first day of third year

In one day, I managed to get two people in the unit I started working in to hug me; got one person to yell at me; got three attendings to call me by my first name without reminders; and put in two Swans (as much as in the previous year together). If I can get these to balance out, the next month might not be too bad. (Although I was starting to get that uncomfortable vibe that becomes so familiar to residents, where on the first day of the month all of the attendings claim to be delighted to have you around, and foretell plenty of hands-on learning, whereas within a few days it becomes obvious that you’re still only a scut monkey.)

Yesterday I also had the biggest fight I’ve ever had with a nurse. Previously, when people say I don’t get along with nurses, I’ve been puzzled. This one was not puzzling. My patients were falling apart. I was moving somebody to the ICU every hour or two, without having the time to stop and think about why exactly they were deteriorating (which makes me extremely nervous and snappy) and there were consults from the beginning of the night still waiting to be seen, and major procedures waiting to be done – and the nurse was trying to quiz me about why I’d decided to do this and not that. I tried explaining nicely, I tried telling her I’d cleared it with my attending, I tried offering to discuss it with any other doctor in the unit whose toes she thought I might be stepping on, but she wouldn’t stop harassing me. Eventually I turned my back on her and told her I was done talking (after she’d carried the argument into the room of a conscious patient whom I was trying to assess for a pressure of 80/40 on pressors). After she finally left, the other nurses in the area had a few rude words for her communication methods, so I know I wasn’t the only one feeling annoyed and frustrated.

I’ve mentioned before how some of the senior residents tease me about doing procedures at the drop of a hat. It’s been a while since I acted like that. Lately, working nights, I’ve been so tired and frustrated that I’ve avoided procedures as much as I can. But in the last 24 hours it all started coming back, I think related to being now responsible for only one ICU instead of four (and thus not having to fear what could happen in a distant corner while I’m tied up in a sterile field), and that the most acute ICU in the hospital (cardiothoracic), where there’s no time or leisure for avoiding lines and tubes. I’m reacquiring my knack with sharp objects, and it feels good; surgeons are supposed to be comfortable moving quickly with knives and needles. When I was avoiding procedures, I felt an uncomfortable camaraderie with the naval captains in Patrick O’Brian’s books, questioning their courage when they decided it was wisest to avoid an engagement with the enemy – but not any more.

 

acid

I’ve written this post in my mind nearly every week for the last six months, and finally I’m so angry it’s coming out.

Half the bitterness and cynicism among residents comes from the job itself – long hours, seeing people suffer and die and often being helpless to change that. But half of it comes from the way we’re treated by administration. When I was a student I saw this, listening to the residents talk about their grievances against the hospital. Back then I couldn’t understand; I heard the aching bitterness, but I had no idea where it came from.

Now I know. The residency administrators are one thing; they use us like pieces in a puzzle, to fill out the schedule and get the work done, but at least they know our names, and have some slight regard for us as individuals who will carry the name and the honor of the place when we graduate. The hospital administrators are a separate breed. I don’t think they even know that residents exist. Perhaps they suppose the work gets done by robots, or by magic. Certainly they have no hesitation to take actions which gut our educational experience, and change our lives permanently, for the worse, at a moment’s notice.

This is what really gets me: I work so hard for this hospital. I do more than is written in the contract, or than is my obligation as an employee. I go out of my way to try to keep patients happy with this hospital. I apologize when apologies are needed, even when it wasn’t my fault (poor communication to families; housekeeping inadequate; nurses too busy to respond to call bells). I talk to irate families even when it isn’t my patient, I’m just covering, and technically am not required to get involved at all. For all its shortcomings, I do like this hospital (perhaps even love it, because it’s my home, and because I like the people here, although not the administrators); I actually do think about making it successful, keeping it in business. And for that, we get slapped in the face by the administration. They don’t realize or care that the face of the hospital, to all of their patients, is the residents and nurses whom they abuse.

Within the next year, I think I won’t be able to care about public relations anymore. Like so many of the other residents, I’ll retreat into doing only what’s required by the book, nothing more, because the people we work for don’t even give us the benefit of the rules. (I really think they’ve broken our contract in more than one way, in a legal sense as well as moral, but I’m too exhausted to look it up, and what would I do about it anyway? Fight them? I can’t risk my place.) And when I graduate and go to work on my own, you can believe that I’ll never trust a bureaucrat farther than I can throw them. Administration is always out to screw the physicians and nurses – that’s the most important lesson I’ve learned in residency so far; and when I’m not part of the slave labor force any more, believe me I’ll remember it.

 

not just in the books

I had a very puzzling experience last night. The arrest pager went off, and I happened to be just one floor above, so I got there a good deal faster than most of the rest of the response team, several floors below. So when I arrived, it was just a few of the floor nurses and an aide. One was making a respectable (although to my mind not very successful) attempt at bagging. Another was doing compressions, and stopping every few seconds to look at the monitor. To me, the monitor looked like torsades immediately, the only time I’ve ever seen that rhythm in real life.

