Monday, December 13, 2010

The Internship Chronicles: Cumulus Clouds

*names details changed to protect anonymity. . .yadda yah. . y'all know what's up!
cloudy with a chance

I'm not sure why, but these days, I have internship on the brain. . . .

(squiggly fingers as we go back in time, anyone?)

Black cloud: (n) A doctor or nurse whose very presence near the wards, clinic, ICU or emergency department, by definition, guarantees a.) multiple new hospital admissions b.) a few very, very sick patients that are just sick enough to keep everyone terrified until sunrise, c.) a random catastrophe such as 35 college kids being brought in by ambulance after a backyard deck collapsed during a keg party or 8 people getting wretched food poisoning off of Ain't Jenny's potato salad. . . .or of course d.) all of the above.

White cloud: (n) A doctor or nurse whose very presence near the wards, clinic, ICU, or emergency department, by definition, guarantees a.) virtually no admissions that evening, b.) very few patients with extremely straightforward problems such as a ringworm, a diaper rash, or head lice, c.) or a medication refill for something that is non-narcotic that their (totally privately insured) patient knows the exact dosage, route, and frequency of, or d.) all of the above.

old school beeper (back when "14" was the way to say "hi.") Yeah, baby.

First Year, Med-Peds Internship: Medicine Ward Month, circa January 1997

"Hey, Kim. I'm down in the cafeteria eating dinner. Care to join?" asked Julia, one of my co-interns on call on another floor that January evening.

I looked at my nerdy calculator watch (I used to calculate a mean GFR back then. . . ) and furrowed my brow. "Dude! It's only 6:15! You're already eating dinner?"

"Yeah, man. Mike is covering us and he's a black cloud," I heard Julia saying as I imagined her leaning against the bank of phones that lined the back wall of the cafeteria. "This may be our only chance for chow, dude. Then again. . . .I'm pretty much a white cloud, so maybe my good luck will cancel out his." We both laughed.

I sat there for a moment and pondered that statement. Julia was right. Everyone knew that the senior resident covering us, Mike, was always in the eye of some kind of storm. A future critical care doctor, there was no doubt about it--this maverick of a resident was as fearless as he was smart. I thought about the other two calls I'd had under his watch. The most memorable occurred not even two months into my internship. This man with pneumonia started out coughing up scant streaks of blood in the emergency department. By the time Mike and I got him upstairs and admitted to the floor, he'd begun hocking up big red lougies. A few moments into us taking the admission history with our TB-proof N-95 masks on, the guy looks at Mike and--I kid you not--starts spraying what looked like buckets full of blood up from his chest and out of his mouth. It looked like something out of a horror flick.

If "O.M. (expletive) G!!!" had been a popular thing to say back then, I assure you that's exactly what I would have said. Instead, I alternated between mouthing "wow" repetitively and being a frozen statue of fear, intensely hoping that this Mike character had at least one clue about what to do next so that there'd be at least one clue between the two of us.

"Turn him right side down!" Mike ordered to the nursing staff in the most sure way ever. Two seconds later, the patient had two large bore IV's in place, Mike was holding a 8 fr endotracheal tube in his right hand preparing to intubate him, and a big metal blade in the other. Four seconds after that, he had a developed stat portable chest x-ray in his left hand that helped locate the source of the bleeding and the position of the endotracheal tube, was writing orders with the right and already had a pulmonologist en route to perform an emergent bronchoscopy. You had to be there, man. It remains one of the dopest, raddest reflex responses to a patient catastrophe that I've ever seen in real life. (Kind of like the way people have all the right answers on those hospital dramas, but this was an actual doctor unscripted--not George Clooney or Noah Wylie.)

Yeah, Mike was a black cloud. I took Julia's advice and joined her in the cafeteria for chicken pot pie and tepid coffee in the 6 o' clock hour.

"I don't know what kind of cloud I am," I told Julia as I poked at a strange piece of meat in my pot pie with a plastic fork.

"Weren't you in the hospital with Mike the night that man with TB exsanguinated on 9B?" She was referring to the aforementioned patient who spewed blood from his chest like a fire hydrant.

"Yeah, that was me," I replied.

"Wait. . .and weren't you there that day that woman came in with the platelet count of 1?"

"Uuuuhhh, yeah. . . .I sure was. That night was crazy. But she did okay. That lady was so nice."

"Dude," Julie stated matter-of-factly, "You are totally a black cloud."

"I did get 14 admissions one night on the Peds wards a few months back," I added, strangely proud of this record. For a fleeting moment, I remembered the three different baby Velasquez-es that I cared for that night--all under one year old and all with brochiolitis. Even though I knew their first names were different, it was scary to imagine mixing them up. That was one rough night.

