Teamwork

A good team can get you through pretty much anything. That's why call is so scary... often, there's no one there but you.

In the mornings for the past month, we've actually had a pretty good time. Our team for November was composed of me, another off-service junior resident (from Family Medicine) and our pseudo-senior (a second year general surgery resident). She's not really a senior cause she's only second year, but she plays the role on our team. We also have anywhere from 2 to 4 medical students at any given time. The helpfullness of medical students (we call them clinical clerks for a reason that I'm sure is historic and makes more sense than is readily apparent) is hugely variable. There are some that are completely useless. I understand if general surgery is not your life's calling (God knows it isn't mine either) but the attitude of some of these clerks drives me nuts. There was the one that was routinely late without apology or explanation. I can understand that it's hard to get to the hospital for 6am in the morning, but she was 20 minutes late for weekend call which didn't start until 9am. She was late every single day, without fail. It drove me nuts. There was the one who rolled her eyes and sulked every time she was asked to do something. There was the one who met every request with a cool "I don't think I'd get anything out of that". And there was the one who would tell us she was going to clinic and then leave. I mean, leave the hospital. Go home. Who the hell DOES that?

There's really not much you can do when you're stuck with a really lazy student on your team. We're not really responsible for their evaluations, the staff are. But it slows the whole team down, because everyone else has to pick up the slack. Usually I'm pretty good to the clerks on my team. When we're on call I don't call them past midnight unless it's something I think they'd really learn from, like an admission or a consult. I try not to lose sight of the fact that this might be my job, but they're paying tuition for the privilege of being worked to the bone. But sometimes, you really start to get resentful.

Thank God for the elective students. These are medical students from other medical schools, usually in their last year, who have arranged electives in general surgery because that's what they want to do. They know what they're doing (in many cases, they know much more about surgery than I do) and they're there to work hard. They make life so much easier.

The two other residents I've been working with have made rounding at 6am much more fun. The surgical resident is somewhat grumpy in the morning, but can be pretty easily goaded into reluctant laughter. The other resident has apparently made it his goal in life to make resident #1 a morning person. The two of them are seriously funny together. Lately, the fun thing to do has been to see how many big fluorescent biohazard stickers resident #2 can manage to stick to the back of resident #1 by the time we finish rounding. Our record so far is 6.

Sigh. It doesn't take much to count for amusement these days.

Note to all of you lurkers...

Hi. I'm constantly amazed by how many people read my blog. What started as an easy way to keep my nearest and dearest relatively up to date on my life during my busiest times has snowballed into a forum where I vent and complain, and generally get things off my chest. And it seems to be read by a significant number of people. And apparently there are a lot of you reading out there that aren't even related to me. That being said... hi mom!

I've had quite a few people in various spheres of my life mention that they read my blog. From Hitched ladies that I barely know to people that I went to school with a while back. I recently got an e-mail from someone whom I haven't spoken to in months congratulating me on my program switch... she had seen it in my blog. Wha? Granted, many of the people who claim to have been reading my entries regularly might just be trying to be polite. Since I don't have the web-savvy to add a counter to my page I have to take their word for it.

But here's the complaint... why don't you post? I love reading comments from people, whether I know you in real life or not. Particularly if you disagree with something I've written. Maybe I'm just not being inflammatory enough. Taking criticism is the risk you take when you expose some of your more personal thoughts with a public audience. But I can take it as well as I dish it out. So post. Tell me what you think. It makes me feel loved. Or not.

(Disclaimer: If you leave a random obnoxious comment and don't identify yourself, I'll erase it. This is not a democracy... it's my page. So there. Heh.)

A Post-Call State of Mind

Being post-call is not a fun thing. It's like that point in the evening when the fun buzz of being drunk has worn off and you just feel mildly ill and very tired. It's not fun being at the bar anymore, and all you can think about is crawling into bed.

Depending on how rough the night was and how many hours (or minutes) of sleep you managed to sneak, there are various degrees of post-call. If you've managed to catch a few hours (for me, this is anything more than 4) it's actually not too bad... you're a little tired, and more than a little anxious to see anything outside of the hospital, but fully aware that it could have been much, much worse. For me, this kind of night is often punctuated by interruptions that I have no recollection of in the morning. I find that I've given verbal orders for all sorts of things the next morning. A little disconcerting, for sure, but they were all appropriate. The ones I found out about, anyway.

