medical education

Due to some convolution of hospital politics (of which no one has really informed me; I deduce its occurrence by the effects on me), I find myself covering yet another service, about which I know even less than some others. Talk about sink or swim. Fortunately none of the patients I’ve handled like this have been truly sick yet, although they always come billed as something quite frightening, and it takes a little investigation to assure myself that they’re actually stable. Also the attendings are still new enough at having resident coverage at night that they actually appreciate my calls – unlike some other attendings, who now take us for granted and regard my calls as a nuisance.

At one point tonight I found myself wandering into the ICU to check on one of my few patients there; I didn’t really want to check on them (since the simple act of a doctor looking at an ICU patient tends to remind everyone of previously ignored issues that need to be addressed now), but somehow I felt like I had to. And there around the corner was another patient crashing. So I got to watch the senior resident taking care of him, for quite a while, which was instructive. I think a major part of his technique consists of putting his hands in his pockets; it’s hard to get too agitated in that posture. I need to practice that.

Lately I’ve started shadowing the senior residents as intensely as, a year ago, I watched the interns. I can remember making quite a nuisance of myself back then. I know this, because the medical students now are nuisances: very eager and enthusiastic and anxious to learn – but only the fact that you can never again leave the hospital early makes one realize how special it was to be a student who could be sent home, or to bed, away from the boring routine chores. So I don’t really mind the students being there, but somehow the fact that they could be free makes me mind having to do the chores even more.

And now I’m hanging around the senior resident at night, asking intrusive questions like, who did you call? why did you call them? what are the rules for calling people at night? why did you do that? why did you pick that medicine? because I’ve only got three months left of being a carefree intern (used to think that was an oxymoron). So far he’s being very nice about it, explaining what he’s doing; I think because he knows quite well how terrifying it will be to pick up those responsibilities in July. It’s good for me to watch his style, because I think up to this point I tend to imitate Brad a lot; and he is way too much of a cowboy. He has the experience to pull it off; but I don’t, and it will be good for me to imitate a resident with a little more restrained manner.

Which brings up another point: now that I’m a little more comfortable with taking care of patients, and then calling somebody who’s outside of the hospital to tell them what happened and ask for further advice, I’m able to feel guilty for waking people up. They, after all, have to come to work the next day. It makes me feel really bad to wake up people I like, and hear them struggling to pay attention and think about the question. That’s also not going to be fun next year, having to call the same person several times a night, especially knowing that they’ve been up in the hospital the last couple nights.


Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.)

I’m beginning to fantasize about adding a lecture to the series of “basic medical things you really ought to know, in case you weren’t paying attention to this part in medical school” that the hospital sets up for the interns during July. In addition to the [valuable] medical things like, when it’s time to intubate, how to think about renal failure (since thinking seems to be the only thing you can really do about it), management of acute coronary syndrome, and so on, I would like there to be a lecture on, “how to consult surgery appropriately.” It would include such basic concepts as

1) don’t call it a rigid abdomen unless it is
2) on the other hand, if you think it is a rigid abdomen, please call us now and not six to twelve hours later
3) please don’t consult us about the possibility of bariatric surgery for a morbidly obese patient during his hospital stay for another medical issue! this requires six months of outpatient preparation, and does not require an urgent in-house consult
4) please don’t mention the words “elevated lactic acid” if you want to be taken seriously; in fact, just don’t check it at all
(sorry, non medical readers; it is the fond belief of medical people that elevated lactic acid is a sign of infarcted bowel, which if true would require immediate laparotomy; however, it is the firm opinion of surgeons, at least at this hospital, that lactic acid can be elevated for many reasons, including renal insufficiency and general low-flow state, and is of no value compared to the clinical exam and, ok, the CT scan; nevertheless, people persist in checking it, and then stat-paging us because the patient, who is sitting up eating, needs to go to the OR now)
5) try to strike a happy medium between consulting us the second you get a positive c diff test, and waiting until the patient is septic on multiple pressors to ask us about a possible colectomy

As you can tell, the main problem with my scheme is that it would be next to impossible to give this lecture without being incredibly arrogant and snarky. So perhaps it’s just as well that no one tries.

