lost in the fog

This will tell you what my nights have been like lately:

I woke up in the evening to go in for the next shift, and my shoulders were really sore. I couldn’t figure out why. I’d been trying to study a little more, but surely I hadn’t spent so much time hunched over a book to hurt that badly. I was at the hospital for half an hour before I remembered that I’d been doing chest compressions the night before.

1am in the ER, one of the ER residents asked about a patient we’d admitted at 7pm. I couldn’t even remember who they were talking about.

A MICU resident asked, How did that laparotomy from earlier in the week do? I said, Which one? The 80yr old with diabetes, the 60yr old with cirrhosis, or the 70yr old who’d arrested? Doesn’t matter, they all did badly.

The OR charge nurses recognize my voice, and start protesting as soon as they know it’s me on the phone. . . doesn’t stop the cases from coming.

Time to go to sleep. . .

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bait and switch

Half of the general surgery attendings at my hospital will do appendectomies laparoscopically. The other half routinely do them open, arguing that it’s faster and requires less equipment (and is thus less frustrating than trying to get techs trained mainly on ortho equipment to get right in the middle of the night), and that a 2cm open scar is no more painful or unsightly than three 0.5-1cm port sites.

My problem is that, after two and a half years, I still can’t remember which half is which. Thus, when I’m explaining to patients – you have appendicitis, you should have surgery tonight, I’ll call my boss and set it up – I usually give them the wrong spiel. Whether that laparoscopy is quick and easy, or that an open incision is quick and easy –  I always get it mismatched. Overall I’m getting better at telling patients ahead of time what the attending’s plan is going to be, which only makes it more painful to have to go back and correct. . . (You may wonder why I’m trying to predict the plan. It looks extremely unintelligent and unprofessional to take the history and physical, and then walk out of the room without explaining anything. If you can’t give the patient some kind of diagnosis, and an idea of whether they’ll be admitted, and whether or how soon they’ll need surgery, it looks as though you’re completely clueless, and not a doctor at all. Much more satisfying all around to immediately say, this is what’s most likely wrong, you’re undoubtedly being admitted, and I expect surgery tomorrow morning; let me check with the boss, and I’ll let you know the final plan. Of course, only satisfying if you get the diagnosis and plan right the first time.)

Tonight it was fun, though. One of the ER residents, feeling cocky, decided to try selling us a case of appendicitis based only on history and physical (how old-fashioned). I had to admire his idea (unlike some of his colleagues’ other attempts, he picked a patient with an appropriate history and physical, rather than say a 24-yr old woman with atypical symptoms). So I bought it, and then I managed to sell my attending on coming in to operate in the middle of the night without a CT scan. . . and we were both right, which was good for us and for the patient.

(And you thought the title referred to the Democrats’ scheme of taking the “public option” off the table to quiet public outrage, then slipping it back in and squeaking it through without adequate debate. . . don’t get me started. Here’s to obstruction and deadlock in the Senate.)

 

electricity is good for the heart

More codes last night. That makes the intern happy; she still thinks it’s a game. Which is all well and good, but I’m the one running the code, and I don’t think it’s quite so much fun any more.

In a way, yes. It’s the nice that the nurses say, “Oh Dr. Alice, it’s great that you’re here. This isn’t your patient, is it? What do you want us to do?” Um, you’re doing good compressions, and I see we’re ventilating nicely, and you paged anesthesia to intubate (that’s how it’s done at my hospital). (These nurses are good. I much prefer codes in the ICU.) How about finding the doctors whose patient it really is? Because I’m getting tired of running codes that I’m not even responsible for. The medical people are supposed to be responsible for codes at night, especially on their own patients. So why am I the only one there for twenty minutes?

So my interns work on lines (they’re good enough with lines on still patients; people bouncing around they’re not so good at yet; we’ll have more practice), and I work my way through every single drug in the ACLS protocol, first-line, second-line, and last-resort. We intubate nicely, and defibrillate more times than I can count. I ask the nurses in the hallway, for the third time, if they would please make sure we’ve paged the medicine folks. By the time they show up, much to my own surprise, we have a perfusing rhythm, a central line, and even an arterial line (which is nice in a prolonged code because it tells you for sure whether there’s a pulse or not, and how much good it’s doing).

I’m a little ambivalent about the value of what I did. After a 45-minute code, I’m skeptical that the patient will have much neurological function left, or that he will even survive till morning. But I couldn’t have decided to stop earlier, without knowing anything at all about his background, and without having managed to get in touch with the primary team. (Also the arterial blood was bright red the whole time, which made me think we were oxygenating and perfusing pretty well, so there was no urgent need to stop.)

