Where there is an end, there is always a beginning

The tents have gone up. Receptions have occurred. Graduation for the seniors has come and gone. We are 3 days away from leaving our posts as interns and moving on to becoming residents.  There are a group of 65 people waiting to take our jobs and we have been given the task of telling them what to expect.

We are finding our assignment more arduous than previously anticipated. The thought of describing this year in a neat package seems as onerous as preparing to walk on the moon. There are the moments of darkness – endless lists, pages every 15 seconds, the perpetual sprint from one triage to another, feeling that the world is a check box, and the nights where sleep is elusive.  There are also the moments of light - tending to a patient in the middle of a night who thanks you for caring.

Sometimes the joy of our job is helping someone to die with grace and kindness. Sometimes the joy of our job is running to a code blue and resuscitating a person near death. Sometimes the joy of our job is learning from people who love medicine. Our writing has augmented our joy. Our patients are our role models. They teach us the most every day, and when we get a brief moment to write a story about one or two who have touched our lives, we are merely reflecting back that which they have given us.

As of July 1^st we will be residents – we will run a team, teach new interns, and most importantly be one step closer to being where the buck stops.  Fear and glee are intertwined when we think about our new lives. But we plan on remaining true to our writing – we will continue this blog, still calling it Intern’s Diary – as that is where the idea was conceived. We plan on telling more stories of our lives on the front lines of care – both nationally and, for a brief month, internationally.  We also hope to be publishing in other venues as we have in the past. Keep checking us out and we’ll keep you posted.

Thank you for sharing this year with us.  It has been an incredible journey – and there is much more to come.

Share your comments8:12:57 PM    

The VA

He was a hard drinking, hard living kind of guy.  He lived alone, with his portrait of his fallen comrades, and an etching someone had made for him from the Vietnam War Memorial.  The name inscribed on it belonged to the person who had come to replace him when he finally left Vietnam as the war was winding down. His replacement was killed two days after his arrival, lying in the same bed my patient had used for months before.

Now my patient had joined the ranks of the legions of Veterans for whom we minister care.  For one month out of each year, we rotate through our local VA.  The patients that land on our doorstep are a unique group of people, most of whom have faced combat time in Vietnam, Korea, or the Persian Gulf.  Soon there will be a new crop of Vets who join this older crowd.  They will be the soldiers from Iraq and Afghanistan.  They will join the thousands upon thousands of men and women we see in our hospitals who are living the daily devastation that War unleashed decades prior.

Many years ago I went to Vietnam to help those who were battling the ongoing spread of HIV.  My father, initially hesitant to see me go to a country that had been our enemy for so many years, subsequently came out to visit me there. He, like myself, came to be inspired by the Vietnamese people. The kindness that was bestowed upon us was only matched by their fierce pride, and their gracious manner.  It was during that year that I came to have an intense anger towards those who had invaded Vietnam and all those who supported that war.

I recall saying that I felt unsure of how my experience at the VA would be.  I felt fearful that I would face Vets who would tell me with glee how they had participated in the massacre at My Lai, rattling off the number of Vietnamese they had killed.

What I found, however, was an entirely different picture.  The most common diagnosis I saw on almost everyone’s chart read “PTSD” for post-traumatic stress disorder.  Each soldier had his or her own story.  My patient had managed to cope with his pain by drinking until he could make it through a day.  As a result of his many years of hard liquor, his liver was now failing him.  Every month he would come into the hospital and get some fluid drained off his belly.

He and I sat together late one evening after he had been admitted.  I carefully stuck a needle into his abdomen and started the process of removing 5 liters of fluid that had accumulated.  While I worked, he talked.  He told me about his son who had left home and died from a drug overdose at age 30.  He told me about his recurrent nightmares only made worse after September 11. He told me how he had gone into therapy to try to cope with his pain.  Tears trickled down my patients face as he lay there, helplessly watching me try to ease his suffering.

I looked up at him. He had no teeth.  His skin was yellow.  His eyes were bloodshot.  “What do you think of this war we are fighting now?” I quietly asked.  “War is pure evil, he replied.  “I pray for those young men and women over there.”

“ So do I,” I thought.  So do I.

Share your comments10:04:45 PM    

Back of the Rig

The page read, “Where are you? I thought your shift was beginning a few minutes ago.”  I was starting my two-week shift in the Emergency Department.  I had already hit the hospital, but was grabbing some sustenance, as the ED is notorious for tough shifts without a break to eat.  I ran into the ED to begin the endless night of triaging one acute emergency after another.

Internists are notoriously slow when they work in the ED.  We are considered the “thinkers” whereas the Emergency Room physicians like to be considered “the doers”.  We like to take our time with patients, carefully working them up, getting a thorough history and presenting it to the attending docs in a calm collected manner.  Meanwhile, our ED colleagues are more than happy to be suturing someone’s wound, or perhaps intubating their roommate.  While it benefits all of us to get experience on the other’s turf, there is always a certain apprehension that one feels entering the controlled chaos of the ED.

