I talk about poo a lot. Which is okay because in general surgery talking about poop is constant. And when you are on GI surgery it's even more prevalent. So, most conversations about poop don't particularly shock me. Until earlier this week when a progression of conversation has had me in hysterics every time I think about it.
It all started when my co-intern and I were sat down eating lunch together on Tuesday. It's rather rare for co-interns on the same service to actually get a chance to have a meal together so maybe the thrill of it all got to us and that's why this conversation happened. BUt whatever the reason it's really too much of a gem for me to keep to myself.
So, here is how it all went down. We were talking about the upcoming holiday, thanksgiving. And he had been going on for days about how much better enjoying a thanksgiving meal would be if he could have a foley catheter for his pee and a rectal tube in for his poop. "I'd never have to get up. I could just eat and drink ALL day." Then he said that it would just be convenient to have the rectal tube in all the time. It would save him a half hour every day, at least.
At this point I had to stop him and ask him what he meant by half on hour, at least. And he explained that his favorite time of day was when he came home, got completely naked and took a 30-45 minute poop. I started laughing . . . he continued talking. First of all, he wanted me to know that he doesn't poop naked at the hospital. And it was also important that I know how he keeps himself occupied during this time "it's not computing, it's compooping," he said. When he brought up how useful smart phones for occupying the time while he poops I was laughing so hard I literally burst a vessel and got a nose bleed.
Now, I was convinced that my co-intern was some kind of freak but he swore to me that this is normal male behaviour. Lucky for me I'm in surgery so my whole team is guys. Which meant that right before rounds we had a little pow wow about pooping. And I discovered that the 3rd, 4th and 5th year residents on my team all have various bathroom activities to keep them occupied while they poop. Two of them are on the same side as my co-intern and enjoy a nice naked poop. But my chief (the 5th year) doesn't understand pooping naked. He's afraid he would get cold, but he does enjoy pooping sans pants.
And, then I asked a question which would start a topic of conversation I'd never even imagined possible, "is there anything you boys won't do while pooping?" The general consensus was eat, until our third year brought up something that I'm sure has only ever happened to him but is hysterical none-the-less. "Sometimes," he said "I eat something with a particularly delicious smell and then when I poop a few hours later it smells exactly like that." At this point he stopped and thought about what he was saying while we are all looking at him like he was crazy. "McDonald's chicken nuggets are the best example I can give you. Sometimes when I poop out chicken nuggets I take a little whiff and I get hungry again, for chicken nuggets." And then as were dying with hysterics he did a little pantomime of him eating chicken, sitting down for a poop (with his phone) and then taking a smell and licking his lips in anticipation of another round of nuggets, "it's a vicious circle."
It took a good ten minutes to recover from that conversation and we still giggled out way through rounds. But the kicker was the next morning when our chief walked in and told us about he had been lying in bed alone while his wife was in the other room and he was thinking about chicken nuggets and started laughing uncontrollably. To the point that his wife had to come and check on him. Now the thought of our chief lying in bed laughing out loud while thinking about someone pooping naked while texting and wanting chicken nuggets is just about the funniest things I've ever heard. And I never would have heard about it if I hadn't been a surgeon.
11/27/10
11/26/10
Hospital for the holidays
I was driving home from work yesterday and I decided to go via the main road in our small university town. I've driven down this road dozens of times at all hours of the day and night but yesterday was surreal. Everything was closed, not a soul was in sight. There were wet leaves swirling in the wind and rain pelting dark windows. It looked like a modern day ghost town. For me, the weirdest thing was that hospital wasn't dead. Yah, it was a little short-staffed but all the lights were on, the beds were full, there was the gentle rush of noise and activity at every nurses' station. But outside the world had quietly retreated into their homes to be with their loved ones on Thanksgiving.
Having done my clinical rotations in New York I never fully appreciated how odd it is that the hospital is awake on major holidays. Because, as we know, New York never sleeps. So, yesterday was a bit alarming for me. The juxtaposition of activity inside the hospital and stillness outside was something I had never really been faced with before. And I suddenly realized that I work in a place that time doesn't touch.
I've definitely been in the hospital before and glanced up at an analog clock on the wall and been uncertain of whether it was AM or PM. But I thought that was more because of how I tired I was. But in all reality it doesn't matter if it's 3 PM or 3 AM . . . the hospital is still going. It doesn't matter if it's Thanksgiving or Christmas or July 4th. The hospital stays open. I think there is something noble about that.
People take it for granted that their local ER will be open whenever they need it. But what about the people working on thanksgiving day. What about their families and friends and loved ones? Well, for the time that you are the hospital you don't think about all of that. You focus on the job you have to do, you get your work done and then head home. Much like any other day. And for me, this Thanksgiving was very much like that. I went in, rounded, discharged 8 pull, placed wound vacs, pulled drains, inserted tubes. And then I went home. I had a headache so I spent my thanksgiving nursing that and giving thanks that I'd gotten out early and would be heading home the next day.
What really got me was all the people I hadn't discharged who would be spending thanksgiving in a hospital bed eating hospital bed watching hospital television getting cared for by people that would probably rather be elsewhere. In fact there was one lady who got admitted the night before thanksgiving. She was a transfer from another hospital. They'd run out of things to do for her so they called up my attending and asked if we would take a look at her. She was weak and tired when we walked in yesterday morning but all she wanted to know was if shed be eating turkey with her family. Even though she hadn't been able to keep down a bite for days.
Anyways,I just finished my rounds for today. So I'll be driving to my parent's house. Where I'll be getting a proper thanksgiving dinner. I'll be leaving my beeper and ID on my kitchen table and I'm going to spend serious time drinking, relaxing and spending time with my family. But, while I'm away the hospital will keep moving forward. The 8 patients I left on the GI surgery service will have changed, some will be better, some will be worse, some discharged and some newbies. Because that's the nature of the beast.
http://www.youtube.com/watch?v=poKiom33nCE&feature=related
. . . a little thanksgiving celebration scrubs style . . .
Having done my clinical rotations in New York I never fully appreciated how odd it is that the hospital is awake on major holidays. Because, as we know, New York never sleeps. So, yesterday was a bit alarming for me. The juxtaposition of activity inside the hospital and stillness outside was something I had never really been faced with before. And I suddenly realized that I work in a place that time doesn't touch.
I've definitely been in the hospital before and glanced up at an analog clock on the wall and been uncertain of whether it was AM or PM. But I thought that was more because of how I tired I was. But in all reality it doesn't matter if it's 3 PM or 3 AM . . . the hospital is still going. It doesn't matter if it's Thanksgiving or Christmas or July 4th. The hospital stays open. I think there is something noble about that.
People take it for granted that their local ER will be open whenever they need it. But what about the people working on thanksgiving day. What about their families and friends and loved ones? Well, for the time that you are the hospital you don't think about all of that. You focus on the job you have to do, you get your work done and then head home. Much like any other day. And for me, this Thanksgiving was very much like that. I went in, rounded, discharged 8 pull, placed wound vacs, pulled drains, inserted tubes. And then I went home. I had a headache so I spent my thanksgiving nursing that and giving thanks that I'd gotten out early and would be heading home the next day.
What really got me was all the people I hadn't discharged who would be spending thanksgiving in a hospital bed eating hospital bed watching hospital television getting cared for by people that would probably rather be elsewhere. In fact there was one lady who got admitted the night before thanksgiving. She was a transfer from another hospital. They'd run out of things to do for her so they called up my attending and asked if we would take a look at her. She was weak and tired when we walked in yesterday morning but all she wanted to know was if shed be eating turkey with her family. Even though she hadn't been able to keep down a bite for days.
Anyways,I just finished my rounds for today. So I'll be driving to my parent's house. Where I'll be getting a proper thanksgiving dinner. I'll be leaving my beeper and ID on my kitchen table and I'm going to spend serious time drinking, relaxing and spending time with my family. But, while I'm away the hospital will keep moving forward. The 8 patients I left on the GI surgery service will have changed, some will be better, some will be worse, some discharged and some newbies. Because that's the nature of the beast.
http://www.youtube.com/watch?v=poKiom33nCE&feature=related
. . . a little thanksgiving celebration scrubs style . . .
11/20/10
The sick role
I've been remiss in posting. I know. I'm sure all 5 of my readers are seriously bummed by this. I've been on the lower GI service this month. Which is pretty much colorectal surgery . . . but for us at my hospital we are the IBD (irritable bowel disease) specialists. The vast, vast majority of our service is made up of patients with ulcerative colitis or chron's disease. For those of you that didn't go to med school these are disease that affect the bowel causing cyclic waves of diarrhea and constipation. They can be painful, uncomfortable and life altering. But, they don't kill you. Well, they might be a contributing factor to your death. But your life expectancy isn't much altered as long as you have close medical/surgical care.
A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.
I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.
So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.
These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.
So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.
It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.
One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.
And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.
Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.
A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.
I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.
So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.
These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.
So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.
It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.
One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.
And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.
Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.
11/6/10
Specialization cut short by drinks.
So, a lot has happened since I last wrote to you. I've finished with Vascular surgery and I'm one week into lower GI surgery. I think I've written to you enough about all things vascular. It was not an easy month for me. Not because the hours were hard, and I even saw the humor in most of the patients. But, the medicine just wasn't for me. Right now, though, in the abdomen, I feel like I've returned to my happy place.
This has got me pondering on how young doctors pick their specialties. It's often said in med school that the professors can tell what specialty you are destined before just by meeting you. The nerdy ones with poor people skills often end up in specialties like radiology or pathology. It's always the geeky guys that are forever quoting journal articles that lean towards medicine. The kids that just quite pick what they are interested in lean toward family medicine. And the rough and ready guys that are always looking for their next adrenaline rush end up in the ED. The surgeons are the ones that are too cool for school. I could keep going on with the stereotypes. Tell you about the ladies the pick OB/GYN and the sometimes super creepy, too nice guys that go for it as well. But, you know all these things. Most of these stereotypes are quite intuitive. My question is about how one picks their subspecialty.
In this day and age being a generalized doctor is a death sentence to your practice. Everyone wants a specialist. We used to joke in med school that we would specialize in something obscure like the pinky and make a mint because people the world over would come to use for their pinky troubles. And we could charge double, even triple because we were the only one in the world. While that is a bit extreme it does have a nugget of truth. Specialization is the only way to survive.
So, now that I've picked surgery how do I pick a specialty?? We spend our first year rotating through a different specialty each month. We meet with an assigned mentor and we really should know what we want to do by our second year. But, it's a hard decision.
Ummmm, I'll finish later. I only just got home at 6 and I have tomorrow so I'd decided to just sit in and veg, write to you guys. But then a couple of my co-interns called and we've decided to grab some drinks since none of us have to work tomorrow. I'm going to wear make up. And fancy jewelry that dangles. Oh My God. It's been so long.
This has got me pondering on how young doctors pick their specialties. It's often said in med school that the professors can tell what specialty you are destined before just by meeting you. The nerdy ones with poor people skills often end up in specialties like radiology or pathology. It's always the geeky guys that are forever quoting journal articles that lean towards medicine. The kids that just quite pick what they are interested in lean toward family medicine. And the rough and ready guys that are always looking for their next adrenaline rush end up in the ED. The surgeons are the ones that are too cool for school. I could keep going on with the stereotypes. Tell you about the ladies the pick OB/GYN and the sometimes super creepy, too nice guys that go for it as well. But, you know all these things. Most of these stereotypes are quite intuitive. My question is about how one picks their subspecialty.
In this day and age being a generalized doctor is a death sentence to your practice. Everyone wants a specialist. We used to joke in med school that we would specialize in something obscure like the pinky and make a mint because people the world over would come to use for their pinky troubles. And we could charge double, even triple because we were the only one in the world. While that is a bit extreme it does have a nugget of truth. Specialization is the only way to survive.
