The last day of ICU

Today was my last day of the ICU rotation. I have to say that I actually learned very little on my rotation. I learned how to write an ICU note. That was something. I learned that despite what everyone says, common things occur commonly.

Today was a very... stupid day. I caught five or six things today that were just silly. One patient had two H2 blockers. Another patient was on heparin and actively bleeding. Another patient had meds that the pharmacy didn't send up. One patient was NPO and getting scheduled insulin. It was just a string of stupidity today.

I greatly confused a nurse today. She needed a boost, but she walked right past me. If you've never met me, I'm a pretty big guy. So I stopped her and we boosted her patient, and that was that, but I think it's sort of... a sign of the times, y'know? I think that a lot of docs and students think they're too good for this sort of stuff.

It's like we were putting in a Cordis, and I can assist someone in a sterile field just as well as a nurse. It takes all of one hour to learn how to maintain a sterile field. And the nurse was surprised at me.

Maybe it's because my mom is a nurse, but whenever I work with nurses, I'm always on my best behavior. I realized one day that nursing is a really tough job, and I should try to be helpful if I can. I mean, why does some nurse need to waste time helping another nurse boost a patient when I can help? Why does a nurse need to stand around at a simple procedure when I can do the same thing?

I thought I was the only person that did this, but I discovered that M was also guilty of doing this stuff, and in fact did much more of it than I did. I think that's why I liked working on rotations with M. We both were eager to do things that had absolutely no teaching value, but were things that were... good-natured.

I thought about it a long time, and I used to think that a lot of my attendings liked me because I was a hard worker, but I discovered that this is not really the case. It's the willingness to do something that really has no value to me whatsoever. It's that I would talk to families of patients on my own. It's that I would stick around late and help out. It's that I wouldn't leave until I'd done what I said I would do. It's that I actually cared. It's that I'm still sad for the wife of a patient I saw who blamed herself for her husband's death. It's that I'm still angry about an aggressive workup on a brain dead patient.

I was thinking today about how devastating oncology was for my mental wellbeing. I was thinking that I'd said that I could never do it. I was thinking today that it's not only a field I could do, but one that I should consider. It's got a healthy amount of intellectual stimulation, but moreover, it and general medicine are two fields where your relationship with your patient can be more valuable than any treatment you have to offer. Y'know the truth of the matter is that I think I could be a decent oncologist. It's simply a matter of whether my heart could stand it.

Zebra hunting

One of my patients died. I was very... angry about it. Well, not angry. It was just that... we did a ton of workup and treatment on a guy that was toast. Y'know, it's very frustrating to be in a setting where we almost don't know when to stop. To me, my patient died at 6AM. The death certificate I'm sure will read sometime in the evening. The family was all torn up about it, and I guess I can understand. I'm torn up about it too.

Y'know, the one thing that I learned in medicine about life is that I'd like to die with a little dignity. I've seen too many people die too messy a death in the hospital. When I go out, I'd like it to be a little less nuts. Y'know, we spend our entire careers in medicine battling the inevitable.

Still, I went down to the coffee cart to try to get an espresso after work, to take the edge off the horrible taste in my mouth from knowing that my patient was alive yesterday and is dead today. I'm not sure if you've never been in medicine that you can really appreciate what it's like to know that someone in your care has done exceptionally badly, and is now dead. You detach yourself. You harp on little things.

It's impossible for me to concentrate, so I spent tonight playing America's Army. It's better than thinking about the whole situation and my aggravation with it. Y'know, the guy is dead, and we're still hunting zebras on him. And everyone feels comfortable with that, and that's the part that bothers me the most.

Y'know, I've greatly disliked my month in the ICU, because it has single-handedly gone against everything I've ever thought about medicine. We order million dollar workups on everyone that comes through the door. We order so many tests that tracking them all down is next to impossible. We order tests that take days to come back for questions on acute management. Everything in the ICU is a zebra. We spend no time with the patients. I've actually written a note on a patient, and only realized after rounds that I had not done a physical exam. We treat numbers almost exclusively.

