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.

The Farmer and the Cowman

I titled my entry today based on the great song in the musical "Oklahoma!" It has to do with the conflict that existed on the open range between farmers building fences to keep their cattle in and the cowmen who pushed their cattle across the open spaces. Both are raising cattle, just in their own way. So too surgeons and medicine doctors, or internists, treat patients, but in their own way.

Which brings me to one of my favorite episodes of "Scrubs" where the main character and his best friend (a medicine intern and a surgical intern) play out the dichotomy between medicine and surgery ala "West Side Story."

Anyway, the reason I bring this up is because part of what is driving me crazy in the MICU is the way the medical interns approach patients. I know in part my prior training is affecting my perception, but seriously, I am suicidal most day on rounds. I just want to know: what is wrong, what are we going to be doing about it, and how soon will they be able to transfer out of the ICU? I don't think about their clinic visits, what their medications were six months ago and 3 hospitalizations earlier, or if they eat beets on Thursdays.

Facts, that's all I want to know. Now, medical people will say the most important part of the exam is the history. In fact, I had a professor in medical school that said that 80% of the time you could make the diagnosis based on history alone. I guess I have to work on my patience... and, dealing with some of the medicine residents, I am going to need a lot of it.

My patients:

an alcoholic, diabetic admitted for leg ulcers who we admitted to the MICU for management of their alcohol withdrawal. They were intubated because we had to sedate them before they went into DT's.

a patient with knee pain who has been taking a LOT of Alleve over the last 2 weeks. So much that they gave themselves an ulcer. In fact, several since I saw the endoscopy while the GI doc did it. Ortho will be coming to see the offending knee tomorrow.

a patient who smoked for a long time, now has emphysema and came in with shortness of breath. They were having a CT scan to look for a pneumonia or possible mass when I was leaving. I wonder if they'll be off of the bipap mask tomorrow.

That's about it. I really don't have a lot going on. It seems like I pick up patients and send them out. I actually picked up a patient that was admitted overnight and discharged them to home this morning. Maybe things will pick up next weekend when I am on-call. Until then, I will be enjoying the attending we have now who also was a surgical resident before changing to anesthesia.... at least I have someone, along with the neurosurgery intern that I can roll my eyes with during rounds... the long, slow painful part of my day.

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