go to lectures, where one of the attendings goes through a pertinent topic like slipped capital femoral epiphyses (SCFE) or idiopathic scoliosis or skeletal dysplasias. After about an hour of lecture, then you run to the OR, and the variety of cases is what always amazed me. In one day I might do 2 posterior spinal fusions on kids with adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis, etc. Or in that same day I could do a posterior spinal fusion, a surgical hip dislocation, a pediatric physeal sparing ACL reconstruction, and a polydactyly removal. And the best part is that the kids usually do really well; even if they are pretty sick they usually leave the hospital in their parents car, not via the morgue. I also really enjoyed clinic days also as you always saw such a variety of cases. Sometimes it would be just a kid with a fracture that was treated with a cast that you are checking up on, or a kid who is post-op from pelvic and femoral osteotomies to fix hip dysplasia, or a 15 yo girl who noticed that her back is slightly curved and wants to know if she needs surgery, or a kid with cerebral palsy and multiple extremity contractures who either needs a Botox injection or tendon lengthenings, etc. I really enjoyed also how much you are in the OR on this rotation. We have 4 attendings in peds ortho, and usually there are 3-4 OR rooms going with cases, so usually you are in the room with just you and the attending or you and the fellow, or sometimes just you with the attending talking you through the case. And the spines they do are sometimes ridiculous and are cases that most other peds ortho docs would turn away because of the complexity of the curve and their multiple comorbidities.
Now of course everything wasn’t pleasant during my peds rotation, as nothing in residency can be. This rotation particularly required you to read a lot, and finding time to do that while your wife is a resident and you have a 3 month old boy and a 1.5 year old girl at home just isn’t easy. Then of course you are taking in house call (6 am to about 12 noon the next day..aka 30 hours) so on those days you are either slammed down in the ER with consults, or you are being yelled at by your attendings because you are scrubbed in to a case and they don’t want you even thinking about the call pager which is ringing every 30 minutes while you are in the case. Then there is of course the self confidence issue; I realized this the most on this rotation how low my self confidence was when it came to being a resident. Through out most of my academic career, I have been positively affirmed that I was doing a good job; but that RARELY happens in residency. Usually, especially when you are a junior resident, you are only spoken to when you mess up, and it is usually in a tone to sear the message into your psyche so that you don’t do it again. Then of course that starts me down the road (inside my head) of me beating myself up for making a mistake or for not remembering something to the point where I am thinking of it days after the incident. You just cant do that to yourself in a surgical residency, or else you will drive yourself crazy. While I am still learning; I have started to realize that my self confidence can not depend on what I am told by others…I have to have my own internal barometer. While I don’t like the cocky surgeon attitude I need to have some semblence of that in order survive, especially at a place like Hopkins.
So to get back to my original topic, pediatric orthopaedics is now really high on my list of fellowships to pursue. I love doing spine surgery, especially on kids since they usually aren’t chronic pain seekers like many adult spine patients; I love the variety of cases; I like how much the cases and problems make me think and want to go back and read, and while it may sound corny, I really enjoy the kids, even when their parents get a little crazy.
Bayview (Joints and Trauma)
After spending 2.5 months on my peds ortho rotation I went over to the Johns Hopkins Bayview Hospital where we primarily get our joint replacement experience. Bayview is a great hospital to be at, because even though it is still Johns Hopkins, the atmosphere is 100% more laid back than the main Hopkins hospital, and you get to have a lot more autonomy. While at Bayview I learned how to do my first total knee arthroplasty and my first total hip arthroplasty which is kind of the bread and butter of orthopaedics. Joints is an interesting beast because while peds ortho is all about variety, you get really good at replacing joints being doing the exact same procedure, the exact same way, every single time, 2-3 times a day. One of our senior joints faculty handed me a 100 step paper on how to do a total knee and told me to know it in a week. It almost seems impossible, but after you do a couple you realize how you become a well oiled machine once you learn the steps and can bang out like 5 joints in a day when you get good. And the best part is that the patients usually love their knee or hip afterwards because they have been suffering from their arthritic pain for so long. I really started to get interested in ortho after my father had a unicompartmental knee replacement, and when I saw how much it changed his quality of life, I knew I wanted to be part of a specialty like that. Bayview is also where I cut my teeth on doing some of my first ER procedures for trauma patients like reducing a distal radius fracture or placing a tibial traction pin. Even though it is a pretty straight forward procedure for most ortho residents, its hard not to look like a bad ass when you walk into a patient’s room in the ER, take a drill with a humongous Steinman pin attached to it, and drill it directly through their bone while they are awake. Every time I do it, the ER docs and nurses either stare in amazement or cringe in pain while watching. For those who haven’t seen one, below is an example of one that I did for a segmental femur fracture:
Overall, while I enjoyed Bayview I did not fall in love with doing joints. Even though each case was unique in its own way, you are still pretty much doing the same procedure, the same way, in a different patient, 3-5 times a day. I really like more variety than that, which is why I don’t think it is very high on my list. Also, when joints get infected…that really sucks. And you are stuck with multiple revisions and washouts and the patient really is never the same.
Interestingly it was at Bayview that I was rebuked the most about a spiritual issue. When you get to your surgical residency you will understand that you are always running the around the hospital, whether it is seeing consults, running to the OR to do a case, running back to the floor to take care of a crashing patient, running to the cafe to grab something unhealthy to eat before running back to the OR, etc. Especially as a junior resident when you haven’t exactly become entirely efficient with your time, you are running around even more. I had one particular attending at Bayview who seemed to really like to tear into me for this or for that to the point where I was confident that I never wanted to emulate any aspect of what he/she was like as an attending. But one day, as I was rushing back from the ER just seeing a consult and was taking out the sponge to scrub for the case, that same attending was scrubbing also. We were both silent while we scrubbed and the only thing running through my mind was what the steps for the upcoming case were going to be, what neurovascular structures I needed to be concerned about, what questions the attending might pimp me with, etc. But my attending broke the silence and out of the blue (and most likely because he knew I was a Seventh-day Adventist Christian) asked me what I think about when I scrub. I told him the truth; that I was thinking about the case, trying to run through the steps in my head. I thought he would be pleased with this answer and cut me a break throughout the case. But he instead responded by saying that when he is scrubbing, he is praying to God to guide his hands. He is praying that the patient does well, that he as a surgeon makes the right decisions throughout the case to help the patient; that the he helps and does not hurt the patient, etc. Needless to say, I was thoroughly rebuked. First I was a extremely surprised that my attending prayed at all, seeing as how he usually ripped me a new hole every day for one reason or the other. But the fact that he was telling me; who was supposed to be an example of relying on God for everything about praying before a case was humbling. I realized that in all the haste to get ready for cases, I rarely if ever prayed to God. That this rebuke came through this attending made it even more clear that God was telling me that I was slipping and that I needed to come back to Him. It is so easy to get caught up in the “doing” of medicine and surgery that you forget WHY you are doing…you forget what the driving force behind your compassion is. But thank God that when He rebukes it is to build you up, and not tear your down. Since then I have made it a point to pray when I am scrubbing and I truly feel that I have noticed a difference in how I operate and the peace I feel as I do various portions of the procedure.
