Monday, August 14, 2006

The long wait

I know it's comming and there's nothing I can do about. There are two empty beds in the MICU and this can only mean one thing. I will not sleep tonight. There are comming. The Code Blue down the hall, the ER patient with urosepsis. All conspiring to seperate me from the necessity of sleep.
Only in medicine is it considered a badge of honor to go thirty something hours without sleep. Every other profession from piliots to the military accept that the human body has needs. That we are not mearly cogs in some great machine. Every one except medicine. And this is one of our greatest mistakes. There is nothing noble in what we do. Our patients are certainly not the better for it. Studies bear that out. Patients would be better treated by a drunk resident than one that has been up overnight. I've certainly made mistakes, and at any one time there is a least one patient here because of a medical mishap.
This notion of not sleeping is just a giant pissing contest that pre-dates modern medicine.
And yet it just won't go away. After high profile deaths efforts are always made to limit hours, to bring some semblence of normalcy to a residents life. And each time it is met with resistence from our attendings, our peers, sometimes ourselves.
So here I am tonight, sleepy as all hell, but not sleeping. Because I know as soon as my head hits the pillow I will get my new admit. So I wait for them to come.
Maybe then I can get some sleep.

Sunday, August 06, 2006

The First

Everyone dreads there first night on call and I 'm certainly not cool enough to pretend that I wasn't scared. For those not in the know, call means that you start work in the morning, stay overnight in the hospital and round again in the morning. It's about a thirty hour shift. The scary thing about being on call is that most of the people who know what the hell there doing leave around six, and then it's all you. The attendings make a big deal about the fact that you can call them at home so technically were not really alone. But if you believe that then I'll order you a psych consult.
Lay people also fool themselves into thinking " Hey, your doctors. What's the problem" Seriously though, we graduate as med students on a Friday and start work on a Monday. There's no great infusion of knowledge over that weekend, so one day we can't order an asprin without a co-signer and the next day were left overnight with critical patients. I highly advise you never to enter a teaching hospital in June or July. The monkeys are running the asylum. But I digress.

So I'm on call in the ICU and I have known my patients for about four hours. Just long enough for me to figure out there names and ventilator settings but not long enough to get used to the incessant beeping of alarms that is the background music in any ICU. My resident, whose job it is to orient me and make sure I don't accidentely kill any one, has clinic and will be gone for the afternoon. Ummm, I'm not really sure this a good idea. And sure enough out comes the nurse from Bed 8 " Mr Alberto has a pulse of 180, blood pressure is 70 over 40 and he's sating (O2 saturation) at 73%. What do you want to do?" What do I want to do: RUN. I don't know what the fuck to do, are you kidding me. I've never felt that inadequate in my life. I walk in the room and sure enough, things are as bad as the nurse says they are. "Page the resident" I order with some semblence of authority in my voice. Vague recollections of orientation are comming back to me, but I can only remember the drugs we give when the heart stops or slows. Not exactly the case I'm facing now. And then I remember that I can give a beta-blocker, a wonderous drug that slows the heart rate and is generally not all that dangerous. So I push my drug waiting for it to fix things and nothing is happening. My patient still has the heart rate of a coked-up hummingbird. My resident calls back and as calmly as I can fake I explain that things have promptly gone to hell upstairs. "Well did you give Metoprolol" he says. "Of course I did" I answer, like how dare he think I don't know what I'm doing. "And it didn't work" Umm, no. "I think you should come up here" Now he's pissed. That whole discussion of how we can call for help when we need it-total bullshit.

My resident heads back to the ICU, walks in and says "This isn't good". Yeah, I'm pretty sure I had already made that determination. Can we move on to the 'How to fix it' portion of the conversation. Out comes a whole arsonal of drugs that I clearly have no idea how to use. We push dig, we give dilt, nothing works. Then the Cardiology team comes wandering in and announces to the world that we need to break this rhythm. I'm going to file that under the "Duh" category. We tell them what we've tried and that nothing has worked and they offer a simulataneously exciting and terrifying option:Cardioversion. Cardioversion is shocking the heart and hoping that when it restarts it decides to beat like its supposed to. It freaks us out because in rare instances you can shock it and it doesn't restart. As the new intern I get to be the one who cardioverts. "Charging 100. Charged. Clear" Blam 100 joules hits the guy and he jumps of the bed. We all stare at the moniter and see the most wonderous sight. Normal sinus rhythm at a rate of 83 beats per minute.
This is that part in the movie where we all walk away and congratulate ourselves for a job well done, but I'm an call. There is no walking away. I'm going to be taking care of this man all night long, by myself, and he could probably do this again and again and again. And next time my resident will be gone and Cardiology won't be in house. I started my call night scared. And that's where I stayed all night long. White knuckling it until the cavelry arrived the next morning. In spite of how hard I can try I will never be able to properly articulate what momments like these do to the soul. Its easy to say well everything worked out, and it did. But looking back I can laugh and joke, but that night was so terrifying. Our only goal is to keep the patients alive until the morning, and you can't fail at that. You can't fail as a doctor. This year is going to be so painful, because I will fail, and people will die. And I will never forget that feeling of just wanting to run and knowing that I couldn't. I cried the entire way home from the hospital.
I'm on call again in three days.