Tube and Lube

I just started my glorious new rotation of anesthesia/ultrasound.  My day consists of early awakenings and oh so early returns to the home base.  I still get up around 5:45am, which is not too dissimilar from my MICU mornings.  After some breakfast, reading email, and some highlights on the NYtimes, I drive to work around 6:30.  I'm only now getting into a routine in the anesthesiology department.  No one truly oversees you, which is good in the sense that you can make your day as long or short as you like.  However, there is most definitely the sense that you are a distraction to the regular flow of the OR.  I was recently told by a CRNA to go stand in the corner, which seemed entirely inappropriate given the nature of my rotation...to learn and act as part of the anesthesia team.  Clearly, this would be difficult to do with zero vantage point.  I dismissed it as a case of the Mondays (and perhaps a juvenile need to enforce authority over someone when you can get the chance) and got on with my day.  In the afternoons, I join the ultrasound team, which consists of our ultrasound director, ICU fellow, and another EM resident.  We scan away at any patient that is a potential appy, choley, AAA, pneumothorax, or any other interesting finding.  Ultrasound seems like an ingenious way to make procedures safer and give additional diagnostic information in little time.  In addition, to your potentially life-saving FAST exam for free fluid, there is the additional utility of a no radiation bedside tool.  It is another tool to make yourself independent of consultants that may delay the workup.  Of course at this stage I still feel like I couldn't grab the ultrasound on my own and make a definitive case for DVT or gallstones, but hopefully in a couple of weeks the skills will be sufficient.  For now, it is a laid back, enjoyable opportunity to learn without the responsibility of patient care as a distracter.

It has been odd not caring for my own patients during this rotation.  I feel liberated and yet surprisingly less purposeful.  It is almost as if by rendering away my patient care abilities, I've suddenly become more relaxed, but feel less good about my day.  However, it has helped me reconnect with family and my sense of humor.  I will not forget the drama of my last day in the MICU ending with the entirely appropriate comment by my fellow intern who I was orienting to her new rotation "What's wrong?  You look so upset."  It's hard not to be upset after witnessing a traumatic cric in a patient who was actually DNR/DNI and then getting the kickback by all the MICU nurses for allowing the patient to be admitted to our service despite a new (old) CMO decision made by the family.  What can I say!  I actually confronted the attending of this particular case today at conference immediately following a very a pro pos discussion on ethics and code decision making.  I got what seemed like a partial apology for my involvement in that case, but no admission on guilt in singlehandedly getting a patient to rebuke their code status when their situation was more than hopeless.  I suppose I need to learn to forgive and forget because there is no question I will be in the same situation some day soon.

MICU take home message

I just finished my last call in the MICU and I can say with certainty that I have found it both challenging, rewarding, and utterly exhausting emotionally and physically.  Challenging because I've done many procedures for the first time.  I did my first intubation on a nonparalyzed patient, I performed my first chest tube, I put in my first central line.  Also, given the resources that most ICUs have at their disposal your therapeutic options are virtually unlimited.  You can practice based on the most recent literature despite cost of drug therapy and because this is frequently a last measure, you can even make the argument for marginally experimental measures.  Xigris here I come.  I've learned how to put virtually everything in a drip - pressors, antibiotics, sedation, insulin, electrolytes.  The sky's the limit.  I enjoyed being the first responder to codes and knowing there was some sense of relief because the ICU team was there.  The team approach and daily rounding were enjoyable, which I can rarely say of any previous rounding experience.  I liked working closely with the families of the patient to explain what the options for management are and to discuss end of life care.

This was easily the most challenging aspect of the month.  The last patient that I declared dead was a metastatic esophageal cancer patient whose oncologist had not yet breached the topic of prognosis and end of life management.  As I navigated the family through the initial full code, to DNR, and eventually to do not escalate and comfort measures only, I realized that no other experience would rival this in complexity.  You need to read the situation for each individual family.  You need to assess whether it is appropriate to discuss the medical situation vaguely or whether a more technical narrative is desired.  You need to be sympathetic, but offer direction and you need to be certain at times when there is not much clarity about the actual events.  In this particular patient it was evident that there was a communication between the lungs and the gut (the NG tube was attached to a clean catch bag that filled with air in seconds), but it was unclear whether this was the cancer eroding the posterior esophagus or whether the friable surgical anastamosis site was coming undone.  What became clear to me throughout the conversation, however, was that the family did not need to know details and wanted to be allowed to mourn before making a CMO decision.  Eventually, they thanked me for everything we had done and I left with the feeling that even if there had been a medical error in his care - my chest tube had punctured the gut or the surgery had been botched, they would recognize that his end-of-life care was appropriate.  It's been difficult coming home from calls like these and moving on to my normal daily activities.

