Hurricane Jill

Living well

Today I got to do my first case of the month. It was pretty simple, just an umbilical hernia. But since I’d never even seen one done before it was all new to me. The chief had text-paged me the evening before to tell me about the case, so I was at least able to find one resource to explain the procedure stepwise. But I didn’t write the steps down, and I’ll have to remember to do that next time. And I need to find a better book for a reference, because the one I looked at seemed pretty sketchy on the details. Although maybe it’s such a basic procedure, the authors found it too boring to write much about.

Still it was a nice case for someone at my level, and I’m proud to say that there was very little bleeding. Until the attending scrubbed in, that is, and promptly nicked an arteriole. It’s possible he did it on purpose, just to see if I know how to ligate an artery intraoperatively (and, um, now I do). But it was still pretty funny. We closed the incision with a subcuticular stitch, which I find very satisfying because the end result is so neat and pretty. Usually. Today the ends gaped a little bit and I wasn’t happy with my work. But it wasn’t awful, and we fixed it with the steri-strips. The chief booked the room for 2.5 hours for the case, and we were done in about half that time. Which is still probably twice as long as that procedure ought to take.

The R3 on my service is a Tulane grad. I didn’t know him as a student, and the Tulane I attended was a very different school, so there’s not a lot of fond reminiscing about good old Tulane Med going on. Not to mention that his job is to make sure I’m doing mine thoroughly, which at the moment doesn’t make for much positive interaction.

Still, I’m finding that I really do like surgery, even when the days are long and grueling. I can’t imagine doing anything else. And contrary to what I thought as I went through the match last year, general surgery is actually pretty cool. Although I’d still take brains over guts any day.

Thanks to all the nurses who DIDN’T page me last night

Or perhaps that’s nurse, singular.

Run, little hamster, run!

Seriously. I gotta take my game up a notch, or I’ll never make it on this rotation. It reminds of back when I started med school–it seemed so doable for a few weeks there, and then wham! the first test. Which fortunately was worth only 5% of our grade, but which the professor would knock down to 2 or 3 percent if you did poorly on that one test and then got your act together for the rest of the semester.

I think it took me most of that year to find study habits that worked for me, but eventually I did.

But I’m learning a lot, so I guess that’s good. However it would be so much easier to keep track of things if we didn’t have four different computer systems, or if any one of them were actually in full communication with the other three. The system seems designed to maximize the likelihood of missing something … soooooooo frustrating.

And the one system that’s truly cool is reserved for the radiologists. They have this voice-recognition transcription program that’s truly awe-inspiring. They talk into a microphone, and their words show up immediately onscreen. So they can edit either by voice or by keyboard. That would be so cool.

Mistakes I made, and bigger ones I didn’t

Hooray for the end of a difficult week. I was on night shift all week, which is a rough shift mostly because no one’s around and if you want help, you have to wake someone up to ask for it.

Even though I made a pretty serious mistake early in the week, the patient’s subsequent hospital course made it clear that doing the “right” thing might not have been right either. There was more going on than just a burn, and over the week we’ve gradually been sorting out her other problems. Right now she’s plateauing, and she’ll probably turn around in the next couple of days.

And we lost a patient unexpectedly this week, which was a shock to all involved. He had been on the upswing for the last couple of weeks, and looked great that morning at signout. But that evening I returned to find a full scale code going on in his room. We actually got his heart to work again, but his other organs were too damaged for him to survive, and he died later that evening. I had to write his death summary, another first for me. We searched his records and our memories for anything we did (or didn’t do) that might have caused his death, and found nothing. No: if there’s blame to be assigned for that, it belongs elsewhere.

On the flip side, I’m getting a little more efficient.

However, it still seems like I’m spending all my time at work. When I’m home, I’m too tired to do much but eat, sleep and do laundry. We have a practice ABSITE coming up in a week or two, and I’ll be surprised if I do anything but poorly on it.

Periodically I remember that my personal life is still in shambles, and it makes me sad. But then I’m kind of glad to have some clarity at last. And that I’m as far away as one can be and still be in the continental United States. And that I’m too busy to think much more about it than that.

