I was encouraged the other day to discover that I am in fact turning into a surgeon, and possibly even a competent one. The fellow had been talking me through a procedure, my first time, and it turned out quite simple and easy, perhaps a little to his surprise (I didn’t know enough about it to be surprised one way or the other).

That night I had to do the same procedure, on a patient who was not intubated, and quite jumpy. Let’s just say that it’s difficult to get good local anesthesia if the patient jumps half off the bed every time you get a 28-gauge (ie very tiny) needle 0.5mm under the skin. . . despite some iv sedatives in assistance. And of course this time, in the middle of the night, without the fellow around, the procedure was much more complicated than it had been in the morning. Also, the instrument tray the fellow had advised using contained instruments that were next to useless for the purpose at hand.

So I got to try and keep that patient calm (with the nurse’s very good help), through a procedure that lasted much longer than I had planned on, without letting on to anyone else that I had very little idea of what I was doing, or what I would do if that didn’t work. . . It did work, finally, when I was about ready to declare defeat and go looking for a better instrument set and/or someone senior to me.

Perhaps it’s not reassuring to the public to say, but to me, being able to improvise in a difficult situation, through a procedure that I’d never seen done quite that way before, means I’m learning how to operate, and how to make instruments do what I want them to do. A small step in the path of the legend of the vascular surgeon repairing a ruptured AAA with a set that turned out not to contain any vascular clamps. . . (the legend doesn’t mention whether the patient survived; I ought to ask).

The attending called me “honey” while explaining a difficult step in a complex operation. He apologized immediately, and we ignored it. That was after he said I was doing a good job.

Now, I’m upset, not because I think it was sexual harassment, but because it’s plain that I have failed to behave maturely enough and professionally enough to earn respect from my attendings. The hardbitten senior female residents would not get called “honey.” The idea is hilariously incongruous.

I don’t want to be as tough as they are, but I certainly don’t want to be regarded as a child by the men whom I need to teach me. Perhaps I need to give up on the first wish. I speak as definitely as I can, and keep my voice as flat as possible. Not helping, I guess. I really ought to cut my hair, but I refuse to do that; it’s one of the last pieces of my identity from before surgery. All the really hardcore surgery women have their hair chopped quite short. At first I took comfort from the residents who kept their hair longer, but now I realize that those are the ones who, because of the personalities and career goals that go with keeping feminine hair, are not much respected either.

Trauma rotation, as the senior resident, later this year, should be interesting. I will either break down completely, or I will learn to stay on top of a mountain of acute information without appearing – not flustered, but excited. Perhaps that’s the element I’m missing. I guess it’s childish to be visibly excited about a dramatic problem, or visibly concerned about a patient deteriorating regardless of all efforts. I need now, not just to keep my face still, but to keep entirely still. Resolved, not to walk around while thinking. . .

One of my friends, an intern, is struggling with the belief that they killed their patient.

I’ve thought that more than once, and in cold reflection I believe it to be true in at least one and two halves. That is, one I’m personally responsible for, and about two others I’m definitely responsible for significant failings. There were several other times that I felt very guilty about for a week, but as time passes I think my responsibility is less weighty in those. I haven’t written about them before because, in close temporal proximity, I was too upset to write, and I didn’t want any time correlation for the lawyers to find.

The one patient that I think of particularly, I personally failed to notice something, and that thing being overlooked led to another thing, and the complications of that other thing led to the patient dying. So it’s not like I directly administered an overdose. But it seems reasonably certain that if I hadn’t overlooked that particular thing, the patient would have been much more likely to survive. Also there were several other doctors, both residents and attendings, from my own and other services, who also had cause to notice that particular thing and act on it, and none of them did, either. But it was my patient, on my service; so I can’t decrease my own fault by saying that others, who were not as directly responsible, although more senior, made the same mistake. It comes down to, my lack of attention led to the patient’s death.

