I once did a survey of nurses because they didn’t know. They didn’t know that when we were up at night we were not going to be off the next day. We worked straight through 36 hours then slept and then began another 36 hours. We were one in 2 nights on call when I got involved in student politics. I objected to that and was one of many involved in limited the ‘call’ schedule to one in 3. The survey showed that even the nurses who worked ‘shift’ work 12 hours on 12 hours off didn’t understand. Increasingly because of the dominance of wasteful endless unnecessary administration demands we as clerks and internet and residents were being woken in the night to sign things buses were being told to do so some administrator could ‘cover his ass’. Increasingly we found that what we were being asked to do wasn’t ‘essential’ and never an ‘emergency’ but a whole lot of ‘paper work’.
It was in my internship I shouted for the first time “I don’t care if the goddam chart dies, my first responsibility is keeping the patient alive.” I would be roundly penalized by the new swaggering elite. There competing motto may as well have been, “Who cares if the patient dies, as long as the chart looks pretty!” As clinicians we loved British humor in an episode of “up the Doctor. Ajournalist is interviewing the hospital admistrator in a bran new hospital. “I see you have a lovely new Hospital’a”
“Yes its very lovely
How long has it been opened.
A year,
“But you don’t have any paints, Doctors or nurse, just office staff,
That’s true
Shouldn’t there be patients doctors and nurse in a hospital.
Oh no. That’s who causes all the poblems in the hospital. !”
I completed medicine. I got my diploma. I attended the ceremony. I also felt alone. My wife Maureen didn’t seem to be there for me. I felt that first then. We’d studied together. I was graduating a year ahead. It was a glorious occasion but she wasn’t happy. She was sad because she wasn’t graduating. Suddenly my day, my occasion I wasn’t centre stage. Her unhappiness was competing. She was on the stage not as the triumphant but rather irritated. It was a minor thing but it would grow. Mrs and more I d see the stages with the people doing all the work being pushed aside by this other group.
By contrast my mom and Dad were incredible. They were there and they were so proud of me and I felt their joy and their love. I was centre stage in their world this day. Other days no. But this day they were so proud of me. The picture of Maureen and her Sister graduating in their robes would be ever front and centre but mine ended up in a bottom drawer or lost. My mother and father would display the graduations of my brother and I on their mantel They’d add Maureen’s and my sister in laws too. But in my home I was moved aside. I felt that.
Maureen would arrange the follow up and it was a non event. I would throw a lavish party for her and her friends on her graduation a year later, doing for her what I wished she’d done for me. I’d remember this too as the time I began to ‘do unto others as I would have them do unto me’ with a sort of twist. If I felt somehow that I had been short changed on uncared for I’d do a return in double and greater. I found that I began doing this in my marriage. The sense of giving and taking was shifting. When we began I felt there was equality. I felt through medical school we were contributing to our marriage and life equally but the sexual life was falling. I became dissatisfied. As she moved along in her career she was moving further away from me and more back towards her family. She seemed to only want to have sex every week or two but I hadn’t changed wanting it a couple of times a week. She seemed to treat it as work. I became more and more an accessory. I was fine as long as I accessorize well.
She also wanted to eat out in fine restaurants all the time. I’d know we needed to eat and be satisfied with quick food or a pizza but she increasingly wanted to be wined and dined in style. I was still the one making extra money and the extra money increasingly was going to her desire for fine dining. I’d have these irritating thoughts begin with internship when the actual work load increased but I began to get paid. We were paid $10,000 a year back then. Together we were still barely managing. My friends were saving but she didn’t like to save and she didn’t like to work more but increasingly wanted more and wanted me to work more so she could have more.
I had had to give up giving blood because I’d collapsed and been told I was depleting my own body dangerously. I kept trying to find ways to make money to pay for this woman who was increasingly self absorbed, my princess.
Of course this was marriage and in marriage individuals move to and fro, together and away, in love and forgiving, to alienated and judgemental.
I was looking forward to her completing her medical school so we could get on to having a family. I was doing a surgical residency, 4 years but she was going to complete an internship and have a baby. Carly Simon was singing ‘that’s the way I thought it would be.”
I loved how songs paralleled the inner world. When I’d gone to England with Baiba, Carley Simon had sung ‘you’re so vain’ and I ‘d love playing that on the jukebox in the men’s only bar where I was working as the bar tender, James Taylor singing, I’m just the bar tender” I was dancing behind the bar to the jukebox songs serving shots to old Scots who called me the ‘colonial’.