I wish I was back on my sub-internship. I liked seeing my patients. I liked taking care of them. My ICU patients, a good number of them got better, but I certainly don't feel any better about it. And maybe that's because I really can't say for sure that we actually did anything to help them. I'm willing to bet that aside from the vent, they did it all themselves.

My resident couldn't believe I wanted to do general medicine, but the thought of doing critical care for a living makes me nauseous. Y'know, people talk about lifestyle and pay and all that stuff, but in the end, you have to do a job that at the end of the day, you can go home and sleep at night. I think about the ICU, and it makes me ill.

I have so many criticisms of my ICU experience that I wouldn't know where to start, but I guess in the end, my biggest problem with it is that you would think that the ICU is where you get the absolute best care in the hospital, and the truth of the matter is that if not for the nurses, I'd never admit anyone to the unit.

Pay it forward

Of all the things I learned from medical school, my best lesson was from M. She taught me something that was more valuable to me than all those lectures and attending rounds and didactics and whatever. I learned from M that it's one thing to meet the standards expected of you; but you've done nothing unless you've met the standards you expect from yourself.

It's not okay to do just enough. It's not okay to skate by. You must be the best that you can, because any less and you'll know in your heart that you came up short. It's why I end up doing a lot of things that I used to make fun of M about. I saw one of my patients this afternoon. I didn't have to. The nurse even looked at me funny. Why was I even there?

I was telling a friend of mine that I'd endeared myself to some of the nurses because I'd given away so many pens and goodies that I got from drug reps. He seemed intrigued by the idea, till I told him that I gave away the good pens, the metal ones. In the medical student world, nothing's better than those metal shaft drug pens. I have given nearly all of them away. He stopped listening to me at that point. He wasn't going to give away the metal ones.

I was dumbfounded. I paid nothing for it, and I could make someone's afternoon by just giving that person a pen. Think about that for a second. We live in a world where I can give someone a pen and make their day. What a simple gesture. There's a wonderful quote by Emerson: it is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself.

I was leaving a conference, and the lunch had been picked over. K had come late and hadn't gotten a chance to eat anything. I had saved my sandwich for later, and I gave it to him. He thanked me profusely. Y'know, that's life right there. That's what life is all about. You share what you have. There's a passage in the Bible that I've always liked, Matthew 25:40. "Whatsoever you do for the least of my people, that you do unto me."

In my life, I've always done what I felt was right, not because I had to or because I thought it'd be good for me in the end. I've always tried to do what's right because it was the right thing to do. You know, life is full of uncertainty and doubt, but if you follow your heart, you'll never go astray, because the heart will never be wrong. I do what's right because I have the sincere belief that the only way to make this world a better place is to make it a better place, one day at a time.

So I lead my life the best way I can. I always act with the best intentions. I always try to be the best person I can be. Because while other people are content to sit on the sidelines and criticize the world, I want people to know that life is what you make of it, and that you can only reap what you've sown.


Y'know, normally, I am a bit of a social butterfly. I used to go to a lot of parties and such. Recently however, I've been very antisocial. Truth be told, I'm sick of dealing with other people. Honestly. Anyway, I mention this because tomorrow I'm going to a get together, and my heart is just not in it. I think to myself that I could just skip it and take a nap. And somehow, that sounds like a good idea. I'm not sure what's wrong with me lately. One of my housemates keeps asking me if I'm doing okay. I'm actually doing pretty well. I just don't feel very upbeat.

Maybe I'm not okay. That's a distinctive possibility. Maybe I'm depressed (unlikely) or despondent or something. Maybe being surrounded by all this death is jading me to existence. I don't know. All I know is that I could skip out on the festivities tomorrow and not feel bad about it.

