Wednesday, October 11, 2006

The MICU: How I Know Antidepressants Work

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.


Return Of Saturn said...
This comment has been removed by the author.
Return Of Saturn said...

Hi DM... Thanks for posting about this topic (mostly the anti-depressants, but it's interesting to hear about medical training, too!)
I have a question for you, and don't worry, it will not be construed as medical advice on my part. Have you been on the same meds since your MICU days? If not, how'd you determine it was time to switch up the cocktail as opposed to it just being a shitty day?

Gregory House, PA-C said...

That post was surprisingly uplifting and calming from the perspective of a premed student who's scared shitless of intern year.

Anonymous said...

Oh lord, that's perfect. Such a good description of the MICU madness that I got flashbacks to residency. Thanks for writing that tonight -- I'm up fretting about a Not Sick patient who suddenly got Sick while on my watch, and boy am I glad that she's in someone else's MICU. Without residents. I wish I could say I don't worry about them any more, but you're right that the difference between the two groups is astounding and unmistakable.


Anonymous said...

Great, edge-of-the-seat storytelling...but, but, on Earth do you cope with the lack of, um, orgasmic activity?? If you've managed to find a pill which lifts the blues and still allows it, do tell! That was what made me come off mine (though I don't suffer from depression, but panic disorder and, the MICU would have been no place for me!).


Phantom Scribbler said...

My husband left clinical practice 15 years ago, and he STILL sometimes wakes up in a cold sweat from a nightmare that he's had to go back on call.

Medical training ain't for the faint of heart, that's for sure.

Anonymous said...

Great post. I'm in a medication struggle at the moment myself. I too have suffered from chronic depression my whole life, some times worse then others of course. I started medication a number of years ago, but too, felt fine, went off for a number of years doing okay until last year when I realized "it's baaacck." It's funny how it sneaks up on you.

I can go a long time functionally serverly depressed so it can be hard for me to see it.

I started meds again last year and felt better, but not as good as I thought I should, and it seems to be slipping, so now I wonder, when is it time to change and go to something different.

And, the answer I came up with is "when I start to wonder, it's time."

Why is it so hard to see it sometimes?


amusing said...

See, that's the tricky question -- "how am i supposed to feel" I'm not bad when I'm off, but something will set me off (usually Mr. X and/or hormone shifts aka my period) and then I'm a mess. On, I'm the same, just a bit less so.

Is the "bit" worth being turned down for medical insurance becauase I take antidepressants and get migraines? Seems unfair to me, since I'd guess a majority of the population takes antidepressants in some form these days. I know the numbers are high among the moms at my kids'school (we laughed about it over ice cream one day -- that all three of us were on something).

Anonymous said...

All I can say is, thank god for the MICU nurses. I remember being an OB/Gyn intern who *had* to rotate through the MICU, even though I went into OB specifically because I didn't want to deal with the sickest of the sick. I would kiss the feet of the nurses when they would call and say "Mr. X (or usually "bed 4") just had a run of V-fib, do you want me to send the usual labs, doctor?" and then call back and say "his K is 3.5, should I give him two K riders, doctor?" If I didn't say it then: THANK YOU!!

E. said...

Sheer curiosity: is the MICU different from the ICU, and if so, how? Is it just the more extreme version of the ICU?

OMDG said...

A 2nd year medical student said to a 1st year that he could tell we had really begun to get into the the swing of things because we had all stopped smiling and were grouchy all the time. I thought that perhaps since we get so many free pizza lunches, that it might behoove Lilly to provide Prozac shakers (instead of pepper flakes) for our pizza. It sounds like it might actually come in handy. I will DEFINITELY keep your story in mind as I progress through school though!

Linda said...

Woo-hoo! I've been a (good) MICU nurse for a little over 5 years now and I love it! Thanks for the back pat. Usually I just read about obnoxious nurses. I can see when the interns are scared and I feel for them. I can tell them what we normally do in a situation, but they're the ones who shoulder a huge load of responsibility.

I work at a huge teaching hospital and we've had intensivists overnight for years. They have a cute little sleeping room, but since we have a helicopter and 39 beds (plus 39 more in SICU) they don't sleep a lot.

Also, if a patient can use a call light, they need to go somewhere else, don't you think?

E. - some hospitals divide their ICUs. MICU is the medical ICU, SICU is the surgical ICU. Some places have coronary ICUs or neuro ICUs.

Anonymous said...

