On the distal side of the line

October 19, 2009 at 10:47 pm | Posted in Uncategorized | 3 Comments

It’s a rum and coke night tonight.  Except I’ve already drank as much as my puny tolerance will allow on a worknight.  Which was about a quarter of a shot.

I have this bottle of dark rum that I bought in Nicaragua (6 and a half years ago), and it’s hardly been touched.  In fact, it sat on my kitchen counter entirely untouched for 5 years.  And then came the Scramble last year.  After which it seemed a fitting time to break it open and have a glass.  I figure when people tell me to go have a drink, I’ve probably crossed over from the simply crappy to the truly craptastic, and a little lidocaine for the psyche is in order.

Today was one of those kinds of days.  Although now I’m just drinking plain diet coke again.

I’m not sure where to start with today’s events.  But I’m going to be a little more frank than usual.  I blame the alcohol.  It’s possible that I drank the alcohol in order to blame it, but nonetheless that’s my story and I’m sticking to it.

First of all, there were plenty of people around, but no one to whom I could actually delegate any real work.  We had an ER resident, who’s not allowed to consent anyone and can’t do any of the procedures that needed doing today.  We also had a new foreign medical grad, who also couldn’t do any of the things that needed to be done, couldn’t even write orders because she wasn’t in the system yet, and in addition to that kept asking me if there was anything she could do to help.  Which is twice as annoying when the person asking obviously can’t. We had one extra resident today, who showed up to run the list in the morning and then disappeared without doing any work.  This particular resident is a master at avoiding work and evading responsibility for it.  Although no one actually trusts anything this resident says, anyway.

I think that’s what bothers me most about this program.  The residents are not a team.  With a few notable exceptions, everyone is out for him- or herself.  No one has your back, not even the chief.  You would think that such difficult-to-please attendings as we have here would inspire a sense of camaraderie amongst the residents.  But it seems to do the opposite.

But getting back to today.  At about 1:30 I was trying to get some hemostasis on our new patient’s scalp wound when I got a spray of lidocaine, epinephrine and arterial blood right into my eye.  Body fluid exposures are frankly a pain in the ass, and I had too much to do to deal with one today.

But I’ve worked in health care nearly all of my life, and the two things that have been pounded into my head year after year are handwashing and the importance of reporting all accidents, mistakes and occupational exposures.  Plus, who can really be sure that this patient doesn’t have HIV or hepatitis? And it didn’t help that my eye actually hurt and I was developing a splitting headache.

And of course, just as I’m getting ready to head over to the Occupational Health clinic, I get a consult for an operative subdural in the ER.  Damn it.  I’m sitting there thinking, do I operate today, or do I get post-exposure prophylaxis and ensure that I can operate 10 years from now?  I wouldn’t be able to do both.  So I saw the consult, got the patient on their way to the OR, and headed over to Occupational Health.  No sooner was I back than one of the attendings sent some random person over to observe me do a neurological exam on a patient.  Then it was 4:30 and the chief wanted to run the list with everyone.  This took an hour, between rounding everyone up, updating the list, and then actually going through the patients.  No one was even consented yet for any of the procedures that needed to be done.  So I was in the middle of doing that when I got a call from one of the attendings asking me why the procedure hadn’t been done on their patient yet.

Well, not really asking.  More like demanding to know what I’d been doing, and telling me that what I had done instead was unacceptable.  Which, message-carrying ethos or not, is an indefensible statement coming from anyone in a position of authority in a hospital.  But it would have been counterproductive to point that out.  So I just quit talking, and instead listened quietly until the subject moved on to what ought to be done now to solve the problem.

The only good way I’ve found to deal with other people’s anger is just to let it flow around and past you like an ill wind.  It’s like walking out the door in Phoenix in the middle of summer.  All of a sudden there’s a burst of hot, dry, hellish air, and you just tolerate it for a little while until you get someplace air-conditioned again.  In fact, that’s exactly what I imagine in my mind’s eye as it happens.

Anyway, I ended up staying about three hours beyond signout in order to avoid dumping most of the work onto the on-call resident.

You know, the other thing this program needs is a more structured way of bringing people along from the knowledge level of a med student to that of a PGY-3.  They really haven’t had to do that with the vast majority of their residents, but it’s the kind of thing that programs who routinely match AMGs straight out of school obviously have to do, and seem to do well enough.

Then again, they use a lot of AANS materials here that I don’t have access to because I’m not officially a resident.  So maybe that’s where the teaching is.