Currently I am on ortho trauma which besides being on the peds service is one of the busiest rotations. Ortho trauma entails everything that you would think; we take care of all of the crazy adult “bone” trauma that comes into the ER like shattered pelvises, femur fractures, tibia fractures, patellar tendon or quadriceps tendon ruptures, etc. This rotation really teaches you the bread and butter of orthopedics because when you are out in the community, you may not only be taking care of routine sports injuries, but you will likely be taking call somewhere and will need to know how to handle any trauma that comes in. The operations that we do on this service are very cool, but similar to adult spine, the patients often don’t leave you with the satisfaction that you would expect. In big cities like Baltimore, its not the unassuming, pleasant 30 yo teacher who gets into a car accident and breaks her femur. Instead it is the 40 yo chronic heroin user, with hepatitis C, who was walking across the street while drunk, got hit by a car and presents to the ER with multiple fractures. These people are not inherently bad by any means, but they tend to not understand the herculean effort that went into keeping them alive and fixing them, and instead treat you and the nurses poorly while you try to take care of them. On top of that because of their pre-injury social status, they often don’t have the transportion or the desire to make it to their follow-up appointments, and will instead be lost to followup for months, only returning when their wound is draining or when they have a non-union.
But again that is quite a generalization and you do have a nice subset of patients (of all socioeconomic levels) that you enjoy waking up to take care of. I don’t necessarily think my time on this rotation so far has convinced me if I want to pursue ortho trauma for fellowship, but who knows what the future will entail.
Okay so I figure after 4 months I should probably start blogging again. Life has been crazy. Stay tuned for more posts.
So right now I’m on my Sports rotation and when you subtract the craziness of balancing family life, Sports is pretty awesome. I basically work with two attendings, one is a big time shoulder guy and the other a big time knee guy. With the shoulder attending I’ve been learning how to arthroscopically evalute the shoulder in the OR, performing debridements, labral repairs, biceps tenodesis, assisting in reverse shoulder arthroplasties, and total shoulder arthroplasties, etc. With the knee attending I’ve been learning how to scope the knee, perform ACL reconstructions both with patellar allografts and hamstring autografts, perform meniscus debridements and repairs, etc.
Our attendings are also the team doctors for the Baltimore Oriole’s (who are actually doing well this year) so that’s cool. They are also the team docs for the Johns Hopkins University athletes, so every Monday we go to their training room and see the injured players and manage their care there.
I now really understand why so many residents go into Sports after residency. You can have a pretty good life, with mostly outpatients, make good money, and still see your family. The one downer I see is that not my folks in 3rd world countries need their ACL reconstructed. So the skillset I would get wouldn’t really help me with my oversea’s mission. But I know I won’t be overseas forever, so its stil something to consider.
In about 2 weeks I switch to my Pediatrics rotation which is what Hopkins is really know for. Peds is actualy at the top of my list of possible specialties to go into so I’m excited to start. Its also an incredibly busy service so don’t expect to hear from me again until Dec. when I switch again.
So, as you probably guessed from my last post, I’m now a proud father of two kids. My wife gave birth to a healthy boy for which I truly praise God for. When he was born I was truly reminded of the awesome gift that God has given us to create; its a gift that the angels and even Satan were not allowed to have. Almost every day I have to remind myself of the happiness of his birth, because the tightrope balancing act that comprises my everyday currently is almost maddening.
My wife was given 5 weeks after she gave birth to stay with my son. Afterwards she started back on her residency training which wasn’t too bad. We would wake up in the morning, me around 3 am, and her around 4 am. By that time my daughter would have already waken up, walked from her room to our bed, climbed into our bed, and promptly fallen right back to sleep. I would shower, log onto our computer, check labs on my patients, prep their progress notes, etc. If I had an extra 5 minutes I would read a devotional out of the Great Controversey or the NIV Bible. At the same time my wife would be getting ready, pumping milk for our son to drink for the day, packing her lunch, etc. We would have a quick morning prayer together and go on our seperate ways. When we would get home that night, I would normally take my daughter for a walk, then put her to bed,while my wife would take our son, feed him, and put him to bed. This system actually wasn’t too bad, especially with an understanding and loving family member/nanny at home to watch our children during the day.
When my wife started on night float (6pm to 6am shifts), the whole plan went to hell. My day would usually start with me waking up around 3 am with my daughter right beside me after her usual routine of waking up at 2 am and walking from her room to our room. I would bath, log onto the computer to check patient labs, etc, then go to work. At around 7 am, my wife (after being up all night delivering other women’s babies and taking care of them post-partum) would arrive home to #1 a daughter who had gotten a good night of sleep and was now ready to play, #2 to a son who was ready for some good ole milk from the breast instead of the bottle, #3 a nanny who had not gotten any sleep overnight because our son was crying from 8pm to 3 am straight. So my wife fights to get a couple hours of sleep with the baby on the breast and a daughter who is just at the beginning of her terrible 2′s. At the same time, our nanny who did not get any sleep really takes our daughter so that my wife can get a couple of hours of sleep for work which will begin again at 6pm that night. Now I’ve been lucky to be on a light rotation, Sports, so I’m actually home by 5 p.m. usually. If something occurs and I’m home at 5:45 pm, I don’t get to see my wife because she is off to work already. When I get home, I immediately take my daughter while our nanny takes our son. I give my daughter my iPad so that she can be occupied while I try to get a little reading in. But often times she gets bored and wants Daddy’s undivided attention. So I abort studying, play with her, read to her, take her on a walk. Then I try to put her to bed, often only suceeding in putting us both to bed and waking up frantically at 11pm because I haven’t ordered labs for the next day or read for cases. So I stay up until 2 am, wake up again at 4 am, leave for work, again not seeing my wife who gets home around 7 am.
