Tuesday, December 09, 2008

In sickness and in health

I have to return to work in a few days and I am of course dreading it. It's not that I dislike my job all that much, contrary to some opinions. I'd say I dislike 60% and all out loathe 30% which means the remaining 10% has a shot at getting a compassionate, caring doctor like on TV. Do you feel lucky today? Yeah, me neither. By the way these odds are pretty much in constant flux so some days my patients are fucked the moment they cross the double doors.
I've been out of work for over a week now because I finally got sick enough to get myself admitted to the hospital and get surgery. There's an old joke that says that residents don't call in sick, we call in admitted. Unfortunately, it's fairly accurate. I've had gallstones for three years now that intermittently bothered me, not enough to do anything about. I've been dreading surgery because I'm afraid of the anesthesia and what I'll say or feel when I wake up. The last time I was sedated they were scrapping my son out of me and I haven't really recovered from that ( See my post http://erdoctor.blogspot.com/2006/12/whered-you-go-i-miss-you-so-seems-like.html) Then three weeks ago I spiked a temp, started vomiting and have had constant pain. we've been treating me as an outpatient because I have vacation in February and like all residents I am expected to save all family and medical crises for when I have spare time. How dare I expect time off, medical care, or compassion. This is a hospital dammit! Go somewhere else for that. We tried treating me with antibiotics, anti emetics and pain control in an attempt to keep me working. When I nearly fainted a work , we just hooked me up to an IV pole and I kept seeing patients. Some of you dear readers are laughing because you think this is in jest. NOPE, the jokes on you because I ran the ER strapped to an IV pole one night rather than getting sent home. In the last three weeks I have been shot up with Toradol and Zofran in every intramuscular spot imaginable. It reached the point where when I would drink a glass of water it would stream out my hips, buttocks and shoulders like a sieve. So I've been slowly getting sicker and sicker as everyone in the ER watched me get thinner, more pale and finally begin to make serious mistakes. The day before I was finally allowed to go home sick, I missed a pelvic fracture on an old man hit by a car. A nurse saved my ass when she insisted I walk over there to re-examine him as his blood pressure kept slowly dropping. This was her third time coming to me and I kept telling her to "just put up another liter" because I didn't want to walk all the way over to Bed 3. He was 80/60 despite three liters when I finally went over there and as soon as I touched his belly I knew he was in trouble. He got emergent embolization, transfused two units and sent to the ICU. All because I fucked up. Because I had no business being there in my condition. I knew it, all the nurses knew it, my bosses knew it. But such is the nature of medicine. We care for the tired, the sick, the huddled masses. We are here twenty four hours a day, seven days a week and all major holidays: Our doors never close. We don't turn anyone away regardless of ability to pay or country of citizenship. We are the place of last resort, the quintessential safety net. We will help you when no one else will....unless you happen to be wearing a white coat. Then you need to suck it up and get your ass back to work.
Our program in particular should have known better, had swore that we had gotten better after what happened last year. You see last year, one of residents had been getting more and more tired, had been getting slower about picking up new patients. Just not carrying her fair share, it had been agreed. Her co-workers of course did what we were expected to do. We rode her harder, picked on her, and threatened her with failing the program if she didn't get it together. She didn't. She ended up in another hospital's ICU on a ventilator, almost dead, with a diagnosis of leukemia. I still wonder what that meeting of attendings most have looked like when that tidbit of information came out. Did they feel like shit for even one minute or were they just worried about covering her shifts. I have my own personal thoughts on that one, but hey I'm a cynical bitch. She is doing okay now. If by okay you mean she will never have kids, she lost her house, and she has to finish her final year of residency or she has no source of income, no health insurance. She has trained her whole life to do one thing. And now everything she had been putting off and waiting for since medical school is gone, that the dream she had been reaching for disintegrated right when she could final touch it. She gave everything to medicine and like the selfish bastard it is, it just kept taking. Her heart is not into medicine anymore, not that I blame her. I know a little about what it's like to give yourself heart and soul to something and almost have it kill you, oh yes, I do. I imagine her story starts in a bright white room to the sound of a ventilator slowly pushing air in and out of her diseased body. But it is her story to tell, not mine.
After this we promised that we would be a more compassionate program. That we would have back up so that if someone got sick they could take time off to get better. That we could all attend funerals, births and weddings. Except we just failed our first test. For those of you who are confused about why this works this way let me explain. In our department there are only four true physicians who are working at one time There are two second year residents (R2's) and two third year residents (R3's) at any one shift and they are the work horses of the department. The R3's are one year ahead of the R2's and so can work pretty autonomously. I am an R3. I can intubate, run a Tier II trauma, run a code and stabilize critically ill patients by myself for the most part. I still fuck up a lot though, which is why I'm still in training. Compare this to an R2 who may or may not be able to put in a central line, may never have run a code by themselves, and have never seen a traumatic airway with blood and teeth and vomit obstructing your view. It's important to have at least two skilled docs on because multiple traumas pour in at the same time plus we get the sick medical runs. Now none of these people can wait, it is life or death right then and there. You need a doctor at the head of the bed for each of these and we barely make it with just four doctors on and only two seniors. If you take out an R3 then we have only one person on who has necessary skills to see sick patients and that's just not enough. Don't tell anyone, but We just can not do it. That's how we ended up with me running a trauma attached to an IV pole. There was no one else available at the time. Part of me understands it and part of me doesn't. There is no backup plan, no re-enforcements to call in when all hell breaks loose in the trauma bay, we just make do with what we have. And while that is happening fast track is being opened up and the charge nurse is having an aneurysm because the 20 year old with chest pain hasn't been seen yet, even though we all know they are not sick. Some shifts are a nightmare and some are no big deal and you never know what your going to get. That's why I'm dreading going back to work. I'm one week post-op and I' m not sure that I am physically up for the challenge.

And let's be honest, I'm angry. Angry that I was allowed to get that sick and no one gave a shit. My last shift I showed up to work febrile with a heart rate of 138. My white count was 19,000 and I was damn near septic. I was sicker than most of my patients and I still showed up for work because that was what was expected of me. Its hard to look at my attendings and not wonder why any of them did not put a stop to this sooner. Didn't put their foot down and insist that I go home. I feel like I've lost respect for people who I work for and that makes it hard to go back . Its hard to work for something that seems to care so much for everyone else but looks the other way when we need help. A system that works itself into a frenzy when a patient accidentally dies across the street but looks the other way when it's one of our own. Medicine is like a marriage, we take the good with the bad, faithful to it and nothing else. Putting it above our real families, our real spouses and our own children. But I'm pretty sure that last line, in sickness and in health, was never intended to be a suicide pact.


Anonymous said...

I almost can't respond to this. It's inhuman, and it's horrible, and it's endemic - and I 'm so sorry. I'll just say that I know something of what you're going through - don't let the bastards get you down. And keep posting - if enough people read this maybe something will change.

SuperBadJack said...


Tell your program.


My God! I know for a fact other programs do it!