The more things change

I have a day off from the ICU today and I’m sitting in Starbucks, putting together a poster for the annual ASN meeting next week in San Diego. I finagled another day off for the conference and will fly to San Diego and back all in one day to present my poster and hopefully meet some of my future colleagues in academic nephrology. Catching a 6 AM flight only to fly home 15 hours later doesn’t sound like much of a day off, but that’s probably just the crazy-tired talking.

The crazy-tired does a lot of talking these days. Truthfully, the ICU has been harder than I expected. Part of the problem comes from that fact that our VA ICU is an MS-ICU, which means that both medical and surgical patients are cared for by the same ICU team. In some ways, this is a good thing. For one, my residents this month come from general surgery and anesthesia, as well as medicine, and I’ve enjoyed meeting and learning from this diverse group. For another, managing a post-CABG patient, the bread and butter at our VA, is good learning for medicine interns. Where else do you consistently encounter concomitant distributive and cardiogenic shock? On the other hand, some of the differences in approach between the two services (medicine and surgery) are -- how to put this delicately? -- frustrating.

Right now in our ICU there is a patient with severe congestive heart failure, in cardiogenic shock. Essentially, the pump function of his heart is failing and he is unable to pump sufficient blood forward to supply oxygen to his organs and tissues. One consequence of this problem is that the patient’s lungs slowly fill with fluid as it backs up behind the failing pump. The medical approach to such a patient is to temporarily give medicine to augment the strength of each heart contraction (inotropy), as well as medicines to reduce the extra fluid in the lungs (diuresis) and to lower the pressure against which the weak heart is pumping (afterload reduction). The surgical approach, apparently, is to insert a chest tube to drain the fluid around the lungs. The surgeons are also refusing to allow the ICU team to provide afterload reduction. Meanwhile, the patient is requiring ever-increasing doses of inotropic support, in the form of intravenous dobutamine, which increases his risk of a dangerous arrhythmia. Our various consulting teams are wondering, first politely, and now with escalating boldness, why -- why, exactly? -- the ICU team is mismanaging this patient so spectacularly. It’s an irritating situation and brings to mind that old joke about the various specialties: Internists know everything and do nothing. Surgeons know nothing and do everything. Psychiatrists know nothing and do nothing.

But despite the irritation and the crazy-tired, I’m doing OK. Brian is home from Japan, finally and blessedly. And Sam is Sam. And that right there is enough for today.

Puzzles and tricks

Last week Alex promised Allie more Sam videos, so here ya go! Replete with our standard gold-plated production values, to say nothing of the editing botch job. Eh. Good thing the kid's pretty cute.

Blogging fail

I can’t help thinking that when I read back over these posts next year, it will seem like my intern year was composed entirely of days off spent at the spa. I’m off today, sitting with my post-pedicure toes under a dryer, wondering how many minutes are required before I can safely slip my sandals back on.

It’s early in the afternoon, but already, it’s been a productive day. Since Sam went to bed last night, I’ve performed the final post-mortem on our Thursday night dinner party (read: two hours of scrubbing dishes, the stove, the kitchen floor), done three loads of laundry, finished up a few nagging research details and sent them to my advisor, planned our family menu for the upcoming week, gone to three grocery stores and dropped off a donation at Goodwill. Now Sam is napping, and I’m blogging. I’m hoping my toes dry in time for me to get in a short nap myself before he wakes up.

I love not being at the hospital. Oh, how I love it.

But that’s not what I wanted this blog to be about. I wanted this blog to be about my life at the hospital and about my patients. It’s not that there’s a scarcity of stories to tell. Just in the last couple of weeks I’ve dealt with addiction and psychosis, sepsis, flash pulmonary edema. I’ve called strangers in the middle of the night to tell them a loved one is unexpectedly dying. Alcohol withdrawal. Heart attacks. But I’m finding it very hard to find the space and the energy to tell those stories.

On a lighter note, Sam loves to watch Brian in the kitchen lately, which Brian facilitates by letting Sam stand on a dining room chair so he can see up on the counter. Downside here, obviously, is that Sam tends to fall off the chair. I've been thinking about buying this:

... but the $200 pricetag has dissuaded me. So tonight while I was napping on the couch, Brian fashioned a solution out of a dining room chair, an old bike tube, two C clamps and some zip ties:

Aaaaaand now I'm thinking $200 sounds like kind of a bargain, now that you mention it.

