acid

I’ve written this post in my mind nearly every week for the last six months, and finally I’m so angry it’s coming out.

Half the bitterness and cynicism among residents comes from the job itself – long hours, seeing people suffer and die and often being helpless to change that. But half of it comes from the way we’re treated by administration. When I was a student I saw this, listening to the residents talk about their grievances against the hospital. Back then I couldn’t understand; I heard the aching bitterness, but I had no idea where it came from.

Now I know. The residency administrators are one thing; they use us like pieces in a puzzle, to fill out the schedule and get the work done, but at least they know our names, and have some slight regard for us as individuals who will carry the name and the honor of the place when we graduate. The hospital administrators are a separate breed. I don’t think they even know that residents exist. Perhaps they suppose the work gets done by robots, or by magic. Certainly they have no hesitation to take actions which gut our educational experience, and change our lives permanently, for the worse, at a moment’s notice.

This is what really gets me: I work so hard for this hospital. I do more than is written in the contract, or than is my obligation as an employee. I go out of my way to try to keep patients happy with this hospital. I apologize when apologies are needed, even when it wasn’t my fault (poor communication to families; housekeeping inadequate; nurses too busy to respond to call bells). I talk to irate families even when it isn’t my patient, I’m just covering, and technically am not required to get involved at all. For all its shortcomings, I do like this hospital (perhaps even love it, because it’s my home, and because I like the people here, although not the administrators); I actually do think about making it successful, keeping it in business. And for that, we get slapped in the face by the administration. They don’t realize or care that the face of the hospital, to all of their patients, is the residents and nurses whom they abuse.

Within the next year, I think I won’t be able to care about public relations anymore. Like so many of the other residents, I’ll retreat into doing only what’s required by the book, nothing more, because the people we work for don’t even give us the benefit of the rules. (I really think they’ve broken our contract in more than one way, in a legal sense as well as moral, but I’m too exhausted to look it up, and what would I do about it anyway? Fight them? I can’t risk my place.) And when I graduate and go to work on my own, you can believe that I’ll never trust a bureaucrat farther than I can throw them. Administration is always out to screw the physicians and nurses – that’s the most important lesson I’ve learned in residency so far; and when I’m not part of the slave labor force any more, believe me I’ll remember it.

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a bit late

Yes, I know Lost is almost concluded; and here I am starting the first season. My only excuse is that I was waiting to make sure it would have a conclusion, before I got involved.

My favorite part of the show is Jack, one of the main characters, who is a surgeon. The writers seem a little confused about what kind of surgeon he is; in the first episode, he refers to having learned not to fear when dealing with a potentially catastrophic bleed during an operation on the cervical spine of a young woman. Characters who don’t like him refer to him as “the spine surgeon.” However, halfway through the season, his most serious conflict with his father, previously the chief of surgery at the same hospital Jack worked at, is revealed to be related to an incident in which his father operated while drunk on a young woman with abdominal trauma from a car accident, and Jack was forced to scrub in to help, but ultimately was unable to save the patient, due to an error his father had made. So I’m not completely sure what a spinal surgeon is doing as the pinch hitter in a trauma laparotomy; but he’s certainly very talented. Maybe he’s double boarded in general and neurosurgery. Or maybe he specializes in young female patients. . .

Apart from that, and the typical cluelessness about medical protocol (horribly incorrect CPR on multiple occasions; the OR is pitch dark; etc), this is only the second realistic TV portrayal of a doctor I’ve ever seen (the first was the murdered fiance, a cardiothoracic surgery resident,  in the first season of Damages, and he was killed off, which I didn’t appreciate). And boy is it realistic. I can completely picture a doctor, and especially a surgeon, behaving exactly the way Jack does, with a hero complex obliging him to attempt to rescue every one, no matter what kind of disaster has occurred, and with a penchant for leadership which really holds the community together, although it also antagonizes some people. Also, most of his medical activities are fairly possible; supposing a plane to actually contain all the useful implement and drugs which he finds, the wilderness medicine he practices doesn’t seem too outlandish.