The next level of post-call hell is when the night was busy, but you managed to get a couple of hours in... often in a contorted position in some random corner of the hospital that is not your call room (whose 4-inch thick matress isn't all that luxurious anyway). In this case you're dragging in the morning, but able to push through until the magical noon hour that (in theory and union contract) marks your release. With the help of copious amounts of coffee, that is.

The deepest state of post-call hell is where I was after Tuesday night. It was bad from the start. I was late for handover because I was draining an abscess off some guys back that was literally 30 cms in diameter... and projected from his back at least 10 cms. The pus that came pouring out of this thing once we hit the right pocket was unbearable. We managed to stink up the entire emergency room. One of the nurses had to leave the room from the stench. Another nurse came back with masks, which helped... a bit. Ugh. So I made it up to the floor by 6:30pm or so, at which time a nurse called me over to mention that his patient had felt a little short of breath while walking in the hall. Not a big deal, except that his O2 sat was 75% at the time. Sigh.

Many investigations and hours later it was determined that this guy had a pulmonary embolus. I wish I could say that I make the diagnosis based on the 'classic signs of right heart strain' on his ECG, but I missed those. I did, however, have the sense to call the SMR (medicine consult from the senior resident on call) when his arterial blood gas (which I got on the first try, thankyouverymuch) showed a pO2 of 50 and a pCO2 of 30. Yikes. For those of you not in medicine... this is VERY VERY bad. Add to the mix a young woman with a post-op ileus (paralyzed bowel) who wouldn't stop thowing up and a woman complaining of pain in her enterocystic fistula (meaning stool was coming out where urine should be) and I didn't sit down until the wee hours. The nurses were great... one of them measured me for TED stockings when I mentioned how much my legs were aching and another scrounged up a half a sandwich for me at 10pm or so. TED stockings, for the uninitiated, are butt-ugly things that help your veins pump blood back up to your heart against gravity. After 24 hours on your feet, the ache is unbelieveable. We put them on people at risk of clots. Lovely, aren't they?

I may have neglected to mention that before this night from hell started, the day was nothing to brag about either. I was also on day call, which just means that whenever there's a consult to be done by surgery they'll page me. I love day call since I'd much rather be in emerg than in the OR. Today, however, we got five consults in the space of an afternoon. One on a 100 and some-year-old man under the care of internal medicine who, I learned later, wasn't expected to live through the day. So why consult surgery, you may ask? Brilliant question. The SMR (acronyms again... Senior Medical Resident) responsible for his care called me later to tell me that she was fully aware that he wasn't a surgical candidate and his family had refused any further intervention, but she was curious if we thought his x-ray showed a small bowel obstruction. You have to be kidding me. YOU TOOK UP 90 MINUTES OF MY TIME DOING A BOGUS CONSULT BECAUSE YOU WERE CURIOUS???? I'm going to end the story there because otherwise there will be violence and coarse language and my mom reads this blog. But as expected, this poor man ended up passing away peacefully that night. Without sugery.

Another consult was in the ICU. The staff there was concerned that this patient's x-rays indicated an obstruction (it was apparently bowel obstruction day). I (and later, my staff) wasn't quite so concerned. The x-rays were borderline, and mostly just suggested the patient was constipated. We suggested trying noninvasive stuff before we suggested surgery. Late that night, which doing another consult in the emergency room, I got another page from the ICU. Apparently they had repeated the patient's abdominal films and found lots of free air under the diaphragm. That's not good. It meant that something had perforated, and this patient needed urgent surgery. So I called the staff member on call and the chief resident, and explained what was going on. I headed to the ICU to get started on the pre-op stuff. Unfortunately, the doors to the ICU slid open to reveal a large crowd outside the patient's door... that's never a good thing. Sure enough, the patient had coded just moments before. The staff surgeon got there just in time to see the ICU doc pronounce our patient dead.

