Done with Overnight Call

I've finished my last overnight call as an intern! My last rotation is on the liver and kidney transplant service and though it's considered a wards service, it doesn't have overnight call. It feels awesome!

Defensive Medicine

When most people think of defensive medicine, they think of the emergency physician ordering unnecessary tests to protect himself from legal action in the future. But yesterday on call, I learned a new type of defensive medicine. The resident heard about a patient with sepsis in the emergency department who was likely to come either to us in the intensive care unit or to the step-down unit. He proactively went to see the patient in the emergency department and felt that the patient would do fine in the step-down unit. But doing "defensive medicine," he helped the admitting team and the emergency department expedite procedures and therapies. It was better for the patient, and it was better for us to get involved sooner rather than later.

Personal

One of my friends was recently in the Stanford emergency department. I got a text from her boyfriend and rushed over there. It was odd, seeing a friend in such a familiar yet unfamiliar place. By the time I got there, the diagnosis was made, and thankfully, it was not a serious one. I stayed with her and her family, tried my best not to get in the way, and followed her course as a patient through the ED.

What's it like to see someone you know in the hospital? It's a strange feeling, traversing two worlds. On the one hand, I knew exactly what was happening; I knew the nurse, the resident, the attending, the medications, the abbreviations, the acronyms. I was a sort-of translator, acting as a mediator and an advocate. I held my friend's hand and reassured her that things were okay. I explained what I knew of the (presumed) diagnosis and what it meant. At some level, I acted like a doctor, tapping into my medical knowledge and my familiarity with the system.

On the other hand, I could not do it too much. It would have, for example, been entirely inappropriate for me to read her chart or her radiology films or her blood tests. I didn't want to step on anyone's toes. It was not my place to be impressing my opinions or judgments on her care. I tried to simply take the role of a friend; I didn't actively seek out the resident or attending to ask about things, I didn't leave the bedside.

As a resident, I sometimes find medical family members to be the most frustrating. They want to know everything - including things that probably should only be shared with the patient. They challenge medical decisions, they discount the value of residents, they cloud and bias our judgment. So I try not to be that person, but it's hard.

Reprise

What's it like to do the same rotation again? The ICU was my first rotation, and now it's my second-to-last rotation. I remember walking into the unit all bright eyed and bushy tailed, eager to learn, naive, and receptive. I was only starting to synthetize things, to problem solve, to fully understand the enterprise I was entering. The "complex" patients in the ICU were assigned to the residents; the "simple, straightforward" patients were doled out to interns. And I began to learn the structure and system in which we work. I was scared at night; I asked for help a lot; I was timid, and I tiptoed. I wrote down copious notes during lectures. My presentations overflowed with the extraneous. I looked for confidence, tried to make assertive statements.

Now, not even a year later, things have changed. Some are good - I feel more comfortable calling some shots, I have a better gauge on when to ask for help, I am a little more daring, I know what to watch for. Patients are distributed equally in the ICU, and even the most daunting cases I feel like I can broach. I know the names of the nurses and respiratory therapists and clerks. I know how to find the medicine ward teams, I know how to navigate the system. But other things are more disappointing: my thirst for learning is dampened, listening to lectures becomes very passive, and I'm not as energetic anymore. I'm sure part of that is the weight of intern year settling. And I hope that changes in a month when I start anesthesiology.

Humility

The ICU teaches us humility. It outlines for us those vague wispy boundaries of medicine, the borders between proven and unproven, known and unknown. It is the edge over which we look, it is the territory which we define ourselves. It takes emotion and draws it out on a line, the end of which we cannot see and almost know. The ICU turns science on its head, creates art from misery, enraptures us in fear. But it is also a place where we tumble into the depths of courage, where we transform, where we find love again.

Philosophy

I was a philosophy major in college. I recently found out from a friend and xkcd that you can start with any Wikipedia article, click on the first link, and repeat the process, and for 93% of articles, you will eventually end up at the Philosophy article. There is actually a "Get to Philosophy" article on this game (which of course leads directly to philosophy). Why everything ends up rooted in philosophy is a good question, and I find it terribly amusing.

Image of "The School of Athens" by Raffello Sanzio 1509 with Plato and Aristotle is in the public domain, from Wikipedia.

