night float

I have a new favorite set of dumb pages: two nurses apparently were trying to divide their work load, and were taking turns calling to ask me questions about the other’s patient. Then, an hour or two later, the other nurse would call to ask the same question, since apparently the division of labor didn’t extend to passing along the answer. I kid you not, they did this a couple of times last night. Silly me, it seemed simpler to just answer the question again than to get into it farther, so I didn’t say much.

I am now officially tired of being on night float. I get to feeling like I’m walking through a valley waiting for ambushes. It’s not so much the patients I’ve been told about – this guy has low urine output, this one will need to be admitted, we’re expecting a transfer, that one is bleeding – it’s the ones I don’t know about. The day people didn’t put any post-op orders on this complex patient, could you please write some right now so they can go to the floor? This patient has a very messy wound dressing and no one changed it all day, please come and fix. And then the number of foley consults. . . quite quite enough of those.

I don’t know whether to be happy or not that the medicine interns – now in addition to the ER folks – seem to have figured out that I’m friendly and available for asking random questions of: what do we with this gtube problem? this foley problem? this iv access problem? I don’t really know as much as they think I do, either, or perhaps it would be simpler to deal with these non-consults.

How about if we skip to April now?

Although April 1st won’t be much fun either. After working the night shift, I get to round on a new set of patients, then sit through what promises to be an extremely boring set of lectures, all morning, and then proceed with the rest of the day’s work. But it will be worth it to get off of nights. I’ll just need to find the right seat in the back of the lecture hall, and maybe get some coffee, which is always good for putting me to sleep.

There ought to be some good news around here somewhere: I’ve learned a lot about the specialties I’ve been covering, and I think I’m getting a little better at figuring out when to call for help and when not.

That was a busy night. Spent a lot of time shepherding a patient who ended up going back to the OR in the middle of the night. Although too bad for the patient, it was kind of nice to have been right about what needed to happen. Then, it seemed like every drug dealer in the city decided to shoot or stab himself in the hand, and come to our ER to see about it. Such babies. For big guys who were playing with dangerous weapons in dangerous situations, they were pretty wimpy about the results. On the other hand, they were also fairly polite about it, and quite willing to explain all the circumstances surrounding their misadventure. Made the time pass while I was suturing.

Maybe surgery residency was like this before the 80hr rule, but we seem to have a very stiff ethic about responsibility for one’s own jobs now. If something is assigned to you, you’re expected to get it done somehow, without asking other people to share the work. (This applies to tasks, not to asking for help if you don’t know what to do.) We’re pretty touchy about making it clear that we can do all of our own work. It would be lazy to ask, or allow, another resident to help out; and laziness is regarded by residents and attendings alike as most of the seven deadly sins.

This was brought up because of the [rare] episode of a surgery resident and medicine resident being on the same team. The medicine resident offered to help fill out some paperwork for the surgery resident, who was shocked. They were his charts, and he had every intention of taking care of them himself – somehow, no matter how late he had to stay for it. The whole group of us then spent an entire lunch time dissecting this difference between the medicine and surgery cultures. I think the point, for us, is that we want to prove to ourselves (and to our attendings, if they’re noticing) that we’re not slacking off just because there are relief shifts.

So I’m trying to figure out the subtle line where, without implying laziness in someone else, I can still offer to help when another resident is truly overloaded. Especially when one resident is being pretty frankly abused by one of our worst seniors/chiefs. There’s no shame in accepting help when you shouldn’t have been given such an assignment anyway. On the other hand, this is also the attitude that lands me with cleaning up constantly after the weakest interns in the program.

If you’re wondering about the lack of Easter posts, it’s because the Orthodox Easter, which is the one I plan on celebrating, is not until April 27th. Our Lent just started two weeks ago. So Happy Easter to you Westerners (and Protestants – meditate on the fact that the date you celebrate Easter is still determined by the Catholic Church ;) ), and if you want some Easter programming, go back to April 2007, when I had the time to blog pretty extensively about Passion and Resurrection.

