Confessions of an Intern

Week Eight

The universe conspires against me....

Monday I was terribly confused all day. I worked with an attending who really seemed bipolar. One minute, I would want to treat a patient one way, and he would tell me I was all wrong. Later, I'd get a similar patient, and try to do what he had suggested earlier and then he would say again I was wrong. I felt that I could not win for losing. This feeling continued the rest of the week with this particular attending. I guess it is due to some excess stress he is under, but it makes it very hard to feel like you are doing what you are supposed to do. He told me he would make a real doctor of me, I hope I (he) succeeded.

Wednesday was very sad and surreal. But I missed out on it. Three intubations, a premature delivery where the 19 week fetus died, and a pediatric code blue. Well, I walked in and the EMS crew walked in a few minutes later, having been unable to raise us on the communications. Poor kid died. Talk about a cold bucket of water over your head, when you'd been complaining about the size of coffee you got that morning. I had good intentions of arriving early to get in more experience, but most of my early morning shifts had included a lot of sitting around waiting for patients to arrive. So I had dawdled a little, hitting snooze on my alarm, just long enough to have to rush around and get the kids ready for school and out the door. Then, I decided I just had to have a certain kind of breakfast sandwich, so I stopped to get it (along with a 'medium' sized iced coffee that ended up being 32 oz.!!) Then..... the traffic on the highway that day was backed up several miles so I pulled off and took the back streets to the urban medical center I work at. I got hung up in my car finding something I needed and then finally was able to go in for my shift to start. No kidding, I just walked in on total chaos. Two patients had already been intubated and my attending was walking around looking very hangdog. After he told me why, I felt so sad for him, having to be the one to deliver the unviable baby. I started to set up my computer (because as the resident, I work off my laptop) and heard "We have a pediatric code! We tried to call in but no one answered." I directed them into the only empty trauma room and helped them get the little body situated. The little boy was intubated already, his pale skin mottled in death, eyes staring into the distance. The EMS crew had already given drugs and done CPR, intubated him and tried to revive him, but couldn't. This was a chronically ill child, who was the size of an average 5 year old, but who was really 16. We tried for a little longer to try to bring him back, but he was already gone. His heart was not responding to anything. When his mother arrived, the attending told her that the child was not responding to our attempts to revive him and that he was likely gone. She asked everyone to stop everything and told us to get out of the room so she could have some time with her child. We all left her after straightening the boy up and covering him. The chaplain stayed in the background so she would not be all alone. That day did not slow down, it continued with difficulty after difficulty, bringing it home how fragile life is. I also got to see one of the toughest and 'worst' doctors in the ED that day show how human he is and how much he actually does care.

The last day of rotations was hard. It was one more under the impossible attending, sandwiched between two of my favorite attendings. They are a a father and son, who is a brand new ER doc. They part with a hug and a kiss every shift they work together. They both have been very supportive of me, and very helpful. They told me that I set a high bar for the residents who will follow after me. Dr. Dad said they would not be able to hold a flame to me, and Dr. Son agreed, but that he hoped they would. That gave me the warm fuzzies. And even the doctor who gave me such a hard time took the time to sit down and discuss the rotation with me, and wanted my opinion on how things went. We discussed the lack of guidance and organization, and offered suggestions, as this is a new director. He informed me that I was one of the harder workers he'd had, and told me it is because I was a nurse. He complimented my work ethic, and need to follow through. Awww. He was still kinda a jerk...I will withhold further judgement until he has done this job longer than a month. Maybe he succumbed to the stress of a new job.

One last thing to share. This is another of my soap boxes. DNR. Do. Not. Resuscitate. I had two very poignant reminders of how important this is and how often it can be misconstrued. We had a patient roll in that was in respiratory failure from a nursing home. The report was that he was on hospice, but the documentation was that he had said "I do not want a do not resuscitate order." So, I intubated him. Not 30 seconds later, the charge nurse rushes in and tells us the nursing home sent the wrong DNR form, that the patient had a new DNR order signed and he did not want to be resuscitated now...-_- Seriously? What is the deal. Why on Earth would the nursing home keep the OLD order? Why, when a patient is on hospice (which gave us pause initially, as we verified his wishes from the documentation we had) would you not send the CURRENT orders? Needless to say, we got a copy of the correct order, the director of the hospice came and did a case review and I'm sure something will be done as a result of the situation. We act in the best interest of the patient, following their wishes to the best of our ability.

This led up to the next circumstance. Another patient sent in by hospice for a palliative treatment. This is something I often sound off on, and loudly. DNR/hospice does NOT mean do not treat. It means if the patient's heart stops, or they quit breathing, let them go. There are finer nuances on some folks' DNR forms like only a chemical code, or no CPR, but intubation is okay, you know stuff like that, but in the end it comes down to my earlier point. This patient came in for a treatment his hospice was unable to perform soon enough for him to feel relief. I do not know why they thought sending him to the ER would make it happen quickly, but once I heard the story, I was more than willing to help out as much as I could. He needed a paracentesis. It was 3:30 on a Friday afternoon. Now I am smarter than your average bear (or intern) when it comes to the way things work in a hospital. I went to the jerk attending and gave him the story and he said get him set up for admission and they can deal with it. In my mind I'm thinking 'Why not just call interventional radiology and have them do it while they are here?' I believe I asked this, but he shot it down. He left at 4. The hospitalist was not keen to admit this patient, the patient did not want to be admitted. Long story short at 6 pm I finally decide to do what needs done, tired of everyone else wanting someone else to take care of the patient and I called radiology. So I must give props to the radiologist who was on. Even though it was after hours on a Friday night, and he did not have any staff, he told me he would help me get it taken care of. At 7, a radiology tech came to the ER to take him to the department to get it done, he would be kept in observation overnight because he was at risk for bleeding and then he could go home in the morning. This was something the people that mattered could be happy with. Why could I not ask for this to be done when I first asked? To me it makes perfect sense to expedite care when it is most efficient. And the radiologist and rad tech were super gracious and kind. They wanted to help me help a terminally ill cancer patient to feel better. They went above and beyond. This was not an emergency in the generally accepted terms, but it was a hospice emergency. And I went home that night, satisfied I had done my best, my last night in the ED. There was a patient with head trauma coming in, and I kinda didn't want to leave, but there will always be more. I needed to get home to my kids.