we few, we happy few!

as you know, i have completed my sicu block. huuzzah! as with nearly everything else, in hindsight, it wasn't such a bad experience. it really wasn't too torturous when i was doing it. the call days were quite tough--there were times when i was managing 12 critically ill patients by myself. sound scary? it was. usually there was a sicu fellow in-house to help, but i had several call nights when it was just me. there is an attending there at all times as well, but this person covers the trauma service as well as so he/she spent a good deal of time in the operating room. this didn't make them inaccessible, since one could go down to the OR and talk to them, but that is tough to do when 3 or 4 bad things are happening on the 6th floor and the OR is on the 3rd floor; i can run fast, but not that fast.

it was certainly a stressful time--partly because of the threat of death as a result of my management, something that was totally new to me. i've been in the ICU before, and i've taken care of some pretty sick people in the ED before. but in those situations there was always someone more senior than i within a 50 meter radius. as i said, there were nights in the sicu when it was just me, 10 patients, 5 nurses, and an attending that was nowhere to be seen. not every decision was life-or-death, and not every patient was trying to die, but it's still a lot of pressure. what's more, not only did i have to worry about the ramifications of each choice i made for the patients, but i know that these choice would be scrutinized by the attending the next morning.

the latter happened every post-call day, occasionally with horrifying results. a little background first: the day in the sciu starts as sit-down rounds in a conference room. there are 2 sicu teams consisting of 2 attendings, 3 residents, and 2 sicu fellows. then there are a few PAs and APRNs who always work there, plus the pharmacist, the med students, the PA students, the pharmacy students. close to 20 people some days. each resident who was on-call the previous night presents a brief summary of the new patients as well as anything that happened with the old patients. there are probably 30-40 interventions completed by each resident per night, and each one of these represents a unique opportunity to have you judgment questioned (as best) or get reamed (at worst). at least, i thought that was the worst that could happen.

i was post-call one morning with an attending known for his volatility and his insistence that males always be cleanly shaven, including post-call days (yeah, right). i'd worked with him before and aside from some goof-natured sparring over the infrequent meetings between my face and a razor, we got along well. all of this was about to change. i will not re-create the entire story, but the general idea is that i made 2 decisions that he really didn't like. they weren't dangerous decisions, just actions that he himself would not have made (one of them involved giving 2 units of blood to a post-transplant patient after having been asked to do so by the transplant attending himself. dr a (for angry) had only wanted 1 unit. without getting into a debate about the risks, etc. of blood transfusions, i figured that the transplant surgeon owned that patient, so i should do what he said).

upon hearing about the 2 units of blood, dr a launched into a 5 minute tirade about my inability to follow direction, my incompetence, etc. i tried to interject at one point that it was not my own decision, but rather that of dr transplant, as which point he said "this is just unbelievable. i can't take it anymore." at which point he walked out of the room, leaving everyone quite stunned. it was the most public yet of my many humiliations.

in his defense, he later apologized. well, he didn't apologize per se--i think his ego does not allow him to acknowledge that he ever actually does anything wrong--but he did say that his anger towards me was not personally motivated. he didn't think i was a bad person, or stupid, etc., that my lack of knowledge given my level of training did not allow me to make such decisions in an appropriate manner. he then proceeded to tell me why he thought the 2 units were such a bad idea.

on the whole, while a bit startling, the experience was not all that bad. partly, i'm sure, because of my sleepless post-call stupor. the real reason is that after all the yelling (which was considerable) there was a good bit of teaching. he made an effort to make me see the patients condition differently and to consider multiple factors and options that i had theretofore not considered. that is to say, he spent some time teaching me, which i need and love. i can take cursing and irascibility as long as there is some effort, somewhere, to show me the error of my ways so that i don't make the same mistake again. failure to do so, in my opinion, is both mean and irresponsible since residency is a time to learn (which says nothing about the fact that it's just juvenile to yell at someone for doing something without telling them why what they did is wrong, how they can fix it, or what they should have done).

the latter is the style of dr rc ("r" for red face--she has one, and "c" for the giant cold-sore she had on her lower lip at which i spent a good amount of time intentionally staring. petty, i know, but i was powerless and abused and i needed some way to revolt).

