ICU


I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU – a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be able to have a gigantic fight and still keep going.

Apart from that central explosion, nothing much else happened. I’m fortunately not on call tonight, which is ok with me, because the trauma pager is going off with one unhelmeted motorcycle or ATV accident after another. You may conclude that the weather is quite fine. Tomorrow morning I will have further evidence that young men are fools (for not wearing helmets) and/or sissies. (Because they all scream and cry about nonexistent or minor injuries. No one makes as much noise as the 20-yr-old guy with a broken clavicle and a lot of road rash; a woman the same age with an open tib-fib, or an older man with an open femur, or an elderly lady with 10 broken ribs, will all be much more stoic. I have had no sympathy for young men since the day that one of them had me persuaded he had a broken clavicle, a dozen broken ribs, and a broken femur, from the amount of noise he made; after giving him dilaudid, we got through CT and xray, and found that he had a cracked clavicle, and nothing else. Pfui.) (And I’ve injured myself in sports too, and didn’t scream for more than five minutes, so I’m allowed to talk.)

I continued my attempts to be in three places at the same time, to no one’s particular satisfaction. I ought to pick one place to be, and do a good job there, and then at least those people will be happy, instead of all three groups being displeased at once. I can’t somehow manage to 1) round with the attending in the trauma unit 2) discharge patients in another unit 3) be present for resuscitations in the ER, all at once. Result, patients are not discharged in a timely fashion, the unit attending is displeased because I’m not continually present, and don’t everything about all the unit patients, and the admitting attending is displeased because I’m rushing in and out of the resuscitations, and trying to get done with them as fast as possible so I can go back to the unit.

(In addition, there are a few secretarial jobs that the residents absolutely have to do, and somehow they’re always lowest on my list of priorities, which means the attendings who care about secretarial details will be out for my hide after a few more days of this neglect. I know it’s coming, and I still can’t find the time to get it done, even with spending 14-15hrs in the hospital.)

And I’m upset with myself, because I miss details on my own unit patients, and because the interns I’m supposed to be supervising turn up all day long with surprising statements like, “Shall we wait to do the CT scan till this patient has had the blood transfusion?” [what blood? I thought the count was just fine; why are you transfusing for that count? are there some symptoms I haven't heard about?] “I have to go talk to this patient’s family about discharging them to a nursing home tomorrow.” [nursing home? they're on the verge of sepsis; who said we could discharge them?] “This patient’s pain is not controlled on a fentanyl drip, what shall we do?” [how did they get on a fentanyl drip, and at that rate? how about some non-narcotic medications?] “I’m going to get a consent for a trach and peg on this patient.” [oh, nice; I thought we were going to extubate them in a few days; what went wrong?] And this kind of conversation ought not to be happening; I ought to know, and if I can’t find out for myself, I ought at least to keep close enough track of the interns that they tell me these things sooner. If I could stop running my hands through my hair when three people talk to me at once, perhaps it would encourage the interns to tell me things more.

On the plus side, I got to supervise a couple of procedures today, lines and chest tubes, and was able to refrain from saying too much, and then was able to complete things correctly when the interns stumbled. Which was reassuring to all concerned.

My sickest patient didn’t die overnight, which was a very nice thing to discover in the morning. That’s one ray of light for the day – he’s still around, still worrying all of us to pieces; but at least he’s there to be worried about.

Halfway through the morning: “Alice, what’s going on with this patient? Why don’t you know?” Alice mumbles something. “That’s no excuse. You’re filling the role of senior resident today. Take care of things.”

Uh, thanks. Thanks for mentioning the role change after I’m already in trouble. I knew I was the senior, I just didn’t realize how much the attendings count on the senior on an every day basis, which means how much they count on me, even when I’m not forewarned.

That was the beginning of the rest of the day. Back to as bad as life was in June, constantly behind, expectations on all hands – attendings, nurses, interns, medical students – that I’m not fulfilling. Patients that are not receiving the amount of care I want them to have. Jobs not getting done, because every time I pick one thing up, three other people call me about something else. And getting berated the whole time.

There’s something definitely broken inside my head. The more I get rebuked, the more I want to do better. Any rational person at this point would say, Who cares what the attendings think, their expectations are unreasonable and their comments are uncalled for, forget about them, I’ll do what I want, and let them deal with it. But no, all I can do is figure that, if they expect me to function as the chief, then I’ll come in earlier and plan to stay later, so I can do everything right. As frustrated as I am, I can’t stand not to beat this. I can be responsible for thirty+ patients, I can know everything about their labs and scans and current conditions, I can be in touch with a dozen different consulting teams whose residents understandably growl at me whenever I page them and change their answer whenever my attending asks; I can. Even if it means working fifteen hours a day all week. The chief does it, right? Why shouldn’t I?

Besides, that’s the only way life will get any better. The attendings sure won’t suddenly decide to leave me alone.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.

Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.

Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.

I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.

