Thursday, August 18, 2011

Update on sign out

OK, now that I've got some more experience on my belt. I gotta say that sign outs really aren't that bad. First, every morning the entire team rounds on every patient on the service, so even though I'm not managing every patient, the fact that I may be responsible for the patient at some other time gives me incentive to pay close attention. The fact that I have that incentive to pay attention has the added benefit of learning about a patients condition without doing all the busy work. The second reason why sign outs aren't that bad is that we're all getting better at effectively presenting patients to each other and writing effective notes. This is a skill that takes some time, but each week it gets better and better. So, now I'm willing to say that shorter hours and more sign outs (in the long run) is better for patients and residents than an overtired resident managing patients. Numerous studies have shown that sleep deprivation severely affects cognitive performance. So, I'd rather have fresh residents who need to spend some time getting to know patients versus an overtired, cognitively impaired one that knows their patient really well.

Tuesday, August 16, 2011

Signing Out

With the new work-hour rules for medical interns, the ICU is no longer a place where every 4 days an intern spends 30+ hours in the hospital. I'm glad for the rules. 12-18 hour days are bad enough. However, what it leads to is a lot of passing patients from one resident to another, which, in turn, leads to a general lack of ownership of a patient. It used to be that you admitted your patient to the ICU and for the next 20-30 hours, stabilized them and figured out what was wrong with them. You knew their history inside-out and knew how to manage them and what to look out for. Now, you may admit a patient, but 6 hours later, you've signed the patient out to the next intern. The sign-out is a five minute conversation relating the patients history, status and what to anticipate. The receiving intern know very little about the details of the patient and has to essentially start over. This leads to lots of information falling through the cracks. I recently got handed a patient that had been in the ICU for several days. He was stable enough to be transferred, which meant, I write out the discharge paperwork. Since I didn't know the patient, all of it is based on previous notes. I have to trust that those notes are completely accurate and thorough enough or something important about the patient could be missed. Unfortunately, many notes are neither completely accurate nor completely thorough.

It's a choice between having overtired residents who are prone to make mistakes or this. I'm not sure which is better.

Tuesday, August 9, 2011


So, I finally get a day off from the ICU today. It's not bad, but there have been a few situations where I felt like I was biting more than I could chew. This is the place where the sickest patients go. It's pretty scary to be playing doctor with people who are just barely hanging on to life. Just a few hours ago, a patient of mine passed away. He crashed in front of my eyes and I can't help but look back at every order I made (or didn't make) to see if it could have been prevented. What's worse is that I can find things that really could have caused him to crash. I suppose this is the reason why the learning curve is so steep. If you don't pick it up quick, lives will be lost.

The fact that I, as someone who hasn't had any meaningful responsibility in a hospital, suddenly am seen by others (patients, nurses, family members) as an expert whose every wish will be carried out (if it's correctly entered in the computer) is terrifying. What's worse is that there never has to be a backup. Yes, there are other interns, residents and attendings, but there is a lot of on-the-spot decision-making that falls on me. Most of it is harmless, but there are times (especially at night) that it can irreversibly affect a patient's health. There are many orders I've put in that I am not confident of (or as a fellow intern said about an order a nurse suggested to her, "I don't know what it was, but I ordered it"). Things go very quickly, there's high patient turnover, and people die (signing your first death certificate is a pretty strange feeling).

I've only worked in the ICU for 7 days, but it's felt like a month. It's an experience where you learn a lot, but it wears you down. I'm glad I'm getting the experience, but I know it's not for me.

Sunday, August 7, 2011

Lost in the ICU

Talk about getting slammed! Working in the ICU doesn't leave much time for anything else. I should have known that when a fellow intern said that I should take care of all my bills before starting the rotation. I will try to have an update sometime soon.