Falling Apart

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.