Today was the very last day of my intern year, and honestly, it couldn't have come fast enough. After 2 weeks of night float followed by 4 weeks of CCU, I was drained and in desperate need of a break. My license expires tomorrow and won't start again until July 1st, so until then I have a glorious 1-week break which I plan to spend at home with family and friends.
The newest batch of interns arrived this morning to shadow us for a couple of hours to see what their jobs tomorrow would be like. They showed up in their brand new white coats and notepads in hand ready to jot down new information. We were pretty amused to find that of the four new CCU interns, three were named David; we joked that they'd have to be called by their last names to tell them apart. One of the Davids would be taking my spot tomorrow, so I told him a little about each patient and what was going on. The fellows, too, welcomed the interns, and one of them immediately sat down and started teaching them about Swan Ganz catheters, right heart caths, and other things essential to the CCU. It was surprising because he'd never taught my fellow interns and me any of this (we had to figure it out on our own), but I guess with these guys being new to medicine and the CCU they had to learn quickly what was important. Our attendings, too, were interested in meeting the new interns "fresh out of medical school;" when the heart failure attending came by and didn't see the interns anywhere (b/c they were in another patient's room), he wondered where they'd gone.
Unfortunately for the new interns, one of our patients coded right in front of them today. This was a woman in her 60s who had been admitted back in April for an infected pacemaker; the infection had spread to her spine, forming an epidural abscess. During her stay in the CCU, she went into multi-organ failure (intubated, needed dialysis, platelets fell to 19 and only responded to HLA-matched platelets, became jaundiced from a failing liver, etc), and we all knew that her prognosis was very poor. Yet through it all, she never complained; she always smiled when she saw us and (once she was extubated) said she felt all right. When we saw her this morning, she was her usual alert and smiling self, albeit more short of breath than usual. Finally it became obvious that she would need to be reintubated, and I felt sad b/c she'd being doing better.
Then she went into PEA, and half the residents ran into the room to assist in the code. One of the Davids donned gloves, ready to help with compressions, but the fellow told them to stay out of the room. So while half of us stayed in the nurse's station to round with the attendings (and sneaking peeks at the tele monitor all the while), the other half stayed in the room with the patient. Fortunately I knew my patients well enough to present them while my resident (who was post-call, too) was helping with the code. Twice this lady recovered with the help of bicarb and amiodarone and epi, but in the end it wasn't enough. Time of death was shortly before noon.
One of the residents later commented that the interns had looked terrified while all this was going on, and I don't blame them. These were all prelims going into radiology, anesthesiology, or PM&R; they probably haven't done a medicine rotation in many months. I, too, was jittery when presenting to the heart failure attending (who's pretty high up there on the cardiology totem pole), and at one point he said, "Calm down, you've got these guys to replace you, and soon you're going to be the boss of them. Scary thought, isn't it?"
Yes, it definitely was. Although the prospect of being a resident (and being expected to teach interns and med students) was frightening, it's also exciting. What's not to love about limited overnight calls (residents only do 30 hr shifts in the units) and having fewer notes to write per day? On the other hand, now I'm expected to do chart dictations and actually know stuff. It's easier to get away with being stupid as an intern, but as a resident I'll have no excuse. One of the cards fellows already knows I have zero cardiology knowledge, and he's going to be the CCU fellow again in 5 months when I return to CCU as a resident. My only hope is that by then, I'll have gained enough knowledge to be more confident as a resident.
Tuesday, June 22, 2010
Tuesday, June 8, 2010
Doctors Are Not Gods
Last month I finally got a chance to read The House of God, which came highly recommended by several attendings at this hospital. For those of you who don't know, The House of God describes a brand new doctor's (mis)adventures during his intern year at a prestigious Harvard-affiliated hospital (aka the House of God) during the 1970s, when overnight was q3 and the intern didn't leave until 5-6 pm the following day (essentially a 36 hr shift). The main character starts his intern year fresh-faced and eager to save lives and help people, but halfway through the book he and his fellow interns were losing their tempers at patients, kicking at elevator doors for being too slow, or secretly euthanizing dying patients with KCl. All this sounds ridiculous to the newly graduated medical student, but interns and residents can definitely relate to the long work hours and the crap we put up with at home and at work.