in hindsight, she is probably the least-favorite attending that i have ever worked with. she spent most of rounds alternating between trying to establish blame for incorrect decisions and making me feel stupid. she never made an effort to teach. i would ask questions in an attempt to learn, and her responses were generally mean "you just got lucky," "did you even think about this patient before you did this?"and even occasionally insulting.

on my last day in the sicu i was on call and there were 2 very sick patients. one was a 30 year old who had been shot in the head and was dying and the other was a woman who had just had a liver transplant and was rejecting the liver. i sat up all night outside these 2 rooms talking constantly with the liver transplant team and the neurosurgery team. during rounds, while discussing one of these patients, she said "sam, just because it's your last day doesn't mean that you can forget about or neglect your patients." this was near the end of rounds so the condescension had been flowing for some time. in addition i had been awake for nearly 28 hours, had not eaten in 16 hours, and there is only so much ignominy i can handle quietly.

this comment put me over the edge; i was raging inside. calmly, however, i said " dr rc, i sat up all night with these patients doing the absolute best that i could. i was constantly on the phone with the transplant team, with neurosurgery, and even the overnight sicu attending. i can accept that i may not have done everything correctly or how you would have done it, but for you to imply that i ignored these patients because it was my last day here is insulting, and i will not accept that."

i think i was shaking when i finished speaking. there was a long and, you guessed it, awkward pause; no one spoke. fortunately, the transplant team arrived after about 20 seconds and broke the silence. the remainder of rounds was largely uneventful, although i'd guess a bit uncomfortable for everyone. after that, i went home and until now, i haven't thought about that day too much.

my fifteen minutes

i have successfully completed my tenure in the surgical intensive care unit. overall, it was a positive experience. despite the stress, icu months are always great in that one learns a lot--far more than in other rotations. before i conclude my narrative of said month, i'd like to share a few humorous moments from my current rotation--trauma surgery.

you may remember that i did a month on this same service during my intern year. it is a busy service, but it's not too bad being back there since i am no longer responsible for the intern-level nonsense. my duties this year include seeing and running the traumas that come to the ED. i also spend some time doing general surgery consults on inpatients. the point of EM residents being on this service, so we are told, is to get more experience evaluating and managing trauma patients, although based on my experience so far (2 days) i think the surgery department needs an extra body to help with the high patient load. said another way, they want me to do some of what i did last year. the problem with this is that the intern year trauma rotation was taken out of our curriculum after last year (ie, my class was the last class to be subjected to it) because it was felt to be lacking in educational value for EM residents. the solution was to have us rotate there during our 2nd year and get some actual trauma experience. so far, that hasn't really panned-out, although as i mentioned, i have only been there for 2 days so that may change. as it was last year, there is still too much work for the interns to do and not enough time in which to do it. i've have been helping out, which i am actually enjoying quite a but--much to my surprise. i like having the opportunity to teach and help out; i enjoy the feeling of contributing to the education of other residents and easing the onus of the trauma drudgery that i know so well.

enough of waxing sentimental. the point of the prior introduction was to relate something funny.

so, here goes: last thursday, october 15th, i had the honor of inserting my right index finger into the anus of a pulitzer prize winning author. i no longer remember his/her name, or the name of the work for which said prize was awarded; in fact, i didn't learn about it until after the handshake had taken place. but i suspect that there are not a lot of other people out there who have done the same (as an aside, i will mention that the finger in the anus is part of the head-to-toe exam that all all trauma patients receive).

humorous anecdote #2 comes in the form of a cautionary tale, as follows: it is not a good idea, while lighting the propane furnace in one's trailer-home, to be simultaneously be engaged in the enjoyment of a cigarette. unintentional explosions and fires may result.

