Going Down or Going Up

Anyone who is familiar with the medical field is well aware of the hierarchy that exists for the typical doctor in training. It starts in medical school, when you are a lowly first-year, and culminates after you finish residency, when you are a polished doctor, an attending, defining your own terms.

During the first year of my emergency medicine residency, we were assigned a rotation of five to seven weeks in a very demanding surgical sub-specialty service. Lucky me. Not only was I assigned this rotation during December and January, the holiday months, but my specific time was seven weeks with this service.

Heart transplants, bypass surgeries, lung resections, and much more--all at my lucky finger tips. The main reason for our involvement in this rotation, as ER residents in-training, was to learn how to perform a chest-tube insertion. Simply, it involves cutting through the skin of your mid-lateral ribcage, through the muscle and cartilage layers between two ribs, and accessing the lung space. You then insert a hollow tube into this lung space, which when hooked to a low-pressure vacuum, evacuates blood or air, or both. Either of these (usually from a trauma) can collapse the lungs and cause respiratory distress, which can lead to cardiac distress, so quickly inserting this tube can be life-saving. This procedure, known medically as a tube thoracostomy, is one of the "musts" that anyone entering the emergency medicine field must learn.

Simply put, though, this rotation sucked. I can't put it in any nicer terms. I was tired and worn-out, depressed and miserable, from all the hours and extreme demands of this rotation. A typical day started between 4 and 5 a.m. and finished, if you weren't on call, around 6 or 7 p.m. I was on call every third day, which meant I worked a 36 hour shift that day. Over Christmas, it got even worse--I was on call every other day. This was genuine, hellish, character-building training back in the days when strict rules and regulations were just evolving.

The hierarchy was never more evident to me than during this rotation. I was a lowly emergency medicine intern on service with several medical students below me and a fellow surgical intern beside me. Ahead, a second-year internal medicine resident, a fourth-year surgical resident, and a "fellow," a graduated surgical resident pursuing several additional training years in a surgical sub-specialty. And, of course, our attending, who varied day-to-day. Eight of us made up the team.

Did I mention that this was a hard rotation?

The funny thing about medicine, though, is that, as a resident, an intern, or medical student, there is much more to be learned from a rotation than just the medical knowledge and patient care. I constantly stress this to our emergency medicine residents. Be alert. Absorb everything about a patient and their case. Be compassionate. And watch those teaching you, extracting the best and worst of those experiences to add or avoid in their own practicing. I credit myself for being the doctor I am from emulating my favorites attendings just as much as from learning how not to behave or practice from certain individuals in the medical field.

From all my experiences during these seven weeks, one negative experience prominently stands out. Unfortunately, it doesn't involve a patient but rather the attending of our team. It was Christmas Day, around 11 a.m., and I was on-call. After finishing morning rounds, the departing on-call team, the attending, and our oncoming on-call team were collectively going down an elevator to the main-entrance lobby. Our attending that day was a fiftyish, hard-working, intelligent physician who, quite honestly, was always quite impressed with himself. His people skills, though, were extremely lacking.

Despite everyone being either depressed or exhausted, a lot of effort by others was going into kissing our attending's ass--laughing at his jokes, hanging on his every word, schmoozing left and right. Someone eventually asked him what the rest of his Christmas Day plans were.

"Well," he answered, "unfortunately, all my kids came home for the holidays."

"That's a bad thing?" I blurted out, surprised by his answer. I would have done anything, anything at all, to have spent the day with my wife and my family.

"Yes," the attending replied, surprised by my question, "very bad, actually."

"May I ask exactly why it's bad, sir?" I asked, ignoring the glare of my senior resident. I knew she wanted me to shut up, but that wasn't happening. "Is it too many people in the house? Too much commotion? Something like that?"

"Hardly," he replied, laughing to himself and shaking his head. "My family aggravates me and, quite frankly, I don't enjoy their company." He could have stopped there but didn't. "My wife and I have four kids, two married, no grandchildren. I would love some grandkids, but my kids are too damn selfish for that."

He got momentarily lost in his thoughts before speaking again. "Let me give you all a little piece of advice. This job we do--make it the priority in your life. Don't get distracted with a spouse and kids if you can help it. Trust me, they only get in the way." I waited for him to laugh, to finish out his joke of a statement. No laugh ever came, though.

His words had silenced the elevator and still, he continued. "Now I have to go home and play nice with my wife and kids. Trust me, that's a much harder job than this, any day. If I had my choice, I'd avoid all of them and stay here for the day." The elevator bell rang as he finished speaking, the doors quickly opening to let the departing on-call team and the attending out. No last holiday wishes from any of them.

