Stronger

Growing up means taking responsibility, learning your place in the world, and just occasionally, royally reaming out someone who deserves it.

But this isn't a post about nurses. You know I love you guys.

Or even med students. I was one once.

My program has a rather large array of personalities and capabilities. Most the people are pretty strong, even the ones I don't exactly click with. There is at least one notable exception.

Simon, as I'll call him, is a nice enough guy. Like all of us, his personality is not naturally that of the perfect physician, but unlike most of his classmates, he has not progressed very far down the path of mortifying these traits.

So yesterday, as he was the post-call intern, his job was presenting the new patients and giving a brief update on the old ones. Since this is the MICU, these patients are complicated, and need detailed notes discussing in depth, by system, the problems they have and what we are doing about them.

Rounds got off to a rocky start because (as my friend the senior resident told me) Simon had spent his night on call sleeping rather than working. So when he got up at 6am to round on six patients in the ICU before 8am, he was understandably far behind. He didn't know what had gone on during the night and had, despite the senior waking him up and directing him on what to do, gone back to sleep on several occasions before finishing his work. When I came in at 6:45 to see my one patient, I heard Simon asking his senior to help him with the note writing. He was rightfully rebuffed.

So notes were not finished before rounds. This makes rounding difficult, and what made it more painful (for Simon and the rest of us) was the fact that he had arbitrarily decided that some vital signs were not important on some patients. So, for instance, with one of his patients with acute renal failure and CHF requiring mechanical ventilation, he hadn't written down CVPs, and the blood pressures he had written down weren't the real range, they were what Simon felt were the "normal" ones of the night. Not cool. You can't just cherry pick data to make yourself look good, these are sick people.

There followed possibly the most painful rounding experience I've ever watched, one which demonstrated every mistake I've ever seen a third year med student make. Actually, I haven't ever seen a third year med student refer to his "Gay-dar" in assessing the patient's sexual orientation. Maybe you could get away with that, in the right crowd, with docs you knew and who understood your humor. Not the first day, when you've already floundered through twenty painful minutes.

This was painful, but I was mostly hoping it would be painful enough to make Simon realize his errors and maybe start slouching towards competence to be born. No such luck. Later that afternoon, about 3 hours after he was supposed to have left, I ran into Simon putting a note on a patient's chart. Unfortunately, this was a very short, 10-15 line note, nothing like the three pages you would expect on a complicated patient with decompensating respiratory effort.

So I called him out.

There followed a very tense, even toned conversation that was, nevertheless, my laying out in very clear language about 85% of what I figure is necessary to be a good doctor. I don't even remember all I said, but I do remember saying things like "this isn't about rules about notes you think are silly, this isn't about work hours, or personality, it is about taking care of patients. And if you don't realize that, you don't belong here. Internship is supposed to be hell, but you have to make it that way. If the pressure doesn't come from within you won't succeed." I added some choice things about needing to write notes, to consider every patient carefully by system because if you don't learn to come up with plans on your own, you'll never be able to. You'll always be an intern, and never a real doctor.

About halfway through this harangue, I realized that the entire nursing staff of that ICU pod, about 20 some odd people, were listening, mostly while pretending not to. I noticed the nurse taking care of the patient in question nodding his head in agreement. I am a bit ashamed to say I enjoyed the audience almost as much as the fact that I finally had an opportunity to maybe, just maybe, work for positive change in this guy's life, and more importantly, in the lives of his patients.

To his very, very great credit, Simon took this correction without offering an excuse for his behavior. He actually wrote a real note, and later, he paged me to thank me for the advice. I wasn't really sure what to say, except "you're welcome."

Heck, I could code in front of that guy some day. And it is nice to know, not just believe, that I have what it takes to give constructive correction. It is also nice to be the strong intern on the intensive care service.

30 hours without sleep? I'm still smiling.

