In medicine, people generally expect doctors to be cool and calm, able to withstand stress under pressure. Sadly, I don't fit that mold. I crack pretty easily under a lot of pressure, and I know it. When I first started residency, I set a rule to myself to never lose control of my emotions at work, no matter how bad things got. I already broken that rule twice during my intern year. The first was during a MICU shift when I had to juggle 7 patients while my resident was post call. The second was during a floor month when I had to juggle 14 patients (including 2 discharges) while post-call on a Saturday with no resident to help me get out before 1 pm. The first time, a MICU nurse was there to reassure me that it was still early in the year and I was doing a good job; the second time, a resident heard me out while I ranted. The insight I got from this is that I'm more likely to lose my temper when all hell breaks loose while running a service alone.
My last Friday on the heme-onc service was no exception. First we had a new admission that had been wrongly assigned to my team and I must have wasted an hour of my time calling the general medicine services to see if they would take this patient (fortunately one attending said yes) and then arranging his transfer instead of caring for my own patients. Then, after my intern went home (she was post-call) we had 5 discharges and 6 admissions in a single day (fortunately I didn't have to do the admissions but I had a black weekend ahead of me so I had to learn all about them). Then a patient who was supposed to be discharged had a clotted J-tube that neither I nor surgery could fix, so our only option was to call IR. The problem: it was 4:40 pm when I called and IR closes at 5:00 pm. And it's a Friday. Needless to say the IR attending (who's an ass to begin with) totally ripped me a new one, asking me why I waited so long to call and if I was just "sitting on this all day." Hardly! The last thing I wanted to do was to call IR to fix a J-tube; that's why I tried every other possible option! At any rate, the stress of caring for 14 patients, worrying about my patient in the ICU, trying to do well on this rotation and now getting yelled at for something beyond my control was too much, so I just broke down and cried.
Fortunately I was in the med room (complete with a computer so I could update my patient list and signout from there) when this happened, so the attendings didn't witness my breakdown. My 4th year student, the other heme-onc resident, a couple of nurses, and later my fellow tried to comfort me, saying that today was a bad day, I was doing a good job, there was only so much I could do, etc., but the waterworks just wouldn't stop. There were times where I thought I'd finally composed myself, but then something else would set me off and I'd be back to square one. One of the nurses even brought in a box of Kleenex so I'd have something to blow my nose on. In the midst of all this, IR called and said they'd take my patient if he came down to the department ASAP, so my med student ran outside, got a wheelchair, and personally took my patient down to IR. I felt horrible that he had to witness his resident falling apart the way he did, but I think he understood how stressed I was. When he came back to the med room, he offered to come in to work tomorrow morning to help me get my work done faster. That was a kind gesture. Finally I regained enough composure to leave the med room and finish up my work. If my attending noticed that my eyes were red, he was kind enough not to say anything about it.
The following Saturday my 4th year came in as promised, and the attending covering the service that day commended him for coming in on his day off to help out. "You've got a fine young student here," one of the patients told the attending, to which she (and I) agreed. I was able to finish most of my work on time with his help and let him go before 1 pm, telling him that today's shift would count as a call (4th years have to take call with residents). The rest of the black weekend went smoother than I thought, and I was so relieved to be done.
But then again I'm a sucker for punishment and went straight from the heme-onc service to a month of heme-onc consults, which is run by the same attendings whose service I just left. In a way it was good because now the attendings can see how I work without the pressure of trying to run a full service, and the consult service is way more relaxing. I still saw my old team from time to time and got the new resident oriented into how the team runs. I was also relieved to learn that my patient who got sent to the ICU was doing better; she was off pressors and recently extubataed, though now she has an EF of 10-15%. Whether this was due to the chemo or infection I can't be sure, but I'm grateful that she's turned the tables...for now.
Wednesday, August 25, 2010
Tuesday, August 17, 2010
Deadly Mistakes
This morning I got to work to find out that one of my patients, a young woman in her 30s who was neutropenic after getting chemotherapy, had been sent to the unit. She had spiked a fever overnight and become hypotensive, which given her neutropenic state wasn't too surprising. She'd first shown signs of infection four days ago, and we'd put her on vanco, Zosyn, and flagyl to treat her empirically. Or at least, I thought we did. Her blood had grown zosyn-sensitive Klebsiella, and I remember thinking, "Oh good, at least she has coverage for it." Then when I spoke to the night float, he said, "You know, she only got a one-time dose of vanco and flagyl four days ago, and hasn't had any since. The only antibiotic she'd been getting was Zosyn."
