another night

A call-night story:

Sometime after the third unsuccessful code, and after walking the intern through a line in the ICU while we were both being paged by four or five separate nurses for patients with increasing abdominal pain/no urine output/difficult to arouse/heart rate of 150, we were admitting another patient in the ER, when the ER radios started chattering, and then people started walking up to me (the charge nurse, some ER residents, the tech who’s best at getting ivs on hypotensive patients): “Alice, did you hear yet? We’re getting a ruptured AAA. It was exciting the last time we did this together, huh? We’ll make sure to give you a heads up when the helicopter gets closer.”

The intern was also excited at the prospect. I used to be excited. By now, though, ruptured AAAs are no longer new and thrilling, they’re old and stressful. I would be just as happy not to be the point person for coordinating the response, and finding out if I can move things fast enough to save a person’s life. (I am still looking forward to actually being the lead resident on my first open AAA; probably that won’t be as great as I expect, either.) Called the OR, called the ICU, made sure that the ER had already told my attending what was happening. Then I ran upstairs to swing through the ICUs quickly, check on my hypoxic vent patients (solved by turning everyone’s PEEP up), and warn the nurses to ask quickly if they needed anything, because we would be unavailable for a while.

Back in the ER, five minutes ahead of the helicopter; the charge nurse came up to me again. She’s not usually very cheerful, but I think there was a lot of adrenaline going around, and she was almost smiling. “Alice, I just want to let you know, we brought a patient back with a cold leg. The ER staff haven’t seen her yet, but I thought you would like to know. She’s in room 10.” I had time for one quick look at the cold leg, which wasn’t too impressive. The patient was a frequent flier on the medical services, and vascular surgery had often been consulted for her legs, but never felt moved to intervene. I decided it wasn’t worth spending time on right then.

The AAA patient arrived: intubated, unresponsive, pale, unable to get a pressure, everyone in the room frantically feeling for pulses, unable to decide if we actually felt them or not. No time to waste. “Don’t worry about monitors or blood draws or better access – let’s get up to the OR and sort it out there.” We ran (as fast as you can when you have to wait for an elevator), and soon arrived in the OR. Anesthesia was not completely thrilled with our plan, which was to move the patient on to the table, scrub while they started inhalational agents, and then let them figure out iv access (only one or two peripheral ivs so far) and blood pressure monitoring (none so far) while the attending and chief resident started cutting. The anesthesia staff were good, though; by the time the surgeons were down to fascia, the patient had a central line and an a-line started.

I left an intern to scrub in and help retract (remembering how thrilled I’d been to have that job once), added his pager to my collection, and went back to look at the cold leg. Now 45 minutes later, it was clearly cold and pale. But given the patient’s complicated medical history, and the number of times I’d been consulted for a cold leg (on this particular patient) which turned out to be a non-issue, and given what was happening in the OR, I couldn’t recommend immediate surgery. So I called the radiology resident: “This patient has a cold leg. You could probably do thrombolytics, and in any case you could give us a definite diagnosis of where the obstruction is. Get your attending to come in, right now. My attending wants this done. He’s scrubbed in a ruptured AAA, don’t make me interrupt him to tell your attending to come in.” (Radiology and vascular surgery have a semi-complimentary, semi-adversarial relationship at my hospital. Friendly during daylight, but if you want a procedure at night, you have to dig in your heels and scream bloody murder. Sometimes it does come down to the vascular attending calling radiology and throwing his weight around.)

They came in, and it was a good thing they did, as the angiogram showed a lesion I hadn’t entirely expected. It still required surgery, but by then the AAA was stabilized, and the attending could pay attention, and started a second room.

Not a big deal, really, but I took great pleasure in treating that cold leg all on my own, without talking to the chief or attending till it was all settled; and a little perverse pleasure in taking my attending’s name in vain to get the necessary procedures done.

