Overnight call in the cardiac ICU is one of the most stressful things I’ve ever done, partly because all the patients are extremely sick, but also because of the number of people I have to answer to. By this time I am a little used to sick patients, who don’t necessarily respond as expected/desired to my maneuvers, forcing me to keep thinking of new things to try. But in this unit, I have not only a large number of cardiothoracic surgeons as attendings to answer to (and they are the most forceful and demanding of the surgeons I’ve worked with), but there are also the critical care attendings (with a level of expertise and devotion to detail that are also new to me, and a penchant for asking for evidentiary backing for my decisions), as well as the fellows, again a level of hierarchy that I haven’t dealt with much before. So many people with the potential to second-guess me in the morning make even simple decisions stressful, let alone hard decisions.

The funny thing is, with all of that pressure, I’m not getting questioned about my actions as much as I had expected. I think I’ve moved to a different level in the resident-attending relationship. In some hospitals, the interns are put in the cardiac unit, and it’s a wild ride. Here, we take a safer route, and the residents on cardiac are expected to have a fair amount of ICU experience, and to be prepared to take extensive responsibility in the unit. As a result, when not doing something absolutely incorrect, I think we’re starting to share in the collegial tolerance that exists between “grown-up” doctors. We know that there are several acceptable ways of getting the same thing done (you could use fentanyl, versed, or propofol for sedation; you could use one super-antibiotic, or two weaker ones with cross-coverage; you could operate based on clinical findings, or you could double-check with a CT – no big deal as long as things are stable), and so we learn not to criticize colleagues who don’t do it exactly our way – as long as the job gets done, and the differences in method don’t threaten the patient.

It’s a strange sensation, but I think I’ve started to reach a point where I’m allowed to make some decisions in that atmosphere. We might have an academic discussion because the critical care attending prefers fentanyl to ativan, whereas my experience has been to avoid narcotics unless I think pain is contributing to the agitation; but I’m not in trouble for doing it one way or the other, unlike how I might have been last year, three weeks ago. The more I think about it, though, that only increases my responsibility. . .

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