Friday, July 16, 2010

The Internship and Residency Chronicles Volume 2: Follow the Yellow Brick Road

*most names and details changed. . . . . .you know what's up.
"You, my friend, are a victim of disorganized thinking.

You are under the unfortunate impression

that just because you run away,

you have no courage.

You're confusing courage with wisdom."

~ The Wizard of Oz in "The Wizard of Oz" 1939

I remember looking at the schedule for inpatient ward assignments during the winter of my intern year. I found my name with my index finger and then dragged it across the paper to find who my fearless leaders would be. My resident was this feisty third year woman. . . . . excellent reputation for being smart although tough. I could handle that. I followed the column upward until it landed squarely on a name that I wasn't so sure I could handle: Dr. Olds. Gasp. My attending that month was. . . .eek. . . the Chairman of Medicine? Great.

Here's the thing: I was in a combined training program where every three months I switched from assignments in Pediatrics to Internal Medicine, and then back again. My yellow brick road was convoluted, to say the least, and finding my footing during those early days wasn't always easy. This upcoming ward month would be my "back to Medicine" month after three rigorous months of Pediatrics. I still had NICU, newborn nursery, and pediatric emergencies on the brain. Those first few days after the switch always felt a little shaky; I'd mastered the art of looking confident when deep down inside I was a quivering blob of jello. But this was even more terrifying than usual. In addition to my normal freak-out, I was given the privilege of having a potential meltdown in front of the Wizard himself: the Chairman. Super.

Okay, so I was a PGY (post-graduate-year) 1 back then, but can I say that even now, as a PGY 13, I would find it equally mortifying to be under the microscope of my Chairman? Picture it. Every day, you get to present your patients, what you discerned from your history and physical, and subsequently do your best to field the barrage of Socratic questioning that would surely ensue. From your Chairman. This meant that a screw up or a bad day could have monumental consequences. A category 1 nausea hurricane quickly organized in the pit of my stomach with every ingredient for growth into category 5.

The good news is that despite how intimidated I was by my Chairman-turned-ward attending, he was pretty nice. In fact, he was more than that--he was really, really nice and surprisingly approachable. The other good thing is that my resident was excellent that month, and she cracked a mean whip on us interns. She'd make us present our patients to her first, and would pick our write-ups apart and then reassemble them before rounds every day. In other words, there was never a performance without a dress rehearsal and a sound check. I mean, this was the Chairman of Medicine, which in case you haven't figured out yet, was kind of a big deal.

Follow the yellow brick road. . . . .

One night on call, I was being covered by a different resident. I was no longer under the watchful and protective eye of my trusted PGY3, but instead was the orphan intern of someone less familiar to me. His name was Gary; a second year resident who was smart, but much less confident than the mini-general that I'd become so accustomed to. This resident would ask me what I thought we should do. And not just in that obligatory way that folks often do when talking to medical students or interns. This guy really needed me to co-sign his decisions. Even though I was feeling more and more comfortable with clinical decision making, his anemic leadership was terrifying. And even more so since my attending was--had he gotten the memo? Uhhh, the freakin' Chairman of Medicine.

It came to a head when we stood before a woman we'd just admitted with community-acquired pneumonia. Gary and I had just gone down to the Radiology suite to review her x-rays which, consistent with her lung exam, revealed a moderate sized fluid collection around her left lung. My wobbly leader discussed the next steps with me as we rode the elevator back up to the patient's room.

"She has a pleural effusion, so the next step is to sample the fluid with a thoracentesis, okay?" Gary asked/said. Then he reached in his pocket and thumbed through the Washington Manual under "Management of Pleural Effusions." He looked up at me and added, "I think that sounds like the right thing to do, don't you?"

I didn't like this co-sign thing. I needed him to speak with authority. I wanted him to be so comfortable with this situation that he could quiz me on the Light's criteria for pleural effusions while picking dirt out of his nails with the edge of an index card. Didn't he get it? I wanted to be his intern, not his co-resident. I furrowed my brow and answered him, "Uh, it's my understanding that an effusion that size needs to be tapped. And I guess depending on what it shows, you determine whether or not a chest tube is necessary."

What did I say that for? Gary's face went pale, and he swallowed hard. "Oh my gosh. I really, really hope she doesn't need a chest tube. Oh my gosh . . ." He shook his head and muttered while devouring the tiny paragraphs printed on the pages of the Washington Manual. Now, I somehow felt like a jinx.