Usually, when I am on a medicine floor, I arrive a good 1-2 hours before the rest of my team who show up at 7:30AM or 8AM.  As interns we are expected to “pre-round” on all our patients.  “Pre-rounding” essentially entails getting vital signs, being clear what medications the patient is taking, getting information on any overnight events, and of course, examining the patient and trouble shooting any emergencies.  We do not do shift work.  We work until everything is complete, and it is rare that we comfortably sign off “scut work” for others to do.

In the ED, we are working specific set shift hours.  We are required to be there the minute a shift begins and leave after it ends. In stark contrast to our usual life, where we wander the pre-dawn halls of the hospital in solitude gathering information, there is a room full of people waiting for us to arrive in the ED.  Our job is to be there to move the endless stream of patients to their appointed destinations. 

Despite the better hours during a block in the ED, we are out of our element as internists.  We have been known to locate the 1 or 2 other internal medicine folks in the ED and glom onto them, deliberating differential diagnoses on patients that are destined not to be our own.  The job of the Emergency Room physician is to triage patients, deciding who can go home and who needs to be admitted.  They need to think fast, move quickly, and get a patient what they need ASAP.  Ultimately, the patient is someone else’s responsibility.  This process of endless triage can be very disorienting for an internal medicine doc, who likes to read the full text of the book, not just the intro. 

It was during the heat of the moment, when I was running from one ED shift to another, like a fish out of water, that I lost all sense of normalcy.  Perhaps I am now rationalizing my behavior, but the link between the ED and the ambulance seemed like an obvious one at the time.  After all, if others could arrive in the ED in the company of paramedics, why couldn’t I?

The two paramedics were parked on the side of the road eating their lunch waiting for their next dispatch.  I ran towards them in my scrubs waving my hospital ID.  “I need a lift, now!” My voice was authoritative, but fear was lurking underneath.  I was merely a few minutes shy of getting the “You are 5 minutes late” page and still miles from the hospital.  They were the only transportation I could find.

In the end, my friends gave me hell for getting a ride in the back of the rig.  My response has been simple: “Anything seems logical when you are pulling a shift in the ED.”  My grandfather may have spent time riding in ambulances while in training to become a surgeon 50 years prior, but this was likely to be the only time I would be offered a free ride.

Share your comments12:56:19 PM    

p.s. the link is:

http://www.nytimes.com/2004/04/06/health/06MATC.html

Share your comments2:46:57 PM    

NYTIMES

Today we are moving to the newspaper -

check us out in the New York Times - Science section. 

Our piece is entitled, "A Job or More School?

Young Doctors Take on the Match".  Enjoy!

Share your comments7:32:49 AM    

White Cape

As primary care physicians, we spend a lot of time examining orifices. We venture where others are afraid, inspecting beefy red throats, peering up drippy nostrils, and probing along boggy prostates for lumps. Each day we don our protective white coats, denying Pasteur's basic principle of infectious particles, and charge ahead to stamp out disease. Although we live among the sick, we act as if we are immune. 

In our daily lives, however, physicians are wimps in the war against infectious disease. We are the first to flee any illness, no matter how small. A friend recently visited with sick children and, although we adore his girls, our stomachs dropped as he described the gory details of their recent illness: sleepless nights, baby vomit, and dozens of diaper changes in a single hour. “It’s just a gastroenteritis,” he reassured us. “Don’t worry, when I had it, it only lasted 48 hours.”

We were far from reassured. Immediately, we began scrubbing our hands, and silently reviewing the past hour of “innocent” playtime. Did we kiss them? Did we touch our mouths? Why weren’t we more careful? We spent the rest of the day hunkered down under a down comforter with tea, anticipating the worst.

Sure enough, a few days later, I was in the emergency room admitting when the virus hit. My patient, an elegant woman in her sixties, was in the middle of describing her struggle with breast cancer when I was suddenly consumed by my own wave of nausea. "Excuse me," I said, tearing open the curtain and running for the bathroom. I vomited three times, cleaned up the mess, washed my hands and face, and returned to her gurney.

“Is everything all right?” she asked, appearing startled by my sudden departure. “Do you need to help another patient?”

“No, it’s fine,” I replied. “Please continue.”

She did, and so did I. Like many interns before me, I downed a few Pepto Bismal and kept on chugging. Later that night, I admitted a 47 year-old man with dehydration from a viral gastroenteritis. I struggled to listen as he described his two-day bout in gripping detail, and I caught a glimpse of the next 48 hours awaiting me. 

Share your comments10:18:55 AM    

When It Rains…

One of the central tenets in medicine is: the more you see, the more you know. Put another way by an old Hopkins surgeon: “If you’re on call every other night, you miss half the cases.”

In the beginning of internship I worked roughly 100 hours a week, despite the new rules limiting resident workweeks to 80 hours. There’s no question my weeks were made longer by my own inefficiency. Despite four years of medical school, internship was a new phase of training with added responsibilities and every day brought unique challenges, from diagnosing aortic dissections to dosing medications. It was also my style: every night before leaving I made a final set of rounds, visiting my patients to make sure that they were o.k.