I'd be lying if I said that I was the same person I was one year ago before intern year started. This year has changed me, and not necessarily for the better. I've become more disillusioned, more angry, and more cynical. When the same patient comes to the hospital week after week for abdominal pain after drinking a pint or two of vodka, then leaving the hospital AMA when he doesn't get narcotics for his pain, it's hard to be sympathetic. And unfortunately, that patient represents a huge chunk of the general patient population here. Sometimes I feel like medicine is draining away my humanity and turning me into a robot. Quite a difference from the medical student who liked taking the time to get to know her patients and strongly believed that doctors should be better listeners and better advocates for their patients. I still believe that, but sometimes I find myself forgetting how to become a better doctor.
One of the patients I had to cover for in the CCU last night was a 42-year-old man with A-fib, chronic kidney disease (on HD) and end-stage cardiomyopathy (EF 5%). Despite having a pulse ox of 100%, he felt like he couldn't breathe properly and was afraid to fall asleep for fear he'd wake up struggling for breath. I assured him that his room was right outside the nurse's station, that he was on tele and we could easily monitor his pulse ox and heart rate, and that his call button was within reach, but he would not be dissuaded. "When I woke up just now, I was panicking! I don't know where the call button is when I panic! I'm scared, Doc! You need to fix this tonight!" The problem: this guy couldn't be fixed. His heart was a quivering mass of muscle on echo, barely alive and pumping right. He couldn't undergo dialysis to get fluid removed because he was too hypotensive. He was also obese with OSA and for some reason has not been on a CPAP ever since his admission. When I told him we couldn't safely dialyse him, he asked if I've been hearing a single word he's said. "I can't breathe! I'm scared!"
His nurse had pretty much given up listening to him rant, so a great deal of my night (which I would have preferred to be in bed) was spent at his bedside, listening to him rant about how he's done everything right ever since he's been in the hospital in order to get well (not true; he's refused beta blockers and cardioversion on several occasions for his symptomatic A-fib), but despite multiple tests and X-rays and even a defibrillator implantation, he's been getting worse. "You aren't doing anything!" he said. "You're a doctor, aren't you? What do they teach you in medical school? There's got to be SOME technology out there that can fix this! You say that my blood pressure's low and you can't give me lasix, I get that, but if I went to the emergency room, they wouldn't just let me lie here and do nothing! Can they send an emergency room doctor here?" I didn't have the heart to tell him that if he did show up in the ER with SOB and an EF of 5%, they'd immediately turf him to CCU. After listening to him rant for a good 20-30 min or so, I called my resident and asked what we should do. We ended up calling the cards fellow, who said we could put him on pressors to get his pressure up and give him some Bumex for his ease of mind. Guess what? He didn't put out a single drop of urine because his kidney function was so bad. He'd officially failed medical management.
Needless to say I didn't get much rest during last night (on top of which I had to share a call room with the heart failure intern and he was snoring loud enough to shake the walls), and in the morning, I told the attending what had happened during the night. She, too, wasn't sure why he was feeling short of breath when his sats were fine, but was concerned that his BP was too low for him to tolerate HD. "If we can't dialyze him, then he'll have to go home on hospice care. End of the road," she said. Later she went into the patient's room and told him the cold hard truth: that if his BP doesn't improve enough to tolerate dialysis, then he's going to die. She then called the patient's wife to the hospital to explain the same thing. I wasn't present at that meeting, but I later saw his wife enter his room with two toddlers (he has seven kids) to see him. Almost immediately, he started venting his frustrations (and reasonably so) about how nothing is helping him, and his wife yelled back, "Are you giving up? If you're gonna give up, you let me know!" The doors couldn't close fast enough to give them privacy.
It's times like this where I wonder why I chose this profession, if only to have patients yell at me and pretty much accuse me of being a crappy doctor, and I wonder if quitting medicine would really be such a bad thing. But that's when I remember that I am only human, that it's all right to be upset and frustrated at times. As a med school professor once told me, doctors aren't gods. We make mistakes, and we can't always fix everything wrong with a person, as much as we'd like to try.
I'd be lying if I said that I was the same person I was one year ago before intern year started. This year has changed me, and not necessarily for the better. I've become more disillusioned, more angry, and more cynical. When the same patient comes to the hospital week after week for abdominal pain after drinking a pint or two of vodka, then leaving the hospital AMA when he doesn't get narcotics for his pain, it's hard to be sympathetic. And unfortunately, that patient represents a huge chunk of the general patient population here. Sometimes I feel like medicine is draining away my humanity and turning me into a robot. Quite a difference from the medical student who liked taking the time to get to know her patients and strongly believed that doctors should be better listeners and better advocates for their patients. I still believe that, but sometimes I find myself forgetting how to become a better doctor.
