Saturday, January 31, 2015

The secret weapon.

The thing about residency is that your growth isn't just related to clinical acumen. A huge portion of it is dealing with people and their personalities. And you have to do all of that while learning to keep human beings alive. As I look back on it, that was one of the most challenging aspects. But you know? Some of my best lessons came from that aspect. Lumpy interactions that helped me learn how to navigate this high stakes job in the midst of not only my own crazy--but the crazy of a bunch of other people.

I've been reflecting on a few of my experiences--and how they helped me to grow. Here is one of them. More will follow.

The One-Upper

There was this woman I trained with who was really smart and highly competent. She had an answer for damn near everything and a lot of the times she was right. And all of that was cool.


She also liked to be the person who'd been to the mountain top before everyone else. She seemed to take enormous pride in superseding whatever it is you saw on call or did on your rotation with some far more sexy experience that she'd already had to trump it. And you know? It was annoying. Annoying as hell.

I've always loved medicine since starting my training. I like to think about it, talk about it, revisit things and hash them out. I like to sort out aspects of a clinical story and try to piece them together. And back then with my learning trajectory going skyward, there was always much to debrief on. The highs, the lows, the wows and the OMGs. Mostly I'd do this with my friends, which this particular woman was not. But what many folks will tell you is that residency is kind of like boot camp. Ward teams are like the folks in the barracks with you and often out of necessity you share when your lives overlap for whatever time that is.

And so. One month in my second year of residency, I was placed on the same team as the One-Upper. And I will just give you a spoiler alert and tell you that it didn't end too well.


We were in the Medical Intensive Care Unit that month. That's a place where the sickest of the sick come for care and the call nights have the most action. Well, the way our schedule was set up, our call days were like two days apart--that is the One-Upper and myself. So whenever I was post call and trying to sort out my patients and their problems, she loved to position herself next to the attending and fellow like she was my boss, too. She'd stand there with folded arms, feeling all super rested from being home the night before-- in contrast to my up-all-night hotmessness and scatterbrain to boot.

One night, I'd gotten this patient who was profoundly anemic for multiple reasons. Due to her hemodynamic instability, she'd been placed in an ICU step-down bed which, at our hospital, was managed by the ICU team. For us, step-down patients were like a breath of easy, fresh air. I figured I'd tank this patient up with the blood that she needed and would have her ready for transfer out of the unit in no time.

So check it--I'd given her a blood transfusion and, much to my horror, like two hours after she received it, she developed severe respiratory distress. Like severe, severe respiratory distress. This was not a woman with a ton of medical problems before hand either. It was terrifying.

Her respiratory status was so awful that she required intubation. And her blood pressure fell even lower than it had been before. And so. We supported her breathing with the ventilator and lots of oxygen and also pumped her with some fluids. Given the time frame of the symptoms, I decided that this might be something called TRALI--transfusion related acute lung injury.


I'd only read about TRALI. This was all academic as far as I was concerned, so I simply did the best I could given the circumstances. And fortunately, by the time the morning came, my patient had taken a turn for the better.

My attending studied the nursing notes and vitals for a moment as I presented the overnight events. "Wow. So that was pretty sudden. These MAPs (mean arterial pressures) are in the basement," he said.

"Yes, sir," I replied. "We started the pressors fairly early since we didn't have much reserve. She was already on the low side to begin with."

I saw the One-Upper shifting from side to side. I knew she was about to say something so I braced myself. "What about steroids?"

I just sort of looked at her and paused for a moment. "Um. Well, mostly what I read said you start out with supportive care."

She stopped talking to me and sort of shifted toward our attending. "I don't know, boss, what do you say? I've seen some good results out of these guys when you hit 'em with a little SoluMedrol."

Oh have you?

"Eeeeehhhh, you can." He studied the chart a little more. "Mostly it's all supportive but yeah, steroids are often given."

"I'm a fan of the steroids," the One-Upper chuckled. Then she turns to the medical student rounding with us and says, "So the patient has acute respiratory distress right after you've given a blood transfusion. We already talked about transfusion related acute lung injury. What else could this be?"

The student floundered a bit and threw out a few options. I felt my face getting hot. Partly because I was tired but secondly because I was tired and this woman was irking the heck out of me.

"Taco," she said with a smarty pants grin.

"Excuse me?" the student said. I could tell that student was wondering whether or not she was speaking of Tex-Mex for lunch.

"TACO," she repeated. "As in Transfusion Associated Cardiac Overload." She looked toward me and asked another question. "Dr. Draper, did you consider a touch of Lasix just in case?"

Let me be clear on something: The One-Upper woman was my PEER. We were at the same level and in the same residency class. And today, she was pissing me all the way off. While my attending allowed it.

"In case of what?" I responded flatly. I hated that she addressed me as "Dr. Draper" like that. A lot of attending physicians would do that. But fellow residents never used such formality unless they were standing in front of a patient.

"In case it's not TRALI and it's volume overload like TACO." I could have sworn that she twisted her neck when she said that part. I glanced to my attending hoping he'd get my cue for him to shut her up. But he kept studying all the overnight event recordings and didn't say anything. When he didn't, she launched into another spiel on TACO and how this could have been that and how it is actually indistinguishable from TRALI. She even sort of nodded to me when she said that as if I was also her medical student. She started to say more and I cut her off.

"She was hypotensive." My voice was flat. Irritated.

The One-Upper paused for a moment. Then went on, "Well, Kim, you've not actually seen both conditions clinically but I have and--" she turned back to the student--"they both present with respiratory distress so they're indistinguishable." Her tone was so condescending. I tried my best to be subtle as a took  drag of air through my nostrils.

