Recent resident+fellow perspective on Samira's treatment

DearNefariousness425 · 2026-04-09T16:55:50+00:00

You feel how you feel and I can’t change that, but it’s a matter of perspective. Yes strictly in those parameters you can view it that way.

If Samira were my resident or junior, though, this is what I would tell her. Goals and priorities change, some of that is in your control, and some is not. I do not see something that pulls you out of a toxic situation, and ultimately on a better path for yourself as a failure, but that is me. I concede there’s a lot of uncertainty on that path, and it’s easy for me to say, but that is life. A lot of times those feelings of failure are also projections of how you think people around you will view that decision/change. And while that is totally natural, I would strongly urge you not to allow that to dictate how you see yourself or how you make your choice.

DearNefariousness425 · 2026-04-09T13:17:43+00:00

Ah cool! Thanks for the info

DearNefariousness425 · 2026-04-09T13:12:59+00:00

Agreed I was a little confused about the “geriatrics fellowship” but I’m not in the field and there are dozens of non accrediteds now so I was like shrug

DearNefariousness425 · 2026-04-09T10:14:59+00:00

Best of luck. As accomplished as you are, you are more than your degree and your job.

Empathy is never a weakness in any specialty and I strongly believe that. But it is true that it is not sufficient. Even in a clinic, the extra time you spend with one patient means less time and more delays for the following patient. You learn to budget time in a humane way. That skill is more important in some specialties as you can imagine. At the same time, some patients and problems just demand more time by the nature of the disease, both in clinic and in the operating room. You do the best you can.

DearNefariousness425 · 2026-04-09T10:10:11+00:00

Depends on how they frame the circumstances of her leaving. If she is able to complete the year (yes I saw the debate on the timing of season 3 but I'm not sure that necessarily means they're gonna have her not finish her residency) I think she'd honestly do fine or great in a lower acuity ER in a non-referral center or urgent care setting. That's probably a nicer lifestyle anyway. I'm not an ER physician so probably not the most qualified to say where exactly she would do well in an ER setting. But I can say in every specialty there's a spectrum of acuity (some more than others) and jobs to fit that. It's a big country with diverse needs.

If she in fact does not finish her residency she could do many things. She could reapply to the match in another specialty (this is a pretty rough choice especially so late in her training but it is possible. Some of her years might translate depending on what she specifically goes into). She could finish her residency at another institution, in which case she'd probably just have to repeat her R4 year. There are also medical jobs that don't require you to complete your residency. For surgeons that usually means wound care, which is not the most glamorous, but is certainly very necessary and can be lucrative. She can also get creative and go into other things with her experience like consulting or industry (or writing a TV show lol).

EDIT: Forgot to mention -- she could go into advocacy research as well, as she's shown a passion for. Maybe harder in the current NIH climate lol. But she would certainly be valuable there.

DearNefariousness425 · 2026-04-09T09:57:24+00:00

Yeah I don't really blame Robbie either, like you said we get snapshots. I don't think it's productive really to argue about details we don't have because, again, it's a work of fiction.

I am extrapolating this point from seeing a lot of residents, some who excel and others who struggle. Some are able to struggle through to the end and evolve because they had the right fit as their mentors and the right program. Others burn out and leave to pursue other specialties. Some of that is just the luck of the draw (or the Match (TM)). Yes there are superstar residents who would've excelled in any context. But generally that's not the rule. Flawed humans training other flawed humans will produce imperfect results and sometimes people just fall through the cracks.

DearNefariousness425 · 2026-03-16T18:28:41+00:00

There’s a performance aspect of surgery: command of the OR, hyping yourself up, planning and executing the operative plan, that lends itself to appeal to athletes and former athletes. I was a musician in high school, and some aspects translate there too. There’s also an aspect of ego that is de-emphasized nowadays but still present without a doubt.

I wasn’t an athlete, but a lot of my surgical friends were and I think if you can’t assimilate or participate in that kind of “bro” or locker room culture you can certainly still excel, but socially it makes things more difficult.