"Sounds crazy, but consider yourself lucky. Black clouds become bad ass seniors later. Nothing scares you when you're used to all hell breaking loose all around you all the time. You and Magic Mike might just be like one big ol' tornado cloud."We both chuckled again.

Suddenly, a pager going off interrupted us. I looked down at my pager and then back up at Julia with a big smile. She checked her quiet beeper and gave an exaggerated stretch signifying the sleep she'd be sure to get based upon her track record.

"Cumulus clouds, baby!" she chided as we gathered up our trays and prepared to leave.

I shook my head and scurried off to get my first admission from "Magic Mike."

The admissions and the pages came steadily, like clockwork, all night long. We admitted patients under a "firm" system--which meant there were no guarantees for equal distribution of admissions. That night? Five for me, none for Julia. Chest pain. Pneumonia. Altered mental status. Neutropenic fever. And the cross cover calls. . . .they just kept. on. coming. Patient awaiting discharge now has a fever. Sudden need for more oxygen in another. It just didn't stop.


But that's okay, I had Magic Mike bumping clouds with me. A six foot tower of teaching and supervising power. (Not to mention the fact that he was easy on the ol' eyeballs to boot which made for some very inappropriate commentary on the part of Julia and me at times. . .but I digress. . . ) Yeah, but Magic Mike was dope. The total "Cool Hand Luke" of senior residents, and I was glad to be his underling that night. I secretly hoped that someday an intern would feel the same way about me.

Finally, after the steady barrage of four worrisome admissions and horrid cross cover calls, Mike gave me my final new patient of the call: an early morning yet super basic case of a vaso-occlusive pain crisis in a young patient with sickle cell anemia. Thank goodness! Bread and butter medicine!

"How is your pain on a scale of 1 to 10," I recall asking my terrified young patient.

"A nine. . ." he whimpered quietly.

"Okay. We're going to be getting you some more pain medicine on a pump in the next few minutes. This way you can push a button to get it on demand. How is your breathing?"

"It's okay," he panted back between shallow breaths splinted by pain. His eyes were like brown saucers and his teeth were chattering.

He didn't look okay. He looked sick. And not just sick. He looked sick sick.

I remembered the advice that I'd always been given in such instances: Keep coming back to do serial examinations. I finished my work up and my orders for pain medications, fluids and antibiotics and made a plan to come back to see him in one hour. I stole away to an empty patient room just three doors down for a few moments of shut eye. Exactly thirty minutes later, I received a page.

I sat on the edge of the bed, rubbed my eyes and called the number back--all the while secretly praying that someone needed an emergent stool softener and nothing more. Fat chance for a black cloud like me.

"Kim, it's Lisa. I need you to get over here. Now. Mr. Jackson. . .this kid is just not right. . . "

Lisa, one of our very best nurses, knew a sick patient when she saw one. I knew she was talking about my final patient, Mr. Jackson. I didn't even say good bye --when Lisa said "jump" to an intern, the proper response was "off of what building?"

When I reached Mr. Jackson's bedside, his entire face was covered with a non-rebreather mask pumping 100% oxygen into his mouth and nostrils. He was leaned forward in a tripod position and working with all of his might to breathe.

"Mr. Jackson?" I greeted him. He looked up at me with extremely tired eyes. He had a right to be pooped--he was breathing more than thirty times a minute. I placed my stethoscope to his chest and heard what sounded like someone blowing bubbles into a cup of milk with a straw. Shoot!

"Mr. Jackson!" I addressed him again. But this time he just slunk down toward the pillow and closed his eyes. I grabbed his shoulder and shook him. "Mr. Jackson!"

Before I could even get scared, sirens were going off above my head and people were swarming the bedside. Everyone that arrived seemed to be equally as junior as me, which 100% freaked me out since there was no one to defer to. Julia was placing a femoral line. Another intern was attempting to get an arterial blood gas. And at the head of the bed stood me and my black cloud--this time with the blade in my left hand and an ET tube in my right.

Totally tubular (image credit)

The respiratory therapist clenched and released the ambu bag that forced the breaths into my patient's chest that he couldn't make on his own. I kept straining my neck to see if someone from Anesthesia would come rushing in to save me from intubating this patient, or even better, Magic Mike to appear in the doorway. "You ready, doc?" asked the respiratory therapist in a tone that sounded far more like a statement than a question. Lisa the super nurse locked eyes with me from the med cart and spoke for me:

"She's ready. Let's go."

This would be my very first intubation on a real, live, non- plastic human being. My heart pounded furiously as I stared at the quiet face of this twenty-something year-old young man who was depending upon me to get this right. Lisa sensed my angst and came directly to my right side after pushing Versed to settle him.

"Eyes on the vocal cords. . . . " I coached myself.

