Wednesday, February 18, 2015

Shut up and dance.

Five days you work
One whole day to play
Come on everybody
Wear your rollerskates today

It's Saturday, Saturday
Saturday, it's Saturday
Saturday, it's Saturday
Saturday, it's Saturday

~ from De La Soul

I love being on the inpatient hospital service. The acuity of the patients, the energy of the wards, and just the dynamic of working as a part of a team just does it for me. Seriously, if it weren't for the fact that being on the hospital service also means working weekends, I'd do it year round.


One of the best parts for us medical nerds is the fact that we get to do a lot of teaching when on the hospital service. The potential teachable moments are endless, man--especially at a place like Grady. But you know what? One thing I have learned is this: Not every moment is a teachable one. That is, in the literal sense. Sometimes the teachable moment is identifying the moments when it really isn't one.


I know that probably didn't make sense, so let me explain. Matter of fact, why not reach back to the source of that lesson--my residency. Since I've been on a bit of a roll with my tales from the residency crypt, I may as well keep it going, right? Ha. Don't mind if I do.

The Unteachable Teachable Moment

My residency training took place before there was duty hour reform. In other words, how many hours we worked in a week or consecutively never seemed to be fully factored into anything we did. In some ways, it afforded us great experiences as learners. But a whole lot of other times all it meant was that  you were guaranteed to be in an exhausted stupor at some point. And how that stupor looked depended upon the person, the call and the location in the hospital.


I will never forget this one morning on rounds in the Pediatric Intensive Care Unit (PICU).  I'd been up all night long without even a few moments to catch my breath. The kids on the unit were sick-sick--I'm talking tenuous and teetering on codes well into the wee hours of the morning. It didn't help that the PICU was, hands down, the most terrifying place in the entire hospital to me. Sure, I learned a lot but the intensity coupled with the nausea-inducing fear that I'd assassinate somebody's child was a lot. Yeah, man.

Well. What I remember the most was that this particular morning on rounds upon which I'm reflecting fell on a Thursday. That's significant for two reasons: The first is that my weekly continuity clinic was every Thursday afternoon. The second was that, because of the fact that this was during the pre-duty hours reform era, I was expected to go to clinic despite having been up all night long with critically ill children.


One of the kids I cared for that night had severe, persistent asthma. A fun afternoon with his family turned into a nightmare when he started having a refractory asthma attack. "Status asthmaticus" they call it; an ambulance whisked him straight to our emergency department who quickly shunted him upstairs to us. His lungs were so tight that he received the entire kitchen sink from the moment he arrived; he even had to have his blood oxygen levels monitored with an arterial line--which isn't an every day thing with kids. Arterial sticks hurt like hell which made my hands super shaky and nervous while attempting to stick him. On top of that, he was only eight or nine years old. God, he was just terrified. With every air hungry inhalation he took the skin over his ribs pulled tightly over his bones like some kind of relief sculpture. I also remember him crying as I stuck his wrist. All of that was right before he got intubated. It sucked, man.

For him more than me, of course, but still it sucked.

That same night, there was another child I cared for that we all knew very well in the hospital. Man, was she cute. Her cheeks always looked like that had a perfect application of blush and the strawberry blond ringlets she'd been born with looked like they'd cost her parents thousands to achieve. But beyond her natural beauty, she also had severe epilepsy. I'd admitted her before for complications of her frequent seizures--usually to the regular pediatric ward. On this night, she was down in the emergency department and the on-call pediatric resident was preparing to admit her for the same. I was called down from the PICU after she suddenly went into something called "status epilepticus"-- a condition where a seizure persists for a substantial amount of time and, in this case, doesn't respond to initial treatment.

We pushed med after med and nothing was working. The pediatric neurologist was en route and the PICU fellow was right there in the trenches, too. The nurses who weren't caring for her comforted her mother, a woman who, by now, was a friend to us all. Finally she had to be put into a medically induced coma. And let me just say that this was some shit I'd only read about on test questions--not actually participated in making happen. By morning, I was metaphorically down on all fours begging the sun to rise into a new day--which would mean a new resident on call.