The thought occurred to me that maybe this is not something I should frown upon. I've spent all this time getting back in touch with who I am. Why should I question now what I've spent so long reacclimating to? Maybe this is me. Maybe I really am a 'goes to the movies by himself' sort of person. I know that I'm getting back in touch with my utter preppiness. I'm dying to wear my new sports coat, or even the old one really.

You know, in the process of getting to know yourself, you end up doing things to test just who you really are. And a lot of it is simple self-indulgence. I don't feel like doing this, so I won't. I don't feel like getting out of bed, so I won't. Let it stew. Let it fester. Eventually, you discover what gets you, what moves you along.

The one thing that I learned about myself is that I place no value in praise. I've won my fair share of awards and recognition. Today my senior told me that he really appreciated that our lists were so up to date, and on all the services he'd been on, he'd never had a list so well done. I'm sure he meant it in a complimentary way. I couldn't have cared less. Why should I be praised for doing what I'm supposed to do? That's ridiculous. If I did something outstanding, then sure, I would like some thanks. But please, for doing what I'm supposed to do, I expect nothing. I've always believed that when someone trusts you to do something, that's sacred. That means you do it, and you do it right.

It's why I've never felt comfortable when attendings tell me that I'll make a good resident. Their opinion is based on the fact that I do what I'm expected to do? Would you congratulate your computer for not crashing? Would you reward your heart for beating? There shouldn't be a reward for doing what you're supposed to do. One of my friends in college was right about me. I'd make a terrible boss, because I expect things to be done, because it's what I'd expect from myself.

And I realized that to myself, I'll never be outstanding. Never. Every time I achieve something notable, I'll always know that it was simply what I should have done anyway. No matter what the world says, I always hold myself to a higher standard. And I think that something my mom told me when I was 12 is sort of the truth behind me. I got a C in one of my subjects, and my mom scolded me. I told her that I tried. And she looked me in the eye and I knew that she could see right through me. "The important thing is that you do your best." And that's the standard I've always held myself to.

Maybe that's why I'm so disappointed with myself sometimes. It's the knowledge that I have not done my best.

On a side note, I helped a couple ladies push their car into a parking lot today. I drove by them and I had to stop and turn around, because in my mind, I knew that if I drove away, I wouldn't be able to forgive myself. How could I call myself a God-fearing Catholic if I drove off without helping a couple women with a broken down car? Y'know, medical school has taught me one thing about life: if you don't walk the path, it doesn't matter that you know the way.

RRC in the ICU

The other student I'm with seems to be enjoying this rotation. I on the other hand am dying. It reminds me so much of my time on vascular surgery, the rotation that convinced me that I wanted nothing to do with surgery. It's criminal what we do to people. I can think of no greater humiliation than dying with a foley and a rectal tube, a decubitus sacral ulcer, and some med student breaking my ribs doing compressions while the intern warms up the defibrillator.

The ICU is not the real world. That is what bothers me the most about it. Everything that happens in the ICU is like medicine practiced on crystal meth. It's the last 30 seconds of a basketball game played for the whole game. It's a hockey game that's 60 minutes of power play. I can't get into it. I can't appreciate it.

I did the math and for an ICU rotation, the residents are actually doing pretty okay. It's not q3 overnight call. There's more than one intern covering a service. Caps are enforced. So when residents complain, I'm just not sympathetic anymore. Medicine isn't supposed to be easy. It's hard. And ICU is the hardest. At some point, you've got to say that there's a limit.

A lot of people in my class are going into radiology and emergency and other fields that are basically shift work, and it depresses me. Medicine should not be a job. It's a profession. Mechanic is a job. Electrician is a job. Plumber is a job. Medicine is a profession, and that means something. It's ridiculous to ask someone to work 80 hours a week, but life can be pretty ridiculous.

You do what you have to do. I've never left the building without updating my patients on the list. That's simply being responsible. Today, my senior told me to go home, and an hour later, I was still there. I could've just left, but I refuse to leave the hospital without doing what I was supposed to do. It's my responsibility, and if I expect to be taken seriously, I have to act serious.