You most definitely bring your work home with you when you're in the ICU.  In the ED, I think it will be easier to walk away from these situations unscathed.  The low point was definitely a couple of days ago when I had been on this streak of all of my patients dying (some that I had carried for weeks) and was assigned a new patient that clearly would die on my shift.  I actually got tearful for a minute while rounding and had to pull myself together.  I'm happy to still have compassion and be able to feel these emotions for a patient, but at times I wish I could just get jaded already and at least be able to close the chapter with move on.

Here are some words of advice for the critical care rotations:
1. Know how to replete electrolytes - this will be an every day task and will eventually become reflexive - correct your Ca for low albumin and keep ventilated patient in the >2 Mg range
2. Love the ABG - you will do it over and over and over again
3. Sepsis is bread and butter ICU care - put in the line early, monitor CVP and SVO2 and transfuse away if needed
3. Do your research and you can make a case for most any treatment, if it is evidence based and your attending likes adventure
4. Communicate with families early, when you breach the topic of code status, it will be a lot easier
5. Pack an on-call bag with toiletries, snacks, water bottle, cell phone charger and ibuprofen - it's amazing what aches and pains will emerge when you're running around for 30 hours
6. Build a good relationship with your team - don't signout quick tasks and phone calls, give a good signout, and when you're on call get everyone else out on time
7. Never underestimate the value of the nursing evaluation - they have more experience with your patient and will help you preempt disasters if you listen well - have them get you when they turn your patient - you can auscultate and evaluate their decubs
8. Sleep when you can, I took melatonin at 5pm on my post call days and on 5pm the day after - it worked great
9. Try to keep some social obligations, you'll feel more in control of your schedule and you'll learn to love on call days for the prospect of post call lunches / breakfasts with friends and family
10. Learn what you can from your senior / fellow - you'll rarely get this much one on one time

Puppy Love

Mac is our 17 week old boxer puppy.  

 

  

 

Labor Day

I have Labor Day off and it's much needed.  My recovery time post-call is becoming longer and longer and my ability to concentrate and read during the day is steadily declining.  As my attending recently stated, our post-call EEG would surely show "diffuse slowing".

  I'm three calls away from being done with the MICU until third year.  At times I regret this because we have a great team right now: our attending is 2-3 years out of fellowship and has a dry humor that makes rounds bearable, we always have one fellow on, one IM senior, one IM PGY-2, one IM intern, one EM PGY-3, and an EM intern (me).  The overnight team consists of either an IM senior and intern or the EM senior and me, each with a fellow for additional support.  With exception of mediating vent settings, the EM senior is far more proficient than the fellow at procedures and management of acute events.  I like seeing one of ours in this light because it gives me hope that some time not too far in the future I will be able to handle this 16 patient ICU all night.  Saturday night was truly the busiest on call night so far.  I slept maybe a half an hour, ran a code, put in three IJs, did two admissions, declared someone dead, and did not sit down once.  

Our nurses are very vigilant and for the most part anticipate most disasters prior to them coming on.  They don't call us for minutiae and when we do get called, we don't hesitate to see the patient ASAP because they are most likely crumping, if the nurse is worried.  Saturday night was the night of flash pulmonary edema and septic shock.  We were giving out nitro paste like it was candy.  Anyone who was on FM was on BiPAP by the end of the night.  Anyone that wasn't getting Lasix was getting lines and being resuscitated.  It was dizzying. 