One of the patients I had to cover for in the CCU last night was a 42-year-old man with A-fib, chronic kidney disease (on HD) and end-stage cardiomyopathy (EF 5%). Despite having a pulse ox of 100%, he felt like he couldn't breathe properly and was afraid to fall asleep for fear he'd wake up struggling for breath. I assured him that his room was right outside the nurse's station, that he was on tele and we could easily monitor his pulse ox and heart rate, and that his call button was within reach, but he would not be dissuaded. "When I woke up just now, I was panicking! I don't know where the call button is when I panic! I'm scared, Doc! You need to fix this tonight!" The problem: this guy couldn't be fixed. His heart was a quivering mass of muscle on echo, barely alive and pumping right. He couldn't undergo dialysis to get fluid removed because he was too hypotensive. He was also obese with OSA and for some reason has not been on a CPAP ever since his admission. When I told him we couldn't safely dialyse him, he asked if I've been hearing a single word he's said. "I can't breathe! I'm scared!"
His nurse had pretty much given up listening to him rant, so a great deal of my night (which I would have preferred to be in bed) was spent at his bedside, listening to him rant about how he's done everything right ever since he's been in the hospital in order to get well (not true; he's refused beta blockers and cardioversion on several occasions for his symptomatic A-fib), but despite multiple tests and X-rays and even a defibrillator implantation, he's been getting worse. "You aren't doing anything!" he said. "You're a doctor, aren't you? What do they teach you in medical school? There's got to be SOME technology out there that can fix this! You say that my blood pressure's low and you can't give me lasix, I get that, but if I went to the emergency room, they wouldn't just let me lie here and do nothing! Can they send an emergency room doctor here?" I didn't have the heart to tell him that if he did show up in the ER with SOB and an EF of 5%, they'd immediately turf him to CCU. After listening to him rant for a good 20-30 min or so, I called my resident and asked what we should do. We ended up calling the cards fellow, who said we could put him on pressors to get his pressure up and give him some Bumex for his ease of mind. Guess what? He didn't put out a single drop of urine because his kidney function was so bad. He'd officially failed medical management.
Needless to say I didn't get much rest during last night (on top of which I had to share a call room with the heart failure intern and he was snoring loud enough to shake the walls), and in the morning, I told the attending what had happened during the night. She, too, wasn't sure why he was feeling short of breath when his sats were fine, but was concerned that his BP was too low for him to tolerate HD. "If we can't dialyze him, then he'll have to go home on hospice care. End of the road," she said. Later she went into the patient's room and told him the cold hard truth: that if his BP doesn't improve enough to tolerate dialysis, then he's going to die. She then called the patient's wife to the hospital to explain the same thing. I wasn't present at that meeting, but I later saw his wife enter his room with two toddlers (he has seven kids) to see him. Almost immediately, he started venting his frustrations (and reasonably so) about how nothing is helping him, and his wife yelled back, "Are you giving up? If you're gonna give up, you let me know!" The doors couldn't close fast enough to give them privacy.
It's times like this where I wonder why I chose this profession, if only to have patients yell at me and pretty much accuse me of being a crappy doctor, and I wonder if quitting medicine would really be such a bad thing. But that's when I remember that I am only human, that it's all right to be upset and frustrated at times. As a med school professor once told me, doctors aren't gods. We make mistakes, and we can't always fix everything wrong with a person, as much as we'd like to try.
Tuesday, June 1, 2010
A Hole in the Heart
I started my CCU rotation last week, and even though the cap for each team is 4 and I only have 3 patients right now, I'm feeling more than slightly overwhelmed. The patients who come up here range anywhere from relatively healthy (rule-out cocaine-induced MI or measuring Swan-Ganz numbers on a heart transplant candidate) to actively circling the drain. I haven't done a unit month since September, and it shows. On top of that cardiology is not my forte, so compared to some of my fellow CCU interns who do like cards, I'm the dumb one of the bunch.
Last week an 81-year-old woman was transferred here from another hospital because she had developed a VSD within five days of having a massive MI. From the start we knew she would be a hard case. She was intubated but had an air leak, had a white count of 25, had elevated creatinine, and had 300 ccs of coffee grounds suctioned from her stomach. The biggest issue, however, was the hole in her heart, the VSD. On echo it was located near the apex of the heart. CT surgery evaluated her and said her mortality risk was too high for open heart surgery. Interventional cardiology said they could probably do it, but the risk of failure was high b/c the patient had a flailing tricuspid valve that could potentially interfere with repair efforts. On top of all that, she had a balloon pump to help her heart and was on 2-3 pressors.
