internship


Okay, now I’m annoyed. I left the hospital at 8:30pm, not because the patients were so sick or I was so busy (although they were and I was), but because the attending took twelve hours to round. I’m telling myself that I’m not upset just by the time of day, but because the time was wasted. I’ve stayed till 8 and 9pm before, and not been too unhappy, because I was doing procedures, or taking care of a patient who seemed too unstable to sign out. But twelve hours rounding?

This is the attending who can be found in the hospital most nights of the week, regardless of the call schedule. This morning we came for sign-in, and he told us about something he’d taken care of overnight. “But you weren’t on call last night. You’re on call tonight.” “Yes, but I was here, taking care of some things.” Um, sure. Today, the night shift nurses had gotten their change of shift report and were ready to discuss their patients, before we finished rounding on some people. Totally insane.

On the bright side, I am now better at putting in brachial and dorsalis pedis arterial lines than I am at radials, better at IJ than at subclavian central lines, and very handy with an emergent chest tube. I skipped half of rounds, taking care of those things. (That encompasses two or three patients who are terminal, and need their families persuaded that it’s ok to withdraw care; two critical head injuries in the ER that needed to be checked on every two hours; a tension pneumothorax that came up out of the blue; an emergent intubation; and a-lines and dobhoffs scattered like pepper and salt all over the unit.) And at the end of all that, I still had a long list of things to be done; I could easily have kept busy until midnight just fixing the feeding tubes, changing vents and checking repeat blood gases, and repeating electrolytes on my patients. That’s what sign-out is for, because this stuff goes on around the clock. So now I have one hour to eat and do anything else – scribble this – before I go to sleep and get ready to start again, with another slow attending, in the morning. At least the attending today has a sense of humor, and doesn’t mind if we crack jokes about his lengthy rounds; the other attendings take themselves much more seriously, and are consequently more difficult to work with, since there’s less legitimate stress relief.

One week. I can do anything for one week, right? And then I won’t be an intern anymore.

(And to be precise, I learned several tricks about chest tube placement; got to do a needle thoracostomy (actually two, just to be sure we did it right); got enough practice to get a dobhoff feeding tube in right on the first try; learned how to calculate how many amps of bicarb are needed to correct a base deficit (wt in kilos x .25 x base deficit = meqs of bicarb; don’t ask me why, I take this attending’s word for it); reviewed what to do for traumatic diabetes insipidus; did a bronchoscopy, and got the best explanation of bronchiolar anatomy I’ve heard yet; changed another whitman patch (basically velcro over an open abdominal wound, used to gradually pull the fascia back together) at the bedside; reviewed inumerable chest xrays, head CTs, and abdominal CTs, and discussed the significance of a wild variety of findings; and had at least six significant discussions with families; and exchanged jokes with an intubated patient (and what kind of a day is it when you feel cheered up by an intubated patient teasing you? unbelievable). Put like that, it was 15 hours very well spent. Until I wrote all that down, I’d forgotten some things that happened in the morning.)

Not a great day at all. We got snowed overnight (and how exactly do you double a trauma unit’s census on a Thursday night? what happened to the concept of partying on weekends?) (although, of course, it’s the elderly people falling and breaking things that really does us in), and I came in expecting a short list, to find a combination of crashing patients brought up from the ER, and patients in extremis brought down from the floor, such that I didn’t manage to do any kind of decent pre-rounds before attending rounds. I’d seen the patients, written down the vital signs, and was staking my life on my belief in the nurses’ statements that “yes, everything’s ok, no major problems.”

They were correct, but I hate rounding on the fly. I know I’m not doing my duty by the patients, if I don’t go through all their labs separately, review the trends, and flip back and forth between recent white counts and culture results and what antibiotics they’re on, or between electrolytes and current iv fluids, or between blood gases and vent settings. If I just rattle those numbers off to the attending and make some off-hand statement about the glaring abnormalities, I haven’t done my job properly, and it makes me grouchy for the rest of the day, until I get the time to sit down and think through everything.

Today, that didn’t happen till 5pm, so I spent the day feeling grouchy, and guilty about not doing my job and about being grouchy. . . not much good there.

Plus, another patient came crashing in at noon, and I volunteered to take care of him (my fellow intern has a highly developed survival reflex which prevents him from volunteering for such disasters; his labs get looked at early in the morning, which puts him on good terms with the nurses, who don’t have to chase him to ask if he’s noticed certain aberrancies). That was what took until five o’clock to sort out. Let’s just say that my hopes for next year are reaching a very low point, due to my utter failure to perform even simple procedures which I thought I had mastered a while ago. I’m having to rethink the entire concept, including set-up, and the very foundational anatomical landmarks; I still don’t know what I’m doing wrong, and it’s very unsettling.

And then, several people decided that would be a good time to raise all sorts of interpersonal issues. . . leaving me with the impression that I’m a technically incompetent intern, a bad person, and no good at communicating even the most basic concepts. . . .

Only ten days left in this month, and I can start being a bad junior resident instead of a bad intern.

Two weeks till the new interns get here. Actually they’ll be here earlier, for orientation, but two weeks till they start working.