I ran my first code that night.  An 84 yo F was found unresponsive in the surgery ward.  There was a question of beta blockade vs. vasovagal and she was found with a pulse in the 30s, sating 70% on 5L NC.  We bagged her, put on pacer pads, and gave atropine and glucagon.  She recovered pretty well, but was transferred to the ICU for closer monitoring of her bradycardia.  When she arrived, however, the picture changed.  She was hypotensive to the 70s with a HR of 50 and we couldn't get the pulse ox to work because her extremities were so cool.  She was clearly in shock.  When we looked at her labs, her hemoglobin had dropped by 4g/dL in 12 hours and we realized she was actively bleeding somewhere.  Given that she was three days post laparoscopic hiatal hernia repair and was tender on abdominal exam without any other apparent localizing findings, we decided to scan her.  Not surprisingly she turned out to have a pronounced hepatic subcapsular bleed with free fluid in the colic gutter.  Surgery was called and we ordered four units and started bolusing her while we were waiting.  I was struggling with her line.  She was in the process of getting discharged home when she coded around 5pm and had been INTed in the AM without any PO intake that day.  Her veins were collapsed; I could barely make out her IJ.  When I finally did get blood return and started feeding in the wire, it kept meeting resistance four to five inches in and nothing I could do would make it go further.  My senior suggested turning around the wire, which I had never heard of.  I fed the wire in backwards with the hooked side last and it worked like a charm.  We resuscitated her with packed rbcs, NS boluses, and got her a bear hugger, which allowed us to finally get a read from her pulse ox.  The next morning a good 15 hours after the code, a surgical attending finally first laid hands on her.  She dodged the surgery question with lets get q6 H/Hs and a repeat CT, which prompted a whole argument with the radiologist, who said it was entirely ridiculous: what change were they expecting to see?  Ultimately, I realized I had to make peace with the fact that I could not single-handedly do a laparotomy and that I would also make mistakes in my career - I should be understanding and work to the best of my ability.  It's a lot easier to turn down an 80+ year old from surgery when you see her after she has been volume resuscitated and narcotized and believe she is not a surgical candidate, than when you code her and are tremulously holding atropine in the radiology suite watching her brady down to the 50s.  A pro pos we still have not elucidated the reason for her bradycardia in the setting of hypotension.  Pain with increased vagal stimulation? 

With all the action we had that night, the emotional burden of declaring someone dead that was perfectly healthy three days prior and now on his death bed from severe sepsis secondary to pneumonia, as well as rankling with surgery all night long, I was more than happy to come home with the prospect of a day off.  I DID leave that day with the feeling that I had helped save someone's life that night and that I had become an indispensible part of the ICU team.  Over the last 24 hours it has really sunk in that I have a pretty powerful ability and after all of those long nights of studying and wondering if I would every make it, I was finally here and it was entirely worth it. 

Overdrive

So, I've survived my first full rotation and am well into my second. I've learned a couple of things. The first: it's close to impossible to make time to read in your off-duty time. Essentially, I've been reluctant to read because I feel that I'm giving so much of my time to the hospital that it would be an injustice to deprive myself of free time yet again to "do medicine". On the other hand, I recognize that not keeping up with my continued education is going to be a disservice to me.

Truthfully, I'm still waiting for the balance to kick in. There is the thinking that if I just get through another couple of days, I'll finally be settled in enough to dedicate some free time to exercise and reading rather than recovering from the last 30 hours on-call. Maybe I should just bit the bullet, head back to the gym, start up my reading routine, and stop with the delayed gratification BS. It's just so much easier to make excuses!

Secondly, I've learned that the uncertain feeling you have as a med student doesn't wear off simply by graduating. You still report to your senior and your senior still reports to the fellow and the fellow still reports to the attending. There is an uncanny ability to find out an intern; it's in your opening when you call a consultant or in your closing when you try to transfer/admit a patient to the floor. Sure, there is a component of choppy presentations, and an inability to sell your cause, but mostly I think it is the uncertainty with which you communicate. It's easy to discredit your efforts of working up a patient and formulating a plan when your counterpart has the ease of experience and confidence on his side. I make a real effort not to be overly apologetic and stick to my instinct when I have a reasonable argument to back it, however the later it gets into my on-call shift, the more reluctant I am to put in the work. At the end of the day it's far easier to reveal yourself for who you are: a new doctor.

The third: it's impossible to schedule any appointments unless you're post call. With that said, the WORST possible post call activity is sitting in a doctor's office waiting to be seen. Yesterday, I had to get three fillings two hours post MICU call. It was painful. I was exhausted - emotionally and physically - and suddenly having my teeth drilled into seemed like the greatest form of torture. As the tears started pouring down my eyes, it occurred to me that lack of sleep certainly makes you a pitiful wreck of a human being with an inability to think rationally and most definitely an inability to sympathize with anything other than one's own needs. How exactly does this state of being translate into better care for our patients? To top it off my dentist thought it would be interesting to me to talk about his Vietnam experience as a medical professional. I almost passed out right there.

