Becoming a surgeon was worth the sacrifice

I recently wrote about whether my MBA was worthwhile. In hindsight, since I now lead Product at Robin AI, it’s more obvious why that answer is yes. The natural follow-up question is, since I’m not practicing surgery fulltime, was surgery residency worthwhile? If given the chance to go back, would I do it again?

I would absolutely do surgery residency again. I love being a surgeon. I’m lucky that I get to split my time between building a future-facing product, and delivering hands-on medicine. In fact, I hope I’m still operating when I’m 70. I consider patient care to be both a calling and a privilege.

Also, surgical training was absolutely as hard as they say. We train like elite athletes. Rounding before dawn. Maintaining focus hour after hour in the operating room. Pushing through fatigue. We practice the motions over and over, with our hands and in our minds, so that when the critical moment arrives we can execute and claim victory for the patient.

Like last weekend. I was asleep in the ICU call room when the overhead PA announcements woke me up:

“Full trauma activation, arriving in 4 minutes.”

Followed by, “Anesthesia STAT to the emergency department.”

and then, “Massive transfusion protocol activation in the emergency department.”

I was on backup call, and even though the primary on-call surgeon hadn’t called me to help, by the time they were activating massive transfusion, I figured he could use a hand. Especially when a second trauma was announced in short succession. So I walked downstairs and helped my colleague stabilize the patient, who had suffered terrible brain and lung injuries in a motor vehicle crash. Then I went back to bed.

The next morning, I took over for my colleague. He caught me up on the patient’s progress overnight: “I had to paralyze him so he would oxygenate.”

Now I’ll stop for a minute. Let’s appreciate that statement. It may sound dry, but it conveys a hands-on struggle to out-maneuver death.

Because I’ve been in that situation dozens of times, I can imagine my colleague pulling the various levers available to him, trying to squeeze oxygen into this young man’s lungs. And none of them working. I know he was thinking, “If I paralyze the patient, I will lose the neuro exam.”

I rely on a neurologic exam — asking the patient to move — to monitor brain function. I’d rather not chemically paralyze a patient with bilateral epidural hematomas. If he can’t move, I won’t know if his brain is working at all.

The brain injury is deadly, but so is the lung injury. I have to get oxygen to the brain. So if the next lever is paralysis, that’s the lever I’ll pull.

I love the dry way surgeons convey the most dramatic information. The bigger the bomb, the more even the delivery. Listen up. As a crisis escalates, an experienced surgeon may sound even more measured and in control. Do not mistake it for calm.

When my colleague said: “I had to paralyze him so he would oxygenate,” I read between the lines and heard: I stood by his bedside all night. I thought he was going to die. He might die still. I don’t want to give the family too much hope. But if we make the right moves, and only the right moves, he has a chance. I do not intend to lose.

I took over the patient’s care for the day. On my watch we pulled him further back from the brink. His oxygenation improved, and a head CT showed the bleeding in his brain was no worse.

Critical care for blunt trauma is not glamorous — it’s not opening the chest and fixing a bullet hole in the heart — but I love it. It’s sorting out signal from noise. Making quick decisions with incomplete information. Putting on gloves to thread life-saving tubes and lines into the patient’s body. It’s hands-on bedside medicine. It’s fun.

After residency plus a year of resuscitating trauma patients at LA County, I live and breathe those ICU resuscitations. As I jokingly tell residents, my philosophy is to “do more nothing” in these folks. Young patients will bounce back. We mostly have to stay out of their way.

The fact that I have lived and breathed surgery informs my role at Robin AI. I’m lucky that my job more or less requires me to keep practicing. If I want to build a great product that helps doctors get through their day, I need to know what it’s like to get through my day as a doctor.

Someday I want Robin (our AI digital assistant) to hear a few dry, evenly-delivered words from a surgeon and recognize the drama they contain. Maybe Robin will say to me, “Hey Dr. Palm, tough case! He’ll live to fight another day.”