night float

I’m still not doing well with this independent judgment thing. I really hate having to put myself on the line: take responsibility for having gathered all the relevant facts, for having weighed them correctly, and for having chosen the right course of action – without checking with anyone else first. It’s kind of like the difference between practice test questions, when you can look at the answers right away and see how you did, and the real test, where you just have to plunge ahead, and wait a few months to find out whether you were right or wrong. That’s the nature of being a doctor, but after spending eight months accustoming myself to checking everything with a senior, no matter how confident I am, and being chewed out if I fail to do so, this is a little bit of an adjustment.

Very very uncomfortable. I spend long periods of time sitting in front of the computer with my head in my hands, trying to make sense of the patient. It doesn’t help when the way the patient looks – fairly comfortable, not too particularly sick – doesn’t correlate well with the awful numbers in the computer (white count, creatinine, fever, tachycardia, borderline hypotension, any combination of those). The nurses keep asking if I’m ok, and then they want to know if I’ve decided what to do. Ha! I tell them, “Let’s start with these two things, and I’m sure in five minutes I’ll think of some more.” So far they’re not complaining too much about me changing the plan ten minutes later. I try to limit it to one change of plan per patient episode. The second plan better be the right one.

Towards the end of the night, the pressure gets to be too much, and I call one of the other surgery residents, just trying to share my indecision. He, of course, doesn’t appreciate me trying to get him to do my work, especially seeing as how he’s got way too much work of his own to do. So far he’s been fairly decent, but I’m furious with myself. So weak. Resolved, not to call him at all for the next two nights, at least. Rest of the month would be better.

Really, it’s not worth all this worrying, because every time I break down and call somebody to check, my plan has been pretty good. A few details one way or the other, but nothing major. The differences could all be put down to individual preference. I’ve got the basic concepts – fluids, electrolytes, add this drug, cancel that one, call a consult, the consult can wait till morning. If only I could trust myself, without giving up and asking someone else.

And then the attending (encouragingly) remarks, “This is a surgery patient. You don’t need anyone else. A surgery resident should be able to manage this patient. Of course, he’s so complex that once you know how to do this, everything else is simple.” Thank you so much, doctor. That makes me feel so much happier about being alone in the hospital with him.

My job description this month calls for a lot of independent assessment, decision making, and interaction with the attendings. Half the time, I have to call very senior staff by myself, no junior resident to run things by first, and I find them making their decision based on my reporting. Apart from burns (where I knew the nurses knew almost everything, and would tell me what they thought needed to be done), this is the first time I’ve had so much responsibility. I spend a lot of time agonizing over whether it’s worth calling the attending with this issue, or whether it can wait; whether I’ll get in more trouble for waking him up at 1am and it turns out to be nothing, or more trouble if I don’t call and then things go bad; whether I’ve gathered absolutely every single piece of relevant data before I wake someone up; whether I’ve thought of every single question that I need answered, before I call. Not much fun, even when the patients aren’t particularly sick; I can’t wait to see what happens when there’s real trouble.

Plus, I find myself with interests opposed to those of the other surgery residents (my supervisors now want the patients admitted to general surgery, and general surgery of course doesn’t want to admit them). So I’m stuck between trying to please the people on the other end of the phone, to whom I’m technically and legally responsible, and trying to please my fellow residents, who are very much present right in front of me, and very much displeased with my actions the last few nights. And when they’re not happy, they let me know.

So, what with getting grief from all sides for just about every decision I make (and questions from my conscience, even when no one else is talking), I was tremendously pleased to be validated by the attendings this last night. I forced general surgery to get involved, over the vociferous protests of the other residents, who insisted there was no call to make extra work for them. This went on until the attendings got called, and suddenly they agreed with my assessment more than with anyone else’s, and acted on it. Very satisfying. I didn’t have all the right reasons for making my decision, and the end result didn’t completely bear me out, so I won’t be able to gloat at the other residents about it, but maybe it will keep them from mocking me for the next couple of nights.

The in-training exam results are back. It is very salutary to finally find myself, for the first time in my life, in company where I am only average on tests. New, surprising, not altogether pleasant, but very healthy. (Now it’s time to start studying for next year. . . I wish I could get past this competitive attitude. . . but at last I’m finally studying information that will be truly valuable to my patients, so however I get motivated, it’s not such a bad thing. . . )

I found myself in the OR at the beginning of a big case. A rather stupendously big case, to be precise – ten times over my head. But the attending was starting by himself. So I asked: “Would you like another pair of hands?” Sure, he said, scrub in, there’s always room.

