Get me out of this ICU!

During my Saturday shift, I kept thinking of all these great topics to write about (starting at 5am when I was wondering if I was the only sober one on the highway, and why I was the only one who hadn't had a fun night out the night before), and since I was there a solid 12 miserable hours, the list got really long.  So I've decided to compile all those thoughts into one-liners in one blog, because if I did an entire post for each it'd be really boring for everyone else.

Thoughts from my Saturday shift in the ICU:

• I'm 25, I shouldn't have to work 80 hours a week
• A resident stole my favorite pen and then lost it, and spent the rest of the day complaining about how she couldn't find "her favorite pen"
• I presented a patient to the team on rounds, remarking that at the time I listened to this patient's lungs, there was no wheezing but that at points overnight it had been recorded, then the nurse jumped in and very brazenly stated that she had heard wheezes every time she listened.  Seriously, this is why doctors and nurses do not get along.
• As a medical student you get to do several things: paperwork, assist on procedures (handing things to the resident, running the machine, etc), do a physical exam, etc. But then you become a doctor and literally the next day you're supposed to know how to do the procedure and what tests to order (not just how to do the paperwork to order them).  Patients need to understand that essentially there's no difference between a new resident and med student, and that if they want to have good care later, they need to let the med student do it now, because in a year that med student will be told to do that procedure as a resident alone and won't have ever done it before. 
• The hardest part of being a third year med student is knowing when to speak and knowing when to shut up. Yesterday there were a few things that I saw not being addressed (like funky EKG rhythms) and little to-do's that were forgotten.  I feel like the worst student in the world when I bring them up, because everyone rolls their eyes and now has an obligation to take care of it.  Not sure I'll ever get to the point where I don't feel guilty about this.
• I think nurses have a huge role in patient care, but they work 3 12-hour shifts a week.  When they come on shift, they aren't sleep deprived or starving like med students and doctors always are.  We work twice the hours as they do, and I think it's difficult for them to realize why doctors are sometimes cranky.  I know it's hard to deal with, but when you only work 36 hours a week I don't think you should have the right to be rude/cranky/obnoxious unless circumstances are dire (super-jerk doctor).  I know they have families, but so do doctors.
• Scrubs outside the hospital: yesterday I had to get something for dinner after work, and I hate going places with scrubs on but there was no way I was going home, changing, and then going back out after an exhausting day.  Nurses fall into two schools of thought: "I wear scrubs EVERYWHERE" (even to the gym) and "it's blasphemous to wear scrubs when you set foot outside your hospital unit." I agree that it's tacky to wear scrubs in public (especially at a bar), but honestly, when am I supposed to do errands???  We work 80 hours a week.

Ok that was most of my rants from Saturday. 

I keep a blank piece of paper in my pocket at all times for note-taking.  Here's a sneak peek into what the notes of a med student (may) look like!

A closer look:

The final transcribed version in my little notebook of pearls, a collection of bits of wisdom from much more experienced doctors:

It's not every day that someone tells you that you are dying

I've been in the ICU for a week now, and it's pretty insane.  As a former paramedic, I saw a lot of death.  But it was more detached- I either saved them or I didn't.  And then I dropped them off at a hospital.

Now it's a whole different story.  I thought that after five years on an ambulance, I'd learned and grown as much as one possibly could in terms of dealing with death.  But I was totally wrong.

The difference is now I'm dealing with people who are in the process of dying.  This is completely different than death, and honestly I think it's a hundred times worse.  Many of the patients are terminally ill, and come into the hospital thinking that they're just experiencing a bump in the road, that death is still always a comfortable distance away.  But it's pretty obvious to us that it's not.  It's almost frustrating that families see them admitted to the hospital and expect that since they weren't sent home with hospice that we'll just give them some medicine and send them on their way, back to living in that limbo of terminal illness indefinitely. 

I know it's easy for me to be critical because I haven't had to experience it personally, but I hope that if I do at some point, I will be able to remember at least a little of my current perspective.  Because honestly, what's best for the family isn't always best for the patient.

Healthcare professionals do a horrible job with end-of-life care, always asking, "Do you want us to do everything?"  This question has one answer: of course.  (Ok, unless you're about to inherit a bunch of money!) Then we stick tubes and needles in the patient, hook them to machines that beep and pump and rumble, and ironically the decision becomes infinitely more difficult.  We can keep people "living" like this for years (remember Terry Schiavo?), and every day you have to ask yourself, do we stop the patient's suffering or do we hold out for that impossible miracle?