The other times are similar: I didn’t do anything – I didn’t cut a major artery, or cause a laparoscopic injury – I’m sure those are down the road – but I failed to pay close enough attention, or to pay attention soon enough, and then the patient died. If I had done a better job – if I had done well the job that I was supposed to be doing – it probably wouldn’t have ended the way it did.

I don’t know what to tell my friend, though. There’s no way around it. Sometimes I’ve tried to reason with interns (because they’re the ones to whom it happens for the first time; for the rest of us, the feeling of guilt is familiar and feared) and tell them, in this case it wasn’t their fault. But inevitably there comes a time, probably before six months are out, when there is no honest way to reason out of it: it really is my fault – your fault – our fault.

I can’t remember now how I dealt with those times. By not thinking about it, I suppose. I considered the facts enough to realize what I had done, maybe asked a senior resident what they thought about it, and then I closed a door in my mind. I think the phrase is from King Lear: “That way madness lies.” Now, one part of me knows I’ve killed people, and the rest of me is for all practical purposes unaware of that fact. It takes time, though, to get that door closed, and to keep it closed. And so for a week or two, it’s quite miserable. M&M helps a little, to have it out in the open. The attendings’ conclusion, surprisingly enough, has rarely been as harsh as my own. After all, only I know exactly when I knew certain things, and exactly what conclusions I drew from them, and whether I could have taken certain actions sooner than I did. The final picture, in public, is always a bit blurry; the blame never settles very definitely. Inside my own mind, though, I know that I failed – and it will happen again, no matter how careful I am; it will happen again. . .

It’s hard to watch interns learning that.

We’re going to try again with the more-frequent-posting concept. Exercising, eating, and sleeping, not to mention studying for the ABSITE, do compete for time. I slept a whole extra hour the other night, and felt on top of the world all day. I ought to try that more often. . .

I’m on the thoracic service now, which seems pleasant enough: busy enough not to get boring, but not as overwhelming as cardiac. I actually get to do some cases, which is surprising and nice. On the other hand, there isn’t the liters of blood in the chest tubes that we had on cardiac, and not the same propensity to go rushing back to open up the same incision you just closed a few hours before; so I’m in adrenaline-withdrawal.

Studying for the ABSITE is occupying more attention (or at least, procrastinating about studying). A friend who I think is very intelligent, in practice a good doctor, and could spout all kinds of data and treatment algorithms by heart, failed the written boards. I was scared just listening to this person studying – I’ve never studied that hard. And now they failed, after all that work – I am going to be in so much trouble . . .

The first patient we rounded on is worse again, and we run back over to see. One of the multiple devices keeping them alive seems to be malfunctioning. . . or is it that their cardiac function is suddenly deteriorating even more dramatically? The device rep happens to be around, but can’t seem to come up with a solid answer; and if he can’t tell what his own device is doing, it’s pretty hopeless. The cardiology attending shows up, and one of the cardiac surgery attendings. A lengthy discussion, and finally out of the confusion, a decision: an OR room has been opened, the patient is going there right now. It’s an immediate decision, laid down by the attending, but it takes nearly half an hour to execute: the cardiac anesthesia team has to come over, get at least slightly acquainted with the myriad drips and machines surrounding the patient, and then a procession is organized to move the patient (being bagged), three iv poles, and two machines at the foot of the bed, through the twisty corridors to the OR.

I try my best to urge the intensivist to finish rounds expeditiously, without actually saying that I want to escape over to the OR. Finally, an hour later, we’re done, and I leave him considering some more electrolytes, and slip over to the OR. It’s an emergency case, so the fellows are tied up in the scheduled procedures, which means I can scrub in and assist with the PAs. I’m not much good in a normal cardiac case, let alone an emergency, but I have learned enough not to be in too much danger of tripping over the bypass cannulas, and I’m starting to be able to see what the attending is trying to accomplish, and help get that done. I think about putting on my loupes before scrubbing in, but decide that it’s going to be a long case, the structures are big enough to see without, and I’d rather be able to see the operative field, and help with the equipment, than be trapped in the tiny field inside the loupes.