At the end of the day, all the patients and all their legs were still alive, which was a little astonishing. The only people who seemed to be in danger of collapsing were the vascular attending and chief resident, who had been operating for nearly 24 hours straight, and still had no end of their duties in sight. I don’t know whether to be excited or scared that I’m little more than a year away from that role.

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in summary

The week was fairly quiet: only a few cases to go to the OR at night, no remarkable activity in the ICU, no dramatic traumas. I was figuring that my white cloud had stuck with me; and indeed it was remarkable how all the arrests on the floor, and all the gunshot wounds for trauma (which it’s part of my responsibility at night to assist with) should all happen during the daytime for a solid week.

Of course Friday night that all changed, and I was completely swamped, to the extent of almost recklessly leaving things unfinished with one patient in order to hurry off to the next, leaving large jobs for the interns to do alone that normally I would help with, and being quite curt in my discussions with patients (completely contrary to the rules of don’t interrupt, and don’t ask closed-ended questions). Once again, though, everyone survived quite nicely (except for the one patient who, sadly, was not expected to; so I am not too cast-down about that death), and not too many anxious families were mortally insulted. The only lucky thing about the night was that the hospital was suddenly smitten with an excess of empty ICU beds, such that no critical patients had to wait to get in the ICU, which was very convenient.

I am developing a great respect for one of the surgical ICUs in particular, whose nurses are so used to having imperious attendings stroll through handing out orders, and then disappear out of range of pages, that they commonly put in all the orders themselves as verbals; and I find them taking care of all kinds of scut for me, and correspondingly ridiculously pleased when they see me putting in housekeeping orders on my own. This is also the only ICU in the hospital in which the nurses are actually excited when something dramatic happens, and all join in happily for bloody bedside procedures; unlike even the other surgical ICUs, where they don’t mind blood and commotion, but prefer peace and quiet.

On the other hand, I am getting quite frustrated with the medical ICU, where the nurses are certainly competent, but have a very different set of priorities. They will not call to tell me that the patient’s urine output is drifting pretty much to zero for a couple hours on end, or that the blood pressure is creeping steadily down to 80. They will however call to say that the potassium is 3.5 (lower limit of normal) or that the troponin (cardiac enzyme, marker for possible ischemia) is 0.12 (lower limit of abnormal); or that the patient’s lungs sound wet, even though their sats are fine. I wish I knew a tactful way to tell them that I would appreciate being told about borderline blood pressures and urine outputs, in addition to the labs; but I can’t come up with any statement that doesn’t sound insulting (as in they’re not doing their job properly) or lazy (I don’t always have the time to walk through the unit every 1-2 hours to check the numbers for myself).

Also on the score of good news, I have a delightfully competent intern to work with. She is remarkably good at assessing things on the floor or in the ER, and calling me only at appropriate times. Also, she is good at procedures – nearly better than me, I am obliged to say.

 

no answer

You know the teamwork/collegiality concept is having a bad day when a nurse walks up and starts commiserating about how difficult it must be for you to keep on executing the attending’s unpopular plan in the face of opposition from the nurses and two or three separate groups of consultants. I fell back on the “no comment” defense. No matter what I think of the attending’s plan, as long as it doesn’t seem positively unethical, I’m not going to express my doubts to the nurses or to nonsurgeons. Besides, as far as I can tell, he’s the expert in this area, and is much more likely to be right than his detractors are.

 

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.

 

non-dominant inheritance

I’ve written before about acquiring my father’s knack for memorizing all the hospital’s phone numbers (due to getting paged so many times).

He has another skill which it might have been healthier not to acquire.

When driving in the car, in addition to his penchant for passing with really minimal leeway, he also likes to dial his cell phone . . . while turning corners, and sometimes while passing. My father’s passengers quickly adopt a fatalistic mindset. He’s had remarkably few accidents, for all this.

