On the second day of the rotation, we circled the ICU as a group, examining patients and deciding their treatment. I had admitted a woman with chest pain the day before. Her tests showed she hadn’t had a heart attack and that she could be moved out of the ICU soon.
Cheryl gave me a smug smile. “So what do you want to do about her UTI (urinary tract infection)?”
“What UTI?” I asked.
Cheryl crossed her arms. I went to the nurses’ station and got the patient’s chart.
“Yes,” said Cheryl, “that is the right thing to do. You want to check the labs.” She spoke to me like I was stupid.
I found the urinalysis report. There were a few bacteria and epithelial (skin) cells, but no white blood cells or blood.
“I thought that epithelial cells and bacteria indicated a contaminated specimen,” I said.
“So how do you want to treat her?”
Huh? Did she not hear what I just said? A contaminated specimen meant the bacteria were coming from the skin, not from the urine. I turned to the patient. “Do you have any symptoms of an infection? Pain with going to the bathroom? Have to urinate a lot? Fever?”
She shook her head “No.”
Cheryl said, “So are you going to get a urine culture? That would cost a lot of money.” I must have looked perplexed because Cheryl continued, “In the Outpatient Medicine Clinic they give the patient a one-time dose of amoxicillin for UTI’s.”
“Uh, OK.” The patient didn’t have an infection. She didn’t need a urine culture. She didn’t need antibiotics. On the other hand, the last thing I wanted to do was antagonize my supervising resident on the second day of the rotation. The key to doing well during residency training was to do the work, get along with your supervisors, not make waves. A bad evaluation could mean the end of a career.
I asked the patient if she had any allergies to penicillin and wrote the unnecessary order. I chose to fit in; I chose my own welfare over the patient’s.
Two days later it happened again. On rounds I mentioned that while a patient’s blood test was technically “within normal limits,” it had changed slightly from previous results and could represent an early sign of infection. Cheryl looked at me blankly. I wasn’t sure what to do next and Cheryl was no help. It was as if she didn’t hear me. Cheryl plowed on with her agenda, never clarifying her thinking, never answering my questions or addressing my concerns.
After our daily rounds, Cheryl spent lots of time with Bobby, teaching him how to take a history and write orders – all the basics he should have learned in medical school but hadn’t. I imagined that Cheryl had mastered the basic skills of being an intern, and wanted to show off those skills. But clearly she had no idea how to be a supervising resident. Maybe that’s why she didn’t respond to my comments and questions. She didn’t want to admit she didn’t know the answers. Teaching Bobby made her feel smart; working with me confounded her.
One day I admitted an elderly lady with pneumonia. She was sweet and lost; her husband had died recently, her house had been burglarized, and she was having a hard time emotionally and physically. I ordered oxygen and antibiotics, hoping the treatment would halt the progression of the infection. The hospital’s protocol was to stabilize patients in the ICU, then transfer them to the medicine ward as soon as possible, where someone else would take care of them until they went home. The medications worked rapidly and her breathing and oxygen levels improved. On rounds the day before this patient was to be transferred, as I asked her about her functioning at home, she started crying. I paused briefly, then redirected the conversation to less emotionally laden topics. It felt like an invasion to delve into her personal issues in front of a bunch of strangers. She’d had enough loss and abandonment already without my adding to her burden. I would make sure the next doctors knew about her issues so they could be addressed in the hospital and after she was discharged home.
But Cheryl was outraged that I interrupted my patient’s tears, that I didn’t let her cry, that I didn’t make her talk about her sadness right then and there. Cheryl arranged for a psychiatrist to come in that day and meet with our team. In the presence of the psychiatrist, Cheryl lectured me on the appropriate ways to address patients’ emotional issues, criticized how I handled my interaction with that patient and enlisted the psychiatrist to lecture me. I was never given the opportunity to defend myself against their assumptions that I was clueless and incompetent.
A few nights later, I admitted Mr. Larkey, an elderly gentleman who was having a big heart attack. He was awake and accompanied by his two daughters, both in their sixties, elegant and articulate,. Their father had been a professor and spoke with a cultured and gentle voice. I liked him immediately.
In 1983 most patient care done by residents was barely supervised by attending physicians. At most, the residents called the attendings to tell them about admissions and to review orders with them. This night the senior resident was a man I’d never met; he was short and officious. He examined Mr. Larkey cursorily, not bothering to get much of a history or to discuss the case with me. Mr. Larkey was just another routine admission. The senior resident barked orders at the nurses and got the patient moved up to the ICU. He called in a brief summary of the patient’s medical history to the internist covering call that night, then left to attend to other patients.
