I can’t decide whether it was a good or bad day.

A lady who was supposed to have a major vascular procedure developed a very serious complication early in to the operation. Through a complicated series of events, the attending got the impression that she was better, and went to his office. I came back to check a little later, and found her much worse. (And I didn’t get up the nerve all day to go and chew out the people who were responsible for letting her deteriorate unnoticed; not that noticing would have changed the course of events. I need to grow a spine and some teeth, and they’ll hear about it tomorrow.) By this time the attending was gone, and every single other surgery resident in the hospital was scrubbed in the OR. So I had her to myself all day.

It was good, because I got to handle an ICU admission, with lines and diagnostic tests and everything, on my own. It was bad, because it took me four hours, and I didn’t get to pay attention to any of my other patients till late in the day. It was good, because I finally put in my first radial arterial line completely unsupervised (as usual, when you are the only person who can help at all, the impossible becomes possible; the attending said categorically – one of the few instructions he gave me – “put in an a-line;” and I wasn’t about to call him and say I couldn’t do it, until I’d tried all four options; fortunately the second radial artery worked); it was bad, because it took me nearly an hour, between trying, and thinking about it, and trying again, to get it done. Starting in July, I’m going to need to be able to do this whole thing in one hour or less.

The really bad part was talking to the poor lady’s husband. We needed his consent for something part way through, so I had to go track him down in another part of the hospital, and then explain quickly that things had deteriorated, we needed him back over there, and we needed consent. . . I am not good at giving bad news. I think if I hadn’t been choking up, and probably visibly disturbed, myself, he might not have taken it so hard. Probably he would have been just as upset; but it’s not reassuring when the doctor is on the verge of tears. I felt like someone could be videotaping me as an example for medical students of how not to give bad news.

One reason I decided to avoid OB was because I couldn’t stop crying for joy every time a baby was born (yes, ok, irrational; I couldn’t help it). Now come to find out, although I’m getting better at not crying while taking care of my patients, I have trouble keeping my voice level and my eyes dry while giving bad news, or discussing a poor prognosis or imminent death. The prospect of the family’s grief almost bothers me more than the patient’s condition, maybe because the patient isn’t aware of what’s happening.

I wasn’t comfortable with that whole part, either, being basically the only person to discuss symptoms, diagnosis, treatment plans, and prognosis with the family. We did consult a couple people, but of course they didn’t talk to the family. The attending was unavoidably detained (he’s a good guy, he talks to families reasonably often, unlike some surgery attendings, who always leave the whole social interaction bit to the residents), and the rest of the team was also in the OR. So it was the intern doing all the talking; at least I’ve learned to be vague about the prognosis. That way if it’s better than I realize, someone else can always give the good news later; and if it’s worse, I’ve just introduced the subject gradually.

Then once that was somewhat settled, I discovered that various others of my patients had had significant things happening to them, and no one had thought it worth calling me, so at 5pm I was trying to fix a day’s worth of trouble. Splendid. I’m learning why the senior residents are so paranoid. There isn’t time to say, I’ll come back and think about this later. You have to act on everything as soon as it comes in front of you. I thought I had a busy day, with one ICU patient and three troublesome floor patients (many others were behaving nicely). What am I going to do in July, with thirty or forty ICU patients, and fifty or sixty floor patients on my hands at once?