A neurosurgical resident’s typical day

I’ve made some fairly outrageous claims about the workload of a neurosurgical resident recently. Seems like a reasonable time to lay out exactly what a day on call can be like for me and my fellow residents.

To be fair an average experience may be hard to articulate. Different rotations and different days yield different … adventures. Right now I’m on a service that could hardly be called grueling, but I cross cover the county hospital when on call. On the other hand I once had a 24 hour period where I took 28 consults. Which is something considering it is you and the chief resident and that is it.

But I thought I’d give a median weekend on call for me right now hour-by-hour. In reality I cover both a VA and a trauma heavy county hospital while on call over the weekend. But considering this is my last month at the VA and my census at the VA, with consults, runs between 2-7 patients I thought I’d condense it and just show a fairly reasonable work load solely at the county hospital.

I’m presenting this under the shadow of the 30 hour straight rule and the 80 hour work week. I know some older physicians will compare it to their training experience. I know some current or recent residents will point out that their program routinely flaunted the 80 hour rule. So be it.

7 a.m I meet with the post call junior resident and the chief at the county hospital. We table round, looking at images from last night and going over any new consults. The list has 60 patients on it. And that truly is a conservative number. Approximately half of them are our primary and half we are consults on.

8 a.m. The chief and post call resident run up to round on the unit and the approximate 5 primary patients up there and the 15 consults (let’s make the ICU players add up to 20 for simplicity, which is reasonable for our list).

I run down to see the 40 patients on multiple floors. I start at the top and work my way down.

9 a.m. My partner in crime is done rounding with the chief and is putting in basic orders and notes, without plans, on the patients in the ICU. I’m still seeing patients on the floor.

10 a.m. Our T9 fracture we added on for today gets an OR room. We were supposed to get to him on Friday, but couldn’t. Luckily I’ve seen everyone on the floor, unfortunately there are three people waiting to get out of the hospital as I run down to the OR. My fellow junior resident manages to discharge two of the people.

11 a.m. I’m in the OR. My fellow resident is getting some of my floor work done but none of my notes.

12 p.m. In the OR I get a consult for a hypertensive bleed with intraventricular extension. I scrub out and run down and see her. My fellow junior resident meets me and checks out. The ICU attending wasn’t going to be available to round until the afternoon and so that task falls to me.

I run back upstairs and let my chief know I think this head bleed needs an external ventricular drain (EVD). I scrub back in and we close quickly.

1 p.m. While we’re putting in the EVD the intensivist calls me to see if I’m available to round.

2 p.m. I run upstairs and round with the ICU attending for 2 hours. Luckily I’m able to put in orders as we go on a computer on wheels. To give an issue of how many times I’m getting interrupted by other providers in the hospital my beeper goes off 15 times in those 2 hours including another consult for a C2 lateral mass fracture down in the ER.

I manage to put in admission orders for the head bleed downstairs on the computer on wheels while I’m rounding with the attending.

3 p.m. Still rounding in the ICU.

4 p.m. I run downstairs to see the cervical fracture. While I’m down there they have another consult with a small volume traumatic subarachnoid bleed. I see him as well.

5 p.m. Then I run upstairs to see the post op on the floor and the EVD we placed, she has made it to the ICU. I sit down (it’s the first time I’ve sat down since 8 this morning) to add my last discharge and then write my consult notes and add the plans to the notes for the ICU patients. I follow up on a stat head CT the ICU attending had wanted while rounding, I call him with the results.

6 p.m. While starting my notes for the floor patients I get called about a patient in the ICU whose EVD has stopped working. I go downstairs and indeed it doesn’t flush or withdraw and the patient needs the ventric. I call my chief and prepare to replace the EVD.

7 p.m. EVD is in and go and see a guy I got called on with multiple parenchymal melanoma mets. I go upstairs and write that consult note, my procedure notes, dictate the op report from earlier in the day and then start on my notes for the floor patients.

8 p.m. I’m still writing my forty floor notes. I get called on a patient with some desaturations on a floor patient. I go and see him, check the CXR, see the atelectasis and with him doing okay go back to writing floor notes.

9 p.m. Still writing floor notes. Done I go downstairs and grab some chicken strips for dinner. I go upstairs and walk the ICU.

10 p.m. Another consult from the ER. A gentleman who fell from standing on Coumadin. There is 2 cm of shift from the subdural. His INR is supratheraputic. I call my chief, who calls my attending. They call me back and I call the OR. I order mannitol and more fresh frozen plasma. I go and talk to the family at length and consent for the procedure. I have to physically run and get the FFP myself.

11 p.m. I scrub into the decompressive crani.

12 a.m. Still in the crani and closing I get called about a teenager with some subarachnoid and an apparent giant basilar aneurysm on an outside CT-angiogram (CTA).

1 a.m. I write my consult note on this emergency craniotomy and dictate the operative report and put in admission orders. I run up the PICU where this new consult has already been admitted. I try to track down the outside CTA; this will be an adventure.

2 a.m. I finally get the CTA and indeed even I can identify the aneurysm. I call my vascular attending and email him some of the pictures from the CTA. I then go down and consent the family for a potential angio later that day.