To say that I was stunned would be an understatement. I can't even describe what I felt when I heard him say that: it was a combination of shock, horror, worry, and fear. Definitely fear. We put our patients' medication lists on a Word document and copy them onto the progress notes everyday, and even though I put my med student and intern in charge of updating those lists, sometimes things aren't done. When our attending had told us to add broad spectrum Abx to this patient's med list, we added it onto the Word document without checking the EMR to see if it was actually being ordered. And all this time, we believed the patient was getting broad spectrum antibiotics when she wasn't. And now she's in the MICU on 2 pressors, intubated and septic, unlikely to survive the remainder of the week unless she really recovers.
It's hard to say who was at fault. The person who put in the abx orders as a one-time stat dose instead of a standing dose had only been at this hospital for 2 months and probably didn't know better. The medical student who's supposed to update the medication list each day never saw that the antibiotics had fallen out of the computer. And I, the resident, have been so busy doing admissions, trying to oversee a capped service, and keeping things in order that I never double-checked the computer to make sure she was getting her abx. Even the patient did not help matters by refusing blood cultures over the weekend (they drew stat cultures in the MICU and it grew out gram negatives within 8 hrs) I felt sick all morning and couldn't help but feel guilty over everything that happened. More so because I am strongly considering applying for a heme-onc fellowship and plan to ask my attendings for rec letters. Would they even look at my application after what happened? Fortunately the attending never once blamed any particular person for this, but I knew very well that that if something like this had happened to a patient on the heart failure service, the heart failure attendings would have done everything in their power to get me kicked out of the residency program. After all, this was a matter of life and death.
I went to see the patient later in the unit; by then she was intubated and had a central line and art line. All she wanted these past few days was to get better and go home to be with her kids. And now she might not survive. *sigh* Hoping she gets through this.
To say that I was stunned would be an understatement. I can't even describe what I felt when I heard him say that: it was a combination of shock, horror, worry, and fear. Definitely fear. We put our patients' medication lists on a Word document and copy them onto the progress notes everyday, and even though I put my med student and intern in charge of updating those lists, sometimes things aren't done. When our attending had told us to add broad spectrum Abx to this patient's med list, we added it onto the Word document without checking the EMR to see if it was actually being ordered. And all this time, we believed the patient was getting broad spectrum antibiotics when she wasn't. And now she's in the MICU on 2 pressors, intubated and septic, unlikely to survive the remainder of the week unless she really recovers.
It's hard to say who was at fault. The person who put in the abx orders as a one-time stat dose instead of a standing dose had only been at this hospital for 2 months and probably didn't know better. The medical student who's supposed to update the medication list each day never saw that the antibiotics had fallen out of the computer. And I, the resident, have been so busy doing admissions, trying to oversee a capped service, and keeping things in order that I never double-checked the computer to make sure she was getting her abx. Even the patient did not help matters by refusing blood cultures over the weekend (they drew stat cultures in the MICU and it grew out gram negatives within 8 hrs) I felt sick all morning and couldn't help but feel guilty over everything that happened. More so because I am strongly considering applying for a heme-onc fellowship and plan to ask my attendings for rec letters. Would they even look at my application after what happened? Fortunately the attending never once blamed any particular person for this, but I knew very well that that if something like this had happened to a patient on the heart failure service, the heart failure attendings would have done everything in their power to get me kicked out of the residency program. After all, this was a matter of life and death.
I went to see the patient later in the unit; by then she was intubated and had a central line and art line. All she wanted these past few days was to get better and go home to be with her kids. And now she might not survive. *sigh* Hoping she gets through this.
Friday, August 13, 2010
Friday the 13th
"You guys do know today's Friday the 13th, right?" These words were said by my attending during rounds today, but I didn't even know that it was Friday the 13th until he brought it up. And even if it was Friday the 13th, I've never been superstitious and I didn't expect this day to be worse than any other day. I was wrong.