I need to stop reading The ICU Book, or at least stop quoting it to my fellow residents. The author has now demonstrated to his satisfaction (though not entirely to mine; I’m still lagging a couple equations behind) that blood gas measurements are entirely useless, and in fact detrimental to patient care, and that most medications used for acute onset atrial fibrillation have no value whatsoever. I think his next chapter is about how giving people oxygen is in fact bad for them.

It’s amazing how good a solid night of studying makes you feel. I only got paged about urology issues, which are also very satisfying, since they call for a quick, relatively risk-free and painless procedure which makes the patient feel better pretty quickly.

So far I’m 30% of the way through The ICU Book (300/1000pp) (and only 3% of the way through The House Officer’s Guide to Urological Emergencies, which perhaps I ought to be reading more of, but somehow it’s not very gripping).

I’m starting to have mixed feelings about the book. On one hand, it certainly contains such wildly relevant and fascinating subjects as, five continuous intravenous vasoactive medications (otherwise known as the five pressors, which about half the ICU population are on, and about which I’ve been frightened and curious for the last nine months, but never before found a concise explanation of), and, three easy algorithms for managing acutely decompensated heart failure (as well as how to differentiate between right and left sided, systolic and diastolic, subjects which are of very little interest to surgeons, but of intense interest to the gremlins responsible for coding diagnoses in such a way as to extract the utmost amount of compensation from the insurance companies) (and one of these days when a senior resident remarks, “ah, ejection fraction of 65%, their heart is fine,” I will reply, “65% is actually a little high, and if you notice, the report also mentions left ventricular hypertrophy and decreased wall relaxation, which means actually they have a fair component of chronic left-sided diastolic heart failure;” so far, to my personal disappointment, I have faint-heartedly kept quiet at every such opportunity).

(Please I don’t want any commentary on the grammar of that paragraph; all the quotation marks and parentheses are closed; I am experimenting in the stream-of-consciousness style. . .) 

On the other hand, at least 50% of the book’s extensive cogitation seems to lead to the inexorable conclusion that sphygmomanometric blood pressure measurement is inaccurate and useless; direct arterial blood pressure measurement (in most circumstances) is inaccurate and useless; central venous pressure monitoring is inaccurate and useless; pulse oximetry is inaccurate and useless; pulmonary capillary wedge pressure measurement is inaccurate and useless; CPR is useless; crystalloid is useless; blood transfusions are useless and dangerous; pressors are useless and dangerous (with qualifications). You get the impression that only certain arcane measurements of systemic oxygen uptake, which require special bedside laboratory equipment, are of any value in directing patient care. Which makes me wonder, if everything the author is telling me about is so useless, why I’m taking the time to try to understand the equations with which he proves the futility and vanity of all ICU activity?

Besides, what I’ve gathered of surgical ICU care so far is rather simpler and more basic: we like fluids. Fluids are good. Push fluids. [cave-man accent, you understand] What’s a little pulmonary edema between friends? And don’t infuse pressors through peripheral ivs (a course of action which the MICU here pursues on a regular basis, leading to pressor extravasation into the hand and arm, which is not pretty; and then they consult plastic surgery, or vascular surgery for IJs in the carotid), or without placing arterial lines.

My senior resident this month is getting a little wary of mentioning procedures to me. He remarks that some stitches here, or a line there, might be useful, and when he turns around, I’ve done it. So far, so good; but perhaps next time I should wait to hear the end of the sentence (he had to go see an emergency, and I assumed he was done with the instructions). I think it’s a problem if even among the surgical residents I’m remarkable for liking sharp objects. I think the trick is to pretend to be a little more blase about it. On the other hand, I’m satisfied that I’m now competent at using the little throw-away suture removal kits as procedure kits. You open the kit, and arrange the paper cover and the little plastic tray in such a way that they make a tiny sterile field that you can put sutures and needles onto. Then you pretend that the flimsy blunt-tipped pickups are useful for holding tissue with, and you force the scissor’s jaws shut over the needle till they snap past each other and lock the needle between them. Then, if you move very carefully, this will hold the needle steady enough to take a stitch with it. This method is primarily desirable in that you don’t have to go hunt a procedure tray out of the OR or the ER (even most of the medicine floors have suture removal kits, though some benighted units don’t); you can throw the whole thing away when you’re done; and you can place a suture and cut the suture with the same instrument – versatility, you see. Plus, you feel like a surgical Boy Scout. (I believe there’s an Eagle badge if you perform an entire appendectomy in this manner.) Even a few months ago, I couldn’t handle the break-the-scissors-in-order-to-hold-the-needle maneuver, and always had to be fished out by a senior. I am now ready to teach this technique to next year’s interns.

