Forget the good, here's the bad & the ugly...

ExtraCrispy

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As I've struggled with my own personal crisis of figuring out what to do with the rest of my life, several mentors have advised me that it's easy to fall in love with any surgical specialty when things are their finest. Vascular is awesome if you're doing carotids and aneurysms. Trauma is terrific when you save a father of three via an ex lap. But this obviously isn't the real picture. The real indicator of the right field for you, they tell me, is how well you can tolerate the bad parts.

So, in an effort to figure it all out, I'm trying to list the rotten features of each field. Would love to have input from others, if the spirit moves you.


Trauma
*Lots of babysitting, not much operating
*When you do operate, often it's on someone who'll go straight to jail after discharge

Endocrine
*You're a three-trick pony for the rest of your life (thyroids+parathyroids+adrenals)

Pedi
*When things go wrong, it's REALLY SAD
*STAT calls in the wee hours of the morning to put in a central line
*Endless broviacs
*Parents

Breast
*To borrow a recent phrase from these boards: "blob surgery"
(no offense Dr. Cox!)

Vascular
*Ulcers
*Civil war surgery
*Surgery in a lead vest (some might see this as a positive)
*Patients hella sick

Surg Onc
*Ok, I stole this from filter below, b/c it's perfect: Staging. Academic minutia. Positive margins. Recurrences.

Thoracic
*Potential for terrifying airway shambles (trachea patients scare me!)
*Patients hella sick

Cardiac
*Tough job market
*When things go awry, patients CRASH

Colorectal
*Frequency of "prone jack-knife" positioning
*Condyloma acuminata

MIS
*Bariatrics

Plastics
*High-maintenance population
*Vanity surgery

Burns
*skin grafts the rest of your life
*ORs hot as hell

Critical care
*Missing out on OR time

Transplant
*Crappy lifestyle
*Livers can be shambles
*Immunosuppressed patients (again stolen from filter below)

Please chime in!
 
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filter07

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Surgery in general:
Long hours. ER consults. Endless paperwork. Forced early retirement compared to "intellectual" specialties. High risk for lawsuits. Long training. Two years of research at many programs.

General Surgery:
Crazy and/or demanding patients. Crohn's patients. Enterocutaneous fistulas. Poop. Limited scope. Terrible reimbursement.

Hepatobiliary:
Crazy and/or demanding patients, e.g. chronic pancreatitis.

Surgical oncology:
Staging, basic science academic minutia. Breast cases mind numbingly boring. Positive margins. Recurrences.

Transplant: Unpredictable lifestyle, immunosuppressed patients.

Vascular: diabetic feet, smokers, rotting limbs, non-compliance, patients dropping like flies left and right

Cardiothoracic: high stress, limited job market, poor lifestyle.

Endocrine: boring.

Trauma: Dumb patients, those who you want to discharge want to stay, those who you want to treat want to leave AMA, high turnover, terrible lifestyle, non-operative management, following up on a million imaging studies, butcher surgery.

Colorectal: butt exams, butt fistulas, poop, being known as the A$$MAN.

Plastic: annoying patients, incredibly boring surgeries, boutique pointless BS surgery, 14hr flaps that thrombose, results are generally pretty crappy

Peds: terrible lifestyle, no one else to help carry the load, performing "miracles" on kids who frankly should not be alive

Burns: Dumber patients than trauma. Crazier patients than Crohn's. Skin grafts, stapling, pseudomonas, contractures, and unbearably hot ORs.
 

Winged Scapula

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Breast
*To borrow a recent phrase from these boards: "blob surgery"
(no offense Dr. Cox!)

:laugh: None taken, but I would add the Surg Onc stuff below because it (in addition to the deadly boring blob surgery) also pertains to Breast and is what keeps a lot of people out (they can't stand the staging classifications, minutia, change a minute practice guidelines, multi-d stuff, patient handholding).