So, now that I've picked surgery how do I pick a specialty?? We spend our first year rotating through a different specialty each month. We meet with an assigned mentor and we really should know what we want to do by our second year. But, it's a hard decision.
Ummmm, I'll finish later. I only just got home at 6 and I have tomorrow so I'd decided to just sit in and veg, write to you guys. But then a couple of my co-interns called and we've decided to grab some drinks since none of us have to work tomorrow. I'm going to wear make up. And fancy jewelry that dangles. Oh My God. It's been so long.
10/21/10
GTFO . . . Getting The Fuck Out
Most people look forward to vacations and breaks. But not like interns. Man, we literally live for them. They are the ONLY thing that keeps you going. As interns we work 80+ hours a week. Get only 4 days of a month and only 3 weeks off in the year. So when we go on vacation it's a big damn deal. I got all my vacation at the beginning of the year. And that is not ideal because it means no more than 2 days off in a row for the rest of the year. (Our year starts with June 24th and ends with the 23rd on the following June.)
So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.
Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.
No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.
I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.
So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.
Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.
No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.
I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.
10/18/10
Not another one
I was on call last night. I spent the day dealing with a patient who had either a ruptured abdominal aortic aneurysm or a small bowel obstruction. Clinically this man looked great. I really wasn't worried about him. My main concern was the nursing staff that just would not be helpful. I was sabotaged every step of the way. I wanted abdominal xrays they wanted me to order them at bedside (not useful). I ordered labs, they cancelled them.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
10/16/10
List management
Census, rounding sheet, list, rounds report, these are all names we have for the list that we print out every morning with all of our patients on it. Each hospital and each service within a hospital has a different way of managing that list. Some hospitals list nothing but room number, patient name and diagnosis. Others are much more extensive. My hospital prides itself on our list. We like to think of ourselves as pioneers in this one bit of data recording. Our list contains not just the basics, but what meds they are on, their vitals, ins and outs and diet for the last 24 hours auto populates every time you print a new list. Additionally you can add in any procedures they have had or that are planned for. You can type up a plan, put in notes for the cross-cover intern. You can stick in random details about the patient that you don't want forgotten.
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
10/10/10
Dr. Give-A-Crap
I'm on vascular surgery this month which brings with it a whole new patient set. These patients aren't adorable kids like in the world of peds surg and they aren't misfortunate like the burn patients. Well, sometimes the burn patients are a little stupid. I mean, really what kind of person burns trash with gasoline? Gasoline doesn't burn, it explodes. But, I digress. The vascular patients are a whole new breed.
For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.
Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.
And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.
I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.
Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.
So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.
There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.
And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?
It takes a toll on you.
As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.
I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.
For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.
Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.
And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.
I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.
Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.
So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.
There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.
And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?
It takes a toll on you.
As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.
I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.
10/3/10
It's not a pager, it's a leash.
My last few posts have been kind off depressing. I don't want all of you out there (you know, the 2 people that read this thing) to think that my job is just one depressing event to the next. And, I don't want to dwell on just the sad stuff either. I see older residents who are angry and bitter because they can't get past the sad. When something good happens they can't enjoy it because they are so jaded. I don't want to become that kind of doctor and I don't want you all thinking that that's the way it is either.
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
9/27/10
Time of death
I watch a lot of movies and a lot of television. One of my favorite shows is M*A*S*H. I can't remember when I started watching M*A*S*H. It must have been on Nick at Nite. But, I eventually bought the box set and I've watched every episode a dozen times. I can quote it, I can give the blow-by-blow of most episodes. But, there are some episodes that stick with me more than others. One in particular is a Christmas episode where an injured soldier is flown into the unit during a party on Christmas Day. Colonel Potter, BJ, Hawkeye and Hot Lips keep everyone else in the dark while they try and save this man. Eventually they realize that he can't be saved and they instead settle for keeping him alive just long enough so that his kids don't find out that their father died on Christmas. Unfortunately the soldier dies just before midnight. They bluff the death certificate anyways. It's a good episode. One of many good episodes. But, like I said it always stuck with me.
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
9/20/10
Proud owner of a used heart
On occasion my chiefs will tell us lowly interns about what it was like when they were first years. Sometimes it will be just to tell us how easy we have it, or how they were better than us. But every now and then you'll get a little nugget of truth out of one of them. A few weeks ago one of my chiefs told us how he used to go home and curl up in the fetal position while listening to Megadeath. He said it soothed him.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
9/16/10
2 year olds shouldn't die.
It was one of those days where things are amazing and awful all at the same time. Today I took a kid who twenty years ago would have spent his life pooing into a bag and created a brand new rectum for him. He won't even remember this first year of his life when his non-functioning rectum meant that he was dependent on an ostomy. And that was amazing.
Imagine if this kid had grown up with an ostomy. We all know how cruel kids can be. The nicknames would have been awful, and would have haunted him in everything he did. I mean, who would go to prom with the kid that everyone calls "shitbag?" It's nice to think that it would have made him a stronger person, a better person. But that's more often the exception than the rule. Fortunately we don't have to wonder about any of that because we took the ostomy and reconnected it to a newly created, functioning rectum. I can honestly say that I helped make this kids life better.
Unfortunately there is a 2 year old girl lying in our PICU for whom I can not say that. She was ejected from her car seat in a motor vehicle collision and suffered multiple skull and head fractures, she was bleeding into her brain and she was taken to the nearest hospital. A rural hospital. They did CTs of her head and body and intubated her. Then they kept her there for EIGHT hours before sending her to us. Who are we? We are the only level 1 pediatric trauma center in the state. We are where she should have been sent the SECOND she was stable. We should have been notified of her the second she rolled into their emergency department. We would have had her on a chopper and in our trauma bay in an hour.
Instead she was transported to us by ground and that delayed her definitive care by another 3 hours. Do you know what happens when a 2 year old bleeds into their brain for 11 hours? They stop clotting. They start oozing from orifice. Their core temperature drops. They become hypotensive and tachycardic. They become unresponsive. Their pupils dilate. They lose their basic brainstem reflexes. They die. That's what happens. And we all stand there incapable of saving her. All of us, interns, residents, attendings, nurses we try to put in lines and get her blood products and warm her up, and raise her blood pressure and slow her heart rate. We call in ENT, Neurosurgery, Optho because we know our limitations. The pediatric surgery and pediatric critical care attendings do all the procedures because she isn't someone that can afford a resident mistake.
This isn't a learning experience for us. This is a desperate attempt to save someone who can't be saved. Because the thought that this little girl is going to die no matter what we do isn't something any of us can bear to entertain. So the attendings pull out all the stops because at some point they know they are going to have face her parents. And when they do they are going to have to look them in the eye and say "we did all we could."
But none of that is going to change the end result. Right now that little girl is lying in a PICU bed. She is intubated, sedated, paralyzed and receiving enough blood products, fluids and medications to keep her heart beating. But, neurosurgery already told us what none of us want to face. She is brain dead. We're keeping her body alive even though what made her who she was is gone. Someone will talk to her family about her donor status. And maybe some part of her will go to another little girl. Maybe that's a silver lining. But it doesn't change the fact that 2 year olds shouldn't die.
Imagine if this kid had grown up with an ostomy. We all know how cruel kids can be. The nicknames would have been awful, and would have haunted him in everything he did. I mean, who would go to prom with the kid that everyone calls "shitbag?" It's nice to think that it would have made him a stronger person, a better person. But that's more often the exception than the rule. Fortunately we don't have to wonder about any of that because we took the ostomy and reconnected it to a newly created, functioning rectum. I can honestly say that I helped make this kids life better.
Unfortunately there is a 2 year old girl lying in our PICU for whom I can not say that. She was ejected from her car seat in a motor vehicle collision and suffered multiple skull and head fractures, she was bleeding into her brain and she was taken to the nearest hospital. A rural hospital. They did CTs of her head and body and intubated her. Then they kept her there for EIGHT hours before sending her to us. Who are we? We are the only level 1 pediatric trauma center in the state. We are where she should have been sent the SECOND she was stable. We should have been notified of her the second she rolled into their emergency department. We would have had her on a chopper and in our trauma bay in an hour.
Instead she was transported to us by ground and that delayed her definitive care by another 3 hours. Do you know what happens when a 2 year old bleeds into their brain for 11 hours? They stop clotting. They start oozing from orifice. Their core temperature drops. They become hypotensive and tachycardic. They become unresponsive. Their pupils dilate. They lose their basic brainstem reflexes. They die. That's what happens. And we all stand there incapable of saving her. All of us, interns, residents, attendings, nurses we try to put in lines and get her blood products and warm her up, and raise her blood pressure and slow her heart rate. We call in ENT, Neurosurgery, Optho because we know our limitations. The pediatric surgery and pediatric critical care attendings do all the procedures because she isn't someone that can afford a resident mistake.
This isn't a learning experience for us. This is a desperate attempt to save someone who can't be saved. Because the thought that this little girl is going to die no matter what we do isn't something any of us can bear to entertain. So the attendings pull out all the stops because at some point they know they are going to have face her parents. And when they do they are going to have to look them in the eye and say "we did all we could."
But none of that is going to change the end result. Right now that little girl is lying in a PICU bed. She is intubated, sedated, paralyzed and receiving enough blood products, fluids and medications to keep her heart beating. But, neurosurgery already told us what none of us want to face. She is brain dead. We're keeping her body alive even though what made her who she was is gone. Someone will talk to her family about her donor status. And maybe some part of her will go to another little girl. Maybe that's a silver lining. But it doesn't change the fact that 2 year olds shouldn't die.
9/15/10
Blerg
I am very, very tired. I worked for 31 hours. I've been up for about 33. It is so bed time but I just had to drop a couple lines about the events of last night.
So, last night I managed a couple of patients without any hand holding. I made decisions and then called and told my fellow or chief. The sky didn't fall. I didn't do things perfectly or with very much finesse but everyone came out alive and not much worse for the wear. That being said I totally had a break down crying moment this morning. Granted, I'd hit that wall that you always hit when you've been up for too long.
I needed a Chest X-ray on a patient whose chest tube we were planning on pulling that afternoon after we'd water-sealed it the night before (basically taking it off suction). I'd might a slight error in the order. I'd written post-pulling eval instead of pre-pulling. Well, the nurse took it upon herself to cancel the order instead of calling clarifying. So, 9 am rolls around and no CXR. My team is pissed.
So, now I order a stat Chest X-ray, which should happen within 30 minutes. It takes 2 hours. Now, I'm pissed. And somewhere in all that I cray in two different supply closets and the work room with my co-intern (he's going into Ortho) sitting beside me made very uncomfortable by this display of womenly emotion.
Also, that was not an easy call. I was never really completely on top of what I needed to handle. So I had this residual I'm not quite competent enough feeling. Added to my frustrations in managing my sick patients not quite perfectly. And then not being able to get a damn chest x-ray done. I was a ticking time bomb.
Okay, my bed calls. I'll sleep till 4 and then wake up so I can actually get a decent nights sleep tonight. before being back at work at 5 am.
So, last night I managed a couple of patients without any hand holding. I made decisions and then called and told my fellow or chief. The sky didn't fall. I didn't do things perfectly or with very much finesse but everyone came out alive and not much worse for the wear. That being said I totally had a break down crying moment this morning. Granted, I'd hit that wall that you always hit when you've been up for too long.
I needed a Chest X-ray on a patient whose chest tube we were planning on pulling that afternoon after we'd water-sealed it the night before (basically taking it off suction). I'd might a slight error in the order. I'd written post-pulling eval instead of pre-pulling. Well, the nurse took it upon herself to cancel the order instead of calling clarifying. So, 9 am rolls around and no CXR. My team is pissed.
