A Higher Level
An essay in which I am completely blindsided, and wonder: what is it all for?
Welcome to Brief Op Notes. In this newsletter, you’ll find my explorations on the medical profession, reflections on my residency training, and my experiences in learning to become a surgeon.
There is a long tradition of physicians who are also writers: Arthur Conan Doyle, William Carlos Williams, Atul Gawande, Abraham Verghese - but women are conspicuously absent from this list. I want to continue in this tradition, while adding my own perspective.
My first few essays here will be from the archive of my writings. I originally published this essay on a previous platform on November 12, 2021, just a few months into my first year of residency, and I am now reprinting it with some minor edits.
I had a feeling, walking into the hospital that morning, that it was going to be a rough call shift. There are people who think that if you believe in something strongly enough, you will it into existence. I think I read that once in The Alchemist, dismissing it at the time as a cheap attempt at layman’s philosophy. Maybe that’s what happened. Or perhaps the opposite is true – the events in our lives are already written out, by actions we’ve taken previously, or by some higher power, and there are times that you get a glimpse into your future, if even just with a gut feeling.
But I wasn’t thinking about any of this at the time. It was 5:30am, I was already tired, and I still had at least 26 hours to go before I could be back home in bed.
I walked into the hospital to a mess. We had two direct admits that showed up overnight, with no orders, no admission note, and no documented medical history. One was a necrotizing fasciitis transferred from another hospital (which did have full surgical capabilities, in case you were wondering). The other patient, as far as I could tell, had no surgical problems whatsoever. Then the senior left shortly after rounds, which left me as the only person in the hospital taking care of all the patients on the vascular service.
All day, I fielded calls from people trying not to work and ignoring the patients under their care. I got yelled at by a hospitalist who was refusing to see a patient who very clearly needed medical, not surgical care. She told me I was mismanaging and endangering the patient. One nurse gave me attitude all day about orders that were or weren’t placed. An ultrasound tech decided I was the intern he was going to take his frustrations out on that day, and aggressively hindered all of my attempts to get a renal ultrasound for one of my patients.
By the afternoon I already felt like all of the ill will in the hospital had been channeled towards me. There were a hundred tasks to complete, not enough time to do it all, and no one seemed to care in the least about helping me finish them. Why get a job in healthcare, I thought, if you don’t want to help people?
But getting through that near-mental breakdown would turn out to be a trifle nothing, compared to the madness that was still to come.
But getting through that near-mental breakdown would turn out to be a trifle nothing, compared to the madness that was still to come.
First, the night proceeded in standard fashion – calls about patients with nausea and vomiting, calls from family members. One of my patients on the floor with a fem-pop bypass was slightly hypotensive, so I ordered labs to make sure she wasn’t bleeding. So far this was all easily dealt with. We even had time to eat Chinese takeout with the whole team.
Then, just after dinner, we got a text from our attending that we would be getting an incoming trauma from an outside hospital – a real trauma, not just a LOL in NAD1. I was cross-covering the trauma service that night along with vascular, so I would actually have to pay attention to the overhead pages.
It boomed loudly when it came: “Attention please, level 1 trauma, Emergency Department. Level 1 trauma, Emergency Department.”
Shoot. I had just mixed together a Shasta ginger ale with apple juice on ice, my favorite on-call mocktail, and was looking forward to sipping it while writing notes. Alas. The mocktail would have to wait.
I made my way to the ER, and saw the PGY2 (2nd year resident) and the attending disappear into the trauma bay, along with dozens of other staff. Then the door closed in my face. I hovered by the door, uncertain of what to do. Surely, I would be of no help inside, with nearly every other person in the room having much more training than me. But technically, I was covering trauma – so maybe I was required to stay? I slowly backed away from the door, but stayed in the ER, walking further down the hall, then back towards the trauma bay, getting in nearly everyone’s way.
At some point the PGY2 poked her head out and told me to stay in the ER to wait for the other trauma.
The other trauma? I realized that the patient the attending had texted us about hadn’t even arrived yet.
So I continued to pace nervously in the hall, trying to respond to pages, and peeking into the trauma bay whenever someone went in or out. I kept looking over my shoulder for the chief resident. Where was he? With the attending and PGY2 in the trauma, the PGY3 and chief in the OR somewhere, there would be no one to run the second trauma. It would be me. It couldn’t possibly be me.
