Hurricane Jill

After the storm

I am inexplicably happy this evening, and I can’t figure out why. There are so many reasons NOT to be happy today: I was in clinic all day, I still don’t have a job next year and I can’t get anyone to even answer my emails about finding one. I hardly ever see the sun, and I haven’t swam in weeks. And there’s certainly no new man in my life to explain it.

Nonetheless.

Maybe it had something to do with scrubbing in on a pericardial window this evening, which I’d never seen before. Or maybe it’s because I finally found a set of gloves that fit my arachnodactylic hands, and it was instantly ten times easier to tie knots. Or maybe it’s just that I have the weekend off.

I’m basically a happy person, and have been all my life. There has to be a lot of shit going on to get me down. Which means there’s been an awful lot of it these last few years, because it’s been a while since the balance tipped toward the happy side when I wasn’t on a neurosurgery rotation.

So I can’t explain it–I just feel like my old self again. And boy did I miss me.

And counting

20 days plus two weekend calls left of internship. Onward to vascular and thoracic surgery.

Damn you, Camus

Ugh! I’m sick today. Actually I was sick yesterday too, but I was on call. And I was still ambulatory and mostly functional, so in I went.

The elevators at my hospital have these signs saying to stay home when you’re sick. I look at them every day and try to remember what it’s like to have the luxury of doing that. Then yesterday it occurred to me that clearly the rest of the hospital is not running at maximum efficiency, if they can spare people like that. We, on the other hand, are the pack animals without which patient care would grind to a halt. We don’t chart the course, we just carry the load. So even a lame pack animal is better than none at all.

It also occurred to me yesterday that it really doesn’t matter how good an intern you are. If you carry the load from point A to point B (i.e. July to July) without it crushing you, then you’ve succeeded. Even if you’re the best intern in the world, the patients keep coming, the bureaucracy gets more elaborate on a daily basis, and it’s always your fault when something goes wrong. And even if it’s someone else’s fault, you’re the one who’s supposed to go the extra mile to make up for it.

Dear lungs:

You are the only reason my patients ever die. Please cease and desist from all activities which detract from your primary duty of oxygenating blood and excreting the acidic end products of glucose breakdown.

Sincerely,

Your patient’s intern

Oh my God I’m so sick of dealing with anything non-neurological. I seriously don’t know how I’m going to make it through two and a half more weeks of this. Not to mention that it’s killing my good record for not readmitting patients to the ICU.

I have two patients who keep getting better, then worse, then better, and so on. There were three, but over the last three days, each of them has successively crashed, and yesterday one had to be readmitted to the ICU. He was within a day or two of discharge, and we had consulted ID for recs on outpatient antibiotic therapy. The ID service had requested a thoracentesis on the guy’s pleural effusion, to make sure it wasn’t an untreated source of infection. I’m a little pissed off that they even asked for it, because clearly the guy was clinically improving, and we were asking them for simple recs on an infection we had already identified and were evidently treating appropriately. We were not asking them to go hunting for an occult infection, nor was there any indication to do so. But we can’t ignore a request like that, when the guy clearly does have a pleural effusion that hadn’t been fully investigated.

So our chief did it, and the patient was fine immediately after the procedure. But then an hour later I went to check on him and found him in respiratory distress. Paged the chief, called a rapid response, recruited a couple of nurses for vitals, O2 and an EKG, and got set up for an ABG. He was tachycardic and tachypneic, but with palpable radial pulses. He’d gotten his post-thoracentesis chest x-ray moments before I arrived, which looked like a pneumothorax but not a tension pneumo. Most of the lower lung fields were whited out, a big change in comparison to the pre-thoracentesis image. He obviously needed a chest tube, but what kind and where to place it was not clear. So I called the radiologist, and he read it as a hydropneumothorax. I’m sure I could have placed it myself, but at this hospital chest tubes are the province of thoracic surgery. But they were busy, so the R2 ended up putting it in. Initial output was about a liter, and his hematocrit dropped significantly, so he went to the ICU for closer monitoring. I was so pissed off at the whole ridiculous sequence of events. One stupid, overly cautious consult rec, and now the guy has to spend an extra two weeks in the hospital.

Not to mention that, this entire year, I’ve never walked in on a patient that sick who wasn’t already being tended to by the nurse or the rapid response team. Seriously, if I hadn’t happened to walk in right then, that guy would likely have died before anyone else came in to check. And what’s up with getting a chest x-ray just moments before? How can you come in, blithely shoot your x-ray (for which, by the way, you have to ask the patient to take a deep breath), and leave without noticing that the patient looks like he’s asphyxiating? This guy’s distress was so obvious that it needed no medical training whatsoever to see.

Ironically, the very fact that I’ve never had to deal with this before as an intern is a testament to how good the hospitals are at which I work. But I was still pretty shaken by the whole series of events.

I remember vividly the last time I had a patient get that sick on me. I was a third year med student, on my medicine rotation at the VA. It was a spinal cord injury patient who had come in for shortness of breath. We worked him up in the ER and found post-obstructive pneumonia from advanced lung cancer, previously undiagnosed. The guy had been a nonsmoker all his life. A couple days into his hospital stay, I had promised him I would come talk to him about what was going on. There had been some discussion that day about making him DNAR, but no paperwork had been filled out. I had forgotten to stop by that afternoon before going home, but it had been impressed upon us the importance of keeping the promises we make to patients. Plus, the guy was dying, and had been such a shit to his family that they refused to have anything to do with him no matter how he’d turned his life around. I mean, can you think of a worse way to die?