Congratulations to all the students who matched this week. Make the most of your time from now till July.

My program filled its places with good people, and I’m looking forward to having them around in a few months. If I have to be a junior resident, they will make good interns.

I made a new rule last night: no peanut gallery when I’m suturing in the ER. I know, that’s supposed to be a basic ground rule. The last few times I let it slide because the family member was somehow medically informed, and very interested, or because the injury was so traumatizing I felt like the patient needed to have more support than just my chatter during the procedure. However, I draw the line at three rednecks joking about matters while I’m trying to figure out which tiny pieces get cut off and which pieces get sutured down. (And I try not to use derogatory words like rednecks, but they were.) I don’t mind the patient asking the same questions over and over (“you said what happened to the bone?” “what’s that piece there?” “did you say I’m not going to lose the finger?” “where’s all the blood coming from?”) because, after all, they’re hurt, and they’re being patient enough to sit still and let me jab needles in them. But the same questions multiplied by four from the gallery, and teasing all around, in a tiny ER room, was too much. I’m afraid I wasn’t too gracious about it; I need to think of a good invitation-to-exit line. But I felt like things went smoother with them gone.

And then there was the poor patient who had a broken bone on one side, so I put a splint on it, and when I was done I didn’t feel 100% satisfied with the arrangement of the splint. He was complaining of pain on the other side, so I xrayed that too, and lo and behold, that side had a fracture too. So I put that splint on perfectly. Makes me happy; I don’t know how he feels about it.

Due to some convolution of hospital politics (of which no one has really informed me; I deduce its occurrence by the effects on me), I find myself covering yet another service, about which I know even less than some others. Talk about sink or swim. Fortunately none of the patients I’ve handled like this have been truly sick yet, although they always come billed as something quite frightening, and it takes a little investigation to assure myself that they’re actually stable. Also the attendings are still new enough at having resident coverage at night that they actually appreciate my calls – unlike some other attendings, who now take us for granted and regard my calls as a nuisance.

At one point tonight I found myself wandering into the ICU to check on one of my few patients there; I didn’t really want to check on them (since the simple act of a doctor looking at an ICU patient tends to remind everyone of previously ignored issues that need to be addressed now), but somehow I felt like I had to. And there around the corner was another patient crashing. So I got to watch the senior resident taking care of him, for quite a while, which was instructive. I think a major part of his technique consists of putting his hands in his pockets; it’s hard to get too agitated in that posture. I need to practice that.

Lately I’ve started shadowing the senior residents as intensely as, a year ago, I watched the interns. I can remember making quite a nuisance of myself back then. I know this, because the medical students now are nuisances: very eager and enthusiastic and anxious to learn – but only the fact that you can never again leave the hospital early makes one realize how special it was to be a student who could be sent home, or to bed, away from the boring routine chores. So I don’t really mind the students being there, but somehow the fact that they could be free makes me mind having to do the chores even more.

And now I’m hanging around the senior resident at night, asking intrusive questions like, who did you call? why did you call them? what are the rules for calling people at night? why did you do that? why did you pick that medicine? because I’ve only got three months left of being a carefree intern (used to think that was an oxymoron). So far he’s being very nice about it, explaining what he’s doing; I think because he knows quite well how terrifying it will be to pick up those responsibilities in July. It’s good for me to watch his style, because I think up to this point I tend to imitate Brad a lot; and he is way too much of a cowboy. He has the experience to pull it off; but I don’t, and it will be good for me to imitate a resident with a little more restrained manner.

Which brings up another point: now that I’m a little more comfortable with taking care of patients, and then calling somebody who’s outside of the hospital to tell them what happened and ask for further advice, I’m able to feel guilty for waking people up. They, after all, have to come to work the next day. It makes me feel really bad to wake up people I like, and hear them struggling to pay attention and think about the question. That’s also not going to be fun next year, having to call the same person several times a night, especially knowing that they’ve been up in the hospital the last couple nights.

