Change of pace

Ahhhhhhhh, ward medicine. Q5 call. Knowing that I'll get to sleep through the night on a normal schedule more than twice a week. This next rotation is going to be nice.

Additionally, there are two interns per team here, and I'm coming on to a team with Rick, one of my better friends from the intern class, so we are going to have a blast no matter what happens. And we have a med student, whom Rick worked with on the last rotation and who is apparently pretty strong. Excellent. The funny thing is, Rick has apparently been talking me up as some kind of uber-intense born cardiologist with no patience for incompetence and laziness. Which I guess is mostly true, but I'm a nice guy about it, I hope. Still, I want the med stud to have fun while becoming the best student in his class, so if I'm hard on him, it will be with good reason and with lots of encouragement in the right direction.

The great thing about medical students is that they encourage me, so recently one of them, to study harder to stay ahead of what they know. Which encourages them to study, and keeps the cycle going. I'm already saving up ridiculous pimp questions to try out.

A joke

Maybe this is only funny if you're sleep deprived. But then you have to be a huge nerd too:

Resident: "Dude, I think being on vecuronium sucks."

Intern: "Nah, man, I think it rocks."

*cue general hilarity*

Deprived

One one of the rare occasions I was outside the cage hospital lately, I watched the "Bourne Ultimatum." Partway through the movie, the fearless protagonist is reading a stack of papers describing his own forgotten training and a line flashes across the screen: "subject has been awake for 56 hours." My first thought was "I could do that."

Q3 call is ridiculous. I'm in the hospital for 30 hours straight without sleep every third day. To think, as a medical student I assumed only surgery interns worked hard. At least they roughly keep to the 80 hour work week. And at my hospital anyway, they have call q5 on most rotations. Part of this may be the fact that my hospital is renowned for its medicine program, and the directors feel they have a reputation to keep up. But after two straight months of work in critical care, I'm noting the diminishing marginal utility of this particular learning environment.

Making matters worse is the fact that I am what is known as a "black cloud." Even among physicians, supposedly highly educated and purely scientific minds, there exist strong superstitions. A black cloud is a doctor who, when he is on call, has worse luck than the average. For example, last month, on the cardiac ICU team, my team admitted over twice the number of patients the other team did. And here on the MICU, the story is the similar. A positive side of this is the fact that my attending noticed it, and last time I breezed through presenting nine patients, he said "dude Nathan, you are like Superman."

I feel compelled to add that he's both a)from California and b)about a year out of his fellowship.

But where that was a motivation, and I was pretty energized previously, the flog is taking its toll. My motivation to read (or at least skim) an article or two on each of my patients before rounds has dropped off. Last night I fell asleep sitting up in my chair, in the process of typing a note. Where I was once understanding of being paged for even the dullest questions from nurses, I'm getting dangerously close to snapping out things like "that's exactly what I wrote in the orders, twice, and I just spent 30 whole seconds clarifying it in person."

Everyone is feeling it. One of the nurse managers pulled aside a senior resident the other day and told him he had to be understanding of the nurses aides, because they worked long hours. The guy shot back "You're right, they work four long 12 hour shifts a week, and the stress of filling the rest of their time with boys, alcohol, and sex must be incredible. On second thought, no, I'm not all that understanding. How about you tell them to do their damn job."

It wasn't the best way to remind the nurse of the truth, but I would have been tempted myself in the same position. But I'm greatly looking forward to my two week subspecialty block coming up in a month. No call, just two glorious weeks of sleeping through every night.

And Jane makes five

Jane was a nice woman, scarcely old, who was admitted for sepsis and pneumonia. But it was only after we intubated her that we heard from her oncologist the truly grim prognosis of her disease. We didn't do her any favors with intubation and the family made the decision to transfer to comfort care only. I handled this completely without my resident, getting the morphine set up, making her comfortable, extubating her, pulling all the extraneous lines, stopping the drips. After the nurse and I called the family back in, it wasn't much more than five minutes before I was pronouncing someone dead for the first time.

Two years of clinical rotations in medical school and I never saw anyone die. Now more of my patients are M&M subjects than any other intern's. That's not a particularly uplifting distinction to have. Thankfully, nothing I've done wrong contributed to their demise. But it doesn't do much for a mood already dulled by lack of sleep.

The karma gods are angry

So I realize my last post was all about conciliation, but last night, all I could think about was my anger at the orthopedic surgery team. Orthopedics is a fascinating specialty, I'm sure, but the practice of it trains that tribe to regard anything that cannot be solved with a stainless steel power tool as beneath them. So when, for example, a patient who had a hip fracture repair is semi-stable but has a few co-morbidities that make them nervous, they are quite anxious to transfer her to a medicine team.

