internship


Again, so annoyed and frustrated I can’t talk. What’s especially bad is that the rest of the trauma ICU knows it: the nurses are commiserating with me (which I shouldn’t let it get to that point), the rest of the residents are teasing me, and so far the attending thinks it’s funny that I’m nearly biting my nails off, and literally pacing the halls in frustration as he spends half an hour rounding on each patient. I simply cannot stand still and think about one thing for that long.

It’s a different attending these couple of days. He’s a nice enough person, but he’s so slooowww. . . It feels like nails grating on a chalkboard. And I feel guilty, because he’s being thorough, and an extremely good doctor – but I wish he would delegate some of this to me (place this feeding tube; change that line; check on this, check on that) rather than doing everything himself, while we all watch him, forever.

I went into surgery in order to avoid having to do the same thing for more than ten minutes in a row. I can’t even study for more than fifteen minutes, without taking a break – at least into a different textbook, if not into a different subject, or even a novel for five minutes. I can think about the same patient in my own head for maybe ten minutes, max, if they’re really sick or complicated. After that, I go on to another patient, and come back later if there’s still something to be dealt with. Definitely a failure of concentration or commitment or responsibility on my part, but I get bored too easily, and then just staring at the same thing doesn’t do anybody any good.

So this month is just torture for me. Even on other services, rounding for two hours, at least we were covering thirty patients, and kept moving. This infinitesimal progress – eight hours for sixteen or twenty patients – is unbelievable.

I got in the OR today, I did a Swan, I placed a couple feeding tubes, and did other hands-on things, but they were so interspersed in the interminal rounding that I got almost no satisfaction from them.

Three weeks left in July. You would think I could survive an ICU for three weeks, maybe. If I stop blogging, you’ll know it’s because I started climbing the walls and they admitted me to the psych ward. Maybe coloring the walls red and purple; that might be more fun.

I’m so frustrated and annoyed, I’m not going to write anything. Some of the attendings are driving me crazy, and so are some of the seniors.

The patients themselves are not bad, especially since I seem to have randomly picked up all the people who are chronically on the vent. I’m familiar with them now, and am getting used to the slow dance of changing one vent setting (oxygen flow, pressure, volume, rate) at a time, and waiting to see if they’ll gain the strength to start breathing on their own again, while keeping a careful eye out for pneumonias which will knock them back by at least a week.

Now if some people would teach, instead of making criticisms all the time, and about things that I didn’t actually do, or had a good reason for doing but they won’t let me get a sentence out enough to even suggest that I had a rational reason for my actions. . .

I’m not talking, see.

One of my patients died today, the first time that I was actually around for such an event.

He was kind of a hopeless situation from the time he came in a few days ago, but we gave it our best shot. His family knew the prognosis was bad, and today when some tests confirmed that he had basically no brain function left, they agreed to withdraw care. I talked to them from the beginning, putting out the likelihood that he wouldn’t recover and that a decision would have to be made. Today I was trying to hide, letting subspecialists talk to them, but of course it wasn’t that easy. “Alice, we finished our discussion, now they’re asking to talk to you.”

The family seemed like great people, a strong family. They had a spokesperson who asked questions, and then announced their decision. I told them what we would do (having just carefully checked with the nurses, since I had never seen such proceedings myself). After the decision had been confirmed several times, we took them back to the room, and the nurse and I took out the breathing tube and left them alone together. I guess I didn’t really need to be there for that step, but I felt like he was my patient and I didn’t want to hide anymore.

I got in a corner and cried. I don’t know why, it was the right thing to do, and the family knew it, but they were so sad to lose their father, I couldn’t help it. Some time I should figure out at least how not to cry when I’m talking to the family, it doesn’t really help the situation.

About half an hour later I came back to check, and the nurse was printing an asystole strip off the monitor. So that was that. It took me three tries to fill the death certificate out correctly. (I have no idea how I’ve gotten to the twelfth month of internship without having had to write a death certificate before.) And then the coroner’s office wouldn’t answer their phone, and I had to keep calling and calling.

