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

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.

Ride along for recognition

Today, I substituted one of my subinternship Emergency Medicine shifts with an ambulance ride-along. The hospitality of the Fire Department staff and the willingness to let me partake in all aspects of the prehospital care was refreshing. It was quite the reversal from the usual hospital hierarchy of doctor, nurse, and somewhere in the abyss... medical student. I make it sound like I deserve a big pat on the back for sitting in classes passively and studying diligently in the library. While others were mastering the admittedly more difficult task of juggling real jobs, children, mortgages, crashing stocks, etc. I was selfishly attending to my 8 years of schooling. The point is that despite my recognition that "medical student" shouldn't evoke universal respect, it is flattering when others subscribe some value to you for having made it in medical school.