Disclaimer: I am especially salty tonight because I have trudged one small step closer to the inglorious age milestone of 30, and have little to show for it except two aborted jobs, knee pain, and a shitty Mazda with an outstanding recall for premature airbag deployment.
This month, I’m taking a hybrid course called Critical Illness, which as you might imagine focuses on the unique aspects of caring for the very sick or injured. We spend a week learning “skills” in our simulation center, followed by some combination of an ICU week and two weeks of case-based learning, similar to what we did first year.
I place “skills” in quotations because the vast majority of the time was spent gleefully stabbing containers of dye-containing gelatin with large-bore needles in simulating placement of a central line.
I just finished a 7-day stint in the medical intensive care unit, the MICU. Patients in the MICU are very, very ill: some have uncontrollable bleeding into their gut, some have overwhelming infection, some require ventilators to stay alive.
I was actually pretty excited to start my MICU week. I hadn’t done an iota of clinical medicine since November, when I was on anesthesia with a broken hand, and was eager to get back to taking care of people.
(This, by the way, is the greatest trick your medical student friends have ever pulled on you – convincing you that he or she is actually taking care of a patient, which is, quite thankfully, very far from the truth.)
Anyway. Any ICU rotation promises to have a fair number of procedures: starting ultrasound-guided IV’s, inserting central lines (which are essentially very large IV’s that dump directly into your heart), placement of various tubes into various unmentionable places, etc. etc.
I was jazzed to have the chance to maybe possibly place a central line, if the universe aligned and Hippocrates himself appeared to the resident in apparitional form to declare “Thou Shalt Allow Thy Medical Student To Perform Invasive Monitoring.”
I was also jazzed to just be done with my research block and would have happily settled for anything offered, except the frequent “offer” to “help the team” by obtaining medical records from another hospital.
(Side note: I would 100% watch a Celebrity Deathmatch between a Comcast customer service retention agent and a medical records clerk at a large hospital. I legitimately do not know whose head would explode first, but seeing it rendered in Claymation would be spectacularly satisfying.)
(Second side note: obtaining medical records is the quintessential medical student job, along with such tasks as “disimpaction” – don’t google that one – and getting coffee for the attending. It is the absolute worst, and will rapidly convince you to abandon ship in favor of flipping burgers for the rest of your life if you do it for too long.)
It turns out that when you haven’t presented a patient in about six months, you are rusty. You are especially rusty when the presentation format for an ICU patient is very different than any other kind of patient, in that you have to present a plan “by systems.”
Let me back up: A typical “plan” part of your presentation comes at the end. It’s the proverbial money shot – when you have the chance, as an intrepid and brilliant medical student, to impress the rest of the team with how spectacularly undereducated and stupid you are, sometimes eliciting remarks such as “no, that’s entirely wrong” which is generally positive feedback as far as I’m concerned.
For most patients, there are only a few things wrong with them. There’s usually only one reason why they’re in the hospital – for example, appendicitis. Maybe the patient also has diabetes and high blood pressure. When you present this patient on rounds, the plan is usually done by problem:
“For Mr. X’s appendicitis, he had surgery overnight and today we will plan to get him up and ambulating… For his diabetes, he is on sliding-scale insulin…” etc.
This makes sense, especially to my emergency medicine-focused and attention span-lacking brain. Fix the problem, all other things do not matter. Next.
Unfortunately, ICU patients never have just one thing wrong. Literally never. It has never happened in the history of the MICU that a patient had only one thing wrong. If it ever did happen, the ICU fellow would spontaneously combust in a glorious paroxysm of joy.
So in the ICU setting, the plan is presented by “systems” – meaning the patient’s existence is subdivided into a series of organs, with a plan for each (even if the organ is fine). The systems are:
- Fluids, Electrolytes, Nutrition (not a system but they had to stick in BS about nutrition somewhere)
- Infectious Disease
- Prophylaxis (also not a system, but people get angry if you forget this one)
Also, I snuck butthole in there. Just to see if you were paying attention.
I have never presented a plan by systems before. I should have done this on my trauma rotation considering it is also an ICU, but I was never allowed to do something above my level of training, such as speaking out loud.
Not that I’m bitter. I did get to staple a guy’s head shut so maybe it balances out.
Anyway. I have never presented by systems, and I have no idea how. The ICU team is also large and intimidating, consisting of three residents, a pharmacist, a fellow, the attending, the patient’s nurse, and sometimes the patient’s family. So my first presentation, on day one of my ICU – which, remember, I was very excited for – looked something like this:
I made it approximately six seconds before the attending physician cut me off and made the resident finish.
Sad day for me.
It got worse from there. Although I became more comfortable with systems as the week wore on, I remained very, very rusty from my lengthy hiatus from the clinical environment. I got simplistic pimp questions wrong, such as, “The knee bone is connected to the…?”
“I’m sorry, no, the correct answer was ‘azathioprine-induced pancytopenias.’”
I did not engender much confidence during my ICU week. I received my evaluation from the attending this morning, which read in its entirety:
“Worked hard, but Nathan does not have a career in critical care.”
Sigh. There’s always burgers to flip.