The weekend wasn’t quite as bad as expected. Enough sick patients and enough traumas can get even the slowest of attendings to start moving, and I like this attending better at midnight, arguing with helicopter command about the tenth ridiculous trauma alert of the evening and struggling to keep the seven car accidents and six motorcycle accidents straight, than during morning rounds.

On the other hand, I had trouble with lines again. I got some good a-lines in, hurrying before rounds started. (I’m afraid I drive the ICU nurses crazy. I show up right after shift change and insist on putting in lines or changing wound dressings, right then. My only excuse is if I don’t do it then, it won’t happen. I didn’t stop moving for 30 hours this weekend, and lots of small things didn’t happen, because there wasn’t time.) But for the rest of the day, all the central lines I tried didn’t work. There were good reasons, but I expect I’m making the seniors who were forced to come help rather nervous about my performance next month. Ah well, let them be; I’m nervous too.

We saved a guy’s life (intubated, lines, the works), and he woke up the next morning to yell at us about some chronic pain issue that had nothing to do with his arrest. When someone’s arresting, you have no idea what kind of person they are; but I’ve found so far that the more dramatically you save someone’s life, the more likely they are to be a nasty personality who won’t ever realize what happened, or even say thank you for taking care of me, let alone, for saving my life.

It’s long been an ambition of mine to calculate some real live TPN. Sadly, although this is a traditional and important part of the surgeon’s trade (being able to provide total parenteral nutrition for someone you’ve operated on), at my hospital it tends to be taken over by the pharmacists or by a physician who specializes in nutrition, because the surgery attendings have no interest in managing outpatient TPN. But in the trauma ICU, we take care of all critical care issues for our patients, including doing the TPN at least through the pharmacists on our team. Sunday, no special pharmacists, and the attending said to start TPN now. So, after 30 hours of being up, I tried my hand at TPN calculations. They’re not that complicated, if you can just keep your eyes open. The weekend pharmacist seemed to think they were reasonable, so we’ll see tomorrow how it worked.

It’s a routine day on the trauma service: one attending operating as fast as the rooms can be turned around (it somehow takes longer when your patients are from the ICU, because anesthesia takes their sweet time about going to get the patient, and it takes forever to package all the lines, monitors, and vent equipment, and then repeat for the trip back, plus wild stops to check and see why the ekg readings have gone skywire, and whether that O2 saturation reading is accurate or not, and did we hook the bag up to oxygen, or not?), and the other attending operating even more busily on unscheduled eruptions: come to find out, that spleen is going bad, after 24 hours of observation, time for an exploratory laparotomy; oh, undiagnosed viscus injury, five days after trauma, let’s call the OR; washout of an open abdomen that’s looking worse, fit that in somewhere. So the most senior resident is necessarily absent there, and various members of the ICU team also get called away to the OR, leaving patchy signout with the other people.

On the floor, patients are sinking at the rate (today) of about one every two hours; you may or may not hear about it until they’ve actually hit bottom. In the unit, organ systems are failing at roughly the same rate.

I have an extremely competent medical student, so competent that I am by turns tempted to give him more to do than he can handle, or frustrated by his willingness to take responsibility for things that I would have liked to have heard about sooner. But he’s so helpful, I can’t really complain.

Lines are everywhere: infected lines that need to be replaced and pulled, impossible lines that need to be placed (to the fates in charge of femoral vein vascaths (dialysis catheters), I would like, one day, to place one of these in a patient who doesn’t weigh 400+ lbs; please? the adrenalin rush from blood poring over my hands in the depths of a space that I can’t see into is awesome, like skiing down a black diamond hill by accident, but it makes my hands shake).

Plus, you have the steady stream of traumas coming into the ER, so heavy that usually only one member of the team knows about any one of them. Then that person is in the OR, and the other one gets a call: “This little lady in room 23, you know the one with a cervical fracture and a hip fracture, is in afib with a rate of 160, do you want to do anything about it?” “Little old lady who? The only lady I know about is 34 and has three rib fractures and a forehead laceration.” “Dunno who that is, but Dr. X saw this patient in 23, and now he’s not answering his pager, what do you want us to do about the heart rate?”