The case drags on and on. One obstacle after another, and with every one the patient’s blood pressure slips lower and lower, and the rhythm tracing looks more and more erratic. The mediastinum fills up with blood, and it’s a non-stop job to suction enough for the attending to see what he’s working on. I fight back an impulse to point out what the blood pressure is. He knows well enough already (there’s a large monitor placed to be visible to the surgeons), and pointing out how desperate the situation is won’t help him get a difficult job done faster. Another attending comes in to help, but things don’t get any better. Both of them start making pessimistic remarks, warning anesthesia that things are not going well, and are not likely to improve. The circulating nurse is occupied, either in a whispered argument on the phone with the blood bank, or searching through the supply cupboard for the increasingly exotic sutures that are being requested in the hope that they’ll hold where others have failed. The attending has the ICU charge nurse called to go convey to the family that things are not looking good, to prepare them for him to arrive with the bad news in a little while.

Eventually, he calls it. There’s so much blood in the mediastinum that it’s impossible to clear, let alone put stitches that have any chance of helping; the mean pressure has been around 30 for who knows how long; and then the heart goes into fibrillation right in front of us. One attempt at defibrillation, with the sterile paddles that are laid at the top of the table for every cardiac case with the hope that they won’t need to be used, and then we admit defeat. The attending scribbles on the requisite papers in the OR, and goes out, to talk to the family and dictate some approximation of a report, leaving the PA and me to close up. I’ve never actually been in the OR with a dead patient before (except on transplant, and that isn’t supposed to count; we weren’t trying any more to stop those deaths). I wish I were more shocked, but actually everyone knew what the outcome would be from the beginning of the day, let alone the beginning of the case. The PA offers to let me put in the sternal wires (too much chance of hitting lungs and major arteries for me to have ever been allowed to do that on a live patient), and with that excitement, and the thrill of having actually been first assist on a big case, I try to forget the family members I had seen crying in the waiting room all morning.

Then it’s back to the ICU. There are still more lines that need to be put in, consultants’ plans that need to be checked on. Have to go and see who was put on a spontaneous breathing trial this morning, who looks like they’ll get off the vent in a day or two, and who is still too sick to wean. Check on the chest tube output of the patients from the OR this morning, since there is nothing guaranteed to get a cardiac attending yelling at you faster than neglecting to inform them soon enough that the output has been approximately 200cc/hr for a few hours. (I know, because I’ve tried it more than once. If you keep checking every 15 minutes, somehow it doesn’t seem like so much blood; but then you add it up after two or three hours, and it’s a lot, enough to be worth opening for, and you get chewed out – again.)

Out by maybe 6pm, but too often, we end up opening a chest in the ICU from earlier in the day, when the volume in the chest tubes, and the amount of blood transfused, passes the attending’s threshold; and then we’re there even later. No rush, the next day is just going to be the same all over again.

In commemoration of being nearly done with cardiac surgery, and in atonement for having posted so sparsely lately, here’s a look at a typical (ok, maybe a little extra exciting) day in the cardiac ICU:

In before 5am to collect data and write notes on some 12 patients, only to discover that two more were admitted overnight, and one of them is very sick. I sit down to look at vital signs in the computer, and two minutes later the charge nurse walks up: “I know you just got here, Alice, but this patient is hypotensive. In fact, the systolic is getting below 40.” Hurry over to that bed, and hastily try to collect the key facts about a patient who was admitted overnight, in extremis, already on three pressors, and deduce from a 50-word summary of their history, delivered by the charge nurse, what is the next pressor to add, and whether or not fluids would be a good idea. (It’s been hard for a person trained in general surgery to adjust to the fact that fluids may not be good, and lasix may be quite beneficial, in the peri-operative period.) Quick calculation: two inotropes, running at maximum dose, not keeping the pressure up; CVP and PA pressures are already quite high enough, so fluids not needed; vasoconstrictor would be the easiest drip to get going just so perfusion pressure doesn’t get too low while we’re thinking, but will have to be careful to use only a touch, and better get the pharmacy working on our third (and last) inotrope. . . Once that drip is running, stay for a minute to make sure it works, and look over the various pumps (balloon pump, and/or temporary VAD, and/or a form of ECMO), inspecting the numbers and trying to look as though I know what on earth all the tubes are doing.

