teamwork


I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective:

Today I worked about 14 hrs – came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and by the luck of the draw, the triage information was inadequate, and the senior residents went with patients who seemed sicker, but turned out to be in better shape. So I’d worked him up, admitted him, followed him for several hours. Then I was told to leave, while his final outcome was still unclear: could we handle him nonoperatively, or would he require one of the now nearly legendary trauma ex-laps (exploratory laparotomies)? (legendary because so many blunt trauma injuries are now managed with just observation or angiography)

If I had thought that I would get to participate if I stayed for the surgery, I would have stayed eagerly. But I knew that the senior resident in-house would get to do anything that was the least bit interesting about him; just because I’d admitted him didn’t mean I’d get to do anything meaningful in the surgery. So I left.

I don’t know which came first, shift work, or the attitude that seniors get all the cases. I’d stay more if I thought I’d do more. As it is, I’m sorry to miss seeing exactly how it plays out, but since I wouldn’t see the inside of him anyway except from a distance, I figure sleep is good, and I’ll hear in the morning exactly how many hours of borderline pressures, and how low of a hemoglobin, it took to get him to the OR, or not.

I was dreading rounds today, but something lit a fire under the attending (perhaps the arrival of three traumas before 9am), and he tore through rounds in what was probably record time for him. We just barely made it, too, because right around 1pm the traumas started pouring in. I don’t think we got out of the ER for more than 15 minutes all afternoon (and watching the pager, they’re still coming in; it’s starting to rain now, instead of the brilliant sunshine, so maybe people will get smart and go inside). One trauma after another, and usually two or three at once.

In one sense, I enjoyed it, because I would much rather be dealing with a whirl of excitement in the trauma bay and the CT scanner rather than dragging my feet through the unit (although after about half an hour of fighting a low blood pressure on the CT table, unable to do anything else but hang one unit of blood after another, that starts to get old, too).

But by the end of my shift, it got to be a little much: so many patients that I barely knew half of the new ones, and then only their injuries. The nurses would go to ask me a question about Mrs. Smith, or the guy in room 7, and I would have to say, “Are you talking about the helmeted motorcyclist, or the unhelmeted one? Is this the 50yr old who fell downstairs, or the 80yr old? Is this the patient we intubated for combativeness and a head injury, or the one who came in tubed with a pneumothorax?” I hate not being on top of things, feeling like patients are slipping through my fingers. I can’t write appropriate orders, call the correct consults, or talk to the patients’ families if I can’t at least keep track of who’s come in. Fortunately (and I have no idea how they manage this) the attending and the senior knew everyone, so nothing got too badly lost. Also, the ortho and neurosurgery residents on today were awesome. They kept circling through the trauma bay, and thus managed to pick up all the consults that were coming to them very quickly. I love being able to trust that the consultants know which patients they’re seeing, and are as interested in stabilizing them and moving them out of the trauma bay as the trauma team is – because we all know there are half a dozen more waiting around the corner.

It was also not a bad afternoon, because everyone we were called for had a real injury. Unfortunate for them, but far less frustrating for us, than getting called to one “oh, nothing serious after all” quote trauma after another. A lot of the injuries were orthopedic: several open fractures, and one horrific foot dislocation. (You just try and picture a dislocated foot. The ortho resident walked up and cocked his head at it for a couple of seconds. He was clearly nearly as offended as I was by the extreme wrongness of the situation. Our eyes met, he nodded at me, and we each took one end of the problem, and pulled. It popped back in, amazingly enough, and then I held it with a death grip while he collected a massive splint. The patient was not at all happy with any of this, but at least a little better after that impromptu reduction. Everyone turned around to ask what all the noise was about – from the patient, and from the joint snapping back together – and he explained nonchalantly that he was just stopping it turning into an open fracture-dislocation, since the skin was so tented that it looked about to tear. An open injury to a joint, especially one as complicated as the ankle, is a disaster for the patient, and constitutes an orthopedic emergency, unlike a simple closed fracture or dislocation, which can wait a day or two to go to the OR.)

