Friday, July 05, 2013

Friday Night Soap Box

"There is no reason children with life threatening illnesses should die in pain and suffering."
Would you believe that even in our own country, with all our medical system has to offer children, most kids with life limiting or life threatening illnesses never receive palliative care? 
Even where palliative care trained doctors, nurses, social workers and educators are available, patients don't have access because health care providers misunderstand and fear "palliative care" and therefore don't access it for their patients.
If you know a child or a family if a child with a serious illness, make sure they get the best of all healthcare, including palliative care.

Until patients and families begin demanding it for themselves and their families, palliative care for babies, children and young adults will remain tragically under accessed and under utilized, and suffering will remain under controlled, under addressed, and tragically rob these patients and their families of quality of life and quality of time. 

Tuesday, July 02, 2013

Auld Lang Syne

“Beware the Ides of March.”
 – Soothsayer, Julius Caesar, William Shakespeare
 La Morte di Cesare by Vincenzo Camuccini

“Beware the first of July.” – Everyone associated with academic medicine. Ever.

While most of America recognizes January 1 as the star of the new year, for those in the world of academic medicine, where we train medical students, interns, residents and fellows for their careers as physicians, it is truly July 1 that is seen as the entre to the future.

Every physician has experienced July 1 as a trainee and my guess is that every time the date looms ahead on the calendar, it makes many of us pause and reflect on our own July Firsts. At least, I do.
Each year my remembrance of the first day I walked into a hospital and introduced myself as “Doctor” makes me a little more squeamish, a little more amused, a little more frightened, and from my vantage point as a young** attending, I sigh and shake my head at that young physician who had no idea what would be ahead of her.

July 1 of my intern year was a Saturday. While most industries would think that starting a whole new crop of employees in their new roles on a weekend would be ludicrous, in medicine it matters not on what day of the week July 1 lands. It will be the first day in practice. Deal with it.

That Saturday, I walked into the local VA Hospital, my stomach full of butterflies, my long white coat feeling like a costume, my pockets full of pens and notecards and pocket guides, and my inner voice on a constant loop of “What. The. $%*&.” I was doing my first month in the medical ICU of that VA, working with another intern, a brand new second year resident, and a seasoned attending. From the outside you ask, “how bad does it suck to be on the ICU, where you have the sickest of patients, your very FIRST month of internship?” It does suck. It sucks bad because it is terrifying, but apparently it is some kind of screwed up compliment from the program. They say the only put the “best,” the “most capable” in the ICUs in July. Though I have no idea what scoring tool or measuring system they are using to gauge this, so I think it’s probably just what they tell people to calm them down a bit before they are made the sacrificial offering.

Most of that day, frankly, is a blur. It was composed of getting used to an electronic medical record system, not getting lost to or from the bathroom, trying to remember which of the patients in the ICU were mine and which were to be followed by the other intern, translating the dear attending’s accent and medical-ese into something that made sense in my brain, and constantly trying not to freak out. I survived it, though, and so did my patients – at least in my memory they all were still alive the next day.
Being a new intern is like being a new parent.
You are constantly scared and tired and scared.
Look how terrifying that baby is!

And it was the next day that would test my mettle as a newbie physician. For, on July 2 and 3, I was to be on call. For 30 hours (give or take, but let’s go with 30 for the sake of what the rules limited us to at that time). I came to the hospital around 6am on Sunday morning, carrying a backpack full of food to get me through the next 30 hours (the VA was not in a good neighborhood for take-out and the only food items available were from the vending machine), a few toiletries, some caffeinated beverages, and probably a book I thought I might get a chance to read.
My team made rounds through the morning and early afternoon. My co-intern and I did our notes while our senior resident stayed near us and answered questions about how to place orders, delete notes we started on the wrong patient, find lab results – all of which she had shown us the day before, but had not quite stuck.