What the ICU is for

I wrote in a prior blog about iatrogenic injuries and described a gentleman who had an elective cardiac cath, suffered injury to his femoral artery, required massive transfusions, and had an ICU course complicated by abdominal compartment syndrome, renal failure requiring dialysis, respiratory failure requiring mechanical ventilation, and emergent vascular surgery. His course was extraordinarily tenuous, and with multiple organ systems affected, his prognosis was guarded. But this is what the ICU is for. All his injuries were potentially reversible with aggressive resuscitation. Over the course of the last two weeks, we've weaned his sedation so he can follow commands on a mechanical ventilator. We've monitored his heart closely with a pulmonary artery catheter and maintained his blood pressures on potent vasoconstrictor drips. We've assisted his breathing with mechanical ventilation. We've dialyzed him to take off the extra volume he received from his transfusions. We've fed him artificial nutrition and given him broad-spectrum antibiotics for fevers.

Over the course of the last two weeks, in managing many complex and interacting organ systems at once, we got him to the point that he could be extubated. We took out the breathing tube, turned off his sedation, stopped his blood pressure medicines, coaxed his kidneys back to life, and began a long course of rehabilitation. This was the most amazing recovery and reminded me why I like the ICU. The ICU has patients who have planned admissions after cardiac, vascular, neuro, or other surgeries. It also has some patients whose disease processes are so severe that there is no hope of meaningful recovery. But there is a small fraction of patients for whom it is miraculous. It makes the difference between death and a salvaged life. It is for this small percentage of patients who have reversible processes only with the intense specialized care of the intensive care unit that the ICU is truly the fulcrum.

Hungarian Doctor

I like this oil-on-canvas painting, "Hungarian Doctor" by Theodore Joseph Louis Geirnaert because it captures so beautifully the facial expressions of the doctor and the patient's family members (including the dog!).

Image is in the public domain, from www.arthermitage.org.

Procedures

Over the course of intern year, I've become better at procedures, even ones that I do rarely. There are several tricks I've learned, none of which have to do with the technical aspects. Like a mantra, everyone who's taught me to do a procedure says that position is everything, and now I repeat it to medical students. Positioning is everything. Anesthesiologists move beds up and down to a surgeon's fancy. I spend fifteen minutes preparing for an arterial line that takes fifteen seconds to get.

I've also realized, strangely, that confidence makes a difference. It's not easy to stick a needle or scalpel or tube into a person. But doing procedures eases that discomfort. And now at the end of the year, I feel more and more confident about my ability to do things, and with that, I find that my success rate is higher. Perhaps this is why surgeons have so much confidence; it's a self-fulfilling prophecy.

In watching multiple people do procedures, I learn a lot. Every person who supervises me has their own tricks and preferences, and I am sure that eventually, I will adapt an amalgam of these idiosyncrasies. But even watching people who aren't successful ends up being immensely helpful. I was watching one person attempt an art line several times and I deduced that the patient's arteries were quite superficial and so when I tried, I was able to accomplish the procedure smoothly.

"Comfort Care"

Some people see palliative care and intensive care as two ends of a spectrum. Palliation is the idea that all interventions are simply for comfort; we treat pain, discomfort, anxiety, shortness of breath, nausea, diarrhea, constipation, dry eyes. We don't necessarily pursue treatments that are curative of the patient's disease. But some things are borderline; sometimes, patients on hospice getting palliative care can still get chemotherapy because treatment of their cancer will relieve their symptoms. But for the most part, the focus is on comfort. On the other hand, intensive care has a reputation of pushing people to their limits, making decisions that incur short-term discomfort or harm for the possibility of long-term benefit, and pursuing invasive and aggressive intervention.

To some degree, these characterizations are true. But what I hope will happen in the next decade is a cultural shift to finding a more reasonable medium. Today, we had a patient who is on maximal life support with no hope of recovery. In morning rounds, our decision was to "continue full aggressive treatment unless the family decides to withdraw care." Is this appropriate? It's not up to me to say what is futile care or not. And it's not my call about what sort of life is worth living. And it's not my place to comment on whether resources are better spent here than elsewhere. But I want to venture a suggestion that we not look at this in such a black-and-white harsh manner. It is not that we can only pursue runaway intensive care without any recourse to palliation. Even if we don't know what intensive care measures to pull back, we can at least get the palliative care specialists to weigh in. And indeed, there was a recent study of lung cancer which showed that patients who were enrolled in hospice lived longer than patients who had aggressive chemotherapy. In any case, this is something I'm more and more interested in, and I think that it would not be odd or inappropriate to do a fellowship in both intensive care and palliative care medicine.

Mistakes

The feeling of making a mistake is guttural. It starts deep down inside. It's an ache, a throb, a visceral feeling. This is the sense of tachypnea; I can't catch my breath. I can't hold still. I can't preserve a thought. The nausea is overwhelming.

Doctor's Black Bag

I really like this postcard of a 16th century medicine chest as it captures some element of magic, mystery, and mysticism in a time before modern medicine.