Now I also am an expert at palming my beeper one-handed, reading it, and dialing my cell phone while driving. I really ought to stop. . . but the reflex to answer the page quickly and make sure it’s not something serious is simply too strong to overcome.

(My interns are paying me back in full for some heartburn I know I must have given my seniors last year. Episodes of “why, why did they have to do/not do that?” And I know, even if I can’t remember precisely the occasion, that I did things equally foolish or foolhardy myself. The really humbling part is, I foresee that next year I’ll look at the second years, and say the same thing. . . which I means I’m continuing to do lots of stupid things now, even when no one says so. . . )

 

3am phone calls

This whole home call concept takes some getting used to.  One of the major lessons I learned last year was how to be on the spot: if a patient’s sick, you don’t wait to get called, you keep walking by. If you do get called, you give some preliminary orders (oxygen, fluid, ekg) on the phone, and then get over there so you can see for yourself. And you don’t leave in five minutes; if there’s nothing else urgent, you stay around to see how things go; work on the computer, make some calls, but stay handy for a little bit. And of course the cardinal lesson in medicine: trust no one, neither those junior to you nor those senior. Everyone lies; verify it for yourself.

Now I have to reverse that. I’m getting a little better at jumping wide awake in the middle of the night, so the intern calling doesn’t have to repeat himself ten times. But you have to have all the answers – maneuvers, tests, medications and doses – completely memorized; that’s the only way they’ll come out coherently at (ahem) 3am. (How about my attending for president? He’s really good with the 3am phone calls. And I’m sure he’d come up with a more practical healthcare policy than the politicians have.)

The worst part is not being there. I have to trust the intern (fortunately the ones I’m working with are quite competent) to assess the situation correctly; without seeing things for myself, I have to figure out the key information, and think of things to ask about that the intern may not have considered. Then we come up with a plan, he hangs up to go do it – and I’m supposed to go back to sleep, instead of lying there worrying about whether either of us missed something, whether the patient is going to get worse before our treatments take effect, whether I misjudged the significance of a piece of information, whether I told him the wrong dosage on a medication. If I were in the hospital, I’d keep looking over the labs, ekg, chest xray, till I felt more confident. But I can’t keep calling the intern to go over things again.

(A bonus last week: in desperation, I dredged up a treatment I’d read about as of historical value only, but it was the only thing available or applicable for this patient. Not fun to play that card from long distance, but next morning the patient was nearly all better. I don’t know whether that old-fashioned trick did it, or whether he wasn’t as sick as we thought. Remind me not to read the historical section of the textbooks, it leads to unsettling decisions.)

Going back to sleep is also tricky. After getting called, I spend the next couple hours unable to sort out whether the phone ringing and the patient deteriorating are happening in my dreams or in real life, and I can’t shake the feeling that it’s really high time to get up and go to work, no matter what the clock says. I used to react the same way to pages at night on call, so hopefully this will get better with time.

 

mindset

A combination of nothing particularly bad happening overnight or during the day, and me getting in earlier, made the day pass a lot more smoothly.

Interns, junior residents, and chiefs, think about a service differently. Interns are focused on the set of patients assigned to them. They know they’re responsible for that group, but anything else is out of their comprehension, and indeed they’ll probably get shooed away if they spend too much time thinking about patients they haven’t been assigned. Junior residents feel responsible to keep an eye on the intern’s patients, but they also limit themselves to some extent, because they know that the chief feels ownership of the entire service, and they don’t want to violate the chief’s prerogatives by taking too much responsibility for the service as a whole.

The chief, on the other hand, knows that there is no one but him to be responsible for the entire affair. Yes, the attending is responsible, but he’ll manifest that by asking the chief about anything that comes up, and expecting a solid, coherent, well-researched answer. The chief has to keep an eye out for the details on every patient, no matter which resident they are “assigned” to. He has to know all the important lab and imaging results, and the treatment plan for everybody, because that’s what keeps the service alive. If he misses a patient, there’s no one else to catch it.

