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.