Surg Onc
*Ok, I stole this from filter below, b/c it's perfect: Staging. Academic minutia. Positive margins. Recurrences.
 

Castro Viejo

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Trauma
*Lots of babysitting, not much operating
*When you do operate, often it's on someone who'll go straight to jail after discharge

*Continue to sleep in-house like a resident when you're a 60 year old Trauma attending.
*Becoming a dumping ground for "Acute Care Surgery" cases (i.e., middle of the night urgent General Surgery cases that General Surgeons have no interest in solely because of the time of night).
*Loss of technical skills and understanding of basic surgical principles, unless you consider "Red to red and white to white" as sound surgical philosophy.

Pedi
*When things go wrong, it's REALLY SAD
*STAT calls in the wee hours of the morning to put in a central line
*Endless broviacs
*Parents

*Kids.

Breast
*To borrow a recent phrase from these boards: "blob surgery"
(no offense Dr. Cox!)

*Constant "empathy" required.

Vascular
*Ulcers
*Civil war surgery
*Surgery in a lead vest (some might see this as a positive)
*Patients hella sick

*Feet.
*Re-do, Re-do's...
*Down grafts after an 8 hour middle of the night case that you discover on hitting the PACU.
*Glorified interventionalist.
*Someone else's re-do, re-do's on the weekend.
*Cataracts, thyroid nodules, and sperm that swim in circles (from the constant flouroscopy).
*Potential for playing second-fiddle to a Cardiologist or Internventional Radiologist (if you're not careful).

Surg Onc
*Ok, I stole this from filter below, b/c it's perfect: Staging. Academic minutia. Positive margins. Recurrences.

*The Whipple. Ugh.
*Re-operative surgery. Ugh.

Cardiac
*Tough job market
*When things go awry, patients CRASH

*Being second-fiddle to a Cardiologist.

Colorectal
*Frequency of "prone jack-knife" positioning
*Condyloma acuminata

*Stool.
*TEM.
*'Rhoids.
*Anus.

MIS
*Bariatrics

*Taking six hours to do something an "Open Surgeon" can do in 60-90 minutes.
*Operating with a set of pool cues (or chopsticks, as it were).
*God-awfully boring.
*Fatties are worse than parents, kids, and Breast patients combined.

Transplant
*Crappy lifestyle
*Livers can be shambles
*Immunosuppressed patients (again stolen from filter below)

*Chances are, you'll be unemployed.
 

Winged Scapula

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Trauma
*Endless rounding on Ortho and Neurosurg patients and begging them to take responsibility for them
*PEG and Trach, PEG and Trach, PEG and Trach...
*"I'm sorry Ma'm but your son/husband/daughter didn't survive..."

Endocrine
*No jobs doing entirely Endocrine
*Scorn from ENT, H&N, Urology, General Surgeons

Pedi
*Some of the kids are as irritating as the parents
*Micromanaging Attendings
*Pediatricians
*Possible need to wear goofy ties in clinic

Breast
*High Maintenance Patients
*Breast Pain Consults
* Consults on patients with normal exams and normal imaging because of medical legal concerns (ie, no one wants to take responsibility to say patient is fine)
*Constant change in management protocols
*Scorn from general surgeons and radiologists

Vascular
*Post OP Day 3 MIs
*Amputations
*Cardiologists, IR encroaching on field
*Grafts going down in the PACU

Surg Onc
*Depressing prognoses
*(that's all = I can't think of too many negatives)

Thoracic
*Can you find a job just doing Thoracic?
*Competition for goose work from above

Cardiac
*Making the same as the PA after 43 years in training

Colorectal
*Psycho Crohns patients
*Stomas
*APRs

MIS
*Bariatrics; yeah Bariatrics
*Lens fogging
*NOTES

Plastics
*Have to be in Academics to do reconstruction
*Trauma call

Burns
*Surgeries boring
*Stupid patients
*Skinning patients

Critical care
*Endless rounding (see Trauma)
*Family Conferences

Transplant
*Never making firm dinner plans again
*Sleeping on strange OR Lounge couches until room ready
*Neurotic patients
*Non compliant patients
 