I’m cautiously trying to develop that attitude. I can’t do it much when a real chief is around, because they hate it when the junior residents supervise too much. But when there’s no chief, I’m the one who has to make sure nothing slips through the cracks: no one gets mislaid in the ER, no important lab results get neglected for half a day, consultants are called as appropriate, patients who are going to the OR are prepped for the OR, and inspected for damages upon their return. I’m gradually shaking the intern habit of tuning out when a patient I’m not “following” is being discussed.

I’m also developing an amazing appetite for reading the textbooks at night. I’d better know more about what I’m doing. Just taking people’s word that “this is what we usually do” is not enough.

 

consulting

I’m tired of my patients dying. Can we just not do that anymore?

You people won’t believe this, but I really am too nice. Even when my attending isn’t on call, the medicine people go out of their way to consult me on things – things which ought to be directed to half a dozen of the other surgical services before they got to me. I take that as a very backhanded compliment, because I know I always consult two cardiologists, because they’re nice and explain things, one pulmonologist because he discusses the plan and doesn’t extubate or intubate your patient without fair warning, one endocrinologist because he’s always available, one GI doctor because he does a very good job. And on those services, I’m afraid there are about four medicine residents that I always call because we play well together, and trade favors back and forth. Especially neurology: I set up a trach and peg on a difficult case, and he writes helpful notes on brain-damaged patients. Give and take.

But I could stand not to get interminable calls from medicine when it’s not my day to be taking consults, just because they know I won’t bite their heads off about how they should be consulting colorectal surgery for colon cancer, or vascular surgery for leg lesions caused by poor circulation, and so on. I’ll just take the call, figure out how sick the patient is and which surgeon they really need to be seen by, and pass it along to the right resident. One of these days, in about two more months by my estimation, I’ll snap, and start not being patient about it.

At least it’s encouraging that when I get into practice I might be able to build a referral base quickly (but perhaps not for very exciting cases).

 

professional courtesy

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

 

balancing

I thought it was hard being the intern and figuring out how to relate to the attendings and all the various levels of residents senior to me.

Figuring out what to do with my intern is even more complicated.

He’s not brilliant, but he tries hard enough that I can’t just write him off as a bad job. But how do I balance between pushing him hard enough that he learns what he needs to do to make a surgical service work, and being friendly? How do I let him make enough mistakes that he takes things seriously, but keep anybody from getting hurt? There are so many things that he ought to be doing, that we’ve told him about, but he forgets or doesn’t know how. So do I just do them myself, which would be the simplest, remind him endlessly and start looking like his mother or older sister, or let them go until he gets embarassed in front of the chief and/or attendings, to make him remember?

He’s not like I was as an intern, which also makes it complicated. If I’d had an intern as naive and hopeful and trusting, and incompetent, as I was, maybe I’d know better how to relate. Someone who says, I want to do it right, but is rather clueless, seems to me easier to deal with than someone who talks brashly and confidently, but doesn’t have the knowledge or skill to back it up. An intern mouthing off like a senior resident throws me off. The older residents have earned the right to make flippant remarks; my intern doesn’t have the experience that in my minds earns a little tolerance for making unkind remarks about nurses or patients. If the chief says he doesn’t care, I know that his record of hard work, long hours, and lives saved show he doesn’t really mean that. But for my intern to say that – it’s too early. The attending can say, “Ah, fibromyalgia, consult rheumatology,” because we know he has the experience to be confident that there’s nothing really the matter; the intern needs to think a little deeper before brushing someone off.

But I’m not the censor. My intern is an adult, and needs to sort things out for himself. I try not to comment on his attitudes or remarks, just on his work. Hopefully in a few months he’ll learn what’s acceptable and what’s not. I trust the nurses, too, to set him down when he needs it. They can do that better than I can. Time will tell. Like me, he needs to see bad things happen just to learn that they can; then he won’t talk about them so lightly.