I should’ve realized that there was no way an intern would be left alone in a trauma. But it was the only thing I could think about. And there was still no sign of the chief. I texted him frantically, trying to do anything I could to keep the impending situation under control.
Finally, minutes before the patient arrived, he showed up. After checking in on the other trauma, he herded me into the empty trauma bay, slapped a “Surgery Junior” sticker onto my shoulder, and looked me in the eye, saying firmly, “You’re going to do the secondary survey.”
I wanted to protest. I had never done a secondary survey before. And for that matter, I suddenly realized, I had never even been in a trauma before. He saw my apprehension and added, “Don’t worry, I’ll help you.”
The chief positioned himself at the foot of the bed, and placed me to his left. He called out instructions as people floated in and out of the trauma bay. Nurses and techs were working on other things: checking a BP, getting IVs placed, drawing blood. I recognized the neurosurgery and orthopedic residents popping in to check on their respective body parts. I continued to get in everyone’s way.
I kept glancing up at the numbers on the monitor, and back at the patient. The numbers could have been worse, but the patient himself looked terrible. That is something you learn when you spend hours upon hours in the hospital, watching over patients. You can start tell when they are close to death. With this patient’s GCS of 3, even being intubated, I wondered if he already was dead.
That is something you learn when you spend hours upon hours in the hospital, watching over patients. You can start tell when they are close to death.
Suddenly, it was my turn to do the secondary. I looked over at my chief as he gave me an encouraging nod.
“Left forehead lac,” I said, and added, “Superficial, 3cm in length,” unsure of how specific I was supposed to be. I kept going from head to toe, with the chief jumping in here and there to mention things I had missed. I could only hope that the recorder could hear what I was saying over all the other commotion.
Before we could even finish doing the secondary survey an ER resident brought the ultrasound machine in to do a FAST exam. It was positive for fluid in the abdomen. The attending appeared at the chief’s side, seemingly out of nowhere, and asked, “What do you want to do?”
“He needs to go to the OR,” the chief said.
“I agree,” she said, “Let’s go.”
The journey from the ER to the OR felt like a distance of a million miles, but we finally made it to a part of the hospital I had never been before, dark and desolate, tucked away behind the radiology offices. I helped set up the patient on the OR table, then when I was dismissed by the chief, I went back to the work room to get back to my night – hopefully labs would be back on my hypotensive patient.
My apple ginger ale was de-fizzed and watered down. No point drinking it now. I sighed, resigning myself to the crushed packet of Oreos I had stashed in my coat earlier that morning.
I had barely logged into the computer when a call came to the work room asking the entire surgical team to report to the OR. At this point, that consisted of me, my co-intern, and a PGY2. We all just looked at each other, stunned. What could possibly be happening in that OR that they needed all of us?
As soon as we got there, the PGY2 started scrubbing, while my co-intern and I just stood at the open door, waiting for direction from our chief.
“One of you scrub, the other one stay unscrubbed – someone who knows the hospital well so you can get us supplies.”
Somewhat randomly, it ended up being me who scrubbed in. I gowned and gloved and made my way to the patient’s bed, still waiting for instruction. It is not every day that an intern finds themselves in a trauma ex-lap. The entirety of the patients’ bowels got piled into my hands and we ran it, all the way from the ligament of Treitz to the cecum. Meanwhile, there was no curtain between us and anesthesia, so I could easily hear their discussion about the lack of access, and snippets here and there about the labs. It didn’t sound great.
We covered and packed the abdomen while the chief grabbed the largest clamp I have ever seen to cross clamp the aorta. They had already performed a thoracotomy at some point, so his heart was splayed open to the world, beating with conviction, even though there seemed to be not a drop of blood in it to pump. I could feel my own heart beating twice as fast from all the adrenaline, thumping up against my chest wall as if trying to encourage the patient’s heart that lay just inches away.
I could feel my own heart beating twice as fast from all the adrenaline, thumping up against my chest wall as if trying to encourage the patient’s heart that lay just inches away.
“Did you get it?” The attending asked.
“I think – ” the chief was still elbow deep in the patient’s chest, “No, there. I got it.”
