ICU


I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.

There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle – but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.

So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole – a hole, any hole – actually the internal ring – back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.

I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.

(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

Another memory that sticks out from my third year surgery rotation was the night I was on call with the trauma night chief. Nights at that hospital, the trauma service was responsible for all ER consults and emergency surgeries, as well as a fairly busy knife and gun club, and several major highways and intersections. So they had their hands full. The trauma chief had his own hospital-provided phone, because he made and received so many calls that it would have been impossible to function with a beeper alone.

There was one patient he was trying to see in the ER, to explain the reasons for doing or not doing surgery (I forget by now which one it was). The phone went off about three times in four minutes, and finally he handed me the phone and said, “Please take this thing out of the room and take care of it for me for a couple of minutes.” In the next five minutes, I answered four more calls and took notes along the lines of, “The patient in ICU 13 just got reintubated.” “The OR will be ready for you in fifteen minutes.” “The trauma patient in ER 34 is having increasing pain and tachycardia, what does he want us to do?” “The xray on ICU 14 came back, the feeding tube is in the wrong place, please come change it.”

When he came back for the phone, he seemed to think that wasn’t too bad of a haul. And I thought, I was ready to pull my hair out, just holding the phone and taking messages for five minutes. Am I ever going to be able to handle this in real life?

And here I am, taking pretty much the same kind and volume of calls, and so far nothing’s fallen apart. I’m not looking forward to doing this overnight, and the prospect of two years’ worth is rather depressing – but one day at a time, it’s not too bad. Eight or ten consults in eight hours, one to the OR, not too horrible. The ICUs had the sense not to make much noise, which helped. I made the ER resident quite furious by declining to admit one patient, and insisting on sending it to medicine; the fact that I got another patient into the OR in half an hour didn’t make him much happier. Most of the trouble came from the medical ICU, which gave me half a dozen perfectly useless consults, of the kind where I had to spend five or ten minutes simply figuring out why on earth they had consulted me (usually it turned out to be a reason they were unaware of, eg their consult order listed abdominal distention, whereas the patient was having GI bleeding, and really needed a GI consult, or the order listed GI bleeding, and what they really had was gallstones). Then I had to call the attending on those, and he got upset at me for wasting his time with such nonsense. Which is why within a couple of months I can see myself being quite crushing to the MICU residents if they call me with such things.

The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (“Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.

. . . ok, got it?

That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal – maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)

Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.

When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.

When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)

This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.

Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster – first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now.

There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs – and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with – hopefully not reverence, but a little respect. And looking ahead, the increasing certainty that the new chiefs don’t feel any  more confident with their role than I do with mine. . . We all perform for each other.

The unit has stopped whirling a little bit, and settled down to more straightforward feverpaced activity. I had my first patient go into a grand mal seizure in front of me – actually the first real seizure I ever witnessed, and she had to go and be in status epilepticus for nearly forever. The seniors were all off elsewhere, in traumas, so I was left rummaging through my memory of the neurology rotation in medical school, and telling the nurses, “Since this patient has been in status for the last 30 minutes, her neurons are seriously burning out now; and we’ve already tried multiple doses of three different medications, so at this point I don’t particularly care what medication that we have to get from the other end of the hospital that the neurosurgeons do in these circumstances, iv valium is the handiest thing we haven’t tried yet, go ahead and push it.” And it actually worked. After we stopped the seizures, then the neurologists, neurosurgeons, and seniors turned up, and of course all looked at me skeptically: “Who’s seizing? I don’t see the patient moving at all.” No, because she’s had high-dose ativan, dilantin, valium, and propofol, she better not be seizing. So I was reduced to imitating the seizure for them, and the EEG confirmed my diagnosis. But I can hardly feel pleased about handling it, because it makes this patient’s prognosis so bad, and the family doesn’t seem to understand yet how bad things are.

I’ve also spent too much time in the last week talking to doctors about their relatives in the unit. Something funny is up, there are so many doctors’ mother/grandfathers/aunts/cousins through here lately. It’s a tricky conversation. You have to show courtesy between professionals, and also deference, since they’re all attendings a long way into private practice, and you’re just an intern. On the other hand, mostly they’ve been in very non-surgical specialties (pediatrics, heme/onc, family medicine), so in all honesty, between their nonsurgical mindset, and how far they are from medical school and internship, I may be (and my attending definitely is) a little more familiar with the management of critically ill trauma patients than they are. I’m still trying to figure out the exact phrases to use for telling them something that they may or may not already know or remember. But they are certainly the most wonderful historians; they can tell you all the medical history, medications, allergies, and surgical history of the family member; it’s like having a walking medical record. And then there’s the concern that if I use a technical term incorrectly, they’ll walk away thinking, “What kind of incompetent residents do they have working here, they can’t even name the fractures correctly?” Mostly, though, it goes ok. Just as I would be in such circumstances, they’re very glad to get some definite information in medicalese – the guild language.