Almost coded

Late this morning, while finishing up the last of my work and hoping for an early exit from the hospital, I rounded a corner of a hallway to have my heart sink within me. For as soon as I rounded that corner, a group of nurses at the other end of the hall turned and said "there's a doctor!"

This is almost never a good thing. But in response to their earnest gesturing, I hurried to the room to see a very pale woman lying on a bed gaping at the ceiling with eyes closed. Meanwhile, in one ear I was hearing "just checked on her, was smiling a minute ago," and in the other I was hearing "there's no pulse on telemetry, just bradyed down and stopped, I think she might be DNR."

I am, in looking back, pleased with my calmness as I said "bring the code cart and her chart, see if she's DNR/DNI." By the time I reached the patient's bedside though, a nurse was standing in the doorway with the chart, telling me this patient was DNR/DNI. The code cart was pushed back to its familiar home and the crowd started to disperse.

I told the nurse to page the resident of the primary team and the staff physician as I felt the carotid for a pulse. Feeling none, and hearing no heartbeat, I realized I had just seen my first death in the hospital. First death ever, actually, which is an odd thing, I think, a sign of our times, a mark of the twenty first century, in which people die in small rooms away from home, attended by a select group of people to whom the experience becomes familiar. And until you join that group, you are insulated from the event, one that comes to us all.

The intern from the primary team drifted in. Though it may not have been the right thing to do, I let him pronounce the death.

"Time of death, July 17, eleven fifty AM."

It would be false to say this affected me greatly. I had never seen the patient before, never spoken with her, never heard her story, except her diagnosis. And I wonder what to make of that. I came into medicine partly because it allowed me to treat people, to be around people, who are dealing with real questions, and to deal with them myself. Somehow the presence of the "unveiled mysteries of life and death" seemed to add profundity to my experiences.

I thought as a medical student. As an intern, I'm harried to the point that thought beyond "what do I need to do now" is difficult. If I'm not moving, there's something wrong. I'm so used to hearing my senior resident say "what aren't you writing this down? You should be writing this down, Nathan" that it has become a bit of a joke. All this action, all this doing, keeps me from thinking.

And so, as I stood in that room, a little nervous, a little relieved that I didn't have to run a code, and a little awestruck by the whole situation, I wasn't really processing. I wasn't having grand thoughts voiced by Longfellow or grim ones by Thomas. I was tired, and after the details were passed on to the primary team, I went to grab lunch before heading back to work.

The beatings will continue until morale improves

So today I presented my first CCU patient, and relearned a host of lessons I had thought were past. ICU patients, of course, are presented in a different format than ward patients, and I was rusty on that format. I was also very far behind in rounding today, and essentially I failed in every quantifiable area of accomplishment where my patient was concerned. Justly, I received some very stern correction for this, culminating in one of the interventional cards guys drifting from "know the patient" to "have a differential diagnosis." This particular lesson was not necessary in my case, but a few others were, so he can be forgiven for going overboard.

He did say that if next year I saw a patient in the ER with severe, tearing chest pain radiating to the back with blood pressure different in each arm and I activated the cath lab, calling him in from a sound sleep at 2am, then "I will throw you off the top floor of the hospital. Which would be tragic. Because the patient would die."

Maybe it's Stockholm syndrome, but I love cardiology.

Obsession

To work at my trade by the dozen and never a trade to know;
To plan like a Chinese puzzle -- fitting and changing so;
To think of a thousand details, each in a thousand ways;
For my own immediate people and a possible love and praise.

I used to think I was obsessive-compulsive. It was my strong point. My concern for minutiae made me a great medical student, as I had all the labs, all the studies, all the details of the patient histories, going back as far as the hospital records would allow.

Then I became an intern. As a medical student, I had charge over one, two, or at most four patients. These were acquired gradually, over a period of days, and I came to know them well. Now, on cardiology, I regularly admit six patients on a call night, and then I have to know them well enough to present the following morning. Gone is the obsession. Or if not gone, I realize that I cannot get information the way I am used to, cannot use the same organization. I must move faster, more thoroughly, more efficiently.

