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.
8/22/10
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.
Subscribe to:
Posts (Atom)