Fear is the mindkiller, part 3

My slogan for internship: "I will not fear. Fear is the mindkiller"--from Dune. But there seems to be no getting around fear.

***

I've been feeling burdened lately. I had the day off on Monday, and I was at a grocery store in a wealthy neighborhood getting myself the best coffee in town. I was there because I felt that with everything I'd been through in the previous week, I deserved a treat.

A young mom wearing some outfit that a skinny person would wear to yoga (the pants were tight and stretchy, not loose and concealing) had run into someone she knew. "Oh, I'm a little stressed right now," she said. "The kids are starting sports, and they're in school now, so lots going on, it's been a little bit overwhelming."

I wanted to turn to her and say, "Are you f***ing kidding me? Seriously. You're at the gourmet store buying $20 a pound cheese and hanging out with your kids, and what you have to say for yourself is you're stressed?"

Then I reminded myself that maybe for her motherhood does count as 80+ hours a week doing a terrifyingly high-stakes job, and although I do have to say that taking kids to soccer practice and the gourmet cheese store doesn't sound THAT stressful, what do I know?

Anyway, I realized that my reaction to her was not about her. It was about my stress, and how annoyed I was that someone else would claim to be as stressed as I am. In other words, I'm starting to feel sorry for myself. It was inevitable that it would start sometime--self-pity is probably the one thing that almost all medical interns have in common at one point or another--and I now recognize that it has started.

But I have always been willing to work reasonably hard, and for long hours. And there are many things about the work that is interesting and challenging in all sorts of good ways. So it isn't the time or the work that makes me feel burdened and sorry for myself. It's the fear.

I have a low-grade fear that never really disappears, like watching a scary movie while the main characters are driving around doing something innocuous. You know something bad is going to happen, but you’re not sure what.

I make mistakes all the time. Most aren't a big deal, and the few mistakes that could have become more worrying were caught by other people. There are only one or two mistakes that can still haunt me. The worst one came very early on in internship, when I didn't recognize an acute problem as it was beginning, until it required more serious intervention than it might have if I'd recognized it earlier. No one blamed me for it. Like many intern mistakes, it was an error shared by several people. And the outcome of the patient's hospital course was unlikely to have been any different as a result.

When I came back to the incident a couple of days later in a check-in session with my attending of the time, he said, "This is why you do residency. You just have to see it often enough to recognize it. If medicine was all things you could learn in books, we could just turn you loose after medical school. You can go ahead and feel bad about it, and in fact, you should, so it won't happen again. But this is what residency is about." He said that I was right on track for where I should be in terms of my skills as a physician.

I guess I took his advice: I didn't let the mistake stop me from coming to work the next day. But remembering that morning can still clench my stomach with a special force. No matter how much I reassure myself or other people reassure me that such mistakes are part of the normal course of my development, mistakes still frighten me.

It's mostly just the most recent mistake or two I've made that I remember at any given time, though, because the main reason the more inconsequential mistakes matter is that they remind me of my potential to create harm. That clutching clenching weight inside my abdomen, the horror of the near-miss, returns even when I think about the smallest errors. It's not usually the errors themselves that make me feel that way; it's the fact that I continue to make errors.

For the first couple of months the excitement of being a doctor, and the new confidence I have as an intern that I didn’t have as a medical student, was enough to compensate for this sensation, enough to keep my energy and enthusiasm high. But recently I think that constant sense of near-miss or about-to-hit, that chronic fear, is starting to exhaust me a little bit.

I don’t want to get rid of the fear, because it makes me a better doctor as I make my lists and check them twice. But I want to figure out a way to live with the fear. I don't think it stops with internship. There are doctors I see who look totally relaxed, but they've been doctors for a long long time, and anyway, I'm not sure they should be as relaxed as they are. What's worse in a doctor than overconfidence?

In other words, fear is necessary. But it is also burdensome. More than the hours, more than the work itself, fear is what makes me feel like this is especially hard. Fear is what makes me feel secretly sorry for myself. Fear is what makes me tired and irritable; fear makes me hate some mom in a grocery store. My task for the year is not only to become a good doctor. It is learning how to live with the constant fear of being a bad doctor.

Night float: "MD aware"

Last night I was on night float--this time, a one-time thing, to give other night float interns a night off. Today, I'm spaced out and headache-y. Some of the other interns are getting together for dinner and drinks tonight, and I should go, but I feel as if I can't bear to talk to anyone or go anywhere. Instead, I'm sitting in my apartment while Ms. Dr. Hemodynamics is on call. I'm listening to KCRW on the internet, writing this after cooking myself some dinner.

I'm not sure when the concept of night float was invented, but it's become a lot more common with work-hour restrictions for residents. In overnight call systems, when residents literally lived at the hospital (hence the word "resident"), "call" meant not only admitting patients to the hospital but also cross-covering other residents' patients.