Not a fun night. One of the services I cover did its usual crazy thing, admitting three patients right at sign-out, and spending five hours in the OR with one of them. I’m getting a little tired of working with the intern on this service. He means well, and I don’t think he’s deliberately neglecting things; but it’s getting to the point where I feel I have to double-check every point he tells me in sign-out, otherwise the nurses will be calling me at 2am: “this patient is for the OR today, did you mean him to be NPO?” “this patient just started coumadin, do you perhaps want an INR drawn this morning?” “this patient got a transfusion, would you like to check the hemoglobin count?” “this patient was admitted the other day, would you maybe like to write an H&P for him?” and so on.

Then, the ER called us with the most outrageous consult. There was no imminent surgical issue – maybe in a few days, maybe – and the patient was to be admitted to another service, but somehow we were called to see the patient in the ER before the admitting service was called. I and the senior resident got so frustrated we actually started arguing with the ER attending, who is a frequent offender on such points. Usually as a resident you try not to get into it too much with attendings; but still. And then there’s this other ER resident who is making a habit of calling me the minute a surgically-related patient hits the door, without having even labs, let alone basic imaging (I mean xrays; I support the idea of not scanning people unless the surgeon asks for it), sometimes without a complete history or physical. I mean, he’ll call me about vascular issues without bothering to check pulses, based simply on the report he was given. I keep meaning to make an issue out of it, because all it does is make me wait in the ER for an hour before I can call anyone (because you bet I’m not calling my attending without a white count and a creatinine), instead of him waiting for an hour before calling me (because once he’s called me, I don’t dare to simply wait for the labs to come back before looking at the patient; maybe the patient is acutely ill and requires emergent intervention without labs; hasn’t happened yet, but it might). But then every so often there’s a delicate patient who I am happy to hear about quickly, so I haven’t managed to argue about it yet. And he’s senior to me, and thinks he’s being efficient, which also makes it difficult.

Finally, and this is the real reason that I am fed up with the day intern, I had to manually disimpact a patient, for the first time in my career. (Yes, I know, you’re not allowed to be done with internship, especially surgery internship, without doing this; and it so serves me right for the time I was a medical student, and ran away from helping a resident do this.) I’m not completely sure how this is the day intern’s fault, but I’m sure it connects somehow, so I’m blaming him.

Back at the beginning of the year I heard some conversation among the seniors to the effect that “it’s your worst nightmare, to be told that your patient is coding and so-and-so is running it.” I couldn’t imagine how they could say that. Now I know. There are a couple of people who already make me uncomfortable when I have to sign patients out to them. Maybe I’m just being arrogant; who knows how the other interns feel about leaving patients with me? I think I’m at least diligent, but I make lots of mistakes.

Plus, my pager broke. All the floors except for the one that pages me most often were still getting through, but the nurses on that floor became convinced that I was deliberately ignoring them, and started telling all the other night staff so, before I heard about it. Bother. I was surprised to find out how much of my identity is tied up in that little pager. I had to trade it for a different one, and I felt disoriented all night. I have my buzz, and my alarms, and my screen style; and without them, I forget how to process calls. Fortunately it’s fixed now.

It’s amazing how good a solid night of studying makes you feel. I only got paged about urology issues, which are also very satisfying, since they call for a quick, relatively risk-free and painless procedure which makes the patient feel better pretty quickly.

So far I’m 30% of the way through The ICU Book (300/1000pp) (and only 3% of the way through The House Officer’s Guide to Urological Emergencies, which perhaps I ought to be reading more of, but somehow it’s not very gripping).