So, now I order a stat Chest X-ray, which should happen within 30 minutes. It takes 2 hours. Now, I'm pissed. And somewhere in all that I cray in two different supply closets and the work room with my co-intern (he's going into Ortho) sitting beside me made very uncomfortable by this display of womenly emotion.
Also, that was not an easy call. I was never really completely on top of what I needed to handle. So I had this residual I'm not quite competent enough feeling. Added to my frustrations in managing my sick patients not quite perfectly. And then not being able to get a damn chest x-ray done. I was a ticking time bomb.
Okay, my bed calls. I'll sleep till 4 and then wake up so I can actually get a decent nights sleep tonight. before being back at work at 5 am.
9/9/10
You can't practice on the patient
So, yesterday was kinda shitty in the OR. Back in December/January I was in the OR all the time as a 4th med student. I got to throw in a couple sutures at the end of a case, suction a little bit, even make a couple tiny incisions. It was pretty sweet and I got pretty good and then I took a long ass vacation from the time I match till the time I started. I drank, I partied, I visited, I traveled. I did not practice my surgical skills or study. It was going to be my last vacation ever and I wanted to take full advantage of it.
I am now regretting this decision. Don't get me wrong. It was the best vacay ever. And I really wouldn't trade it. But, when I get in an OR and I get handed the scalpel or asked to close or any number of tasks I feel clumsy. My hands feel to large and I feel the sweat dripping down my back. Gross, I know but an OR is a hot place. You're wearing a heavy gown, gloves, a mask, a hat, you stand under hot lights and it isn't exactly a stress free environment. Plus, we keep the rooms warm because our parents are open, lying naked on a table. So, yah I get a little sweaty.
Anyways, I know how to do all these things. But the added pressure of being a doctor instead of a med student, not to mention having gone without practice for so long makes things difficult. I can feel myself willing things to go right, willing myself to do it quickly, to do it efficiently. I can feel the attending's eyes on me. I can feel my upper level resident judging me. It's paranoid and insane, I know. But, it's the reality.
Every time I apologize for not being perfect, for not being fast enough, for not knowing the answers my words are brushed away with a simple, "you'll learn." And I know it's supposed to be comforting. But, for some reason that makes it worse. It's like be an awkward teen all over again. Yah, I know it'll get better some day. But, right now it kinda blows and I kinda wish it could be "some day" already.
On top of all of that there is the fact that these skills I'm learning are being learned on a human being. This person that I speak with in the holding area, that I round on every morning, this person that trusts me not to fuck up. Well, interns fuck up. I've been lucky, I haven't as yet. But, I'm not special. It will happen. Most likely it will happen right when I start getting cocky. It's how we are humbled. Because in order to hold your hand out and ask for a knife you have to some amount of hubris. But too much and you get dangerous. It's unfortunate how often it takes a mistake to realize how in over our heads we can get.
I know there are times in the OR when I hold back. Which is very unlike me. But I get into my head and I worry too much about hurting the patient. But that means that I won't learn properly and then when I don't have the luxury of doing these procedures with a safety net things will go badly. Which means, that I have to get out of my head. I have to stop worrying about what the others in the room think, I have to stop envisioning every worst-case scenario happening because of something I do wrong. Not because these things won't or aren't happening. But because dwelling on them makes me a bad surgeon.
I owe it to the patients I am operating on to learn as much as I can from each case. To do that I need to put my own insecurities on hold, keep my ego in check and focus 100% on the task at hand. Single-minded determination is what is required. If I can't do that I don't deserve to operate.
I am now regretting this decision. Don't get me wrong. It was the best vacay ever. And I really wouldn't trade it. But, when I get in an OR and I get handed the scalpel or asked to close or any number of tasks I feel clumsy. My hands feel to large and I feel the sweat dripping down my back. Gross, I know but an OR is a hot place. You're wearing a heavy gown, gloves, a mask, a hat, you stand under hot lights and it isn't exactly a stress free environment. Plus, we keep the rooms warm because our parents are open, lying naked on a table. So, yah I get a little sweaty.
Anyways, I know how to do all these things. But the added pressure of being a doctor instead of a med student, not to mention having gone without practice for so long makes things difficult. I can feel myself willing things to go right, willing myself to do it quickly, to do it efficiently. I can feel the attending's eyes on me. I can feel my upper level resident judging me. It's paranoid and insane, I know. But, it's the reality.
Every time I apologize for not being perfect, for not being fast enough, for not knowing the answers my words are brushed away with a simple, "you'll learn." And I know it's supposed to be comforting. But, for some reason that makes it worse. It's like be an awkward teen all over again. Yah, I know it'll get better some day. But, right now it kinda blows and I kinda wish it could be "some day" already.
On top of all of that there is the fact that these skills I'm learning are being learned on a human being. This person that I speak with in the holding area, that I round on every morning, this person that trusts me not to fuck up. Well, interns fuck up. I've been lucky, I haven't as yet. But, I'm not special. It will happen. Most likely it will happen right when I start getting cocky. It's how we are humbled. Because in order to hold your hand out and ask for a knife you have to some amount of hubris. But too much and you get dangerous. It's unfortunate how often it takes a mistake to realize how in over our heads we can get.
I know there are times in the OR when I hold back. Which is very unlike me. But I get into my head and I worry too much about hurting the patient. But that means that I won't learn properly and then when I don't have the luxury of doing these procedures with a safety net things will go badly. Which means, that I have to get out of my head. I have to stop worrying about what the others in the room think, I have to stop envisioning every worst-case scenario happening because of something I do wrong. Not because these things won't or aren't happening. But because dwelling on them makes me a bad surgeon.
I owe it to the patients I am operating on to learn as much as I can from each case. To do that I need to put my own insecurities on hold, keep my ego in check and focus 100% on the task at hand. Single-minded determination is what is required. If I can't do that I don't deserve to operate.
9/7/10
It's not like I need to see my family
So, this past weekend was labor day and my family get together every year at a lake in Georgia. About 25 aunts, uncles, cousins and my Mom, Dad and Brother. Every year. This year I was working. Because I'm an intern. I guess this is the first casualty of my life choices. I just wonder how many more things I'm going to miss.
My residency is going to be at least 5 years long. I'm assuming that at some point during that time some of my friends will get married, some might have kids. There will probably be school reunions. And family events, I might become an aunt or a godmother. I could be asked to be a bridesmaid. And I'm also willing to bet that I'll be missing out on a lot of those occasions.
On the other hand I am going to be learning how to save lives. So, that's the toss up, I guess.
But, that's what I signed up for. So I'm going to quit my bitching and go to sleep.
My residency is going to be at least 5 years long. I'm assuming that at some point during that time some of my friends will get married, some might have kids. There will probably be school reunions. And family events, I might become an aunt or a godmother. I could be asked to be a bridesmaid. And I'm also willing to bet that I'll be missing out on a lot of those occasions.
On the other hand I am going to be learning how to save lives. So, that's the toss up, I guess.
But, that's what I signed up for. So I'm going to quit my bitching and go to sleep.
9/5/10
Divide and conquer
The thing with being an intern isn't just that the work is hard and demanding. Or that the hours or so long and we're always so tired. The main thing is this overwhelming sense of disconnect. You spend so much time at the hospital and the hours that you aren't there are reserved for sleep, eat, shower and repeat that you have no time for your family or your friends. Maybe this is different if you actually live with someone. But I come home to an empty apartment every night after working anywhere from 10 to 15 hours a day and I just don't have the energy to talk to my parents or even my best friends. Some of whom are actually in the medical field and might be able to relate.
Maybe it's just that I work in such a big university program but I feel the same disconnect amongst my fellow interns. The 20+ of us are split amongst 13 different services and another at an entirely different hospital. If you are lucky you might have one other intern on your service, in addition to a chief or a mid-level resident. You spend a lot of time with your nose to the grind-stone just trying to get everything done without screwing things up too badly. Everyone talks about how your intern class is your support group. Which would be great if I ever saw them. But we just don't see each other that often. And when we do it's not like we have time to sit down for a chat. Even when we sign out to each other (ie, when the on-call intern gets the low-down on all the patients on a particular service from the covering intern) one of us always has an eye on the clock. Either because we're the one that wants to leave and get home or because we're the one covering 4 services and already have so much shit to do it's not even funny.
The uppers tell us that we should take a second during sign out to relay a funny story or two. But there are some days/nights at the end of a shift when you feel so run-down, beaten and just incompetent that you can't bring yourself to make a joke or laugh at one of theirs. And often times you are so wrapped up in your own perceived failures you don't see the same dejection written all over them. Logically we all know that no one is expecting perfection out of any of us. Attendings will be the first to tell us that there is a reason residency is so long. But, we're surgeons for a reason. We hold ourselves to exactingly high standards that have nothing to do with what others expect of us.
I can't speak for all of my fellow interns. But I'm fairly certain that what I'm saying is true to varying degrees for each of them. When I make a mistake, when I ask a stupid question, when I don't know an answer, when I forget to put an order in or any of the hundreds of other tiny mistakes I can make I always feel like I'm letting someone down. Usually the person I've let down is myself as opposed to one of my superiors. I've actually been really lucky in that while most of my chiefs have been exacting they have also been understanding. But that doesn't mean I haven't had my fair share of cries in supplies closets.
For weeks I thought I was the only one with these feelings. But, then a miraculous thing happened. I went for drinks with a couple of the interns in my call pool. The ortho intern walked into the Burn Unit to sign out to me looking like someone had punched her in the gut. And one of the ENT interns who is always so smiley looked like she was about to spit nails. And me, well my chief had to fix all the orders I'd put in on my patients cause I still couldn't figure out the damn order system so I wasn't feeling too great about myself either.
So we get to this bar and order a highball each and a giant plate of french fries. 10 minutes later we're swapping stories about which chief yelled at us. Which attending terrifies us. Which nursing stations drive us crazy. Which patients are the scariest. And somehow all that self-loathing I'd been feeling for days started slipping away. I felt like a new person. It didn't matter that I was screwing up, because these girls were too. Even though all of us that the other was a model intern we were all suffering through the same insecurities.
The funniest thing was that this whole thing only lasted about an hour. We ate, drink, laughed and even got a little teary in over-drive. We were manic in our thrill at having found an outlet for our self-recriminations. Anyone looking at the three of us in our green surgeon's scrubs, with our beepers sitting on the table, would have seen something like a cross between a psychotic episode and an intense cocaine high. There was intensity and desperation in our eyes. We were trying to live out ten different meals filled with gossip and drinks in one evening. We didn't have the time to do this leisurely. All of us had to be up 4 the next morning and it was already nudging closer and closer to 9. None of us wanted to relinquish our precious sleep. But that night I slept like a baby. The recurring nightmares of me screwing up so badly that I got kicked out or someone died didn't wake me up that night. I felt good about myself.
I took this experience from a weeks back to heart and decided to start a weekly intern drinks conference. It's an outlet for all of us. We can get together and share our stories. We can bitch to the only other people who will truly understand what we are going through. And even though that same desperation and mania lingers around us while we do it. It's still the best outlet I can imagine. We've managed to bring the crew together twice in the past few weeks. And of course it's never all of us because there are always those of us on-call. But I genuinely think it's the best thing we can do for ourselves. It's something for us to look forward to. It's a way for us all to feel connected. And most importantly it's a way for us to form a relationship that will go even deeper than just co-interns.
I know that my program doesn't have some nefarious plot to divide and conquer the interns. And I know that we're split throughout all these different services because otherwise their would be no way for the surgery department to function. But, a tiny, tiny part of all of us do feel that this is their master plan. But, our little weekly "intern conference" is the perfect act of civil disobedience.
I know that in ten months when we are all no longer interns we'll look back on all of this fondly. And these people I've worked with all year long will be like family. And in the 5-8 years it takes us to get through our residency together we're going to get even closer and it makes me glad that I have such great people to do it with.