In the ICU, Mr. Larkey’s daughters hovered politely, making room for the nurses to work around their father’s bed. As they prepared to leave for the night, they thanked us for the care we were providing. Mr. Larkey rested his head on the pillow, looking exhausted. I sat at the desk in the nurses’ station in the center of the ICU to write orders for the nurses to carry out, to record the patient’s history, and to document the physical examination. About an hour later, one of the nurses came up to me to express concern that the patient wasn’t doing well.
“It isn’t anything specific,” she said. “But I just get that feeling. I think he needs a Swan-Gantz catheter. I’m afraid he might be developing cardiogenic shock.” A Swan-Ganz catheter is a thin tube that is threaded through a vein into the heart and then into the pulmonary artery. It diagnoses if a heart is working effectively, provides sensitive information about heart failure, and helps monitor whether or not medications are effective. It is used in the very sickest of patients.
I examined Mr. Larkey. He was pale, a little sweaty. He smiled at me and patted my hand.
“Thank you for taking such good care of me,” he said. “I’m so sorry to bother you in the middle of the night like this.”
I smiled and shook my head. “That’s what I’m here for,” I said.
I didn’t tell him that I was just an intern and had no idea if he was getting worse or not. But I did know that the nurses in the ICU were experienced and knew a ton of medicine. If this nurse suspected he was getting worse, I believed her. I paged the senior resident who seemed irritated that I had bothered him. He looked quickly at the patient’s vital signs, listened to his heart and lungs, and shook his head.
“He looks all right to me.”
“I’m afraid he’s going into cardiogenic shock,” said the nurse.
“That’s ridiculous,” said the resident.
I pulled out my Washington Manual of Medical Therapeutics, the paperback bible of inpatient medical care. It told me that cardiogenic shock, where the heart loses the ability to effectively pump blood, has a mortality rate of 85 percent. It described pallor and sweating and difficulty breathing. I looked over at the patient. His forehead was shiny with sweat. The nurse had raised the head of his bed to 60 degrees so he could breathe more easily.
“The nurses think that it might help if we put in a Swan,” I said to the resident.
“He doesn’t need a Swan!”
The nurse asked him to call his attending physician, but he refused and left the unit. She called the nursing supervisor. I could see she was frustrated and concerned. She also suggested that maybe I could call the attending.
I hesitated. I was uncomfortable disobeying the resident, I didn’t have enough knowledge to judge how sick this patient was myself, and I’d been told that it was the senior resident’s responsibility to speak with attendings, that the on-call doctors would become royally angry if they were bothered by stupid interns. It seemed like I would be violating all kinds of rules to do that. I didn’t have long to ponder my options. The nurse and supervisor determined that the patient’s blood pressure was falling. They paged the resident back to the unit. By that time he was livid.
“No, you don’t need to call the attending. No, he isn’t going into cardiogenic shock.” He seemed to be taking the situation personally as if the nurse’s questioning was about him and not about the patient.
Suddenly Mr. Larkey’s blood pressure plummeted, his complexion went from waxy white to sickly blue, and then – his heart stopped. A nurse ran for the code cart that held emergency medications; another nurse started pumping on the man’s chest, another nurse put a mask over the patient’s face and cranked up the oxygen. CODE BLUE was announced over the hospital loudspeaker, which brought all kinds of people running to help. The resident barked orders for medications. An EKG machine kept running long strips that draped onto the floor, demonstrating his heart’s rhythm, or the lack of it.
The anesthetist put a tube down Mr. Larkey’s throat to supply oxygen more efficiently. The resident shocked Mr. Larkey with electricity and got a weak pulse, but it dwindled despite all the medications that were administered. I could hear the nursing supervisor in the background calling the family, asking them to come back in. Eventually, the resident pronounced the code over, the patient was dead. He called the attending, who I hoped felt a pang of guilt for never examining the patient, never supervising us. More likely the doctor was irritated that his sleep was interrupted again.
We were all crying, the nurses and the resident as well, and the family, too, when they arrived. The resident told Mr. Larkey’s daughters that their father’s heart had stopped beating and that we had run a code but it didn’t save him. My tears were of sadness but also of anger and frustration. Why hadn’t the resident listened to the nurses? Why was he such a dick?
No one told the daughters that the resident ignored the nurse’s warning, that we could have done more, could have responded earlier. I had to look away when they thanked us, when they praised us for taking such good care of their father, for working so hard to try to save him. My only consolation was that the mortality rate for cardiogenic shock was so high that all of our efforts, including a Swan-Gantz catheter, probably wouldn’t have helped. Two days later the local paper printed Mr. Larkey’s obituary. The family donated a significant sum to the hospital in gratitude for our excellent care.