Back in medical school, I learned the [very] hard way to give warning before trying to do something (close fascia, place a line, etc) that I’d never done before. Sometimes, it seems that I still need to give warning that I’m only an intern. Here, I didn’t. For one thing, I kind of assume that the attendings will recognize which residents have been around the OR a lot, and which ones are relatively new faces. Wrong assumption, apparently.

Five minutes in: “Tell me again, what year are you?” Never a good question; they only ask when you’re doing something wrong. “An intern, sir. [I don't know anything, I'm good for nothing, I'm sorry.]” And I proceeded to not-very-helpfully assist with the very first, basic part of the procedure. I think his frustration was evident, because a senior showed up and scrubbed in pretty quickly, and I took the excuse of my pager going off to leave quite shortly. It was a retreat, but I knew people would keep paging me (it was that time of day), and there was no point to adding the noise of my beeper to that tense room, since I couldn’t contribute anything to the case.

I hate being so awkward. Everything moves so smoothly for the seniors and the attendings, but when I try it, nothing goes quite where I want it, the threads get tangled, and I fumble for everything. It seems rather unfair, that I rarely scrubbed (until last month, and then the simple cases), but when I do scrub, they expect a lot. I guess that’s the way it has to be. There are no graduated expectations, because every patient needs things done completely right. One day, I’ll get the hang of it. (Anyway, I suppose I should have known better than to even go near such a big case without reminding the attending that I was only an intern.)

For the next week I’ll be sewing up dozens of hands and faces in the ER. Resolved, to go very slowly, and do everything very precisely. Who cares how long it takes, or what the audience (patient, family, nurses) think of me. Who cares how miserably useless the ER suturing tools are (a pickup that won’t hold, a needle-driver that lets the needle slip out every time you try to place a stitch, a scissors that won’t cut). I’m going to pretend this attending is watching me, and I will plan ahead, think of everything I need before I get started, and make every motion delicately. The car-accidents-waiting-to-happen don’t know it, but this week they’re going to get the most painstaking repairs ever.

I discovered for the first time today (at least as a doctor) that it is possible to be tired of doing surgery. Of course, the fact that I spent enough time in the OR to reach this conclusion was wonderful. I also hope that when I progress to doing something more than holding one instrument and (this is what distinguishes me from the medical student) having to stay alert enough to agree when the attending says, “Don’t you think this is the right place to cut?” or “I don’t see anything else bleeding, do you?” and so on, I will have more stamina. Today I tried falling asleep again in a dark OR. Fortunately the only thing I was supposed to be doing was holding pressure on something, and since the attending didn’t say anything, I figure I managed to both hold it and stay standing up while sleeping.

Later on, after placing a few foundational sutures in a difficult wound closure, the attending handed me the instruments and said, “Ok, finish it up, just don’t disturb those stitches.” I don’t really remember now how or why I had the scissors near that suture, but of course I cut it. Fortunately by this time the attending had given up on getting out in time to do anything else with his day, so he wasn’t really upset, but he certainly gave me a hard time for the rest of the day about openings in Outer Mongolia for surgery residents who can’t handle sharp objects. Hilarious. I knew he wasn’t angry, and it was entertaining the rest of the OR staff, so I didn’t care.

It’s nearly the end of the month, and it’s still a good thing that February is a few days short. I’m ready to move on to something else, since these last few days have been pretty stressful. I have high hopes of March (as I do for every new month). I will enjoy the independence that comes from working alone at night, and the freedom of not having to round on a set list every morning. The other residents on nights next month are great people, and I think we’ll have fun. Our senior resident is one of the ones who believes in surgeons doing as little work as possible, and he tries to prevent the residents from doing unnecessary work (ie, he hates admitting patients who don’t need surgery). He should make a great supervisor.

When PEs (pulmonary emboli) get bad enough, even I can see them on the CT scan. That doesn’t mean I appreciate Brad categorizing them that way: “I tell you what, (chief), these things are so big, even Alice here can see them.” Deep breath.

On the other hand, when a femoral line on a rather highstrung patient was needed, he announced: “You’re going to get this one right. No other options. I’m not even going to put on gloves.” And he didn’t. He just stood there at the foot of the bed, and refused to say a single thing. It went in beautifully.

Of course within a few hours that patient developed renal failure from a medication, so it’s a good thing the line was in, but it kind of ruined the satisfaction of a perfect procedure. (That, and the fact that the nursing supervisor felt a need to spend the next hour arguing with me about why we decided to put a femoral line in a stable floor patient. It was indicated, ma’am, and I wrote a nice note to that effect in the chart, in addition to the standard cookie-cutter line placement note.)