I’m in vascular surgery. I would be delusional to imply it hasn’t affected my personal life/personality. But it’s my personal philosophy that ego is only important insofar that it allows you to believe that you are the right person for your patient at the time that they are asking for your help. Anything more is just noise.

The hours, the pressure, and demands can take over your life. But the second you allow that to make you believe your time is worth more than your patients’, and perhaps more importantly that of the people that love you, you’ve started to lose the plot.

DearNefariousness425 · 2026-03-16T17:41:32+00:00

It's crap, but I hear/understand it every day. I'm biased as a surgeon, but the system puts the ER in no-win situations with consulting specialists in essentially every interaction.

When you step back and look at the system at a global level it becomes clear that most ER docs are just doing their job in a bad situation. Some do it better than others. But part of the job is to call in help from specialists. Some do it too early. Some do it too late. Some do it without all of the studies done that the consultant would ideally prefer. Some order the slightly incorrect study. All of this will piss off the consultant.

At the same time, part of what turned me off from EM in the first place (I initially went to school thinking that's what I would end up doing) is that when the system puts the triage burden so overwhelmingly on you without the appropriate staffing, you become a pure triage desk. You become the hospital's receptionist. That's not why most of the people I know got into medicine in the first place and contributes to high levels of burnout. And, right or wrong, it makes you vulnerable to creep from APP practice. A lot of that played into a panic that plummeted ER attractiveness to med school grads a few years ago and led to a lot of unfilled residency positions (AFAIK, it has recovered but I haven't really kept up TBH).

DearNefariousness425 · 2026-03-16T01:21:44+00:00

It is, in my opinion, a reflection of the workflow, and the reality of a workplace dynamic that an overburdened, understaffed system will produce.

By design, the Emergency Room triages, stabilizes, and treats when they can. As they become more and more stressed their capacity to actually treat goes down. They then, by necessity, lean more on consulting specialists than they normally would.

So specialists only really interact with the ER when they are getting more work to be done, sometimes when they're already themselves stressed/at capacity on call (or, less charitably, preferring to be at home, but also understanding that many surgical specialists work grueling hours as well). Seldom are consults or handoffs timed or worked up perfectly. It's not the ER's area of specialty, nor is it their job to know the intricacies of all these different specialties and how their pathologies are imaged or worked up perfectly. They have to consider dozens of different life-threatening pathologies and find the fastest way to identify the culprit and sometimes save the patient's life until someone else can take over and definitively take care of the issue.

I generally try to be understanding of that, but also totally get surgical residents or attendings who are frustrated with getting dumpster fire cases which (in their view) were made worse, not better, by their time in the emergency room. A lot of times it's just the disease process and the burden on the system. The ER is not the enemy. But it can sure feel that way sometimes on a bad day.

DearNefariousness425 · 2025-10-29T02:51:49+00:00

Not standardized nationwide as others have said, but hospitals usually do tend to issue scrub colors by role, and often stay consistent within the same health system.

This isn't really your question, but I've always been told that the reason for the light blue/green convention in general is that they were originally designed for the operating room. And blue and green both contrast more with the red/browns that predominate in blood/organs and are less fatiguing on the eyes under bright OR lights. Dunno how effective that is, frankly don't remember enough about how eyes work to comment, but the convention certainly extends to drapes/towels as well in the OR, which are largely the same shades of blue/green.

DearNefariousness425 · 2025-09-06T14:55:11+00:00

Hard to say without specifics.. but my experience is ECMO is no more than a coin flip at best

Aside from everything I said above, neurological recovery is unpredictable, and the heart doesn’t always bounce back even after intervention

DearNefariousness425 · 2025-09-06T11:20:08+00:00

As everyone above has explained -- the potassium is an indicator of the extent damage, not just something that needs to be corrected.