Now I was listening to Carly Simon still years later. We had our record turntable, the amplifiers and component parts. We had our albums. When we were home alone , the rare occasions, we’d put on mood music. We danced in the living room. Slow dancing. Rumba. Fox trot. Or Jiving to the Beachboys. Joni Mitchell was our easy listening favourite. I loved James Taylor. It was all yuppie fare. I’d later get the Yehudi Menuhin and Ravi Shankar album and play it all the time. I also began by internship to take an interest in classical music. It was simply a progression. I’d love the Scottish ensemble’s Bach Brandenburg concertos. We’d listen more to Cleo Lane. We loved Cleo Lane. Clowns. We’d go to her outdoor concerts when she came from London to Winnipeg. Jazz was so important in those internship days. A flavour more than a mood. It went well with the red wine we were drinking more of.
I did two months of intensive care. I followed this girl who had the highest IQ in our class. I loved her because I followed her on two rotations .ICu was one of them. She had absolutely zero common sense. She’d go onto be a great researcher in a lab somewhere without humans. Because I followed her everyone loved me after a month of this clutz female high functioning aspergers. The stories about her were rife. Given the call beeper and shown her call room she took the bus home. With the first emergency she answered from her home. She thought the call room was for napping. She’d not thought she’d have to sleep there. The buses had stopped running too so she’d only be able to get there the next day.
ICU was incredibly easy for me. Lots of procedures. I did procedures well. The old ‘see one, do one, teach one’ was in play. The staff man showed me a ‘cut down’ and I did the next one by myself then was teaching the other interns. I did countless cut downs, intubation s and lumbar punctures after that. I learned thanks to the great nurses how to assess the comatose and what needed to be done in Myocardial Infarctions and Respiratory failures. We would run all over the hospital with the crash cart and save lives. It was really exciting. I was being a real doctor for the first time, calling the shots, making all the decisions myself and trying not to wake my staff man who was at home sleeping with his wife and kids. Yet if I did call I got these incredible doctors who would either tell me what to do and go back to sleep or tell me what to do and show up at my side within a half hour. Sometimes I’d have another resident from another service, like surgery or cardiology, tasked to help me. I never felt unsupported and the doctors in ICU were all amazing. Everyone had a job and everyone knew it and everyone did it well.
By the second month of ICU I found I knew it all. That sounds ‘arrogant’ but I’ll try to explain. In one month of ICU 99% of what is done daily is repeated. The same limited set of procedures and routines is followed. By the end of one month of learning I was really the ‘senior intern’ or ‘resident’ in ICU. If you watch tv you don’t know this. Everyone is doing the same thing over and over again. It’s not liked Dr. House and internal medicine. It’s not like surgery. In other fields there’s a wide variety of activities and cases but in ICU it’s relatively straight forward. The whole thing is routine but 1% of the time it’s completely unusual and that’s when the genius ICU head stepped in. He saved the day. But the rest of the time it was basic. Airway, Heart, Consciousness. Managing ICU flows and oxygen mixtures was something I took to like a duck to water.
I had one guy who was dead but the family were flying in from Africa and South America so I was tasked with keeping him alive for 3 days. No sweat. I managed his meds and flows and he looked pink for the relatives and then I pulled the plug. I pulled plugs. Pulling plugs isn’t easy. None of this is easy. Lots of folk are critical about the language or the short hand or the way we talk in the front lines. That’s because they are so protected and removed from reality. People are doing lots of near death and death like things in ICU. We lost people. Very few people survive to get to the ICU and mostly when we were called to the ward the person was dead. We saw a lot of horror, ICU nurses get ptsd just like soldiers. Death and more death with the rare life saved.
In one case the woman we were called to on the ward had rigor mortis. Not a good sign. That meant she was dead hours before someone had checked. On the general medical wards the administration had begun to short staff nurses . So I was called with the 99 cart and a nurse to find this patient frozen solid.
Observe is the first rule of medicine.
Palpate is the second.
I’d looked at her and thought she was off. She obviously wasn’t breathing. I felt no pulse
Auscultation is the third.
I listened with my stethesecope and no heart sound. So I thought we were done. If a person’s death is ‘unwitinessed’ and there’s no pulse or breathing when we arrived the chance of resuscitation, even in the hospital was next to nil. If that occured in the community, for a person to leave the hospital required a miracle. We could resuscitate them. We could get them on the machine. I could keep dead people pink.