Image is in the public domain, from the U.S. National Library of Medicine.

First, Do No Harm

"First, do no harm." This seems like an easy tenet to uphold, but here in the ICU, we occasionally see dreadful cases of iatrogenic harm; that is, problems caused by physicians. None of these are intentional or negligent; they are simply unfortunate outcomes that were foreseeable risks of the procedure they had.

When we get informed consent, we tell a patient or their surrogate of the risks associated with the procedure. Every procedure - from placement of an IV to heart surgery - has risks, and for all the large procedures, these risks include death. For the most part, these procedures proceed without a problem, but when a serious complication occurs, they come to the ICU.

We have a patient who had a bypass surgery but afterward, could not be successfully extubated; that is, we could not remove his breathing tube due to hemodynamic instability. Now, he has received a tracheostomy - an incision in the neck to allow access to his airway. He walked in expecting only one surgery, and now he's received another and has a prolonged stay in the intensive care unit.

How does the patient or family cope with this? Even if the best informed consent is performed, no one expects to go into surgery and come out worse off. Even if the surgeon performed everything as well as she could and this is simply an inevitable consequence or statistic, this is an awful outcome. I struggle to understand my emotions and my rational explanations of these circumstances, and I think families do as well.

Coronary catheterizations are incredibly common procedures to visualize the arteries of the heart to risk stratify heart disease or to intervene during a heart attack. Sometimes I think that cardiologists do them more frequently than indicated. But it was not until I saw a devastating complication that I have started to understand how this "simple" and "straightforward" procedure can kill someone. A patient walked into the cath lab for an elective angiogram and due to damage to his femoral artery, required massive transfusions, emergent vascular surgery, and now multiple life-support measures in the intensive care unit. After receiving so many blood products, his lungs began to fail. Then, his abdominal pressures started to climb. His kidneys could not filter out all the volume (and took a hit from the contrast). He went into heart failure. Multiple organ systems petered out, and now he may die.

A circumstance like this creates a profound emotional tension on the practitioners. We caused this. And that colors the picture. We feel immensely guilty about what happened, and we lose objectivity of the situation. As the picture became worse and worse, we were reluctant to admit it. We push the mortality statistic of multi-organ system dysfunction out of our heads because people who walk into the hospital for an elective procedure should not look like this. We avoid discussions about the end-of-life with family because that shouldn't happen, and yet it is happening.

Medicine is not a "safe" enterprise. Over the course of intern year, I've realized that we do good in this world, but not as much as I had thought, and what we do comes with enormous risk and responsibility.

Short Blogging Outtage

Oh, we've become so dependent on the Internet. Even services like Blogger, which I use to publish these posts, feel essential. There was nearly 24 hours of blackout when blogger services were down, and I didn't know what to do! How interesting our society is today - if we lose even a day of Internet or cell phone access, or we are unable to check our email, or we cannot pay or bills online - our lives are significantly disrupted. Who could have said how central Internet, wireless, electronics, and computers would be in our everyday activities? In any case, we're back in business so hopefully things will be smooth from here on out. That being said, I love Blogger; I've used it for the last 11 years and am completely satisfied with it.

Feedback

Feedback is incredibly central to learning. I do not mean the kind of feedback that program directors want to institute. They want us to sit down with attendings at the end of each month to discuss what we've done well and what we can improve. Attendings give constructive criticism on presentations, notes, and patient interactions. Certainly such discussions can be important, but I never got too much out of them, and indeed, when I try to give such feedback to medical students, I'm unsure how much I contribute to their education. Of course, this may be because we don't have great formal training on giving and receiving feedback, but that's a different point.

No - the feedback I find important - is that after a difficult call night when our actions, interpretations, and interventions are put to scrutiny. Overnight on call, I struggle with various problems and do my best to address them. But all that is laid open the next day when the rest of the team, the attendings, the consulting services look at what I did and either praise or criticize me. Last call in the ICU, we had a post-operative gentleman whose urine output had trickled off. In sending lab studies and looking at the clinical picture, I felt that he was dehydrated and underresuscitated in the operating room. I kept chasing after the urine output by giving him IV fluids. In the light of morning, the team and the surgery service looked at our overnight actions and the consensus overwhelmingly was that I gave too much fluid. Now, the patient did not come into harm - he was otherwise fine, and we got extra fluid off by diuresis - but that sort of feedback - standing up in front of rounds and saying that I gave 4L and coming under fire for that - made an indelible impression on me. That is how we learn as residents and house officers. And I worry a little that as medicine becomes shift work due to new work hour restrictions, this sort of education may become less and less important.

Poem: What's in a Name?