My senior has been sending the interns home early recently, and while I'm sure I'd be thankful if I was an intern, I'd also resent it somewhat. When you're on a team, you work as a team. That's the way teams work. You don't see a pitcher in baseball happy to be taken out of the game.

It's tough to put into words what I'm trying to say, so I'll stop here, and note that I had a successful radial stick for ABG today. Nice.

Stuck in the hospital

Last month, one of the nurses took to calling me doctor. I informed her, on several different occasions, that I'm not a doctor yet. Her reply was that I would be soon enough, and she loved the startled, panicked look on my face when she called me doctor. After all, I'm not very used to it.

For those of you not in the field, being called 'doctor' by others must sound somewhat appealing, but anyone who's been in the hospital knows that the only time someone calls you doctor is when they want something from you.

I've learned that I can only be so upbeat. After doing two months of inpatient back to back, I'm pretty tapped. I just want to get done and go home. I can't be a gunner right now, as much as I'd like to. I'm too tired. I just wish this was all over, but what I've come to realize, to my horror, is that it'll never end until my retirement party. I didn't get home to 8 PM tonight. How nuts is that?

It's all about trust

I completed the nomination forms for graduation awards for clinical faculty and students. The docs that I nominated were folks who I thought deserved it, but my votes for students were not exactly predictable. I would guess that none of the people I voted for have any chance at winning. At the onset, I tried to come up with a set of qualities and traits to rank people, but in the end, it really just boiled down to trust. Do I trust this person?

On my sub-I, I consulted an attending whom I'd worked with before. I told him about the patient, and he took my presentation at face value. He didn't have to. I'm a student. As an attending, it's his right to talk to my attending, or my senior resident, or even my intern. He doesn't have to take my word for it. But he trusted that I was giving him the whole picture, and that I would follow up on what he had said. And that's something.

Attendings have the liberty of avoiding scut work in house, but they have to trust that the residents will get it done, and rely on the work of the residents to base all of their clinical decisions. That's a lot of trust. Some attendings don't trust the residents or students at all. I know several attendings who repeat the entire comprehensive physical exam on every patient they see. Some check all the labs themselves, not trusting that the numbers we've written in our notes.

Everything after trust can be worked on. You can teach a person knowledge and judgment and clinical skill. You can't teach someone to be trustworthy. And that's why I didn't vote for some of my classmates. When the rubber hits the road, I just don't trust that they'd get the job done.

As an example, on my sub-I, there were a couple personal emergencies, and as a result, I was the only person on my service. No senior. No interns. I had to work with an intern pulled from another service to emergency cover. As we rounded, it became plainly obvious that the lists for the patients were not up to date, and we were paralyzed because we were spending all our time figuring out what medications our patients were on. The 3rd year students are supposed to keep those lists up to date, but they hadn't been keeping up.

After rounds, I had a talk with my students. I was nice. I said that it's important for them to keep their patients' lists up to date to avoid what happened. And from that day, I watched the list. There's truly no better, objective measure of a medical student than asking him to do the most trivial task on a daily basis.

When someone follows through on that, you know that you've got a winner. Because that student has shown the desire to earn your trust. And if someone can be trusted with minor things, than perhaps he can be trusted with greater things. And when a student doesn't follow through on something as simple as updating a list, that tells you something too. If someone can't be trusted to do something as trivial as update a list, how can he be trusted with something major, like the lives of his patients?

One of my students, my gunner, she was great. I could ask her to do something, and I knew that she would do it. She called people. She got old records. She tracked down a patient's baseline creatinine. She got the name of a patient's psychiatrist, of all things. She's a 3rd year, and she's got a ways to go with history taking and that stuff, but you can learn that crap. You can't learn being trustworthy. If I was a resident, I'd take her as my intern any day of the week and twice on Sundays. If we were picking teams, she'd be my first pick.