I’ve figured out (I think) that when Brad says we work well together, he actually means it. I still sometimes feel like a medical student, unable to believe that I’m part of the group. He treats me like a colleague, half the time, and I’m always surprised. He was the first person to ask my opinion on a diagnosis or a management plan, and really give some weight to what I said.

I try to be nice to the medical students, and apparently they all like me, but they still spend a lot of time being bored. I am so glad not to be a student anymore. Anything is better than being in medical school – including internship. (But students should note that sleeping through three pages is not a good way to impress the residents, or procure more notifications; if you’re that deaf, you’re going to have a hard time when the pages are important.)

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Tonight was absolutely great. I diagnosed a guy with rapid afib (actually the nurse did; the rate was so irregular you only had to feel the pulse for a few seconds to tell, unlike some people, where all you can tell without an EKG is that it’s fast), did the appropriate tests, moved him to a monitored floor and (with Brad’s supervision) organized enough meds to convert him back to sinus. (Which was thrilling to me; I hadn’t actually believed it possible, his rate was so high and variable.) We signed out to the day team: “Your patient went into afib with rapid ventricular response; we started him on a drip and converted his rhythm. You can consult cardiology if you want to, but he’s fixed.” (I’m sure they will put in the consult, for completeness’ sake.)

Better yet: while I was on the monitored floor watching my patient’s heart rate fluctuate wildly, the monitor techs suddenly started shouting about another patient: “What’s she doing in there? Her rate is dropping through 30!” I think literally every nurse and both aides on the floor ran in there, and found our little tiny bird of a patient huddled on the floor covered with vomit. We called a code, of course. It was the first time I’ve ever been there at the beginning, and actually it went pretty well. I started off doing the first thing I could think of, chest compressions, while everyone else was setting up suction to clear her airway. After about thirty seconds I remembered that I was supposed to be in charge, and I couldn’t think straight and do compressions at the same time, so I handed it off, and then realized that this wasn’t some random patient, it was one I was responsible for, so I actually already knew her history and her labs. Amazingly, and undoubtedly because we found her so quickly, by the time the code cart got there and got everything set up, she had a pulse again, and a viable blood pressure.

It gets better. I tried to do a femoral line and couldn’t, so Brad tried – and failed twice. He didn’t talk at all the whole time we were in there. He couldn’t very well poke fun at me, when he was being so spectacularly unsuccessful himself. I am very wickedly enjoying some schadenfreude at his expense.

And the patient is doing well in the ICU. She has a bad underlying disease, and will no doubt be dead within a few months on that account. But tonight, we saved her life.

This is why you have to know everything about all of your patients. She had been signed out very cursorily to me. If I hadn’t gone and looked at her labs and old documentation, I wouldn’t have known anything of any value in that code. The bottom line reason for knowing everything is so that you don’t waste time when things go bad.

Brad’s version of the established and respected surgery practice of critiquing your juniors rudely in front of a large audience during stressful moments made for a rather unsettling night. At one point I found myself standing outside a room with two nurses (we having all been found fault with, loudly, me most of all). One of them said, “I’m just going to defuse some anger here before going back to my other patients.” I told her, “Then one of us needs to move away, because this cubic foot of air doesn’t have room for all of our anger.” Six hours later, I can tell myself that the attendings speak to the residents this way all the time, in the middle of the OR, during both elective and emergent cases. Seniors to juniors is quite normal, as well, I suppose. You copy your role models. This is surgery, a side I haven’t had much experience with yet, but it’s probably not too late to start.

There was a ruptured AAA tonight, and I got to scrub in and help. I saw the red mass of hematoma accumulating in the mesentery, and the attending’s deft discovery of the right spot for cross-clamping, more by feel than by sight. I learned that everyone’s hands shake with adrenaline – including the attending’s; but that doesn’t need to keep you from sewing neatly. And the whole OR listened to the chief being chewed out for not doing x y or z more efficiently. It comes with the territory. I guess.

Bottom line, my patients are all still alive. The nurses were right, and the certain knowledge that the attending is going to be angry with Brad and me because of what happened doesn’t give us the right to blame the nurses for doing their best.

One more night this week.

Somebody, somewhere in the hospital, has offended the trauma gods. I think it might be the chief, because whatever service she’s on tends to just get rained on, with crazy admissions, weird procedures, and spectacular complications. The night started off with four traumas on top of each other (which Brad and I only showed up to accidentally, because the pages looked so similar we assumed it was just one patient being announced several times), and progressed in a similar fashion, with at least one call every hour, often two or three at a time. We wound up with a trauma code, which is supposed to mean a patient in really serious condition. This one wasn’t at all, which was kind of the last straw to ruin the chief’s night. After getting all keyed up, for one trauma after another, it’s somehow crushing when nothing actually happens. You feel kind of useless, as though all your energy and choreographed teamwork is really pointless.