Chronic Student

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Neurosurgery
* 15 hour long meningioma cases (associated with stretched, dystonic bladder, varicose veins, rumbling stomach, sore back/neck syndromes)
* Frontal lobe syndrome
* Chronic pain patients
* Bolt, vent, PEG, trach
* I'm sorry your (son, daughter, husband, wife, etc): is brain dead and will never wake up or if they wake up, they will never be the person you knew and will have to relearn how to speak, swallow, walk, poop, pee, etc.
* Call q1week, every other week
* Endless "I've got a lady/man who had a fall on coumadin/plavix" calls
 

geekgirl

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Trauma
* non-operative, "polytrauma" i.e. broken finger and facial fx
* 24hrs "trauma clearance" admits
* ED work
* the dreaded fall from standing trauma
* rarely enough blood and guts trauma

Endocrine
* necks, necks, necks
* oh, yes, more necks
(although i did work with 1 endocrine surgeon who had an awesome practice with bigger onc whacks amidst $-making neck stuff - but that's rare)

Pedi
* pediatron crises (i.e. pt has a fever, can you lay hands...)
* pediatron IV access (i.e. we just d/ced pt's PICC but now need STAT IV access)
* sadness (i.e. shaken babies and whatnot)

Breast
* anatomy-less icecream scooping
* no respect

Vascular
* dead toes, dead legs....
* operating on the same patient again and again (i.e. local bandaids for a systemic disease)
* as mentioned, going back to the OR for a cold leg immediately after an 8 hour flog of a revascularization

Surg Onc
* knowing the hospice team by first name

Thoracic
* the spit pit
* airway shambles

Cardiac
* no jobs
* god complexes - perhaps a diffuse phenomon, perhaps just here
* electrophysiology

Colorectal
* your most complicated structure that you operate on is the sphincter (i can't sit around at meetings talking about the sphincter)
* prone positioning

MIS
* bariatrics - 'nuff said

Plastics
* only skin (well, and muscle) deep - it's superficial

Burns
* crazy, crazy, crazy
* hot, hot, hot
* and who ever said the words "operation" and "procedure" were synonymous, because i am CERTAIN we're doing procedures and not operations here

Critical care
* usually lives with trauma - see above

Transplant
* HD pts - access issues
* noncompliance
* lifelong immunosuppresion
 

Winged Scapula

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Interesting comments about breast surgery.

Apparently you guys have not been taught oncoplastics and complex tissue rearrangement if it still seems like "blob" or "ice cream scoop" surgery. Its a little more complicated than that if you do it right.

As for respect, the pissy general surgeons can be disrespectful all they want. They're just jealous that I'm at home while they're in the ED and all the PCPs are referring the breast cases to me. If other surgeons disrespect me, that's fine...I don't need their approval. :p
 

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Apparently you guys have not been taught oncoplastics and complex tissue rearrangement if it still seems like "blob" or "ice cream scoop" surgery. Its a little more complicated than that if you do it right.

Probably, but we don't have any fellowship trained Breast Surgeons in these parts. We just have a bunch of General Surgeons whose only instruction to the R1 doing the case is, "Make f***ing sure you get the thing on the mammogram out the first time."
 

surg

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That's really too bad. It really was a revelation for me when I started learning oncoplastic techniques (and I work on improving them all the time).

-WS, how much are you willing to do completely on your own, or do you have a favored plastics person that you get to scrub with you on the bigger stuff. I'm doing internal mastopexies on my own, but haven't been willing to do major breast reductions yet (besides I figure I will need the plastics guy for the other side anyway). Also not putting in my own expanders/implants yet, but I'm always tempted...
 