My slacker, it got to the point where I just couldn't trust her to get the basic stuff done: writing notes, updating the list, checking the labs, stuff like that. I had to ask her every day if she even saw her patients. I blame myself to some extent. I should've corrected this behavior from the get-go. But the heart of the matter is simply that I couldn't trust her.

So I'm glad that some of my classmates are going into fields without direct patient care or are far removed from internal medicine. I'd rather work with people I trust. And that's how I voted for the graduation awards. Despite all the flourish and prose written to encompass the awards, to me it boiled down to this: who would I trust to care for me? And when presented with that question, the answers were quite simple.

Medicine treats disease. We do not 'help' anyone.

The ICU is not for me. I know that now. There's something so... unsatisfying about taking care of a patient for only a few days, and then turfing that patient to another service. One of my patients made it out of the ICU, despite our best efforts, and I can't help but wonder what will come of him. It's like another patient I have from last month. He's still in house, and I keep meaning to visit him, but I don't have the time. I wish I could see him. I feel like I should. And that's how I know I'm meant for primary care. Because the thought that I'm not going to follow a patient is sad.

On the slacking front, it's become next to impossible to slack. I'm trying to slack, but there is just so much work to do. I'm only following two patients, but it adds up with other patients. Find this lab. Write this order. Do this. It's making the interns' lives a little easier to have another set of eyes and ears to catch the little stuff that slips through, but this rotation is one of the busiest I've ever done.

And I know you're saying to yourself, it's the ICU, man, what did you expect? Well, honestly, I expected that I'd get to be a medical student again. Instead, this rotation is far more like a subinternship than my actual subinternship.

I keep seeing attendings that I've worked with before. Uniformly, I get the comment that I'll make an excellent resident and that they hope I stay. Y'know, everyone tells me that I'll be a great resident, but I know me. The aspect of medicine that I excel at is just the work. I work hard. That's all. I think I know less than most. I just try to keep at it. I try to move things along.

We had a lecture about goal-oriented care, and I thought it was pretty stupid, because it's something I think about every day. We do all these things to patients, and half the time, I question who we're really treating: the patient or ourselves. In the end, I applied to medical school thinking that I'd get to help people, but most of the time, we don't help too much. It's mostly trying to hold back the tide. And the only rewarding part of that is knowing that at least you tried.

I had a patient who was put into Hospice care, and I was glad. Glad that we avoided putting in a PEG tube, putting in a trach, and doing all those things that make me hate medicine every day. I had always thought that the role of medicine was to help people. It's only now that I understand that the role of medicine is not to help people but to treat disease, and that is not the same, not by a longshot.

Don't be single on Match Day

I RSVPed for my school's Match Day reception. Just me. That's flat out depressing. It's not that it's depressing that I'm single. Nah. The depressing part is that there really is no one in a 500 mile radius that could come to this deal who gives a rat's ass about where I go for residency. There's something infinitely disturbing about the thought that no one really cares where I do my training. Someone should care. Someone should want to be there. And I think ultimately this is what disturbs me the most about being single. There's no one to share things with. There's no one to share the good times with, or to weather the tough times with.

I'm sure my family is interested. But interested is a long way off from caring. It's not like where I go will affect them all that much. I'm not going to train near any of them, based on my rank list, so it's sort of a moot point where, really.

It just seems sort of unfair that one of the biggest decisions in my life should have so little impact on anyone else. To any other medical students reading this that are not 4th years, I'd suggest getting yourself a boyfriend or girlfriend to have for Match Day. And maybe you'll end up matching in a program so far away that you'll be forced to break up, and that's okay, because someone should view this decision as huge other than yourself.

When you're the only one who cares about where you match, the decision begins to seem as trivial as whether you super size your extra value meal or not. I was talking to my friends about Match Day, and someone mentioned that he'll be on the phone for a lot of Match Day, telling people where he's going. It dawned on me at that moment that I hadn't even thought about informing my family or friends. It's become meaningless to me, just another excuse to get out of a day of rotations.