I’m starting to have mixed feelings about the book. On one hand, it certainly contains such wildly relevant and fascinating subjects as, five continuous intravenous vasoactive medications (otherwise known as the five pressors, which about half the ICU population are on, and about which I’ve been frightened and curious for the last nine months, but never before found a concise explanation of), and, three easy algorithms for managing acutely decompensated heart failure (as well as how to differentiate between right and left sided, systolic and diastolic, subjects which are of very little interest to surgeons, but of intense interest to the gremlins responsible for coding diagnoses in such a way as to extract the utmost amount of compensation from the insurance companies) (and one of these days when a senior resident remarks, “ah, ejection fraction of 65%, their heart is fine,” I will reply, “65% is actually a little high, and if you notice, the report also mentions left ventricular hypertrophy and decreased wall relaxation, which means actually they have a fair component of chronic left-sided diastolic heart failure;” so far, to my personal disappointment, I have faint-heartedly kept quiet at every such opportunity).

(Please I don’t want any commentary on the grammar of that paragraph; all the quotation marks and parentheses are closed; I am experimenting in the stream-of-consciousness style. . .) 

On the other hand, at least 50% of the book’s extensive cogitation seems to lead to the inexorable conclusion that sphygmomanometric blood pressure measurement is inaccurate and useless; direct arterial blood pressure measurement (in most circumstances) is inaccurate and useless; central venous pressure monitoring is inaccurate and useless; pulse oximetry is inaccurate and useless; pulmonary capillary wedge pressure measurement is inaccurate and useless; CPR is useless; crystalloid is useless; blood transfusions are useless and dangerous; pressors are useless and dangerous (with qualifications). You get the impression that only certain arcane measurements of systemic oxygen uptake, which require special bedside laboratory equipment, are of any value in directing patient care. Which makes me wonder, if everything the author is telling me about is so useless, why I’m taking the time to try to understand the equations with which he proves the futility and vanity of all ICU activity?

Besides, what I’ve gathered of surgical ICU care so far is rather simpler and more basic: we like fluids. Fluids are good. Push fluids. [cave-man accent, you understand] What’s a little pulmonary edema between friends? And don’t infuse pressors through peripheral ivs (a course of action which the MICU here pursues on a regular basis, leading to pressor extravasation into the hand and arm, which is not pretty; and then they consult plastic surgery, or vascular surgery for IJs in the carotid), or without placing arterial lines.

My senior resident this month is getting a little wary of mentioning procedures to me. He remarks that some stitches here, or a line there, might be useful, and when he turns around, I’ve done it. So far, so good; but perhaps next time I should wait to hear the end of the sentence (he had to go see an emergency, and I assumed he was done with the instructions). I think it’s a problem if even among the surgical residents I’m remarkable for liking sharp objects. I think the trick is to pretend to be a little more blase about it. On the other hand, I’m satisfied that I’m now competent at using the little throw-away suture removal kits as procedure kits. You open the kit, and arrange the paper cover and the little plastic tray in such a way that they make a tiny sterile field that you can put sutures and needles onto. Then you pretend that the flimsy blunt-tipped pickups are useful for holding tissue with, and you force the scissor’s jaws shut over the needle till they snap past each other and lock the needle between them. Then, if you move very carefully, this will hold the needle steady enough to take a stitch with it. This method is primarily desirable in that you don’t have to go hunt a procedure tray out of the OR or the ER (even most of the medicine floors have suture removal kits, though some benighted units don’t); you can throw the whole thing away when you’re done; and you can place a suture and cut the suture with the same instrument – versatility, you see. Plus, you feel like a surgical Boy Scout. (I believe there’s an Eagle badge if you perform an entire appendectomy in this manner.) Even a few months ago, I couldn’t handle the break-the-scissors-in-order-to-hold-the-needle maneuver, and always had to be fished out by a senior. I am now ready to teach this technique to next year’s interns.

Last night was slightly better, as in none of my patients crashed, I didn’t have to talk to any of the people involved in last night’s debacle, and that patient continues to do crazy things, but seems to be surviving them. One of his nurses paged me tonight: “Alice! I knew you would call me back. I’ve been calling cardiology and pulmonary, but they don’t answer me.” I guess sometimes reliable is better than – intelligent. I managed, that time, probably because I was more awake than the consultants had been.