But the truest part is Jack’s perpetual flashbacks to medical tragedies which haunt him, and drive him on a perpetual mission not to lose another person for whom he feels responsible. I can’t believe the writers had any idea of how true this is, since even the medical dramas, with medical advisers, don’t capture it; but without being lost an a magical island, all doctors are haunted in this way, and this is the most vivid portrayal I have ever seen.

 

some pet peeves

Another part of my role as a junior resident, rather than an intern, is to handle consults from the medical ICUs. There is always a constant stream of these: mesenteric ischemia in patients who’ve been hypotensive for too long for whatever reason (MI, sepsis); toxic C diff; upper and lower GI bleeds which elude medical management.

The consults themselves are not so bad. The patients are usually intubated, which means one simply examines them, and then collects data from the chart, and calls the attending.

The part that’s driving me crazy are the MICU residents and nurses. The surgery residents have a saying: if you get paged with a stat consult from the MICU, it’s probably nothing important, and you can take your time getting there. If, on the other hand, you receive casual notification, through a string of secretaries, of a consult for which the original order was placed some 12 or 24 hours ago, you’d better run, because that patient needs to go to the OR already.

Partly it’s sarcasm, but there’s a lot of experience behind it: innumerable stat pages regarding bowel obstructions which are really ileuses (ilei?), as determined by an abdominal xray, or for uncontrollable GI bleeds which have after all only received two units of blood, and haven’t been scoped (or sometimes even seen) by GI yet (we have to have a scope, or some other study, showing where the bleeding is coming from; you can’t operate at random), or for mesenteric ischemia in which the patient has no abdominal pain, and is severely acidotic from urosepsis and lack of resuscitation; and so on.

Then there are all the times when a CT scan is done early in the evening for abdominal pain, and when radiology reads it around noon the next day, then we’re notified about the gross free air, the occluded superior mesenteric artery, the glaring small bowel obstruction in a toxic patient: all patients in whom 18 hours lost between the initial complaint and the OR time could mean, if not death, certainly a dramatic increase in morbidity. Why can’t they look at their CT scans? I’m not asking for detailed reads, just a glance: gross free air (as opposed to a microperforation) shouldn’t need an official radiology reading to be acted on. I know I’m no good at all at chest CTs, but I can see a saddle embolus, a lobar pneumonia, an aortic dissection. If I can stumble through the pulmonologists’ scans, can’t they look at the abdominal ones a bit?

And the nurses: I’ll stick to one chief complaint: NG tubes. It’s like a trap. No matter how many times I check on the NG (nasogastric) tube, by the time the chief comes to see, it will not be to suction. It may be buried under the pillow, or under the blanket, or down the side of the bed; it may be tied in a knot, or the connecting piece may have been artfully abstracted and lost. Somehow, the MICU nurses seem to believe it would be detrimental to the patient to actually leave the NG to suction. (For your information: an NG is a sump pump, meaning it has an air port, so there is no danger of damaging the stomach mucosa by leaving it to continuous low suction. On the other hand, it stents open the upper and lower esophageal sphincters, so having it in place increases the patient’s risk of aspiration, unless it is being used as intended, to suction.) If the MICU team sincerely believes that their patient has a bowel obstruction, why on earth do they insert an NG tube, and then not put it to suction? It’s not a surgical thing; it counts as medical management! Even three written orders to that effect will frequently not prevail on the nurses to put the thing to suction (I’ve tried).

Fortunately, every now and then I encounter the surgical ICU nurses moonlighting in the medical ICU – a breath of fresh air, although they sometimes look fairly frustrated too.

(And yes, ok, neither I nor the surgical ICU nurses have much knowledge of steroid drips or neutropenic precautions or the intricacies of hyponatremia. . . but an NG is not that complicated!)

 

got it

I finally figured out what’s wrong with all the portrayals of doctors on TV. They show emotion.

They have to, of course; they’re actors, for one thing. And basically, the drama would be a lot less gut-wrenching if the doctor didn’t act heartbroken when delivering bad news.