Anecdotally, I recently overheard one of my attendings consulting another attending in another state who had been an intern with him decades ago. I heard his raucous laughter as they aped a chief they had both despised. I heard them discuss another one of their co-interns who had recently fallen ill in hushed and reverent tones. And I heard them pass the care of this particular patient from one to the other the same way the had done all those years ago when they cross-covered for each other as interns.
That little bit of eavesdropping gives me hope.
Maybe it's just that I work in such a big university program but I feel the same disconnect amongst my fellow interns. The 20+ of us are split amongst 13 different services and another at an entirely different hospital. If you are lucky you might have one other intern on your service, in addition to a chief or a mid-level resident. You spend a lot of time with your nose to the grind-stone just trying to get everything done without screwing things up too badly. Everyone talks about how your intern class is your support group. Which would be great if I ever saw them. But we just don't see each other that often. And when we do it's not like we have time to sit down for a chat. Even when we sign out to each other (ie, when the on-call intern gets the low-down on all the patients on a particular service from the covering intern) one of us always has an eye on the clock. Either because we're the one that wants to leave and get home or because we're the one covering 4 services and already have so much shit to do it's not even funny.
The uppers tell us that we should take a second during sign out to relay a funny story or two. But there are some days/nights at the end of a shift when you feel so run-down, beaten and just incompetent that you can't bring yourself to make a joke or laugh at one of theirs. And often times you are so wrapped up in your own perceived failures you don't see the same dejection written all over them. Logically we all know that no one is expecting perfection out of any of us. Attendings will be the first to tell us that there is a reason residency is so long. But, we're surgeons for a reason. We hold ourselves to exactingly high standards that have nothing to do with what others expect of us.
I can't speak for all of my fellow interns. But I'm fairly certain that what I'm saying is true to varying degrees for each of them. When I make a mistake, when I ask a stupid question, when I don't know an answer, when I forget to put an order in or any of the hundreds of other tiny mistakes I can make I always feel like I'm letting someone down. Usually the person I've let down is myself as opposed to one of my superiors. I've actually been really lucky in that while most of my chiefs have been exacting they have also been understanding. But that doesn't mean I haven't had my fair share of cries in supplies closets.
For weeks I thought I was the only one with these feelings. But, then a miraculous thing happened. I went for drinks with a couple of the interns in my call pool. The ortho intern walked into the Burn Unit to sign out to me looking like someone had punched her in the gut. And one of the ENT interns who is always so smiley looked like she was about to spit nails. And me, well my chief had to fix all the orders I'd put in on my patients cause I still couldn't figure out the damn order system so I wasn't feeling too great about myself either.
So we get to this bar and order a highball each and a giant plate of french fries. 10 minutes later we're swapping stories about which chief yelled at us. Which attending terrifies us. Which nursing stations drive us crazy. Which patients are the scariest. And somehow all that self-loathing I'd been feeling for days started slipping away. I felt like a new person. It didn't matter that I was screwing up, because these girls were too. Even though all of us that the other was a model intern we were all suffering through the same insecurities.
The funniest thing was that this whole thing only lasted about an hour. We ate, drink, laughed and even got a little teary in over-drive. We were manic in our thrill at having found an outlet for our self-recriminations. Anyone looking at the three of us in our green surgeon's scrubs, with our beepers sitting on the table, would have seen something like a cross between a psychotic episode and an intense cocaine high. There was intensity and desperation in our eyes. We were trying to live out ten different meals filled with gossip and drinks in one evening. We didn't have the time to do this leisurely. All of us had to be up 4 the next morning and it was already nudging closer and closer to 9. None of us wanted to relinquish our precious sleep. But that night I slept like a baby. The recurring nightmares of me screwing up so badly that I got kicked out or someone died didn't wake me up that night. I felt good about myself.
I took this experience from a weeks back to heart and decided to start a weekly intern drinks conference. It's an outlet for all of us. We can get together and share our stories. We can bitch to the only other people who will truly understand what we are going through. And even though that same desperation and mania lingers around us while we do it. It's still the best outlet I can imagine. We've managed to bring the crew together twice in the past few weeks. And of course it's never all of us because there are always those of us on-call. But I genuinely think it's the best thing we can do for ourselves. It's something for us to look forward to. It's a way for us all to feel connected. And most importantly it's a way for us to form a relationship that will go even deeper than just co-interns.
I know that my program doesn't have some nefarious plot to divide and conquer the interns. And I know that we're split throughout all these different services because otherwise their would be no way for the surgery department to function. But, a tiny, tiny part of all of us do feel that this is their master plan. But, our little weekly "intern conference" is the perfect act of civil disobedience.
I know that in ten months when we are all no longer interns we'll look back on all of this fondly. And these people I've worked with all year long will be like family. And in the 5-8 years it takes us to get through our residency together we're going to get even closer and it makes me glad that I have such great people to do it with.
Anecdotally, I recently overheard one of my attendings consulting another attending in another state who had been an intern with him decades ago. I heard his raucous laughter as they aped a chief they had both despised. I heard them discuss another one of their co-interns who had recently fallen ill in hushed and reverent tones. And I heard them pass the care of this particular patient from one to the other the same way the had done all those years ago when they cross-covered for each other as interns.
That little bit of eavesdropping gives me hope.
8/22/10
Against Medical Advice.
Oh, I have so much to tell you. LOTS of things have happened since my last post. There was getting threatened with my first law suit, trying to deal with intern isolation, operating as a doctor for the first time, and of course my ongoing battle with leaving my patients at the hospital when I get to go home, or maybe my first end of life conversation with a family. It's been a busy, busy week. I really don't know which if these I ought to tackle first so I think I'll just go chronologically.
On Sunday I admitted a gentleman with bilateral near circumferential second degree burns to his upper extremities. They needed to be treated surgically. But, this man did not want surgery. So, we made a deal with him if he showed us there was someone at home who could do his dressing changes, if he was cleared by hand therapy and if he showed no signs of infection he could go home on tuesday. Well, by Sunday night we were pretty sure this man's burns were infected. We told him that and asked that we be allowed to start IV antibiotics because that would provide the best efficacy. He was not happy.
He refused that pain meds at that time and said he was leaving in the morning. Over night he got a fever and his wound edges were turning red. Again we told him that he needed IV meds. He refused until we took the dressings down to change them and he saw how bad they looked. He agreed to a day's worth of antibiotics and insisted on leaving the next day. So Tuesday roles around they day we had said he could go if he could do his own dressing changes, clear hand therapy and not be infected. Well, 2 out of 3 really wasn't enough and we told him we wanted him to stay to finish the IV antibiotics. He said he wanted to leave.
Now, as this point if a patient leaves when aren't ready to discharge we call that leaving "Against Medical Advice." By clarifying it as such we absolve ourselves of any legal ramifications should their choice prove detrimental to their overall health and well-being. It also requires that you sign a paper stating that you are leaving AMA and will not sue the hospital, if for instance, your hand were to fall off because you weren't treated with the appropriate antibiotics.
I knew that a lot of my patient's concern was over incurring hospital bills without proper insurance coverage. Now seeing as I work at a state hospital I don't give two shits about a person's insurance. The state covers it. As a resident I am specifically told not to know about patients' insurance standings. It makes me a better doctor. So, with this patient I was at a loss I couldn't understand his refusal so I involved patient relations, risk management, financial planning . . . everyone I could think to include so that this patient would not leave and come back with necrotising fasciitis.
But, the more I badgered him to stay the more frustrated he got. He threatened to sue me, he threatened to "whoop my ass" not to mention my Chief's ass, my Attending's ass and the asses of any security guards foolish enough to stand in his way. This from a man with his hands bandaged from finger tips to elbows. Oh, and of course, we'd be responsible for worsening his condition because we'd made him fight.
I was literally at a loss, I had no idea how to proceed. Conveniently my Chief, the Fellows and the Attending were all in the weekly Burn Morbidity and Mortality conference so I couldn't really go to them for advice because this man was about to take me out on his way to the door. I called the hospital lawyers to find out what I could and could not give this man. I settled him down long enough to tell him he could leave AMA, I could give him prescriptions for oral pain meds and antibiotics (useless for skin infections) but no IV meds (we don't send people home with IV meds, we just don't) but he would have to sign the AMA paperwork.
This caused an even bigger ruckus than before. He flat out refused to sign anything saying he was leaving against AMA. But, he would sign it to say he wasn't going to sign it. And he even added a little note "I'm not signing this cause I'm leaving because I was told one thing and then another thing happened." I think this is in reference to the deal we'd made earlier in the week. I don't think the patient fully believed that he got an infection, and if he did I think he believes we gave it to him on purpose, Hippocrates be damned.
I urged him to come back to our clinic on Thursday so we could reassess his burns there and give him more meds, dressing supplies. Well, my Chief came waltzing into the Burn unit on Thursday afternoon and said he had a special, special surprise for me. I thought this might have something to do with the promise that I might get in the OR that day. Instead he handed me a stack of admit papers and asked if anything looked familiar. It turned out Mr. AMA had indeed returned to clinic, hours early for his appointment because his infection had spread, the man was convinced he was going to lose his hands.
I saw him as he was being wheeled back into the unit and he lunged off the bed in an attempt to grab me. Luckily the transport tech was a burly guy and held him down. Mr. AMA started screaming obscenities at me. It turns out that I should never have let him leave, I shouldn't have been so stingy with the meds, I should have cleaned his wounds personally, I should have let him keep his IV and a whole litany of other "I-done-him-wrongs."
We'll operate on him next week . . . hopefully we can save his limbs and their function.
On Sunday I admitted a gentleman with bilateral near circumferential second degree burns to his upper extremities. They needed to be treated surgically. But, this man did not want surgery. So, we made a deal with him if he showed us there was someone at home who could do his dressing changes, if he was cleared by hand therapy and if he showed no signs of infection he could go home on tuesday. Well, by Sunday night we were pretty sure this man's burns were infected. We told him that and asked that we be allowed to start IV antibiotics because that would provide the best efficacy. He was not happy.
He refused that pain meds at that time and said he was leaving in the morning. Over night he got a fever and his wound edges were turning red. Again we told him that he needed IV meds. He refused until we took the dressings down to change them and he saw how bad they looked. He agreed to a day's worth of antibiotics and insisted on leaving the next day. So Tuesday roles around they day we had said he could go if he could do his own dressing changes, clear hand therapy and not be infected. Well, 2 out of 3 really wasn't enough and we told him we wanted him to stay to finish the IV antibiotics. He said he wanted to leave.
Now, as this point if a patient leaves when aren't ready to discharge we call that leaving "Against Medical Advice." By clarifying it as such we absolve ourselves of any legal ramifications should their choice prove detrimental to their overall health and well-being. It also requires that you sign a paper stating that you are leaving AMA and will not sue the hospital, if for instance, your hand were to fall off because you weren't treated with the appropriate antibiotics.
I knew that a lot of my patient's concern was over incurring hospital bills without proper insurance coverage. Now seeing as I work at a state hospital I don't give two shits about a person's insurance. The state covers it. As a resident I am specifically told not to know about patients' insurance standings. It makes me a better doctor. So, with this patient I was at a loss I couldn't understand his refusal so I involved patient relations, risk management, financial planning . . . everyone I could think to include so that this patient would not leave and come back with necrotising fasciitis.
But, the more I badgered him to stay the more frustrated he got. He threatened to sue me, he threatened to "whoop my ass" not to mention my Chief's ass, my Attending's ass and the asses of any security guards foolish enough to stand in his way. This from a man with his hands bandaged from finger tips to elbows. Oh, and of course, we'd be responsible for worsening his condition because we'd made him fight.