Or my favorite: a posse of concerned family members standing outside the room of the latest spiralling patient. You walk up, hoping to take a look, maybe gather some clues from a thorough physical exam before you go read the chart and review the labs and medications, and there are they are, concerned about this, that, and the other. Some of which is important, because they know medical history that I need to have; otherwise it’s important because letting a family get angry at you just sabotages the whole thing. We need to be on speaking terms, even if it means spending ten minutes I can’t really afford listening to them and trying to answer questions I have no idea about. (After making sure the patient is stable, of course.)

I’ve gotten used to dealing with half a dozen pages at once about floor-type issues: blood pressure, urine output, pain control. But half a dozen pages about critically ill ICU patients – in opposite corners of the hospital – plus attendings telling me I forgot to do something, PAs trying to sign out to me, and trauma alerts which set a time limit for anything else to get done before they arrive – it’s a little overwhelming. A lot overwhelming. But it’s what I’ll be responsible for, continuously, in three weeks, so I should stop fussing and get used to it.

The really bad part of this rotation is the constant sensation that I am singlehandedly responsible for some very sick people, with unfortunately very little idea of what to do about it. There are things I need to know, that aren’t in books, and no one to teach me. I’ll find out by trial and error, sooner or later; but I wish I didn’t feel so completely abandoned by the hierarchy. There’s something wrong with the system that leaves me, my first time really in the ICU, with so little responsible supervision. Sink or swim, I guess, for me and the patients, and trust to the nurses to stop me from doing (or neglecting) anything truly aberrant. A foresight of the next year, which leaves the unsettling impression that life isn’t going to get better any time soon.

Tomorrow: more of the same, with most of the alleviating factors removed.

I am, again, pleased with myself. We have a patient who’s septic from quite mysterious reasons (well, I suppose positive blood cultures ought to explain why he’s septic, except you still have to figure out how it got in his blood, and why he’s growing, as the nurse said, “everything but the kitchen sink” in there – gram positive cocci, gram negative rods; gram positive rods, gram negative diplocci; and who knows which of those to believe). (Not to mention what he’s doing on the trauma service; but that’s another perennial issue, how we end up with general surgery, orthopedic surgery, neurosurgery, and downright medical ICU patients on our service. Educational, but frustrating.)

Anyway, the a-line was going bad, and we needed another one. I spent nearly two hours on him, and had to ask for help, but in the end got my own line in the brachial artery. Which is technically a no-no, since the brachial artery (at the elbow) is the only major arterial supply to the hand (unlike the radial artery, at the wrist, which is duplicated by the ulnar artery), and if it gets in trouble, you have a serious problem. But it was acceptable in this patient, who had no other arterial access; and my first brachial line.

Plus, later in the day, running more trauma resuscitations, with the attending standing by making sarcastic remarks about me and all the other staff: “You’re forgetting something, Alice. . . You don’t know what you’re forgetting? . . . Does the patient have iv access? You can’t trust these nurses when they say they have an iv. You have to check what gauge it is. Just because it’s there doesn’t mean it’s working. These nurses don’t care about ivs, just about drawing blood. . . Are you going to get an xray? Where are the xray techs? Do they not come to traumas anymore? You are going to get an EKG, right? You wouldn’t forget that, hmm? Make sure you look at it yourself, because I don’t trust these ER doctors.” And so on. All true, that I ought to be doing those things, but really not helpful to be ripping up the staff while we’re trying to work together on something. Now I know why the seniors have all developed this particularly flat, matter-of-fact voice for using in the trauma bay. It’s the only way you can answer him.

Now if I could figure out how to stop getting chewed out by the trauma attendings for things I didn’t do – in fact, wasn’t even in the hospital at the time – life would be better. So far I and the other residents just duck and don’t say anything; and that’s the only thing to do. But I’m going to get tired of being rebuked for things I couldn’t even theoretically be responsible for.

I used not to drink coffee at all. I got all the way through college and medical school, and six or seven months into internship, without drinking coffee. I didn’t like the idea of depending on any chemical to be awake, and I knew that a coffee habit could become quite expensive.