Now, the interns and residents on call stop admitting after a certain point in the evening, and a nighttime team takes over both admitting and cross-coverage. In our hospital, the night float interns respond to the problems of patients already in the hospital. The night float residents admit new patients who are coming in overnight.

That means that as an intern, I was answering pages from nurses for some large number of patients--I didn't want to know exactly how many. Something in the range of 50 or 60 or 70, I think, but I never counted; I just answered pages.

Some of these pages seemed simple; this patient wanted medicine for back pain, while that one wanted something to help him sleep. But for me last night, anything but the simplest and heavily chart-documented chronic back pain warranted a visit (was it new? where was it? was it a kidney infection or a spine infection? or just from sitting in a hospital bed for days?). Help with sleeping required at least a chart review (how was the patient's kidney function? liver function? what had they taken in the past? any psychiatric issues?) to try to figure out whether the easiest choices might make them crazy or dangerously sedated.

Then there were the pages that went something like "[Patient name] down to 90/56". A drop in blood pressure can be truly ominous: it can be a sign that someone has a new serious infection, or an acutely failing heart, or new internal bleeding. But the majority of overnight pressure drops last night were probably mostly caused by something simple: sleep.

One of my more alarming pages about low blood pressure last night was solved by turning on the lights and talking to the patient and listening to her heart and lungs with my stethoscope. When that was done, she was at an average blood pressure, and I was convinced by her quick wake-up and easy return to coherence and consciousness that she'd been doing fine all along. The unfortunate effect of this kind of evaluation: when the number on the screen means a nightmare for me, that's the end of sweet dreams for you. On the other hand, it's better than getting a bag of unnecessary IV fluids.

Some reasonable proportion of us, if we had telemetry monitors hooked up to us at home every night, would be setting off alarms all the time. But even when nurses are reasonably sure that this kind of normal situation is why the pressure is low, they need to page the doctor anyway. In the nursing note, they have to make note of abnormal vital signs, and they write something like "BP down to 89/56 during night while pt sleeping. MD aware."

As with my first night on the MICU, I was once again grateful for my hospital's well-educated and experienced nurses. In one case, a renal fellow talked to me about the patient in some detail in the late evening, and then checked back in with me in the morning about how the plan had gone. I explained that we'd stopped the fluids, and why; the fellow was pleased because this is what she'd called to recommend.

"Actually," I said, "the nurse called when the labs came back, and said we should stop the fluids, and I said that sounded like an excellent idea." The fellow laughed, and praised me for listening to the nurse.

I said, "I try to do what the nurses tell me, probably... mmm... 85% of the time." She laughed again: "Sounds about right," she said.

The rest of the 15% is complicated, and it's rarely due to some error on the nurse's part. More often, it has to do with differing priorities. For instance, since the nurse is hearing the patient complain all night, and is sick of answering the call button again and again, the nurse might be more ready to want the patient to get a sedative medication for sleep. Often, this is informed by knowing that a particular medication is given all the time, and knowing that a particular patient is medically stable, and knowing that it's really hard to get good sleep in a hospital.

On the other hand, for people with complex medical problems, a lot of these medications can be frightening for the doctor to prescribe, and if I can avoid prescribing them, I will. The most satisfying visit last night was with one of these patients, who had many medical issues. The patient and the nurse wanted a sedative to help him sleep. The idea was worrying to me, since all I knew about the patient was a list of medical problems, and the drugs I knew best each had some possible bad interaction with at least one of those problems. I was doing some other things, and took a while to come up to evaluate the patient, probably to the annoyance of the nurse and the patient. But by the time I got there, the patient was asleep without my help. (The ideal solution for this situation is for the doctor who is taking care of the patient by day to anticipate this problem and suggest a possible sleep medication for the night float intern to prescribe if necessary--but it's July, and that kind of hand-off is a ways off.)

The most frustrating thing about night float was one of the things that makes night float systems worrying to most people who think about their risks and benefits: hand-offs. I got some less-than-totally-informative descriptions of what was going on with some of the patients I got called about overnight. And on my end, hopefully just because it was my first night, the system I was using to keep track of overnight events turned out to be much-less-than-excellent, and I fear that I may not have handed off all the information I should have.

But looking at the hospital computer system from home, it looks like everyone is OK for now. The people I worried about didn't get the kind of labs drawn that would suggest problems (like arterial blood gasses, which are drawn for people in respiratory distress). A tentative sigh of relief: night float is over, and the day has come.

Wise words: internship starting

Illustration: William Hogarth, Industry and Idleness, Plate V (1747). "The idle apprentice: turn'd away and sent to sea." The British Museum. (Sad: he probably violated rule #8, below.)

Internship starts tomorrow. I'll be starting with the medical ICU, and my first day will include an overnight call night.