One of the doctors reflected on it, remarking that we are treating people like science experiments, pumping things in them and seeing what comes out, because we don't really know how to make them better at this stage of their illness.

Doctors are getting better about giving options now- giving antibiotics, medicines that may help, but suggesting that certain futile measures be withheld. 

Yesterday a patient came in, talking and alert, but not feeling well.  He knew his disease was terminal, but he thought he had a while to live, but we found out yesterday that his cancer had returned and was overwhelming his body.  When asked during a procedure how he was doing, he turned and looked at me and said, "It's not every day that someone tells you that you are dying."

I had no idea what I'd say to that.  The doctor stopped what he was doing and responded, "Maybe this is a good thing.  I could walk outside today and get hit by a car, and I wouldn't have had time to get my affairs in order or say goodbye to my family."  I know it was hard to hear for the patient, but the doctor is right.  Now this man can make sure that his death is dignified, that ridiculous measures aren't carried out, that his suffering isn't prolonged. 

Another patient of mine unexpectedly became seriously ill, and now his wife is having to make all these gut-wrenching decisions about what she thinks he would have wanted, all while trying to accept the fact that she's about to lose the love of her life.

Listening to the doctors talk among themselves, you begin to see that the easiest families to deal with are the ones who are able to put their own feelings aside for the good of the patient.  It may be a tiny bit easier when they've been suffering for a long time, but it's never an easy decision to turn off life support or agree to a do-not-resuscitate order. No one wants to be responsible for letting someone die, when they aren't 100% sure that that person couldn't have been saved.  But in this time of advanced technology, people rarely just die anymore.  

Advances in medicine are mind-blowing, saving lives and improving quality of life.  But they also change the definition of death and dying, and now more than ever, loved ones are having to take responsibility for end-of-life decisions.  

Why did I pick this career again anyway?

Almost every day I have a thought along the lines of "Why didn't I become a ____, instead?"  Usually the blank is filled with nurse or secretary, today it was person-with-a-desk-job and anything-but-doctor.  Thinking about it a bit more, if I had to list all the characteristics of a my dream job, almost none of them would describe what I'm doing now or what's in my future.

Characteristics I DON'T want in my dream job:

1. Lots of classes: FAIL.  Grade school, college, med school.  Twenty of my twenty five years on this planet were spent as a full-time student.

2. Lots of tests: FAIL.  Grade school, college, med school.  In med school you have 8-hour exams every six weeks for three of the four years.  After the second year, you have a board exam (also 8 hours, but requiring approximately 4-6 weeks of studying 8 hours/day), after third year you have another board exam, then another board exam during intern year, then another to become board-certified after residency, and then to become board-certified after fellowship. Then you have to renew this board certification every ten years for the rest of your career.  Why didn't I become a board exam maker/grader/whatever???

3. Long hours and night shifts: FAIL.  I'm one of those pathetic people who needs eight hours of sleep per night.  And I really shouldn't wake up before 6:00am also.  Too bad I've got about 8 more years ahead of 80+ hour work weeks with lots of night shifts.

4. Lots of confrontation: FAIL.  I am all about everyone being happy.  I'm the one who after the first sign of disagreement goes, "OMG YOU'RE TOTALLY RIGHT," in order to have to argue.  Medicine is full of confrontation and unfortunately not the field where you can back down when someone's life is on the line.  Luckily, I'm pretty motivated to just do the right thing on my own.

5. No early retirement: FAIL.  Ok the problem is two-fold: first, I have an inordinate amount of debt and will have to work my until I receive social security just to afford a decent living after paying it all off.  Secondly, I'm a very Type A person and will die as soon as I stop working (like sharks that stop swimming) so I'd like to prolong that as much as possible.

6. No opportunity for advancement: FAIL.  Medicine is such a snowballing field (lots of new research published daily) that you're rarely on the leading edge.  I really don't want to do research and most instruments and techniques have already been named so there's not much else to hope for.

7. Constant change: FAIL, FAIL, FAIL.  This is probably my biggest one. I would be perfectly happy to get a job today and do the same exact thing in the same exact place in the same exact way for the rest of my life.  (Ok, not exactly.)  But really, I'm not a big fan of new places, new people, new environment, new rules every month or so.  However, this is what becoming a doctor is all about.  In med school you rotate every 6 weeks, in internal medicine residency you rotate every month (July 1st isn't the only bad day to go to the hospital people..), in fellowship you rotate every month or two, then you have a new job.  That's a lot of freaking change.