Finding myself the only doctor on the scene willing to talk (the interns had a deer-in-the-headlights look), I announced, “That looks like torsades. It’s a shockable rhythm. Where’s the defibrillator?” One nurse pointed out that she was attaching the pads to the machine, while the other two immediately contradicted me, saying that the rhythm was not torsades, or that it was not shockable. They kept doing compressions.

Clearly I need to learn how to talk louder in emergencies – that particular crowd-control voice which rides right over all the other noise, without being quite as energetic as shouting. (The first time I was alone in the ER with a bad trauma, I found myself squeaking quite shockingly. At least now I lower my voice, instead of raising it, to get control.) It took a little bit of effort to get them to stop compressions long enough to get a real read on the monitor, and strangely enough it was torsades (torsades de pointes, a particular type of ventricular fibrillation, where the waves alternate in height); in this case, it was a beautiful spindly pattern, completely classic (says me, the first time I’ve seen it). Then of course there was the matter of figuring out how the defibrillator worked (an area where I will freely admit that once I got them to go along with me, the nurses were better at the mechanics than I was). We shocked him once, and it worked almost immediately.

The entire event felt surreal. For one thing, torsades. I was starting to think they were purely a textbook phenomenon, like Janeway lesions and Osler’s nodes, antique entities that no longer visit us in real life. Then, the nurses. They were specialty cardiac nurses, twice my age, but seriously? They’ve worked with me off and on for two years. Why didn’t they recognize that it was at least some variety of vfib, and why were they arguing with me? And lastly, the defibrillator worked immediately. That made the whole thing feel like a badly scripted episode from ER: conflict between resident and nurses, and then the defibrillator working like magic. I was so surprised by that, it took me a second to think of what we ought to do next (intubate the poor fellow, who was still blue, despite a strong pressure). (And for icing, the interns standing by gaping at me and the nurses. Yes, it’s June. Yes, these were the old interns. Don’t ask any more questions.)

In any case, for all the chaos, it was the most perfect code I’ve ever been to, and the most perfect code I’ve ever run. So much nicer than the usual asystole arrests, where you can’t shock, just do compressions and push drugs and it never really works that well. Next time I’m going to see if I can not blank out when looking at the defibrillator.

(And yes, as various people pointed out to me later, the textbooks also say that magnesium is the appropriate treatment for torsades. To which I say, 1, I’m not going to discuss whether I remembered that detail or not; 2, in any case, in a code on a regular nursing floor, one has a much better chance of getting the defibrillator to work than of finding magnesium and pushing it fast enough to make a difference. Next time, we’ll schedule the torsades, and arrive with magnesium in hand. The discussion with the nurses was about the diagnosis, not the treatment.)

 

hindsight

Most of the residents on call that night were women, and it was a very bad night, multiple disasters at the same time. Towards morning, a couple of us were standing in the hallway, in between ICU errands, propping up the walls and playing one-up: whose disaster was the worst. One of the older nurses walked by, one of my favorites (her name and her face remind me of one of my aunts); she saw how tired we were.

“You doctors don’t get enough credit,” she said. We figured she had to be joking – what nurse would say that out loud to residents? but she went on. “It takes some special drive to do what you do. We nurses complain sometimes, but when was the last time any of you worked a 40 hour week?” We nodded slowly, realizing that she was serious. “When I was young, getting out of school, there were no female doctors. It couldn’t be done. It really was the old boys’ club. Good for you.” And she disappeared down the stairs.

I turned to the other residents. “Maybe we should have let the old boys keep their club, and we could be sleeping.”

Sarcasm aside, I can’t believe she actually said that to us. Maybe there’s hope for relations between senior nurses and female surgeons.

 

midnight special

 Night shift is like a nonstop final exam. Remember how waiting for the test score was sometimes harder than studying for the test? Nights is a series of problem-solving exercises, where you have to come up with your best explanation and plan, then leave the building. You come back twelve hours later, and like it or not, the answer is up in public view. The rest of the residents and attendings on that service have had all day to think about it, and the official position is out: you got it right, or you missed this or that diagnosis or test or medication, and everyone knows.

 

I need a handbook, something like “Medical Spanish for Dummies,” maybe “How to Break Bad News in Three Easy Steps.” Last night was the worst test ever: a CT scan so bad I had to look at it three times before I completely realized how bad it was (and then radiology was overwhelmed, and perhaps felt I’d used up my quota of over-the-phone consults, and couldn’t read it for me till two hours after I needed it). After a few bad experiences early in the year, there’s a couple of conversations I try to avoid having with patients: being the first one to tell them they have cancer, especially as a consultant; giving bad news in the middle of the night; giving bad news without a family member available for support. So I looked at the CT another three times, to see if I could get out of it, and I couldn’t. How do you tell someone, You’re going to die within the next few days; I could try to stop it, but you really don’t want me to. And then, in the textbook scenarios, the patient is supposed to have something to say to that: questions, denial, grief – something. When they don’t say anything except, OK – you can’t even really try to comfort them, because there’s nothing left to say.