It wasn’t clear to me whether I was seeing integrity or cowardice, but now the excuses are stripped away, and I know. Cowards are cowards, whether you live next door or on the other side of the globe, and it’s stupid to sacrifice something so huge for someone who only cares, in the end, about his own image.

Disorganized? Really?

{insert long string of cursing} I simply canNOT win, no matter what I do. So last night I was feeling a bit shellshocked after yesterday morning, and second guessing myself on even the stupidest of things. Fortunately it was a relatively quiet night for most of the night, which is good because part of my job on nights is to write the notes for the ICU patients, and I’m drawing on experience from practically a decade ago (i.e. on the job self-education as an ICU pharmacist) to try and figure out a plan each morning. And this week we have 6-7 ICU patients–two more than we’ve had any other week this rotation. It’s barely doable on a quiet night like last night, and seriously overwhelming on a busy night like the one before.

I suspect it’s mostly the BS skills that are killing me, because I get criticized for things that seem to go unnoticed in others.

The other thing I’m having trouble with is the requirement that if we’re not absolutely certain of what to do, that we should ask. If I followed that tenet, I would never make an independent decision. I would be calling about every single thing, and I’d never learn anything, because at most I’m 90% certain of my decisions. So what I do instead is try to figure out what harm would result if I’m wrong, and if it’s anything nontrivial, I ask. If not, I do what seems right in the situation.

The problem is that one of the people who provide backup for us overnight and on call has an extremely low tolerance for independent problem solving at any level, while the rest of them don’t want to be called unless it’s important. It’s really driving me nuts.

But as I said, it was quiet last night until about 4am, when I started getting calls about various small issues. Then at 5am (an hour before signout), all at once I got called about an ICU admit in the ER, increasing signs of compartment syndrome in a patient I’d been called about by the primary team but specifically told was NOT a formal consult, excessive pain in a postop hand patient (must go see, because it’s compartment syndrome until proven otherwise), and a stellate lac in the ER. Any one of these things could take anywhere from 15 minutes to an hour to handle, depending on what’s actually happening. And I know I’m going to endure the wrath of my R3 if I don’t have the list updated and printed by 6am-a task that takes 15-20 minutes by itself to do in the particular way she likes it.

So here’s how I dealt with it: went to see the postop patient on the way down to the ER, no evidence of neurovascular compromise, so I increased the pain meds. In the ER, I examined the patient, quickly looked over the documentation, called my backup person for that service who asked me to write admitting orders. Called my backup for the other service as I was writing orders for the ICU pt, to explain the situation with the non-consult. That person asked me to call ortho hand about it. Paged ortho hand, got no response, was told the second call for ortho was in the ER so went to talk to him. By now it’s 5:30 and I have to go upstairs and print out the lists for everyone on the service. So I told the doctor managing the lac patient that someone would be down after rounds to suture it–either myself or the day intern. Then I went upstairs to update the list to include these patients and print it out. The nurses had gone down to bring the patient up to the floor, and were told by the ER staff that no admitting orders had been written. I had put them exactly where I was supposed to, so I called to tell them, and of course they were found immediately. But it nonetheless delayed the patient’s arrival on the floor.

Yet on rounds I got taken to task about not knowing more about the new patient than the very basic details. The patient was unable to give a history, and the ER people had none to give me–only the stack of paperwork to wade through, at a point where I had limited time to do so.

It’s just very frustrating to get blamed for not finishing my work when I really don’t think anyone could have in that situation. I felt like I prioritized appropriately, and yet that doesn’t seem to matter.

Oh well, at least the lac I sutured looks fabulous.

Too much thinking, not enough suturing

Oh…bad day, bad day, bad day. It’s a fine line between catastrophic and potentially catastrophic, but hooray for its existence. And all those people who keep second-guessing me on every little thing, where were they when I was actually wrong? I mean what’s the point of having a safety net if it only saves you from mistakes that won’t really hurt anyone? Not that there’s anyone to blame other than me. But still.

At least I do a decent job of consenting patients for surgery. And I did get a chance to do a two-layer closure on a stellate lac using a nifty triangular stitch in the middle. Took me forever but it was beautiful when it was done. Too bad it was on a guy.