So the way it worked was that we rounded with the ICU attending the following morning to discuss every single nitty-gritty detail of the overnight events. My attending that month was this really, really nice man who loved to teach in a Socratic style which, usually, I responded to as a resident. But on this particular morning, I wasn't really up for Dr. Quizbowl or any of what would surely be his standard litany of questions.

Now. Let me also just remind you that at 1PM, I was still expected to go and see a panel of seven patients in the clinic. Whenever this was the case, the goal always was to knock every single drop of work out so that you wouldn't have to return after clinic.

Yes. You read that right. RETURN. AFTER. CLINIC. POST. CALL.

The only way this could happen--and I do mean the ONLIEST way on this morning in particular--would be for my attending physician to focus more on the care of the patients than the quiz bowl soliloquy. And NO, I'm not saying that it's cool for things in residency to be all service related and not education related. But what I am saying is that the ground was fallow and not EVEN fertile for a whole bunch of extraneous teaching seeds to be planted. I needed this dude to get down to business. And focus on just the damn facts.


But he didn't. Not one bit. Dr. Quizbowl started first with a bunch of questions about the AV mismatch in asthma and I swear I don't know how, but from there he jumped off into a tangent about fetal hemoglobin and oxygen carrying capacity. Even though this child with asthma was not a doggone fetus or anyone with something warranting that as a discussion at the moment. (No, he didn't have sickle cell anemia, you medical nerds.) I did my best to answer his questions which escalated in difficulty.


Dr. Quizbowl liked to grill only the post call resident. Again, that was usually fine for me but this night was so bad that today it wasn't. I also couldn't keep my eyes off of the clock. I wanted nothing more than to get the plans locked in by 11:30 so that I could tie up loose ends and scoot to clinic.

But then we went to see our sweet curlyhaired girl.

First, he waxed poetic about the mechanism of status epilepticus and what happens on a physiologic and pharmacokinetic level with the anti epileptic drugs. From there he began quizzing me about the mechanism of action of some of the newer agents and then, after studying the vitals overnight, decided he'd start asking me a bunch of pathophysiology questions that I hadn't really thought of in such detail since my second year of medical school. And you know what? I didn't effing know the answers.

I didn't.

Well, I take that back. It was past 11:30 and I was already feeling nauseous from being so tired. While maybe, just maybe, with some thought I could have found some piece of the answers to his questions to at least prime his teaching, at that moment? I had nothin'. The more his mouth moved the faster the clock seemed to tick. Before I knew it, it was already 11:45.

"Why a pentobarbitol coma, Kim?" he finally asked me.

"What?" That is literally what I said in response. Because that was too vanilla a question for it to be almost lunch and too nebulous for me to even hold on to the tiniest chance of me getting any more work done.

"Pentobarbitol. Why do we use that in status epilepticus?"

"Um, to stop the seizures, sir. To quiet brain activity."

"Be more specific. Talk me through what is actually happening in a noisy brain that sees pentobarb. Why is this something we do in this situation?"

And just as he said that, the clock struck twelve noon. I promise you it seemed like it happened in Dolby stereo, too. Honestly, the whole team was shifting between their feet, but lucky for them, they weren't on the hot seat like me. Noon and he was still teaching with no end in sight. It was official. I would have to return to the PICU at 5:30 that evening to finish my work. Even though I'd been up for more than 24 hours at this point.



"What say you?"

My eyes began to throb with tears. As soon as my chest started heaving, I knew it was a wrap. My mouth hinged open to talk but only a squeak came out. "Status Postcall-icus," they should have called it.

"Dr. Draper?"

I wiped my hand over my face hard to try to mask the tears that were now falling straight from my eyes to the linoleum floor in big splashes. Shaking my head in embarrassment I responded. "I don't know, sir. I don't. I just. . ."

"Are you okay, honey?" The nurse on rounds with us rubbed my back and tried to console me. She looked over at Quizbowl and added, "On sign out the night nurses told me she didn't sleep a wink."

"Welcome to the PICU," my attending responded with a heartless chuckle.