I hate fractured and dislocated bones. They turn my stomach worse than any kind of general surgical disaster. Maybe it’s because I can picture that happening to me, more easily than I can picture the rest of the stuff. It just looks so painful; I can’t stand broken bones, and especially displaced fractures jarring and grating against each other. The ortho guys get a gleam in their eye, though, and then, since I’m the intern, I always end up helping them, holding pieces together, or holding them apart while they pour irrigation all over the patient and me. Ick. That’s why I cringe when I see a motorcycle accident on the trauma pager, even helmeted, because I know it’s going to end up being a nasty fracture – and me holding the fracture.

This next week is going to be a marathon: the end of June, gorgeous weather, everyone doing stupid things with motorcycles and ATVs and waterskis, and climbing trees and roofs. . . Plus the prelim interns will all be gone, the chiefs are gone, and the assigned interns – ortho, neurosugery, ENT – have all gone off to their respective programs; overall, I think we’ve lost half our warm bodies. That’s why, in a week, we’ll be happy to have an intern, any intern, to fill spaces. As long as you can speak English and follow instructions, my eagerly-awaited new interns, you’ll be just fine. (Probably even just understanding English would be ok.)

The trauma service has a lot of paperwork associated with it. There’s a three-page form to fill in when the patient is admitted. Obviously, when you’re first trying to stabilize the patient, there’s no time to fill in forms, so these tend to get written when the team is waiting around in the CT scanner (there’s a law engraven in stone, that at least one trauma resident must be with the patient at all times until they’re finally dispositioned, due to way too many bad experiences with patients coding, seizing, freaking out, or having serious neurological deteriorations while going through CT; even when it’s located inside the ER, any branch of the radiology department has the capacity to seriously impact a patient’s condition; we don’t call it the cave of death for nothing).

The nurse is there filling out her papers too, and the scanner techs have forms as well, so it starts to sound like a game of Go Fish:
Tech: “What’s the medical record number?”
Resident: “Here you go, it’s 18009834321232; what time is it right now?”
Nurse: “What size did you say their pupils were?”
Resident: “4mm, reactive to 2mm bilaterally; what were the admission vital signs?”
Nurse: “36.5, 89, 112/54. What scans are we doing?”
Tech (exasperated): “The same scans we do on every single trauma patient who comes through here, regardless of their mechanism of injury.”
Resident: “Hey, don’t look at me, that’s the chairman’s policy; we’ve been trying to explain to him for ten years that someone who fell down the steps and landed on their bum doesn’t need their belly scanned for a splenic rupture, or that people who got shot in the belly don’t need their head and neck scanned for epidural hematomas or Cspine fractures.”
Attending walks in the door: “What were you saying? Let me tell you about the octagenarian I took care of who fell out of a wheelchair and ruptured his spleen. . .”
Resident, sotto voce: “There is such a thing as clinical suspicion, physical exam, and directing your scans based on lab results and xrays, rather than giving everyone enough radiation to cure a low-grade case of lymphoma.”
Attending: “Did you finish the form yet? Did you look at the cspine scan? Is there a spinal cord injury? Is the spleen ruptured? Do we need to call the OR? Stop gossiping and do some work around here, people!”

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Then there’s the form to be filled out when a patient is transferred from the ICU to the floor. Lately, due to a surplus of work to be done in the ICU, we’ve been rather remiss about filling these out. At first, this led to complaints from the floor team to the attendings, which led to a rather nasty reaming-out during morning report.