On the other hand, I’m making myself a reputation for successfully running codes while also placing impossible lines. A reputation for invincibility doesn’t hurt, until it breaks. It is true, though: the key to being relaxed while someone else learns how to do a procedure is being confident that you can fix it. I knew I could get the lines any time I really wanted them, so it was ok to let the interns try for a while. Next time, maybe I won’t have to run the code, and I can coach them through it better.

(I guess that paragraph definitely qualifies me as a cocky surgery resident. I never thought I would be that person, so I’m going to enjoy it, until it breaks in a night or two.)

(Next time I’m going to see if I can think coherently enough not to have to ask the nurses every five minutes what the patient had been admitted for. They must have told me the same thing six times, and I just kept asking again, as though they had a secret that would tell me why the patient arrested.)

 

so far so good

Not so bad for nights so far. Not much luck at making people come in to operate in the middle of the night, but no one but adrenaline junkies like me and the night float interns really mind that.

Speaking of adrenaline: somebody was messing the code pagers tonight. There was one real one, early on, at which I practiced not touching and not talking while the intern did the line (harder than you’d think), and verified that after working on three-hour long resuscitations on open-chest patients in the cardiac ICU, I no longer care very much what particular order the code drugs are pushed in. Epi; bicarb; calcium; is there a pulse? it must have been three or five minutes; more epi. . . And never let the fact that you got pulses once after CPR delude you into thinking that the pulses will still be there two minutes later.

Then there were several more code pages over the course of the night, none of which were real. In fact, for most of them, there wasn’t even a patient at the location we were sent to. I was never trying to sleep when it happened, so it didn’t bother me too much. I think the intern was mainly disappointed not to get any more lines.

I’ve also been carrying on a heated argument with the chief and attending on one particular service, for the whole month to date, about one particular patient. Every evening I come in and try to persuade them again of my diagnosis; and every morning the chief has some more barbed comments about my sad lack of clinical acumen (as demonstrated by my disagreeing with him). I think the final result is that I was half-right, and he was half-right; and of course each of us thinks our half was the more important. (I was right that the patient needed surgery; he was right that I had the wrong diagnosis.) Note to self, there’s no percentage in fighting with a chief; but next time I’ll show him. . .

 

first day of third year

In one day, I managed to get two people in the unit I started working in to hug me; got one person to yell at me; got three attendings to call me by my first name without reminders; and put in two Swans (as much as in the previous year together). If I can get these to balance out, the next month might not be too bad. (Although I was starting to get that uncomfortable vibe that becomes so familiar to residents, where on the first day of the month all of the attendings claim to be delighted to have you around, and foretell plenty of hands-on learning, whereas within a few days it becomes obvious that you’re still only a scut monkey.)

Yesterday I also had the biggest fight I’ve ever had with a nurse. Previously, when people say I don’t get along with nurses, I’ve been puzzled. This one was not puzzling. My patients were falling apart. I was moving somebody to the ICU every hour or two, without having the time to stop and think about why exactly they were deteriorating (which makes me extremely nervous and snappy) and there were consults from the beginning of the night still waiting to be seen, and major procedures waiting to be done – and the nurse was trying to quiz me about why I’d decided to do this and not that. I tried explaining nicely, I tried telling her I’d cleared it with my attending, I tried offering to discuss it with any other doctor in the unit whose toes she thought I might be stepping on, but she wouldn’t stop harassing me. Eventually I turned my back on her and told her I was done talking (after she’d carried the argument into the room of a conscious patient whom I was trying to assess for a pressure of 80/40 on pressors). After she finally left, the other nurses in the area had a few rude words for her communication methods, so I know I wasn’t the only one feeling annoyed and frustrated.

I’ve mentioned before how some of the senior residents tease me about doing procedures at the drop of a hat. It’s been a while since I acted like that. Lately, working nights, I’ve been so tired and frustrated that I’ve avoided procedures as much as I can. But in the last 24 hours it all started coming back, I think related to being now responsible for only one ICU instead of four (and thus not having to fear what could happen in a distant corner while I’m tied up in a sterile field), and that the most acute ICU in the hospital (cardiothoracic), where there’s no time or leisure for avoiding lines and tubes. I’m reacquiring my knack with sharp objects, and it feels good; surgeons are supposed to be comfortable moving quickly with knives and needles. When I was avoiding procedures, I felt an uncomfortable camaraderie with the naval captains in Patrick O’Brian’s books, questioning their courage when they decided it was wisest to avoid an engagement with the enemy – but not any more.