Unfortunately, they performed this transfer directly to my staff, without informing me, the guy who would actually get paged to her bedside about an hour later to find a patient I didn't know with new ST depressions of 5mm in all her precordial leads and a tachycardia to the 140s, complaining of chest pain but unable to point to it, because she also developed sudden onset of bilateral paralysis from the neck down. To add beauty to the situation, the patient also had mental status changes and was unable to tell me anything about her history, and the chart was full of worthless surgery notes saying "vital signs stable" and "wound healing without signs of infection" but little else. The nurses were able to tell me that the patient at baseline had left sided paralysis, but that the right was new. And fortunately the orthopedic team had ordered a nephrology consult at some point, so the life-saving nephrology consult note functioned as my understanding of the history long enough for me to get the basic ACLS stuff started and to page my resident with more to say than "please come save me." Even more fortunately, we were able to help the short term things with her. Long term, I have no idea if her apparent stroke will resolve. Probably, even knowing about her wouldn't have stopped all the craziness, but I would have been far more comfortable and would have lost less time.

I'm going to prepare more war paint.

Internecine

Late last month, Sri Lankan police killed 12 members of the Tamil Tigers, a rebel group with which they have been fighting for nearly 25 years. At issue is self determination for two rival groups sharing a small island with limited resources.

It is easy to see how this is like a hospital. Within the four walls (figuratively speaking, since my hospital was built in about 50 different stages and has long since ceased to be rectangular) of this building are numerous warring tribes, calling themselves internists, surgeons, pediatricians, radiologists, and the like. Through the vicious coming of age ceremonies involved with these tribes, they come to identify all outsiders as unclean, beneath their attention, untouchable. What makes this caste system more complicated than the politics behind Alexios I Komnenos' hold on the throne of Byzantium is the fact that no one group recognizes an ultimate ruler, and no one group is treated equally badly.

Surgeons, for example, tend to look down on internists as nitpicking, reactionary types overly concerned about minor lab values, most of whose conclusions need to be regarded with considerable skepticism. Even nice, earnest surgeons can fall into this category at times. Internists, for their part, are generally frustrated with surgeon's apparent disregard for important but small lab values and seeming inability to document more than the most obvious one or two physical findings, usually in cryptic, barely legible acronyms, but we reserve our most earnest hatred for ER physicians.

Surgeons, we reason, have an area of expertise beyond our ken, and we beyond theirs. I, for one, will never presume to take out an appendix or a liver, just as I wouldn't expect a surgeon to handle renal tubular acidosis or manage diabetes. We only step on each other's toes in presuming outside our area of expertise, and both our specialties can complement one another. An ER physician on the other hand, oftentimes appears to be actively involved in undermining our patient's health. For instance, I recently admitted a patient with atrial fibrillation causing a rapid heart beat. The ER physician though, assumed this was due to alcohol withdrawal, so despite reading the patient's old notes, he started the guy on a Versed drip rather than a diltiazem one. As a result, the patient got more and more somnolent and had to be intubated. Fortunately my resident and I got to him in time to start a medication that would actually treat his condition and prevent damage to his heart.

What gets lost in the griping as the tribes head back to camp to prepare more war paint and weapons is the fact that, even if we aren't shooting radiologists like Tamil Tigers, real people can be hurt in these conflicts. The ER, for example, does see acute alcohol withdrawal, and they did a)realize this was a bit atypical and b) call me before it got out of hand. I'm sure many times they would have been right with the Versed. So despite recognizing my growing attachment to my tribe, and my earnest defense of it in the call room, I'm trying to remember also that most of us have the patient in mind, most of the time. Sri Lanka I can't help. Bed five in the ED? I'll be right down, and sure, I'll consider alcohol withdrawal.

In the Zone

Maybe it was the phase of the moon. Or maybe it was the fact that my day on call followed Simon's, and in comparison anyone would look good. But I was on today. By "today" of course, I mean my last thirty hour shift, in which I only say down for about 10 minutes total, and never touched my call room bed.

But despite being crazy busy, and rather stressful at times, everything went well in general. I had to bag ventilate a patient for about an hour and a half (trading off with one of the nurses) but he survived while teaching me much more comfort with mechanical ventilators (and incidentally, which are the good respiratory techs in this hospital). I had to get an arterial line on another patient, and did it perfectly it on the first try. I had 30 minutes of free time at exactly the right stage of the night and managed to look up articles which may positively alter our therapy for two different patients. I looked like a superstar on rounds and the fellow and attending both complimented me on my work and my presentations.

Not that I'm complacent. I know how hard it was to keep myself moving for that long, and how much busier the night could have been. Still, good days should be enjoyed.