So, no surgery. Still plenty to do, though, since the patients on the floor seemed to be having all sorts of problems needing immediate assessment. By 4:30am I was starting to feel physically ill from the effort it was taking to stay awake. I managed to curl up on the reclining chair in the closet they call the resident's office on the floor... there was no point going down to my callroom when I knew that even if there was nothing else happening on the floor I still had to be up in an hour to look up bloodwork and x-rays before teams started rounding at 6am. I got two 15 minute naps before it was time to get up for good. It was brutal. This kind of post-call is the worst. You feel completely depersonalized. You're nauseous. You are unable to formulate coherent thoughts, let alone express them. At this point, I have to honestly say that I feel like I'm a danger to my patients.

And then we drive home. Scary, isn't it? Studies have shown that the number of medical errors made by interns was much higher at the end of a traditional 30-hour shift than if the shift were limited to 16 hours (New England Journal of Medicine, 2004). Other studies (which I don't remember the citation for) found that the response time (as measured on a driving simulator) of a post-call resident is equivalent to being intoxicated. Yet we think nothing of letting interns and residents drive home after a 30-hour shift. A group of residents had this discussion after one of our seniors confessed to falling asleep at the wheel and ending up in a ditch. One might think that we'd be better at setting boundaries for ourselves... knowing when it wouldn't be safe to get behind the wheel. Then again, people who are injured (or who injure others) while driving drunk have sued the people providing the alcohol, whether it be the bar or the hosts of a party. If we were to do the same, would the hospital be liable?

Hmmm.

Grey's-Anatomy-Inspired Thought of the Day

The moment between George and his father as he was picking shotgun shells out of his father's ass made me think. A lot of people assume that if you're a doctor you're confident. Overconfident, in some ways. But sometimes, a little approval from someone whose opinion means a lot to you means the world. We spend so much of every day feeling completely incompetent and stupid that 'confident' does NOT describe my impression of my own intellectual abilities. On most days, anyway.

Today I spent the entire day in a state of panic. Even after three weeks and four nights of call, I still feel like I'm in WAY over my head in general surgery. Today, a patient got sick. When I say 'sick', I mean this poor man spent the better part of the day actively trying to die. I was called when his O2 sat dropped below 90 on 50% oxygen. For the next two hours, I tried everything I could think of. All of my seniors were in the OR, and my staff didn't seem nearly as concerned as I thought she should be. Finally, after watching his sats fall to 87% on 100% O2 as he panted like a dog and started to get obtunded, I called the staff and told her quite bluntly that I was not comfortable managing this patient on my own and that she'd better get her butt up to the floor ASAP. Maybe not my exact words, but at that point I was on the verge of needing a new pair of scrub pants.

In the end, he ended up intubated in the ICU. I don't know what I would have done had he crashed in front of me. I've never run a code, and I am petrified of my first time. Will I know what to do? Will I be able to be calm under pressure? Will the patient die? Will it be my fault?

Try to imagine feeling like this EVERY DAY. Welcome to the life of an intern. I've developed heartburn, which I've never had before. It usually hits around midafternoon, the peak of my day. I'm nauseous constantly. I rarely eat anything solid past breakfast because of it. My sleep (when I get it) is irregular and punctuated by odd dreams of the hospital. I'm lucky if I see the gym once a week. I've never known this kind of stress for such a long period of time. Can I really survive two months of this?

So yeah. Doctors (or residents, at least) DON'T think they know it all. We don't think we're smarter than everyone else. In fact, when you have so many incredibly intelligent people making you feel stupid it's hard NOT to believe it after a while. So if you know a doctor, be nice. We're fragile.

Things that make me giggle inappropriately:

1. When people refer to the ICU as "the unit". Heh. Unit.

2. The little greek man on our service who follows me around the floor asking about "the plan".

3. The staff who ask me difficult questions about the pathophysiology of chronic pancreatitis in the middle of the night and expect a coherent answer.

4. The fact that when I happened to protest the fact that I was put on call on the day before my vacation (therefore working until noon or so on the first day of my oh-too-short 5 day holiday) I was told that 'no one has ever had an issue with that before'.

5. The suggestion that I have any control whatsoever over the chaos that my life has become.

Heh heh... unit.