As you can see from my short spiel, it is like walking a tightrope when you have two doctors, both with busy residencies and two young kids. There are many nights that I ask God why He would allow us to have kids if I wouldn’t even have the time to raise them adequately. Then I realize how stupid the question is, as there are thousands of parents who want children but aren’t able to conceive. But my wife and I sure picked the perfect storm when it came to professions and kids. The only way this is even manageable is that we have a family member who is willing to stay and help and we have our parents who can take the kids on the weekends.
When are we supposed to study? As an orthopaedic resident at a program where the residents run the service, the only time to study is at work. I’ve tried to whole studying at home thing and its just not possible when you have a daughter who is intent on being the center of your attention 24×7. So I stay at work for an hour later to read and do questions for the upcoming OITE. What does this mean of course? It means that my nanny and my wife are taking the heat while I study. It means that I can’t do this consistently or my wife won’t get much time to study. It means that we are just screwed for now while my wife is on night float. This is the reality of the two resident physician home. If either of us were doing a peds, internal medicine, PM&R, etc residency, life would be better. But we aren’t.
I am not at all dissuading other couples from going the same route; just know that you will have to be okay with either 1 of 2 things, #1 excelling at parenting while not excelling at work, #2 excelling at work while not excelling at parenting, i.e.-someone else is raising your kids. We are lucky in that our nanny loves our kids as we love our kids so we are confident our kids will be taught the right way, but its hard to let someone else do your God given job. Also when you are in a surgical residency, you really can’t be content with not excelling because if you suck at work consistently, then you get on the attending’s radar, if you stay on the attending’s radar for too long, then you could get fired. And then you really won’t be able to provide for your family.
And let’s not even mention the other things like #1 when do you cook dinner #2 when do you exercise #3 when do you go grocery shopping #4 when do you have time to be intimate with your spouse #5 when do you have time to deeply study your Bible…and the list goes on.
So in summary, life is pretty tough right now. But God would not give me anything that I couldn’t handle…its just hard to realize that while you are in the midst of it. I find solace in that my kids are too young to remember how much their parents are gone, but its still tough. Anyways, thats whats going on on the family front.
Its unbelievable that I haven’t posted in 4 months, but such life when you are balancing a surgical residency and a family. So much has happened since April:
1. May 2012: This was my last general surgery rotation and it was pediatric surgery. It was actually a breath of fresh air finally getting a chance to take care of kids instead of adults, but this is Hopkins so the kids tended to be medically more complicated than you would think, but it was cool regardless. I actually got to operate a good amount on this rotation but in general this rotation confirmed that I chose Ortho well because none of the procedures really got me excited. Case in point, my rotation culminated in that the very last general surgery operation I took part of was a manual disimpaction (of stool for the uninitiated) in the OR which took ~ 2 hours!!! Needless to say I was happy to move on to Ortho.
2. June 2012: This was the best month of residency because I was on Anesthesia, and those guys generally have better hours than us surgeons. I actually had a chance to hang out with my daughter and bond more with her while my wife started her orientation for OBGYN residency. Since I hadn’t had a vacation since the first 2 weeks of residency, it was nice to have this rotation before the hell of PGY-2 started.
Now I am 1 month into my second year of residency and they were not lying when they said it was the hardest and most painful year. Intern year was actually a cake walk in comparison because when I was an intern on my Ortho rotations, they knew I didn’t know much so their expectations were low and the residency work hours limited me to about 16 hours a day. When I was an intern on General Surgery they knew that I didn’t plan on being a general surgeon so their expectations were low and of course our hours were great because of the ACGME rules. Now that I’m a PGY-2 I have taken my first bevy of 30 hour calls and it literally saps the life from you. The adrenaline of seeing patient’s in the ER and reducing fracture after fracture keeps you going but then when you sit down to write a note your eyes start to get very heavy.
Don’t get me wrong, I am so happy that for now on I will only be seeing patient’s with orthopaedic issues, but the biggest problem I’ve had being a PGY-2 and taking call is that its almost impossible to get through the 30 hours without pissing off someone, whether that be your attending, chief, an attending in the ED, one of your co-residents who wanted things done a certain way overnight while they slept, etc. It also sucks because each consult takes you forever to complete because you have to look up everything in the Handbook of Fractures and then figure out how to put it into practice. Then there is the dance of trying to figure out whether you should call and wake up your chief to ask for help. You don’t want to be a maverick and possibly do the wrong thing for the patient, but you also don’t want to call your chief for every consult you see.
Honestly I’ve lost like 10 lbs this month just from stress and lack of time to eat. But I’m not complaining; this is what second year is about..its a steep learning curve and by the end of this year there won’t be many fractures that I will have trouble dealing with, and I will also be used to the general level of sleep deprivation that surgical residents live under.
I’ve still struggled to balance all of this with maintaining my spiritual and family life. I usually don’t have any time to sit down and have a long, in-depth devotion, but having apps like the Tecarta NIV Bible on my phone the E.G. White app has allowed me to get quick devotions in between surgical cases or during brief down times through out the day. As for the family part, I try to at least get home before my daughter goes to sleep. If I do then I put her to sleep to at least spend that time with her. And of course on my post call days I try to spend as much time with her and my wife as possible. But its difficult, and it will always be difficult; all one can really do in a 2 physician family like this is always strive to spend time with each other. Eventually it will happen.
When I’m not on call, I’m on my spine rotation and I actually really like it. Again, I’m at Hopkins, and so the spine cases are often crazy 12 hour cases. Meaning that the cases I’m scrubbing into, like a T1 to sacrum posterior spinal fusion with a vertebral column resection of T10 and multiple osteotomies, with 6 L of blood loss, etc just isn’t the type of stuff most spine surgeons would do in their practice. I really like seeing a patient come in with terrible degenerative scoliosis and after a marathon surgery leave the room with a virtually straight spine (in the coronal plane of course). If I became a spine surgeon I don’t think I would do cases that are as long and as complex as my attendings here, which is fine. My only reservation is again keeping my future mission plans in mind, I’m not sure that spine surgery would make much sense as it requires a high level of hospital care (anesthesia and ICU) which will likely not be available in rural environments. But I won’t be overseas forever and so whatever I do when I come back to the states, I need to be able to enjoy.
In other news my son will be born tomorrow (planned induction) so I’m super excited. Keep us in your prayers that the delivery is uneventful.
So I noticed that over the past couple of months I haven’t commented on what I’ve actually been doing as a resident. Starting in late December I began my general surgery rotations that are required as part of my orthopaedic surgery residency. It is kind of the luck of the draw in terms of which particular rotations you get but mine worked out to be 1.5 months of Vascular Surgery, 1 month of ICU, 1 month of Plastic Surgery, 1 month of Surgical Oncology and Endocrine Surgery, 1 month of Trauma Surgery, and 1 month of Pediatric Surgery. The last rotation of my intern year is actually anesthesia which is wonderful because its a low stress rotation and will allow me to rest up before the infamously terrible ortho PGY-2 year arrives.