Back to scribbling furiously to get all my notes finished in the allotted time, which is further reduced by all the nurses coming up to ask for supplements on potassium and magnesium. In cardiac patients, one likes to run these electrolytes on the high end of the normal spectrum. Even if you write prn sliding scales for replacements, there’s always a special circumstance necessitating giving more or less, and the nurses would much rather catch me while I’m sitting there in plain sight, than page the overnight call person.

6am, rounds with the fellows. Try to deliver all the information I’ve collected, examine the patients as a group, hear the nurses’ reports and concerns, and make plans for the day, in time for the fellows to leave for the OR, hopefully not much later than 7am, as they need to review the cardiac catheterization films a final time before the cases start. I have the remnant of the 7:00 hour to finish my notes, pull all the chest tubes from the day before, get started on transfer orders for the patients who can leave the unit, and reorder sedation drips and restraints as needed, before the cardiac attendings start coming in one by one. They each expect me to give them my undivided attention as we look through their individual patients, and I give an account of how much lasix we have or have not given, who needs a transfusion, who’s ready to go upstairs, who’s still on an epinephrine drip and why, and who didn’t get extubated overnight, and why haven’t I fixed that already. (The usual procedure in our unit is for the patients to come over from surgery intubated, then be quickly weaned off the vent over the next 4-6 hrs as they wake up. If the patient is slow to progress, and the overnight call person is not aggressive, sometimes people are still intubated the next morning, which throws the schedule off, as they can’t be fed and mobilized and moved upstairs to make way for the next round. Plus the patients and their families don’t appreciate it, either.)

Hopefully I manage to fit coffee in before the critical care attending arrives around 8am, ready for “real” ICU rounds – ie, slow ones. With my luck, there’s usually at least one important arterial line down by this point, and my conscience does not allow me to look for coffee or breakfast before all the lines are fixed and chest tubes pulled. Our unit is between one-half and one-third populated by LVAD patients – those with ventricular assist devices, whose arteries have no pulses, and who are thus especially challenging to get a-lines in.

Then there’s the patient whose blood pressure is spiraling down, increasing NG output, decreasing mental status – time for an intubation. New lines are called for. Once those are in, they have to be gotten down to CT, and sure enough, time for another consult to general surgery for ischemic gut. Have to find a general surgery resident who hasn’t learned, in the last few weeks, not to to take my calls, and a general surgery attending who isn’t sick and tired of operating on sick cardiac patients. These complications – a nuisance to the cardiac surgeons – are very distracting to me, because I find myself much more interested in the patient’s abdomen than in their cardiac status, and I wish I could just stay with the general surgery residents as they work out their plan.