One of the services I cover is in a permanent state of disarray, so sign-out consists of: these patients had surgery today, those ones are having surgery tomorrow please make sure their papers are in order, I don’t know what these three people are doing on our list, look here are two new consults could you see them, and oh here are two new admissions, I have no idea what they’re doing here, please see them and write orders. To which I say, helpfully, let’s call the OR office and see what these mystery patients are booked for; let’s call the nurses and see why they were admitted; let’s look up the orders and see why the consults were placed. I’m trying not to be frustrated with the guys who sign out, because 1) they’re definitely out of their depth, and 2) the service is so insanely busy that even with the best will in the world and the strongest work ethic, they still wouldn’t really get all the work done. I have to keep reminding myself to withhold judgment until I do this service myself in a few months. It’s a sign of how hard they’re working that the patients they have had time to see and work on are usually in very good shape and need little help overnight. I’ve had other interns who signed out as though things were cleaned up, but then their patients had disasters all night, which turned out to have been brewing all day and had never been attended to.

An interesting call from the ER: “This man was brought in with suicidal ideation, and we found incidentally a vascular lesion. Come and give clearance so psych can admit him.” I had some difficulty to persuade the ER resident that, however suicidal the guy might have felt, his current weakness was not due to intentional neglect and a will to die, but to pure medical illness. Once you get old enough and have a long enough medical history and medication list, suicidal ideation ought to be a diagnosis of exclusion. Calling psych, for this resident, was easier than finishing an extensive and frustrating workup.

Funny, now that I’ve collected a small stack of useful textbooks, my free time at nights has evaporated. Shoulda known it was too good to last.

The thing I hate about sleeping in the hospital (and sometimes at home, too) is that I can never tell the difference between pages I really get, and the ones I just dream about. When I’m napping in the call room, I wake myself up every half hour or so (in addition to real pages) by imagining that my pager is going off, and that I’ve talked to someone about some emergency that I need to deal with right away. Then I drift back to sleep, and wake up five minutes later, panicked about having missed something, and trying to remember what the problem is. If I don’t wake up thoroughly at that point, I can spend the rest of the nap fighting subconsciously about that nonexistent page – or sometimes more than one. I even imagine whole conversations with nurses or referring residents, and detailed histories of the patients I’m irresponsibly ignoring.

So far my only solution is to be meticulous about making a note on my papers about any real calls that I get, since I do have to be fairly awake to talk to real people on the phone. Then when I really wake up, I look at the papers to see if there are any new patients or emergencies that I haven’t taken care of yet. I haven’t ever really missed anyone, but it makes for pretty restless naps, with a lot of adrenaline surges.

Maybe on a Freudian level the problem is that I feel guilty for having the quiet time to sleep, so this is in compensation. Result of being a white cloud, I guess.

Just spent nearly the entire night working on the most horrible hand injury I’ve ever seen. I brought some textbooks, planned to study conscientiously all night, got bored, said it too loudly, too many times, and of course got called by the ER. (Note: even more certainly than the taboo against saying “quiet night” is the rule against walking into the ER without having been called; it’s just asking for trouble, and you’ll always get what you ask for. I was going to look for some ivs to start, but instead I got this.)

It was messy, nasty, bloody, bits and pieces hanging out all over the place. I didn’t particularly enjoy that part of it, but with the patient and family looking so horrified, it’s not too hard to keep calm, act like you’ve seen it all before, and try to normalize it for them by showing that you, at least, are not disturbed. The really bad part was that the poor guy had just essentially lost his hand; not all of it, but it won’t be much good to him after this, and he knew it. He won’t be able to work, not as he’s used to, and he knew that, too. And what could I say to help with that?