I already commented on my time on Vascular Surgery and ICU. Plastic Surgery was truly a pleasant surprise. I must admit that I had no true concept of the scope of operations that plastic surgeons performed, but my month plastics opened my eyes. They were doing masseter nerve transfers for kids who lost function of their facial nerve after a tumor was resected to breast reconstructions, to repair of carpal and phalangeal fractures to closure of complicated spinal wounds, to in utero repair of spina bifida defects, etc. They did so much more than just the characteristic comestic surgery and they truly do work everywhere on the body. I loved the variety of sutures and the realitive healthiness of the patient’s which is what also drew me to ortho. During one of my last days on plastics one of the attendings liked my closure so much that she said I should consider switching to plastics, lol. I must admit, there really weren’t many other fields I liked besides ortho but after this month I could definitely have seen myself doing it. I don’t think I had the medical school grades to get into plastics, but I found out that you can actually do a plastics fellowship out of any surgical residency, including ortho, ENT, general surgery, etc. Doing another 3 years of plastics after my 5 years of ortho really isn’t palatable to me, but it was nice to fancy the thought for a bit.
Surgical Oncology/Endocrine Surgery
If you lined me up beside 1000 other ortho and non-general surgery surgical residents I would likely be ranked close to number one in terms of my disinterest in bowel surgery. So clearly I was dreading have to go through all day Whipple cases. However I was somewhat pleasantly surprised that most of the cases I scrubbed in on during surgical oncology were related to liver resections and I had no idea how cool liver surgery was. Our attendings here both preferred open approaches so I got to look directly at the biliary system, hepatic veins, and portal venous system. One time we were resecting a tumor that had incorporated itself into both the liver and the IVC that ran through it. When we got the last piece of tumor out a small hole appeared in the IVC and boy…DAT MOFO CAN BLEED, lol. I definitely have to give it up to general surgeons who on a day to day basis deal with life and death situations and barely break a sweat. Coming into medical school I thought I wanted to be that guy, but I’m too much of a softey to have my patients die on a somewhat consistent basis. Ortho is definitely for me, but again I was pleasantly surprised by the Hepatobiliary Surgeons here.
As for Endocrine Surgery, I must admit that the thyroid is by far the least exciting structure in the body. I guess what really made me not like the cases was that the field was too small. Every tool was itsy bitsy tiny, and you had to constantly worry about retracting too much. This is probably the reason why hand surgery so far hasn’t appealed to me. Who knows, that could all change.
This is the rotation that I am currently on and its amazing how variable my night could go (I’m currently doing 5pm to 5 am shifts). One night this past week, we had like 3 gun shot wounds come into the ER; they all came in as trauma arrests so the room is just full of people doing compressions, placing lines, putting in chest tubes etc. They all ended up passing away which was terrible…more dead black Baltimore 20 year olds. I can see how people who do this stuff for a career can get jaded. Moving on, last night, when I was on, there was not 1 trauma and the nurses decided not to page me for anything on the floor patients. So I stayed up and watched documenteries on Netflix and slept a couple of hours. You truly never know what the night will bring on trauma surgery. So far though I like it because again it teaches me how to take care of pretty sick surgical patients and it also gets me back to interacting with my ortho brethern since we consult them often.
Yesterday, Johns Hopkins dedicated its new, 1.1 billion dollar hospital:
We move into the hospital on the 29th of this month and guess who the administration has volunteered will wheel the patients from the old hospital to the new? Of course the interns; we have expertise in this sort of thing lol. Honestly though the process is supposed to be pretty straight forward in terms of when we are to transport a patient to the new hospital but I just forsee huge mishaps along the way. Its my hope that no patients get lost or misplaced :-).
The hospital has 6 trauma bays decked out with all sorts of technology. The ER is huge and should hopefully alleviate me having to see patients in the waiting room as I have often had to do. What this means for me also is that after spending all intern year learning how the Hopkins system works and where to find everything, I will have to relearn it again 2 months before the new interns arrive. But you can’t impede progress and quite honestly it will be cool working with stuff that is finally brand new.
There there ya go, that has been my general surgery experience so far. In other aspects of my life, my wife matched into an OBGYN residency in Baltimore City so I am still praising God for that. We also are moving out of downtown baltimore and into the suburbs of the city which are much nicer than anything you have seen on TV about Baltimore. Anyways, I will report back on any new events that occur in my residency.
Above is an ultrasound of my next child, a boy! The excitement I have felt about this new addition to my family is somewhat hampered by the knowledge that I am “unfortunately” having a black boy. When I first saw the story about Trayvon Martin, the very first thing that entered my mind was that that easily could have been me. I know it sounds cliche, but when I take off my white coat and my scrubs at the end of the day, and walk out of the hospital in my hoodie and jeans, I look like any other black Baltimore man. And for many people that means I am more likely to try to rob to or attack them than give them fix their fracture. I’ve seen their eyes as I walk through the parking garage without my hospital garb. They clutch their purses tighter or the walk faster to the crosswalk that takes them to the hospital in hopes that they can get there before I “might” do something to them. It doesn’t matter that I have a terminal doctorate degree, that the last time I got in a fight was in 4th grade, that I’m more concerned about getting home to my family than going after their purse.
This event reminded me that still in 2012, another black child dead is less important than if it happened to someone of a fairer complexion. It reminded me that the world I am bringing my son into isn’t much different than the one world that Emmett Till grew up in. There are still many details to be discovered and it may very well be that Trayvon, after being approached (a fact which is not in dispute) went on the offensive. But even if he did, the fact that he didn’t have to be approached in the first place makes the loss for his mother even more difficult.
I’ve only been able to come this far secondary to all those who sacrificed their lives before me. If we don’t make a stand now and make sure that people know that they can’t get off easy by killing our sons then we have truly disgraced those who have sacrificed all before us.
Like most residency programs, my program has a hall that has the pictures of resident classes dating back multiple decades. When I first arrived on campus I walked the hall in our department, looking to see when the first black resident was accepted. It took me awhile, because everyone looks the same in black and white, but I finally found him in the picture below (can you pick him out?):
For the longest time I wished I could meet him, but I figured he was probably retired or dead. Well last month I got the chance to meet him by chance at a department homecoming of sorts. I got his number and couldn’t wait to hear his story; I just knew that he faced an environment similar to the Little Rock 9 kids who desegregated our public schools. Imagine, in a field as undiverse as orthopaedic surgery, being the first black resident at a place like Hopkins? His true story was actually quite different and less dramatic.