Getting a little more efficient

So this past call day was a little better. I’m getting the hang of how things work, so even though I had about 9 consults in the ER, resulting in 8 admissions and one transfer from MICU, it wasn’t the nightmarish experience it would have been last weekend.

For some reason I had the idea that there would be less paperwork on surgery than medicine, but so far it doesn’t seem like it. I cover three services this rotation, and the R3 is chief of one and senior for the other two, each of which has its own chief. There are three sets of attendings involved. So it’s administratively a complicated service.

I did 6 or 7 admission H&P’s (my senior did the two ICU admissions), 8 or 9 sets of admitting orders (including the ICU patients), daily notes on all 6 ICU patients, the plastics service and the 5 or so admits who came in before midnight, one transfer summary and 4 discharges. Electronic medical records are nifty, but not any faster than good old pen and ink. Although more readable, I guess.

The transfer summary was for a patient with new onset crushing substernal chest pain. I was all over that for about 10 minutes with the nitro and oxygen, etc., when I suddenly realized that I don’t have to deal with this particular problem. As my chief for that service said, “we’re surgeons; she needs a real doctor. Call cardiology.” So then cardiology came by, scouted out the situation, decided it probably wasn’t cardiac, and called the MICU cavalry. After much discussion and differential generation based on her many common and uncommon comorbidities, they agreed to take her on their service.

Personally, I think the most therapeutic thing they did was move her to another room.

Later that day I ran into another pharmacy person, who asked me if I used to wear glasses. I said yes, although I haven’t for the last 8 or 9 years, and he met me 5 years ago. Surely I don’t look that different?

And all night long, the nurses kept calling me about various abnormal lab values on ICU patients. They’d ask me what I want to do, and I’d hem and haw and end up doing some piddling thing and asking them to recheck. Meanwhile I go look up the patient’s results on the computer, and find out that every single value for the last couple days has been similarly abnormal. Now that just pisses me off, when people call and act like the sky is falling when they know full well that it’s not.

The following morning, I walked in on one nurse talking to another about how she thinks I don’t know what I’m doing, because I wouldn’t give a patient with a low hematocrit a blood transfusion. I told her that if she liked, I would ask my senior about it. So I did, and the answer was no, the patient didn’t need a transfusion. Now, she may very well be right, that I don’t know what I’m doing. But in that particular situation, I did.

So I managed the service mostly on my own, and nobody died. Only one patient even decompensated, and I was immediately at the bedside, and notified my senior ASAP.

Although when people call me Dr. ____, I still look closely to see if they’re just being sarcastic.

There’s no crying in surgery

Sunday was my first real call day. It seemed incredibly busy, although I know that it’s largely due to my own inefficiency. It was the same way in retail pharmacy: when I started out, everything seemed to take so much time, and I got bogged down in work so easily. I would walk in to take over from the other more experienced pharmacist, who was usually standing around, caught up and calm, then ten minutes into my shift it would turn into a madhouse. Or I would start the day and it would be crazy, and then the other pharmacist would come in and clean up my mess almost before I walked out the door. After a bit, I got to the point where if it was crazy when the other pharmacist got there, then it took both of us working full speed for an hour or two to catch up. But it was a good year or so before I could consistently handle whatever got thrown at me, and know how much time it would take me to do each task so that I could get it all done in a timely manner without delaying any particular task to the point where it would be a problem.

It’s pretty safe to say I am not at that point as a resident.

In fact, leaving aside all my patient care duties, there were a number of small errands I had planned to do and never got to at all. Since I can’t say much about the patients, I thought I’d include that list to give some indication of how busy I was:
1. I carried two letters around in my pocket the entire time, and never mailed them. I know exactly where the mail room is at the hospital, but I could never get over there to do it.
2. I left my call bag out in my car, and everytime I thought about going to get it, there was something else I had to do first. I never did manage to go get it.
3. I had planned to call the outpatient pharmacy and transfer my anti-inflammatory meds there, and get them filled. It never happened. And I was out of my main one, so I just went without. I did call them to ask a question about discharge paperwork, though. The other two were out in the call bag, so I ended up not taking those either. I’ve been off prednisone since February, so being off schedule with my medications is not nearly the huge deal it used to be.
4. I had intended to change scrubs at some point while I was on call. I didn’t have quarters to do laundry beforehand, so I wore a pair I’d worn earlier in the week. However, this To-Do item was less important than sleeping, and I never even came close to doing that, so…
5. I had to pee pretty badly for a number of hours before I finally got a chance to. It’s always a balancing act between “how badly do I need to pee?” vs. “how badly does X need to get done?” It seems I never have to pee quite as bad as that. Not to mention that I’m a little leery of using public-access restrooms at county hospitals.