Last July 1 seems like a million years ago, a different lifetime. The time has flown since then; I don’t feel like it’s been as long as a year, but somehow more than a year has happened in between. I really am a doctor now, and the more I think about it, the more I think I do know enough to take care of the interns and their patients properly. It’s my new patients, four ICUs full of them, that I’m more worried about. I have a feeling I’m going to be on call 4th of July weekend; perhaps it would be just as well to jump right in and get it over with.

Most of our interns for the next year came through here as medical students, so hopefully they’ll have an easier transition than I did. I spent the longest time, that first week, trying to get between the fourth floors of two separate towers, which of course only connect on the third floor. On the other hand, they probably won’t know about our crazy computer system, and teaching them will be infuriating in that special kind of way, when you know how to make the computer move, but everyone else is just stumbling around it (which makes it so painful to watch the attendings trying to find something out from the computer, when deference forbids you to say, Here, give me the mouse, let me get it).

I understand now that peculiar grin that the previous year’s interns greeted us with, last July, saying, “It’s nice to have someone else be the intern now. Here’s the list, see you later!” And disappeared around the corner. I think I’m going to have that precise smirk – a mixture of satisfaction and pity.

My list of patients has steadied down to a group of long-term ICU inhabitants. Good, because I don’t have to figure out four or five entirely new patients every morning. Bad, because since they stay so long, they get very complicated. Rounds are always full of pitholes from the attending: “A new arrhythmia, eh? Let’s consult cardiology. Oh, we already did consult cardiology? What did they say?” “Um, actually [flipping wildly through the chart and the computer] we consulted them five weeks ago with a questionable MI, which they said wasn’t significant, and they seem to have signed off a while ago. . . I can’t see any notes in recent memory here.” “Ok. . . this drain here, where does it go?” “Sir, I really couldn’t tell you. The various operative notes refer to a drain by the liver, a drain in the pancreatic bed, two drains in the pelvis, and a jejunostomy. There’s only one tube left, I have no idea where it goes to, and I doubt that you want me poking it or pulling it out in order to find out.” “This patient initially had a heart attack? What is he doing on our service?” “Well, the heart attack led to a car accident, which led to bilateral pneumothoraces [guarantee that no medical service will accept any responsibility for the patient for the next two months], plus he broke a good many bones. Which bones? I have no idea. He’s been here so long, they’ve nearly all healed, and ortho doesn’t want any weight-bearing restrictions, if only we could get him strong enough and off the vent enough to move out of bed.” “Why is this patient on imipenem? Don’t you think zosyn [or vanco, or cefepime] would be more appropriate?” “Sir, to the best of my understanding, this is the fifth episode of pneumonia this patient has had, plus three UTIs and one questionable line sepsis versus line colonization due to pre-existing bacteremia, and as far as I can tell, the bugs are becoming progressively more resistant, which makes this the best antibiotic. Plus, at the third episode, we consulted ID, and this is what their note says to use.” [And please stop trying to make me explain ID's reasoning, since those attendings insanely round an hour earlier than the surgery residents, no doubt to avoid our questions, and their notes consist of "Events noted. Cultures pending. Continue antibiotics." Which is hardly enlightening.]

Then the attending tried to teach me to do bronchoscopy today. I think I made him dizzy. You stick this thin flexible tube, with a camera on the end, down the trachea (it helps if you have a trach already in place to go through), and move it with your right hand, while your left hand supports the piece to look through, plus controlling suction and flexing the end of the tube. Yes. And then you have to make the whole thing go left and right, plus up and down and sideways, using the unidirectional control in your left hand. Apparently the key is to turn the piece that you’re looking through around and around – and your head goes around and around, and then it won’t go any farther, so you have to spin 180+ degrees, and try again from the other direction. The attending very helpfully looked in through his scope and explained in a running commentary while I wandered around: “There you see the anterior wall of the trachea – and now the posterior wall – there’s the right bronchus – no, go down the right one first . . . all right, back out and try the left side – no that’s right, you already did that one – no, that’s still right, you need to go left – no, the other left -” I was ready to try standing on my head at one point. I got a little better at controlling up and down, but I have no idea where I was at any point in the proceedings. Fortunately we didn’t find anything, so I didn’t absolutely need to know where anything was. I guess there’s a reason the lung is diagrammed in such detail in Netter’s Anatomy.

One of my patients this month has been an amazing teacher. He hasn’t said a word yet, and I might be off the service before we get him off the vent and onto a trach that he can talk with, but I’ve already learned a lot from him.

He was in a car accident, and came in with some broken ribs. Not bad, right? So no one could understand why his vital signs steadily dropped in the trauma bay. He looked good initially, but right when the team thought they had him figured out and ready for admission upstairs, he took a turn for the worse. The on-call attending stayed four hours late, intubating him, scanning him again, starting him on pressors, fighting with the vent settings, trying to save his life, and completely lost as to what the problem was.

He got to the trauma unit eventually, and I picked him up. We spent the next three days desperately trying to figure out what on earth could be wrong with him. He seemed to be septic – but how can you be septic from the moment you hit the door? That should be something that starts three or four days in, not that gets to its worst three days after admission.