He told me that he was treated with nothing but respect from the orthopaedics department at the time. The only time that he ever received rascist remarks were from some of the general surgery attendings (who happened to be from the south) when he did his 2 years of general surgery that was required at the time. He also mentioned that whenever a patient made it clear that they didn’t want to be treated by a black orthopaedic resident, that their chairman would show the patient the door. We talked about a lot more but it was so amazing to hear that his experience was so pleasant, but in hindsight not really surprising at all. One of the main things that attracted me to Hopkins was that second to Howard University’s ortho program and perhaps UVA, Hopkins had just as many minorities and woman. To me it spoke of a program that took the best regardless of what they looked like. In honor of black history month, I think its important to remember all those who came before us to make our opportunities even possible. If that first black resident really sucked, who knows when Hopkins would have taken their 2nd one. In the same way, where ever we end up, we have to strive to not just be on par, but be the best, to continue opening up doors for those behind us. And when we reach the top, we have to remember to BE AVAILABLE as mentors. Okay, I’m off my soapbox :-).
I’ve seen people die before. The very first post of my blog shows the first person that I saw die; he came in with a gunshot wound to his chest, a thoracotomy was performed, but he didn’t make it. Since that shadowing experience in college through medical school I have certainly seen patients pass away, but never was it MY patient. For the first time during residency this happened to me and it was the most sobering experience of my life.
Just 30 minutes before I was talking with the patient, reassuring him/her that they would be leaving the hospital the next day. We had already set up the rehab location and the patient was ready to finally leave the hospital. The patient didn’t show any signs that anything was wrong with him/her at that time; no chest pain, no shortness of breath, no change in mental status, no decrease in oxygen saturation, nothing. I walked out of his/her room and 20 minutes later I heard a nurse scream and call, “CODE BLUE, CODE BLUE!!!”. I was in the physicians work room and for a second I froze…although I was on the surgical floor, there were some patients who were being managed by internal medicine…perhaps it was one of their patients. But reality set in that 98% of the patient’s were mine on that floor or at least my cointerns’ and I at least needed to see who it was. Lo and behold people were running towards MY patient’s room.
I ran into the room and it took one look to realize that my patient wasn’t breathing…her eyes were wide open. I knew a code team was coming so I started doing chest compressions, praying…praying that he/she would come back. The code team arrived and followed the normal steps, 1) intubate 2) hook up defibrillator pads 3) analyze heart rhythm. He/she was in asytole; we gave him/her epi, atropine, we defibrillated him/her multiple times, we kept at it for 30 minutes, but he/she still didn’t have a pulse or a rhythm that we could defibrillate.
When the doctor running the code team called it I was still doing chest compressions. I know it sounds soft and ridiculous but I wanted to cry. This was MY patient, who was supposed to leave the hospital the next day. While he/she was in very poor health, most vascular patients are, and most of those people eventually leave the hospital. I talked it over with my chiefs and they all said it was just one of those times when an old person with multiple comorbidities just has a heart attack or a massive pulmonary embolism. There really aren’t many other explanations for sudden death like that. Of course the family of my patient did not want an autopsy, and how could I blame them. While the autopsy would have given me closure as a doctor, it delayed them being able to bury their family member by 3-4 weeks. If it was my mother/father I would have chosen the same thing.
When I left the hospital I had to drive around for an hour before I went home. There were too many emotions swirling around. The only solace I could take was that I hadn’t caused his/her death, but it did not take away the pain of losing someone you spent weeks taking care of. But unfortunately this is an experience that every resident will have. While it is hard to admit, I am not a superhero…I can not assure that I will be able to pluck all of my patient’s from the edge of death. It is hard not to view each death as a failure in your life’s calling, but if you do hold this view you will not last long in medicine. It is one of the costs you pay for attempting to save the lives of people who would otherwise pass away.
For the past 2 weeks I have been on my first General Surgery rotation called BayView Red. The service is primarily composed of vascular surgery, thoracic surgery, and trauma surgery. Needless to say these patients are much sicker than the orthopedic patients and I can truly say that I’m learning how to keep patient’s alive. Just in the past 2 weeks I’ve had patients how couldn’t breath anymore or who had acute mental status changes or who were having a heart attack. These situations would have scared the poo out of me when I was on ortho, but I’m becoming much more comfortable with managing them now.
Before medical school I was really gung-ho about becoming a general surgeon because that was all that I had been exposed to initially. In particular I had been exposed to the trauma side of general surgery and I was completely enthralled. Then when I did general surgery as a 3rd year medical student I was put on a completely GI service with colostomies, anal abscess, etc and I vowed that I would never do general surgery. Since then I’ve had a mild distaste for the field primarily because of the bowel…I hate bowel. However these 2 weeks on the BayView Red have truly made me appreciate how diverse the field of General Surgery is. In a given day you could be in the OR dissecting through the neck to stop the bleeding caused by a gunshot or you could be doing a thoracoscopy to resect a lobe of the lung or you could be taking out a gallbladder. None of which involve the bowel, lol. I’ve been getting a lot of OR time on this rotation too, slowly honing my suturing and bovie skills. As a medical student watching residents use the bovie and the scalpel numerous times I always thought it would be easy to do it myself. But when the attending is looking at you and you are making the first cut its a whole different ball game, but its also exhilarating.
I’m slowly becoming a surgeon. Its an insidious process, but slowly you start to make decisions more definitively, slowly you are unfazed by taking 1 foot of gauze out of someone’s wound and repacking it, slowly arriving at the hospital at 4 am is becoming normal, etc. One day last week I was feeling really sad because all I wanted to do was be home with my wife and little girl, however when I went into the OR and did a couple of cases I completely forgot about my homesickness. Its experiences like this that have reassured me that I belong in surgery. But experiences like this have also reminded me that if I’m not careful, becoming a surgeon can destroy my family, which is unacceptable. Finding the right balance will be my life’s achievement.
Attending: DoctaJay, please describe this lesion.
Me: Well its a intramedullary lesion, with clear rings and stiples denoting cartilage. There also appears to be an oblique fracture traversing the distal femur.
Attending: What is the diagnosis?
Me: I would call this a fracture with an incidental finding of a enchondroma.
This is what I did for the past month and I truly loved it. Our attending is a world reknowed bone pathologist who also did an orthopaedic surgery residency. He basically tells us to read a chapter from his book, let’s say on primary bone tumors. The next day, he gives us a couple of folders filled with x-rays and corresponding histology slides. He gives us an hour to come up with a diagnosis based on the xray findings and the histology. After that he comes in with another huge stack of xrays and pimps us on every single aspect of the various bone lesions.