Inevitably, one of them wasn’t. Mr. Jones’ blood pressure was elevated, Mrs. Smith was having chest pain, or Mr. Brown was suddenly seizing. Each time I stayed until the problem was solved and the patient was safe. As the nights grew longer, I often encountered the on-call team of residents admitting patients. One time, one of them turned to me sympathetically, saying: “You know, you can’t save everyone. The longer you stay in the hospital, the longer you stay…”

As the year stretched on, I could leap most of the hurdles that internship threw me, but one thing remained constant: every fourth night I got another bolus of seven patients. They arrived in varying states of health. Some were admitted with simple heart attacks, pneumonias, or bad cases of dehydration. Others arrived literally dying, bleeding out from an aneurysm, bottoming out their blood pressures, or herniating from a large mass in their brain. We took whatever patients came to us, did our best to care for them, and discharged them as quickly as we could because we knew that in a few days seven more were coming.

I often hear patients complain that they are being forced to leave the hospital before they are ready, and a few times this year I have wondered if they are right. I worried I might be discharging a patient too hastily in my effort to make space for the next one coming in. There are policies designed to discourage premature discharges: if a patient “bounces back,” or is readmitted to the hospital within 48 hours, the team who had him before resumes his care. “Bounce backs” bring a certain embarrassment to the team, and extra scrutiny to ensure that the patient is better before they are discharged the next time, but despite these protections, I still worry.

In my darkest hours, I fear that our assembly line style of admissions pits our interests against our patients’. Under the tremendous pressures of volume, we prize speed over healing, and place more weight on testing than talking. As interns, we are protected by rules limiting the number of patients we can care for—in our program, no intern can have more than 15 patients, and no team can take care of more than 25 patients in total. But caring for 15 patients sounds easier than it actually is; if any are sick, the others can easily become neglected.

As physicians, we could learn a lot from the airlines and the nurses. Our new work hour regulations reflect the growing evidence that sleep deprivation impairs decision-making, but it is interesting to compare how the airline and medical industries have addressed this problem. Airlines mandate that their pilots cannot work more than 100 hours a month, or 18 hours consecutively, while the ACGME stipulates that residents should not work more than 80 hours a week, or 30 hours a shift. There’s a certain hubris we display believing we can work two to four times as long as pilots, and still offer the same level of safety. It’s the same arrogance that let an old Hopkins surgeon work every other night and still complain about missing half of the cases. Some traditions die hard.

Share your comments9:02:12 PM    

Moving On

I received the page: “Your patient is short of breath with a heart rate in the 120’s. Please come.”  At this point in internship, I am able to distinguish benign pages from those that set off warning bells.  This one sent me running down the hall. The patient was an 80 year-old woman being cared for by my medical student.  As house officers, part of our job is to supervise students, while we are in training ourselves.  I told her to come join me, and decided to grab my resident on the way. 

“What are her vitals?” I asked, taking a look at the patient.  She was becoming increasingly short of breath.  I laid my stethoscope on her chest.  Her heart was in an irregular rhythm, and her breathing was labored. Her neck muscles stood out against her gaunt frame, as she struggled to breath. This was my moment to shine. When the resident joined our team, he told me he would let me run most of the show since I was a few months shy of taking his place. It was time to prove myself. I would show the medical student how to manage a patient in rapid atrial fibrillation, and reassure both the resident and myself I was capable of it.

I asked for the EKG and confirmed that she was in atrial fibrillation.  “So what do you want to do?” my resident asked.  The medical student hovered by, waiting for my word. The nurse asked which medication to give. I looked down at the patient. She was clearly tiring, and becoming increasingly disoriented. I took a deep breath. Right, so here we go. 

In medicine we live on the edge of our expertise. As soon as we are comfortable in our position, it is time to move on. For the past few weeks, I have been feeling an increasing mix of emotions about finishing my internship. Almost daily, my attendings ask: “Are you excited to be a resident?” My response is always the same, “I am ready to finish internship.”  There is a notable absence of input about my moving forward. I am both excited and full of dread. “Am I ready?” I ask myself.

I think back to my third year of medical school. I remember walking in the door of the hospital in San Francisco to start my first rotation, Obstetrics and Gynecology. I thought to myself: "Now everything rests on my shoulders, and I am responsible for all these patients." Only later did I realize how many layers of supervision sat above me. I suppose I am overestimating the solo nature of my role as a resident with the same mix of fear and naivete. Medicine is, after all, a team endeavor. But, I will still need to be the one who knows the answers much of the time, and this fills me with great fear. I have started to look at my residents in a new light, and wonder whether I will ever know as much as they do.  

In the end, however, I will need to move on. We are one week away from the match, where the names of the new interns will be unveiled. My replacement has already been hand picked, and my fate is sealed. Come July 1st, there will be someone ready to step into my intern shoes and assume the responsibilities that I have undertaken for the past year. It will be my job to help teach and guide, while learning my new role as the resident.

Share your comments6:48:55 PM