Brad is starting to get on my nerves. He hands out both compliments and abuse all night, and I never know where I stand with him. It’s probably dependent on whether he’s just gotten a string of serious calls from the ICU before I show up to bother him, or not. But even so, I’m still admiring his thoroughness in evaluating patients. He leaves no stone unturned. Patient was transferred at 2am from a remote hospital three hours away in another state? Great; call that hospital, track down the sole live person in the medical record department at night, and have the patient’s operation report from four years ago faxed over – already. The patient had cancer twenty years ago? Find out who treated them for it and with what regimen. A CT angiogram? He’ll pore through every piece of the film, flipping back and forth till he has a complete mental image of every major vessel. CT of the abdomen? He looks at every organ system, up and down, not just the abnormalities that jump out at you, or the organ system that caused us to get the CT in the first place. Such mental discipline is still a step beyond me; and I need to acquire it.

I owe my medical student an apology. There wasn’t much with my patients at the beginning of the night, so I sent him to get dinner, and promised to page him if anything came up. But somehow, when I’m struggling to figure out why a patient’s heart rate has, in one hour, jumped from 100 to 150, and why his mental status is deteriorating nearly as fast, paging Brad is all I can manage. The student’s existence unfortunately skips my mind, until we’ve got things calmed down. Which was no doubt ok with this student; if he’d really wanted to see things, he would have stuck around. Out of sight, out of mind; unfair as it may be, if you’re a medical student wanting to experience things as they happen, hoping to be paged is not an efficient way to stay informed. (And it is unfair; I know, because I was you, 12 months ago.)

One thing I have accomplished this month: I’ve gotten the nurses on three or four floors to recognize me and call me by my first name. “Dr. Alice” is fun, but plain Alice is better, because it means they know me and we’re working as a team, rather than me being just another blank white coat. (The ER secretaries know my name too – that’s not quite as desirable.)

We started off the night with another central line, which went pretty smoothly, all things considered. Brad was willing to try a different approach that we hadn’t done before, which made things slightly more tricky, but it went in the right place.

Some time later, I got called by one of the medicine attendings: “Your patient just had a code purple [substitution for hospital's pet phrase for not quite a code, but deserves an emergency response team] called on them for unresponsiveness, I’m up here, and my resident is determining whether they need to be moved to the unit.” There goes one of my nightmares come to life: my patient crashing, and I didn’t know about it. I ran upstairs after paging Brad. Things were under control, and probably could have been handled without all that commotion, except that the operator whom the nurses had told to page me stat, ten minutes earlier, had somehow decided not to, and everyone had assumed that when the code purple was called, I would know about it. Which I don’t; surgery pagers are busy enough with real code blues and trauma alerts; we can’t pay attention to every code purple, which is usually a plain medicine problem. Bother. “The medicine resident will decide if the patient needs to be in the ICU”; thank you very much, she’ll be fine right here on the floor, with me checking on her every half hour all night, now that I know about her. (And she was.)

So there I was on the floor, cleaning up odds and ends, when another nurse came up: “Alice, did you know this guy in 765 has a pretty high fever?” “Sure, give him some tylenol. And do you know the rest of his vital signs?” “Well, he’s pretty tachycardic, almost 120.” Now I’m interested. We got an EKG. Somebody ought to list fever as one of the presenting signs of heart attacks in the textbooks. . . One of the nurses, who has a big chip on her shoulder, and antagonizes most of the residents, but for some reason likes me, took over for that patient’s nurse, who seemed remarkably uninterested in her hypoxic, tachycardic, febrile patient, and procured all the equipment for a nonrebreather face mask, continuous pulse ox, and other paraphernalia. I felt a strong temptation to call my own code purple just to make the Xray and lab people come up faster, but the guy was so remarkably comfortable in spite of everything that I decided not to be histrionic.

From now on everyone with a heart rate over 110 is getting an EKG. I don’t care how good of a reason there seems to be for them to have tachycardia. EKGs for all!

A very educational night overall, and reassuring that I’m learning to handle some emergencies pretty decently. That fairly outweighs my defeat for the night, when I let a temperamental and manipulative patient talk me into completely reversing her npo status (after she bugged the nurse so much that she paged me every five minutes for half an hour).

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