"You got this, baby," Lisa whispered.

". . .vocal cords visualized. . . . ET tube please. . . . ." Thump-thump. Thump-thump. I was certain I would have a heart attack. Or wet my pants. Or both. Please don't eff this up, Kimberly. Please don't eff this up. He's only twenty. Oh my gosh. Please don't eff this up. Despite what my mind was saying, I tried my best to look calm--doing my very best impersonation of Magic Mike. ". . .okay, guys. . . I'm in." I stepped back and let the respiratory therapist connect the tube to the ambu bag.

"Good job, sweetie," Lisa kept coaching in my ear.

And right then, after gazing at those pink vocal cords for dear life, I blinked for the first time in two minutes, losing my left contact lens from one of my bone dry eyeballs. Toric ones, too. Damn.

Just as the respiratory therapist connected Mr. Jackson to the carbon dioxide detector, Magic Mike bounded in gasping. "Shit. What happened?" It was obvious that he'd just run up several flights of stairs.

"You're in, doc," confirmed the RT after looking at the carbon dioxide changer, this time a statement--no question about it. I offered her a smile of relief.

"The chest x ray is completely whited out," I told Mike, "I think it's either acute chest syndrome or maybe ARDS from a bad Pneumococcal pneumonia, but it evolved pretty fast. He lost consciousness right in front of me and Lisa."

"Did he lose his pulse?" Mike queried with worry in his eyes. "Gosh, he looked pretty good when I saw him."

"No, he never lost his pulse. It was all respiratory and witnessed. He'd been on a non-rebreather for a bit and just crashed. We ordered blood and called the Hematology fellow. She's coming in." I thought for a moment about my first encounter with Mr. Jackson, and how I struggled with whether or not he was sick. . .or sick sick. Now I knew that answer. He was sho' nuff sick sick.

"Damn, I'm sorry, Kim," Mike apologized. "I was drawing blood cultures in the skilled nursing facility when I heard the code. Dude, I'm so sorry. I'm so glad you guys had it under control."

With my one good eye, I watched the ICU team whisk Mr. Jackson down the hall as the respiratory therapist bagged breaths that sounded like rhythmic sighs. "I hope he's okay. I never should have left him. I was so tired and I wasn't sure what else to do. I guess I should've called you." I said quietly.

"You were right on the floor, Kim. With such a rapid response by everyone, hopefully he'll do okay." Mike began walking backwards to catch the elevator. "You done good, kiddo."

Once things were quiet again, Julia and I stood outside the doorway, sort of in an intern daze. Lisa passed by and patted my shoulder before going to give report to the nurses coming in for the morning shift. "Good job, Kimmy."

"See?" Julia said with an eyebrow raised.

"See what?"

"Told you it was good to be a black cloud. I probably would have given him a foot rub and fluffed up his pillow." She laughed softly, but I could tell she was somewhat serious.

Julia had been scarce that evening. Not because she was lazy or anything. . . she was just. . .a white cloud. I studied her obvious bed head and took note of her throaty voice--all signs of someone who'd gotten some sleep. I glanced at the snow-covered cars now visible in the top deck of the parking garage as the sun rose in the window behind Julia's head. I had officially been up all night. After a much-needed back stretch, I shook my head and yawned.

"Lucky you, man," I teased Julia.

She reached toward me with her right hand and delicately plucked what was my contact lens from my left cheek.

"Here ya' go, three blind mice."

I smiled gratefully as she placed what now looked like a tiny piece of Saran Wrap into my cupped hand. "Thanks for the help with that line placement, chica."

"Ha. It was the least I could do."

I hi-fived her with my free hand and we bid each other adieu. All was finally quiet on the mid-western front.

After a prolonged hospitalization in the ICU and ward, my 5th admission, Mr. Jackson, was discharged home. He had a full recovery and celebrated his 21st birthday a few months later.

Almost fifteen years later, I now know that Julia was right. When you're a trainee--as crazy as it sounds--you probably want to be a black cloud. Because just maybe enough of those stormy nights might set you and your patients up for cloudless skies later.

Just maybe.


  1. Wow, what an amazing post, i just loved it! And getting your first tube, what a scary situation and great relief...way to go!

    For some strange reason, one of the things that made me want to go in to advanced EMS was to be able to learn to intubate a person. Such a life-saving event.

  2. Interesting story. Nice post. I would like of agree that being a black cloud is "better" in training than post. I don't think things get any "easier," like you said, but I think experience helps in making decisions that one is more sure of. Maybe.

  3. Such a great story. I love all your residency stories. Seriously there is something kind of "silver lining-ish" about being a black cloud. I am definitely known as one on my unit... but the interns don't tend to mind cause they end up learning a lot and so do I!


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