A critical point in my intern year

The ICU. If you talk to or read about any new doctor or medical student, you will invariably hear the stories about the fear of that first night on call in the ICU. I too experienced that fear, the patient's are sick and the nerves are endless. Well here I am, 3 call nights shy of finishing my first experience as a doctor in the intensive care unit. This month has been challenging for a number of reasons, but it has also been good for me I think.

The first challenge for me has been a recurring theme; lack of sleep. I have been on call overnight every third night. It makes for long days and a lot of fatigue. I have managed to get anywhere from zero to 2 hours of sleep on those nights. Honestly though, it hasn't completely messed with me the way I was sure it would.

The real challenge has been the emotional aspect. It is tough to feel like I am constantly trying to learn and constantly being pushed to know more than I do, but that isn't the source of the emotional exhaustion for me. I have two stories that come to mind. A word of warning though, they are emotionally exhausting for a reason. Here goes:

The first is my most proud and yet is quite disturbing to me. A lady in her 70's came in for what we call a CHF exacerbation. Her heart was pumping as well as it should. Now, typically when this happens, we look for what set off the event. Sometimes we find a reason and sometimes we don't. That day I got lucky, and the patient got incredibly unlucky. When I went to the emergency room to start the paperwork to get her admitted, I pulled up her EKG. Now keep in mind, reading these things takes years of experience and training and I am by no means good at this, I miss a lot of stuff. But for some reason, I noticed an abnormality. I mentioned it to the cardiologist, but he wasn't convinced. He said he was willing to watch her closely from that standpoint, follow a few lab tests, and repeat an EKG later. Well, lo and behold, 8 hours later my concern for this abnormality being a heart attack held up. Now, in hindsight, the cardiologist told me I was probably right. Huge moral victory, right? Well it turns out it wouldn't have changed anything we did, but the hard thing was she got sick. She was on the brink of death that night. I had to tell her husband that I thought he needed to call family in from out of town because I wasn't sure she would make it. This story ended happy and she got better, but it really left me thinking. I was really happy that I found this abnormality when even the cardiologist hadn't. But how could I have been so excited about something that was so bad for this patient? Perspective can be a funny thing.

And the story that is already haunting me a little. A patient in her 20's came to the ICU one night when I was not on call. She was initially being seen at a rural hospital for abdominal pain. A CT scan at that hospital showed some really strange abnormalities, so she was told they wanted to send her to Denver for better workup. She arrived and looked ok. The CT scan was weird, but she seemed stable. That scan showed a bunch of lesions in her abdomen, the most prominent of which being in her liver. There was an onslaught of discussion about what might be causing all this, ranging from strange infections all the way to cancer. The picture wasn't making sense though. She had a diagnosis of lupus for many years, but was otherwise previously healthy. She was followed closely by her doctor. The mystery was, how could someone with such close medical follow up end up with such widespread abnormalities on her CT scan? Well the answer came in the coming days after a biopsy revealed that dreaded word: it was cancer. Based on the type of cancer, she was going to start aggressive chemo while in the hospital. One afternoon while I was on call (strangely enough it was the same call day as the previous story), I was approached by a nurse asking that I keep a close on the patient because she was worried. Now this request was somewhat strange that day because it was still during the day. The team taking care of her was still there, so typically the nurses would call one of those doctors. It just so happened that the resident on that team was in clinic, the intern responded really poorly (not important for this story), and the medical student taking care of the patient didn't seem to grasp how sick she was (a skill I am still developing). As I was working on our other patient, I decided to check in on this lady. She looked SICK. Her breathing was labored and she looked like she was heading towards respiratory failure. I decided there was no time to contact her regular team, I just acted. I called in the pulmonologist, the attending, and my resident. We decided it was time to put her on a ventilator. She had lots of family around and we gave them a chance to tell her they loved her and then intubated her (thank God we let them do that). Over the next few days she seemed to get more and more sick. Then came the point where we started to turn off the sedation and see if we could get her off the ventilator. She wasn't waking up. It later turned out she had massive bleeding in her brain and it became obvious that we had already lost her. Her primary doctors had to tell this family that never left the hospital, that stayed with her day and night, that 1 week ago didn't have any clue that anything was wrong, that this patient, this 20 something year old woman with two young children, that she would not get better. She died later that day. I keep thinking about her and her family. It is weighing on me a little, but appropriately so I think. If this story didn't bother me, didn't make me incredibly sad, I think I would have to reevaluate my career choice. I thank God that I feel sad about this, that it affects me.
One thing that struck me about this whole situation was how things carried on. The day after she died, I walked past her room. It was cleaned and still empty. The bed was made, the family was gone, but the buzz of the unit carried on just the same. The nurses, therapists, doctors all running around trying to help patients, trying to heal others. The medical world is such a strange place.

I have other stories, but this post is getting really long. I don't intend on being depressing in every post I make, but this last story is an overwhelming microcosm of the roller coaster of emotion I have been experiencing this past month.  Please do not misinterpret, I realized as I was speaking with her family throughout this disastrous time that I am called to do this, and I will continue to answer that call every way I know how.

~vaya con dios