I’m going to have to stop talking about best days ever, because this is all good. The last few nights I and the other night people have been seeing one case after another of those “classic” things, where it looks like the textbook, sounds like the textbook, and even was caused by all the risk factors in the textbook. Not really famous cases, but I’m always tickled to find out that things exist in real life, not just in textbooks and legends. (Gallstone ileus, cecal volvulus, intussusception – that kind of thing.)

Several nights back we had a med student on call, and there was a unique case going on. It was the first I’d ever seen or heard of, and the resident doing it also knew it only by anatomical drawings. The attending was a great teacher – ok, so he whispers and has a thick accent, but if you listen closely, you learn a lot. I called the med student, told him what was going on, and encouraged him to go see the case. I think he went to eat dinner first, which is not laudable, but not reprehensible either. Maybe an hour later, I finally had enough free time to go back to the room. They weren’t very far into the case, but the med student wasn’t scrubbed in. He was just standing in the back, flipping through the chart, while the surgeons sliced smoothly through to expose some beautiful anatomy. I observed to the student that he was allowed to scrub in. I admit that I wasn’t too forceful about it, because I knew that in about two minutes I would be invited to scrub in. I did, and the medical student drifted off, to go study for the SHELF, maybe. It was a tremendous case: easy to see anatomy, the surgeon a great technician, teaching the whole time both about the pathology, and about how to use instruments. FYI, students, that’s one way not to make a hit on your surgery rotation. Always always always scrub in whenever possible. It’s what we live for, and we can’t really fathom why anyone would not be interested. (And yes, this student wants to do psychiatry or something like that, so he has an excuse of sorts; but not really.)

So this morning we had another one of these gigantic cases, the same kind of thing which not too long ago I found myself assisting at, and tremendously annoying the surgeon by doing so. Thus, when I knew a similar case was on this morning, I resolved to come only to watch, with no hopes whatsoever of scrubbing.

I guess my efforts to rehabilitate myself in that attending’s eyes (by studying the subject, and showing up at all times of day whenever he’s doing anything, and doing my best to assist exactly the way he says to) have paid off, because he was quite friendly, and invited me to scrub in right at the beginning. (It’s a good thing that my reading the day before actually covered that case, so I had some vague idea, finally, of what I was looking at.) I had a great time. It was a complex case, with plenty to do, and I got to do half the work on a fair piece of it.

The only drawback is that it took me all week to catch my sleep cycle up, after staying up all day for that first case; and now I have to start all over again.

I was very wise last night, and made no remarks about having nothing to do – didn’t even let the word “bored” cross my mind, and that took some effort. As a result, I got almost no calls, and spent several hours curled up with The ICU Book. After some research, I have finally found a comfortable place to read. The call rooms are impossible: a boardlike bed with a single flat pillow, and an impossible chair, and, if you’re lucky, a metal cart for a desk. (I’m looking forward to graduating out of the intern call rooms.) But I have discovered the closest thing to a comfortable chair, in the same-day section of the recovery room.

Unfortunately, now that I’m actually studying intently, I’m afraid I’m going to turn into one of those people who is always opposing orthodox (traditional) practice on the grounds of “I was just reading about this, and the evidence demonstrates that. . .” I’ve already discovered that one of the senior residents, whom I took for slightly crazy, must actually have read this same book in the recent past.