"it was chilly inside so i decided it was time to start-up the furnace. i went outside and opened the gas line, then i came back in to light the pilot since the electric starter is busted. i got down on my knees in front of it and the next thing i remember was waking-up in the bedroom [15ft away, according to the husband] with the paramedics and firemen all over"

her husband, who was at home at the time but in another part of the trailer, informed us that just prior to attempting to light the furnace, she had come to him and asked for a newport from the fresh pack he had just opened.

obviously i cannot say exactly how and why the explosion occurred, and i have certainly perpetrated my share of boobery. however, the words "propane furnace" and "smoking" in close proximity to one another sets of numerous alarm-bells, at least in my mind. apparently this is not the case for all.

two hours after she arrived, i went home. i ran 5 miles, took a shower, and i could not rid myself of the smell of burned flesh and singed hair. i had nightmares last night as well.

CTD*

continuing with the thread from the previous posts, i herein provide an update on the condition of the unfortunate ms k.

i was on call last night, and she survived. when i left this morning at 11am, her blood pressure was 53/31 and additional medications were being started to augment it. not a positive indicator.

*circling the drain.

follow-up

continuing on the story from my last post, the meeting between the judge, the conservator, and the doctors occured today. not surprisingly, the outcome was not in the best interest of the patient, in my opinion. he decided that the "best" thing to do was to let the patient's daughter make the decision about changing the goal of care to comfort measures.

this is the same daughter who was been estranged from her mother for more than 10 years. in addition, the mother repeatedly stated, after admission, that she wanted her daugheter to be given no information about her condition, and have no role in any decisions. she lives in california and now we must start the process of trying to contact her, inform her of the situation, etc--this will take days, at best.

meanwhile, the patient is deteriorating: her liver failure is accelerating and now she has begun to bleed--from here nose, mouth, eyes, and IV sites. i doubt she will survive much longer, but i truly cannot see why she should be made to suffer. i cannot understand how a rational and pragmatic person, such as this judge should be, can make a decision like this, which is essentially consigning this woman to die a slow, prolnged death.

let's have bizarre celebrations

i currently spend my days toiling away in the SICU (i may return to earlier events later). one of my patients is a 78 year-old woman who has been in the hospital since may. she initially came in as a trauma--according to the ED chart she tried to kick a box of kleenex out of her way and lost her balance and fell. she broke several ribs. being on the older side, and with a few other medical problems, she subsequently developed pneumonia, then sepsis, and things have not gone well for her since then.

skip forward to september. she is still on a ventilator and there is difficulty weaning her. she also has a huge hiatal hernia (meaning her stomach is in her left chest cavity) which is felt to be a possible contributor to this problem, as the left lung is much compressed by her ample stomach. during the surgery to remove the stomach from the chest there was a colon injury, and she wound up with a colectomy and end-colostomy. this is major surgery for anyone, recovery can be slow and is not guaranteed, particularly if one has spent the preceding 3 months septic in an ICU.

where she stands now: she has had repeated episodes of sepsis, is on some serious antibiotics, and her wound is not healing well. in fact, about 7 days ago it fell apart--literally. the skin incision broke open, and a day after that a brown-green liquid--enteric contents, ie, shit--began leaking out her abdomen and mouth. her blood pressure remains low, despite 2 medications that artificially raise it. she makes almost no urine, and her liver is failing. we are doing everything we can for her, yet her condition deteriorates daily. she will never recover from this.

why, you ask, does this continue? where is her family? someone to make her comfort care only and end her suffering? she has none. she is estranged from her only daughter--something about a suicide of a boyfriend the daughter blames the mother for instigating. instead, the patient has a court appointed conservator who gets paid for every day that she spends in the hospital. it takes him three days to call back every time we try to get consent for another procedure. he wants us to do everything we can; shocking.

as i was falling asleep last night, i was thinking of her. no one should have to suffer like that. i was trying to think of ways that i could surreptitiously hasten her demise and not get caught, thereby ending her suffering.

of course i would never actually do this. i unequivically state that i have no intention whatsoever of attempting to harm this patient.

the most execrable part of this whole situation is not that i had this passing thought, but that a system has been set up that allows her conservator to financially benefit from his malfeasance (read, inaction) while her condition progresses to such a lurid extreme.