Real doctors don’t do that. We learn to hide emotion, from everyone – our colleagues as well as our patients. For example:

– Fear. This one is especially important to hide, perhaps because it’s such a constant companion. After all, fear is what makes us good: you have to be scared of how easily something bad could happen, in order to work hard at preventing it. You have to have seen vent-associated pneumonia, and fear its return, to really care about preventive measures or early diagnosis.

But it has to be private. After all, they say surgeons are like sharks: they attack at the smell of blood. Fear of not knowing the right answers only draws more pressure.

As for fear of the outcome for a patient, that has to be hidden, because such things only get stronger by being shared. If everyone in the trauma bay getting ready for a bad level I admitted their fear, we wouldn’t be able to function. Some of the seniors lately have been demonstrating that to me. The trauma pager has been going off again and again, one trauma after another, and now a really bad one. The patient was intubated en route, which is not good, and the confused early reports suggest that there’s something seriously wrong. The nurses and techs run around, laying the room out, assembling the monitor wires, getting the ventilator set up beside the bed, laying out the needles for starting ivs and drawing blood. They’re efficient, but the atmosphere is hectic. Then the senior physician in charge walks in. It could be the ER attending, or a chief surgery resident. They walk slowly (when there’s time), and move deliberately; no wasted steps. Calmly, loudly enough to be heard, they start arranging: who will stand where, who’s responsible for which part of the resuscitation, who’s in charge of the airway, who’s standing by to place a central line, where the thoracotomy kit is if it should be needed. Their calmness settles everybody down, and keeps the room from exploding into chaos when the patient actually arrives. (The worse a trauma is, the quieter the room is. When things are really bad, no one chatters, for fear of drowning out important information.)

Fear also has to be suppressed when talking to patients or families. They ask for the truth, but they don’t really want to know what we know. Even when things are unquestionably bad, the news has to be broken gently, maybe over the course of a couple conversations – because they need to be able to keep functioning. And if the worst-case scenario is only a shadow in my head, there’s no need to torment the patient and family by discussing what will most likely never happen. If I look excessively worried, that scares people so badly that they can’t think; the other children still need to be fed and put to bed.

– Sorrow. I learned this probably in August or September of intern year, and keep relearning it: if you cry about every patient, there’s no time or energy for actually working. Really, I’m hurting my patient if I allow more than a minute or two to consider how awful their predicament is, and how tragic it must be for their family and friends. I need to be thinking about can be done to make him better.  Crying wastes time; meditating on the nature of evil wastes time.

– Of course anger has to be hidden as well (another emotion that TV doctors are frequently good at). Anger, like fear, wastes time and clouds judgment.

Above all, emotion is unprofessional. We’re supposed to be cool, calm, rational – in charge. And that means not showing our colleagues or our patients what we really feel. Drama is for the soap operas, not for professionals.

 

turf wars, revisited

Sorry for the light posting, folks. Life is extremely dull these days.

Which leaves more time to observe the political delicacies of the transplant service. Transplant is unique as a surgical specialty, in that it is a surgical cure for a medical disease. Normally, there’s no surgical role in diabetes, renal failure, or cirrhosis. But once the patient is sick enough to have a transplant, the surgeons and internists have to work together. Very closely.

I don’t know how other places manage it, but nobody has ever defined, here, exactly who is in charge, although everybody agrees that I get to admit and discharge all the patients. There is a great deal of collegial conversation among the attendings (“I trust Dr. Smith, let’s do whatever he says;” “don’t worry about it, I’m sure nephrology/GI/endocrine has it under control”). The residents and fellows also do a fair amount of the same, perhaps a little more barbed (“Good morning, I was just wondering what you thought about. . .” [which being interpreted means, what on earth where you thinking when you did this?])

And then I end up in the pleasant situation of the patient asking me the meaning of a test I didn’t order and had no idea about, or the purpose of a medication I thought he wasn’t supposed to be on. Or better yet, the attending asks me what the immunosuppression is/what the iv fluids are/what the blood pressure medications are, and whatever I tell him is wrong, because someone changed it since I last looked at the chart.

The key seems to be politeness, no matter what you think or are saying, because as long as you say, “what on earth was the point of that?” or “did you not notice this major problem?” in a very polite way, you can keep working together. And I’m sure the nephrology and GI fellows feel the same way about me; perhaps with more justification, because after all, what is a surgery resident doing with these medical patients?