“Do we have updated labs?” The attending asked. Anesthesia just stared back at her. The nurse didn’t know. I could tell it was taking all of the attending’s patience not to yell.
“Shruti, go check the labs.”
I unscrubbed, took my pagers back from my cointern (who had been juggling calls from five different pagers, essentially dealing with issues for every surgical patient in the hospital), and logged on to the OR computer. As soon as I reported the labs for them, I pulled up my floor patient’s chart, to try and fix her hypotension remotely. Her hemoglobin was 7. And now her blood pressure was 77/43. I hoped to God she was not dying on the floor while I was running around in the OR trying to assist the others. I decided to order a unit of blood, figuring it would take time to get it approved and sent up from the blood bank, by which time I would hopefully be out of the OR and able to run up to see her again.
By the time I got off the phone talking to the floor nurse about the blood transfusion, they had done a femoral cutdown because they couldn’t cannulate the vein for a central line, the patient had a chest tube, and we were activating another massive transfusion protocol while getting ready to transport the patient.
When we got the patient up to the surgical ICU, eight nurses, two PAs, and a resident flooded the room, and I immediately stepped out. Finally, a break. By now I most definitely needed to go see my floor patient.
I told the PGY2 everything I had done so far, wanting approval for my plan, but she said, “If you’re ordering blood overnight you need to tell the chief.”
So I accosted the chief, and repeated myself to him. He listened patiently, then said, “You need to call the fellow on-call. I can do it if you don’t want to, but she needs to know before you give blood.”
“No, that’s okay,” I said, “I’ll do it.” I was nervous to call the senior fellow, but I also knew the story better and could explain to her my rationale.
So I called the fellow, clearly waking her up. I told her about the patient, how she started out hypotensive, with strangely unequal blood pressures, how her hemoglobin had dropped but her exam was benign, how she had heart failure but since we didn’t know her ejection fraction, I wanted to order a unit of blood, but to run it slowly over so as not to overload her heart.
“Okay,” she muttered sleepily, “I agree. That’s fine. I’ll see that patient first when I come in today.”
I was stunned. Not only had I managed a complicated post-op situation myself, in the middle of multiple traumas overnight, but the fellow had agreed with my plan. She had nothing to add. I could only allow myself a moment of congratulation before I remembered that my trauma patient was actively dying. But for him, there was nothing I could do.
I could only allow myself a moment of congratulation before I remembered that my trauma patient was actively dying.
By the time everything quieted down, it was 4:30am. Just in time to print a list for the incoming day team, but not nearly enough time to recover from the night.
I slept all day. I woke up confused, because it was dark outside and my clock said 6. For a moment I thought I was late for work. Then I remembered that I was post-call, and it was 6pm. I still didn’t know how to process what had happened.
The next day I got a text from the PGY2, to me and the other intern: Guys. Radiology called last night for our ex-lap patient. He was internally decapitated. He was dead the whole time.
The ligaments attaching the skull to the spine had torn from the whiplash so that the only thing holding his head on his shoulders was skin and muscles. Slowly, it started to make sense – why his vitals were so difficult to fix, why there was no blood when we looked in his abdomen.
He had been dead the whole time. Nothing we could have done would have fixed him. It had all been for nothing.
It was a few days later that I heard the overhead call for a Code Starlight.
What’s a code starlight? I thought.
It’s something our hospital does to honor organ donors. The staff lines the halls, holding up lights and bidding farewell as the patient is wheeled off the floor. As one of the residents explained this to me, I suddenly realized it was for my patient from that night. I raced to the elevators and pressed the button repeatedly, hoping it would understand my haste. When I got up to the ICU, I saw that I had missed it. The patient was leaving the ICU, being pushed into the transport elevators. But behind him I saw a throng of people, his friends and family, dressed in bright, happy colors, holding each other, and weeping. They slowed as he reached the main hallway, their steps getting smaller, wanting to go with him but limited by the size of the elevator. The doors closed on him and the elevator dinged, taking him to another level.
I don’t know where organ donors go. Perhaps he was going to the OR, for harvesting? Or being airlifted to another hospital, where they would operate? Or maybe it was down to the morgue.
Wherever it is, it feels very far away from here.
Shem, Samuel. The House of God. New York: Berkley Books, 2010. Print.