In order of awesomeness

Things that are awesome:

1. Chicken schwarma for dinner
2. Pictures of Sam on the Golden Gate Bridge
3. Three tickets to Tuscany for my vacation in April
4. A day off from night float

In no particular order

Things that suck:

1. Night float
2. Night float
3. Night float

Night float

It's almost 2 AM and I'm camped out in what passes for a "hotel room" in our hospital. It looks more like a drab dorm room: narrow twin bed, non-functional lamp, cramped desk. Even the alarm clock is broken. Tonight's my second of fourteen nights on night float and my pager has been relatively quiet but I can't sleep because a) ever the pessimist, I drank an enormous quantity of coffee four hours ago and b) I'm waiting for a repeat hematocrit on a bleeding patient, anxiously refreshing and refreshing my computer screen.


Night float is a necessary evil in medical training. In years past, before new limits on duty hours for residents were adopted, the on-call resident handled cross-cover and admissions, but this genius system resulted in marathon shifts lasting far longer than the supposedly enlighted 30 hour maximum that's the current standard. So now we have night float and for the next two weeks, I'm it. My shift starts around 8 PM and lasts until the primary interns and residents return to the hospital in the morning to resume care of their patients. I cover patients for 12 doctors overnight -- typically about 80 -- but I'm not responsible for admitting new patients. All night long, I answer pages about Ambien and hypotension, I follow-up on recommendations made by subspecialty consultants, and I see and evaluate patients for whatever comes up overnight: pain, agitation, abnormal vital signs.


Night float is generally considered to be a pretty miserable time, and so far, I'd say that's right. It's lonely, it's boring, it's annoying, it's frightening. The good stuff about residency -- the honor of a patient's trust, the commaradie among residents, the satisfaction in mastering a new skill -- is essentially absent. What's left is the chaff of residency: paperwork, a never-ending succession of pages, uncertainty and inadequacy. For instance, I just took a break from writing this post to see a patient downstairs who's nauseated and vomiting. I have no idea why he's vomiting. A quick review of his chart reveals that the vomiting is a new problem for him, so the doctors who know him well haven't left me any clues. He could have an infection, or the vomiting could be the result of his kidney disease, or maybe it's from the medicines we're giving him. I suppose he could have an entirely new problem: heart attacks and pancreatitis can cause vomiting. So can a million other conditions, like migraine headaches, toxic exposures, small bowel obstructions. But my patient doesn't have a fever or an elevated white blood count. He's getting regular dialysis that appears to be adequate. He has no additional symptoms like chest pain, abdominal pain, headache. So here I am. Other than medication to treat his nausea and a couple of simple blood tests that I don't expect to be spectacularly revealing, I'm not sure what to do. It's now 3 AM and frankly 7 can't come soon enough.

Day off

Yesterday morning, post-call and semi-delirious, I was rushing around the hospital to examine each of my patients before our early rounds in the CCU. One of my patients this week is a lovely woman in her mid-50s with radiation-induced pulmonary fibrosis and severe damage to her heart from chemotherapy many years ago. The radiation and chemotherapy cured her cancer, but that's small comfort now that her heart and lungs are failing. She's been virtually confined to bed for years, but lately she's taken a turn for the worse. Her left lung is full of fluid and she can't so much as roll over in bed without becoming severely short of breath. Making matters worse, several times each day, her heart goes in and out of a very fast rhythm that exceeds the upper limit of her pacemaker. After listening to her breathing (crackly in some regions and eerily silent in others) and her heart (fast with a loud whoosing murmur), I started to leave her room, already ruminating on my next task. Once I was halfway to the door, I thought to turn around to ask my patient if there was anything I could do for her before the day got underway. "Just enjoy your life," she said sadly.

Whew.

So today, my first day off in ten days, I am determined to do just that. I started the day with an early morning hot tub soak and massage, then biked home to play with Sam and feed him lunch. This afternoon, my sister and I will pick our youngest brother up at the airport and I'm hopeful that we'll have time to take Sam to the park before the gang of us go out for dinner. Maybe after Sam's in bed, we five can sit in the backyard and share a bottle of wine. There's laundry to do and dirty dishes in the sink, but they can wait. Today I'm enjoying my life.