I just googled "characteristics of a dream job" and found a poll where you vote for your top choice.  "Creative freedom" and "flexible hours/workplace" were definitely the top two.  WTF?!

Dangerous Water

I actually heard this conversation last week in the office.


Patient: Doctor! I'm having these symptoms [of heart failure] that are listed as side effects of my heart failure medications! So I stopped taking them!

Cardiologist: Actually those symptoms are due to your heart failure.

Patient: But I have every single one!

Cardiologist: Those are also the side effects listed for WATER.

They done "GERD:" an amazing acid reflux fix

Medical technology follows the same rules as everything else: sometimes the simplest ideas are the most brilliant.

GERD (acid reflux) is often a result of an incompetent muscle at the end of the esophagus where it meets the stomach.  It should be able to constrict to prevent food (coated in nasty stomach acid) from "refluxing" back up.  This is why people complain of burning after eating.

One of my few soapboxes (I feel entitled to one or two more each year that I've been in medicine, so I only have a few, but they're important and evidence-based!) is about reflux.  It's a known fact that untreated or poorly controlled reflux can sometimes lead to cellular changes in the esophagus, causing Barrett's esophagus which is basically pre-cancerous.  So preventing reflux (by watching what you eat, and taking the over-the-counter medications) you can actually help PREVENT esophageal cancer!  Of course, like most other things, just because you prevent reflux doesn't mean you are 100% protected against cancer (like non-smokers can still get lung cancer), just to protect my reputation here.

A quick interjection: esophageal cancer is horrible.  Treatment often involves surgery and chemotherapy/radiation, neither of which are pleasant, to say the least.  After surgery, you are left without a stomach- the stomach is actually pulled up through the chest to replace the esophagus.  This leaves you unable to keep much food down at a time- you must eat frequent, small meals, and have a lifelong propensity for nausea, vomiting, pain, and lots of other problems.

So I got really excited when I saw this new device, which is basically a ring of magnets that is placed at the bottom of the esophagus!  When the problem causing the reflux is a muscle that doesn't constrict properly, how brilliant is it to help it out by putting a circular magnet there?!  Anyway, in people who still have reflux despite medication and diet modification, it has been shown to lessen and sometimes eliminate symptoms altogether.  I don't think it's FDA approved yet but there are research trials currently.

Just some "food for thought!"

The complete cardiothoracic surgeon

Published in The Annals of Thoracic Surgery in 2004.

The complete cardiothoracic surgeon: qualities of excellence

1. The first quality of a complete cardiothoracic surgeon is that of being an excellent surgeon

2. The complete cardiothoracic surgeon of the second millennium must have a detailed knowledge of cardiorespiratory physiology

3. The complete cardiothoracic surgeon must also be an excellent teacher and have a knowledge of cardiothoracic surgical education

4. The complete cardiothoracic surgeon must be an excellent radiologist

5. The complete cardiothoracic surgeon must have a detailed knowledge of healthcare economics

6. The complete cardiothoracic surgeon must have an in-depth knowledge of new surgical technology 

7. The complete cardiothoracic surgeon of the second millennium must be a leader

8. The complete cardiothoracic surgeon must be adaptable

9. The complete cardiothoracic surgeon must have a knowledge of the history of cardiothoracic surgery

10. The complete cardiothoracic surgeon should develop, to the best of his ability, the quality of being persistent

11. The complete cardiothoracic surgeon must also be a humanist

12. The complete cardiothoracic surgeon should develop a hobby

13. The element of faith

The Unwritten Rules of Hospital Chair Hierarchy

So the ONE thing I have gotten in trouble for more than once during the first half of third year?  Sitting down.  Harkens back to my days as a lowly paramedic student (I'm on about the same level still, five years later), when nurses playing solitaire on the computer got to sit down, while I stood for 12-20 hours at a time (my back STILL HURTS from that).  This has resulted in my NEVER sitting down, which draws a lot of sarcastic remarks like, "You can have a seat, unless you're glued to the wall."

Anyway, a brief reflection on the hierarchical (or bureaucratic, who knows) manner in which seating rights are determined:

• Patients with legitimate complaint
• Attending physicians
• Family of patients with legitimate complaint
• Staff controlling salaries/quality assurance/billing
• Senior nurses
• All other nurses
• Resident physicians
• Patients without a legitimate complaint
• Family of patients without a legitimate complaint
• Intern physicians
• Purses, suitcases, laptops, stuffed animals, and children who have strollers but prefer that last chair
• Bed bugs, noseeums, and the like
•  
•  
•  
• 
  
• Med students