 

not just in the books

I had a very puzzling experience last night. The arrest pager went off, and I happened to be just one floor above, so I got there a good deal faster than most of the rest of the response team, several floors below. So when I arrived, it was just a few of the floor nurses and an aide. One was making a respectable (although to my mind not very successful) attempt at bagging. Another was doing compressions, and stopping every few seconds to look at the monitor. To me, the monitor looked like torsades immediately, the only time I’ve ever seen that rhythm in real life.

Finding myself the only doctor on the scene willing to talk (the interns had a deer-in-the-headlights look), I announced, “That looks like torsades. It’s a shockable rhythm. Where’s the defibrillator?” One nurse pointed out that she was attaching the pads to the machine, while the other two immediately contradicted me, saying that the rhythm was not torsades, or that it was not shockable. They kept doing compressions.

Clearly I need to learn how to talk louder in emergencies – that particular crowd-control voice which rides right over all the other noise, without being quite as energetic as shouting. (The first time I was alone in the ER with a bad trauma, I found myself squeaking quite shockingly. At least now I lower my voice, instead of raising it, to get control.) It took a little bit of effort to get them to stop compressions long enough to get a real read on the monitor, and strangely enough it was torsades (torsades de pointes, a particular type of ventricular fibrillation, where the waves alternate in height); in this case, it was a beautiful spindly pattern, completely classic (says me, the first time I’ve seen it). Then of course there was the matter of figuring out how the defibrillator worked (an area where I will freely admit that once I got them to go along with me, the nurses were better at the mechanics than I was). We shocked him once, and it worked almost immediately.

The entire event felt surreal. For one thing, torsades. I was starting to think they were purely a textbook phenomenon, like Janeway lesions and Osler’s nodes, antique entities that no longer visit us in real life. Then, the nurses. They were specialty cardiac nurses, twice my age, but seriously? They’ve worked with me off and on for two years. Why didn’t they recognize that it was at least some variety of vfib, and why were they arguing with me? And lastly, the defibrillator worked immediately. That made the whole thing feel like a badly scripted episode from ER: conflict between resident and nurses, and then the defibrillator working like magic. I was so surprised by that, it took me a second to think of what we ought to do next (intubate the poor fellow, who was still blue, despite a strong pressure). (And for icing, the interns standing by gaping at me and the nurses. Yes, it’s June. Yes, these were the old interns. Don’t ask any more questions.)

In any case, for all the chaos, it was the most perfect code I’ve ever been to, and the most perfect code I’ve ever run. So much nicer than the usual asystole arrests, where you can’t shock, just do compressions and push drugs and it never really works that well. Next time I’m going to see if I can not blank out when looking at the defibrillator.

(And yes, as various people pointed out to me later, the textbooks also say that magnesium is the appropriate treatment for torsades. To which I say, 1, I’m not going to discuss whether I remembered that detail or not; 2, in any case, in a code on a regular nursing floor, one has a much better chance of getting the defibrillator to work than of finding magnesium and pushing it fast enough to make a difference. Next time, we’ll schedule the torsades, and arrive with magnesium in hand. The discussion with the nurses was about the diagnosis, not the treatment.)

 

hindsight

Most of the residents on call that night were women, and it was a very bad night, multiple disasters at the same time. Towards morning, a couple of us were standing in the hallway, in between ICU errands, propping up the walls and playing one-up: whose disaster was the worst. One of the older nurses walked by, one of my favorites (her name and her face remind me of one of my aunts); she saw how tired we were.

“You doctors don’t get enough credit,” she said. We figured she had to be joking – what nurse would say that out loud to residents? but she went on. “It takes some special drive to do what you do. We nurses complain sometimes, but when was the last time any of you worked a 40 hour week?” We nodded slowly, realizing that she was serious. “When I was young, getting out of school, there were no female doctors. It couldn’t be done. It really was the old boys’ club. Good for you.” And she disappeared down the stairs.

I turned to the other residents. “Maybe we should have let the old boys keep their club, and we could be sleeping.”

Sarcasm aside, I can’t believe she actually said that to us. Maybe there’s hope for relations between senior nurses and female surgeons.

 

midnight special

 Night shift is like a nonstop final exam. Remember how waiting for the test score was sometimes harder than studying for the test? Nights is a series of problem-solving exercises, where you have to come up with your best explanation and plan, then leave the building. You come back twelve hours later, and like it or not, the answer is up in public view. The rest of the residents and attendings on that service have had all day to think about it, and the official position is out: you got it right, or you missed this or that diagnosis or test or medication, and everyone knows.