And I swear to you, that was that. No further acknowledgement of my brief outburst or any such thing. We just kept it moving. Yep. That dude talked and taught for another half hour or so and finally let us go. All I ended up with was enough time to change into my clinic clothes, eat some leftover stromboli from the night before, and hoof it to clinic. And yes, at 6PM I was BACK in the PICU finishing up some notes and trying to stay awake for sign out rounds. While Dr. Quizbowl took it upon himself to make a few more teaching points to boot.


I know that the only thing that allowed me to drive home without face planting on my steering wheel was how resentful I felt of my attending and his irresponsible use of our time that morning. Not only did he not recognize a dangerously exhausted learner in front of him, he also ignored the fact that we needed to transfer patients out, care for new admissions and just get some damn work done. And I wasn't a lazy resident by any stretch either. I loved being taught and guided--and still do. But this day? It just wasn't a teachable moment, man. I mean, not in the way he forced it to be.

I bet you a million dollars that from eleven o'clock on, nobody heard a damn word of what he said. That I know for sure.

Let me quickly contrast this by saying that just a few months later, I was rounding on a Saturday with the chairman of the Department of Pediatrics. The service was busy and he was even busier. That said, he was an outstanding teacher and champion for children's health. And so. I remember him starting rounds that morning by simply saying this:

"It's Saturday. It's busy. And it's Saturday. A Saturday where our team isn't admitting new patients and where the ones we have are primarily stable. The teachable moment this morning is on focus and efficiency so that we can take excellent care of our patients and then leave. Y'all got that?"

And yes, he said "y'all" which he often did. That didn't mean be cursory or rush things. It meant to focus on the essential tasks at hand. It meant that this wouldn't be the day to draw algorithms on the chalk boards or sit the whole group down to review a new article. There were teams assigned to the hospital for the full day on Saturday and his point was that we needed to do our work and then allow them to take over so that we could achieve some semblance of work-life balance.

Oh. That.

Now that? That was pivotal for me. The thing I remember the most was that he was SO right about THAT being the teachable moment. The fact that this wasn't the time for him to review every study he has ever published or to recount all that is in his memory about every subject he can think about. It wasn't.

You know what else? Midway through rounds he looked at one of my post call interns and then interrupted rounds. He pointed straight at him and said, "You. Go ahead and sign out so that you can go home. You look like you're about fall under the nurses' station. Go get rest." The intern just stared at him. He looked from side to side and then repeated himself. "I mean NOW. Leave. Now. Get rest. Your work here is done today."

And yes--we, too looked conflicted when he said that, but nobody questioned the dang-on Chair. See, he was right. That intern was about to collapse on his face from exhaustion and that man had the sense to know it. Then he said to me, "Kim, the teachable moment here is knowing when somebody is on fumes.  Getting him out now means he'll be better tomorrow. Trust me. We can pitch in and finish what needs to be done."

And yes, he said "we." I loved the way he often said "the teachable moment is. . ." That put us all in the right state of mind for whatever it is we were doing. And helped us to see the teachable moment as just that.

I have never, ever forgotten those two experiences. Every single time I am attending on the wards I remember both Dr. Quizbowl and Dr. Chairman--and apply their mighty lessons to the way I manage my own teaching and team management. Yes, in medical education, we walk a fine line between balancing service and education. And, of course, our learners are there for supervised instruction, not just scut work--I get that. I do.


As awesome as the music of medicine can be and as fascinating as the melodies often are, sometimes? Man, sometimes the very best thing that we can do as teaching maestros of this symphony called medicine is simply shut up and dance. . . . .

That, my friends, is sometimes one of the most powerful teachable moments of them all.


Happy Humpday. This post made me think of this post on Saturdays, balance, and why it's so important.


Every time I round on Saturdays when my team isn't admitting, I think of Dr. Chairman and hear this song in my head. Then I say to my team, "It's Saturday." (Even though I am hearing this song in my head the whole time and feel like I have on roller-skates. Ha!)

But first, here's some proof--I sent this text to my ward team last weekend--complete with a witty emoticon. Heh heh.

Next time I'm just gonna text them this. . . . 

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