But this patient looked good. In fact, the only thing that had prompted her admission was her abnormal x-ray. She'd had this fever for two days associated with a cough, and when it didn't go away, she decided to come to the emergency department. This patient was youngish--in her fifties--and had been in perfect health. Since she didn't usually get sick and made regular visits to her primary care doctor, she grew a bit worried. She didn't smoke, didn't use drugs or alcohol, and was breathing well enough to not require oxygen. During her visits to her PCP, she'd had regular lab work including several negative HIV antibody tests. And so, the truth is that this lady was not sick-sick by any stretch of the word. She just had an ugly x-ray which sometimes can be enough to make even the most bad-ass the Emergency Department doctors uncomfortable.

A third year senior from the ICU supervised me as I did the procedure since Gary wasn't comfortable being the overseer. The patient tolerated the thoracentesis quite well--in fact, what I remember the most about her was just how great she looked overall. In fact, she was so cool that I remember her talking to me about banana pudding during the procedure. So clinically? She looked cool. Clinically cool, yes. But radiographically cool? Uhhh, not so much.

After carefully removing a sample of fluid from the space around her lungs, I confirmed that we hadn't introduced air or caused any complications by checking on both her follow up x-rays and how she was doing. Just like when I'd seen her in the Emergency Department earlier that night, she looked great. My nervous upper level stood beside me as I led the conversation.

"How are you feeling, Mrs. Elmore?"

"I'm actually feeling a lot better. The cough seems to be loosening up some more, and now I'm bringing up more phlegm. I still have a little pain on my left side, but it seems a touch better since you guys took some of the fluid off of my lung." She really did look like she felt better. Even better than she looked before the thoracentesis. "I think my fever broke, too."

"Are you breathing alright?"

"Yeah, I'm okay. My nurse says I am still breathing a little faster than normal, but like I said, I was surprised when they wanted to keep me. I guess I'm glad you guys did since I had the fluid around my lung--what did you call that again?"

"A pleural effusion," I answered with careful annunciation of the technical terms.

"That's right, the pleural effusion. Yeah, but I am feeling a little better. I think I'm going to try to get me some rest," she said with a smile, "I hope you all get some, too." I glanced up at the clock on the wall beside us. 1:36 a.m. I smiled back at Mrs. Elmore and raised my eyebrows. Sleep? Yeah, right.

"You do the resting," I laughed. "I'll be checking on the results of your fluid, and will let you know what it says. The fluid looked pretty clear, so I won't wake you if it isn't too exciting. Right now, I'm anticipating that we won't see anything alarming." I did my best to speak with the authority that I knew my supervisor that night had not quite grown into yet. We both bid Mrs. Elmore adieu as she nodded and rolled over in her bed.

2:21 a.m.

I had my head down for a catnap at the nurses station when my pager startled me awake. It was the "Stat Lab"--I recognized the number. I whipped out my pen and a piece of paper in preparation of Mrs. Elmore's unexciting pleural fluid values.

"I have a critical lab value for you on patient Elmore," spoke the lab technician. He didn't waste any time. "I've got a pH on a pleural fluid specimen of 6.9."

I thought I'd heard him wrong. "Excuse me?"

"The pH on your pleural fluid sample. It's 6.9," he repeated firmly.

"6.9? On patient Elmore?" Again, he affirmed that this was indeed the patient, and no, he didn't stutter: 6.9 was indeed the value. I felt the hurricane swirling in the pit of my stomach again. A pH of less than 7.2 meant the fluid was likely pus, or what we refer to as an empyema. And one of the first things you learn in medical school is that "pus must pass." Uggh. Mrs. Elmore needed a chest tube--the only way for pus to pass out of the pleural space.

"Shoot!" I said aloud thinking about how peaceful she'd looked when we'd left her bedside. I imagined us rustling her awake only to have some baby-faced surgical intern consent her for a hollow tube the size of her pinkie finger to be inserted into her chest. "Shoot!" I repeated. This stunk.

as heinous as it looks: a simulated-model patient with a chest tube

Before I could even fully process it all, Gary was flitting about me like some sort of anxious hummingbird. "You saw that the pH is 6.9!" he exclaimed, "I already called surgery for a chest tube. They're coming. You think she needs a chest tube? I mean, less than 7.2 then she does, right? This is awful. This is so, so awful." He looked like he was going to be sick, which made me feel the same. I longed for my drill sergeant day resident, who likely would have smacked Gary and told him to get a grip. He was making me anxious. I gathered my cards up and prepared myself to go and speak to Mrs. Elmore.

