Yes, it has been very long. This is because my life outside of residency lately has been consumed with raising a small weapon of mass destruction named Otis.

This is Otis when I got him:

This is Otis now:

As you can see, he is a) much bigger and b) a Systematic Toy Destroyer. A well-meaning resident gifted me a plush toy for him; Otis ripped it in half in about thirty seconds.

One of Otis’ favorite pastimes is to wait until I fall asleep for a well-deserved nap on the couch, at which point he decides I might be dead. He checks my vitals by sniffing directly in my ear, then he licks my eyelids until I wake up.

My naps do not last very long. To be fair, it’s probably worth the tradeoff to have a four-legged antidepressant walking around all of the time.

Anyway. I’m still a senior resident and I guess I should write something about being a wise and jaded experienced old man.

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One of the upgraded responsibilities of being a senior resident is that we are supposed to “lead” the trauma and medical resuscitations. This means standing at the foot of the bed and, nominally,  telling other people what to do.

On the surface, this pleases me. One of the defining, genetically-driven features of my lineage is an overriding and pathologic need to be in charge. My dad, a lawyer, left a top-tier firm when I was a kid to start his own practice because he couldn’t abide taking orders from anyone else. He approaches litigation like it’s World War II and he’s planning the Normandy landing. My brother bode his time in a big commercial real estate company for exactly one year before also going out on his own. None of my cousins tolerate bosses well.

It runs in the family.

When I interviewed for med school, a frequent question was “why not become a nurse practitioner or a physician assistant?”

I would answer frankly: “I have to be in charge.”

It’s a curse.

Anyway, running a resuscitation (on the surface) scratches an itch that’s been there since starting med school. One of the downsides of all the training is you don’t get to stretch your wings until now, right about eight years since I decided to apply to medical school. It’s a nice feeling.

I say “on the surface” because in reality, the ER nurses and techs have been there for years before I even set foot in an emergency department and will be there after I leave. They know exactly what they are doing and they don’t need direction from the uppity little third year resident. I am well aware of this. I am also aware that I am (still) not in charge: the attending physicians standing next to me are, although they take varying approaches in how much guidance they provide. Some attendings will stay quiet unless something is drastically wrong. Others will murmur tips in your ear. Some will hijack the entire affair while simultaneously stealing procedures from the junior residents.

Despite knowing that I am not actually running anything, and that my title of “trauma leader” or “resuscitation leader” is as relevant as wearing an “I Voted” sticker, it is still deeply gratifying to boom, “LET’S GO AHEAD AND GIVE AN AMP OF D50” or “WE ARE GOING TO ACTIVATE THE MASSIVE TRANFUSION PROTOCOL.”

(I especially like the phrase “Massive Transfusion Protocol.” It sounds so dramatic. It’s a protocol! It’s massive! We get to use the LEVEL ONE TRANSFUSER!

Really, it just means the people who staff the blood bank get their steps in for the day ferrying coolers of O-negative blood back and forth to the ER.  And we use a machine that pumps blood in fast. It just has a cool name.)

Here is a short list of my favorite sayings that I get to say now.

We’re gonna go ahead and…
– Give an amp of D50
– Run a unit of blood
– Intubate this patient for airway protection
– Shock the patient
– Put in a central line
– Activate a “code stroke”
– Activate a “code STEMI”
– push a milligram of epinephrine
– Start chest compressions

Interestingly, despite my abiding love of Doing Things, announcing one of the above results in other people having to Do Things. A Code Stroke brings a neurologist running and ruins the MRI tech’s day. A Code STEMI makes a bunch of cardiologists excited and gets the cath lab up and running. The junior resident intubates the patient or puts in a central line.

I’m still there at the foot of the bed, pretending to be in charge.

The other joy of senioring, besides pretending to run traumas, is moonlighting. Oh, my god, moonlighting. As a third year we are allowed to start working – and getting paid – at area urgent care centers. Although credentialing for these takes a full Paleozoic Era, once you start working you can earn essentially market rates.

The money is amazing. I’m used to getting paid for indentured servitude, which the ACGME (the residency governance body) and the hospital have set at somewhere in the range of $3.75/hr.

(That is a slight exaggeration.)

The cost of living adjustment we receive makes it possible to eat, and our recent unionization made things a fair bit better. But in the middle of the night seeing your twelfth psych patient of the shift,* you’re still confronted with the frequent realization that you’re getting paid less than everyone else in the hospital.

Anyway. I am here to tell you that I am extremely okay with taking care of whatever nonsense walks in when I am getting paid approximately fifty times my residency rate per hour. In one moonlighting shift I will make more than half my monthly salary.

(That is not an exaggeration).

I got my first paycheck two weeks ago and almost called the center’s payroll office to alert them of what had to be an accident. Once the truth settled, I am proud to report that I spent only a fraction of my paycheck immediately, and mostly bought new chew toys for Otis.

As of this writing, they are already destroyed.

The final thing I’ll say is that despite being just as busy as a second year, third year is just easier. I spend less time agonizing over medical decision-making because I know a little more. I know how to work the failure of a system at NARH and the angry consulting services at the specialty hospital. I’m comfortable with a bigger list of patients actively needing things done and don’t get overwhelmed easily.  I find it funny, not frustrating, when a subspecialist tries to tell me how to do my job.

It’s still hard, and emergency medicine will always be a humbling job. But the deathly stress and pressure of second year that had me resorting to antidepressants and a spontaneous puppy adoption is relieved.

Things are looking up!

*Don’t “@ me” about the psych thing. (And don’t read this paragraph if you want to end on a high note.) Yes, patients with psychiatric complaints need help and often have a terrible situation. But as a society we’ve given up on these people and dumped their problems on the ER, where they sit for days awaiting transfer to a mental health facility that barely scratches the surface of their needs. They paralyze the department waiting for these transfers, taking up valuable beds, and we ER docs have essentially zero to offer them except some food and a ludicrously long time lying in a hallway gurney just waiting to leave. If we had a functional mental health system, we could be using those precious beds to treat people we can actually care for. Don’t blame us worker bees for being frustrated.