Events of the day included:

Me deciding to address all the attending’s pet peeves by acting on them before he did. Result, the nurses were mad at me as well as him, and I don’t think I saved much time. It did make the attending happy, though.

Attempted bronchoscopy: Attending: “Sure, you can do it with me. Have you ever done any of these before?” Me: “Yes, definitely. (sotto voce Twice, to be precise.”) Attending: “This is how it’s done, bzzzbtttbzzz (words all blurred together). Ok, go.” So whatever I remembered from the previous two times disappeared, between the attending being not wanting to do it at all, and being in a hurry, and the patient actually having a problem.

For my commenters: Attending: “Anesthesia left the a-line hanging loose again. Suture it in right now.” Me: “Yes, let me find some suture. Um, I once heard a rumor that suturing radial a-lines promotes infection and thrombosis. (Although my literature search showed nothing of the sort.” The attending looked at me as though I had just sprouted an extra head. (Note to self, not to refer to blog commenters anymore unless accompanied by evidence.)

Taught three different people how to place post-pyloric feeding tubes – on the same patient, because every time we got one in, confirmed placement, and start feedings, he’d get it out by yet another method.

And spent all spare minutes trying to adjust the ventilator settings on the sickest patient in the unit, who has all kinds of unusual methods being tried on him, and none of them are working. Only two doctors in the unit really understand his respiratory status, and of course they’re not there all the time. I perhaps flatter myself in thinking that I understand a little of their methods, certainly more than the people who say, “I have no idea why he chose these settings, I don’t understand the rationale at all, let me tweak it a little.” So all day long the people who did have a clue would walk by and laugh bitterly at my blood gases, and inquire why it was taking me all day and I hadn’t done x/y/z obvious thing to correct the glaring abnormalities. Thanks for the help, folks.

I forgot how much I hated, er, didn’t like, trauma. It’s pleasant to be back in a closed unit where the nurses recognize me, and most of them seem to like me (as in, they’re very happy to have me back around because I do scut the fastest, like reordering meds, and fixing orders that other people put in wrong, or coming quickly when they want someone to look at the patient).

On the other hand, as I said, I forgot how much I hate rounding all day. This weekend, fortunately for all who are interested in my sanity, the most annoying attendings are not rounding. The one who was, however, has certifiable ADD; so does the chief; and I come close, especially in their company. Neither of them can finish a sentence, let alone a train of thought, without jumping to something else, and then jumping back halfway through. The chief and I get along well, because I’m just scatterbrained enough to follow his jumps, and guilty of it enough myself that I can’t get as annoyed with him as other people do. (Incidentally, I don’t believe in ADD either; but it’s a convenient label that lets you all know what I mean.)

But rounds with the three of us was kind of crazy. I’d recite all the facts on a patient, the attending scribbling away and giving a very good impression of listening. Then he’d give some orders about the patient we’d just walked away from, run into the next room to check on something, come back, and ask me whether I’d mentioned a blood pressure or a fever on the patient, and what did the CT results show? So I would repeat what I had just told him. “Let me see the chest xray. Oh good.” Run back into the room to look at the pulse ox. Back out. “We need to start tube feeds. What’s the white count? Did we order a CT for the last guy? Has this person had a head CT recently? Is neurosurgery going to come see the guy down the hall?” And every time you start an answer, he moves on to the next one, then comes back, impatient because you haven’t answered the last several questions.

It works ok, because we’re all conscientious enough to make notes, and keep coming back to go over things until it all gets covered. But it does get a little wearing, and the nurses were left standing there with a dazed look, saying, “Were you talking about my patient at all, and if you were, did you decide to do anything important?”

I ran into one of the critical care fellows the other day. “I hear you’ve been stepping on my attending’s toes,” he told me.

I wasn’t sure what was coming next, and I really didn’t feel like apologizing for protecting my patients, so I answered cautiously: “It felt to me more like he was the one stepping on my toes.”

“Oh, he does that all the time. People hate it. When he’s not yelling at you, he’s playing turf wars.”

Seeing that this was a moaning session and not another episode in the turf wars, I told him my story, and he traded me an even worse one, seeing that it happened inside of the pulmonology service. He left me with the impression that the MICU inhabitants were quite pleased to have the surgery residents acting as surrogates in their quarrel with this attending.

So I won’t go out of my way for this attending in either direction: I’m not out to pick a quarrel, but I’m encouraged by this encounter not to stand for any territory grabs towards my service.

I just experienced a revelation.

I’m a doctor, in fact a not-an-intern doctor; and doctors can call the ICU to check on their patients, right? So now I can worry about my patients with great accuracy even after I leave the hospital. All those times when I’ve lain awake (ok, only for about 30 seconds before sleep deprivation catches up, but still) worrying whether something bad happened yet – now I can call and find out that the something bad did happen, and keep worrying about what has happened rather than what might happen.

Life was better before phones and beepers.

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