Fascinating post. I have a really, really, really dumb question. What's the difference between an attending and a fellow?

B.E.C.K. said...

I have a hard time knowing whether I need(ed) antidepressants, and knowing whether they do/did what they're supposed to do. It certainly wasn't like having an infection and taking antibiotics and feeling significantly better. I did notice the decrease in libido, though. How to get around that?

I enjoy your stories and yet I find myself feeling anxious about the ridiculous custom of putting residents (? - I never know the right terms for the hierarchy) through such long, sleepless periods. I don't know of any other profession, off the top of my head, that does something like that, nor do I see how it could improve *anything*. Could you imagine flight schools putting pilots in training through long, sleepless periods? What would that prove? Would you want to fly with someone who hadn't slept? Why would anyone want to receive medical care from someone who hasn't slept? Give me a well-rested doctor any day.

Val said...

DM, do you mind sharing w/us the med that has worked for you? It's gotten to the point that I don't know whether it's the depression itself or my own hard-headedness that's keeping me from seeking meds...

Unknown said...

DM, thanks for sharing that story here. As yet another depressed medical student with a long-time history of on-again/off-again medication, I too struggle with the decision to medicate. (I've got ADD as well, so it's a double-whammy - do I get treated for one, both, or neither?)
It seems from the comments that there are quite a few of us. It's comforting to hear from someone who's made it through and who successfully uses the meds as they're intended. Congrats and thank you.

Mignon said...

So is this sleep-deprivation, trial-by-fire training approach another unique and Draconian product of the good ole U-Nited Sates? I know we're running behind the pack for vacation, family leave, post-partum care, etc. What's the deal? Am I being too soft - do you think this scary litmus test for doctors is crucial to your development as a quality physician?

C. said...

Hey Sara:

Not a doc but I am treated for depression, anxiety and add. The add meds I take as needed. For example if I have a big project or feel I need them because I am not focusing, so I dont take them everyday. I do however take my SSRI everyday. I have seen a vast improvement in my productivity and concentration.

I really do wish my add was diagnosed years ago. Now that is has been I have been considering Med or Law school. Nothing like another degree to add to the pile.

Anonymous said...

I live much of my life in a sleep deprived state and have stayed up for 72 hours at a time to finish papers that are due. It's very common for me, actually. There are many days where I go work when I've only slept for one or two hours. Sleep deprivation has an interesting effect on cognition. Sometimes it is a bit like being drunk where you are numb to things or less inhibited but also you look back later and it is difficult to remember what you've experienced. However, I've found that sleep deprivation makes difficult experiences seriously traumatic for me--it's as if my brain cannot process events correctly at the time and if something upsetting happens I will literally have flashbacks, etc. of it later. I cannot assess things clearly in retrospect because I wasn't all there in the first place.

So I would imagine that the schedule you describe combined with the intensity of the situation would be a set up for depression and a host of other psychological problems.

I hope someday I can live like a normal person but if I want to publish, I kind of doubt it. I always wonder if I can live this resident lifestyle into my forties and fifties.

As for anti-depressants. I'm not sure how well they work over time. I sometimes think I take them for performance enhancement in a way--but I guess that does mean something needs correcting. Still, it's a little bit depressing in itself.

I think I mentioned Atul Gawande in my last comment but I really loved his essay on learning and making mistakes as a resident. There was so much I could relate to in it--and then I realized: No one can die from any of my screw ups! Much of my work seems so critical and yet on that scale, it's entirely trivial. Since I am cracking under the stress now, I wonder how I'd fare with a much more critical set of criterion for success. Maybe I'm wrong but I tend to think that it's usually possible to learn almost anything. I think many of us could learn to deal with death, even the possibility a mistake you made caused a death. But I still find it kind of amazing that one can learn that.

Larki said...

Whoo, that's good stuff. I could feel the sweat trickling in sympathy as I read.

I'm glad to hear other people use the Sick-Not Sick dichotomy. My varient for the ER is Discharge-Admit-Fly, aka Kick'em Out, Put'em In, or Send'em Up.

amusing said...

Hi -- 47 year old here who has been pulling all nighters and, in the occasional emergency, 72 hour shifts to finish papers for school. It is rough going. The Eldest called me my evil twin after the 72 hour stint. And I fell into a nap on the couch so deep that when I woke up I had total amnesia -- didn't know who I was or where I was for a time. Very scary.

Sleep. Good.