I did manage to eat lunch and dinner on Sunday, and I had some SweetTarts in the ER early Monday morning. But breakfast is my favorite meal of the day, and I missed it both days.

When I left the hospital this morning, I was seriously questioning my career choice. I was tired, punchy, and I ached all over. And I was frustrated by all the conflicting demands on my time throughout the day and night. I’m still in it, though. Not because I’ve come to any profound philosophical conclusion in the meantime. But I’ve slept, and gotten my prescriptions filled, and mailed my letters. And I have quarters, now. So I’m good for another day at least.

The thing I really worry about is the fact that I hate to see people suffer. I’m profoundly reluctant to do things that I know will cause pain, and I absolutely have to get over that or I can’t be a surgeon. At the very least, I have to be able to ignore my discomfort over causing the patient short-term pain for their long-term benefit. Theoretically, I get it. But it’s difficult to remember when you’re causing the patient severe pain right then and there. On the one hand, I hope I never really get over it. But on the other hand, I can’t allow myself to be incapacitated by empathy.

Still better than being a student

Finally my desktop computer is up and running. I repacked my car in Houston and ended up leaving the monitor behind unintentionally. It actually arrived last week, but package delivery seems a bit problematic at my new apartment. Plus my brother sent it with signature required, and I’m never home to sign. So I ended up driving out to Redmond where the UPS package pickup place is. It’s quite a drive.

Then it sat in my trunk for a couple of days until I finally set it up last night.

I’ve been working off my laptop for the better part of a year. I had taken my desktop with me to my mom’s house when I drove to Phoenix back in August, because I didn’t want it sitting in my empty apartment for two months just asking to be stolen. Then my plans changed practically weekly throughout the rest of the year, and I never was able to go get it.

Anyway, it’s a relief to have it back. I’d forgotten how much I missed my iTunes, and the songs on my iPod were getting old. Not to mention that the browser has all my important bookmarks.

Yesterday was easily the most exhausting day I’ve had so far. Just page after page after page all freakin’ day. I’m not kidding–I’d be on the phone answering one page when I’d get another, and I spent easily half my day in page/call back/get-paged-elsewhere-during-the-call mode. It was completely nuts. And right now I have a low threshold for going to see the patient, so very frequently I’d be on the way to go see one, and get sidetracked by another page or three en route.

So here I was, barely managing to keep up with my pages, and at 6:10pm (when I’ve been “off duty” for 10 minutes) I get a page from the floor. I call back, and the nurse tells me that they’ve been paging me all day through the operator, with no response, and that she finally looked at a chart signature of mine to get my actual pager number, and called that instead.

This annoys me, not because she called me after hours, but because I specifically called the page operators on Monday to give them all my pager number for 6a-6p calls and my fellow intern’s # for 6p-6a calls this week. So those pages should have been coming to me and they weren’t. However, I’m not sure I could have handled more pages than I got.

They actually page me less than they need to: whenever I call, there’s always a line of two or three to talk to. So when I got this particular page, I went and took care of the issue, and made sure before I left that they put my fellow intern’s number up on the board for the rest of the evening. I got one more page before I left, to I&D a boil in the ER. As satisfying as that would have been after a long day of scut, I passed on the task to my fellow intern, who I’m sure would enjoy it as well. I feel pretty OK leaving him stuff he likes to do, if I absolutely have to sign something out.

I did get chided yesterday for not utilizing help when it was offered, but really, who wants to be labeled the “weak intern?” Not me, and certainly none of my fellow interns.

Anyway, that’s it for my week as the day ICU/floor intern. I did learn a little bit about managing sepsis, and a lot about managing time and nursing calls (thought it may not be apparent yet). I may also have to retract my statement about how it’s harder to be the night intern than the day person, but we’ll see the week after next when I’m on night duty.

