Thoughts from the ICU

It's about 2 am, I've got a few minutes, and I figured I would post a few thoughts.

There was a game we played sometimes as kids in which a new player had to figure out the rules of the game as he went along, without knowing anything about them before the game started. It's torturous for the uninitiated, because they don't know what they're supposed to be doing, and when they try something, they're told they're not doing it right -- and they aren't, because, again, they don't know the rules.

Although everyone around me has been very nice and supportive, I often feel like I'm trapped in this game. Everyone else seems to know the rules, how things are supposed to be done, but I feel like I don't even know the objective of the game, much less how to achieve it. Learning the rules -- where to be, what to put in the note, how to order things, how to dictate, how to operate all these computer systems, how admissions work, etc. etc. etc. -- takes so much time that I feel like I can't work on the game's objective -- what's going on with this patient and how should I intervene. I'm used to being good at things, and I don't feel like I'm particularly good at this yet.

The ICU feels like the last place in the world you'd want to be if you're used to perfectionism. Unknowns abound, and either those around me aren't considering them, or they're more comfortable with not knowing. What's wrong with the patient in room 204? Who knows! Multiple concurrent disease processes to be considered, volumes of history to review, piles of medications to sort through. It's exhausting. I guess I anticipated that things would be a lot more lucid.

An elderly male patient of mine died last week. He came in Tuesday with trouble breathing, pneumonia, and leukemia. I talked to him for a little bit before he was sedated, paralyzed, and intubated. His family decided that their father wouldn't want to go on like this. The tube was pulled on Friday afternoon. He died five minutes later. I never talked to him after that first night. We never figured out what caused the pneumonia that ultimately killed him.

A man came in two nights ago after being in a car accident. He has a severe traumatic brain injury. He's in a coma. The prognosis is extremely grim; many are surprised he hasn't died yet. He almost did last night. He has a lot of family members here at the hospital, and I've found myself reluctant to introduce myself to them for fear of not knowing what to say. I know I wouldn't be able to answer any detailed neurosurgical questions. I don't know specifics about his prognosis. If I talk to them and can't answer their questions, it seems like I wouldn't be much help. So I read his chart, glance at his vital signs, and walk away, feeling like I've failed.

These two stories, and many others like them, leave me thinking frequently about what success is. Is it keeping people alive overnight? Nobody has died on my watch yet, but somehow I don't feel successful. Is it figuring out what is going on with each patient? I hope not, because it seems like the ICU in general, and especially at night, is more about keeping patients alive long enough for others to figure out what's wrong with them. But isn't that just passing the buck? If I'm caring for this person, don't I have an obligation to try my best to figure it out?

Maybe success is knowing the answers when the attendings, nurses, and family members ask me questions. I've never said/thought to myself "I don't know" this much in my life. Is success continuing to come in every day? That seems insufficient. For now, I guess it's continuing to give a crap, doing my best to think critically, paying attention to detail, and trying to learn.

Thank you for your comments, thoughts, and prayers. I'm committed to keep trying.

My First Night of Internship

I finished medical school two weeks ago, and have sinced moved to Spokane, Washington to start my year of internship at Sacred Heart Medical Center.

Last night was my first experience as a new doctor/intern. My first rotation is "Night Float ICU," which basically means I take care of patients in the ICU overnight while their primary doctors get some rest. I also take care of any new patients that come to the ICU overnight until the main team comes back the next day.

I showed up at 5:30 pm and got the scoop on who I would be taking care of. Here are some highlights/lowlights of the night:

-- Writing my first order as a physician: "Ok for patient to take ice chips by mouth."
-- Introducing myself as Dr. Weed for the first time and thinking that it sounded silly
-- As I'm sure you know, the ICU is full of really sick people. I have never done an ICU rotation before, and I can't remember the last time I felt as inadequate as I did last night. These poor people are in bad shape. Some are young, most are old. I kept cursing the situation that puts me in this position.
-- The senior resident was fortunately extremely patient and kind, and made me want to work harder and better so I didn't disappoint her.
-- An older woman lost feeling and movement below the waist yesterday due to bleeding around her spine. As soon as it was recognized, the neurosurgeon removed the clot, but the prognosis is grim for her recovery, and she knew it. What am I supposed to say to comfort someone who now possibly faces a life of paraplegia? That I'm sorry? That's all I could think of, but it seemed like so little.
-- There is a young woman in there who is extremely ill and we don't yet know why. I feel like I should figure it out.
-- I participated in two "codes." At around midnight, I got paged to go to the 6th floor. There were about 15 other doctors and nurses already there, doing CPR on an elderly man. I did chest compressions part of the time. The man was having a massive heart attack. 20 minutes later he still had no pulse. We stopped CPR. His wife and sisters came in, crying. We talked for a bit and then shuffled out of the room. It was horrible.
-- I didn't even so much as lay down all night. Miraculously no caffeine was involved. Around 3 am, I went to the cafeteria for a "rally breakfast" of bacon, eggs, potatoes, and chocolate milk.

I haven't wanted to quit anything so much since the first few days at the MTC. I've never wondered if I was really cut out for this until last night. It was a long, fatiguing night filled with feelings of inadequacy interspersed with a few moments of pride and exhilaration. I'm hoping that tonight, when I go back there, the patients are doing better, and that I feel at least a little more comfortable than last night.