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Winged Scapula

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That's really too bad. It really was a revelation for me when I started learning oncoplastic techniques (and I work on improving them all the time).

-WS, how much are you willing to do completely on your own, or do you have a favored plastics person that you get to scrub with you on the bigger stuff. I'm doing internal mastopexies on my own, but haven't been willing to do major breast reductions yet (besides I figure I will need the plastics guy for the other side anyway). Also not putting in my own expanders/implants yet, but I'm always tempted...

I'm willing, but its a matter of getting the hospital to give me privileges to do so. But as a matter of fact, some of the PRS guys here have actually suggested teaching us how. There are very little free flaps done here...they don't get reimbursed much more than the expander/implants (and with LOTS more post-op problems). So the PRS guys are really only doing these cases as a "service" (ie, they'd rather being doing aesthetic work).

I have one whom I work with almost exclusively...it helps that he's very good, well respected, nice, etc. but one of the problems we have here is that most of the PRS guys aren't on any insurance plans and they want my office to spend the time getting out of network authorization for the patients. I don't care to have my office spend time doing THEIR work while they get reimbursed for it, so it really would behoove me to learn how to do these for my patients.
 

geekgirl

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Interesting comments about breast surgery.

Apparently you guys have not been taught oncoplastics and complex tissue rearrangement if it still seems like "blob" or "ice cream scoop" surgery. Its a little more complicated than that if you do it right.

As for respect, the pissy general surgeons can be disrespectful all they want. They're just jealous that I'm at home while they're in the ED and all the PCPs are referring the breast cases to me. If other surgeons disrespect me, that's fine...I don't need their approval. :p

i'm kinda being facetious about these topics.

i'm doing breast this month and it is quite a complex and academic field and the surgeons we work with are awesome. they do practice oncoplastics and are quite skilled at what they do.

that said, the surgeries are not particularly fulfilling for me. despite learning various techniques for doing them.

in the above post we all have to criticize the fields - hence the title "the bad".

i plan to do surg onc and think big hepatic resections are awesome. others just see dying pts. it's all in your own personal decisions.

however, agree that the schedule is good on breast. i almost wish i could like it, but it's just not for me.
 

Winged Scapula

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i'm kinda being facetious about these topics.

i'm doing breast this month and it is quite a complex and academic field and the surgeons we work with are awesome. they do practice oncoplastics and are quite skilled at what they do.

that said, the surgeries are not particularly fulfilling for me. despite learning various techniques for doing them.

in the above post we all have to criticize the fields - hence the title "the bad".

i plan to do surg onc and think big hepatic resections are awesome. others just see dying pts. it's all in your own personal decisions.

however, agree that the schedule is good on breast. i almost wish i could like it, but it's just not for me.

It wasn't necessary to explain as I assumed you were being facetious in the name of the thread but it IS a common complaint and mostly made by people who don't understand that there IS anatomy (if you know what you are looking for) and that its a little more complicated.
 

Pir8DeacDoc

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It's really quite interesting how each of us loves the OR and operating but we have different operations and organ systems that we do/don't like...

In my defense, I don't love snot/mucous/cerumen or suctioning trachs and stuff but you get used to it.
 

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Neurosurgery
* 15 hour long meningioma cases (associated with stretched, dystonic bladder, varicose veins, rumbling stomach, sore back/neck syndromes)
* Frontal lobe syndrome
* Chronic pain patients
* Bolt, vent, PEG, trach
* I'm sorry your (son, daughter, husband, wife, etc): is brain dead and will never wake up or if they wake up, they will never be the person you knew and will have to relearn how to speak, swallow, walk, poop, pee, etc.
* Call q1week, every other week
* Endless "I've got a lady/man who had a fall on coumadin/plavix" calls

Haha, thanks for posting this up, I was wondering about neurosurg
 
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Pir8DeacDoc

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What about ENT?