1 weekend of call
3 sepsis workups (on the same night)
1 last-minute presentation for resident's rounds
5 12-hour workdays... and 1 30-hour workday
2 patient transfers to the ICU
2 Whipples (DAMN the Whipple!)
1 meeting with the dean
1 program switch
7 first-year med students expecting me to teach them something
1 ACLS Instructor's course (with much prep work needed)
4 unprovoked crying fits (not in public, at least!)
1 night of journal club
1 postcall meltdown
0 personal life

= 1 very, very bad week.

More when I feel better.

Things That Go 'Beep' in the Night

My first night of surgery call. I survived it. More importantly, so did every patient under my care. Even the guy on the colorectal team (i.e. under the other surgery team's care and therefore a total stranger to me until something goes wrong and he needs me to know everything about him) who was supposed to die (according to the resident on his team) was considerate enough to keep on trucking until the light of day broke over the many montiors and buzzers that echo through the halls of 4Z in the middle of the night.

It actually wasn't too bad. The time went quickly until I finally dragged myself to my call room at around 2am. Things were steady, but not overwhelming. For my first few calls I have a senior who serves as my back-up. I saw a few consults in emerg, my clerk saw one from another service (and reported it back to me... I could get used to this 'delegating responsibility' thing) and there was the usual scut from the floor. I don't mind scut. It makes me feel competent.

"What's that nurse? Your patient can't sleep? Well, let me, the incredibly useful and competent intern, give you a verbal order for Ativan 0.5 mg PO qhs prn, thus SAVING THE DAY."

Or not.

But don't think that hitting my military-issue hospital cot at 2am was the end of my night. Oh no. After about 45 minutes of hard-earned sleep, my pager went off. It was the emergency room. Uh-oh. Another consult. But no, it was a nurse asking about a patient who had come to emerg after being discharged by general surgery the week before. This was a 34 year old guy who had apparently, for reasons that are still unclear, taken a 30 foot swan dive from a building resulting in some nasty internal injuries. Apparently, she had been collecting a stool sample from this guy only to find that instead of stool, his bowels had produced a thick, mucous-like substance that was yellowish green in colour. She wanted to let me know.

"Um, thanks."

"Well," asked the nurse impatiently, "what is it?"

I decided to be honest. "I have no idea."

"Is it normal?"

"Beats me."

"What should I do about it?"

I paused. It was just before 3am, and I was in no mood to play 'guess the bodily fluid' with this nurse.

"Look, is he being referred to us? Is he direct to general surgery? Are we responsible for him in any way?"

The nurse admitted sheepishly that we were not.

"Then I really can't help you."

I am not in the mood for pleasentries at 3am.

About 20 minutes later I ended up down in emerg for another consult anyway. While I was down there looking at the notes on the patient, I overheard a nurse on the phone with the orthopedic surgery resident.

"But it doesn't even LOOK like stool, it just looks like mucous. What should I do about it?" She apparently had not given up on her quest to find someone to identify whatever the hell was coming out of this guy's ass. A moment later, she hung up the phone. Another nurse asked her what he had said.

"He said to put it in a sample jar, send it to the lab and leave him the hell alone."

Word.

Is "Less Awful" the Best I Can Hope For?

A new month, a new rotation. I am now a general surgery intern on the hepato-biliary team. Here's how surgery stacks up to anaesthesia:

Surgery Cons:
1. I start at 6am most days. That's pretty damn early. I'm trying not to get up earlier than 5:30am to be on the floor by 6am, but I'm cutting it close. My personal hygiene is taking a dangerous downturn.

2. I am the sole responsible person for a ward of approximately 20 very sick patients. My backup (another R1 and an R2 in general surgery who is my senior) both decided to take vacation this week. Who the hell approved THAT request?

3. I don't know the first thing about managing actual sick people. My previous rotations have been emergency psych, obs/gyn and anaesthesia. Not a sick person in the bunch. I am just realizing this now.

4. I hate surgery. My attention span is far too short to stand still holding a retractor for more than 30 minutes. My team seems to do a lot of Whipples. A Whipple is 6-8 hours long. My goal is to avoid the Whipple at all costs.

5. I am lucky to leave here at 6pm. That's a bloody long day.

Surgery Pros:
1. It's not anaesthesia.

Surgery wins.