M, I See You

I have not been a very faithful poster on here. And I am sorry for that. It can be quite cathartic when I do post. Other times it is an amazing tool to vent or process the jumble of thoughts and emotions that plague me on almost a daily basis. Other days, I feel mindless and numb. To use the old cliche, it’s an emotional roller coaster. I’d like to begin this post by sharing a quote by Dr. Atul Gawande:

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.

I spent the entire month of September on the Medical Intensive Care Unit (MICU). The last time I had been there was last year — also in September — during my intern year. It was a new experience coming on as the senior resident. Fortunately for me, and the patients, there is an MICU fellow and attending above me. There are also usually a slew of experienced RNs more than willing to share their accumulated wisdom. Unfortunately, there are also less experienced ones who freely give away things as well. But that may be a topic for another time.

Prior to the month on MICU, I knew that I would be spending every 4th night at on the unit covering all the patients from the two teams. At capacity, that would be about 30 critically ill patients. I knew, also, that the month would include my fair share of very sick patients who ultimately lose their fight against death.

The very practical part about dealing with death when you are the senior resident on call is that someone has to do a death exam. Someone has to pronounce the time of death. And at my institution, that someone must be a licensed physician. Otherwise, you have to look around to other services to help you out in pronouncing. And you don’t want to have to call the Surgical Intensive Care Unit (SICU) attending to pronounce an expected death.

My license arrived in the mail about a week before I came onto the MICU service. And so I entered into the month with at least one less worry.

As the month began and I survived through my first week, I noticed I was averaging one death per on-call night. I supposed it was better than averaging one cardiac arrest per on-call night like one of the other senior residents. Though grim, pronouncing an expected death was a lot more peaceful than running towards a code blue at whatever god-forsaken hour of the night. Fortunately, I didn’t keep up with the 1-death-per-overnight-call rate.

It was definitely an adventure — albeit a tiring one. I had amazing interns and an awesome co-resident. My interns worked their butts off. I watched as they slogged through the long hours and always tried to smile and help with whatever they could. Towards the end of the month, both my co-resident and I thought we could see them burning out. It happens frequently on the MICU month. I tried offering words of encouragement where I could; admittedly I am not the greatest at it.

I remember when I was an intern going through my MICU month. I often felt like I was drowning and always trying to catch up. I hope that they were able to learn from their experience. I hope I was able to contribute to that learning. After all, teaching them is supposedly one of my responsibilities as a senior resident.

As expected with such a sick population, there were many cases in which I wished we could do more. We had our victories. We also had our losses. Regardless of the outcome, though, we had our lessons. And hopefully, they were lessons that have made us better doctors.

  • remmelkemp

    What do you think of long hours of working in MICU ? Nobody other then doctors work those long hours, not even your experienced nurses.
    Most other countries have restrictions on working hours, they have less doctors then US, still manage to have at least same outcomes.

  • To be honest, I’m not familiar with how other countries regulate their hours. So I cannot compare my training here in the US with physicians from other countries.

    I feel that experience is what prepares us for the practice of medicine. And I am opposed to the current duty hour restrictions. I think there are plenty of studies that demonstrate that duty hours have not reduced errors. Also, duty hours, I think has decreased resident morale and even hurt resident education.

    A surgeon needs repetition. An internist needs repetition. Whether that entails repeating a motion or working through an algorithm makes no difference. Sure, I should be able to know how to treat a typical DKA patient after a couple cases. But maybe case #39 has a rare complication.

    Now, one could possibly provide experience with reduced hours if residencies were extended, but that, I fear, would decrease morale even more.

    Just some thoughts. Perhaps I’ll have to think about it more and write a post about this.

    Thanks for your comment!

  • remmelkemp

    just few comments
    1. Repetition can be achieved even with restricted hours, as it is done elsewhere. Emphasis can be given to the number of patients seen for training rather then hours worked(say 250 colonoscopies to be certified as gastroenterologist!).
    2. Before introduction of restricted hours, it was touted that errors will go up due to hand offs, which is not the case. At least it is same. When errors are same, why increase the hours again ?
    3. Longer hours are nothing but a way for hospitals to get cheap labor. Hospitals which are run by trained physicians(smaller hospitals) do have less hours (due to pay issues) and have no more errors.

    I will wait for your post.