There are no bad parts to ENT :)


Things that people may not like about ENT:
1. Snot
2. Working in confined places/spaces
3. Trachs
4. Crazy dizzy patients
5. Crazy sinus patients
6. Pedi parents
7. Cancers that are largely self-inflicted


I'm sure others can come up with more but those are the first things that come to mind.
 

Chronic Student

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There are no GOOD parts to ENT :)


Things that people may not like about ENT:
1. Snot
2. Working in confined places/spaces
3. Trachs
4. Crazy dizzy patients
5. Crazy sinus patients
6. Pedi parents
7. Cancers that are largely self-inflicted


I'm sure others can come up with more but those are the first things that come to mind.

Fixed that for ya.

j/k
 

forbin

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There are no bad parts to ENT :)


Things that people may not like about ENT:
1. Snot
2. Working in confined places/spaces
3. Trachs
4. Crazy dizzy patients
5. Crazy sinus patients
6. Pedi parents
7. Cancers that are largely self-inflicted


I'm sure others can come up with more but those are the first things that come to mind.


Would definitely agree with #4-7 above. But I'd rather deal with a hundred snot covered trachs than poop, anuses, and ostomies.

I would add:
1. Epistaxis
2. LOTS of clinic time, LOTS of chronic management of medical problems (i.e. hearing loss, dizzyness of various etiologies, allergic rhinitis, sinusitis, hoarseness, GERD, dysphagia, ......)
3. Cerumen impactions
4. Neck pus of all varieties
5. Foreign bodies in various holes in the head

That being said, I would never think about switching to another specialty. ENT rocks!
 

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Plastics
*High-maintenance population
*Vanity surgery
* only skin (well, and muscle) deep - it's superficial
*Have to be in Academics to do reconstruction
*Trauma call
***annoying patients, incredibly boring surgeries, boutique pointless BS surgery, 14hr flaps that thrombose, results are generally pretty crappy

Please chime in!

***where did you do plastics at?
cant do anything if the surgeries bore you, to each his own. flaps rarely ever thrombose, results generally crappy? high maintenance only if you actually work hard to get those patients.

How about HAND CALL, bane of my existence, idiots with chainsaws/tablesaws/etc..saws.
 
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droliver

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Also not putting in my own expanders/implants yet, but I'm always tempted...

Unless you're fluent in revisional reconstructive surgery, I think you're biting off more then you can chew getting into that. Even in the best trained hands, breast reconstruction is associated with frequent complications and reoperations.

Complications from reductions, mastopexy, breast augmentation, and reconstruction are associated with the most frequent malpractice claims area in Plastic Surgery (hand surgery being the other FYI). If you're untrained in Plastic Surgery you're arguably (rightly I think) going to be particularly vulnerable liability wise doing these procedures.

For the increasingly modest reimbursement with those procedures and involved care, I couldn't imagine the risk is worth it for you. I personally know of at least two such cases currently being pursued re. to complications from tissue expanders being placed by general surgeons where this argument dominates the plaintiffs cause of action.
 

surg

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Unless you're fluent in revisional reconstructive surgery, I think you're biting off more then you can chew getting into that. Even in the best trained hands, breast reconstruction is associated with frequent complications and reoperations.

Complications from reductions, mastopexy, breast augmentation, and reconstruction are associated with the most frequent malpractice claims area in Plastic Surgery (hand surgery being the other FYI). If you're untrained in Plastic Surgery you're arguably (rightly I think) going to be particularly vulnerable liability wise doing these procedures.

For the increasingly modest reimbursement with those procedures and involved care, I couldn't imagine the risk is worth it for you. I personally know of at least two such cases currently being pursued re. to complications from tissue expanders being placed by general surgeons where this argument dominates the plaintiffs cause of action.