 

As if that wasn’t bad enough, then I felt obliged to call their family and explain the momentous decision we’d made. No one answered the phone, so I thought I had escaped at least that difficult conversation. Then, ten minutes before the end of my shift, the family got my message and called back; so I did have to tell them. I could have deferred it to the primary service (we were just consultants), or to the daylight team that I had already signed out to, but although I try not to be the one giving bad news (I think I’m still too junior to be the one making life and death pronouncements), I despise doctors who dodge their responsibility, and let days go by without telling patients and families the bad news that the medical team already knows. I was the one who’d read the scan, talked to the primary service and my attending, and had the discussion with the patient. So I talked to the family, on the phone (even worse than in person; another rule from medical school – don’t give bad news over the phone), stammering and repeating myself and hiding in a forest of medical details. They understood me, though; the only question was, how long do we have?

 

(And how do you answer that question, anyway? I’m in the business of trying to keep people alive. I’m not really familiar with how things go when we decide to give up. All I could do was make a guess, and warn them that I could be off by several days in either direction.)

 

So then I had to go home, and try to sleep, and wait to come back in the evening and find out –if the radiology attending agreed with our preliminary reading of the scan (what if I had made all these dramatic statements, and been wrong on the diagnosis?); if the surgery attending agreed with my assessment of how bad the prognosis was; if discussion with the family in the light of day changed the decision about whether to intervene or not. I couldn’t decide whether to wish that I had been flamingly, humiliatingly incorrect on all points, and the patient would do better than I thought, or that I was correct, with all that implied for patient.

 

I was right.

 

I don’t feel any better.

 

relativity

Finally, I’ve figured what is so fatiguing about night float. The shift is only 12 hours, so we actually spend less time in the hospital per day this way than usual. But no matter how hard I try to believe that it’s a normal day (at night), it’s impossible to completely ignore the fact that I spend two days in the hospital, but go back each evening on the same day that I started. So I spend less than a day at home, and two days at the hospital. . . or something like that. Anyway, overnight feels like a longer, more significant length of time than a day.

Plus, of course, the inevitable 2am disaster; I can almost set my clock by this one, and usually from the same floor (admittedly the busiest surgery floor, so it’s not really their fault). The only question is how big of a mess it’s going to be: can it be handled on the floor, does it require moving to a step-down unit, or all the way to an ICU, and how many times am I going to have to call people at home to inform them of developments before things quiet down?

 

progress

I got to do a kidney transplant the other day. It was great. For one thing, the attending didn’t even draw a line for the incision. He just stood there, so I started measuring out for myself (two fingerbreadths above the inguinal ligament, which is a straight line between the pubic symphisis and the anterior superior iliac crest). He pointed a little higher (my fingers being a little small for the standard measurements), and then I just made the incision by myself. A small thing, I know, but a step away from the dotted line. . .

The best part was, when we got to sewing the anastomoses, he said, “You’ve been hanging out with the vascular surgeons, haven’t you? It shows.” And here I thought I hadn’t gotten enough OR time with vascular surgery to learn much of anything. It was good to have reassurance that I really have learned something since the beginning of this year (when I was on transplant).

High time to have learned something, I guess. Two weeks till the interns come, till we accept the current interns as our equals, till I’m a third year and have really no more excuses for not knowing the right answers.

 

night in the ICU

I didn’t want to ask for help because it would be a confession of weakness. But my patient was dying, really dying, all of a sudden, out of nowhere, and I didn’t know why, and I didn’t seem able to do anything to stop him. I figured it would be even worse if he died because I didn’t ask for help. So I did. I don’t know what’s worse, that I was weak enough to ask, or that the person I asked didn’t really know any more than I did, and didn’t do any more than what I was about to do anyway. The patient survived, mostly thanks to the nurses, and due to what they and I did before the help arrived. I guess it’s good, in a way. I’ve proven to myself that I can get through anything (with the right nurses). I need to stop using the comfort blanket of asking senior residents for help. If I could just not get so worried by my patients dying, or trying to, that I can’t seem to think straight. . . and why do they always do it at 3am, when I can’t think straight anyway?

I’ve mentioned the ghosts before – memories of other times when things went wrong. They’re starting to add up now, so whenever I have a really sick patient, there’s usually an analogous memory, where things didn’t turn out well. I don’t know whether it’s good, to have those to make me paranoid and anxious to check into every possible explanation or treatment option, or whether knowing the answer to those old puzzles sets me thinking down one track, unable to see what might be different about this time.

