Dear lungs:

May 8, 2008 at 11:52 pm | Posted in internship | 2 Comments

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.