Hurricane Jill

Posting from my interview at Gigantic Hospital.  I’m still mystified as to why they’ve invited me to interview.  I must be their token outside applicant.   I hope not, though, because this interview is costing me a fortune. 

There is apparently no way to do this cheaply.  My lone cost savings was on the plane ticket, for which I spent a large portion of the miles I had accumulated from last interview season in order to avoid paying actual cash.  I was saving them for a rainy day, and well, it’s raining.

Anyway, this place is everything I’m looking for in a program.  I just hope I’m what they’re looking for in an applicant.

Progress

Another call night, another incremental gain in knowledge.  This time I can tell that there’s a difference.  Maybe no one else can, just yet.  But I know that two weeks ago, this past night would have had me rending garments and comtemplating the consequences of skulking away at 3am and never coming back.  (And before you pass judgment, we have a census that would support at least one additional resident every other year than the program currently is allowed.  Plus we are the critical care service for the neuro ICU, including the neurology patients, in addition to handling neurosurgical issues.  I like this, and I’m not complaining.  But it is more work, and more stuff for me to learn.)

But somehow it wasn’t that bad.  There were consults, there was power-paging by what seemed like the entire hospital while I was gowned and sterile for a line placement, and thus unable to answer.  And during which I was also completely abandoned by the patient’s nurse for at least 20 minutes.  Which is a fairly serious no-no of nursing, if I understand correctly.  That nurse was obviously hating her life last night, as she was saddled with two brand new, unstable patients, both of which needed tubes and lines and labs and scans galore.

And yet, all of those things got done.  Not quickly enough to make my senior happy with my work, but whatever.  There are some situations where you’re just never going to win, and it’s important to know when you’re in one.

There were a few things that didn’t get done, but then again, it’s not like I slept at all, or even ate a decent meal.  In fact, I’d been there 18 hours before I’d even had a chance to go to the bathroom.  And I’d had to go since that morning.

I’m waiting for the day when we ask some patient to ” show me two fingers!” and the patient flips us off with both hands.  It’s gonna happen someday, I just know it.

Anyway, I have one dictation left to do from today.  And unfortunately, I’ve just discovered that the hospital’s dictation system doesn’t recognize the keypad touch tones from my iPhone.  And I don’t have a landline, so I’m basically screwed until tomorrow morning.   But hey, there’s only one this time.

And most importantly, no one died last night.  In fact, nearly everyone is doing better this morning than they were yesterday.  And nobody chewed me out for any of the changes I made overnight (although this is partly because I’m overcautious now.)  But equally important, no one got mad at me for not making a change when one was needed, or not discussing it with someone senior to me.

I’m starting to think I might actually get the hang of this at some point.

My ego needs some fentanyl, stat

It’s been a long couple of weeks.  Longer because I stayed far later than normal a couple of times in order to learn some new things.  Like invasive line placement, a skill at which my lack of experience was apparently quite unexpected.  UW doesn’t give its interns much opportunity to place central lines or arterial lines.  But as it turns out, it’s not actually that difficult.

I’m not keeping very close track of my overall hours, since it really doesn’t matter.  But I think the schedule I’m on involves alternating 100- and 60-hour weeks.   Which isn’t bad, compared to what my schedule might have been like elsewhere.

Right now, I’ve got several very irksome problems:

1. It’s been over a year since I worked as a physician, and the mindset is completely different from that of a pharmacist.  Granted, it’s a better fit than pharmacy, but there’s still an adjustment to be made.  Another aspect of this is my habitual use of weasel words.  I got in all kinds of trouble in pharmacy school for making definite statements in response to drug-related questions.  And I remain persuaded that few things in medicine (or surgery) are truly black-and-white.  But there’s no Heisenberg principle in surgery.  Either it’s operative, or it isn’t.  And either you operated, or you didn’t.  There’s no shadow world where it may be either case in the future, or could be both at once.  So the weasel words have to go.
2. There’s also a huge difference between being a trainee and being a fully independent professional, legally responsible and expected to make my own decisions.  I’ve spent the last year making my own decisions, answerable only to my own conscience and a court of law.   It’s hard to regain the balance I had finally struck as an intern, between knowing when to simply do something I knew was correct, and knowing when to ask permission anyway.  So right now I’m getting very mixed messages on how I’m supposed to behave: I don’t run things past my seniors enough AND I’m not independent enough.
3. On top of this, there’s a lot of stuff I flat out still need to learn.
4. There’s also a lot of stuff I know, but can’t recall with enough facility at the moment due to the stress of all these other things I’m trying to get right.

So, you know, the going is a bit tough right now.  And there are some days when I understand why residents quit or transfer into other fields with such frequency.  It’s hard to face seven years of feeling like an idiot about some thing or other every day.  Much easier to break it up into smaller pieces, like a medicine residency and fellowship, where at least in the middle you get to feel like an almost-attending.

But I’m not going to be one of those people.  For one, I have an abnormally well-developed tolerance for delayed gratification.  And secondly, I can’t really picture myself doing anything else.  At least, nothing else that doesn’t require a residency that would make me go postal (integrated vascular spots are too scarce to be a realistic option).

