Internship and Residency



Internship and Residency





I Marry Dollie Ross

As mentioned in the last chapter, I’m a timid man. If the Queen knights me, I will choose the title Sir Ted the Timid. In my third year of medical school, I courted Dollie Ross (Figure 4.1), a Northwestern student of speech therapy. It took 2 years for me to gather sufficient courage to ask her to marry me. She said yes! Huzzah! Just after graduation, on June 15, 1955, we married. My father was my best man. For several years, Dollie and I shared a close and happy life.


Internship

I interned at St. Luke’s Hospital in Chicago, a rotating internship that broadened my clinical experience and gave me time to seek a good residency. Dad gave us the keys to one of several apartments he owned near Wrigley Field, which would be our housing for the year of my internship. Midway through internship St. Luke’s generously doubled my starting salary of $25 per month. Although it still wasn’t much money, housing, uniforms, and food were free. My father partially underwrote our living expenses and Dollie became a speech therapist, thereby providing additional financial support.


Choosing a Residency

I had no organized approach to choosing a residency. I visited Midwest programs, and one distinguished program in Boston. The prestigious program in Boston had nothing but unhappy residents. They uniformly advised me to go elsewhere. Eventually I chose the University of Iowa. In medical school, I had become an avid reader of everything I could find about the practice of anesthesia. One of my treasures was Stuart Cullen’s Anesthesia in General Practice, a booklet of 200 pages that went through numerous editions. I still have a partial collection of six editions. Dr. Cullen was the head of the anesthesia program at the University of Iowa. Based on his book, I applied for a residency at the University of Iowa. When I visited, Dr. Cullen invited me to stay at his house. The book, the outstanding program, and the courtesy extended by Dr. Cullen led me to choose the University of Iowa. I don’t think I could have done better.







Early one July day in 1956, 16 fellow residents and I arrived for our indoctrination into the 2-year anesthesia program at the University of Iowa. Residency at that time was vastly different from today’s training. For example, I was on call the first evening of residency… my first day as a resident! I didn’t know a great deal but from my attention to anesthesia as an extern in medical school and subsequent studies, I knew more than most of my fellow residents. I called Dollie to ask for toiletries and clean underwear. Emergency cases had already been listed. For my first case, I would anesthetize a farmer’s wife who had an empyematous gall bladder. All the faculty had left for the comforts of home and dinner. I wasn’t exactly on my own. There was a team “leader,” a newly minted second-year resident. I asked for guidance: “What should I do?” He suggested an epidural anesthetic and showed me how. The rest of the evening was a blur. I quickly learned to give an epidural anesthetic. My patients and I survived.


Residency Supervision in the 1950s

My first official day in anesthesia illustrates the limited supervision of residents at the time. This unfortunate necessity reflected the short supply of trained anesthesiologists. Anesthesia was not the prized specialty that it is today. Since they were in short supply, a single faculty member might supply the supervision of three, four, or five residents independently conducting as many cases at a given time during the day. Faculty disappeared to home in the evenings. They were on call, but rarely
were called. I remember calling my faculty only twice during my 2 years of training. For one, I had been asked to see a young housewife who was comatose from some unknown evil that had devastated her brain. I was asked for suggestions for her management and could think of none, so I called Bill Hamilton. To his credit he soon appeared at the hospital (I didn’t ask him to come). Unfortunately, Dr. Hamilton was similarly perplexed. The patient died despite our efforts.

One evening, later in my residency, I was assigned to provide anesthesia for a newborn afflicted with a tracheoesophageal fistula. Having never dealt with such a problem I called my consultant, Dr. Cullen, who advised intubation of the trachea and controlled ventilation by hand. I followed his directions, not expecting further guidance. About 20 minutes later Dr. Cullen was at my side, saying little, yet guiding (or was it overseeing?) my every move.


I Learn the Correct Dose of Phenylephrine

I hadn’t been at Iowa more than a few weeks when I was assigned a list of cases in the cystoscopy suite. The primary procedures were transurethral prostatectomies and transurethral removal of bladder tumors. We used a spinal anesthetic with procaine for such procedures. Why procaine? “Because anesthesia wouldn’t last more than an hour.” The brief time course of procaine spinal anesthesia mitigated the risk of the absorbing too much irrigation fluid. Roughly 45 minutes after injection of the procaine, the patient would terminate the procedure with a well-placed kick.

The fourth-floor cystoscopy suite lay two floors below the main operating suite. Like all residents, I took my drugs and equipment with me. I kept everything I might need in a carpenter’s toolbox. We usually were unsupervised in the urology suite. “If you need help, call upstairs.”

I had performed few spinal anesthetics previously, but I’d read how to do it. I felt ready. My first patient was a genial Iowa farmer. Insertion of the spinal needle and injection of 100 mg of procaine went without incident. Clearly, I was getting better at this anesthesia thing. But then, the blood pressure decreased, as it will with spinal anesthesia. “No problem” I thought, “I’ll just give a vasopressor.” I rummaged in my toolbox, finding a 10-mg ampule of phenylephrine. “Let’s see. How much should I give?” I reasoned that an ampule would contain a standard dose, but I cautiously gave just a quarter of the contents of the ampule. The farmer soon looked up at me saying, “Doc, I have a terrible headache.” His normal blood pressure of 120/80 mm Hg had risen to over 300 mm Hg. That was as great a pressure as my sphygmomanometer displayed. I had the wit not to do more than wait, and the hypertension and headache resolved in a matter of minutes. I had learned more about the standard dose
of phenylephrine than any text could teach me. I’ve not forgotten. 2.5 mg of phenylephrine is too much.


Learning From My Errors

One aspect of residency that hasn’t changed is that we learn to give anesthesia from our errors as well as from direct instruction by faculty and reading. Providing anesthesia stressed all of us. We truly did (and do) have the patient’s life in our hands at every moment. Weariness at the day’s end limited our learning by reading.

Dr. Cullen was kind and forgiving. We revered him for his honesty and openness to contradiction. We knew we could say anything, oppose anything, share any thought, without fear that we would offend him. Even today as I write this, I think of him as Dr. Cullen. A few (never I) called him “Stu.” Dr. Cullen eventually bought a vanity license plate saying, “Stu who?” However, even today, most of us wouldn’t call him anything other than Dr. Cullen.

I remained intensely curious. Having no concern for what the Institutional Review Board (IRB) might say (IRBs didn’t exist), I was free to try this or that, and I did. I’d read about the use of intramuscular injection of succinylcholine to produce the paralysis that might facilitate tracheal intubation, and I applied it with abandon. One morning, absent faculty in my operating room in the Ear, Nose and Throat suite, I anesthetized an infant with a cleft lip and palate with ether. The infant sustained his airway and breathed spontaneously. Then I gave an intramuscular injection of succinylcholine. As I had anticipated, paralysis followed the injection. I had not anticipated that despite my best efforts I could neither intubate the trachea nor ventilate the lungs by application of positive pressure with a mask. Now terrified, I called for my faculty supervisor, Dr. Jack Moyers, who quickly arrived. Dr. Moyers found that he, too, could neither intubate the trachea nor ventilate the lungs, at least initially. With great effort, he finally placed the tracheal tube and the crisis passed. Then, learning what I had done, he (correctly) called me an idiot and other things that Dr. Cullen would not have called me.

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May 24, 2022 | Posted by in ANESTHESIA | Comments Off on Internship and Residency
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