The biggest challenge was her family. Her husband, daughter, and son-in-law were all physicians; in fact, her daughter was once a chief resident here and her son-in-law gave the residents a quick talk on acids and bases when we discussed the patient's acidosis with him. They knew, I'm sure, that the patient's condition was poor, but they still insisted that everything be done, as they saw the VSD repair as her only hope for survival. The interventional cards team took her down to the cath lab around noon, and someone suggested that she needed all the prayers she could get to make it through the procedure.
She returned to the floor 5-6 hrs later, and the fellow looked worn out. He said that the procedure itself went well, that she no longer had a VSD, but afterwards she lost electrical activity in her heart and had to have a pacemaker put in. She left the floor on only 2 pressors, and came back with 5. Despite being maxed out on the pressors, her pressure continued to decline. As the intern (and scutmokey), I was told to take elevator 16 flights down to collect PRBCs and FFP for the patient (who was actively bleeding) or else throw in bicarb drip orders into the computer. Her ABG came back with a pH of 6.8 and a bicarb less than 10. 2 residents and I stayed an extra 2 hrs to help my resident (who was overnight) keep this woman stable, but things were not looking very good. When my resident finally sent me home, I passed the conference room and saw the patient's daughter sitting alone in the conference room. Surely she knew her mother was in bad shape, worse off now than she'd been before the VSD repair, and I was just grateful that she was not in the CCU with us watching us work. That would have been way too much pressure on us.
What upsets me the most is that even after 11 months of internship, I still don't know what to do when patients crash like this. I was just standing around waiting for orders while the residents were already gowned up at the bedside or on the phone making the necessary phone calls. I was almost no better than a medical student. I was useless. And my defense mechanism for all this? Daydreaming about being back in Austin, taking a dip at Barton Springs Pool, sipping milk tea from Momokos while walking down the Drag....*sigh* I wish I were back in TX.
Last week an 81-year-old woman was transferred here from another hospital because she had developed a VSD within five days of having a massive MI. From the start we knew she would be a hard case. She was intubated but had an air leak, had a white count of 25, had elevated creatinine, and had 300 ccs of coffee grounds suctioned from her stomach. The biggest issue, however, was the hole in her heart, the VSD. On echo it was located near the apex of the heart. CT surgery evaluated her and said her mortality risk was too high for open heart surgery. Interventional cardiology said they could probably do it, but the risk of failure was high b/c the patient had a flailing tricuspid valve that could potentially interfere with repair efforts. On top of all that, she had a balloon pump to help her heart and was on 2-3 pressors.
The biggest challenge was her family. Her husband, daughter, and son-in-law were all physicians; in fact, her daughter was once a chief resident here and her son-in-law gave the residents a quick talk on acids and bases when we discussed the patient's acidosis with him. They knew, I'm sure, that the patient's condition was poor, but they still insisted that everything be done, as they saw the VSD repair as her only hope for survival. The interventional cards team took her down to the cath lab around noon, and someone suggested that she needed all the prayers she could get to make it through the procedure.
She returned to the floor 5-6 hrs later, and the fellow looked worn out. He said that the procedure itself went well, that she no longer had a VSD, but afterwards she lost electrical activity in her heart and had to have a pacemaker put in. She left the floor on only 2 pressors, and came back with 5. Despite being maxed out on the pressors, her pressure continued to decline. As the intern (and scutmokey), I was told to take elevator 16 flights down to collect PRBCs and FFP for the patient (who was actively bleeding) or else throw in bicarb drip orders into the computer. Her ABG came back with a pH of 6.8 and a bicarb less than 10. 2 residents and I stayed an extra 2 hrs to help my resident (who was overnight) keep this woman stable, but things were not looking very good. When my resident finally sent me home, I passed the conference room and saw the patient's daughter sitting alone in the conference room. Surely she knew her mother was in bad shape, worse off now than she'd been before the VSD repair, and I was just grateful that she was not in the CCU with us watching us work. That would have been way too much pressure on us.
What upsets me the most is that even after 11 months of internship, I still don't know what to do when patients crash like this. I was just standing around waiting for orders while the residents were already gowned up at the bedside or on the phone making the necessary phone calls. I was almost no better than a medical student. I was useless. And my defense mechanism for all this? Daydreaming about being back in Austin, taking a dip at Barton Springs Pool, sipping milk tea from Momokos while walking down the Drag....*sigh* I wish I were back in TX.
Subscribe to:
Posts (Atom)