night float

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.

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