This is a rough poem I wrote during the last writing group. Right now, it's all one stanza and I'm playing with breaking it into parts.

-
What's in a Name?

Your identity haunts you forever.
The names you accrued through middle school
scribbled in yearbooks, sepia-colored,
rhymed alliteration of food-snorting incidents,
the ones that sent you to mother wishing that
identity fades in an instant.
When you close your eyes, engulfed in dreams
you see a new job, a new quest, new love, new ambition.
Eventually, you have enough dreams
to carve away self, discard old clothes,
move from home to the city where you find that
identity haunts you forever.
You can't dispense your accent, walk, mannerisms
and in a few months, a year, your skin doesn't feel right
and you beg parents to go home, to your bed,
to an old job, to a place where
identity fades in an instant.
The high school sweetheart is married,
the streets are different, your parents have changed.
Your friends no longer hang out at the coffee shop.
You exfoliate your skin every month and finally
you meet someone new and
your name changes
but your parents call you the same
for identity haunts you forever.
Now your parents are in your house.
You install shower safety bars,
find abandoned walkers a nuisance.
Jeopardy is always on
and the world outside seems foreign
fading like identity.
It's insidious; first an address, then a phone number,
then the year. You drive to the police station
where they've been picked up
and then it happens again.
Soon their eyes glaze
and they don't remember your name.
Your identity haunts you forever.
No, identity fades in an instant.

All-Nighters

After a few clinical years and months of call, pulling an all-nighter for something else isn't bad at all.

Retreats

The internal medicine residency program put together several day-long retreats for us, for some reason always at a winery. It feels so good to get out of the hospital and see friends in a non-work setting. An intern retreat early in the year involved a wine tasting, a tour, some horseback riding, and a BBQ. And then recently, we had a residency retreat where we had some skits and bonding activities. In groups, we parodied some situations in residency such as silly morning reports, ridiculous overnight calls, etc. There were a lot of exaggerations of program director mannerisms. In any case, it's interesting because during these retreats, someone else covers our patients in the hospital, either residents at intern retreat or fellows at a resident retreat. It's the only practical time during residency that an entire class can hang out together. And at both retreats, I had a fantastic and fun time getting to know my co-residents and enjoy some sun outside the hospital.

Back in the Unit

Coming back to the ICU is an interesting experience. Being in the ICU requires a different knowledge base and set of skills than any other rotation. The diseases, medications, complexity, and interpretation of numbers in the ICU far outstrips any normal ward rotations. Yet my intern year is comprised mostly of ward rotations and my two ICU months are spread apart. Since my last rotation, a lot of that quick ICU agility has atrophied. I am spending a lot of time reviewing things that once came quickly and naturally. It can be scary as the pace in the ICU is incredibly fast and dynamic, and keeping up with a coherent stream of thought can be challenging. Hopefully as this ICU rotation nears the end of my intern year, it prepares me for the physiology and acuity of next year.

Full Circle

At the end of each rotation, we have to "sign out" our patients to the oncoming group of interns and get sign out from the interns of our next rotation. My first rotation of internship was ICU and at the end of the month, I wrote a long email explaining the daily details of the intensive care unit at the VA. This month, I have a second month of ICU. In the "sign out" email from the outgoing intern, he writes, "Oddly, I think Craig may have written some or all of it back in block one." It's come back full circle! It's funny rereading my words, now edited as it's been passed along from intern to intern, almost like a game of telephone. It's also nice to know that the extra half hour or so in the middle of the night writing this paid off.

May Day

I was surprised to find that the growth curve of internship involves more emotional and personal development than gaining fund of knowledge. I don't think I learned many particular facts during intern year, but I learned a lot about myself, the way I handle stressful situations, the way I interact with patients, the way I perceive death and dying, and the way I have stepped into this new role and responsibility. As a medical student, I never lead a family discussion regarding the end-of-life care of a patient. I had observed many of these interactions and we had lectures on how to approach them, but I always took a passive role. Now, I realize what it means to plan out a conversation in my head, to tuck in other patients to minimize pages, to coordinate an appropriate location for the meeting, to acquire the right affect and demeanor -- all things that occur before even saying a word. I tested out the different approaches - taking control of the discussion versus asking the family what they understand - and now I know why it's recommended to solicit reflection from the family members prior to medicalizing the conversation. I've gained more insight into the depth of being a physician - someone who manages a whole patient - their fears, their hopes, their families, their sense of self. As a medical student, being a physician is about knowing the right drugs, interpreting numbers, producing differential diagnoses. But now, that takes a back seat as I learn to traverse those gray areas of what illness, death, dying, and recovery mean and as I learn to finesse the quiet moments of reflection.