With all of this seemingly depressing commentary, I should add that the experience is made worthwhile by the team you work with and the support you get outside of the hospital. In my current rotation in the MICU, the team effort is great. All the residents are looking out for each other, encouraging you to sign out your tasks for someone else to complete. The nurses give helpful suggestions and have not once made me feel like a klutz when I have to redo my orders a million times and forget to write for morning labs or get a creatinine on a renal failure patient. The attendings cut you slack for the most part because you're new to all of this and your senior forgives you a million times over for creating extra work for them by your inability to dispo confidently. Sometimes I almost look forward to my Q3 call days because I know that means there will be postcall time to spend with my husband, my puppy, and my bed. There's nothing better than banana pancakes and the outlook of a day of rest when you come home. The next day you forget how painful the recovery was, forget how your tooth is still aching, and you hate dentists, and you find the strength to do it all over again.

Freefalling

There is nothing like rappelling into ice cold murky water to wake you up out of a daze. It seems that ever since the Match, I've been in an excessively reflective mood - perhaps because a major life event, the culmination of eight years of education and a student existence, is coming to an end. Or, maybe, it is that I've begun the process of redefining myself as a professional.

I imagine that eventually there has to be a break from fourth year medical student persona to responsible physician. As is my nature, I decided to take it upon myself prematurely rather than sometime midway through intern year when you've appropriately acquired enough experience to redefine yourself through new skills, relationships, and patient responsibilities. For me, this took the shape of defriending people on facebook that were no longer central to my life (why should they be privy to my updates, if they would never pick up the phone and call?), booking a trip back home, and becoming a silent observer of the people around me. Perhaps, I thought, by reflecting on what I did and did not like about my friends I could realize what kind of self improvement I could practice. It turns out I just realized how different I was than a lot of the people I spend my time with. After the pretense of studying and "school stress" becomes passe, you learn quite a bit about other students in your class. Sometimes, it's not a very welcome discovery either.

Part of the thrill about moving to a new location and meeting a new set of friends lies in the intriguing possibility of redefining who you are. People no longer have preconceived notions and you can "become" the person you wish to be. Perhaps I would like to be a person that my cointerns can trust with their problems, will want to share a beer with in their freetime, and is outgoing, approachable, and fun. I'd like to hope that this is only an upgrade of my current state and not a new program alltogether.

Anyway, I went rappelling with a group of friends this weekend and it woke me up out of my stuporous state of reflection. We camped overnight near the entrance of the hiking trail at a site that required the ability to truly rough it. The bushes became bathrooms and the brush fuel for the fire. A couple of grilled chicken sausages and bottles of beer later it felt like the best idea ever. The weather was playing along too; it was just cold enough to want a sleeping bag and warm enough to enjoy the breeze. I went to sleep satisfied that I could enjoy the simple things in life and had made a good set of friends in four years time. I wanted to be sad to leave by graduation and I finally realized that despite the sometimes difficult times, I would be losing a lot of close friends in two months time.

In the middle of the night I felt something pressing against my soles and woke up. It turned out to be a prairie fox with huge pointy ears and a long tail looking curiously into my tent. I must have been in quite a daze because I simply pulled in my feet and continued sleeping. Sometimes it surprises me what I will sacrifice to get a good night of sleep. The next morning a close friend of mind no longer had a sandal. I wonder who made away with it?

We cleaned up camp and headed to the hiking trail where we met our three guides. At this point it hit me that maybe what we were doing wasn't quite as harmless as I had imagined. Why would 14 perfectly able young med students need this many guides to go rappelling? It turns out there is a lot of setup and spotting necessary to rappel safely and we could never have managed on our own even with the appropriate equipment. A couple of awkward warm up exercises later (don't ask me why we had to sprint back and forth in preparation of an 8 hour hike) we were finally set to leave. Part of me didn't want to believe it when they informed us that everything we had with us would get wet. Little did I know that we would be rappelling directly into pools of water and there was no way of evading full immersion.

The hike was beautiful. The mountains were bare of anything but the rare bush and yet the white polished surface of rock alongside the gulleys was quite a site to behold. There had been floods only two weeks before, so we were assured that the murky water was actually "fresher" than usual and we didn't need to worry. The first release of the safety rope and backward propulsion into the water was everything but easy. You're never quite ready to let the rope go knowing what awaits you below. The water was icy cold and it took a second to regain my breath and yet there was a sense of accomplishment on having enough courage to let go and make it to the embankment. The thrill of those final minutes of rappelling and being suspended in midair - many times without a secure foothold - was worth the shock of the cold water and downtime between descents. I could make a metaphor about the leap of faith when going into the specialty of Emergency Medicine, but I'm going to spare you the cliche.

By the end of the day, we were tired out, exhausted but happy. It was definitely a fun trip that made you proud at the end of the day that your nerves didn't get the better of you and you held your own. It's times like these that I'm so grateful to be evading a desk job for the rest of my life. Thank God for shift work and the many random day trips that will follow...