I was literally at a loss, I had no idea how to proceed. Conveniently my Chief, the Fellows and the Attending were all in the weekly Burn Morbidity and Mortality conference so I couldn't really go to them for advice because this man was about to take me out on his way to the door. I called the hospital lawyers to find out what I could and could not give this man. I settled him down long enough to tell him he could leave AMA, I could give him prescriptions for oral pain meds and antibiotics (useless for skin infections) but no IV meds (we don't send people home with IV meds, we just don't) but he would have to sign the AMA paperwork.
This caused an even bigger ruckus than before. He flat out refused to sign anything saying he was leaving against AMA. But, he would sign it to say he wasn't going to sign it. And he even added a little note "I'm not signing this cause I'm leaving because I was told one thing and then another thing happened." I think this is in reference to the deal we'd made earlier in the week. I don't think the patient fully believed that he got an infection, and if he did I think he believes we gave it to him on purpose, Hippocrates be damned.
I urged him to come back to our clinic on Thursday so we could reassess his burns there and give him more meds, dressing supplies. Well, my Chief came waltzing into the Burn unit on Thursday afternoon and said he had a special, special surprise for me. I thought this might have something to do with the promise that I might get in the OR that day. Instead he handed me a stack of admit papers and asked if anything looked familiar. It turned out Mr. AMA had indeed returned to clinic, hours early for his appointment because his infection had spread, the man was convinced he was going to lose his hands.
I saw him as he was being wheeled back into the unit and he lunged off the bed in an attempt to grab me. Luckily the transport tech was a burly guy and held him down. Mr. AMA started screaming obscenities at me. It turns out that I should never have let him leave, I shouldn't have been so stingy with the meds, I should have cleaned his wounds personally, I should have let him keep his IV and a whole litany of other "I-done-him-wrongs."
We'll operate on him next week . . . hopefully we can save his limbs and their function.
8/16/10
3 days down, 12 more to go.
I've been remiss in writing lately.
I've switched to days, which are a little impossible. And let's face it, not all my entries are going to be winners.
I really want to tell you all why days are so impossible but getting the whole picture across will take too many words. So let me give you just the nuts and bolts and break it down for you like this. I got into the hospital at 5 this morning, rounded for a couple of hours, put in orders, placed a central line, discharged a patient, convinced a patient not to leave "against medical advice" so his hands wouldn't fall off, attempted to place a post-pyloric corpack (and failed), so I then had to place a NGT, wrote progress notes, saw a consult in the ED (butt burns), wrote procedure notes. I left at 7:30, it's 8 now. I need to eat and shower and every minute I spend typing to you is one less I spend asleep before I start another 15 hour day in the hour day in the hospital.
So, yes, I'm going to attempt not to fall asleep in my food (a real concern for most surgery interns). Shower, cause I'm covered in all kinds of yucky, yucky bacteria. And then crawl into bed where I will fall instantly into a death like coma, which I guarantee you will be interrupted by my pager at some point tonight.
Good night all.
I've switched to days, which are a little impossible. And let's face it, not all my entries are going to be winners.
I really want to tell you all why days are so impossible but getting the whole picture across will take too many words. So let me give you just the nuts and bolts and break it down for you like this. I got into the hospital at 5 this morning, rounded for a couple of hours, put in orders, placed a central line, discharged a patient, convinced a patient not to leave "against medical advice" so his hands wouldn't fall off, attempted to place a post-pyloric corpack (and failed), so I then had to place a NGT, wrote progress notes, saw a consult in the ED (butt burns), wrote procedure notes. I left at 7:30, it's 8 now. I need to eat and shower and every minute I spend typing to you is one less I spend asleep before I start another 15 hour day in the hour day in the hospital.
So, yes, I'm going to attempt not to fall asleep in my food (a real concern for most surgery interns). Shower, cause I'm covered in all kinds of yucky, yucky bacteria. And then crawl into bed where I will fall instantly into a death like coma, which I guarantee you will be interrupted by my pager at some point tonight.
Good night all.
8/12/10
Not a black cloud anymore, but some thoughts on death.
So, it looks like all the predictions were wrong. I had 0 admits overnight. Don't get me wrong I had plenty to do all night long. But, I wasn't attempting to do 5 things at once. I spent most of time worried that some very sick people might die on me. I know it's going to happen some time. But I feel really, really unprepared for that.
They don't teach "dealing with death" in med school. I think because everyone is going to handle it so very differently. There are no hard and fast rules. And we don't like anything without rules in Medicine. So, we start our intern years eager to save lives. Realize that we're basically glorified baby sitters and scut monkeys who get payed just above minimum wage to make sure no one dies. But, patients are sick and some of them are going to die. And even if you have nothing to do with it you're going to be convinced it's your fault.
I've known patients that have died. Luckily they've never been patients I was following, they've never died when I was in the same place and most importantly they've never died right in front of me. I haven't had to run the code that may or may not save their life. And I haven't pronounced them or talked to the family about an autopsy.
Right now I feel almost insulated from death. I've accepted that it will happen, I understand the science behind it. Last night when the vascular intern was signing out his patients to me he mentioned that a patient I'd told them was arriving at some point that day was still in the OR and we be lucky to leave their alive. This man was a 59 year old ruptured AAA (abdominal aortic aneurysm). All the blood that was pumping through his aorta-the major artery of the body- was spilling into his abdomen. We were blase as we quoted the mortality rates. And neither of us was going to show weakness by admitting that the frailty of life was somehow distracting us from being clinicians.
But, after he left I called the OR and asked to be paged when the patient left. I breathed a sigh of relief when I got the page saying the patient was on his way to the SICU. An hour later I heard the overhead PA blaring out a code in the SICU. Interns don't go to codes in the ICU but I knew what was happening. I kept checking the computers until his death summary loaded and then forced myself to read every word. The patient hadn't even been in our hospital for 24 hours, and he'd spent about 12 of those hours open on an OR table. All of this was documented. But when it came down to saying what had happened the word "dead" was never used . . .
"Patient pronounced with pulseless electrical activity at 11:45"
They don't teach "dealing with death" in med school. I think because everyone is going to handle it so very differently. There are no hard and fast rules. And we don't like anything without rules in Medicine. So, we start our intern years eager to save lives. Realize that we're basically glorified baby sitters and scut monkeys who get payed just above minimum wage to make sure no one dies. But, patients are sick and some of them are going to die. And even if you have nothing to do with it you're going to be convinced it's your fault.
I've known patients that have died. Luckily they've never been patients I was following, they've never died when I was in the same place and most importantly they've never died right in front of me. I haven't had to run the code that may or may not save their life. And I haven't pronounced them or talked to the family about an autopsy.
Right now I feel almost insulated from death. I've accepted that it will happen, I understand the science behind it. Last night when the vascular intern was signing out his patients to me he mentioned that a patient I'd told them was arriving at some point that day was still in the OR and we be lucky to leave their alive. This man was a 59 year old ruptured AAA (abdominal aortic aneurysm). All the blood that was pumping through his aorta-the major artery of the body- was spilling into his abdomen. We were blase as we quoted the mortality rates. And neither of us was going to show weakness by admitting that the frailty of life was somehow distracting us from being clinicians.
But, after he left I called the OR and asked to be paged when the patient left. I breathed a sigh of relief when I got the page saying the patient was on his way to the SICU. An hour later I heard the overhead PA blaring out a code in the SICU. Interns don't go to codes in the ICU but I knew what was happening. I kept checking the computers until his death summary loaded and then forced myself to read every word. The patient hadn't even been in our hospital for 24 hours, and he'd spent about 12 of those hours open on an OR table. All of this was documented. But when it came down to saying what had happened the word "dead" was never used . . .
"Patient pronounced with pulseless electrical activity at 11:45"
8/11/10
Black cloud rescinded
So. We in surgery are a superstitious group of people. Never, ever say that it's going to be a quiet night or that you are bored. Because the surgery Gods will slam you. Never say that everyone is doing fine because someone will tank right then. Never say that it should be an easy op cause they patient will try and die on you on the table. We talk about jinxing ourselves in the same breath as we denounce an old protocol based on hard fact-based evidence.
We are trained to be logical in all things clinical. We do everything for a reason. We have formulas for therapeutic loading doses, fluid resuscitation, vent settings and just about everything else. We've been trained to ignore our gut and go with the facts that are presented before us. But in everything else you'll see us knocking on wood, not saying the dread "q" word (quiet) and wearing our lucky scrub caps.
It's ridiculous, I know it is. But, that's not even the end of it. We are all convinced that full moon nights and Friday the 13th are guaranteed to bring a disastrous workload. Sure, we believe the same thing about St. Patty's, but that makes sense. You've got a lot of drunk people wandering the streets. But, most people don't even know it's a full moon night. So why are we so worried? There is also a general belief that an all male or an all female staff will make the night easier or harder (it depends on which sex you are talking to).
We even have our own equivalents of coolers. These poor people are called black clouds. And whenever they are on they make it rain patients. They've got admits, sick people, consults, lab mishaps, nursing error, physician error and 100 other things that only happen in confluence with them. I am a black cloud.
But, last night I had a great night. Only 1 admit. Nobody signed out the work they should have done over the day to me. I actually had time to sit and study for the in-service exam I'll be taking in January. When my team walked in this morning I told them how amazing it had been and asked that my black cloud status be rescinded.
Unfortunately asking for that angers the Surgery Gods and everyone is convinced that when I start back tonight at 5:30 I'm going to get SLAMMED. They were taking bets on who was going to be circling the drain when I come back in a few short hours. Will it be the patient who has been crapping out every day for the last few days? Will it be the person-the only person-I admitted this morning who might have inhalation burns and renal insufficiency? Or will it be some new patient I don't even know of yet? I guess I'll find out tonight. Till then I'm going to get some sleep cause I'm in for a long night.
We are trained to be logical in all things clinical. We do everything for a reason. We have formulas for therapeutic loading doses, fluid resuscitation, vent settings and just about everything else. We've been trained to ignore our gut and go with the facts that are presented before us. But in everything else you'll see us knocking on wood, not saying the dread "q" word (quiet) and wearing our lucky scrub caps.
It's ridiculous, I know it is. But, that's not even the end of it. We are all convinced that full moon nights and Friday the 13th are guaranteed to bring a disastrous workload. Sure, we believe the same thing about St. Patty's, but that makes sense. You've got a lot of drunk people wandering the streets. But, most people don't even know it's a full moon night. So why are we so worried? There is also a general belief that an all male or an all female staff will make the night easier or harder (it depends on which sex you are talking to).
We even have our own equivalents of coolers. These poor people are called black clouds. And whenever they are on they make it rain patients. They've got admits, sick people, consults, lab mishaps, nursing error, physician error and 100 other things that only happen in confluence with them. I am a black cloud.
But, last night I had a great night. Only 1 admit. Nobody signed out the work they should have done over the day to me. I actually had time to sit and study for the in-service exam I'll be taking in January. When my team walked in this morning I told them how amazing it had been and asked that my black cloud status be rescinded.
Unfortunately asking for that angers the Surgery Gods and everyone is convinced that when I start back tonight at 5:30 I'm going to get SLAMMED. They were taking bets on who was going to be circling the drain when I come back in a few short hours. Will it be the patient who has been crapping out every day for the last few days? Will it be the person-the only person-I admitted this morning who might have inhalation burns and renal insufficiency? Or will it be some new patient I don't even know of yet? I guess I'll find out tonight. Till then I'm going to get some sleep cause I'm in for a long night.
8/9/10
Crying in the supply closet
So, if you've watched any doctor show on prime time you know that supply closets can be a very busy place. It's a place for residents and attendings to hook up, for med students to hook up, for nurses and docs to hook up, for patients to hook up . . . well, according to most of those shows that's all anyone does in those call rooms. In a real life hospital a supply room is used for one of two things, stocking supplies and a safe place where a resident can go to cry.