Gary shuffled beside me as I reached the foot of her bed. I could hear her breathing; peacefully sleeping without oxygen or any respiratory distress whatsoever. I whispered to Gary, "Don't you think she looks too good for that pH and way too good to need a chest tube?"

He gave me a puzzled look. "But the pH is 6.9," he spoke more firmly than he had all evening. He paused for a moment to make sure we didn't wake her before adding, "Despite how good she looks, she needs a chest tube!"

"Could it maybe be a lab error? I'm just worried because a chest tube is like a really big deal." We both stared at her quietly for a few moments. I turned and faced Gary before saying the unthinkable. "I think you should call the attending."

It was like my mouth moved in slow motion. I just suggested to my nervous upper-level that he call not just the attending, but the Chairman of Medicine--oh, at 2:40 in the morning to boot. Good luck with that.

"But it is clearly less than 7.2. It's even under 7.0, Kim. This is clear cut. She needs the chest tube."

Great. We've been on this yellow brick road all night, and now the lion finds his courage on the first decision of our call that I actually wanted him to get my input on. I decided to challenge him. "This doesn't make sense, Gary. Dr. Olds always tells us to pay attention when things don't make sense. I think we should call him. If you won't, I'm willing to."

"Call Olds?" he gasped. "You will not call our Chairman at 3 a.m. to ask him an obvious question. Absolutely not." He scowled and walked out of Mrs. Elmore's room to punctuate his position. Great. Now he'd found some heart, too.

I wouldn't give up. I finally convinced Gary to let me call Dr. Olds, but he made it clear that I should tell him I did so without his blessing. In other words, "If you have the audacity to kick open the gates of Emerald City and smack the Wizard on the back of his head in the middle of the night, you'll be doing it on your own." That was fine with me. I just didn't want to see this healthy woman be subjected to a chest tube that she surely wouldn't want and that possibly she didn't need.

And so I called the Wizard a.k.a. Dr. Olds at 3-something in the morning -- without a lion, the tin man or the scarecrow to back me up. Just PGY1 me, waking up first, the Chairman's wife who (as I sat there mortified) let me hear her calling my Chairman "honey" until he was wakeful enough to grab the receiver. Lawd.

Fortunately, just like he had been all month long, the Chairman was wonderfully patient when I got him on the phone. Once I got past my fear, I methodically ran down all that had happened--including her low grade temperature, bright smile/not-sick appearance, normal oxygenation, and then peaceful slumber I'd witnessed a moment before. "Could she look this good with a rip-roaring 6.9 pH empyema in her chest?"

"Call the lab and ask them to repeat it," spoke Dr. Olds decisively. "It sounds like a lab error. If she looks that good and it's still low, I'd retap her. It's possible that the specimen sat too long. Definitely don't put a thoracostomy tube in her without having them run it again."

"Okay," I eeked out while looking at Gary. He held his hands out to say, What? I wrote in all caps on an index card what Dr. Olds had just told me:

NO CHEST TUBE YET. And that's exactly what we did.

3:39 a.m.

Page from the Stat Lab.

"Repeat pleural fluid pH: 7.38." (normal.)


Today I'm reflecting on the importance of making sense of things in clinical medicine, but also the value of being an approachable leader and supervisor. Although I often point out the differences between my pre-duty hours reform training and the current regimented and humane training, I can proudly say that even then we always had invested faculty supervising us along the yellow brick road. Having a good fund of knowledge helps, but sometimes it takes experience to become a sho' nuf and bonified voice of reason. For this reason, I try hard to channel my inner Dr. Olds when called by residents in the middle of the night or other inopportune times. I make an effort to work through their thought processes, and when necessary, I use my PGY 13-ness to provide that 3 a.m. decisiveness that maybe they've yet to acquire.


Later that morning before rounds, I stood at the foot of Mrs. Elmore's bed as she continued to sleep. I looked at my pinkie finger, then back at her and sighed a breath of relief. She was discharged early the following day--without an extended hospitalization, complications, or a chest tube.

me with my former Chairman/Wizard, G. Richard Olds, MD, MACP
at the National ACP meeting, 2009

Still as approachable 12 years later (and just think, he's a med school Dean now!)

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