But they weren’t walking out the hospital on their own steam. That was when I began to learn about the manipulation of statitistics. I learned how politics was used to falsify data, not really,but really. So there was this set of data about who came to and got out of the ICU which made the ICU look good. This was important because the ICU was the most expensive part of the hospital and when I worked there I never was asked to think about the cost of anything. I could use whatever I needed to get a person back to life. I did. I was really good at resuscitation after only one month.
This lady though was stiff. She wasn’t coming back . When I lifted her head to see if I could incubatedher , her neck was frozen forward by the rigor mortis. We weren’t going to get a tube down her throat. We couldn’t even open her mouth. The nurse and I were going through the motions and knew it was a lost case.
“She’s in rigor mortis” I said. He nurse shook her head.
“There’s a new resident.” I said.
“Thinks she’s a hot shot.” The nurse said.
“We should call her.” I said with a wicked grin.
“Yes,” the ICU nurse laughed.
The new resident had already pissed off the nurses talking down to them. The nurses liked me because I knew they were essential and always they helped me. I didn’t have this Me Tarzan You Jane, I’m the officer , you’re the enlisted men attitude. This worked great for me in clinical work because we formed teams really well and the work got done immediately. I never had problems with good teams either, fitting right in. Later I’d have problem with the really bad member of a bad team the bad one keeping the rest of the group down. This is the Union nemesis. But that was years to come. The new resident had dished the ICU staff and me acting like she ‘knew’ everything, planning on being a cardiologist and having done a month of cardiology before coming to ICU.
“Let’s calll her.” I said. “We can hide and watch. This dead person is the best teaching case we’ll ever get.”
The nurse was all for it. Decades of experience in ICU. I was the bad apple. Pranks were still the William Osler thing to do. I was still doing pranks.
We called the 99 again.
She came running, out of breath. and didn’t stop to look. She didn’t observe. She Didn’t stop to palpate. She just put her stethescope on , didn’t hear a breath, pulled out the incubator and tried to get the neck back. We were watching from behind and she was man handling the little dead lady like an Intubation Sally but the neck wasn’t going back and the claw hand was flung up and still she didn’t stop. She was on the verge of breaking the woman’s jaw and neck to get the neck back so she could incubate when I stepped out and said
“Did you notice the tell tale hand” I’d notice the claw sign first thing but couldnt believe it. It was more pronounced.
“Did you happen to notice she was dead and rigor mortise had set in?”
She stopped. Almost cried. Stood up , furious. Screamed at the nurse and I for doing that. I said.”Observation.” Palpitation. Auscultation. If you did the BASICS we’d not be having this discussion. I’m not the one who made the mistakes. You did. So own it and don’t make the mistake again.”
“I’ll get you if it’s the last thing I ever do. “ she screamed “ No one sets me up and makes me look bad. You bastard. You fucking bastard.” She stormed out of the room. She complained to everyone about me but she was digging her own grave. Everyone asked if she’d looked at the body. The nurse backed me and said we’d thought it good training. We really had thought it was a good teaching exercise. We hadn’t thought she’d miss it so completely she almost broke the patients neck and jaw. She totally failed to do all the basics.
“That didn’t go so well” I said to the nurse.
“No it didn’t. We hate doctors like her. They’re really rare but they seem not to have the smarts and these huge egos and don’t take correction well.” The nurse shared.
When she couldn’t kill the messenger she shut up. This was good because the administration didn’t want it out they were mismanaging nurses and people were lying dead with rigor mortis on the acute care hospital wards. The nurse who had called me felt really badly. The resident, after using up all her bullying tactics, actually began to learn. The staff came in to spend time teaching her because she obviously couldn’t be trusted without the basics. I liked that. The head of ICU just cared about patietns and his staff and seeing what a nutbar she was came and taught her himself so he could go to sleep at night sure that she’d not be killing someone or manhandling dead people. Everyone just left me to myself.
“You know when to call for help. You can’t imagine how hard that lesson is for some to learn.” I had no trouble calling for help. I didn’t like to but if I needed help I always got it. I’d spend my career doing that. It would eventually have me pounding on the doors of health ministers and others trying to get my patients help.
The story went through the hospital and the next month or so everyone asked her ‘have you resuscitated any dead people to day.’ She began to laughed when other interns and residents waved at her with a claw hand. She became accepted when she laughed. Everyone made mistakes. The thing was to learn from them.
I just loved ICU. Even the macabre memory of teaching the ICU disco dancing Staying Alive between rows of huffing respirators
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