To my surprise (after I’d gotten started, I remembered that back when I was doing plastics, I never managed to get a digital block to work), my digital block worked very well, right off the bat. (injecting local anesthetic in a few exact spots at the base of the finger to specifically numb the digital nerves that run on either side of the finger, rather than having to put anesthetic all around a large injury) I guess I’ve learned something about needles and anatomy since July. I think I did a good job for him, but it’s hard to feel satisfied, considering how un-useful any kind of a good suturing job is to him.

Right when I finished, and was starting to work an another hand consult in the ER, a nurse stat paged me from the floor: “There’s bright red blood pouring out of the patient!” She sounded so panicked I didn’t try to figure anything out over the phone, just asked her to hold pressure, and ran up there. There was no bright red blood, just a small pool of brownish fluid, and the patient sitting there shaking his head. “I feel just fine, it’s nothing, I told her that, I don’t know what y’all are so excited about.” After investigating a little, I agreed with him, and went back to the ER. I mean, the difference between bright red and dark brown is fairly clear, don’t you think? But at least I got good practice, running through in my head what I would need to do if it was real. And one should never complain about a patient not bleeding.

I was being cocky, daring the ER fates, by talking about being bored. I learned my lesson for the month: bored is good.

I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great.

They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities.

Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don’t need a large chest tube). The nurses seemed equally uncertain about where to find the supplies, or what to do with the supplies once we had them. Meanwhile the patient’s vital signs became more and more unstable, reminding me very unpleasantly of those questions which occur on every single test from third year medical school up till specialty boards, about the patient with hypotension and tachycardia and absent breath sounds on one side, who will die unless you perform an immediate needle thoracostomy. If you wait and do a chest tube, you always get the question wrong. Now we see why tests are bad for you, because this patient was still ok, but I have seen so many of these questions on tests that I got needlessly concerned about the possibility.

Fortunately at this juncture a senior resident wandered by, noticed the large congregation in the room, and stopped to see what the fun was. He pointed out a couple of errors I was about to make, and with his supervision the catheter got in the right place. (Rather to his surprise, since he seemed not to have done many of these either.) Everyone relaxed. The senior resident left to attend to his own patients. The congregation dispersed.

And then it turned out that the patient had inadequate iv access. Very inadequate. Moreover, nearly every site you could imagine trying was unuseable, for various reasons, including the fact that several attendings had already tried to place central lines, and failed. The nurse, however, continued persistently to fiddle with the lines, and every time I suggested giving him some treatment (because his blood pressure continued to be erratic), she would remark, “That’s fine, but how do you want me to get it into him?” and continue with a litany about how every line was either blown or already in use. So (again with a little supervision) I put in a line, in one of the spots that the attendings had already failed on. That’s why I’m now inordinately pleased with myself; and it’s nice that the senior residents kept walking by and being impressed, too.

I feel like a surgeon. I can do (difficult) lines and procedures on an unstable patient, and be successful, and the patient survived (so far, at least). I made some other decisions, too, which caused the seniors (who were suddenly much more interested in hearing about my problems than they were the last couple nights) to raise their eyebrows and make remarks about clinical indications or the absence thereof – but the morning labs bore me out.

I know that tonight I will get in trouble, because it’s impossible to be so happy with myself, and not make a mistake. “Pride goeth before a fall.” So I remind myself that I was being supervised (some of the time), and that really it was more my good luck that things turned out ok, rather than that I knew precisely what I was doing. Moreover, next year I’ll need to handle, not one, but several critical patients at the same time. This one alone occupied my whole night. I still have a long way to go to being able to balance several ICU’s worth of patients – in four months.

Part of the fun of the night was working with the ICU nurses. They make a great team for each other, always moving to share work whenever anyone’s patient becomes too critical. For this particular patient, since it was such an unusual case, and neither they nor I knew much about what to do, we got along very well: they told me whatever they could remember of “what we did the last time this happened,” and I told them the specifics that I had gathered from the attending’s hasty and detailed instructions, and we did fine.

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