For what it's worth, I generally agree with you, which is why I stop at basically internal rearrangements of the breast tissue to fill the cavity that I made (what amounts to a mastopexy), but avoid large things. I'm currently of the opinion that unless you are willing to do the revision, don't routinely do the surgery. However, at the last breast surgery meeting, they really are promoting that this is the wave of the future, that breast surgeons will eventually take on these implant reconstructions, or place an expander to prep the site for the future plastics case (although, I know if I was the plastic surgeon, I'd want to place my own expander personally if I was responsible for the implant placement). Reimbursement wasn't really the driving force so much as being complete providers and really pushing toward improving cosmesis of breast surgery, since so many people have trouble finding plastic surgeons to do immediate reconstruction or joint cases at the hospital.
 

droliver

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However, at the last breast surgery meeting, they really are promoting that this is the wave of the future, that breast surgeons will eventually take on these implant reconstructions, or place an expander to prep the site for the future plastics case. Reimbursement wasn't really the driving force so much as being complete providers and really pushing toward improving cosmesis of breast surgery, since so many people have trouble finding plastic surgeons to do immediate reconstruction or joint cases at the hospital.

Reimbursement & liability issues involving reconstruction are going to nip that idea in the bud in the USA. It pays poorly (even before the discount fee the surgeon would be recieving for the multiple procedures penalty) and has frequent complications. There is going to be no stampede of people dabbling to do this as doctors aren't dumb and the risk/reward ratio is so high.

Major complications are just going to be indefensible in court and you're going to have expert witnesses falling out of trees testifying.

On a practical level, who are you going to hand complications or bad outcomes over to? If you thought you had a hard time finding plastic surgeons available before, wait until you try to find one ex post facto
 

IFNgamma

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I'll add some stuff I hate about Surgery:

Gen Surgery:
a ton of annoying consults, i.e. sacral decub, SBO
NGTs
getting called in the middle of the night to fix a leaking VAC
M&M

Vascular:
a ton of annoying consults for DVTs, ulcers
disgusting feet
unna boots
checking ABIs
sick pts with every major co-morbidity known, CAD, CHF, DM, COPD, etc...

there's more, but that's all I can think of right now...
 
I'll add some stuff I hate about Surgery:

Gen Surgery:
...
getting called in the middle of the night to fix a leaking VAC

When I was a PGY-2 taking home call at the VA, I came into the hospital THREE SEPARATE TIMES on Christmas Day to fix a leaking WoundVAC. THREE SEPARATE TIMES. This was on a demented patient who kept messing around with his wound and dressings...while the assigned sitter sat in the hallway watching TV and chatting.

Needless to say, I was not very happy that day.
 

Winged Scapula

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When I was a PGY-2 taking home call at the VA, I came into the hospital THREE SEPARATE TIMES on Christmas Day to fix a leaking WoundVAC. THREE SEPARATE TIMES. This was on a demented patient who kept messing around with his wound and dressings...while the assigned sitter sat in the hallway watching TV and chatting.

Needless to say, I was not very happy that day.

Blade if that ever happens again: change to wet to dry and fix the vac (or the sitter) in the am.
 

Winged Scapula

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Yeah, I've been told since that a simple wet-to-dry dressing with saline-moistened Kerlix would suffice. But thanks for the tip. :)

Man I was so fired up at that sitter. THREE SEPARATE TIMES. :mad:

I'll bet - we took home call for the VA as well and there were days when the beeper would go off *just* as I pulled into the driveway (after a 30 min drive home in the snow) for something they knew about when I was in house.:mad:

Unfortunate part is that I suspect you, like most junior residents, would have been loathe to refuse to come back in for something like that, that was clearly nursing's fault.
 

droliver

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When I was a PGY-2 taking home call at the VA, I came into the hospital THREE SEPARATE TIMES on Christmas Day to fix a leaking WoundVAC. THREE SEPARATE TIMES.

There's a real easy solution for that:

Have the nurse put the VAC tubing up to low wall suctionat -75mm. That will hold suction with the sponge for all but the largest leaks until the AM.
 
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