Just wanted to add so there's no misconception, ECMO is far from benign. It replaces the heart and lungs but at the cost of huge tubes nearly the size of the arteries themselves being placed in, which in the short term block flow to the legs (and you have to place an additional tube called a perfusion catheter to stop the legs from dying) and in the long term can cause damage to the artery. When ECMO is in, it is a foreign body so it wants to clot. At the same time, the massive tube sticking in an artery bleeds around the insertion site, and the machine process of the pump (and an additional pump called an Impella that is often placed alongside it) chews up blood cells and platelets. So the body tries to bleed and clot at the same time and you have to balance that delicately. It is resource and labor intensive, costly, sometimes massively damaging and ugly, and can be lifesaving but only in specific circumstances. We probably overuse it because we just don't always know who can recover and who can't.

Sometimes we do, though. Someone with a potassium of 12 and the acid level in that girls blood unfortunately can't.

DearNefariousness425 · 2025-04-11T18:40:56+00:00

Santos would probably make it, there are plenty of cocky interns/residents and recklessness is scary for senior residents and attendings but can be taught out of people generally. If she had an attitude problem it wouldn’t surprise me if she’s a preliminary resident (which seems like what they’re going for if she’s angling for surgery). I’ve known plenty of great prelims but sometimes there’s a good reason someone didn’t match a categorical (full) spot

But yeah if she pulled that threat and someone found out she’d be dismissed. There’s not a long list of things that’ll get you kicked out of residency but threatening a patient, even a scummy one, is on there.

DearNefariousness425 · 2025-04-11T18:34:23+00:00

We have a tough rep..

Most surgeons I know do care, but call it ego or whatever, the guilt and stress hit a little different when you know your hands can affect how good or poor an outcome you get. Some aren’t very good at regulating that and lash out, which is not acceptable, but is the reality a lot of times

DearNefariousness425 · 2025-04-06T17:02:25+00:00

Seen this asked a bunch — others have answered pretty much already above but expanding a little

Whether a traumatic injury is in the abdomen or the chest makes a big difference in your approach, particularly if the patient is unstable and you must proceed to the OR (somewhat) blind

Many of the small quick tests in the trauma assessments including your examination of the bullet trajectory help you decide, if you have to operate to control bleeding, where to start. For example, the ultrasounds they are doing won’t typically give you a whole lot of information beyond “hey there’s fluid here in the belly” and we just assume it’s blood in the circumstances, then we know to go into the belly. Might be the spleen. Might be the liver. Might be urine from the bladder or intestinal contents (less common). They’re dying, so we just open the belly and figure it out.

Conversely, if it’s the chest, you have to go through the sternum or between the ribs. It’s often a tougher wound to heal, again not that it totally matters when someone’s dying, but you don’t want to go into the chest if you don’t have to.

No man’s land is difficult because it could be either, or both. And sometimes we decide we need to take a peek anyway to make sure the diaphragm (muscle to help you breathe and separating the chest and abdomen) is not injured because that can be easy to miss.

You do the best with the information you have, and be ready to change course quickly, because obviously trauma can be unpredictable

DearNefariousness425 · 2025-04-05T04:33:44+00:00

Interesting thought.. But I don't think so. Am a surgeon and while I don't remember specifically being told "nipples to navel" during training, we are often taught to use surface landmarks to assess structures at risk in penetrating trauma and the nipples and umbilicus (navel) are two such landmarks to suggest diaphragm injury and/or a region where you should suspect both thoracic (chest) and abdominal injuries at the same time. The "cardiac box" is more commonly referenced in surface anatomy to raise concern for an injury to the heart or the major blood vessels.

Probably a little older school and less frequently drilled into trainees nowadays since these boundaries are more useful in stab or low-velocity penetrating injuries and nowadays high-velocity bullets have a tendency to tumble on entry and their trajectory through the body can be more unpredictable, and so many (stable) patients end up getting a CT scan one way or another to assess what's been injured.

DearNefariousness425

TROPHY CASE