My Big Fluffy White Cloud

So, I don't know if I've ever talked about the "Cloud Theory" in this blog. Essentially residents come in two flavors: white clouds and black clouds. White clouds keep the badness away. Calls are lighter. Not too many admissions. Black clouds bring chaos. Everything goes wrong. Admissions are numerous.

I've always considered myself a white cloud. My calls are generally on the easier side. Other than the "Night of 13 Traumas" and the "Week of Deaths" my call nights have been mostly, well, boring. Last night, nay, this whole month, has been an example of that. I had one admission yesterday at around 10 in the morning... and that was it. After 10:30 p.m., the most important medical decision I had to make was ordering some nasal saline for a patient complaining of a dry nose from their oxygen. Twelve hours later I was on my way home. End of rotation.

So, what did I learn this month on the MICU service?
1. Take care of your body.
75% of our admission were complications due to patients not taking their meds or not taking care of themselves. The complications were further complicated by the fact that these patients smoked or drank in excess. When you need to have a breathing tube put in, because you're in acidosis (producing too much acid) because you decided to not take your insulin for several days, it's going to take a while to get you off the breathing tube because your 2 pack a day smoking habit has lead to COPD and emphysema, and your chronic pint a day habit is leading into withdrawals and DT's. So you stay in the MICU while we correct your acid imbalance, try to prevent you from getting a ventilator associated pneumonia, and keep you turning from side to side to prevent bed sores. Three weeks later, we might be able to get you well enough to make it to the ICLU (intermediate care level unit) with a tracheostomy, on hemodialysis, and several new holes in your skin.

2. Learn when to give up the fight.
I was lucky this month to have attendings who know when care has become futile. I have heard of attendings who "flog" their patients until the end. The ones I had this month acknowledged that there was a time to fight, and a time to pull back and let nature take over. Luckily, they also had the personal skills to be able to help families with the making these very hard decisions.

3. Even different disciplines can work together when you've got the right group.
I am an emergency medicine intern. We had a family medicine & neurosurgery intern as well. All of us mixed in with the three medicine interns. One of our senior residents is a medicine-pediatrics resident. And, we worked as a team. No one complained. Everyone did the work. We gave each other breaks, and helped each other out. No one took advantage of the situation. Toward the end, the three of us "non-medicine" interns began to focus on our up-coming rotations outside of the MICU, but we still got the work done.

Of course, in every group there has to be someone who doesn't quite fit in. That was, unfortunately, one of the medicine interns. Early in the year, you figure out who "gets it" and who's having some problems. By this point in the year, you hope that everyone has pretty much caught on to how things work. You worry about those that haven't. This person is in the "hasn't quite gotten it yet" group. Which is scary.

It's the end of the year. In a month, this intern is going to become a resident and be in charge of interns and running the unit. The senior residents tried to limit their patient care, and the rest of us tried to keep them from managing our patients as much as possible.

And, again, unfortunately, a lot of the lighter times in the unit came at their expense (these are funny to those in the medical profession, let me know if you need an explanation):
- asked if it was possible to put a drain into a brain abscess to help with the infection. Um, the answer to that would be no.
- when asked to check a heme-occult on a patient with a falling hemoglobin, they came out of the room and said no blood noted on exam. When asked what the card showed, they answered first, "what card?" and then answered that since the stool was brown, there couldn't be any blood in it.
- was asked to go to the floor to evaluate a patient for possible admission to the MICU. They came back an hour later, and when the resident asked about the patient's condition that required admission to the ICU, the intern stated that they had spent the last hour explaining to the family about Do Not Resuscitate and Do Not Intubate orders because it hadn't properly been explained to them. When asked about the patient, they stated they hadn't examined the patient.

These are just a few examples. Again, scary. I am just wondering when they are going to be scheduled in the emergency department as second year medicine residents do a rotation through the E.D. We already heard about an OB-gyn intern that was asked to leave in the middle of a shift because of incompetence. I am just wondering if I will be working the E.D. when this intern comes through. Like I said, scary.

OK, have to be going to bed. Tomorrow I start the geriatric medicine service. My last rotation of my own personal intern year. We'll see what the new morning brings, and if white clouds will continue to color my sky.