On Thursday night I had my first experience with an attending chewing me up and spitting me out. When I came on the Burn floor that night my chief told me how very critical a new admit was. That because of his burns we would need to resuscitate him drastically but that because of his preexisting congestive heart failure if we did so too much we could literally drown him. And so I was to follow his hourly urine outputs and report back to him with any changes. In addition to managing the other 80 patients I was covering for that night and admitting any new burn patients. But that's what I'd signed up for so that is exactly what I did. When our patient's urine output suddenly spiked around 10 o'clock I was thrilled and called my Chief who said to go ahead and lower the rate of of fluids from 1,000 mL/hr to 750 mL/hr. It was quite a drastic jump but I didn't know that at the time and I asked the nurse to make the changes right away.
A few minutes later the charge nurse (the head of the nurse for that unit) received a phone call from the attending who had been following that patient. I decided to stick around in case he decided to make any changes to the patient's care. But I noticed that the charge nurse was getting increasingly more agitated and eventually handed the phone over to me. I didn't know what was wrong but I was about to find out.
"Young lady, how many burn resuscitations have you managed?" a deceptively calm voice practically whispered across the phone line. His voice was so soft I had to press the phone to my ear to the point that it hurt. It wasn't until I hung up the phone did I realize that my hand had cramped from clutching the reciever so hard.
"None" I responded.
"So I take it you've never managed a patient with congestive heart failure either. Am I right?" His voice had a dangerous edge even if I'd managed 7,000 I knew there was only one answer he wanted.
"No, sir"
"Well," his voice boomed now, so loudly compared to his previous whisper that I jumped in my seat. "It's a good thing you didn't kill this poor man, then." I was so shocked by this statement that I just sat there in stunned silence. The receiver again pressed painfully against my ear. "As an intern I never would have presumed to make fluid changes on any patient without the express okay of my attendings. I've never even met you. For all I know you could be the night custodian. And with your decision making skills I wouldn't be surprised if that's where you dod go to school." He wrapped up shortly after that. He did mention that I should keep the patient's fluids running at 750 mL/hr and that I should learn to communicate better if I wanted to stay on in this program.
When I hung up the phone I was hard pressed to hold back my tears. I remembered that I had a corpack (a type of naso-gastric feeding tube with a weighted head) to place in a patient who had pulled hers out earlier that evening. I tried to maintain some sort of dignity as I headed into the supply room and shut the door behind me. I leaned against the door and sank to the floor. It wasn't comfortable and neither was trying to control the sobs and the self-doubt washing over me. Had I really almost killed that patient? What had I done wrong? When was I supposed to have called the attending? Was I truly that incompetent?
It took me a minute or two to get control of myself. Luckily they keep tissue boxes in this supply closet so I at least had something to blow my nose on. I gathered up the supplies I needed and went to drop the tube on the patient in bed 8. I spent the entire procedure nagged by my own self recriminations. I went through the next hour or so like that. Second guessing my every move and questioning my own competency. Until I got a call from my chief. I was expecting another lecture. Another close examination of all my faults as an intern and a human being. Instead all my chief said was, "I just got off the phone with attending, he's pissed at you, but he can't remember your name."
I didn't know what to say that. But it was okay because my chief continued "so, what happened there was unfortunate, the attending called the floor before I got a chance to call him."
"But, I still shouldn't have the changed fluids." I said, I'd had guilt instilled in me at a early age and the berating I'd just gotten from the attending proved that it could still take charge of my psyche.
"Actually, you did what I told you to do, and I told you to do the right thing. That's why he didn't ask you to change the rate again." My chief's tone was rather brusque as he said all this. I knew he'd probably gotten torn a new one too and that it was late and he wanted to get back to sleep. But, I was touched that he was taking the time to explain that it wasn't my fault.
I spent the rest of the night pondering that hour. I came to certain conclusions. First of all, this would not be the last time something like this happens. It probably wouldn't be the last time I sought solace in a supply closet. But it would be the last time I would let myself doubt my abilities. I was not performing my best when I placed that corpack. I was pre-occupied and nervous because of the scolding I'd just gotten. And that was the biggest mistake I'd made all night. There are going to be times in the next five years when I'm going to eat shit whether I deserve it or not. But, I CAN NOT let that effect how I care for my patients. There are going to be other residents, chiefs, attendings, nurses and even patients who don't like the decision I've made or the way I've done something. And yes, I need to take the time to reflect on their accusations and figure out where I went wrong if I did go wrong. But, once I've sorted that out I need to regain my composure and go back to caring for my patients with confidence and compassion. If that means a few more moment huddled on the floor of the supply closet then so be it.
Later, after I'd gone home that morning and gotten some sleep I was reminded of an episode of ER I'd watched a long, long time ago. It was from the first season and said by an attending surgeon to a lowly ER resident. "When I was a resident, I was always worried about getting people's approval, the attendings', the patients', maybe because I was a woman, a black woman. Life was a lot easier once I got over it"
I see what she's seeing. I can't do this job expecting everyone's approval. I won't get it and in looking for it I could very well do harm to my patients. So, it looks like I'm just going to have to get over it.
On Thursday night I had my first experience with an attending chewing me up and spitting me out. When I came on the Burn floor that night my chief told me how very critical a new admit was. That because of his burns we would need to resuscitate him drastically but that because of his preexisting congestive heart failure if we did so too much we could literally drown him. And so I was to follow his hourly urine outputs and report back to him with any changes. In addition to managing the other 80 patients I was covering for that night and admitting any new burn patients. But that's what I'd signed up for so that is exactly what I did. When our patient's urine output suddenly spiked around 10 o'clock I was thrilled and called my Chief who said to go ahead and lower the rate of of fluids from 1,000 mL/hr to 750 mL/hr. It was quite a drastic jump but I didn't know that at the time and I asked the nurse to make the changes right away.
A few minutes later the charge nurse (the head of the nurse for that unit) received a phone call from the attending who had been following that patient. I decided to stick around in case he decided to make any changes to the patient's care. But I noticed that the charge nurse was getting increasingly more agitated and eventually handed the phone over to me. I didn't know what was wrong but I was about to find out.
"Young lady, how many burn resuscitations have you managed?" a deceptively calm voice practically whispered across the phone line. His voice was so soft I had to press the phone to my ear to the point that it hurt. It wasn't until I hung up the phone did I realize that my hand had cramped from clutching the reciever so hard.
"None" I responded.
"So I take it you've never managed a patient with congestive heart failure either. Am I right?" His voice had a dangerous edge even if I'd managed 7,000 I knew there was only one answer he wanted.
"No, sir"
"Well," his voice boomed now, so loudly compared to his previous whisper that I jumped in my seat. "It's a good thing you didn't kill this poor man, then." I was so shocked by this statement that I just sat there in stunned silence. The receiver again pressed painfully against my ear. "As an intern I never would have presumed to make fluid changes on any patient without the express okay of my attendings. I've never even met you. For all I know you could be the night custodian. And with your decision making skills I wouldn't be surprised if that's where you dod go to school." He wrapped up shortly after that. He did mention that I should keep the patient's fluids running at 750 mL/hr and that I should learn to communicate better if I wanted to stay on in this program.
When I hung up the phone I was hard pressed to hold back my tears. I remembered that I had a corpack (a type of naso-gastric feeding tube with a weighted head) to place in a patient who had pulled hers out earlier that evening. I tried to maintain some sort of dignity as I headed into the supply room and shut the door behind me. I leaned against the door and sank to the floor. It wasn't comfortable and neither was trying to control the sobs and the self-doubt washing over me. Had I really almost killed that patient? What had I done wrong? When was I supposed to have called the attending? Was I truly that incompetent?
It took me a minute or two to get control of myself. Luckily they keep tissue boxes in this supply closet so I at least had something to blow my nose on. I gathered up the supplies I needed and went to drop the tube on the patient in bed 8. I spent the entire procedure nagged by my own self recriminations. I went through the next hour or so like that. Second guessing my every move and questioning my own competency. Until I got a call from my chief. I was expecting another lecture. Another close examination of all my faults as an intern and a human being. Instead all my chief said was, "I just got off the phone with attending, he's pissed at you, but he can't remember your name."
I didn't know what to say that. But it was okay because my chief continued "so, what happened there was unfortunate, the attending called the floor before I got a chance to call him."
"But, I still shouldn't have the changed fluids." I said, I'd had guilt instilled in me at a early age and the berating I'd just gotten from the attending proved that it could still take charge of my psyche.
"Actually, you did what I told you to do, and I told you to do the right thing. That's why he didn't ask you to change the rate again." My chief's tone was rather brusque as he said all this. I knew he'd probably gotten torn a new one too and that it was late and he wanted to get back to sleep. But, I was touched that he was taking the time to explain that it wasn't my fault.
I spent the rest of the night pondering that hour. I came to certain conclusions. First of all, this would not be the last time something like this happens. It probably wouldn't be the last time I sought solace in a supply closet. But it would be the last time I would let myself doubt my abilities. I was not performing my best when I placed that corpack. I was pre-occupied and nervous because of the scolding I'd just gotten. And that was the biggest mistake I'd made all night. There are going to be times in the next five years when I'm going to eat shit whether I deserve it or not. But, I CAN NOT let that effect how I care for my patients. There are going to be other residents, chiefs, attendings, nurses and even patients who don't like the decision I've made or the way I've done something. And yes, I need to take the time to reflect on their accusations and figure out where I went wrong if I did go wrong. But, once I've sorted that out I need to regain my composure and go back to caring for my patients with confidence and compassion. If that means a few more moment huddled on the floor of the supply closet then so be it.
Later, after I'd gone home that morning and gotten some sleep I was reminded of an episode of ER I'd watched a long, long time ago. It was from the first season and said by an attending surgeon to a lowly ER resident. "When I was a resident, I was always worried about getting people's approval, the attendings', the patients', maybe because I was a woman, a black woman. Life was a lot easier once I got over it"
I see what she's seeing. I can't do this job expecting everyone's approval. I won't get it and in looking for it I could very well do harm to my patients. So, it looks like I'm just going to have to get over it.
8/5/10
An actual phone conversation with my Chief
Me: Hey, did I wake you up?
Chief: Yes. Is anyone dead?
Me: No.
Chief: Keep up the good work.
Chief: Yes. Is anyone dead?
Me: No.
Chief: Keep up the good work.
8/4/10
Chicken biscuits and burn patients.
So, I'm a southern girl and ever since moving to this little University town I've been trying to find somewhere I could find an economical chicken biscuit. I didn't think it would be hard. Seeing as there are college students everywhere and we are in the south. So, it hasn't happened in the 2 months or so I've lived here. Until this morning. I stopped by the cafeteria on my way out this morning because I really wanted an orange juice. But I decided to stay for some breakfast. It was amazing. I also hadn't eaten for 12 hours. So that might be part of it.
I don't why I'm fixating on this biscuit. I think it's cause tonight got a little crazy, 6 burn admits. I'm just going to list them all out for you and you decide if I'm making any of this up.
#1 - A man driving around on a John Deere tractor said it just exploded from underneath him (his blood alcohol was 438)
#2 - A spanish-only speaking lady burned her face when she tried to pour hot grease into a plastic container and it exploded.
#3 - A woman came in with Stevens-Johnson Syndrome. An allergic reaction that causes your skin to literally peel off.
#4 - A young boy was trying to build a smoke bomb out of stump remover (potassium nitrate) and sugar got his arm singed and took some shrapnel to the eye.
#5 - A little girl accidentally had boiling water spilled on her when her aunt tripped carrying the pan.
#6 - A man working at taco bell came in with a deep fryer basket stuck to his back after a fellow employee hit him with it.