 

different angles

Another small instance of the difference between medical and surgical approaches to hospital life: the history and physical, familiarly known as the H&P. This is supposed to be a complete summary of the patient’s current problems, past medical/surgical/social history, medications and allergies, physical exam, and available laboratory data. To the internist, especially the residents, this is a work of some detail, which can occupy a few hours, and comes to several pages when written out fairly.

 

To surgeons, on the other hand, it’s a task to be finished as quickly as possible on the way to somewhere else. The rules quite reasonably require that one must be written and on the chart before the patient goes into surgery, as there are many things which will need to be known while the patient is still unconscious or unable to answer coherently. Thus, I have written an H&P in five minutes while waiting for anesthesia to get an iv into a vascular patient with a tourniquet on a bleeding limb before we go back to the OR. On the trauma service, one fills in the checkboxes on a form in between resuscitating the patient, entering orders, and paying close attention to the CT scan in progress (usually a good deal more attention is given to the CT than to the form). Even under routine circumstances, I’ve worked it down to an artform: I have my own mental template, which I scratch out on the paper and fill in known points while flipping through any paperwork that came with the patient, then scribble in the rest while talking to the patient, and fill in the physical exam bit while talking to my attending on the phone. 15 minutes, 20 if complicated. (In fact, this is one of my most standardized private methods of assessing the interns, in addition to how omniscent they are on rounds: how fast can they write an H&P? I’m a little despondent about the ones who still, at the end of the year, spend 15 minutes talking to the patient, then another 10 minutes writing things out, and only then are they ready to do orders or move on to another job.)

(Speed should not be at the expense of thoroughness or completeness. I’ve also worked out a few key questions to elicit the information that patients tend to forget, or consider not worth mentioning: a medication list is key, since it will show up all the major medical conditions (so many people feel that if their blood pressure is treated, they don’t have to list it as a problem; or elderly people may not know that they’ve been diagnosed with heart failure, but the combination of lasix and a beta blocker will suggest the possibility); are there any other surgeries you’ve had; do you have diabetes?; anything else you’ve been treated for? etc. On the plus side, if you need an H&P really fast, the history of present illness is usually pretty quick and obvious, eg patient fell and cut arm on glass 3 hours ago and has had tourniquet on ever since then, complains of numbness and paralysis in arm. Plan, will go to OR right now.)b

 

work ethic

Last year, I mostly viewed the scutwork the seniors demanded as an exercise of their power, nothing else. I did it, of course, but I couldn’t really see why they didn’t just do it themselves. Why the interns and juniors had to write all of the notes in the morning, write most of the post-op orders for the seniors’ own cases, write the post-op notes on the patients the seniors had just been operating on – it seemed rather pointless; or rather, too pointed: they got the fun of operating, and I got all the busywork.

Now, with a little more experience in the OR, I can see more reason to it (or perhaps, now only a year away from being a senior myself, I’m starting to rationalize giving a lot of the work to the intern). For one thing, the work hour limits hurt the chiefs a lot: simply being present for all their cases takes pretty much all the available time. Being in the hospital a few hours early every day to round would put them way over. Nevertheless, the good ones seem to know more about their patients than I do, for all they spend less time on it. The most fearsome chief I had this year seemed to be able to put me in the wrong every time we sat down to run through the list: despite having been in the OR all day, and me not, there was always some test result, some lab value, some change in the patient’s condition, which he knew about and I didn’t. He wasn’t trying to do anything in particular to me, either; he was just taking care of his service.

For the rest, writing orders and helping to get cases started, I’ve realized that “simply” doing three or four cases in the day can be quite tiring, and it’s only kindness to the seniors to use my energy instead of theirs to move in and out of the OR. (My hospital has an inefficient OR setup; neither the OR staff nor the anesthesia staff has any motivation to move quickly. It doesn’t decrease their workload or their hours, or improve their pay, to turn things around quickly. This leaves the surgery residents as the only people who really care whether it takes twenty minutes or fifty minutes to get the next case started, so the day will move more quickly if there’s one of us turning up to make sure that the patient has in fact arrived in pre-op holding, that their pacemaker is being turned off appropriately, that the CRNA is aware when the scrub tech is ready for them to come back to the room (instead of both parties sitting waiting for the other to call, as I frequently find them doing), that there are enough hands available for transport and to finish setting-up details in the room.)

So, I think my approach has changed since the beginning of internship: instead of figuring out what the chief was going to check to see if I’d done, now I look for any work at all that needs to be done, and take care of it, regardless of exactly whose responsibility it technically is. I wish I knew how to teach this work ethic to the new interns; but luckily, I think it’s primarily transferred by example, so I just need to keep doing my job properly.