how embarassing

several days ago i included a factoid at the end of a post about the success rate of cpr on television shows. the numbers i quoted, were, in fact, incorrect. the correct data is as follows: the success rate for immediate return of circulation was 79%, and survival to discharge was 67%.

the prior post has been addended to reflect the knowledge of said error.

i sincerely regret the error.

yours &c.,

SC

side effects may include...

this is one of my favorite bits from the colbert report. the funniest stuff starts around the 2:15 mark.

watch me!

why do i have to be mr pink?

my, my, how time slips away. i was just looking back at my last post, which detailed the close of my intern year, and now here i am nearly 25% through my 2nd year. yikes. i'd like not to skip any of the wonderful experiences i've had, but it seems as though i just can't keep up. so now i will quickly summarize the end of my first year and the first few months of this year.

end of the year as an intern, orthopedics and back-up:

basically, during this month we are supposed to go to work from about noon until 8pm with the ED ortho consult resident. i think the goal is to learn basic management principles of orthopedic injuries and how to apply splints and casts. i say "think" because i'm only guessing what they want us to learn because i never actually went. not once. it was the end of a tough year and i needed some time to decompress. you only work with other residents so no one really knows if you are there or not--the ortho resident is usually very busy and my guess is that they don't really care if you are there or not. there was a little scare for me after the fact--apparently, part of this month was supposed to include a few afternoons in an outpatient ortho clinic. i actually didn't know this, so of course i didn't go (nor did 11 of 13 residents in my class, since they didn't know about it either). essentially, my program director asked me if i went and i told the truth, stating that i had not attended because i didn't know about it. i got scolded a little, was told to pay closer attention to the rotation requirements, and sent on my way. phew.

i also got called-in to work 3 shifts in the ED for back-up, meaning someone else called-in sick so they needed someone. that someone was me. not too bad to have to work 3 out of 28 days; plus, the residency now "owes" me 3 shifts, meaning that i get to work 3 fewer shifts this year in return for the 3 i worked this month.

what did i do with all my free time? i did a lot of pleasure reading, i got back in shape, lost 15 lbs, drank a lot of wine, and did lots of bike riding (i even won a race and brought home $200 dollars). all much more rewarding than splinting some broken bones (i should mention that i have done a good deal of splinting in my time as a resident, and am fairly adept at it, so i don't think i really missed any great opportunity).

exit intern year.
HOORAY!

2nd year, block 1: pediatric intensive care (PICU)


not such a bad month. it was pretty slow when i was there, so i generally had only 2-3 patients at a time. kids don't generally get that sick, so often (not always) kids get admitted to the PICU for higher-level nursing needs rather than because they are really sick (eg, frequent vital sign monitoring). this month also required being on-call every 4th night, which as an ED physician, i naturally eschew. i think that i slept at least 5 hours on each call night except 1, so on the whole, not so bad.

i learned a fair amount--largely due to the amount of reading i did during the slow call nights--including the fact that it is somewhat more sad when a child dies than when an adult dies. i also saw a good number of children with rare genetic disorders and bizarre deformations. there was a lot of stuff i had read about in medical school but never actually seen first-hand: rocker-bottom feet, dandy-walker syndrome, poly-dactyly, and cri-du-chat (yes, they really make a cat-like sound). this was both interesting and depressing.

the disappointing portion of this month was that there are no interns in the PICU, so i was left to do all the degrading intern-level work: pre-rounding, writing notes, making pointless phone calls, etc. wasn't this kind of thing supposed to have been completed last year? fortunately, given the low patient volume, there was not enough of this work to make it truly ignominous.


2nd year, block 2-4: ems, pediatric ED, surgical intensive care.

i'm in the SICU right now, and am on-call tomorrow, and every third night thereafter. egad. thus, there is not much time for ranting these days. but my goal is to churn out at least 1-2 malevolent soliloquies each week going forward. i'm cautiously optimistic about this goal, but we shall see.

to close, an interesting fact: a study published in the new england journal of medicine in the late 1990s found that on TV shows, the success rate for the immediate success of CPR was 67% and survival to discharge was 93%.**

**the above quoted numbers are incorrect; for the corrected data, please see the posting dated 3, october, 2009.