June 2006 Archives

Theres an old saying in ancient nursing lore that if a fly lands on a patient in the ICU, that patient will die within 24 hours. One of the more wizened nurses here swears by this. She says that every time she has seen a fly - and how often do flies get into the incredibly atmospherically controlled and conditioned ICU? - a patient has died. It is a horrible omen.

On saturday morning when I got here to round, sadly, one of my patients had died. I did a cartoon-esque double take as I walked passed his room, and then stopped and backed up. There was a slight delay before I registered that the monitor was off, the room was silent, the curtains were drawn, and he no longer had a breathing tube in. He was lying there, cold, still, dead. God damn it, I said out loud. He had died about an hour previously.

A fly had landed on him the day before, smack dab in the middle of his forehead.

This makes me think that either the fly has some sort of heightened sense of smell that is so sensitive to rotting flesh that it can detect biochemical changes in human skin and secretions that indicate impending organ failure before our own medical tests detect anything. Either that or each fly in the ICU is actually a tiny winged angel of death that has taken on insect form to deliver its grim news to future victims by gently landing on their foreheads, kissing them with many soft, beconning, feathery feet.

Then again... later that same day I saw a fly on another one of my patients. And she did not die that day. In fact, she is extubated now, looks much better, and is being discharged from the ICU. I think perhaps instead of it being an omen of impending doom, the presence of a fly in the intensive care unit is simpy a sign of a gap in the ventilation system.

I put in a central line! I put in a central line!

I stuck a huge needle under a person's collar bone and into their subclavian vein, and then pushed a line all the way down to their heart. And I got it the first time, rejoicing silently at the satisfying flow of dark red blood into my syringe. It felt awesome.

An then and then! I got to run to the ER to do chest compressions on a guy whose heart had stopped. I got to say things like "resuming compressions now." And after practicing on plastic dummies for years, it wasn't really that different in the heat of the moment. Except for the softness of his skin, the suprising give of his sternum, the blood smears on his chest, the nervous tension in the air as a group of concerned strangers stared intently at a small monitor, the occasional lapses into silence that were broken only by my own rhythmic efforts and the question, offered to everyone and no-one, has anyone got a hold of the family?

Today was hectic and busy but incredibly satisfying because I got to do something. Usefulness feels like a tremendous accomplishment.

P.S. Things that I have attempted and failed thus far: putting in an arterial line, and doing a lumbar puncture. I am so far 1 in 3 in terms of putting gigantic needles into people and getting the right liquids out.

If I have learned anything in medical school, it is this: if your pager is going to go off, it will inevitably do so within a 5 minute time range of lying down in bed. If you were to plot this out, on a graph of pages vs. time, the peak of the curve would fall at the exact moment that your eyes close, immediately after turning out the light.

Knowing this law to be true, I had some tough decisions last night. My mettle was tested.

It began at 9:30 pm, as I was preparing to get ready for bed. My pager went off, followed closely by a series of expletives. There was a new patient just arrived in the unit with confusion and very low blood pressure. "You might like to see this," says the attending on call. Translation: "Be here within 5 minutes." I'll be right over. Eff.

At 11:45 pm came the first major decision point of the night. There was a gun shot wound on the way, to be arriving shortly via helicopter. Should I stay? "You can go home if you want to." These are very tricky words for the astute medical student to interpret. Because honestly, I did want to go home. I wanted that very much. But does it look bad to want to leave? Is chosing sleep over a potential learning opportunity a one-way ticket to medical mediocrity? Will it be worth it tomorrow when I am incredibly tired - will it look worse if I am groggy and slow during rounds? I deliberated over these questions for a good 10 minutes. And then I decided to go home. After all, they can page me if they need me.

As I made the 7.5 minute walk back to my apartment, I looked up at the clear starry sky. Cold. Beautiful.

Without taking my scrubs off, I climbed into bed, my pager in its customy place of honor on my bedside table. All laws of physics were satisfied when that pager went off literally the exact second that I closed my eyes, announcing the upcoming arrival of the next patient. I lay in bed staring at the ceiling for many minutes, weighing the benefits of continued sleep versus the perception of laziness. The thing is, I am not needed at that code. The patient will in no way benefit from my being there, as I cannot actually do anything to help them. I will more likely be a hindrance, my mere presence occupying valuable space during a flurry of activity. The last code I was at, I was directly asked to leave becaue I wasn't doing anything useful and was "getting in the way". I thought standing next to the patient, blocking the surgeon's access was fairly useful, but apparently I was wrong. This was in no way humiliating or demoralizing. Do I want to get out of bed only to be kicked out?

The helicopter passed overhead, wings beating violently against that beautiful sky. Bearing tragedy through a star-studded veil of calm.

In the end, I decided to get out of bed. Somehow it seemed like the right thing to do. Of course, when I arrived I found that I was indeed completely irrelevant. People in gowns were yelling things and rushing around with great purpose. I stood in a corner, and noted a hint of annoyance when I was slow handing a nurse the paper towels that I was standing in front of. No one aknowledged me. My attending was not there. The patient went to surgery and I walked home.

The sky was once again calm, the stars spread out above the desert. My pager did not go off again.

