Caleb Campbell, M.D.
Ben Taub Hospital:
The day begins before dawn at 4:48 a.m. My alarm goes off, and I begrudgingly roll out of bed. It is important as a chief resident to set an example, and arriving at the hospital before the other members of your team is never a bad idea. Upon arrival, I peruse the admissions and various disasters from the night before, so that I can mentally begin planning the alterations to the daily OR schedule that are sure to follow. Administrative duties are numerous as a chief resident at the county hospital: the order of cases, position of patient, implants needed, outpatient surgical scheduling, outpatient phone calls/questions and all manner of necessary tasks all fall under the purview of the chief resident. I mentally begin formulating a plan of attack to accomplish these tasks as the other team members filter in. At 6:00 a.m. sharp, morning report begins. Every consult from the previous 24 hours is reviewed to ensure it was triaged or treated appropriately. Preliminary surgical plans are formulated in conjunction with staff present. Junior residents are frequently the target of focused questions regarding management as a part of their ongoing education.
Once morning report has concluded, every patient that has been admitted is seen by me with the junior resident who admitted the patient. Once every injury has been examined and the diagnoses confirmed, paperwork awaits. I fill out the necessary forms to post the next day’s cases and verify the surgical plans with the attendings of record. Next, every implant representative must be contacted to ensure that the mandatory equipment will be available on the morrow. It is now time for a second cup of coffee, and the McDonald’s in the Ben Taub basement happily obliges.
The remainder of the day is spent primarily between two activities: teaching in the OR by performing various cases with the operative third and fourth year residents and oversight of the clinic. Due to the fact that only two community hospitals serve the underprivileged in a community of over 3 million people in Houston, all manners of complex and complicated cases meander into clinic in various stages of repair. Many have already undergone definitive or temporizing surgical treatment at outside hospitals and then told to follow up at Ben Taub. As you may imagine, this requires a tremendous amount of mental gymnastics to determine the best course of action for these patients. Along with our various attending physicians, I, as chief resident, will come to a coordinated plan for operative and non-operative management of these problems in a timely fashion. I am also constantly talking to family members of inpatients and the patients themselves. This is usually due to various surgical delays required by the frequent stream of urgent cases that flows inexorably into the ER at all hours of day and night. In order to alleviate the aforementioned scheduling difficulties, I am also constantly lobbying the surgical front desk for more OR time and more ORs. It is nothing short of a pride-swallowing siege.
As the day winds down, clinic will generally finish between 5 and 6 p.m., [with] over 100 patients usually having been seen. The ORs (if there were ever more than one) dwindle to a single operative suite. As chief resident, I am constantly changing the schedule as needed to accommodate any urgent cases that arrive during daylight hours. This, of course, requires dialogue with various attendings and implant representatives, as well as the circulating nurses, to ensure that every case proceeds as smoothly as possible. Before the day concludes, I contact the upper level resident on call, and a frank dialogue regarding the evening cases and their surgical plans is undertaken. Additionally, I locate the day-time call resident and a review of the day’s consults and admissions is completed. This process is generally ongoing during most of the day at various intervals determined by the influx of new admissions. At last, the sun has set, and I walk to the parking garage, keys in hand. If I am the chief on call during the night, I can generally expect one to two phone calls regarding possible transfers from outside hospitals. I make sure to have my pager at the bedside in anticipation of these 2 a.m. surprises.
Michael E. DeBakey Veterans Affairs Medical Center:
The day begins in a more leisurely fashion. My alarm goes off at 6:15 a.m., and I rise with the sun. Upon arrival to the hospital, the first orders of business is to determine if there were any admissions from the night before, and ensure that all of the patients currently admitted are in good health, or as good as can be expected. This is accomplished by locating the junior resident on service and going over the list of patients to review any complications from the inpatients overnight and any new admissions. If an admission needs surgical treatment in an urgent fashion, the OR schedule is altered by talking to the anesthesia service and the front desk of the OR. If a new patient needs surgery in a non-urgent fashion, the schedule is altered in accordance with the best timing for the patient.
I now make sure that all of the patients for surgery are marked and all of their questions are answered. Surgery then ensues, which is usually a combination of total knee arthroplasty and total hip arthroplasty. Between three and eight arthroplasty cases are accomplished per day, except on Tuesdays, which is an all-day clinic. Variations to this theme include two to four arthroscopic rotator cuff repairs per week, the occasional ACL reconstruction, and, of course, the fixation of all manner of hip fractures.
Once the OR is complete, I proceed to clinic. The junior resident on service and several physician assistants have generally seen most or all of the patients in clinic. Any complicated post-op or new patients are then reviewed with the staff and the junior resident. As would be expected, the attendings and I formulate the appropriate plans of treatment, and the various tasks for the execution of these plans are delegated to the appropriate members of the team.
As chief resident at the MEDVAMC, management of the OR schedule is my responsibility. The schedule is reviewed several times per week, and the cases are posted in an en bloc fashion, usually a week in advance. As with Ben Taub, the implant representatives are contacted in a timely fashion so that the necessary equipment is available and the cases are appropriately templated.
The day usually concludes around 5 p.m. Generally, there is no evening or night-time cases with which to be concerned. However, the junior resident is located and all issues, both inpatient and new consults, are reviewed in their entirety.