This month was such a breath of fresh air as compared to the 3 months I spent on inpatient orthopedic surgery.When I was on ortho trauma I barely saw my family and barely got any sleep. This month on pathology I got to sleep in until 8 am, chill with my family all day, read about bone lesions (which I didn’t think I would find as interesting as I did), and just overall have a normal life. Rotations like this remind me of how lucky I am to be a resident here as not many ortho interns get introduced to ortho oncology so early. Anyways, next month I start general surgery, so the vacation will be over!
This past week I witnessed and participated in something I would say is akin to the secretive and mysterious process of choosing a pope…ranking ortho sub-interns.
For the uninitiated, sub-interns are 4th year medical students from Hopkins or from other medical schools who spend 2-4 weeks rotating at our hospital to find out if they would want to spend the next 5 years here as a resident and to give the residents and attendings here a chance to see if we would want them here. There are a lot of things that go into doing a good job as a sub-intern but I will go into that in some future post.
The ultimate job of ranking sub-Is is done by the chairman and program director. However many residency programs value the input of the residents because we have had the most contact with them and we will have to deal with their shortcomings if they match here. Here at Hopkins we have a powerpoint presentation with the pictures of all the students who rotated at our program. As each rotator’s picture is displayed the residents as a whole have the opportunity to voice how much they liked or disliked the applicant.
It was truly a surreal experience to be part of this process because just 1 year ago I was still a 4th year medical student, rotating at Hopkins, hoping that I had impressed them enough for them to rank me highly. Seeing the process now as a resident I saw how easy it was to rise quickly to the top of the rank list or drop to the bottom. It lead me to offer this advice to MS-4s who are are rotating around the country for different residencies:
- Try to get to know as many residents as possible at the program, because you want multiple residents vouching for you during the ranking process
- It was very rarely mentioned that such and such student was smart but really couldn’t suture well. Don’t fret if you mess up once in the OR. That will not hose you as much as pissing off a resident or attending in some other way
- Students rose to the top of the list when it was mentioned that they were 1) extremely hardworking not just in front of attendings but residents also and 2) were cool to hang with outside of the hospital
- Students who’s pictures popped up and no one could really remember them rotating were shot down to the bottom of the list. Meaning, if you spent 1 month at a program and no one can remember it, you did not do a good job
- Never ever ever lie. If you are caught in a lie while rotating you are finished.
Sitting through this process as a resident, I remember being a MS4 and fretting about messing up on a subcuticular stitch. After that day I was sure that I had completely destroyed my chance of matching at Hopkins. But there is a lot more to being a good rotator than perfect suturing skills. You will definitely learn those manual skills as a resident. What most programs seem to look for are hard workers who are fun to work with. I saw many a high board scorer drop low on our list secondary to not working hard enough or having personality that wasn’t interesting to be around. With that being said, if you have the combination of good scores and a strong rotation, then you are golden.
Part of me wished I could have been a fly on the wall last year when these same residents were discussing my rotation. Who liked me? Who advocated for me? I will never know, but I truly praise God for the favorable outcome.
Being an intern is like constantly being embattled. You are responsible for everything that happens to the floor patients, and every aspect of their care. If you miss something related to their care, no matter how small or big then “you suck”. Honestly, even on my best day, I miss something, and I tend to come down really hard on myself, which isn’t healthy because this is in addition to what I may get from my seniors. I arrive very early (usually get the first spot in the parking garage) and I leave late, and still things slip through the cracks. That is why medicine is composed of teams, so that whatever the intern misses, the PGY 2 or 3 will catch. And then whatever they don’t catch, the PGY 5 will catch, or the attending. It doesn’t however negate the fact that something was missed by the intern, and it doesn’t negate the pain inflicted upon the intern when it is brought to his/her attention.
With all that said, I really am thankful to God for being an intern here at Hopkins. The ortho service is actually really detail oriented here, and its training me to pay extremely close attention to every aspect of my patient’s care so that they have the best outcomes. Its a painful process however to be trained in this way, but it is better for me in the end…or at least I tell myself that every morning when I wake up at 3am, lol.
When I started this 2.5 month ortho rotation, I thought I would have time to read every night and spend time with my wife and child, etc. But that is just not the case. By the time I get home, I am so burned out and tired that I have no time to study, or time to study but not time to play with my daughter. Thankfully the new intern work our rules have giving me about 8 hours, uninterrupted, to spend with my family each friday, which I am very thankful for. However the thought that next year when I am a PGY-2 and don’t have work hour restrictions that things will be worse is sobering. I can see how many divorces occur to surgical residents; and I just will not allow that to happen. I am still trying to find that balance between excelling at work and at family life, and I refuse to give up on that ultimate goal of doing well in both.
I am the only intern out of the 5 to do ortho trauma for 2.5 months straight without other rotations in between and it truly has been grueling. With that said, the rest of my intern year will be much more chill in comparison. My next month will be spent doing ortho pathology and radiology. My seniors have told me that by the end of that rotation I will be able to look at almost any lesion in a plan X-ray or any histology slide and diagnose the mass/tumor. We learn a lot of ortho tumor here and I really enjoy it actually. There is just so much to learn that I never even heard of in medical school in this field, particularly in orthopaedic oncology.
After my 1 month of ortho oncology, I start my 6 months of general surgery. And while anyone who knows me knows that I hate anything dealing with bowel, I have actually heard that life is much better for ortho interns on general surgery because 1)intern work hours mean that I have every Friday night and Saturday off 2)we are not pulled in 1000 directions as a g.surg intern as we are as a ortho intern. I will actually probably have more time to spend with my family during those 6 months of gsurg than I have had in the last 2.5 months. I really plan to read a lot during my g.surg time because I truly love ortho and I don’t want to be the least knowledgable in my class all because I have a wife and kid.
I had another ethical dilemma because the orthopaedic in-training examination (OITE) is coming up next month and it is traditionally always held on Saturday. The Lord blessed me to match at Hopkins I believe because I honored Him by not interviewing on the Sabbath when I was applying for residency. However I started to waiver again when I learned about the OITE only being held on Saturday. I didn’t want to be the only resident to cause “trouble” by requesting to take it on another day. But I also wanted to honor God and His Sabbath day. I was encouraged by a fellow Loma Linda classmate of mine who matched into ortho at Mayo. His words encouraged me to just sit down and talk with my PD about my faith and desire to take the OITE on another day. My PD was so receptive and within a couple days I was cleared to take the OITE on a Friday instead. Praise God!