I plowed through the rest of that month in the ICU as best as I could, my frustration growing every day. We were scheduled to take call every three days. First it was my turn, then Bobby’s, then Cheryl’s. Bobby and I each took care of the patients we admitted while on call. The patients Cheryl admitted were supposed to be divided evenly between Bobby and me, but it didn’t work out that way. Cheryl told me she needed to protect Bobby so he wouldn’t have to work too long on his day after call, so she assigned all her admissions to me.
While I probably should have gone across town to the residency office to talk with the director about my concerns – about the lack of supervision, about Cheryl’s apparent ineptitude, about how to best deal with unfairness – it would mean leaving work in the middle of the day, a significant lapse that wasn’t allowed. I couldn’t see the residency director in my free time because I didn’t have any. While it would have been nice to share my experiences with the director, to get her advice on how to work more effectively with Cheryl, and to assure her that I was as competent as any other new intern, it just didn’t seem possible.
I tried to compensate by taking better care of my patients. One night on call I was paged to the emergency room to admit Mr. Smith, a cheerful, fifty-year-old man who was having a heart attack. Although he was pain-free, thanks to the medications given to him in the Emergency Room, the damage to his heart was already done. We needed to monitor him closely, give him medications to prevent abnormal heart rhythms, and keep him stable over the next couple of days.
I completed his history and examination. Mr. Smith introduced me to his wife, told me about their kids and their farm thirty miles south of the city. He praised his wife’s cooking.
I pointed to his belly. “I think you like her cooking a little too much!”
He laughed heartily then asked me about my family. It was easy to talk with the Smiths. For the first time that month I felt like a person again, not just a grunt who did mindless chores and hurt patients without knowing better.
I taught Mr. Smith about the medications we were giving him, and what was in store for his recovery. I found myself lingering in his room, wanting to spend time with him and his wife, even if there was no medical reason for me to be there. It seemed like the Smiths were the one bright light in the ICU dungeon. Before they left, Mrs. Smith handed me a piece of paper with their address and phone number on it.
“I hope you will come visit us soon,” she said.
“You remind us of our own kids,” he said. “And you’ve taken such good care of me. We thought you might like to spend some time at the farm.”
I stared at the paper, my face growing warm. “I’ve enjoyed getting to know you, too,” I said. “Make sure to talk with the dietitian, and work on the exercise. You’ll start feeling stronger soon.” I put the paper in the pocket of my white coat. “And yes, I’d love to come visit you.”
Both the Smiths grinned. I was fully aware that they had been taking care of me just as much as I had been taking care of him.
The rotation ended much as it had started, with Cheryl not understanding my questions, not responding to my concerns, and ignoring my needs. On one long, gray day I was supposed to do yet another admission while Bobby flitted around the new patient’s bed, talking with the specialists about renal failure and sepsis. I explained to Bobby that I needed to get to the bank before it closed, as I had to deposit my pay check in order to pay bills and buy food, but Bobby shook his head. Cheryl had told him he didn’t have to work up this patient. As the specialists crowded around the patient, discussing the procedure they planned to do that afternoon, I realized it could be hours before I would have the opportunity to take a history and do a proper physical exam. In frustration, I sat down to write the admission note based on the patient’s medical record. It wasn’t ideal, but at least the paperwork was done in some form. By the time I finished the bank was already closed, and I ended up going home to cry.
I’m ashamed to admit that in that final week, in my exhaustion and frustration, I confronted Cheryl at the nurse’s station in the ICU. I don’t remember what I said, just that I said it loudly, in anger. She seemed perplexed, as if she hadn’t even noticed the tension between us, as if I was speaking in some kind of foreign language. Despite our conflicts she gave me a passing grade for the rotation.
Thankfully, I never had to work with her again.
Author's CommentIt would be nice to think that my experiences during this ICU rotation only happened to me, only involved a couple of poorly trained supervising residents, and never happened anywhere else. But the problems I encountered over thirty years ago – haphazard education in sometimes abusive environments where flawed medical care is provided to unwitting patients – still occur today. Throughout my career I wanted to change medical training and practice, to develop doctors who are competent, ethical and humane, but my efforts seemed to make little impact. This piece is part of a memoir project that connects me with people who actually do have the power to effect change – everyone who ever has been or will be a patient.
One thought on “The ICU”
I really enjoyed your piece and related to it at several levels. I worked as an ER clerk from 1976-79 and saw a lot of the behaviors you mentioned. My future daughter-in-law is a second year resident in internal medicines and she has talked about some of the same dynamics among interns and residents, although I get the impression things have improved a bit since you were an intern. I’ve been working on a memoir about my ER experiences 40 years ago.