I gave up, of course. The hospital has a very nice coffee shop, and our meal tickets work there. That means trading a real meal later on for coffee in the morning, but if you have time for coffee, and no guarantee of having time for a meal, that doesn’t matter so much.

I think it was the second month of night float when I really stopped even trying not to drink coffee. If you put enough milk and sugar in, it doesn’t taste bad. It feels like a grown-up thing to do, and it actually does help you stay awake. (Yes, I know I’m the last person on the planet to figure that one out.)

Then there was vascular surgery, lasting fifteen hours a day routinely, and I started plotting opportunities to slip downstairs for coffee. And now trauma. It’s somehow acceptable to sip at coffee endlessly on rounds, but not acceptable to actually eat anything in the ICU halls. Reasonable infection-control measure, I suppose. And when rounds go so slowly that my attention span runs out before I’ve even finished presenting my patient, coffee starts to be quite valuable, both as a substitute for breakfast, and as a means of breaking up the boredom.

————–
I had to revise my opinion of one of the attendings. I put him down for an complete bore (and one who could benefit from some coffee himself; falling asleep during your own lecture is a little extreme). The other day he found me struggling with some complicated vent settings, and instead of yelling at me for mismanaging the patient, he drew me a diagram and wrote equations until the whole thing was quite clear and simple. I resolve not to complain about his interminable rounds anymore – just the other attendings’.

There was one point the other day where all the senior residents associated with the trauma team had disappeared – some into the OR, and others apparently into thin air. The attending had also dematerialized out of the middle of rounds. Probably to the OR, but he never said where he was going, and we were left in limbo, wondering where exactly everyone had gone.

Then the trauma pagers went off. (You always know it’s a trauma page, because in the trauma unit it’s like an orchestra of pagers has started – all kinds of beeps and trills and cheeps and buzzes, in complete unison. The charge nurses and respiratory therapists and other random people get these pages, as well as us.) “50yo male pedestrian struck by car, thrown 20feet, chest pain.” You can never tell from these brief summaries, which often grossly overestimate or underestimate the severity of the injuries. They’ve even been known to report patients as intubated who are not only breathing on their own, but wide awake and talking. Nevertheless, it seemed like the kind of thing that ought to be properly attended to.

We couldn’t tell who was supposed to be doing what, so pretty soon the whole group of interns and medical students trickled over to the trauma bay in the ER. It was a good thing we did, because for a trauma that was reportedly minutes away, there was very little of the usual crowd present. So we got dressed, lead aprons and gloves, and the medics rolled in. The patient was sitting bolt upright, very quiet. We moved him onto the stretcher, and tried to get him to lie back so we could look at him. He started protesting that he couldn’t breathe, especially when leaning back, and his side hurt.

Well, that one wasn’t hard. We’d suspected it the minute we saw the page (ok, we suspected it because we’re procedure-hungry interns, and we read the trauma pages only to gauge what and how many procedures we might get out of it), and his symptoms were classic. We skipped a couple steps in the trauma protocol (actually, come to think of it, treating an immediate threat to Breathing, in the ABCs, probably counts as a good reason to leave finishing the entire survey till later) and opted for a simple chest xray and chest tube. (He had a pneumothorax, of course, quite glaring. It wasn’t a tension pneumo, but big enough to be bothersome.) By the time the seniors came around to investigate, we had a chest tube in and he was breathing better, enough to let us finish our survey and do CT scans.

I know to our friends in South Africa this will seem quite ridiculous (their medical students could probably handle a pneumothorax unassisted), but it’s always exciting to discover that you can do something completely on your own. (This makes only four chest tubes for me, counting medical school; I’m planning on several more this month. Yes, my city has quite a deficiency of penetrating trauma.) (For the non-medical folks, that means we don’t have a large drug and gang population shooting each other; which really one ought to be thankful for.)

Trauma is crazy.

I’m not going to tell you how long I spent in the hospital today, but let’s just say that for a day I wasn’t supposed to be on call, I saw an awful lot of the night float people.

Prolonged ICU rounds has got to be the definition of torture for surgery residents. That explains why we all tend to have the feeling that there is something deeply wrong with the attendings, who trained as surgeons, and are still surgeons enough to dive comfortably into trauma bellies and chests, but nevertheless choose to spend their lives rounding on trauma patients.