Then it happened. The other interns, who were not on call, started paging me and wanting to give me checkout on their patients.  It was time. My call coverage was starting. The other interns flocked to me, armed with their printed off patient lists that seemed to be hundreds of pages long, rattling off the demographics, the diagnoses, the problems to watch out for, the labs to follow, the plans in case of disaster. After hearing “Mr. Jones is a 72 year old guy who came in with COPD and chest pain and is on {fill in antibiotics} and {add in ant-hypertensives} and has labs at 8 o’clock tonight…” and “Mr. Johnson is a 67 year old guy with CHF and shortness of breath who came in for a COPD exacerbation versus CHF and is on {fill in diuretics} and {fill in breathing treatments} and has labs at 7:30 tonight…” and “Mr. James is a 76 year old guy with COPD and CHF who came in with nausea and diarrhea and is …” over and over again (say, 50 times because that’s how many patients you are going to be in charge of tonight), these wonderful vets become a big old medical soup of CHF, COPD, CAP, C diff, AMI, AMS, VRE that has no chance of being able to distinguish one clearly from another.

I suspect I almost cried. Or at least had some “stomach issues.”

For a couple more hours, though, my co-intern and my senior were still close by, since we had a lot to get finished before they could go home. The scariest moment, though, was when that dear, sweet, lovely, patient senior resident picked up her backpack and told me “See you tomorrow. Good luck!”

I felt abandoned. Vulnerable. Inadequate. Like I had been kicked in the stomach and then dropped at sea.

There was, of course, another senior resident on call with me and another intern that night. It was a senior I knew well. And it was his first night on call as a senior resident. His first time in charge of the interns. His first night running the show and making sure the interns didn’t screw up too badly. And he was well qualified to do this, since just 48 hours prior, he had been an intern. But, from June 30 to July 2 he had been given that mystical power that all interns assume will be granted upon them and was now “the senior.”

The night was, as you may have predicted, horrible.  New admissions. Sick guys**. With blood pressures in the 80s. Admitted to the ICU with guardian angels of ICU nurses there to say things like, “Doctor, you want to order another bolus now, don’t you?” and “Doctor, you’re getting ready to start antibiotics, right?” and “Doctor, which pressor are you thinking of starting now. I’ll go get it from the Pyxis…maybe some dopamine?” Here is where I will say it: nurses kept patients alive that night. Sure my name and my seniors name were on the orders and the notes, but the nurses are the ones who had the experience to see when patients were on the brink of disaster. They are the ones who had the sixth sense about patients preparing to crump. And it didn’t take me long to realize that I needed them desperately.

The flip side to this, is that the nurses know we aren’t to be trusted, and they know they need to initiate the fresh interns. If you are a nurse and you deny this, I will take back the last three sentences in that prior paragraph. I’m giving you all huge credit for keeping patients alive the first week in July. However, you guys know that you get a little thrill out of paging at 2am and asking for orders for a bowel regimen for the patient who “hasn’t pooped in 2 days. Can you order a laxative?” And you all are good at sensing that moment when we have finally gotten all orders in, patients relatively stable, and can steal about 30 minutes for a cat nap. Just as the brain goes fuzzy and sleep sets in, “BEEEEEP BEEEEP BEEEEEEP.” The pager goes off. And the patient who is soundly asleep despite not having pooped since Friday is granted an order for some milk of magnesia…that he will take when he wakes up…in five hours. It usually takes interns until about mid-September to realize the ridiculosity**in this, though.

Back to the night of July 2, and morning of July 3. Around 5:45 the sky begins to lighten. Pagers start going crazy as the nurses preparing to hand over their patients to the day crew request new orders or draw your attention to the labs starting to come in. This is when, as a sleep deprived, stressed, and hungry intern (seriously, those 5 granola bars and the PB&J I packed were NOT enough food) I began to get a little snippy despite my best efforts.

Then I had to go through the process of handing back over the patients to the bright eyed, well rested, clean smelling, breakfasted group of interns coming back in for the day. And those interns were probably asking really annoying questions like “what was the K last night?” and “how many doses of Tylenol did he use?” and I probably felt really guilty inside for not knowing those answers, but at the same time, probably thought to myself, “DUDE! I had 50(!!!) patients under my watch last night. I don’t know all this shit! Look it up yourself!” and “Just wait, my friend, you have no idea what you are in for when you have your first call.” But I got the patients back under the care of their primary team intern, and then started to pre-round on my own ICU patients and then rounded with my ICU team.