You may perceive that my ambition to know all about medicine has long since vanished. I don’t care about the intricacies of lopressor vs atenolol, or all the possible ways to control blood sugar, or unasyn vs zosyn. It doesn’t need to be cut, I’m not particularly interested.

Bonus: after he counted me coming in at 5:30am for nine days in a row, one of my patients told the attending, when we rounded several hours later, that I was an exemplary doctor and deserved a raise and/or a day off. Makes things worthwhile.

 

warning, rant ahead

I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration.

Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right – this despite signs all over the medical records department warning physicians of the events that are now not permitted to occur, as well as notices popping up all over the charts, and random walls in the hospital. I had no idea that my time in the medical blogosphere was so well spent.

(For further information on the concept developed by some genius in Medicare (who really deserves a million dollar bonus – this scheme is going to save the government so much money – except didn’t they take it all from us in the first place? – until all the hospitals go bankrupt; do you think the government will bail out hospitals who fail because they tried to take care of patients, the way they’re bailing out the financial institutions that made foolish choices?) – excuse me. Back on track: for further information, see Buckeye Surgeon’s analysis, and this piece by Dr. WhiteCoat (as well as a good deal more on his site). Basically, the idea is that Medicare (and the private insurance companies will inevitably follow suit) picks several events which everyone would prefer not to happen, and unilaterally mandates that they will now not pay for these occurences; the goal being to promote “quality” healthcare. Which is fine for the “never” events like wrong-site surgeries and mismatched blood transfusions; those are rare and truly preventable. But then you come to things like urinary tract infections, central-line associated bacteremia, C difficile infection, wound infections, and on and on – things which we all deplore, but which there is no scientific evidence to suggest the possibility of completely eliminating. All the studies show ways to decrease their incidence, but not to prevent them from ever happening at all. I can quote you the statistics; that’s stuff I get pimped on. Anyway, basically, Medicare is going to penalize hospitals for existing in the real world. They’ll all go bankrupt. Somebody please help me figure out some alternative career options? I need to get out of this circus before the whole thing falls apart.)

(And in case you were wondering, I know that the goal of all this is to decrease costs to Medicare, not to improve patient care. Because if patient care were the point, hospitals could be held to evidence-based standards for acceptable rates of infections and other complications. But this whole rigmarole is being arranged by some accountants and their secretaries, who know nothing about taking care of sick people. . . . I’m looking for the exit, and that’s only partially rhetorical. I do not want to spend my life explaining myself to bureaucrats, and begging for permission to take care of the patients that I am morally and legally responsible for.)

 

appreciative

I’ve discovered something extremely useful that the medical doctors do.

I hate walking into patients’ rooms (or into an office encounter), introducing myself for the first time, and within the next ten to fifteen minutes trying to familiarize a patient with an operation enough for them to consent to it. It feels like such an imposition – Hi, I’m Alice, you have cholecystitis, you need to have your gallbladder taken out, we have an OR slot available tomorrow morning, the risks include death, heart attack, stroke, damage to your liver/intestines/bile ducts, bleeding, and infection, please sign this paper. That is really what I say, except more smoothly, and spread out over fifteen minutes. Or, Hi, I’m Alice, your father really is not getting off the ventilator any time soon, he needs a trach and a feeding tube, he can fit into the schedule tomorrow afternoon, please sign this paper. Or, Hi, I’m Alice, I regret to say that your increasing abdominal pain is due to an obstructive colon cancer, you need to have surgery, you’re first on the list for the morning, please sign this paper.

That’s how it happens, because we try not to drag our feet about inpatients. If they’re inhouse, and they need surgery, we’ll do it within the next day or two. And I simply don’t have the time to walk by the room three times in the next 24 hours, to give the patient time to think about it, and then answer questions, and then get the consent signed. The attending will come around, too, but I’m the one who has to get the paperwork in order.