And don’t even talk to me about ENT.  Blood, guts, vomit, stool, smushed brain: none of those bother me much.  Earwax, however, nauseates me to the point where I have to put the scope down and leave the room.  It makes no sense, but we all have our kryptonite, and that’s mine.

I’ve learned a lot already, in just three weeks.  And now I have this weekend free to do some actual book-learning.  Hopefully it’ll make the next two-week sprint a little less painful to my ego.

Ask the right question

I survived my first call.   There was one death on the service, an assault victim-turned-homicide for whom there was nothing we could have done.  And one ICU transfer that I’m not entirely sure was inevitable.  As far as I can tell, the rest of the patients were not worse off in the morning for the decisions I’d made overnight, although there were a couple of instances where I wasn’t able to defend myself adequately when put on the spot, though that doesn’t necessarily mean I was wrong.  The number of consults was about what you’d see on a light night in Seattle, but the process is far less streamlined here, so it seemed like a lot more work.  In fact, pretty much everything here seems take a lot more effort to get an acceptable result.

And then list is pretty long right now, which meant that there was a lot of work aside from the consults, and there were a couple of things that didn’t get done.  Which is never a happy thing to have to report in the morning.

And now I need to come up with a research project.  I was hoping that I’d be inspired by some case that came in while I was on call.  But frankly, the question that kept popping up in my head was, how many days is one’s life shortened by each overnight call?  Does it age you an extra week or so?  Or does it just feel like it ages you excessively, without actually doing so?

By far, though, the biggest surprise was how much energy I still had the next day.  I didn’t sleep, and yet physically I could have gone at least another full day.  Mentally, probably not.  But that has more to do with where I am on the learning curve with all this stuff than anything else.  In time, there’ll be fewer things I have to think my way through from scratch, and I’ll become physically exhausted well before I run out of gas mentally.

As an aside, that’s why I think hour limitations aren’t such a bad thing overall for interns, and why I don’t think they work as well for senior residents and chiefs.  People don’t usually make mistakes because of physical exhaustion.  They do so because they’re mentally exhausted.

I read recently that when asked how he would spend an hour, if that was all he had in which to come up with a way to save the world, Einstein said he would spend 55 minutes formulating the problem into a question, and only 5 minutes answering it.

Perhaps if we made that distinction between mental and physical exhaustion in our discussion of work hours vs learning vs patient safety, we might come up with better and more workable solutions for all aspects of the problem.

Cat juggling

Wow, a year away from surgery has done bad things to my stamina.  More mentally than physically, but both still need work.  Yesterday was only a twelve hour day, and yet by the end I could hardly think straight.  I’ll have to build it back up again, and quickly.

It was partly my sleep schedule, which had gotten way off kilter such that I woke up at 1am and couldn’t get back to sleep.  But even so, I shouldn’t have been that tired.  I think the real problem is that my cat thinks I’m a large toy when I’m asleep, and likes to pounce on my face and torso, claws extended, at random times throughout the night.  Which isn’t great for sleep quality.

I may have to kick her out of the room at night.  Or have her declawed so that I don’t have to be so hypervigilant about an accidental claw to the eye while I’m sleeping.  Declawing is probably the more humane option in this particular situation.  But God, from the reaction of the shelter people to the idea of declawing, it’s like you’re threatening to murder small children.  I mean, come on!  What’s crueler in the end, nightly isolation from her human in addition to all the hours I’m away in the day, or a one-time procedure under anesthesia to amputate the front claws of an entirely indoor cat?

Yes, I said amputate.  I know you people use the word as an emotional appeal, to evoke images of a barbaric and painful procedure.  But I’m a surgeon; I know exactly what it involves, and it’s no more barbaric than spaying when done correctly under anesthesia.  And make no mistake, we spay and neuter primarily for our benefit, to control the number of cats who become feral, and ensure that the population doesn’t exceed our ability to care for them.

Declawing is no different, in that it enables me to give her a better quality of life without jeopardizing my health and safety.  In any event, I don’t see a better solution at this time.

(Note: Actual cat juggling is wrong.  Also not funny, unlike Steve Martin’s stand up routine about it.)

Facepalm

Orientation is a necessary evil, I guess.  But really, how many times do I need a review of OSHA regulations and handwashing?  Or HIPAA?  Well, I’ll admit I haven’t had quite as many reviews of HIPAA.  But my training on its bastard cousin HIPPA has been so frequent that I now despair even about graduate and professional education here in the U.S.

So I entertained myself yesterday with a comparison of how different institutions emphasize different things in their orientations.   Where I was before, their main goal was to get everyone ready to work on Day 1.  So we got set up with pagers and chart access, scrubs and labcoats, door codes, dictation codes and cheat sheets, and lots of talks about what to expect on the service, professionalism, etc.

Here we did bloodborne pathogen training, basic network access but not chart access, nametags, insurance cards, work/life balance, ACGME competencies, the standard HIPAA {“HIPPA”} presentation, and had a discussion of appropriate prescribing practices.  But nothing in terms of getting what we need to do the actual work of a physician.  No chart access, no scrubs, no lab coat, no pager.

Fortunately I had some free time in the afternoon while everyone else was off getting oriented at a hospital where I won’t be rotating.  So I got all of that done.  But had that not been the case, I would have been woefully unprepared to work today.