Today was kind of bad. 16 patients to see in less than two hours; I just barely managed to see them, certainly not to write notes in their chart. So I wasn’t completely prepared to talk with the chief. Then, while I was struggling to catch up, a medical attending paged me to tell me a number of things that were wrong with one of my patients that he was consulted on, ranging from slightly abnormal electrolytes, to a funky coag abnormality that I should have noticed, to the fact that she was having extreme difficulty breathing.
I went to see her, and she was gasping for air on full face mask oxygen, and begging me not to leave her and not to let anything happen to her. Did not make me happy. I started asking the nurses to get a CPAP machine, but apparently that can only be done in the ICU. So between us arguing about whether she could or could not get CPAP right now, pending an ICU transfer, and her being very anxious and obviously dyspneic, the nurses called an almost-code status, and I didn’t stop them. It did make me feel better to have the hospitalist show up and order people around. It also succeeded in producing a CPAP machine and an ICU bed very quickly.
The attending was not thrilled with this management, and I was ashamed of myself. Her cardiac status was fine throughout, she was maintaining her airway, all she needed was CPAP. I shouldn’t have let myself get stampeded into the almost-code, and then let the reins go to a medicine person. The end result was right, even if the attending didn’t like it, but I shouldn’t have let myself be so bothered by the patient’s panic. Hand-holding doesn’t do anybody any good.
The day just went on downhill from there. One admission after another from there, one patient after another developing serious issues. I was running all day and am still wondering what I missed, what I forgot to do, and who will be in the ICU tomorrow as a result of my oversights.
Seventeen patients to see tomorrow morning. . .
One of the junior residents, bless his heart, noticed me being in the hospital at 4am all the time, and I think he told the rest of my team to help out more; which is nice of him to be concerned about me, regardless of whether my seniors do as he asked. I like them, anyway. I need to be pushed, it’s the only way I’m going to get stronger. Hand-holding between residents doesn’t do much good either. The chief observed to the attending that she’s been called intimidating, and he asked indignantly what the problem was with that. I think she just has a more forceful manner than some female surgeons; I’m never going to be that forceful, but she has an absolutely magnificent bedside manner. Her patients adore her – her, not just the attending, although she never claims any status other than a resident under them. She sympathizes with them, gains their confidence, and acts decisively, and they know that she’s taking good care of them.
August 8, 2007 at 6:23 pm
Could you have had the respiratory therapist paged? I’d expect an experienced RT to get the CPAP going while you were waiting for that ICU bed regardless of anything the nurses said.
I suppose the nurses were afraid they’d be left to deal with the CPAP machine, and they may not have had much of a choice about calling the almost-code status. Some hospitals have protocols that don’t leave the nurses much leeway. You should have been notified before it came to that, of course, but by the time you were on the scene, they might not have had a choice.
We have a rapid response team (for those almost-code patients). They get paged fairly frequently these days, but I haven’t heard a code on a medical or surgical floor in months.
August 8, 2007 at 6:34 pm
That’s tough, I’m sorry. Chalk it up to another step in learning.
You’re right about only getting stronger through pressing your limits though. I’m sure you’ll do fine.
August 9, 2007 at 7:43 pm
You are in a tough place right now Alice. Needing to act like you know everything, when you don’t. Taking the heat for not knowing everything, when you don’t and not being able to give excuses. Everyday you learn a little bit more. Wait until the end of the year and you an look back and see how far you’ve come.
I am not a doctor but have been in quite a few emergency situations, a few life threatening. You are right, it’s not the time for handholding. My advice? Touch the patient, look into their eyes, firmly tell them, “I’m doing everything I can to help you.” and then go do it. Hopefully a few other people around will take a half second to do the same thing when the patient needs it-if you are really lucky you might have a nurse available and room for them TO handhold but that may be a pipedream. When things are stable and you have a minute (if the patient is able to understand you) stop and tell them what you did, why you did it and what they can expect and ask if they have any questions.
You’ll hit your stride, it’s only been a few weeks.
August 10, 2007 at 7:44 am
We have been reading your blog for sometime Alice and thinking of you! Hang in there…you are capable, strong and smart. Remember when you fall in bed each night and look back on the day: You may feel frustrated, exhausted, defeated, and you may proclaim it a downhill day but you never know what someone else may have seen reflected in your day. God takes all of our days, no matter how awful we think they were, and molds them to serve His purposes despite our failings and shortcomings. Take joy in the knowledge that each day (be they “downhill” days or not) adds something to the surgeon that God is calling you to be. As long as you try your utmost, learn, and represent Him as best you can then your day will not really be downhill.
Know that we care, are here and rooting for you my friend!
August 10, 2007 at 9:11 pm
Thanks to all for the encouraging words.