The fine line between nice and spineless

I did some things right today. The first was to decline to give a medication that initially seemed to be the right choice for a semi-crashing patient (it would have made thing worse). The second was to push for an antibiotic change on a patient who appeared to be fine on his prior regimen (he improved dramatically within hours). The third was to make an overly-dependent patient do things himself. The fourth was to decline to leave the time off a restraint order (I would have been off duty at the time it went into effect, and this patient’s records may be examined very closely sometime in the future, so that needs no explanation).

In each situation it would certainly have been easier to go with the flow. Plus, I like these people, and it’s always hard to disagree with people I like. Especially when they surely know more than I do. But that’s why we get so much training in the first place–so we can know when it’s OK to go with someone else’s suggestion, and when we need to think it through a little more and/or ask for help.

Now, that’s not to say that I did everything right today, because I most certainly didn’t. But at least with regard to patient care, I didn’t make any huge mistakes.

AND, I got all my work done today before signout. Now that’s an accomplishment.

That’s how I roll, yo (klunk, klunk, klunk…)

Alright, so I didn’t suck quite as much today. Or at least, I got more accomplished. Whether or not I sucked any less is up for debate. Two admits, three signoffs, wound rounds, and two of the three ICU daily notes, one transfer from ICU to the floor, a teaching conference, some heavy duty list maintenance, and whole host of random calls about patients with various issues. I could get more done if checked fewer things with my seniors, but I’m still seeing a lot of new things and it wouldn’t be a good idea to fly solo on very much of it.

Also I need to get better and faster with dictating. I keep hoping that the transcription people will take pity on me and organize my disjointed reports into something less idiotic-sounding. But I know that’s not their job. I dictated one H&P today, and when I got the transcript, I ended up rewriting half of it anyway. So I might as well have just typed it to begin with. Thank God we can at least correct things on the computer now, instead of having to stick with the original document and make corrections in pen.

There’s sooooo much inertia in the system, and with any given patient it can either grind to a halt or run out of control so easily. It’s tough to figure out just how much effort is needed to keep each admission rolling smoothly through the hospital and out the door at the appropriate time, while still maintaining enough control to stop and change course if necessary.

My goal right now is just to be a little better each day. If I can keep that up, then surely by the end I’ll be competent at all these intern-level tasks. Or at least, I’ll have built a passable facade over the Vast Knowledge Vacuum.

I suck at this.

Ugh! I’m so frustrated with myself today. It was my first day as the ICU intern, and I can’t stand how tentative I am about everything. It’s like I can’t quite get my act together enough to look competent. Between the stuff I know I’m supposed to know and don’t, and the stuff I don’t even know I’m supposed to know, I forget to present the big picture, and get lost in the details. Or I have too much big picture and not enough details. And I’m not slick enough to hide my incompetence behind a facade of big words and literature citations.

Although I’d like to point out the fact that no one has actually said anything demeaning or derogatory to me about my Vast Knowledge Vacuum (VKV, for short–no doubt I’ll be referring to it numerous times throughout this year). And that’s the thing: it’s completely unnecessary. The feeling of inadequacy is shameful enough all by itself. I think if someone were mean to me about it, all that would do is give me an excuse to turn my anger outward instead of using it as motivation to improve.

Nobody gets this far without some kind of intense internal drive to do things well and correctly. And that’s not something you want to subvert by externalizing it.

Anyway, it was a rough day. Not only did we have a very sick patient in the ICU, but it was a pediatric patient. And I just wasn’t prepared to handle a septic, desquamating pediatric ICU patient. At all. Especially on my first day in the unit. So my senior had to take over. And the attending spent an hour or two at the bedside as well.

Reading that makes me feel a little better: it was an attending level crisis, after all. But still. I was so thrown off my game that, down in the ER seeing a new patient, I nearly introduced myself as a medical student. I certainly felt like one at that point. Now that’s bad. I didn’t even feel like a medical student when I was a medical student.

It also made me feel a little better to find out that the other intern hadn’t gotten his assigned tasks finished that day either. He had to sign out a consent to the night intern. But still…I will be on top of things tomorrow if it kills me.