I am now done with my ICU month. I would just like to reiterate, again, that being on 30-hour call every third day for an entire month is total and complete bullshit that ruins your body and soul and no one should have to do it.

I have also been advised by legal counsel, also known as one-half of the Bringers of Life, that in my previous post I apparently ran a small risk of getting in trouble. I am not sure why; perhaps this is because I reference in somewhat pointed terms that one of my hospital sites (the Not A Real Hospital one) is run about as efficiently as a traffic jam.

We should also note that the Chief Privacy Officer, aka Lover of Thumbscrews and Bamboo Shoots Under Fingernails, and often referenced here, does not have jurisdiction at NARH.

Thus, my previous post (Stories from an ICU Black Cloud) is now password-protected. Send me a message if you want the password. It includes letters, numbers, at least one special character, and has to change every 60 days… just like my password for the medical records system at this same hospital. In related news, I forget my password every two months.

(I have also solved this problem, but it is also kind of skirting the rules, so I will not explain myself here.)

Anyway. Working thirty-hour call for a month does interesting things to your body. For starters, I am now able to sleep at the oddest times without incident. For example, earlier I fell asleep while pumping gas, with my hand on the pump holding down the lever. I fell asleep last week sitting down in my shower with water hitting me directly in the face. The icing on the cake was on my last call night around 3 AM, when I fell asleep while leaning against the wall as I tried to decide whether a patient needed to be intubated.

Poor form.

Anyway. Despite my sleep deprivation hallucinations (yes, that’s a thing), body-turning-into-the-Pillsbury-Doughboy weight gain, and clear acceleration of whatever timer sets off early-onset Alzheimer’s, I did learn some things.

For starters, I learned how to BUFF and TURF a patient. BUFFing a patient comes from The House of God, which has been covered here before. It refers to making a patient’s numbers, appearance, and vital signs look pretty (despite underlying disease to the contrary) in order to send that patient to another service or another part of the hospital.

TURFing is transferring a patient to another service. The best TURFers in the world are orthopedic surgeons. We all envy them.

Because I am a black cloud, we routinely ran into the problem of Not Enough Beds. At this particular Not A Real Hospital, we usually had physical spaces in the ICU – but no nurses to take care of the patients. This is partly because the staffing protocol was designed many years ago by an 8-year-old boy named Steven using a K’NEX set and a handful of marbles. It is also partly because the nurses have figured out when I am on call (it’s not hard, it’s every third goddamn day) and reconfigured their own schedules to avoid it.

When a sick patient from the ER would need an ICU admission, I would thus have to BUFF (or politely, downgrade) a patient so I could TURF them out of the ICU. This usually meant taking someone who was stable-ish (if they were totally stable, they wouldn’t be in the ICU at all) and making them look really good for thirty minutes so that the floor staff would be convinced to take them as a transfer.

This worked successfully in all but my first BUFF & TURF, which was a learning experience: two minutes after my downgraded patient made it to his bed on the floor, the nurse decided she disliked his vital signs and activated a Rapid Response. I have discussed the finer points of a rapid response previously, but the general mood is “clusterfuck,” and often results in a transfer to the ICU. My poorly-BUFFed patient went right back to the ICU, and my intubated patient getting sixteen units of blood and an emergency surgery stayed in an ER bed the entire night.

This, by the way, is not particularly unusual.

Besides manipulating the transfer system like a puppeteer, I learned that supervising a junior resident performing a procedure is many times more terrifying than performing the procedure yourself. For instance, I put in roughly a gazillion lines on the Liver ICU,  and am now comfortable enough with central lines that I could probably put one in with a blowdart and a little bit of saline.

On my first week in this ICU, I did a line with my intern, who had performed exactly zero lifetime procedures. After coaching him through the steps and setup, I helped with the ultrasound as I watched him start with the big needle in the neck. He advanced…and advanced… and advanced the needle, as my heart rate went up and up and up and OKAY STOP PLEASE.

I was convinced he had given the patient a pneumothorax or hit the carotid artery. I had him withdraw the needle and coached him through starting over. At that point my calm and reassuring voice allowed him to successfu- okay, no, I had sweat pouring down my back. I was as calm and reassuring as a buffalo stampede.

We eventually got it together enough to put the line in, but holy shit is supervising scary.

Lastly: I realized that I, in fact, like critical care. I enjoy the acuity, the procedures, the focus on fixing active issues while caring not even a tiny bit about chronic ones, the teaching, and the physiology. All of us medicine people are science nerds at heart, and science (or at least the semblance of it) is on heavy display in the ICU.


(you knew there was a but, right?)

ICU rounds take forever. FOREVER. For this reason alone, I am disqualified from pursuing advanced training in critical care. I cannot do the rounds. I just can’t. I can’t sit around a table, or stand around a COW*, for hours discussing the relative merits of steroids (who knows) or the cause of this patient’s hyponatremia (who knows) or the differential diagnosis of this patient’s acute kidney injury (who knows) or or or or SHUT UP AND MOVE ON THERE ARE TWENTY MORE PATIENTS TO SEE.

*A COW, by the way, is my favorite acronym ever. It stands for Computer On Wheels. This alone does not make the acronym funny. However, someone took offense to calling the machines COWs because it sounded derogatory! I am not making this up! Someone seriously complained about what we named our computers to hospital administration.  This is potentially more West Coasty than the recent debate over whether coffee is known to the State of California to CAUSE CANCER (it doesn’t).

We are now supposed to refer to them as WOWs, or workstations on wheels. In addition to sounding stupid, everyone walks around like Owen Wilson at the start of rounds:

“Do we have WOWs? Where are the WOWs? Grab a WOW from the other side of the floor.”

Of course, I categorically refuse to call them anything but COWs. Come at me snowflakes.


I just can’t do the long rounds. I’d never survive an ICU fellowship. In fact, it is lucky my month ended when it did; if I had to stand and discuss the treatment of GI bleeding (referred to by lay people more dramatically as “blood erupting from the butthole”) one more time I would spontaneously explode like the inside-out alien from GalaxyQuest.

Thankfully as the “senior resident” I am afforded somewhat more leeway than the interns when I present patients. To wit, on my last day, I related the entirety of my patient’s presentation in three words: “We fixed him.”

I then stood in silence until my attending blinked and stuck his hand under the hand sanitizer to enter the patient’s room.

7 thoughts on “BUFF and TURF

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