After that, I think the floor folks felt bad about getting us yelled at so much, but they still wanted their updates about patients being transferred, which leads to whispered conversations in the hallway when we think that particular attending won’t notice:
PA: “What exactly surgeries did he have while he was in the unit?”
Me: “As far as I can tell, he had his spleen taken out, and then something happened which turned the wound into a disaster, and he spent the next two weeks with an open abdomen, before we put a vac and a whitman patch on it, and then it finally got closed one week before I sent him upstairs.”
PA: “But exactly how many times did he go to the OR, because the insurance company wants to know for their records?”
Me: “I honestly have no idea; I don’t think they dictated op notes every single time, because things didn’t really change for a while; and then there were all the vac changes/whitman patch advancements at the bedside – do those count? And anyway, I came on service after everything had been closed, so I don’t know.”
PA: “Did he ever get the post-splenectomy vaccines?”
Me, feeling bad because this is really important, and could lead to the dreaded OPSSS (overwhelming post-splenectomy sepsis syndrome) if we don’t get it right: “I don’t know, shouldn’t that be in the nursing or pharmacology records?”
PA: “Yes, but his chart was so thick it got edited three times, and all the important pieces are missing.”
Me: “Well then, just give them to him again, I’m sure it won’t hurt anything.”
Attending, coming around the corner: “What’s going on here?”
Me: “Um, we were just. . . discussing post-splenectomy vaccines, sir.”
Attending: “Good, give us a power-point presentation tomorrow morning about the indications for vaccines, and how long after splenectomy they ought to be given.” (Which is not funny, because there’s a big controversy about this, since the best immunological response is if you give the vaccines before taking the spleen out, but obviously in trauma you can’t plan that; next best is to do it 10-14 days after surgery, when they’ve gotten over the stress of surgery; but many people advocate doing it 1-2 days after surgery, so they don’t get discharged from the hospital and lost to followup and never get the vaccines at all.)
Me, to the PA, ironically: “Catch me ever talking to anyone in the hallway again!”

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My favorite is the form documenting a patient’s risk factors for developing a DVT/PE, and what we plan to do about it. They’re so nice, because once you finish filling them out, and inform the attending that based on the results you plan to a) use only SCDs (sequential compression devices) on the patient’s legs, b) give them subq heparin, c) scan their legs regularly for DVTs, d) prophylactically place an IVC filter, one of the attendings is guaranteed to respond: “That form is all nonsense anyway. Just give them lovenox. I don’t care what the contraindications are, lovenox takes care of everything.” Ah, that’s great, could you just write that on the bottom of the form, or better yet, make it so I don’t have to fill out the form, since you’re going to have the same answer anyway?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My service is a mess. Despite me and all the other residents and some mid-level providers scurrying around all day, every night we find ourselves with a crazy list, on which I don’t recognize half the names, don’t know what procedures they had done, why they’re in the hospital, what medications they’re taking, or what we’re supposed to do with them tomorrow. I’m not sure how it happens. Perhaps the habit of sending the intern to do the last cases of the day, which are the small potatoes, at the same time that the ER and the office flood us with new admissions and consults, might have something to do with it.

A few months back, when I was covering at night for vascular, I used to be very frustrated with the intern who signed out to me. He’s perhaps the most incompetent of our year, and he told me nothing useful; I was always left to figure out for myself who had had surgery and who hadn’t, who needed coumadin (blood thinner) and who didn’t, who needed to be prepared for surgery in the morning and who didn’t, and was always taken by surprise when patients were admitted in the evening.

Now, I’m ashamed of my frustration with him. I sign out nearly as badly (at least I make sure of the coumadin status before I leave) because even after evening rounds with the chief, it would take me another hour to go around by myself and figure out what’s happening, and although I’m fairly responsible, I’m not that crazy. So every morning I come in to find half a dozen people whom I’ve got to figure out completely in seven minutes each before sign-in rounds with the chief. Then it’s off to the races again, and by the time I’ve got the overnight people sorted out, a third of the list has been discharged and replaced by a whole new crowd with new problems.

I feel like I’m running very fast and just barely staying in the same place. It’s frustrating, after spending a year learning how to be a good intern, to find myself unable to manage what I think I ought to be doing. There’s just too much going on.

On the other hand, I’m doing way more surgery than I expected to, so I ought to be happy. This is how the service is, controlled chaos, and no one seems to expect any different from me or the list. Plus, the chief and other residents are almost a dream team – the ones out of the whole program whom I would have chosen to be on a crazy service with. We have a lot of fun, in spite of everything, and they don’t leave me alone with all the work, which some people would do. The patients are doing mostly well, as well as can be expected from the kind of sick people with lots of comorbidities who have vascular surgery, and that’s the best that can be hoped for.

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