Up to that point in my life, I never knew what it was like to have been awake for 27 hours. And it isn’t just the physical strain of being awake that long. It’s the emotional and mental strain as well. It’s the kind of strain that causes atypically articulate, quick-witted person to not be able to find the right term and instead fumble around saying, “we got results of that test. The one that tells about the number of cells…in the blood…like the red ones and the white ones and the platelets…” Until the attending looks with confusion and says, “Do you mean a CBC?!?”

“Uh, yes, I meant a CBC…”

Then, a few hours later, after rounds are finished and notes are in and it’s finally time to go home “post call,” that physical, mental, emotional fatigue is what made me collapse into a puddle of tears as I turned on my car. That’s the thing about me. I know I’m exhausted when I start crying. I had called my husband to let him know I was on my way home, and when I heard his voice, I started bawling. All of the fear and anxiety and worry and self-doubt came out right then.

“What the hell have I gotten myself into?”

“How am I qualified to take care of people?”

“When am I going to know what I’m supposed to do if…”

“How am I going to drive all the way home like this?”

It was a mash up of emotion all the way home. When I got home, I was greeted by my sweet dog and my husband, who had some food for me and let me cry some more on the couch. I told him, “this isn’t right. This isn’t how people should be treated.”  I lamented the state of residency training for a few minutes before I crashed for the next 17 hours.

Then I woke up, got dressed, and went back for more.

I was in one of the last residency classes (I did a four year med-peds residency) that still had 30 hour shifts. New rules went into effect the year after I graduated residency, and now the maximum shift for an intern is 16 hours. It is a rule change fraught with controversy and new problems – how do you learn as much when you are so much more limited in your exposure to clinical patient care? What do we do with all those extra hand-offs? In ways I envy their limited shifts, but mostly I don’t. In the moment, it was terrible. I left that first 30 hour shift thinking that it was going to be a brutal four years of training and that it was seriously flawed. Yet in hindsight, I know that those 30 hour shifts over those four years were likely among my most educational. They forced me to begin taking charge of patient care, making decisions on my own, interacting with families and answering questions and, yes, getting beaten down at times. Did I make mistakes along the way? I’m sure I did. Did they cause harm to any patients? I truly don’t know. And I can see that side of the argument for restricting work hours and trying to modify resident training, absolutely.

Through the rose colored glasses of hindsight, it is only that first 30 hour shift that stands out for being torture to me. There were other bad shifts, but not like that one. No other that, simply for their existence, brought me to tears. That young intern in my memory is like a child to me, in fact, I see her much as I see my 13 year old self embarking into high school, or my five year old self embarking into kindergarten – so very much to learn about the world and about herself.
This was taken at my 8th grade graduation. Look, it was the very
early 90s and floral prints were all the rage, so stop mocking.
After all "Everyone's a Star!"

It’s probably that perspective of the young intern me that has kept me in academic medicine, now seeing that there will always be learning to do, always be teaching, always be those fresh young minds to try and help shape into excellent, compassionate people and physicians. It gives me a chance to make resolutions, which I no longer do for January 1. Now I do it on July 1: I will teach better and more, I will be more patient with learners, I will set an example for them, etc.

So, to everyone out there, Happy July. May we all embrace our own past, thank the patients, nurses, and physicians from whom we have learned, and may we continue to grow and learn ourselves.

**”young” is a relative term. I am still in my first 5 years as an attending, but am in my mid-30s as a human. Thanks to the wrinkles and dark circles that come as a perk from this job, though, you might mistake me for someone a few years older.

** patients in the VA, at least in the Midwest in the mid ‘00s, were almost all male. Like, we fought over who would get to take the 1 in 1000 female patient who got admitted because she might be more interesting.
** yes, ridiculosity is not a real word. Neither is "ridiculopathy" which is a nerdy word that nerds like me prefer. I would explain it but it would be way, way too nerdy.