I'm going to head for a shower and bed now. And hope that I manage to block out enough of this crap to get a decent night's (day's) sleep. Yesterday my circadian hadn't caught up with me yet so I wasn't very well rested when I woke up.
I don't why I'm fixating on this biscuit. I think it's cause tonight got a little crazy, 6 burn admits. I'm just going to list them all out for you and you decide if I'm making any of this up.
#1 - A man driving around on a John Deere tractor said it just exploded from underneath him (his blood alcohol was 438)
#2 - A spanish-only speaking lady burned her face when she tried to pour hot grease into a plastic container and it exploded.
#3 - A woman came in with Stevens-Johnson Syndrome. An allergic reaction that causes your skin to literally peel off.
#4 - A young boy was trying to build a smoke bomb out of stump remover (potassium nitrate) and sugar got his arm singed and took some shrapnel to the eye.
#5 - A little girl accidentally had boiling water spilled on her when her aunt tripped carrying the pan.
#6 - A man working at taco bell came in with a deep fryer basket stuck to his back after a fellow employee hit him with it.
I'm going to head for a shower and bed now. And hope that I manage to block out enough of this crap to get a decent night's (day's) sleep. Yesterday my circadian hadn't caught up with me yet so I wasn't very well rested when I woke up.
8/3/10
Night floating.
So, the next two weeks I'll be working nights. Which means I'll be working roughly from 5 pm every night to 7 am every morning. I'll be on for the burn unit. But I'll also be making sure the patients for Neurosurgery, Vascular and Plastics don't die over night. The average for burns is about 40 patients and the other three add up to about 30-40 depending on the time of week (the lists tend to be cyclic. Emptying out at the beginning and end of the week and filling up over the weekend and mid-week).
A lot of people hate being on night float. And I get the down sides. Especially you have something resembling a life. Being nocturnal is not how people were meant to live. But if you only have to do it for a couple of weeks it's really not so bad. For starters, no 24 hour calls, a guaranteed weekend off, no rounding, a very focused amount of work. Your basic goal is just make sure no one dies. So you aren't worrying about calling consults or dealing with social work. It's straight reflex patient care.
All that being said you are all by yourself. Sure there is a senior resident you can call. But he or she is at home, asleep in bed. And it's always a judgement call. There are basically two bad outcomes and only one good one. Option one you didn't need to call. The resident can yell at you then and make fun of you for the rest of your time with them. Or you can not call when you should have. This is by first the worst thing you can do. Even if you did exactly what they would have done you shouldn't have done it without clearing it with an upper level. And you don't have to worry about a little good-natured you have to worry about loosing your residents trust in your judgement. Which is something that will spread like wild fire through all the senior residents and will make your intern year suck. Of course you can be right on the money about calling. But no one care when you do the right thing. They didn't hire you to screw up.
So, two notable things happened last night. The first was a 12 year old boy who came to us from out in the sticks some where with a second degree burn to one palm and another second degree to a shin. (Random note about burns, when a patient comes in. They have to go through an extremely painful washdown of the burned area as well as a peeling off of all the burned skin because dead tissue is just a breeding ground for bacteria) The hand was basically just one big blister which had to be popped, drained and then peeled off. The charge nurse, a a 6 foot tall bear of a man was in charge of this part of the procedure. While I held the young boys hand and tried to make him believe that the giant man leaning over the bed wasn't going to hurt him. I asked the boy to look at him. I asked him about his pets, a cocker spaniel named cocker. I asked him about his girlfriend. A girl named Cheyenne whom he "guessed was pretty." All of this was in an attempt to keep his mind off the painful procedure that was literally happening an arm's length away from him. But with one painful last tug on the blistered skin the boy snapped his head out of hands and took his first look at the newly exposed hand. "THAT'S MY MEAT, I CAN SEE IT!" he balled before just dissolving in tears. The words were hilarious but watching that boy cry was heart breaking.
Not too long after that a patient on the burn floor I had admitted over the weekend was found by his nurse out of bed, with his IV pulled out, blood all over the floor tugging on the foley catheter coming out his penis screaming about having tickets to the Braves game and having to get out of there. This patient was admitted for second degree burns to all extremities. He was also a heavy, heavy drinker and his Urine tox screen had come back positive for cocaine and marijuana. The trifecta. We knew he was going to be a pain control nightmare. His body being used to a high would need much higher doses of pain medication to relieve his significant pain, but those high doses were going to make respiratory shut down a real possibility. But our main concern was the inevitable alcohol withdrawal. We put him on some meds to try and wean him off the alcohol but it wasn't going to prevent them. And as soon as I ran into the patients room I knew that was what was happening. I immediately asked the nurse to give him some extra ativan and hoped that was the end of it for the night. But two hours later he was at it again. Thrashing against the restraints I'd ordered just in case he decided to pull out another line. I really didn't want to have to fix his penis. We gave him some more ativan but oxygen saturation started to drop and then when he woke up a bit he went crazy again, he spike a fever of 105, his heart rate was going in the 140s and 150s, he was breathing twice as fast as he needed to and wouldn't keep the face mask on so his oxygen was again dropping. At this point it was 4 am and my chief would be in in a couple hours. The charge nurse was telling me he needed to be intubated so he could ride out his withdrawal heavily sedated the respiratory therapist was telling me that if we could just calm him down enough we could manage this with a nasal tube and an albuterol treatment. I was telling myself that I had not idea what to do. I was leaning towards the intubation (for all the wrong reasons, basically it was just the easiest for me). But I knew I was going to have to wake up my chief.
When I made that call he immediately started barraging me with questions. I only knew the answers to about half. And the ones I did know I couldn't get across quite right. I swear that man thought I was a moron. He decided not to intubate, then called his chief who told him to intubate. So there I was calling anesthesia, placing orders I'd never placed before and panicking that I should have made the call earlier, I should have thought about this when I admitted him and a thousand other insecurities. Three hours later I left and now I'm sitting here typing about him and wondering how he'll be when I come back at 5 pm. How long is going to be intubated? Is he going to get pneumonia? Is he going to hate me when he comes off the vent?
I need to get some sleep now. But I know my vent patient and that little boy are going to be my last thoughts as a I fall asleep. And I'm a little worried where my subconscious my head when I'm not reining it in
A lot of people hate being on night float. And I get the down sides. Especially you have something resembling a life. Being nocturnal is not how people were meant to live. But if you only have to do it for a couple of weeks it's really not so bad. For starters, no 24 hour calls, a guaranteed weekend off, no rounding, a very focused amount of work. Your basic goal is just make sure no one dies. So you aren't worrying about calling consults or dealing with social work. It's straight reflex patient care.
All that being said you are all by yourself. Sure there is a senior resident you can call. But he or she is at home, asleep in bed. And it's always a judgement call. There are basically two bad outcomes and only one good one. Option one you didn't need to call. The resident can yell at you then and make fun of you for the rest of your time with them. Or you can not call when you should have. This is by first the worst thing you can do. Even if you did exactly what they would have done you shouldn't have done it without clearing it with an upper level. And you don't have to worry about a little good-natured you have to worry about loosing your residents trust in your judgement. Which is something that will spread like wild fire through all the senior residents and will make your intern year suck. Of course you can be right on the money about calling. But no one care when you do the right thing. They didn't hire you to screw up.
So, two notable things happened last night. The first was a 12 year old boy who came to us from out in the sticks some where with a second degree burn to one palm and another second degree to a shin. (Random note about burns, when a patient comes in. They have to go through an extremely painful washdown of the burned area as well as a peeling off of all the burned skin because dead tissue is just a breeding ground for bacteria) The hand was basically just one big blister which had to be popped, drained and then peeled off. The charge nurse, a a 6 foot tall bear of a man was in charge of this part of the procedure. While I held the young boys hand and tried to make him believe that the giant man leaning over the bed wasn't going to hurt him. I asked the boy to look at him. I asked him about his pets, a cocker spaniel named cocker. I asked him about his girlfriend. A girl named Cheyenne whom he "guessed was pretty." All of this was in an attempt to keep his mind off the painful procedure that was literally happening an arm's length away from him. But with one painful last tug on the blistered skin the boy snapped his head out of hands and took his first look at the newly exposed hand. "THAT'S MY MEAT, I CAN SEE IT!" he balled before just dissolving in tears. The words were hilarious but watching that boy cry was heart breaking.
Not too long after that a patient on the burn floor I had admitted over the weekend was found by his nurse out of bed, with his IV pulled out, blood all over the floor tugging on the foley catheter coming out his penis screaming about having tickets to the Braves game and having to get out of there. This patient was admitted for second degree burns to all extremities. He was also a heavy, heavy drinker and his Urine tox screen had come back positive for cocaine and marijuana. The trifecta. We knew he was going to be a pain control nightmare. His body being used to a high would need much higher doses of pain medication to relieve his significant pain, but those high doses were going to make respiratory shut down a real possibility. But our main concern was the inevitable alcohol withdrawal. We put him on some meds to try and wean him off the alcohol but it wasn't going to prevent them. And as soon as I ran into the patients room I knew that was what was happening. I immediately asked the nurse to give him some extra ativan and hoped that was the end of it for the night. But two hours later he was at it again. Thrashing against the restraints I'd ordered just in case he decided to pull out another line. I really didn't want to have to fix his penis. We gave him some more ativan but oxygen saturation started to drop and then when he woke up a bit he went crazy again, he spike a fever of 105, his heart rate was going in the 140s and 150s, he was breathing twice as fast as he needed to and wouldn't keep the face mask on so his oxygen was again dropping. At this point it was 4 am and my chief would be in in a couple hours. The charge nurse was telling me he needed to be intubated so he could ride out his withdrawal heavily sedated the respiratory therapist was telling me that if we could just calm him down enough we could manage this with a nasal tube and an albuterol treatment. I was telling myself that I had not idea what to do. I was leaning towards the intubation (for all the wrong reasons, basically it was just the easiest for me). But I knew I was going to have to wake up my chief.
When I made that call he immediately started barraging me with questions. I only knew the answers to about half. And the ones I did know I couldn't get across quite right. I swear that man thought I was a moron. He decided not to intubate, then called his chief who told him to intubate. So there I was calling anesthesia, placing orders I'd never placed before and panicking that I should have made the call earlier, I should have thought about this when I admitted him and a thousand other insecurities. Three hours later I left and now I'm sitting here typing about him and wondering how he'll be when I come back at 5 pm. How long is going to be intubated? Is he going to get pneumonia? Is he going to hate me when he comes off the vent?
I need to get some sleep now. But I know my vent patient and that little boy are going to be my last thoughts as a I fall asleep. And I'm a little worried where my subconscious my head when I'm not reining it in
8/1/10
Post-Call = Split pea soup
*AS I'M WRITING THIS I'VE BEEN UP FOR 32 HOURS*
For those of you not in the know. After we interns have been been in the hospital for a full 24 hours we are referred to as being "post-call." Per the current regulations we can stay for an additional 6 hours while we are post-call. It's really not the first 24 hours that's hard. It's that transition into being post-call. Something about hitting the 25th hour of being awake make all your systems shut down. Your depth perception is off. Your thermoregulators shut down. Your filter disintegrates.
Of course by this time you probably haven't eaten in the last 8 to 12 hours so you are definitely dealing with some hypoglycemic issues. And if you did drink anything it's been super caffeinated so you are dehydrated. Not to mention that you've had anywhere from 5-20 bouts of high intensity cardiovascular activity. Whether it was a critical lab, a trauma, a code, a scary attending. Something kept you running all day and all night.
They've done studies on what sleep deprivation does to a person's reflexes, recall ability and even judgment. I am sure there are interns out there who gripe about it so often they have these stats memorized. I for one am not griping. I approve of this system. Don't get me wrong I don't think the days when surgeons spent 80 hours straight in the hospital made any kind of sense. But this 24 + 6 system is a good one.