So the medicine guys are great, because they get the patients and families accustomed to the idea of having an operation, and give them some time to come to terms with it, between when it first comes up, and when we arrive to talk about it. Ok, maybe they could stand to check some coagulation labs for patients on coumadin when they call us for an urgent problem, but there’s a limit to how much surgical thinking you can ask from nonsurgeons. Maybe the patients end up with the strangest ideas about how the operation proceeds, or what they can expect afterwards, but I daresay the majority of those miscommunications come from their ears, not from the medical doctors. It is nice to get into the room, introduce myself as a surgical resident, and have the patient say, “Oh yes, they told me I need to have my gallbladder out, my children agree, let’s get it over with, where do I sign?” Sometimes I regret having the wind taken out of my sails, since the patients often don’t want to listen to my speech about the chances of recurring incidents if they leave the gallbladder in, and the possibility of nonsurgical treatment, but I can’t exactly argue about that.

 

give and take

The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (“Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

 

tribal conflicts

Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.

. . . ok, got it?

That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal – maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)

Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.

When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.

When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)

This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.

 

too much of a good thing

I’m convinced I’m a white cloud, and I’d like to know how to change that.

“White cloud” is residents’ slang for a person who doesn’t seem to have patients come in, surgeries or codes happen, or patients transfer to the ICU or die on them. I think it really developed more as a corollary to the original phrase, “black cloud,” which is someone who attracts bad luck: when they’re on call, their team picks up more than their fair share of new patients; their patients always go to the OR, or the ICU, or die.

Being a white cloud is nice for a while, since it means less work – fewer admissions, transfers, and postop orders to write. But it really adds up to worse education. Getting slammed all day and night with admissions and disasters isn’t fun while it’s happening, but it’s extremely educational. A quiet day where no one crashes, no disastrous transfers land on the doorstep, and almost no one gets admitted to your service is pleasant, but not useful.

As long ago as third year, I knew I was a white cloud. On OB, even though I was crazy to deliver babies, they would rarely come on my shift. When it was another student’s turn on labor and delivery, they’d have four or five babies in eight hours. When I was on, six women would labor for twelve hours, and five of them would deliver after I had to leave. On trauma as a student, the gunshot wounds always came in on other people’s nights. On medicine call, I always got rule-out chest pain and COPD exacerbations. The other students picked up the fancy autoimmune complications, complicated cardiac issues, new cancer diagnoses, and so on.

This year, for being nearly done with a surgical internship at a tertiary care center which routinely picks up the disasters of several counties and states surrounding, I have had remarkably few people die on my hands, and have been present for remarkably few emergency trips to the OR. It’s always on someone else’s service that the patients develop bleeding that requires operation, perforated viscus, mesenteric ischemia, intra-abdominal sepsis, etc, or come in hypotensive and coding from the transport. It’s nice, I suppose, because I really don’t like it when my patients crash.

But I can’t believe that this white cloud effect is going to persist for my entire career. If it is, I should start marketing myself as a means to reduce the morbidity and mortality of almost any operation. (And it’s not because I do anything special. One of the chiefs is extra-paranoid about her patients, and boasts of having the lowest morbidity/mortality as a result. I’m not that good.)

This weekend, of course, is a case in point. Last weekend, the team on call got slammed. They doubled their list, and spent half the weekend in the OR. Two or three people ended up in the ICU, and all kinds of drama occurred on the floor. But now that I’m on call, we had one admission and one OR. No disasters. Everyone got out of the unit. What’s up with that?

I really should start tallying the morbidity and mortality of my patients compared to my fellow interns. Either I need a bonus from the hospital for improving their statistics, or I should get rid of this superstition about white and black clouds.

I’m just afraid that the other shoe is going to drop sometime. Like in two months, when I’m alone at night, and patients will start doing things that I’ve never seen or heard of before, because I have such incredibly good luck on call.

(Actually, I do know how to change this. Go around talking about “quiet night,” “being bored,” and “nothing interesting in the ER.” This really works very well, so well that the rest of my team curses me every time they hear me say it; so I don’t do it so much anymore. It tends to produce four ER consults in a row, and two or three admissions at once. I’m not sure what it does to the ICU; I haven’t tried it there.)