internship


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.

Probably the person that I feel most sorry for, over the last month, is the neurosurgery intern. At my hospital, the neurosurgery intern belongs to general surgery for eleven months, and then in June, the mother ship comes for him and he gets swallowed up by the neurosurgery program (which, since it has twice as many attendings as residents, and all very busy, does indeed literally swallow up the residents). He’s doing q2 or q3 call now, and can be found in the hospital, running between the ICU and the ER, at basically any time of day or night, any day of the week. He will be doing this for at least the next year, as the junior-est of the neurosurgery residents gets worked to death by the attendings, and by the rest of the residents who regard it as their turn to stop taking q2 call. He looks about ten years older, already, than he did last July, and I think greyish-yellow comes close to describing the color of his face. Actually he’s amazingly cheerful about it, which I guess is the only practicable response.

I shouldn’t feel sorry for him, really, because he chose this, knowing what he was getting into. In fact, he claims this program is nice to its residents, compared to some others. I tell him I don’t even want to imagine the others, in that case.

For an intern, having graduated from medical school at the same time as me, he knows an amazing amount about neurosurgery. He must be truly in love with it. I, and even my senior residents, respect his opinion when we talk to him about trauma patients (which is good, because half the time he’s the only neurosurgery representative easily available). That, I’m still trying to figure out. He is so extraordinarily good that, as an intern, he can give a recommendation to the senior trauma residents, and have it followed with respect. That’s not just because he represents neurosurgery. He earns that respect, by living in the hospital, studying incessantly, having made several remarkable correct calls, and having saved more than a few lives already. I’ve caught the neurosurgery attendings actually listening attentively when he tells them about a patient, which is also a rarity, and a high mark of respect. (Usually they don’t even listen to their own residents till they’re four or five years in.)

(Oh look, there’s blood scattered all over my scrubs. I wonder where that came from. I guess that solves the question of whether to take a shower now or later.)

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.)

I was dreading rounds today, but something lit a fire under the attending (perhaps the arrival of three traumas before 9am), and he tore through rounds in what was probably record time for him. We just barely made it, too, because right around 1pm the traumas started pouring in. I don’t think we got out of the ER for more than 15 minutes all afternoon (and watching the pager, they’re still coming in; it’s starting to rain now, instead of the brilliant sunshine, so maybe people will get smart and go inside). One trauma after another, and usually two or three at once.

In one sense, I enjoyed it, because I would much rather be dealing with a whirl of excitement in the trauma bay and the CT scanner rather than dragging my feet through the unit (although after about half an hour of fighting a low blood pressure on the CT table, unable to do anything else but hang one unit of blood after another, that starts to get old, too).

But by the end of my shift, it got to be a little much: so many patients that I barely knew half of the new ones, and then only their injuries. The nurses would go to ask me a question about Mrs. Smith, or the guy in room 7, and I would have to say, “Are you talking about the helmeted motorcyclist, or the unhelmeted one? Is this the 50yr old who fell downstairs, or the 80yr old? Is this the patient we intubated for combativeness and a head injury, or the one who came in tubed with a pneumothorax?” I hate not being on top of things, feeling like patients are slipping through my fingers. I can’t write appropriate orders, call the correct consults, or talk to the patients’ families if I can’t at least keep track of who’s come in. Fortunately (and I have no idea how they manage this) the attending and the senior knew everyone, so nothing got too badly lost. Also, the ortho and neurosurgery residents on today were awesome. They kept circling through the trauma bay, and thus managed to pick up all the consults that were coming to them very quickly. I love being able to trust that the consultants know which patients they’re seeing, and are as interested in stabilizing them and moving them out of the trauma bay as the trauma team is – because we all know there are half a dozen more waiting around the corner.

It was also not a bad afternoon, because everyone we were called for had a real injury. Unfortunate for them, but far less frustrating for us, than getting called to one “oh, nothing serious after all” quote trauma after another. A lot of the injuries were orthopedic: several open fractures, and one horrific foot dislocation. (You just try and picture a dislocated foot. The ortho resident walked up and cocked his head at it for a couple of seconds. He was clearly nearly as offended as I was by the extreme wrongness of the situation. Our eyes met, he nodded at me, and we each took one end of the problem, and pulled. It popped back in, amazingly enough, and then I held it with a death grip while he collected a massive splint. The patient was not at all happy with any of this, but at least a little better after that impromptu reduction. Everyone turned around to ask what all the noise was about – from the patient, and from the joint snapping back together – and he explained nonchalantly that he was just stopping it turning into an open fracture-dislocation, since the skin was so tented that it looked about to tear. An open injury to a joint, especially one as complicated as the ankle, is a disaster for the patient, and constitutes an orthopedic emergency, unlike a simple closed fracture or dislocation, which can wait a day or two to go to the OR.)

I hate fractured and dislocated bones. They turn my stomach worse than any kind of general surgical disaster. Maybe it’s because I can picture that happening to me, more easily than I can picture the rest of the stuff. It just looks so painful; I can’t stand broken bones, and especially displaced fractures jarring and grating against each other. The ortho guys get a gleam in their eye, though, and then, since I’m the intern, I always end up helping them, holding pieces together, or holding them apart while they pour irrigation all over the patient and me. Ick. That’s why I cringe when I see a motorcycle accident on the trauma pager, even helmeted, because I know it’s going to end up being a nasty fracture – and me holding the fracture.

This next week is going to be a marathon: the end of June, gorgeous weather, everyone doing stupid things with motorcycles and ATVs and waterskis, and climbing trees and roofs. . . Plus the prelim interns will all be gone, the chiefs are gone, and the assigned interns – ortho, neurosugery, ENT – have all gone off to their respective programs; overall, I think we’ve lost half our warm bodies. That’s why, in a week, we’ll be happy to have an intern, any intern, to fill spaces. As long as you can speak English and follow instructions, my eagerly-awaited new interns, you’ll be just fine. (Probably even just understanding English would be ok.)

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