Wednesday, March 12, 2008


One thing you learn early on as a doctor is to show no fear. Patients don’t feel comfortable if their doctor looks scared. Occasionally I will tell a patient they are scaring me if they need to realize how their behavior is affecting others. Rarely, I will end a session if I am feeling scared. Even more rarely I will call the police. I had to do this once when a patient threatened to break my f-ing neck. I didn’t think he meant it but the risk of violence was too high and the person wouldn’t deescalate.
The most fear I ever experienced as a doctor was early in my training. There was the frequent “Please don’t let me kill anyone,” prayer. There was the feeling of being incompetent, exhausted, unsupported and overwhelmed.
My second or third call as a medical resident was one of the worst. All psychiatrists are required to have basic training in Internal Medicine which was what I was doing at that time. I was covering at a VA hospital and was only two or three weeks out of medical school. When you begin a call night, the residents who are going off duty hand you a list of their patients that you will be covering with the bare essentials of their illness, medications, labs that need checking and so forth. Then they head home leaving you with a pile of papers regarding some 20-50 patients for whom you are responsible, depending on the night and the hospital. Some of the patients are pretty sick.
I was training in a system that was pretty sick itself. In medical school I had become used to the notion that green residents get plenty of back up and support. Not so where I was training. When I found myself in over my head I tried to call on my back up resident. No answer. I tried to call my back up attending physician. No answer. I was on my own.
I had a crappy pager. This may not seem like a big deal but it was a voice pager, sort of like a walkie-talkie. The nurses paged me on average every couple of minutes. Many of them were foreign and it was hard to understand them through my pager which had poor reception and no voice mail. I’d frantically try to scribble down information, a call back number, a ward number, a patient name. If I was already busy, e.g. placing an IV, I had to miss the call and they would keep calling back and getting more and more irate.
On call if I was lucky I would get 20 -30 minutes of sleep. Sometimes I had time for dinner if I didn’t mind eating mystery meat in the same cafeteria as the psychiatric patients from the addictions unit. Or I got the peanut butter and jelly sandwich on white bread to go, under the assumption that at least I wouldn’t get food poisoning. The jelly was always that cheap, see through, grape stuff.
But the worst night was that second or third call. The pager hadn’t stopped. The emergencies had piled up. Maybe that was the night I tried to put a nasogastric tube in the fellow who had been vomiting blood and I just couldn’t get it to go in. You can’t force that procedure. The tube can to in someplace it doesn’t belong. There was no one to help. I had only observed the procedure a few times in medical school. My back up didn’t answer. So the patient didn’t get his tube. Keep praying I don’t kill someone. Another guy had a seizure. It took a lot of medication to stop the seizure. Then he wouldn’t wake up. I didn’t know if he was overmedicated or had just had a stroke. We wheeled him down to the CT scanner where I was responsible for giving the patient the contrast dye. I looked up the dose of epinephrine in my little pocket guide in case he had a (potentially lethal) allergic reaction to the dye. There was no radiologist, only me and a technician. The film would have to go to a different hospital to have a radiologist on call interpret it if I couldn’t. It might be hours before I learned if the guy had a stroke or not. More praying.
At two or three AM, I was checking on a patient in the pulmonary step down unit (for cases one step below needing an ICU). I started to feel I just couldn’t take it any longer, that I couldn’t do it. I looked at the pile of sign out sheets in my hand and seriously considered putting them down, walking out of the hospital and never returning. I was ready to abandon . . . everything. And a male nurse walked up to me and started rubbing the back of my neck. Normally I don’t like strangers touching me but he seemed to sense the extremity of the moment and that one brief empathic gesture turned things around for me. I stayed put. The pager stopped ringing for a few brief moments. I caught my breath, controlled my fear and kept moving.
I finished my 6 months in that dysfunctional system and then got back to where I belonged, to my psychiatry training. It had its bad moments too but that night was the worst. It was the only time fear overwhelmed me to the point where I thought about quitting. I’m glad I didn’t. I’m eternally grateful to that one nurse. He probably has no idea how much he helped me.


Kathe said...

Hokey-wah. My li'l rock in the woods is looking better and better.

self taught artist said...

i feel bad for you
and i feel worse for the patients
sounds like hell.

Pilfkin said...

Wow. Your post made me extremely glad (yet again) that there are people out there who dedicate themselves to a profession that, to put it mildly, gives me nightmares just thinking about the level of responsibility.

When my sister had menengitis aged 18 she was in the Intensive Care Unit which only had one free bed. I will always remember the Consultant saying that with one free bed he was happy. It was when he had no spare beds and was paged to say that there had been a multiple car accident and there were 3 people requiring an intensive care bed that he found it hard. And I remember feeling sick at the thought of having to be the person that made that decision as a routine part of their job.

Rayne said... I got stressed just reading this. I have no idea how you did it. It's hard sometimes to remember to see it from the doctor's perspective. It must have been so frustrating and terrifying for you. I am extremely impressed that not only did you make it through but you came out the other side a caring and dedicated professional.

Jud said...

As cool as the story was, I was drawn to the buffalo sign. I lived for several years around a lot of buffalo and we were taught to be very, very wary of them.

Larry said...

That was interesting for me to read.-Thanks for the behind the scenes background.-It sure sounded like a tough go-glad you survived it!