One step closer

Today, I spent a significant part of my day filling out paperwork for residency. I always thought third year electives would be the last wrangling with forms that I would have to do in medical school, but I was gravely mistaken. Not only do you need to submit a several paged detailed account of your health and vaccination history, but you also need to fill out paperwork for a limited medical license, a parking pass, a hospital ID, confidentiality agreements, etc.

This could have been an easy task, if it were not for the fact that our school secretary is neurotic and the least task-oriented person I know. It took me a good two hours to get a Dean signature and another hour to get my titer record. Then, I had to make an appointment to see the notary services at the embassy and call the school doctor to get my health forms signed. Wasn't I supposed to be at the beach sipping martinis post MATCH?

We're on day three of our medicine subinternship. I was dreading returning to the medicine wards after all the negative attitudes that resound about this particular rotation during interviews. I have to say it is not nearly as bad as I was anticipating and far more enjoyable than it was last year during our clinical clerkship. My ward specializes on infectious disease and the professor is somewhat of a regional TB expert, so if nothing else I will come out of these three weeks with a superb knowledge of how to work tuberculosis into virtually every differential. We covered some particulars of DKA management and insulin dosing today, which should come in handy during internship. Suddenly, I see everything in the light of how this will make me seem less clueless in residency and it is my hope that this new found motivation to learn will actually let the material sink in for longer.

Malcolm Gladwell's theory of 10,000 hours of practice leading to expertise most definitely applies to medicine as well (at least this is my excuse for not feeling nearly ready to be a practicing MD). Given that the average medical student spends forty hours per week either studying or in the hospital in the last two years of medical school and there are on average 30 days of vacation time, we should reach around 3500 hours of medical training by the end of medical school (40hours x 30days x 11 months). How many years should it take for us to be truly competent in medicine then? An additional 6500 hours. In internship, residents work an average of 60 hours per week as indicated on the aamc website for emergency medicine residency training. So, in internship we should accumulate another 2640 hours. This means that mid way through our PGY-3 year we should reach the 10,000 hours of clinical training in medicine. I'll let you know in January 2012, if I've reached that point.

Now to apply this to the 3 vs. 4 year emergency medicine debate...With this line of thinking it should make sense that a three year residency program would suffice for adequate training. BUT, if you really want to be an expert in your specialty, you should only start counting on the first day of your emergency medicine training, in which case you really need to be in a four year program to accumulate 10,000 hours of clinical training in residency. However, this exercise does not account for time spent in off rotations, the repetition of material, the ability of a resident to retain knowledge, and the varying patient load depending on the hospital where you are located.

On a completely different note, I listened to a great NPR podcast today on PTSD in Tibetan monks. I can't imagine a better past time when you're commuting than listening to Fresh Air podcasts. Terry Gross does a great job of conducting insightful, interesting interviews that keep even the most inpatient listener engaged. On 3/26 she interviewed Dr. Michael Grodin, who is the co-director of the Boston Center of Refugee Health and Human Rights. He talks about his experience treating monks that were tortured for resisting the Chinese. His efforts to lead them in meditation often failed because they would have flashbacks of their time in prison. He also talks about the challenges of drug compliance in this population and helping them create a meaningful existence in present day Boston.

Interestingly, he also works with Holocaust survivors that relive their terrible WWII experiences with the onset of dementia. He theorizes that the disinhibition of dementia is leading to flashbacks from this time. The smell of urine in the nursing home, for instance, is enough to revoke thoughts from the Nazi era concentration camps. I find it quite tragic that these people must relive such sad events in the last years of their lives. Dr. Grodin mentioned that one important therapeutic measure was to emphasize to the patient that they are not burdening the therapist by revealing this information. Many Holocaust survivors are worried that by relaying painful memories they are spreading the suffering to another generation.

It is a difficult role caretakers must play with post traumatic stress patients. You need to encourage the individual to vocalize their fears and at the same time protect them from reliving past traumatic events over and over again. Unfortunately, the prognosis is grim with 50% becoming chronic, especially when treatment for PTSD is delayed. Many times the hypervigilance that is seen in this condition is addressed with meditation (something that lead to the unexpected observation in Tibetan monks). Dr. Grodin describes a particularly helpful therapeutic approach of visualizing a lotus flower that floats down the river every time a disturbing thought comes up. He has had quite some success employing this strategy in addition to medication, psychotherapy, and other methods. Here is a link to the podcast, if you're interested.