 

I need a handbook, something like “Medical Spanish for Dummies,” maybe “How to Break Bad News in Three Easy Steps.” Last night was the worst test ever: a CT scan so bad I had to look at it three times before I completely realized how bad it was (and then radiology was overwhelmed, and perhaps felt I’d used up my quota of over-the-phone consults, and couldn’t read it for me till two hours after I needed it). After a few bad experiences early in the year, there’s a couple of conversations I try to avoid having with patients: being the first one to tell them they have cancer, especially as a consultant; giving bad news in the middle of the night; giving bad news without a family member available for support. So I looked at the CT another three times, to see if I could get out of it, and I couldn’t. How do you tell someone, You’re going to die within the next few days; I could try to stop it, but you really don’t want me to. And then, in the textbook scenarios, the patient is supposed to have something to say to that: questions, denial, grief – something. When they don’t say anything except, OK – you can’t even really try to comfort them, because there’s nothing left to say.

 

As if that wasn’t bad enough, then I felt obliged to call their family and explain the momentous decision we’d made. No one answered the phone, so I thought I had escaped at least that difficult conversation. Then, ten minutes before the end of my shift, the family got my message and called back; so I did have to tell them. I could have deferred it to the primary service (we were just consultants), or to the daylight team that I had already signed out to, but although I try not to be the one giving bad news (I think I’m still too junior to be the one making life and death pronouncements), I despise doctors who dodge their responsibility, and let days go by without telling patients and families the bad news that the medical team already knows. I was the one who’d read the scan, talked to the primary service and my attending, and had the discussion with the patient. So I talked to the family, on the phone (even worse than in person; another rule from medical school – don’t give bad news over the phone), stammering and repeating myself and hiding in a forest of medical details. They understood me, though; the only question was, how long do we have?

 

(And how do you answer that question, anyway? I’m in the business of trying to keep people alive. I’m not really familiar with how things go when we decide to give up. All I could do was make a guess, and warn them that I could be off by several days in either direction.)

 

So then I had to go home, and try to sleep, and wait to come back in the evening and find out –if the radiology attending agreed with our preliminary reading of the scan (what if I had made all these dramatic statements, and been wrong on the diagnosis?); if the surgery attending agreed with my assessment of how bad the prognosis was; if discussion with the family in the light of day changed the decision about whether to intervene or not. I couldn’t decide whether to wish that I had been flamingly, humiliatingly incorrect on all points, and the patient would do better than I thought, or that I was correct, with all that implied for patient.

 

I was right.

 

I don’t feel any better.

 

relativity

Finally, I’ve figured what is so fatiguing about night float. The shift is only 12 hours, so we actually spend less time in the hospital per day this way than usual. But no matter how hard I try to believe that it’s a normal day (at night), it’s impossible to completely ignore the fact that I spend two days in the hospital, but go back each evening on the same day that I started. So I spend less than a day at home, and two days at the hospital. . . or something like that. Anyway, overnight feels like a longer, more significant length of time than a day.

Plus, of course, the inevitable 2am disaster; I can almost set my clock by this one, and usually from the same floor (admittedly the busiest surgery floor, so it’s not really their fault). The only question is how big of a mess it’s going to be: can it be handled on the floor, does it require moving to a step-down unit, or all the way to an ICU, and how many times am I going to have to call people at home to inform them of developments before things quiet down?

 

night in the ICU

I didn’t want to ask for help because it would be a confession of weakness. But my patient was dying, really dying, all of a sudden, out of nowhere, and I didn’t know why, and I didn’t seem able to do anything to stop him. I figured it would be even worse if he died because I didn’t ask for help. So I did. I don’t know what’s worse, that I was weak enough to ask, or that the person I asked didn’t really know any more than I did, and didn’t do any more than what I was about to do anyway. The patient survived, mostly thanks to the nurses, and due to what they and I did before the help arrived. I guess it’s good, in a way. I’ve proven to myself that I can get through anything (with the right nurses). I need to stop using the comfort blanket of asking senior residents for help. If I could just not get so worried by my patients dying, or trying to, that I can’t seem to think straight. . . and why do they always do it at 3am, when I can’t think straight anyway?

I’ve mentioned the ghosts before – memories of other times when things went wrong. They’re starting to add up now, so whenever I have a really sick patient, there’s usually an analogous memory, where things didn’t turn out well. I don’t know whether it’s good, to have those to make me paranoid and anxious to check into every possible explanation or treatment option, or whether knowing the answer to those old puzzles sets me thinking down one track, unable to see what might be different about this time.