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.