Case in point, one of the patients I admitted last night was only in the hospital because on his more recent discharge, his medication instructions were not clear. This resulted in him not taking a medication he needed. Now I know the intern who wrote those instructions wasn't intentionally trying to harm anyone, and in fact, he had all the information on the instruction sheet, he just didn't take the time to format it in a readable way. Even I couldn't figure out the sheet, and heck, I'm a doctor. But he probably fell into the same trap I do, having to discharge ten patients in a morning, typing furiously, dealing with the interruptions of pages needing to be returned, residents updated, patients seen.

I never realized the sheer volume of work that goes into being an intern. I was a good medical student, and a good sub-intern, but it is impossible to know what all is entailed in being a doctor, in being an intern, until it is your signature on those late night medication instructions, your fingers entering all those discharge orders, your head running on empty because you've been awake for 30 hours.

Probably I will never be a success in my own eyes. But when I make stupid mistakes, like today in rounds, actually forgetting to write down half of a patient's chemistry panel and asking my resident for the numbers in the middle of my presentation, in front of the cardiology fellowship director, it is easy to sink farther in my own estimation than usual, even. Sigh. The only positive I can think of is the fact that I'm learning the hard way, which tends to make a more lasting impression. I just don't want to destroy my chances of success here before I even start.

Maybe that obsession isn't entirely gone.

First call

So my first call night came off relatively well. Though in medical school I thought it the limits of my ability to follow four patients at one time, on this particular 30 hour shift I admitted five, learning all their complicated stories at one time, and without the safety net of an intern above me basically doing the work. I had honestly not realized that it was possible to remain in motion for 30 hours. Not even once did my head hit the pillow in my call room. But it wasn't as horrible as I had feared. The only patient who died was one whom we had transitioned to "comfort care," as the family had recognized the inevitable. And I was able to handle all the questions I was paged without needing to bother the senior. But nevertheless, at about 4am, I had pretty much decided that I picked the wrong field, or at least the wrong specialty. Very few laboratory chemists work 30 shifts as part of a group hazing ritual.

The uneasiness continued to morning rounds. I had not gotten a chance to do more than write down vitals and say "hi" to my patients, by no means getting a thorough exam on each of them, before it was time to start.

My fears were rapidly dispelled. About halfway through my first presentation, my attending stopped me and presented the most welcome piece of constructive criticism I've yet heard. He said "stop. I have no doubt that in three years, you're going to be one of the strongest residents in the program, but you're presenting like a medical student." He then proceeded to tell me exactly how to present as an intern. Noted. Afterwards though, the fear came back, as the fellow drew me aside as said "Dr. Ricker was complimentary, but just remember that your presentations were only acceptable for being the first week. If you are still presenting like that at the end of our weeks, we're going to have problems." Also noted.

Long white coat

Today I put on my long white coat for the first time, along with my name tag with the initials "MD" after my name. Then I put my stethoscope, notebook, pocket reference books, pens, pen light, EKG calipers, rubberstamp, and spare paper in my pockets, and walked into the conference room to start my intern year. The first thing I noticed was that the coat wasn't appreciably lighter than it had been in medical school, and it had the added pain of stretching down to my knees. The second thing I noticed was that the notebook in which I have been writing immensely useful hints, like the REAL number for radiology, the outline for writing up a stress test, and the proper way to evaluate half a dozen common problems, the notebook I've been working on since third year of medical school, had disappeared somewhere between my car and the door of the conference room. But it is long white coat.

Not exactly a stress-free way to begin my intern year. But, as if in sympathy, the schedule worked out very much in my favor. I wasn't on call, so after relatively brief rounds, I was sent on my way rejoicing, and given tomorrow off. I can only complain by saying, I'm about ready to begin, already, and no, I didn't find the notebook on the way back to the car. Sigh.