"Hypotension," I repeated, this time with what I know was an attitude.

"Mmmmm. . . . .Well, actually the blood pressure in--"

I cut her right off. "They are distinguishable. One gives you really high blood pressure and one bottoms you out."

She squinted her eyes and tapped her lip with her index finger.  "I'm trying to remember what my last patient with TACO looked like blood pressure wise."

"Hypertensive," I shot back. Then I took a clear swipe which was immature, I know. "That's how she looked. And if she didn't, your diagnosis was wrong."

"Somebody sure is post call snarky!" the One-Upper replied with a snort. Then she turned back to our student and put a hand on her shoulder. "When you really see a patient with transfusion related respiratory distress, you'll be just trying to keep them alive in anyway you can."

My face was hot. Thank goodness for melanin because I know it would have been beet red otherwise. This had been going on all month and I had been up all night. I decided to clench my jaw and just shut up. Finally my attending decided to climb from under the chart and chime in.

"Well, that's true. . . but Kim is right about the blood pressure being the hinge that swings you from one diagnosis to the other. TACO occurs because of a massive upswing in the blood pressure." He yawned and swirled the tepid coffee he'd been nursing all morning and took a little sip of it. "Looks like things are  going in the right direction for this patient. Who do we have next?"

And that was it. That is for that patient, it was. That same thing happened four or five more times on rounds. And each time, my blood boiled just a little more. By the end of rounds I immediately walked off the ward to get away from her.


But everyone knows that when you really, really need to escape this kind of person they somehow keep popping up in your personal space. I was writing the last of my notes in the corner of the physician team room when the One-Upper came strutting in with the medical student behind her.

"Heard you ran two codes last night. Pretty busy," she opened up in my direction.

"Yuh." I kept myself busy, nose down in the chart and hand writing feverishly. My fuse was short and I knew I needed to get away from her before I lost it. I was also totally exhausted.

"I had a guy with a horrible pulmonary hemorrhage a few calls ago. Thank goodness I was able to position him to keep him stable until the Pulm team arrived."


"Did both patients make it?"

I looked up and rested my eyes on her. I knew she knew that one had expired and one hadn't. But she asked anyway. I'd had enough.

I laid my pen down in an exaggerated slap. "Why are you asking me that? Like, why?"

"I was just wondering. Sheesh."

Her pseudo-innocence was making my head hurt. "No, you weren't. You heard me debrief with the fellow and you knew that one passed away and one didn't. So what I want to know is why are you asking me this?"

She put her hand on her chest and acted like she was surprised. "I-I-I I didn't know that--"

"YES. YOU. DID." I turned to medical student. "I'm sorry for this. I'm just really tired."

She awkwardly mumbled that it was okay and then excused herself, which was probably smart. Now it was just me and the One-Upper. Before she could speak,  I just shook my head and asked that she leave me alone. But she just couldn't respect that request.

"I just don't understand why you have to be so hostile. All I asked was a question."

I closed the chart and stood up. Against my better judgement, I spoke. "Did you just say hostile?"

"I mean, yeah. I asked one thing in small talk and you got all hostile."

"No. You didn't just ask a question. In fact, you never do. You just. . . " I wiped my face with my hand, sat back down, and sighed. "You know what? Just leave me alone. Please. Just go away."

She just stood there staring at me. Like someone had frozen her or something. "This has happened to me before in med school. People feel intimidated when someone smart comes along. Usually it's men who have the issue. But I guess this time it's a fellow sister."

"What?" I whipped my head over at her and crinkled up my face. That's when I knew I needed to remove myself. Which is exactly what I did.


I called my dad and lamented to him about her. He listened and then said, "Why is she able to take over so easily when you have the floor? You need to think about that." That was pretty much the gist of what he said. I thought about it all night and throughout the following day.

That was enough inspire a new strategy. For the rest of the month, I spent at least one hour reading on every one of my call nights. I showered, changed into clean clothes instead of scrubs and arrived as ready as I could for rounds after those overnights. Instead of looking haggard and beat down, I coached myself to be the exact opposite. I countered her one-upmanship with excellence. And man was it an awesome weapon.


What I learned from that experience was that it didn't even matter whether or not she was being an asshole. I'd given her space to step on my toes by not being excellent. In my head, I'd convinced myself that looking broken down would translate to how hard I'd worked and gain me some kind of badge of honor. But what it did was give someone room to usurp my presence as a competent clinician and teacher.

So I guess that's what I'm reflecting on. Excellence as a secret weapon. Instead of getting angry, I bleached and starched my white coat, shined my shoes, and prepared. I looked my attending in his eye, tried to anticipate his requests, and covered my bases. It was much more empowering than all that huffing and puffing I did before.


Eventually, she stopped trying me on on rounds. The fun of it was gone. My buttons weren't pushable thanks to the perspective my dad had given me. And look---I have no idea what's going on with any of you in your lives or on your jobs. But let me just say this: When plotting your attack, consider just focusing on being more excellent. I can't say I always get it right, but trying at it makes a huge difference. Excellence is the pièce de résistance that shuts the haters down every time.

And even when it doesn't, trying to be excellent takes up so much energy that you won't even have time to care.


Happy Saturday.


  1. I loved this story. Thanks, it has some excellent advice when dealing with my "One-Upper."

  2. Wow. This is so timely. Thank you SO much for sharing.

  3. I really, really love your point of view and your writing. I hope you never stop blogging.

  4. Wow. I so needed to read this. I supervise someone who is a habitual one-upper who doesn't get it at all. Thanks for posting.

  5. Wow! Thanks for this proactive perspective for how to handle these sorts of difficult co-workers!


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