Here is something weird that I have been doing lately: dictating. Everyday, I call up the hospital's dictation service, punch in a bunch of numbers, and speak aloud the progress note that I am to write each day on each patient. Then some nice middle aged lady somewhere in this hospital types out literally exactly what I say and posts it in the computerized medical record system for everyone to read.

This is strange for a number of reasons.
Reason #1: it is more difficult to speak out loud than write down what you want to say, especially when you factor in things like punctuation. It comes out like this: "The patient is a 67 year old male with chronic atrial fibrillation comma and chronic obstructive pulmonary disease comma with respiratory failure during an elective cardiac catheterization yesterday period."

Reason #2: I suck at dictating and it takes me forever. When I attempt to produce coherent medical verse, it actually sounds like this: "uhhhh the patient is a uh 67 year old male with..... ..... uh..... ..... chronic atrial ... fibrillation and ... uh..... sorry.... um, can we please go back to the part above when ..um... I say......." You get the idea. This is why it takes me 20-30 minutes for each daily progress note, when it takes my attending approximately 3 minutes. I am not in any way exaggerating. Half of the dictation time I spend rewinding and starting over, and then apologizing to the transcriptionists.

Reason #3: Tanscriptionists listen to me! There are people that are paid to listen to me bumble through in agony and decipher what I'm saying. I'm just picturing them, this group of middle-aged women in a windowless room in the hospital basement, calling eachother over to listen to my ridiculous dictation, making tallies on the wall of the number of "uhhh's" I utter in a row, placing wagers on how long my next dication will be. Oh, the eye-rolling that must occur when my name pops up in their cue. How I pray that I never run into them on the street. The infamous roving gang of angry medical transcriptionists.

Reason #4: Other people read what I say. My dictations immediately become a part of that patient's electronic medical record. This happened before when I put notes in paper charts, but somehow it seems so much more official when it is typed out all fancy. And sometimes I don't feel very official. This hit home the other day when, while standing outside a patient's room, I turned to the nearby computer to check on some labs. The window was open to my dictation from the day before, halfway scrolled down. The nurse had been reading it, to verify the plans of the CCU team. Fortunately, they had filtered all the "umm's" out.

One day, they say, dictating will be easier. One day, they say, it will fly off my tongue. I hope that day comes soon.

Speaking of dictatorships and public speaking... last night I watched the Steve Colbert address at the national press dinner. Oh my god. That man. Respect.

I have now officially made it around The Bend. I have successfully (more or less) completed my third year of medical school and have turned the corner into the much coveted and universally admired position of 4th year medical student. MS4. I am now a Senior, of the highest rank on the student totem pole, one of those people who I looked at in awe a few short years ago, because they seemed to have this swaggering confidence, this incredible grasp of medical knowledge, this enviable foresight into their own clinical futures. Plus they looked really cool in scrubs with their important little pagers hanging jauntily at their hips.

Now I realize that the vast majority of those people were faking it, and they were in reality bumbling through their last year of school, completely and utterly terrified at the idea that in one year - in literally less that a single year - they would become doctors. They would be responsible for patients. Which means that they would very likely soon be killing someone. At least, this is what I am assuming was their train of thought. Conjecture based solely on my own present newly 4th year anxieties.

But there is yet more. For I am attempting to be very clever with the double meaning of the phrase "around the Bend," for not only have I passed the 3rd year milepost, I am also currently in Bend, Oregon. Yes! BEND! That city in the high desert, named for the bend in the Dechutes river upon which it sits, home of the Deschutes Brewing Company, named for the river from which it got its name, is wear I am living RIGHT NOW! Ah hah, you say. No wonder she kept suspiciously capitalizing the word "Bend." It was simply very clever foreshadowing.

I am starting out my 4th year with a rotation in the Critical Care Unit (or CCU, often referred to as the ICU or Intensive Care Unit - same thing). At some point this seemed like a good idea. "Why don't I, instead of taking it easy after third year," I thought, "head straight into one of the most demanding, time-consuming rotations, which requires every-other-night call in attempts to care for the sickest of patients?" Or atleast, that's what I would have thought if someone would have been polite enough to pass along that the Bend CCU rotation is insane. Or atleast, it is insane right now. Apparently, in order to herald my arrival, the good people of Central Oregon decided to have heart attacks and car accidents and gun accidents in epic numbers, in order to fill every single bed in the unit. They are air-flighting them in from other hospitals, for pete's sake. One of the nurses was joking about calling in the national guard, because they had almost never seen so many people in here before. This is good and bad for me. I get to see a lot of stuff. But I have to be here for very long hours.

Dealing with the sickest of the sick is interesting. Exciting and terrifying (and sometimes monotonous). They are here because they are at serious risk of dying. And some of them do. One of my patients died last night. I came in this morning to find an empty bed in an empty room. It was so calm and sunny and clean, that room. Ready to accept the next patient, as if the person who had been fighting for her life in that bed for the past month had never even existed. But she did. And I got to be there to stroke her hair and interpret her feeble handwriting (she was intubated and unable to talk) and watch her father's lip tremble as he talked about withdrawing life support. This is what I am learning, in spite of the madness.