3 a.m. As I’m writing my consult note I get a call about one of our ICU consults, actually on the trauma service, having a seizure. I go up there just to see if the trauma guys need anything. I then go back to writing my consult note on the pedi patient with the aneurysm.

4 a.m. I get called on a thoracic burst fracture down in the ED on some gentleman who jumped from a 2nd story window likely related to a positive drugs of abuse screen. I go downstairs and see him and as he’s intact I’ll just keep him in bed. I write my note.

5 a.m. I head back upstairs and start working on the list for the morning. Moving people around, taking the discharges off, adding the new patients and getting the labs for all the new patients and the 20 guys in the unit. I run and make copies for the chief and the junior resident coming on.

6 a.m. I pull up all the images from overnight on all the consults and on anyone who got uprights or repeat head CTs or MRIs.

7 a.m. The junior coming on and the chief show up. We table round going over all the images and everyone on the list. I’ll see the ICU patients today.

8 a.m. Me and the chief resident go up to the unit and round on the ICU patients including the consults up there. Let’s say we signed off on some of the consults yesterday and so even with the new admissions I still only have 20 ICU patients. There are the daily little things to do like drawing CSF.

9 a.m. I start writing my ICU notes.

10 a.m. The ICU attending wants to phone round today and so I take his call and run all the patients with him. It’s a little bit shorter over the phone. I’m able to sit at a computer and put in orders while we’re talking.

11 a.m. I finish up my notes in the ICU.

12 p.m. I check to see if my fellow resident needs any help and I get out with an hour to spare.

As with any service I’m taking numerous pages and answering questions and doing the basics for my patients, 20+ on the floor and 5+ in the ICU, during this whole time. I’m also constantly reviewing results such as sodiums for hypertonic therapy and repeat head CTs at 6 and 24 hour intervals for head bleeds.

I’ve written more than 60 notes, rounded on 80 patients, done 2 EVDs, scrubbed 2 operations, seen 5 consults in 29 hours. Often fun and always rewarding hopefully but like any training program difficult at times. Even with the work hours.

Colin Son is a neurosurgical intern who blogs at Residency Notes.

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  • pat

    I know you have a steep learning curve but it seems unlikely to me, given current guidelines, that you do most of this without teaching or direction, as you are an intern (a 5 month intern at that). Also, seeing 40 floor patients, even without notes, in 120 minutes is quite a stretch given little obstacles like hallways, elevators, beeper interruptions, etc. At best they got 120 seconds apiece, including your introduction (if there is one) and your answering questions from the not unconscious patients or from the unconscious patients’ families, which makes me wonder…….

    • Primary Care Internist

      I don’t think that seems so far fetched. As an IM intern doing my second month in ICU, about 4-5 months after starting (maybe october or november) I remember how crazy it seemed. Not nearly as bad as what’s described here, but a crazy combination of admissions, rounds, emergencies/codes, radiology review, morning report/resident conferences, presentations etc. And the first month in ICU (maybe august?) was the steepest learning curve – learning basic CXR reading, order entry, interpretation of lytes in ICU setting, etc. This mostly became second nature very quickly. After that it seemed like 90% scut, and 10% learning. But in retrospect it really was a valuable learning experience.

  • everyman

    that’s nuts dude! even if it was half true, as a former IM resident, i may have worked 80 hours once, i’ve dealt with a brutal schedule but definitely nothing like this, there is a shortage of surgical specialists, because there aren’t enough programs, it’s pretty obvious based on what you just wrote

  • v

    “it seems unlikely to me, given current guidelines, that you do most of this without teaching or direction, as you are an intern (a 5 month intern at that).”

    Hahaha Pat, that was a good one…Maybe some programs are better at this than the ones I have seen but teaching or direction, especially for the intern, is minimal when there is a heavy case load or patient load, which is almost always nowadays…Residency for most is just a grueling right of passage with 80 hours only serving to minimize the pain and scut work (where they even follow the work hours rules)…

  • http://www.aneurysmsupport.com/ Mike

    To me, this seems like indentured servitude.

    • jsmith

      Pretty much. But you get to help people.

  • jenga

    As a ortho resident we took call at 5 different hospitals in the same city. I remember one weekend, I got absolutely crushed. Monday morning my gas light went off in my car to my shock and I had filled up the previous Friday. I put 330 miles on my car in one weekend and never left town!

  • Muddy waters

    Hmmmm….I wonder how mistakes happen???

  • http://www.signatureagency.com Sid Reynolds

    There is a novel that has absolutely nothing to do with medicine and everything to do with workflow-constraint issues. It won’t take you long to read, it’s well written, and, maybe because it isn’t healthcare focused, it may really help you rethink productivity bottlenecks. It is: The Goal by Eliyahu Goldratt.

  • stargirl65

    This sounds like the surgery rotations I used to do in the early 1990s. Arrive 6 am one day and leave the next day at 8pm. Arrive next day at 6am. You got 10 hours off every other day day. Your were on every other day. Clearly exceeded the 80 hour rule but was the standard. This was as the medical student. It included OR time, procedures, and everything mentioned above. Since it was a VA, there was very little oversight, even of the students. I would often go 24 hours without eating. One time got woozy in OR due to lack of food. Asked to be excused. Surgeon refused and had scrub nurse just stick sugar candy in my mouth while I was still scrubbed in. I never even let go of the retractors I was holding.

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