By the time you hit your post-call mark the entire team has reassembled. You are no longer responsible for patient care decisions, you are no longer allowed to operate. You are there solely to maintain the patients' continuity of care. You can tell each and every member of the time exactly what happened for each patient after they all went home last night because not only were you there but you managed each situation. And in managing the situation is where true learning starts. Yes there are dozens of safety-nets in place, from the nurses experience to the computer binging every time you order contraindicated medications. Not to mention the mid-level, senior and chief residents who are all available for you to call (if you are brave enough). But the autonomy of being the only person on the floor, and sometimes the only one physically in the hospital gives you the balls you need to take charge of a situation. And, yes mistakes will be made, but that's why the overly redundant back-ups to make sure they caught before ANY damage is done the patient.
But, I digress - as one is wont to do after 32 hours of sleep deprivation. One is also wont to wax philosophical and use high-falauting phrases one would never normally use for fear of sounding like a pretentious jack ass.
Anyways, back to my point. Which is that when you are post call it often feels like the rest of the world is coming at you through a dense fog of split-pea soup. Everything is insipid and murky and bogged down. When people talk to you the words sort of float past you and you can't quite grasp what's being said until the third repetition. Simple tasks like a dialing a 5 digit extension become monumentally difficult. Was that 5-6561 or 6-5651? Remembering that PCs use Ctrl+C to copy and not Command+C like your mac at home leaves you hunting for that damned command key for a full 30 seconds before you realize idiocy of your mistake.
All-in-all I've never really been a fan of split-pea. It had something to do with it's ickiness and goopiness and greenness. But that doesn't mean I won't shovel down a full mouthfuls if there is absolutely nothing else (hospital cafeterias have the worst soup selections so this has been the case before).
So that is the simile I wanted to put forward. Post call like split pea soup. Check.
Falling asleep with computer on lap. Must shower and sleep. I haven't showered in 32 hours either. It's kinda gross.
For those of you not in the know. After we interns have been been in the hospital for a full 24 hours we are referred to as being "post-call." Per the current regulations we can stay for an additional 6 hours while we are post-call. It's really not the first 24 hours that's hard. It's that transition into being post-call. Something about hitting the 25th hour of being awake make all your systems shut down. Your depth perception is off. Your thermoregulators shut down. Your filter disintegrates.
Of course by this time you probably haven't eaten in the last 8 to 12 hours so you are definitely dealing with some hypoglycemic issues. And if you did drink anything it's been super caffeinated so you are dehydrated. Not to mention that you've had anywhere from 5-20 bouts of high intensity cardiovascular activity. Whether it was a critical lab, a trauma, a code, a scary attending. Something kept you running all day and all night.
They've done studies on what sleep deprivation does to a person's reflexes, recall ability and even judgment. I am sure there are interns out there who gripe about it so often they have these stats memorized. I for one am not griping. I approve of this system. Don't get me wrong I don't think the days when surgeons spent 80 hours straight in the hospital made any kind of sense. But this 24 + 6 system is a good one.
By the time you hit your post-call mark the entire team has reassembled. You are no longer responsible for patient care decisions, you are no longer allowed to operate. You are there solely to maintain the patients' continuity of care. You can tell each and every member of the time exactly what happened for each patient after they all went home last night because not only were you there but you managed each situation. And in managing the situation is where true learning starts. Yes there are dozens of safety-nets in place, from the nurses experience to the computer binging every time you order contraindicated medications. Not to mention the mid-level, senior and chief residents who are all available for you to call (if you are brave enough). But the autonomy of being the only person on the floor, and sometimes the only one physically in the hospital gives you the balls you need to take charge of a situation. And, yes mistakes will be made, but that's why the overly redundant back-ups to make sure they caught before ANY damage is done the patient.
But, I digress - as one is wont to do after 32 hours of sleep deprivation. One is also wont to wax philosophical and use high-falauting phrases one would never normally use for fear of sounding like a pretentious jack ass.
Anyways, back to my point. Which is that when you are post call it often feels like the rest of the world is coming at you through a dense fog of split-pea soup. Everything is insipid and murky and bogged down. When people talk to you the words sort of float past you and you can't quite grasp what's being said until the third repetition. Simple tasks like a dialing a 5 digit extension become monumentally difficult. Was that 5-6561 or 6-5651? Remembering that PCs use Ctrl+C to copy and not Command+C like your mac at home leaves you hunting for that damned command key for a full 30 seconds before you realize idiocy of your mistake.
All-in-all I've never really been a fan of split-pea. It had something to do with it's ickiness and goopiness and greenness. But that doesn't mean I won't shovel down a full mouthfuls if there is absolutely nothing else (hospital cafeterias have the worst soup selections so this has been the case before).
So that is the simile I wanted to put forward. Post call like split pea soup. Check.
Falling asleep with computer on lap. Must shower and sleep. I haven't showered in 32 hours either. It's kinda gross.
7/30/10
My First Day Redux
So, it's the end of the first day. I think the most surprising thing was the fact that I spent very little time with patients today. Don't get me wrong, they were on my mind almost all day. But, I spent very little time with them. As a medical student you are the one who spends 30 minutes talking to each patient, but spend absolutely no time worrying about their management. Today I fretted over the dose of pain meds, whether to discharge a patient or not, the state of their wounds, their mental capacity but I spent very little actually talking to them.
I always thought the residents I'd worked with in the past were callous for not spending time with their patients. I guess I'd never realized how much time they spent dwelling on their patients even when they weren't there. Right now as I sit here typing this I keep thinking back to the Polish man who woke up from surgery with a strange dry patch on his face, the woman whose endocrinology follow up I'd scheduled and all the other patients from today. Their faces and our brief conversations keep swimming on the periphery of my psyche.
But, I have to shut that all out. Because my alarm is going to go off at 4 am, I need to be in the hospital at 5 am and I go on call at 6 am . . . I'll get off again sometime after 6pm on Sunday. That's a 36 hours in the hospital. 24 of them responsible for all the burn, plastics, vascular and neurosurgery patients in the hospital and an additional 12 in charge of just the burn patients. It's my first call as a grown up a doctor. I really need my subconscious to settle down so I can get a few hours sleep.
I always thought the residents I'd worked with in the past were callous for not spending time with their patients. I guess I'd never realized how much time they spent dwelling on their patients even when they weren't there. Right now as I sit here typing this I keep thinking back to the Polish man who woke up from surgery with a strange dry patch on his face, the woman whose endocrinology follow up I'd scheduled and all the other patients from today. Their faces and our brief conversations keep swimming on the periphery of my psyche.
But, I have to shut that all out. Because my alarm is going to go off at 4 am, I need to be in the hospital at 5 am and I go on call at 6 am . . . I'll get off again sometime after 6pm on Sunday. That's a 36 hours in the hospital. 24 of them responsible for all the burn, plastics, vascular and neurosurgery patients in the hospital and an additional 12 in charge of just the burn patients. It's my first call as a grown up a doctor. I really need my subconscious to settle down so I can get a few hours sleep.
7/29/10
My First Day
Some of you may know that the pilot episode of Scrubs was titled "My First Day." Some of you, with lives, probably don't know that. But I'm sure that most of you know what Scrubs is and that for doctors, it's the most realistic medical show on TV. Well, I recently got into a surgical residency and was supposed to start work on at the end of June. But because of a number of unfortunate delays getting my license I'm only just starting. Hopefully tomorrow.
So, I'll be about a month behind my co-interns. I'll be the only intern still getting lost, forgetting to sign out my pager and making people wonder why I was hired in the first place. I've been looking forward to starting my residency for years. I've studied, I've worked hard, I've spent sleepless nights in hospital trauma bays all leading up to this one moment. And suddenly, a terror is gripping me. I'm feeling it right now in the pit of my stomach. It's been growing slightly larger ever since I got the call saying my license had been issued. I've spent the past few weeks in a state of panic convinced that this moment would never come and now that it's here I'm wishing I'd done more to prepare myself.
I know it's totally irrational, and that every new intern feels the same way I do. But I also know that tomorrow marks the actual beginning of my career as a doctor and that today is the last day I can use the "I'm just a student" excuse. From now on I am the one that is responsible for ordering the 3 am labs, for writing admit orders and for making sure the prescriptions are renewed on time. I know all the things I am supposed to do. I even have an inkling of an idea as to how to go about doing them. And I also know that no one is expecting perfection on my first day. Except me, of course.
"Four years of pre-med, 4 years of med school and tons of unpaid loans had made me realize one thing . . . I don't know jack" - Dr. John "J.D." Dorian
So, I'll be about a month behind my co-interns. I'll be the only intern still getting lost, forgetting to sign out my pager and making people wonder why I was hired in the first place. I've been looking forward to starting my residency for years. I've studied, I've worked hard, I've spent sleepless nights in hospital trauma bays all leading up to this one moment. And suddenly, a terror is gripping me. I'm feeling it right now in the pit of my stomach. It's been growing slightly larger ever since I got the call saying my license had been issued. I've spent the past few weeks in a state of panic convinced that this moment would never come and now that it's here I'm wishing I'd done more to prepare myself.
I know it's totally irrational, and that every new intern feels the same way I do. But I also know that tomorrow marks the actual beginning of my career as a doctor and that today is the last day I can use the "I'm just a student" excuse. From now on I am the one that is responsible for ordering the 3 am labs, for writing admit orders and for making sure the prescriptions are renewed on time. I know all the things I am supposed to do. I even have an inkling of an idea as to how to go about doing them. And I also know that no one is expecting perfection on my first day. Except me, of course.
"Four years of pre-med, 4 years of med school and tons of unpaid loans had made me realize one thing . . . I don't know jack" - Dr. John "J.D." Dorian
4/3/10
"I'm not a serial killer, I swear"
You would think that being a surgery resident is as easy showing up at the hospital on July 1st and grabbing the nearest scalpel. Well, you would be wrong. Setting aside all the usual adminstrative nonsense of starting a new job there is still the hassle of the car, the computer, the phone, the apartment all of which have to be sorted out well before your first paycheck. A few days ago I tackled the furniture for my new apartment. Today I took a two and a half hour road trip from my hometown to the University town where I'll be doing my residency and looked at about 6 different apartment complexes.
Now, as a resident I need some place that takes less than 10 minutes to commute, including parking. Not to mention, it should be quiet, have a rent drop box and things that deliver and a number of other little variables that become necessities when you work the hours I'll be working. So, I had to explain to each property manager why I was asking seemingly irrelevant questions. Well, it seems I forgot to mention this to one lady. So, when she said that dividing my renter's insurance out over 12 months made it a nominal fee and I said that I don't need to do math because "I cut people open" I caused her a brief moment terror. In fact, she took a step back, the color drained from her face and she stared at me open-mouthed while I floundered for a rational explanation. The best I could come up with was "don't worry, I'm not a serial killer" and "I don't cut people up for fun, I swear." After a few more minutes of this I eventually got her to understand the whole surgeon thing.
I think living there for the next couple of years should prove entertaining.
Now, as a resident I need some place that takes less than 10 minutes to commute, including parking. Not to mention, it should be quiet, have a rent drop box and things that deliver and a number of other little variables that become necessities when you work the hours I'll be working. So, I had to explain to each property manager why I was asking seemingly irrelevant questions. Well, it seems I forgot to mention this to one lady. So, when she said that dividing my renter's insurance out over 12 months made it a nominal fee and I said that I don't need to do math because "I cut people open" I caused her a brief moment terror. In fact, she took a step back, the color drained from her face and she stared at me open-mouthed while I floundered for a rational explanation. The best I could come up with was "don't worry, I'm not a serial killer" and "I don't cut people up for fun, I swear." After a few more minutes of this I eventually got her to understand the whole surgeon thing.
I think living there for the next couple of years should prove entertaining.
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