So I came back after dinner to talk to him, thinking I would just sneak in and out to keep my promise without making the other students look like slackers. But I found him in respiratory distress with an O2 sat in the 60’s. He already knew his diagnosis was terminal, so I asked him if he wanted me to try and do everything possible to help him live right now, and he nodded. So I checked the chart for DNAR paperwork, and finding none, went to get the nurse to call a code. He died in the code, and the senior resident wasn’t too happy that I had called one, since his diagnosis was terminal. Not to mention, what the hell was I doing at the hospital at nine o’clock at night when I wasn’t on call? My explanation sounded unbelievably lame, even to me. I could just hear them all thinking “what a f-ing gunner.”

Except I’m pretty much the opposite of a gunner: I try not to look like I’m working harder than the other people in my group, while still getting all my work done thoroughly and well. But that whole medicine rotation, my patient list was like a cancer ward. Plus I had a bunch of super-complicated patients with obscure diagnoses. Meanwhile my fellow students’ patients were all pretty much SNF candidates, waiting on placement. It’s funny how the luck of the draw (which it totally was) can still lead to such a skewed distribution.

So I had a few patients die on that rotation. But it’s funny, I never cried over a patient’s actual death. I only cried about the things we did wrong that hastened it. Which I guess is a good thing in a neurosurgeon. There’s too much death to function adequately, if you find even inevitable death seriously disturbing. But it should be very upsetting to have made it happen sooner.

In other news, I have an interview back in hurricane country next week. It’s a solid program with pretty much all the things I’m looking for, so hopefully they’ll offer me the spot. The one intern there that I know from the trail is a good guy. But it’s literally the opposite corner of the country from here, so I’m spending twelve plus hours traveling for five or so hours of interviewing. Kind of crazy.

If I don’t end up getting that position, it’s unclear what I’ll be doing next year. What I had thought was a solid backup plan is no longer a sure thing. 47 more days to figure it out.

Can’t stop the clock

53 days of internship remaining…

Back on General Surgery this month. The first day on service was incredibly painful. Not only was I taking over for an intern who was actually a mostly-trained general surgeon in another country (and thus finds everything in general surgery easy and straightforward, unlike me), but I also had a schedule that day which literally required me to be in two places at once for most of the day.

In any event, things calmed down after the first day. Part of the problem was that I’d never really had to pre-round on a general surgery service since the point at which all the vitals and allied health notes were switched over to the new computer system. So the first day, I was completely unable to find large chunks of the info I was expected to have available on rounds. I know exactly where to find it on the old system, but that knowledge is now useless.

On a side note, it sucks to be an intern during your hospital’s changeover from one EMR system to another that’s completely different. You have to know all the details, and when they’re suddenly somewhere else, and buried in a non-physician-friendly format on a program that loads information slowly (this is a key point), patient care can easily be compromised.

The slow-loading program is what’s currently pissing me off. It takes twice as long as it should to collect the data I need in the morning, and most of my time is spent waiting for pages to load and display information. And the pages purporting to provide an “MD Summary” are frustratingly incomplete, superficial and completely un-tailored to the patient’s primary service. The programmers were clearly lacking sufficient breadth of physician input.

If it’s going to be that slow to load, there should be some way for me to create a tab for myself that automatically loads all the information I need, as a surgery intern, and allows me to add or delete things as my data collection needs change on various services and with various supervising residents and attendings. Man, if I could do that, I’d be Super-Intern. There would need to be a huge variety of things I could pull into my tab, and I’d have to be able to control the format to a reasonable extent, but I know it can be done. It’s just a matter of institutional will to make it happen.

Theoretically, it’s possible to do that with notes. But I find the process to be prohibitively difficult and the options on formatting and information retrieval limited. It’s OK for attendings, whose formatting needs don’t change every month. But for residents, and particularly interns, on whom the brunt of data gathering and documentation rests, it’s actually more efficient just to wait for the pages to load. Seriously.

Anyway, when I had initially looked at the schedule for this rotation, it appeared that I would be in clinic nearly every day. Thankfully, that has turned out not to be the case. I have dedicated clinic time on Tuesday and Friday afternoons, and occasional duties at other times when the load is particularly heavy. And the clinic I work is a vascular service, with an attending who mostly does research, and loves to teach.

So it’s not as bad as I expected. Although it seems that most of what I learned about vascular disease in medical school is wrong. I don’t know what kind of vascular program Tulane had–I don’t recall meeting any faculty who were vascular surgeons, but it’s possible I did and just forgot. I did see some truly horrendous vascular disease in New Orleans, but I don’t recall seeing any that had been surgically treated. It’s a real gap in my education, and the subject is interesting enough that some remediation is welcome at this point.

But the hospital I’m at is notorious for its bureaucracy, which makes any rotation here just that much more painful. The joke is that JCAHO ran screaming from the building when they came to accredit this hospital, because we have more policies, procedures and forms to fill out than even they want to deal with. And the internal culture is such that everyone seems more concerned about getting the proper form filled out than anything else related to patient care. Also, if you like having some autonomy as a junior, you won’t get it here. The sphincter tone is substantially higher at this hospital, no matter how competent a resident you are. I don’t know if patient care is any better, but the leash is definitely shorter. It’s kind of funny – I had more autonomy my first three months as an intern than I do now in my second to last.

I figure if I just pretend I’m a med student again–albeit one with order-writing authority and twice as many patients–I should get through this rotation without running afoul of anyone. I was frustrated then at not having authority to make even low-level intern decisions. That’s all I get to make on this service, so that should be just about right.

Anyway, in less than two months it’ll be all neurosurgery, all the time. So things are about to get a whole lot more interesting. And two rotations is nothing, compared to the eleven I’ve already done.