Finally, the attending who had first admitted him came back on call. He came to get signout from another attending, and found us all kind of hanging around this patient’s room. He was by that point on three or four pressors, and extreme vent settings were barely keeping his oxygen level in the acceptable range. The attending looked at the situation quietly for a couple of minutes and then announced, “He’s clearly septic, and we have no idea why. It’s time to do surgery. I’m calling the OR.” The rest of us mostly shrugged our shoulders, considered that this attending was being the worst kind of cowboy, and left to get some sleep.

The next morning, we discovered that the patient had suffered massive intra-abdominal injuries, severe enough to make him septic within hours of his reaching the hospital. Due to various considerations, our best efforts had failed to diagnose the problem. That attending operating on him – jumping blindly over the cliff, just to see what he would find – saved the patient’s life.

Lately, he’s doing better. He’s alert, which is more than he was for many days after admission. His abdomen looks like it might eventually – weeks or months from now – recover. He’s not septic anymore.

We were ready to give up on this guy. I still can’t believe that he’s actually likely to leave the hospital now. Along with the whole idea of not giving up on people till you’ve given them every possible chance, I learned from the attending: a surgeon’s job is to operate. That’s the reason our patients belong to us, because a lot of them really do need surgery. There’s a place for not operating without investigating first and having some idea what you’re going in after; but sometimes, cowboy is the only way to be, the only behavior that will give your patient a chance. Trauma is a surgical field because trauma victims often need to be operated on. When in doubt, cut (or think seriously about doing so). I’m still trying to figure out how much weight to give this lesson, but it will stick with me for a long time.

There was another patient like this last month, too, on the vascular service. He’d had a simple operation, and three days later crashed into the ICU overnight. We had no idea why. We couldn’t figure out what about the surgery he’d had could possibly be making him so sick. In desperation, the vascular surgeon consulted one of the general surgeons, who looked at the patient and the labs and scans for about half an hour, and then shook his head. “I don’t think it will do any good, but let’s call the OR for an emergency case. We have to at least look.” And sure enough, he had a perforated ulcer that had somehow randomly developed at exactly the same time that he came in to get a vascular problem taken care of. That patient also would have died within hours if the general surgeon hadn’t decided to take a chance and just look, to make sure nothing was missed. CT scans are so fancy nowadays, we think if we can’t see it on the scan, it isn’t there. The younger surgeons and residents especially tend to forget that some things can only be found by putting your hands inside and touching the problem.

The only resident I met in medical school who made me seriously reconsider my interest in surgery was rotating on trauma. In fact, he seemed to have stopped rotating, and have come to rest in the trauma unit. Between the summer transition, and the vagaries of scheduling, he was spending three or four months consecutively on trauma, either days or nights. He was not happy at all. In fact, he was downright bitter. I think his wife was giving him grief about never seeing him, but he also hated the trauma unit in itself.

“Do anything else at all, just don’t do surgery.” “I would never do this again.” “If there’s anything else you could be happy doing, don’t do surgery.”

I remember watching him walk around the unit, running from one disaster to another, placing one feeding tube after another, changing central lines all night long, his face growing longer and grimmer the whole time I knew him. He was pleasant enough to the medical students when he remembered our existence, but most of the time he was too morose to even acknowledge our presence. He was a good teacher, when he had the time, but mostly he was too overwhelmed with work to explain anything about critical care.

I remember wondering what exactly was bothering him so much. To me, it looked he was doing a lot of procedures, was saving the lives of some critically ill patients, and was perfectly at home with pressors and complicated ventilator arrangements.

Now I understand that lines aren’t as much fun when you’ve got five of them to do, and only enough time for three or four, or when they keep going bad on you the day after you struggled to get them in, or when the attending comes in the next morning, criticizes your choice of location, and insists on it being pulled out and replaced elsewhere immediately. Feeding tubes are no fun when you’re going to spend three hours walking around the unit in circles putting them in, waiting for an xray to show that you’re in the wrong place, and trying again, while the patients complain. Disasters are no fun when they keep on coming, and for most of them (folks, if you’ve got to ride motorcycles, please wear helmets) success means you’ve saved someone to live without word or motion for another five or ten years.

Most of all, I understand the frustration of having every day a different attending come through the unit, require you to defend your reasons for doing xyz to any patient, rip you apart, and insist on doing the opposite (ie, the opposite of what the attending yesterday told you to do).

All I’m hoping for is to be a little more cheerful, at the end, than that resident. I know I’ve got the long face, and I’m snapping at people, and I’ve given up on being nice to the medical student; now I just use him as another pair of hands to get the interminable amount of work done. (He’s gone at the end of the week, and from there on the work force shrinks and shrinks, till I’ll be completely alone at the end of the month. It keeps getting worse.) It’s a good thing this is the last rotation of the year, otherwise, like that other resident, I would be seriously thinking about quitting. As it is, I can’t throw away a whole year’s work just to escape another two weeks of this; but the prospect is attractive – just to walk away from this whole game, and leave the attendings to deal with it by themselves.

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.

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