Back to critical care rounds. Someone’s sodium is either too high or too low, and I’m supposed to pay attention while we calculate the free water deficit. . . I know it’s a serious moral failing, but I cannot get myself to care about the sodium. Potassium, yes, but sodium, unless under 118 in a trauma patient, and threatening seizures, really doesn’t hold my attention, no matter how hard I try. (Some days I don’t try too hard.) Then we have to look at a vancomycin trough (why is everybody’s blood growing staph at once, and in how many of them is it real, and how many are just contaminated cultures?) and adjust the dose, and the pharmacist wants to adjust the cefepime dose due to rising creatinine. . . My attention is wandering, and I notice a nurse at the other end of the hall looking anxiously out of the door of an isolation room (meaning that once inside, she can’t just come running out in the hallway without stopping to take off the isolation gown). I slip away from the intensivist and the pharmacist eagerly discussing renal dosing of various cephalosporins, and verify that yet another patient is hypotensive, and I guess I can’t forestall putting in another a-line. If I’m lucky, I can do it in less than ten minutes; maybe the rest of the team won’t even notice that I’ve left rounds. . . grab the supplies, prep the wrist. . . I’m getting pretty good at guessing the location of the radial artery in hypotensive patients (in whom there’s only a faint, semi-imaginary pulse, and if you were really going by touch, it would take a long time). Verify that the pressure is indeed as low as the cuff suggested, start a pressor, order some blood and sputum cultures, and go back to suggest a bronchoscopy to figure out whether or not this ventilated patient actually has pneumonia or not.

While the attending is looking at xrays, trying to decide how serious the left lower lobe consolidation is, I see the case manager out of the corner of my eye. Quick, better talk to her now, and reiterate that two or three of these chronic patients are about ready to leave, and I really hope she has a place at a rehab facility for them when they’re ready (because people who stay in the ICU even a few days longer than necessary have an unpleasant habit of developing pneumonia or bacteremia, and delaying their transfer indefinitely).

Ok, better pay attention to these next few patients with the attendings. I have another bad habit. When a patient has been hopelessly sick for more than a few days, and I can’t figure out what’s wrong with them, my mind starts blanking them out. I can’t stand to think about how little progress they’re making, and I’ve already gone in circles trying to figure out why they’re sick, and then I can’t concentrate on them any more. . . which means I make myself pay even closer attention when the attending is discussing them.

Two months in the ICU have given me about all the procedural practice I can handle. (As opposed to OR practice, that is.) I’ve gotten to do – or attempt – several intubations. I tried to explain to the attending today that I have a 50/50 record: half the ones I’ve done have been when he wasn’t there, and they all went fine. Half of them were with him around, and they all failed. He opted to reiterate the pharyngeal anatomy and technique of laryngoscopy again.

Also central lines. I got a subclavian line today, in an intubated patient with no access, and thus no sedation and no drips. First stick, right in. The attending (same one; I don’t think he has 100% confidence in my procedures, for some reason!) was setting up to do a femoral line, as being quicker and more reliable, but I got the subclavian in before he could do more than prep his site. (I wanted the subclavian for central venous pressure monitoring, plus you’re allowed to leave them in longer, so conservation of effort.)

On the other hand, I proceeded to struggle with femoral a-lines for the rest of the morning (for the nonmedical folks, these should be the easiest of all lines, whereas a subclavian in an unstable patient should be the most difficult). Something about putting them into patients with VADs (ventricular assist devices), and thus non-pulsatile flow, and thus no pulse at all, seemed to complicate matters. Invariably, as soon as the nurse gave up on me getting the line any time in the next 5-10 minutes, and went out of the room for a quick errand, I got the line (you need the nurse to attached the pressure tubing in a semi-sterile fashion, otherwise you risk contaminating the field and losing your brand-new line by reaching for wherever the nurse tucked it).

Overall today was the worst possible of all my days in the cardiac ICU so far, except that I was with an attending I like and trust, which helps a lot. Without really verbalizing it, we split the unit in half: he took the most unstable patient, and the most hopelessly stable (no progress except in a steady downward direction), and I took all the others. It felt as though I was competing to see how many other procedural specialties I could involve in my patients’ care. By the end of the day I had a pretty full tally: general surgery, vascular surgery, GI, interventional radiology, plus some noninterventionalists: neurology, endocrinology, nephrology. At the same time, I managed to have fairly decent conversations with the families of four different patients, which is better than my usual ICU record. (Especially cardiac ICU: I usually feel as though I don’t know enough, or control enough, of the patients’ course, to be able to explain fairly.)

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