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.

Thanks everyone for the encouraging comments. I think things are getting better overall; I can handle four more days.

Today continued to be splendid. My efforts to discharge patients to the floor succeeded mainly in disgruntling the floor staff, and led to one of my . . . episodes . . . with an attending today. All the hard work didn’t do me much good, because we just admitted more patients through the ER as fast as I could discharge them to the floor.

Yes, I seem to have ticked off every single attending in this group – three of them today. That has to be some kind of record for the worst resident performance ever, wouldn’t you think? With one of them I really did something wrong – forgot something that a resident four days away from being a responsible junior resident shouldn’t forget. That was very bad, dangerous even. As everyone within hearing range pointed out to me, I can’t do that stuff as a junior resident, I have four days to mend my ways, and I’d better watch out. And I have to agree with them, which feels worse..

The other two attendings, I don’t know what happened. Apparently I’m such a bad communicator that even when I say, “Yes, sir, absolutely,” meaning, “Yes, sir, absolutely,” it comes across as “No way, you #$*&^, why are you even asking me? &^%” Or that’s what the attendings told other people they thought I’d said. Which is pretty hopeless. Because if a nurse is angry, and I respect her, I can go talk, and we usually sort it out. But there’s absolutely nothing an intern can say to an attending even by way of complete apology that doesn’t make everything worse. My latest plan is to say nothing but “yes” in the most colorless voice I can come up with, to anything that anyone says to me (except requests for pain medicine). I’m sure the only attending I haven’t infuriated yet will perceive this as incompetence combined with negligence, and then I’ll have antagonized a quarter of the attendings at this hospital. Brilliant, Alice.

On a brighter note, I took care of some sick patients today, and except for that one really disastrous oversight (ahem) did ok; a lot better, I think, in the department of not panicking when patients are screaming and blood pressures are dropping. I certainly refrained myself from paging people and suggesting calling the OR, which is a key technique (since the junior residents are relied on, at night, to sort out who needs surgery and who doesn’t, and when an attending needs to be called in from home, or not).

Four days to go, and then, as everyone as explained to me, I’ll really be in trouble, so much so that this month will look like cake. At least that stops me worrying about hospital politics, and gets me back to considering how incompetent I may be, which is slightly more cheerful, because it’s at least within my control.

I really had better not talk. I wrote a very bitter post about how angry I am at the hospital administration, but it was too nasty too publish. I’m so stressed out, between the administration’s actions, and just the ICU and trauma craziness, I’m making myself sick, which isn’t smart, because there’s absolutely no one to cover for me, so I’m not about to try to find out what happens if a resident takes a sick day (although I’m tempted to try it, just to pay some people back).

Today wasn’t so awful, I’m learning to just not talk to the attendings and then things go smoother. Tomorrow, I think the seniors have arranged things so that I get to cover the entire trauma ICU, and go to all the trauma alerts in the ER, by myself. I’m so thrilled, I can’t find words for it. I feel like the system, and people that I’ve built trust in for twelve months, are at the end of the year failing me so badly (not just tomorrow’s schedule, but other things), and I’m angry with myself for ever trusting people this much. But what can I do? I’m a surgery intern, and I have no control over my life. I have no bargaining capacity at all, nothing to stand on, nothing valuable that I hold. I belong to “the man,” and there’s nothing I can change at all. I have life and death responsibilities for my patients, but for myself I have nothing.

Ok, that’s enough bitterness for one night. Hopefully my patients all survive tomorrow, and you might hear from me later. And even if I manage it all ok, no one is going to care about that either.

Never trust administrators, they screw you every chance they get.

(For the last week, I was telling myself, at least if I have to work crazy hours and places, it’s this kind of work I want to be doing, and with these people. Silly of me. I don’t matter to these people, I’m just a number to fit into a slot. If I ever get to be a senior resident, which I’m starting to question, I know what kind of senior not to be.)

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