This is another testament to standing up for your beliefs not matter what arena you are in. For all of you who are not in environments where God is talked about, don’t let others suppress your beliefs. Trust me, you will be respected more for adhering to your beliefs than wavering at the first sign of resistance. Honor God and He will honor you.
Last week I took overnight call for the first time as Orthopaedic resident and its was…exciting. It was exciting not only because it was my first call, but because Hurricane Irene was also bearing down on the East Coast, ready to bear all sorts of carnage. On the drive in to work, I saw this in my neighborhood:
Of course since I was driving in at night (I took this on my post-call day) I almost hit that tree, not expecting it in the streets of Baltimore. But this was only the continuation of my “exciting” call since when I woke up on my call day I had no power due to the hurricane showing Baltimore Gas & Electric who’s boss.
I finally arrived at the hospital, and at that time I got sign out from all the services, Trauma, Spine, Peds, Hand, and Sports. They all gave me their pagers, and I was left to fend for myself. Okay, just kidding, they also left a PGY-4 from Union Memorial to help me through my first call too, but it didn’t change the terror I felt of having 5 pagers on my waist. At around 5:30 pm all the pagers began to go off. Its a known fact that you get the bulk of your pages about floor patients around the time that nurses are getting ready to switch off. By 10 pm many of the patients started to go to sleep, so the pages that started coming in then were ER consults, because everyone with a fracture decides to wait until Friday night around 11 pm to come in to the ER.
The night was pretty eventful and the one thing I noticed immediately that was different from being a medical student on call was that the option of sleeping just wasn’t there. Often as a medical student when things started to slow down at around 2 a.m. the resident would tell me to get some rest. I wrongly assumed that the resident himself/herself were also heading to their call room for some shut eye. But this just is not possible; when you are not getting paged about floor patients to come change Mr. X’s IV pain med to PO, or that Mrs. X started to get tachycardic and is complaining of 10/10 pain; and when you are not getting paged by the Adult or Peds ED to see such and such patient who they have been sitting on for like 3 hours before they call you, then you are typing up all the consults that are required to be done before 6 am the next day when the attending comes in to round on the new consults. In addition to that, you also have to present all the consults you saw at “The Board”. The Board is where the resident on call pulls up all the X-rays of the consults they saw in the ER or on the floor and describes the fracture/problem, and shows how they fixed it/splinted it, etc, and what the overall plan is. You are doing this in front of all the residents and a couple of key attendings. Most times this can be a stressful but benign event, however if your splint looks sub-par on X-ray, or you missed something important on X-ray, or you are asked a pertinent question about the fracture classification and don’t know it then the event can get particularly stressful. As a new intern, really just 2 weeks into being in the hospital, on my first call, I had to make sure that I had my presentations for The Board down pact.
So really all this equates to the fact that you just can not sleep at all when you are on call for ortho at Hopkins. There is too much to prepare for even when the ED isn’t harassing you. However this was the aspect of the program that I really liked as a student. I liked the fact that even though its an academic institution, you work very hard. Its better to put in the hard work now than suffer and stumble through things later as an attending.
I’m writing this currently after finishing my second call as an ortho resident and it was even more busy. Although I must say that I did learn a bunch; I learned how to put on a spica cast, I learned how to evaluate a deep laceration of the forearm for tendon and muscle damage; I put on a sugar tong splint and ulnar gutter splint without supervision, which is truly the only way to know that you do or don’t know how to put one on correctly; I learned how to deal with patients calling the on-call pager for pain scripts or cast care, etc. There truly is so much new information to learn in the field of orthopedics and I’m excited to even get the chance to do this. I’ve still be struggling with having devotion during this ortho rotation, but I know that at some point I have to make it a priority over other stuff I do in my limited downtime.
So my honeymoon is over. This past week marked the beginning of my 2.5 months of orthopaedic trauma and it is a doozy. I had to think so much on my first day that I had a headache by 10 a.m. This past Friday was especially crazy since I had the floor pager, the ED consult pager, and my personal pager on my hip…all of them going off every 20 min. As I would be walking to a certain floor to check the wound of such and such patient, I would get a page on another pager about a patient in the ED with knee pain, then as I start walking towards to the ER I would get another page about patient so and so having lots of pain.
It was really challenging this week to decide which page would get my attention first. I suppose I will get more efficient at everything, but its pretty amazing how I never really understood how much you work as a resident until I started. After a full stressful day of floor work or ER consults, I can see how you can fall into the trap of using profanity all the time or drinking your sorrows away.
Either way I am just praying that God gives me strengths using these next couple of months.
So July 1, 2011 just passed and thus began my life as a resident. A lot of things happened before my start date including taking ACLS and ATLS certification classes, getting my LONG WHITE COAT (oh yeah baby baybay!), sitting through 1.5 weeks of orientation by the general surgery department, meeting the other surgical interns, learning about my schedule, having my ortho orientation, lots of free dinners and outings, and finally getting my pager and my ID badge. It has truly been a whirlwind, but I must say that the thing I’m most excited about is what I saw on Hopkins’ website on June 30th (see below):
Something about seeing it on their website made it a lot more official for me than even having the long white coat, lol. Anyways, during that orientation time they gave us a 1hr long lecture on social media and what we can and can not post on the internet. The general idea is to basically NEVER EVER NEVER EVER NEVER EVER mention ANYTHING about a patient. Even if I have completely deidentified a patient in my description, its still somehow a HIPPA violation. They gave me enough examples about residents being let go over social media issues that I certainly was scared into submission. So I will continue to blog but I really can’t talk about patient care at all. I do however plan to describe as much as possible about what it is like to be an orthopaedic surgery resident.
So how did my first day of work go? It was actually extremely cool. I got into the hospital around 4:45am along with my fellow ortho intern in order to work on the list. Normally it takes a seasoned intern about 30 minutes to get the patient list ready for the day. However since this was our first day, we wanted at least 1 hour to figure everything out and make sure our computer log ins worked. We got the list done and then met with our chief resident who divided the patients up among us. He thankfully didn’t assign the interns any patients and instead told us to follow a PGY-2 to see how its done. The first patient I saw we walked into their room and the PGY-2 introduced himself has Dr. So and So. For the past 4 years I’ve been introducing my self as the medical student or Student Doctor Brooks. This time however I said Dr. Brooks and I felt as if I had told the patient a lie. I know I graduated last month, but I still felt like I had to earn the title of Doctor, lol. Over the course of the day it got a little easier to say Dr. Brooks but the feeling of speaking incorrectly didn’t go away. After we saw our patients I watched the PGY-2 write a note for each of them. Hopkins is now completely electronic so instead of the quick hand written progress note that I wrote when I was a Sub-I here, we actually had to sit down and type everything out…times are a changin.