The day was a long stretch of boredom – staring at my hands while the other residents presented their patients, or staring at my note sheet while the attending slowly wrote his note based on what I had told him – interrupted by wild bouts of excitement: interns running a serious trauma by themselves, by accident, procedures cropping up randomly all over the ICU, a brief trip to the OR for some of us, and one or two patients crashing in the middle of rounds.

I’m going to have to figure out a way to cope with the boredom that doesn’t consist of covertly banging my head on the wall while winking at the nurses and students, or making sarcastic remarks under my breath (in concert with the rest of the team), or frankly walking away and ignoring the ongoing rounds (which is a serious temptation). I think I’ll have to revive the electronic books in my PDA. Which would mean reviving my PDA, which may be beyond my medical skills.

Nevertheless, if I can get past the interminable rounding, this month will be very valuable. I have nearly as many patients as I did on the floors, and they’re all intensive care, which means three times the attention required. I can tell already that I’ll get plenty of procedures, and I’ll become very comfortable playing around with vent settings and pressor arrangements – very necessary for my responsibilities in July.

Oh, and figuring out a way to eat at least one meal in the course of the day would be nice.

I have more stories from vascular, but the best ones are so unique, they’re almost worthy of being published case reports, so I don’t want to tell them for a while, for hipaa-type reasons.

In general, I’m going to miss this month. Usually it’s a service the residents love to hate, because it’s so insanely busy, and the patients, though wonderful people, have a propensity to spiral at any moment. You have to have a much higher level of suspicion for all kinds of things, from heart attacks and strokes to UTIs and wound infections.

But I had perhaps the best chief of the year, and one of the best junior residents, and the attendings are great. Most vascular attendings are. There’s something about the field that attracts people who like to dissect a problem with protracted analysis (for ischemic disease in the leg, you can do almost innumerable angioplasties, you can do femoral-femoral bypasses, iliac-femoral bypasses, femoral-popliteal bypasses, femoral-anterior tibial bypasses, femoral posterior tibial bypasses, and all of the above with either harvested vein or one of three different kinds of prosthetic grafts; now let’s discuss which one would be best for this patient), and yet also enjoy intense surgeries which can last all day long and get into serious blood loss and potential for complications. It’s different from general surgery, which I think tends more toward quick, clear-cut solutions (either the bowel is dead or not, so you should operate on it, or not).

Sign-out at the end of the month is time-consuming. Figure 15-20 patients per intern, plus 5-10 consults, all of whom need to be explained in rather more detail than just the nightly sign-out (which, if the person’s been there for a few days, often consists of “post-op day three, eating ok, working on increasing activity and planning for discharge; no impending problems”). At the end of the month, you need to give what surgery was done, why it was done, what the other medical problems are, what you’re doing about them (on vascular, this consists of a lot of afib-coumadin and hypercoagulable disorder-heparin drip arrangements, as well as blood pressure meds and other things), what infections they’ve got and what antibiotics have been gone through so far, how well they’re walking, what their family situation is like and how likely they are to have good help at home when they leave, in addition to who needs surgery in the next few days and who’s at risk for major cardiac or respiratory issues in the near future. Plus, it’s nice to give the next intern a heads-up about which attending wants his notes written by a certain time, which attending hates consulting endocrinology, which attending wishes you would consult all the specialty services and don’t mention medicine to him, which attending does all the fistulas, and all the details that keep you from stepping on the invisible mines. That takes 3-45 minutes, if you’re both being conscientious; and then you still have to go and get signed-out to about your new service. It’s nice when it happens on weekends, there’s more time for talking. Otherwise you find yourself running up against the end of the day, when staying for an hour and a half (total, spread out) could mess up your hours.

And then, I also like to walk around and say goodbye to my patients, especially the ones who’ve been there for more than a day. I don’t know what they think, but I’m under the impression that we have a little bit of a relationship, at least some recognition by them that I work for their surgeon and have been trying to take good care of them, and it’s nice to give them some warning that a stranger will be walking in to wake them up at 5am tomorrow.

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