Amidst all the emotions associated with the anticipation of such an event, some of the graduating interns came up with tips for us while on rounds, and one of them wrote them up and sent the list out to our email list. Here's an excerpt (the first six are mostly hospital specific):

7. Send each other funny pages--it will keep your spirits up. And make you laugh in the middle of an otherwise serious conversation.
8. Get your coffee on the way to work. Otherwise you'll never get it, and nobody wants that.
9. If you're thinking about writing an order, just write it. Don't make a box on your to-do list to write an order.
10. If you don't know the answer, don't lie and make it up.
11. Don't forget to pee. They trigger patients for more urine output than some interns have. And drink a lot of water.
12. We know you're scared to death. Under no circumstances (unless you are [name of graduating intern]) should you memorize ACLS protocols.
13. And from [name], a graduating senior: "Nobody ever died of note-penia. Just take care of your patients. The note will come."

The bag kills the fear. The bag is the mindsaver.

Above: retro/vintage flight bags from KLM and Aeroflot, from inretro.net. Below: my bag..

Today, I bought a bag, and I fell in love with my bag.

My bag is a dorky bag. I wouldn't buy or wear it under other circumstances. It's like a wierd zipper-heavy backpack-influenced re-creation of airplane bags that the airlines used to give out in the 1960s, but without the cool retro airline logo design.

REI calls it a "Boarding Bag"; like its predecessors, it's designed to be a small carry-on bag that holds the stuff you want on an airplane journey. Probably only someone who was a little worried about flying would buy such a thing. I didn't buy it for flying. I bought it for the hospital. But I did buy it because I was worried.

To explain this dorky-bag purchase, I must first explain that among medical students, interns, and residents, there are white coat people and there are bag people.

White coat people take their notes and reference books and PDAs and energy bars and reflex hammers and shove them all into the various pockets of their short white coats. The very disciplined or the wildly neglectful can get away with this easily: either you pare your carry-around stuff down to an incredibly small amount of stuff, in which case your white coat can easily handle it; or you simply leave all your stuff at home and try to get by without it. (In which case you never look anything up unless you're sitting at a computer terminal, and you test your patients' reflexes by hitting them with the end of your stethoscope.)

The much more common approach is to jam your pockets full of as much stuff as you can get into them--and at my hospital, the pockets are really big, and durable. A woman at the education office said, "I had students show me how big the other hospitals' white coat pockets were, and then I went bigger." My hospital is nothing if not scrappily competitive.

Unfortunately, this creates two more problems: the gunfighter problem, and the water-carrier problem. Because there is so much stuff bulging out of your pockets, you have to walk around with your arms out, like a gunfighter, or a police officer. Also, the stuff is heavy and usually poorly-balanced, and weighs down on the doctor-in-training's shoulders and back, leading the unfortunate coat-wearer to walk around burdened as if constantly carrying water from a well.

For these reasons I've almost always been a bag person. But my bags are usually too big. For instance, I have a big black messenger bag that can carry a whole desk inside of it, and I'm a little bit of a pack rat, so that by the end of a rotation the bag usually does actually have about as much in it as my desk at home has on it. That means that the bags are heavy, and therefore they solve only the gunfighter problem but not the water-carrier problem.

Worse still, I'm constantly having to leave the bags in places like underneath desks in nursing stations, or in call rooms, because I need to go do something where I don't want the extra weight. Or I take the bags off when I'm examining patients, in which case I end up leaving the bags in patients' rooms. Having to come back into a patient's room to retrieve my stuff is a little embarrassing; it seems like a pretty amateur move, and not very confidence-inspiring, especially in terms of my confidence in myself if not for my patients' confidence in me.

I saw an intern this spring with a bag that seemed to solve these problems. Small enough to keep with him, large enough to carry the right amount of stuff, it looked just right. I asked him where he'd got it; and today, I chose this bag as my version of it.

Afterwards, I kept looking at the bag; looking inside it again to think about what I would put in its pockets; zipping and unzipping its various compartments. I would be able to put private personal things in private personal places, my notes in easily accessible places, and my reflex hammer somewhere handy. I could carry my medicine manual and my energy bars and my headache medicine and a little bottle of water. But the bag won't carry more than that--so I don't think I'll be able to jam it so full of stuff that it will become unwieldy and impossibly heavy, like most of my other bags.

I was so in love with my bag that it became clear that my love had gone far beyond the bag itself. My bag had become my metaphor: it would give me organization, control, and my own little secure space within the hospital, even if it is only about 9 inches by 12 inches by 4 inches. Seeing all of these things in my bag, I realized not only why I loved my bag--or at least, the idea of my bag--but also what I had been fearing the most about internship. I fear becoming disorganized; losing control; and never having a space of my own. The first two might harm my patients; the third will make me crazy. Until now. Now I have my bag. Now I need not fear, and I will not. Because fear is the mindkiller.

Fear really is the mindkiller

ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.