A student recently asked me, “When did you get to the point where you weren’t scared about seeing patients?”
That’s an easy one.
By the time a medical trainee gets to the point of making independent decisions about a patient and has the power to carry out these decisions—the first year of residency, or internship year—they have been through four years of medical school training (generally two years in the classroom and two years in a clinical setting). Most interns are reasonably well equipped to assess a patient and make initial management decisions. This is not to say that they are not absolutely terrified. The first month of internship is a heady time, but an anxious one. The first time a nurse pages you in the middle of the night demanding that you assess a patient in trouble, your heart starts to beat like a cornered stoat. I’ll never forget my first such call, that a patient was having “rigors.” As I descended the stairs to her floor, I went over the causes of rigors. Fever? Medication reaction? When I got to the room, however, I realized that the patient was not having rigors; she was simply shaking. I examined her and talked to her, but nothing obvious emerged as a cause. Finally she made the confession that unlocked the mystery: she had panhandled for change in the cafeteria, then called her connection to come to her room, and the two of them had smoked crack in the bathroom.
That explained the shaking, but what to do about it? This is how raw I was: I actually pulled out my little intern’s pocket guide, called something like “How Not to Make A Complete Ass of Yourself on the Medicine Floors,” and tried to look up what to do when your patient has smoked crack in the hospital.
Over the months, as the call nights add up and your experience grows, the initial white-knuckle terror fades, but a sick patient can still give you a little frisson of fear. What if I can’t figure out what’s wrong? What if I do something stupid and kill her?
Then you become a second-year resident and are placed in charge of the MICU (the Medical Intensive Care Unit, pronounced “Mick You”). This is the place for the sickest of the sick. If you train in a large tertiary-care hospital, as I did, it’s the place for the sickest of the sickest of the sickest of the sick, from miles around. And I do mean in charge. Sure, there’s an attending and a fellow who are technically your superiors. But they don’t spend the night. When dinnertime rolls around and your team is on call, everyone drains out of the unit like tepid bathwater and you are left In Charge.
(I should note here that I trained several years ago, when fellows NEVER spent the night in the MICU. They’d paid their dues, now you pay yours, page them if you need them and they might step out of the movie theater to tell you “Sounds like you’re doing all the right things! See you tomorrow!” These days I have reason to believe that this is less common. I dearly hope this is true, in case I ever end up in intensive care.)
Twenty-four beds, stocked with the most amazingly ill people you’ve ever seen in your life. People who shouldn’t be alive. People who really aren’t alive as that term is conventionally understood. People who have been on machines for months, who are yellow, bloated to the point of splitting, and have mold eating away at their noses and ears. Twenty-four beds, two raw interns, and you. (Also a handful of the baddest of the bad-asses, the ICU nurses. In some ways they are the ones In Charge, and the good ones will save your sorry know-nothing ass, but you do not know yet which ones are the good ones and which ones simply enjoy watching helpless doctors squirm. Not to mention the fact that there are many, many brand-new nurses—if you think doctoring can burn a person out, try nursing.)
Adding to my stress was the fact that when I started my second-year rotation in the MICU, I was slogging through the tar pit of a fairly bad depression, one which had come upon me with almost no warning. Some background: episodes of depression since childhood, some worse than others, always lasting months, usually but not always precipitated by a stressful event. Finally started on antidepressants during my last year of medical school while I was not in fact depressed, just not great and trying to extricate myself from a bad relationship. Worked brilliantly, stayed on them through internship year “just in case”and was truly happy that year. Then started going out with my running partner, and given the fact that the pills made getting to my own private Idaho a near-impossibility, I decided to go off of them. Without telling my boyfriend. My sex life improved, and I felt fine! Hey, I don’t need those silly pills! They’re for wusses! Until the morning I woke up and felt like I couldn’t, well, anything. I managed to hide it for a week or two until I couldn’t anymore. At which point my boyfriend made me promise never to go off my meds again without warning him first. (He was absolutely awesome about the whole thing, further cementing my belief that he was My Mensch.) So I got to my doctor, got some slightly different pills, and started on them just as I started in the MICU.
It’s hard for a normal person to stay sane on an ICU rotation. You’re on call every third night, for starters. This means: Arriving early Monday morning, working all day, staying up all or most of the night admitting or managing people who are trying their best to die, working all the next day, and finally going home about 35 hours later. Then you collapse into sleep, wake up, and come in for your one “normal” day. Go home, collapse into sleep, wake up, and come in for your next call day. I counted one week: I worked 108 hours, exactly one of them spent sleeping.
So the situation is tough. In a way, going into it depressed didn’t seem inappropriate. But it did make it harder. And by far the hardest part was getting the calls after everyone had gone home telling me that a patient was being helicoptered in from an outside hospital. This patient was coming to ME. Of all the people in the whole tri-state area, I was supposed to save them. As I got the information, I literally could feel cold sweat trickling down my sides from my armpits. Up till then, I’d thought that was just a figure of speech.
There were two kinds of patients choppered in. The first kind were outrageously well, but something in their test results had freaked out the other hospital so much that they thought the person was about to die. These people were kind of like the full-term infants brought to the NICU for observation: the contrast between them and the truly critically ill folks was surreal. They were also more annoying in some ways, because they could talk and demand sandwiches and want to know why they were there.
The second kind, well. These were the ones that warranted my sweat. They were so sick, so unstable, that it was hard to know where to start first. I once put a central line in a patient’s femoral vein that, when the patient began to develop a blood pressure again, turned out to be in the femoral artery. (And I left it in, because a good arterial line is hard to get.) But the scariest thing of all was: although I could (and was expected to) call the fellow to discuss the case, if I didn’t know what was important enough to tell her—if I didn’t recognize the important physical sign, the critical lab result—I could easily miss something and kill the patient.
After a few weeks of this, a pattern started to emerge. Hey, I’ve admitted scores of sick patients, and I haven’t killed any of them. Some died, sure—the mortality rate was something like 50% overall—but the ones who could be saved, were (along with a few who probably shouldn’t have been). And I got very, very good at looking at a patient and knowing whether they were Sick or Not Sick. It is very hard to kill a Not Sick patient, and there are a limited number of ways to fix a Sick one.
And about three weeks in, I was strolling through the unit one evening humming a little tune.
“You’re in a good mood tonight!” the intern said.
“Yes, I am,” I said. And then I stopped in my tracks. I’m in a good mood. I’m on call in the MICU and I’m IN A GOOD MOOD.
Shit, those drugs work.
I never stopped them again.
And once I left the MICU, I never panicked about any patient ever again, because I’d seen Sick, and the vast majority of patients are Not Sick. As for the rare Sick ones, there are medications that can keep a lump of hamburger alive for a few hours—long enough to get them to … the MICU.