As one of the foregut attendings at Carolinas Medical Center likes to say as you clumsily attempt to tie your laparoscopic suture, tightening the stomach’s grip around the esophagus, “Put that thing down, flip it and reverse it.” Yes, that is a slightly ed lyric from the legendary rapper, Missy Elliott, who then goes on to quite literally reverse her words, creating a jumbled hook that still leaves some fans in confusion. “Flip it and reverse it.” That’s what the coronavirus has done. It’s flipped and reversed all the roles, all the rules, all the knowledge that has become quite innate to us physicians. So let’s regress for a minute and recap to try to understand “anoroC fo selur eht.”
Rule 1: Avoid the physical exam, at all costs.
When previously we may have been admonished for not documenting a subtle skin rash on a trauma patient’s left foot or feeling the prostate during a digital rectal exam—“but sir, it’s a woman.”—we now are standing back, hands awkwardly to our sides, trying to limit contact to only what is necessary. Seeing a trauma chief and attending run a low-acuity code from outside the trauma room doorway, one would expect to turn around and see Dali’s melting clock slide down the opposite wall. This is no dream. Limiting contact is essential to minimize unnecessary close contact between providers and patients. Forget what you have been told. If you don’t need to exam it, then don’t. If you don’t need to touch the patient, then don’t. Less is more here. This brings us quite nicely into . . .
Rule 2: Do not be seen, but be heard.
Starting as a medical student, you are constantly taught to soak in everything. See everything you can. Learn from every situation. Be present, be active, take initiative. Scared you’ll miss an opportunity, you cling to your resident mentors with such tight grips that it’s quite instinctive that you accidentally follow them to the bathroom daily. This same attitude carries forward into residency and into practice. Even the resounding principle of learning an operation starts not with “hear one” but with “see one.” However, right now, being there, showing you care, watching the trauma code, eyeing the laparoscopic monitor, sitting in the surgeons’ lounge stalking cases is currently harmful. The truth of the matter is that showing you care now means staying away. While this may seem blasphemous and almost unethical, at the present time it’s what’s necessary to flatten the black diamond ski slope we currently face. So do a virtual sign-out on patients, have M&M (morbidity and mortality) and educational conferences over Zoom, and limit teams to only essential members.
Rule 3: Call in sick, please.
As residents, we try so hard to work through sickness. If we call in sick, our workload falls onto another colleague. It does not wait for us to get better. Patients have to be rounded on, cases have to be done, and clinic has to be staffed. So often, we work through it. But that mindset needs to shift with the coronavirus, and we need to call in sick. If one resident comes in with the virus, they can take out other residents, attendings and vulnerable patients. So don’t just medicate up and work through it. Be transparent with your peers, with your program directors, and tell them if you are not feeling well, even if it is just the sniffles.
Rule 4: Decrease your Slytherin, amp up your Hufflepuff.
(Warning: Read only if knowledgeable of Harry Potter otherwise skip to Rule 5.)
As a specialty that has high numbers of Slytherins, we are naturally ambitious, competitive leaders who crave power and success.1 And these traits facilitate success in the OR. But now, we need to tap into our other personality traits that may be a bit more “Hufflepuff” in variety. As virus cases rise and elective cases are canceled, we may be called upon to help out medical personnel and assist in the management of nonsurgical patients. This calls for loyalty, patience and inclusivity: traits highly prized in Hufflepuffs. So put down your butterbeer and embrace your inner badger the Slytherins are reporting for duty!
Rule 5: Trust the emergency department’s (ED’s) diagnosis. (She’s peritonitic I promise!)
Don’t roll your eyes. I know what you’re thinking. (Are you crazy?) We have always been taught not to trust what others tell us. Always examine the patient yourself, and never blindly trust another physician’s diagnosis or make an assumption off of imaging. This is not only how we learn, but different specialties have different skill sets, and sometimes an ED physician may not see what a surgeon sees and vice versa. At CMC, in order to decrease unnecessary ED traffic and exposure, all ED consults are first being called to the at-home attending. If the attending deems the consult appropriate, the patient is admitted and then the in-house resident is called to assess. Wait, what? Correct. This avoids ED exposure and fast-tracks patient disposition as ED beds become hotter commodities. Extreme times call for extreme measures. Diagnoses are coming before exams but trust your colleagues, and, for now, it is better to admit unnecessarily then risk exposing further personnel and patients.
Rule 6: Take off your white coat.
Being a professional presence is part of being a surgeon. However, the white coat that we wear from room to room—that carries our notes and stethoscopes, stores all of our pens that have touched countless floors—carries lots of germs, too. Take them off and hang them up for use in a corona-free future. Stick to scrubs-change when you get to work, and change when you leave work. Easy.
Rule 7: Shift your work–life balance.
The craze over resident wellness had just reached a peak when the virus emerged. Lectures on how to maintain happiness and normalcy when working 80 hours per week, wellness days with group breakfasts or park play dates, and attending-led weekly yoga sessions were the new normal. Right now, forget it all. Focus on maintaining distance and solitude when possible. Avoid the unnecessary places or activities. It’s not forever it’s a temporary necessity. We need to stay well so we can continue to take care of people and do our jobs at the hospital. That is priority No. 1. So give yourself the best shot you have and quarantine between shifts.
Between virtual fellowship interviews and not worrying about Accreditation Council for Graduate Medical Education case logs, this list is far from exhaustive. But this resident is exhausted and ready to attempt a call room nap. So to end again with the better words of another, “It is not despair, for despair is only for those who see the end beyond all doubt. We do not.” Stay healthy, my friends.