After the notes were written, we met with the chief again to give an update on our patients. Then we went to Boards, which is a session in which the on-call-resident presents all of the patients they saw overnight in the ED including their X-rays and the attendings have the opportunity to pimp the resident. When I start my ortho rotation in a couple of months I will be sitting in from of all those attendings doing the same thing….yeah scary, lol.
After Boards, the PGY-2s, 3s, 4s, and chiefs went to the OR and I immediately learned what interns primarily do…we take care of the floor. I vaguely understood this as a medical student but not really because as a student you go to the OR in order to spend as much time with the attendings who would be writing your evaluations. But now as an intern I write orders, write discharge summaries, order meds for discharge, check labs, and see consults down in the ED. If I’ve taken care of all of this THEN I get to go to the OR. Its going to be hard to get used to this new role but I’m sure it will be second nature very soon.
I really want have many interesting things to blog about this month because I am technically on PM&R which isn’t an ortho or general surgery rotation. In August when I start ortho I will have a lot more to say. Let me end with telling you what my schedule will look like for my intern year:
PM&R (1 month) –> Vacation (2 weeks) –> Orthopaedic Trauma/Oncology (2.5 months) –> Radiology/Pathology (1 month) –> Vascular Surgery (1 month) –> Surgical ICU (1 month) –> Plastic Surgery (1 month) –> Surgical Oncology (1 month) –> Trauma Surgery (1 month) –> Pediatric Surgery (1 month) –> Anesthesia (1 month)
On Sunday I left my short white coat behind and became a man, lol also known as a Doctor of Medicine. I walked across the stage, received my diploma and just like that became a doctor. After the ceremony many family members and friends asked me, “How does it feel to finally be a doctor?” And to be honest the only answer that really fit was, “It feels weird.”
I was sitting down talking with my wife who also got her M.D. this past Sunday about how she felt and she agreed with my answer. All our lives we have worked towards one goal, and that goal was to become a doctor. As we tried to get to that final goal of becoming a doctor we had multiple mini goals that had to be reached: 1. Go to a good college 2. take the required science classes and be at the top of the class 3. Do college research during the summer instead of chilling at the beach like your classmates 4. Get involved with some community service project in order show that your have a heart with that brain of yours 5. Study for the MCAT 6. Do well on the MCAT 7. Get into medical school 8. Do well on step 1 9. Do well on step 2 10.spend $5000+ applying for a residency spot 11. Match into a residency spot hopefully in the field that you prefer and hopefully in the city that you prefer.
I have always had a goal to look forward to, and now that I have reached the final one my mind screams, “What’s the next goal?” “Are you sure there is nothing more to stress about?!” Now of course there is still residency, and I am sure that Hopkins will give me enough goals to reach but it just isn’t the same as medical school. Residency will have much less tests (probably 1-2 per year) and will require more self learning.
Either way I am confident that I will not feel like a doctor until I get my long white coat and see my first patient on July 1st. But I praise God that He brought my wife and I through this process with so many positive experiences and so many testimonies. I earnestly look forward to the next phase in our lives and am excited to see what work God has for me at my new residency.
I recently watched a movie called Something the Lord Made. It starred Mos Def playing the role of Vivien Thomas, a black carpenter who helped the famous Dr. Blalock of Johns Hopkins develop the surgery to correct Tetrology of Fallot. Vivien Thomas went just about his whole life without any official acknowledgement of his role in the process until finally, when racial tensions eased in the hospital he was given an honorary doctor and a painted protrait which hangs beside Dr. Blalock’s picture to this day. If Vivien Thomas could accomplish so much without a college education then how much more should I expect myself to accomplish? Overall, I was inspired by the story and would encourage any aspiring minority and non-minority doctors to see it if you haven’t already.
Viven Thomas helped to change the world through medicine, and while the movie didn’t delve too much into it, some of that change came at the cost of his family. And not just his…in the movie Dr. Blalock’s wife mentioned that their daughter wished she could be a patient so that she could see her daddy. I never want to her that from my wife or daughter, yet Dr. Blalock and Viven Thomas changed the world! There always seems to be the delicate balance. But the question I will be pondering for the day is: “Has there been anyone in history who has changed the world without sacrificing their family in the process?”
So I was reading a paper written by Dr. Augustus White III, M.D., entitled: Compassionate patient care and personal survival in orthopaedics. A 35-year perspective. Dr. White is not only a prominent name among minority orthopods but in the entire field itself. With that said, I was reading his paper and he had a wonderful quote in it from a lecture that Sir William Osler gave at Yale in 1913 that I wanted to share because I plan to live by it for the rest of my career:
“I have held four professorships in medicine. I have written a successful textbook. You would think a man with these achievements might be some kind of genius or have some special gift, but this is not true. These things were accomplished without any unusual talent. I am going to tell you how I acheieved these things, and you may not believe me, but I am going to tell you anyway because there may be at least one person here who will believe me. I am not brilliant…What I have done is to simply follow this dictum: Do today’s work today.”
It is so true that we can accomplish so much more if we just do today’s work today, without the constant evil of procrastination. So this will be my mantra from here on out. If it worked for Dr. Osler it can certainly work for me.
I was talking with my mom and she was mentioning that the thing they love about me is that I don’t know how talented I am. In all honesty I don’t see myself as especially talented but I know all mothers probably think their kid is special. However I think her comment brought up an issue of humility, and how important it is to success in this world. So from her comment I came up with this quote:
“Always be consciously oblivious to how great you are, and you will continue to be great.”- DoctaJay
The Bible is riddled with examples of how much farther God will take you in life when you are humble. One parable that I just read is from Luke 14:7-11:
7 When he noticed how the guests picked the places of honor at the table, he told them this parable: 8 “When someone invites you to a wedding feast, do not take the place of honor, for a person more distinguished than you may have been invited. 9 If so, the host who invited both of you will come and say to you, ‘Give this person your seat.’ Then, humiliated, you will have to take the least important place. 10 But when you are invited, take the lowest place, so that when your host comes, he will say to you, ‘Friend, move up to a better place.’ Then you will be honored in the presence of all the other guests. 11 For all those who exalt themselves will be humbled, and those who humble themselves will be exalted.”
Humility is not something that comes easy to any person, particularly someone going into surgery, but I pray that I can hold fast to God’s word and remember that true greatness and success comes not from man’s praise but God’s.