So far, after just one night of continuous reading, I’ve already learned that: picc lines have no benefit over central lines in the acute setting (no decrease in infection rate, and actually higher rate of complications and cost), nexium is bad for ICU patients (promotes pneumonia, and the GI bleeding it’s supposed to prevent isn’t that big of a danger), blood pressure cuffs are wildly unreliable (even the manual ones aren’t that great, and the automated ones – which are all anybody uses anymore, unless specifically ordered not to – bear absolutely no relationship to reality; and what does that tell you about the diagnosis of hypertension in ~50% of the population?), and that D-dimer and lower extremity ultrasounds are not of great utility in diagnosing pulmonary emboli (ok, that’s not so new). Being as I am, an intern crazy to get my hands on sharp objects, I was particularly interested in the part about picc vs central lines (since the ubiquity of iv team doing these means the house staff do much fewer central lines these days), and went and looked up some literature. I can see where the data was coming from, although there’s some on the other side, too. I printed up some abstracts to show the critical care attendings; one of them is unorthodox enough himself that he might say the book is right. When I rotate in the ICU, maybe I’ll outlaw piccs in my patients.

Oh, and the ultimate bit of heresy: no proven infection control value to masks in the OR. I have to say, I think this one is unproven because no one dares to do a controlled study on it. Anyway, I’m not going to challenge it.

I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great.

They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities.

Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don’t need a large chest tube). The nurses seemed equally uncertain about where to find the supplies, or what to do with the supplies once we had them. Meanwhile the patient’s vital signs became more and more unstable, reminding me very unpleasantly of those questions which occur on every single test from third year medical school up till specialty boards, about the patient with hypotension and tachycardia and absent breath sounds on one side, who will die unless you perform an immediate needle thoracostomy. If you wait and do a chest tube, you always get the question wrong. Now we see why tests are bad for you, because this patient was still ok, but I have seen so many of these questions on tests that I got needlessly concerned about the possibility.

Fortunately at this juncture a senior resident wandered by, noticed the large congregation in the room, and stopped to see what the fun was. He pointed out a couple of errors I was about to make, and with his supervision the catheter got in the right place. (Rather to his surprise, since he seemed not to have done many of these either.) Everyone relaxed. The senior resident left to attend to his own patients. The congregation dispersed.

And then it turned out that the patient had inadequate iv access. Very inadequate. Moreover, nearly every site you could imagine trying was unuseable, for various reasons, including the fact that several attendings had already tried to place central lines, and failed. The nurse, however, continued persistently to fiddle with the lines, and every time I suggested giving him some treatment (because his blood pressure continued to be erratic), she would remark, “That’s fine, but how do you want me to get it into him?” and continue with a litany about how every line was either blown or already in use. So (again with a little supervision) I put in a line, in one of the spots that the attendings had already failed on. That’s why I’m now inordinately pleased with myself; and it’s nice that the senior residents kept walking by and being impressed, too.

I feel like a surgeon. I can do (difficult) lines and procedures on an unstable patient, and be successful, and the patient survived (so far, at least). I made some other decisions, too, which caused the seniors (who were suddenly much more interested in hearing about my problems than they were the last couple nights) to raise their eyebrows and make remarks about clinical indications or the absence thereof – but the morning labs bore me out.

I know that tonight I will get in trouble, because it’s impossible to be so happy with myself, and not make a mistake. “Pride goeth before a fall.” So I remind myself that I was being supervised (some of the time), and that really it was more my good luck that things turned out ok, rather than that I knew precisely what I was doing. Moreover, next year I’ll need to handle, not one, but several critical patients at the same time. This one alone occupied my whole night. I still have a long way to go to being able to balance several ICU’s worth of patients – in four months.

Part of the fun of the night was working with the ICU nurses. They make a great team for each other, always moving to share work whenever anyone’s patient becomes too critical. For this particular patient, since it was such an unusual case, and neither they nor I knew much about what to do, we got along very well: they told me whatever they could remember of “what we did the last time this happened,” and I told them the specifics that I had gathered from the attending’s hasty and detailed instructions, and we did fine.

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.

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