I started the morning with 15 patients on my service (the other heme-onc team had 16 so our teams were both beyond capped), and starting at noon I had to run the whole service alone. My intern had clinic, and my sub-I was attending his brother's wedding on the West Coast. I knew my afternoon would be hellish since I had to be a "resi-tern," but between 11 am and 2 pm everything went to hell. One of my patients who had been admitted with anasarca and was responding well to Lasix and albumin suddenly had grossly bloody stools and a drop in Hgb from 8.4 to 7.2. We transfused her 2 units, but when she had a second equally bloody BM, we knew that was trouble. The poor woman had been doing so well and was crying when she learned we had to put in an NG tube. At the same time, I had a patient whom transport was supposed to pick up at 1:00 pm exactly, and I had to scramble to do his discharge paperwork while the GI fellow was at my heels telling me to throw in an NG tube and start Nexium and octreotide on my GI bleeder. Fortunately my fellow could see I was swamped and put in the NG tube (which yielded bright red blood), and she helped transfer that patient to the unit while I ran around like a madwoman filling out scripts, admitting two direct admissions, answering calls from nurses, etc. There were a few times where I felt like crying, but fortunately that didn't happen. Then a patient on the other team had an unwitnessed fall, the same reason for which she was admitted, and we had to send her down for a head CT. *sigh* Is it Friday 13th, or just a bad day? Who knows. At any rate I didn't leave work until 9 pm (I was on call until 8 pm).
What a day....
I started the morning with 15 patients on my service (the other heme-onc team had 16 so our teams were both beyond capped), and starting at noon I had to run the whole service alone. My intern had clinic, and my sub-I was attending his brother's wedding on the West Coast. I knew my afternoon would be hellish since I had to be a "resi-tern," but between 11 am and 2 pm everything went to hell. One of my patients who had been admitted with anasarca and was responding well to Lasix and albumin suddenly had grossly bloody stools and a drop in Hgb from 8.4 to 7.2. We transfused her 2 units, but when she had a second equally bloody BM, we knew that was trouble. The poor woman had been doing so well and was crying when she learned we had to put in an NG tube. At the same time, I had a patient whom transport was supposed to pick up at 1:00 pm exactly, and I had to scramble to do his discharge paperwork while the GI fellow was at my heels telling me to throw in an NG tube and start Nexium and octreotide on my GI bleeder. Fortunately my fellow could see I was swamped and put in the NG tube (which yielded bright red blood), and she helped transfer that patient to the unit while I ran around like a madwoman filling out scripts, admitting two direct admissions, answering calls from nurses, etc. There were a few times where I felt like crying, but fortunately that didn't happen. Then a patient on the other team had an unwitnessed fall, the same reason for which she was admitted, and we had to send her down for a head CT. *sigh* Is it Friday 13th, or just a bad day? Who knows. At any rate I didn't leave work until 9 pm (I was on call until 8 pm).
What a day....
Sunday, August 1, 2010
Two Days Later...
After my hellish non-call day, I wasn't sure what to expect on the day that I was actually on call, but this call was probably the best one yet. My poor intern stayed at the hospital until 5-6 pm yesterday discharging patients and trying to hold the team together; it was his first weekend shift and he'd never written all 14 notes at once before. I was told that he seemed stressed and a bit overwhelmed (not unlike how I was on Friday), so sometime this week I'll have to find time to sit him down and go over things with him. Fortunately for me I only had 11 patients to see this morning, and between seeing patients and rounding with both the fellow and the attending, I managed to get all my work done by 1 pm. Not too shabby.
I emailed the triage resident and we were able to clear the air about what happened on Friday (she got 6 admissions at once and thought we were almost done with the admission so she wanted me to oversee it without realizing that my intern hadn't even started on it). I wonder if she told today's triage resident (who was my resident back in February) to cut me some slack today, because I didn't get called for a single admission all day. At most I was asked to oversee another intern's admission, and when I found out she wasn't able to do it b/c she was sending a patient to the unit, I took it out of her hands and did the H&P myself to help her out. We went over it together afterwards since the patient was going to her team, but overall I had enough time today to dictate about 6-7 patients. And I got to leave on time. If only all calls were like this =)
I emailed the triage resident and we were able to clear the air about what happened on Friday (she got 6 admissions at once and thought we were almost done with the admission so she wanted me to oversee it without realizing that my intern hadn't even started on it). I wonder if she told today's triage resident (who was my resident back in February) to cut me some slack today, because I didn't get called for a single admission all day. At most I was asked to oversee another intern's admission, and when I found out she wasn't able to do it b/c she was sending a patient to the unit, I took it out of her hands and did the H&P myself to help her out. We went over it together afterwards since the patient was going to her team, but overall I had enough time today to dictate about 6-7 patients. And I got to leave on time. If only all calls were like this =)
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