Atul Gawande

       I am a resident in surgery–two years down, five to go. I’m not allowed to make excuses. If a patient needs something done, I can’t say, “But my shift is over,” or, “I’m too tired.” With 100-hour workweeks and many nights without sleep, I’m also trying to learn to be a surgeon.
       This weekend I was on duty, which means starting work at 5 a.m. on Saturday and not going home until Monday night. My service, cancer surgery, had a handful of patients. A frightened college student had a lymphoma that triggered his spleen to sponge up his platelets, which you need for blood to clot. We had to take out his spleen before any unstoppable spontaneous bleeding started. An irrepressibly cheerful woman in her 50s had a cancer in her thigh. We excised all her quadriceps muscles and then replaced them with some of her hamstrings so she could get out of a chair or walk up stairs again.
       My other patients came in for mastectomies. Breast cancer really is different. Not only is it cancer, but your breast has to come off. (Testicular and prostate cancer are similar, I suppose.) Women choose different ways to remake themselves. My patients include a 39-year-old who preferred no reconstruction, a 75-year-old who took a saline implant, and a 37-year-old who wanted the most realistic-looking breast possible, one rebuilt from her abdominal muscle and, for the nipple, a skin graft. I had one young patient with bilateral mastectomies who wanted to be the first Playboy pinup with wholly reconstructed breasts.
       Everyone was recovering uneventfully. There are few emergencies on a cancer service. My sleep was disturbed only occasionally.


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       The last time I was on weekend duty, I was at another hospital and it was far busier, more like usual. 50 pager calls a day. Four patients in intensive care needing to be checked every three hours. Midnight Saturday. I need to go to the bathroom. My pager goes off. An obese man in the ER has a rectal abscess. I figure that can wait. I get paged again. ICU needs me stat (like yesterday, pal). A patient can’t breathe. Pager goes off again while I’m fixing the problem. A Jehovah’s Witness is bleeding from his colon. He’s already lost half his blood volume. He refuses a transfusion. I consider going to the bathroom but think better of it. I go talk to the patient. No surgery, no blood, he says. He knows he could die. We hook up monitors, intravenous lines, a bladder catheter. We give fluids. The bleeding stops. I talk to my boss. I fill out the inevitable paperwork.
       I go to the ER. The fat man is angry I took so long. I give him numbing medication and use a knife to open the abscess. Pus pours out. The stench is fearsome. He feels better. More paperwork. 3 a.m. I finally go to the bathroom.
       The Jehovah’s Witness checked with his church. He can have surgery, but no blood. Then he has another bloody bowel movement. His blood count drops to 15% (normal is 45%). Surgery or not, he will die. Amazingly, at 12%, he is still alive. Stone-faced, scared, he changes his mind. He wants blood. Later, having revived him to a count of more than 30%, we took out his colon. He made it home the next week.