If only the attending had remained silent and lost in his thoughts, I wouldn't have had to pity this man and his ridiculous words. "Have a nice fricking Christmas," I mumbled to no-one in particular.

Here I was, an intern-- a low-life medical scum barely clinging to the bottom of the totem pole--wishing for nothing other than to be surrounded by the ones I cherished on that Christmas Day. And here was the attending-- a worshipped doctor high on his pedestal--wishing for anything but to be surrounded by his family on Christmas Day. Clearly, he was letting his life be defined only by his successful professional accomplishments. And he seemed to be okay with that. He didn't seem to be affected by his failures as a husband. As a father. As a friend. As a man. He probably didn't see it, even.

How sad. How very, very sad.

Although I learned a lot during this rotation, none of my gained medical knowledge came close to the perspective I gained going down that hospital elevator on that Christmas day. I was shown a clear example of what I did not, nor would ever, become. No textbook could have taught me that.

Writing this post, I realize that I never found out how that Christmas day turned out for this attending. I wonder if there were any family arguments? Did anyone drink too much? And what emotion saturated the dining room while this family ate their holiday meal? Anger? Silence? Am I too hopeful and naive to think that maybe there was a little happiness? I picture extreme silence, barring the silverware clinking the plates, with everyone maintaining their robotic and detached manners. I hope I am wrong.

This attending gets full credit for teaching me something valuable during that rotation. Climbing up the hierarchy of medicine did not mean that I would have to sink down the hierarchy of family and friends. I would never sacrifice one for the other.

Best Christmas present I got that year, for sure.

As always, big thanks for reading. I hope you all have a great weekend. See you next week...

"Yoo-Hoo"

As I sat down at my computer station to finish the chart on a patient I had just treated, I heard something quite interesting. A voice, smooth and mellow, was calling out.

"Yoo-hoo."

It was an older woman's voice. I was immediately taken back to when I was a child, in my grandparent's house, standing beneath a small, cottage-shaped clock that hung on the wall. With a new hour approaching, I held my breath, staring up at the clock, its small pendulum swinging beneath, clicking a constant, relaxed beat. Eventually, the clock chimed, a little trap door opened, and a small bird popped out and chirped it's greeting.

"Coo-coo. Coo-coo. Coo-coo." Three times, like clock-work (no pun intended). Standing outside of my memory looking-in, I saw the little boy in his summer shorts, his tanned face framed with shaggy brown hair, smiling as he looked up expectantly at the wooden bird that never failed to mark a new hour.

"Yoo-hoo. Yoo-hoo." The woman's voice snapped me back to the present.

I got up from my chair and followed the yoo-hooing until I was standing at the bedside of an elderly woman with matted soft-grey hair and empty hazel eyes. She clearly had dementia. She looked quite comfortable, though, and was mumbling something to herself between the yoo-hoos.

"Do you need help with something, maam?" I asked, straightening her sheets and tucking her in. "What can I get you?"

"Help me!" the patient screamed, "I need help."

This patient's nurse walked in just then, a younger nurse that I enjoyed working with. She was compassionate, knowledgeable, and hard-working. And apparently, at that moment, frustrated.

"Is everything all right in here, Victoria?" I asked, ready to help.

"Everything's fine. Mrs. Pello has Alzheimer's and was sent by the nursing home because the nurse there thought she was acting 'more demented' today." Victoria gave me a knowing glance. We both recognized the bullshit excuse by the nurse who sent in Mrs. Pello, trying to make her own shift easier. At our expense, of course.

"Anything wrong?" I asked. "You need me to see her?"

"Dr. P. picked up on her. We're just going to get some baseline tests and a CT scan of her head. If it's all good, she'll be heading back soon enough."

"Yoo-hoo," Mrs. Pello called out, yet again.

"On second thought," Victoria said, laughing, "if you can get her to stop yelling 'yoo-hoo' every five minutes, I would appreciate it."

"I kind of like it," I said. "It reminds me of a coo-coo clock my grandparents had when I was a kid. She sounds just like the little bird that popped..."

I was interrupted by Mrs. Pello. "Help me! I need help!" Her sudden outburst had caught Victoria and I both by surprise. Then, without pausing, Mrs. Pello continued. "Yoo-hoo. Yoo-hoo."

"Just wait," Victoria warned me, both of us chuckling, "you might like it now, but after a few hours of this, I'm not so sure."

Well, little did I know at the time, but Victoria had hit the nail right on the head. Mrs. Pello's loud "yoo-hoo" was methodical and rhythmic, an audio alarm that was set to go off every five minutes, interrupting our workday. Unfortunately, her door had to be left open so that the nurses in their station could keep a close eye on her. And the risks of sedating her outweighed the benefits. So her yoo-hooing would just have to be accepted for a few hours.

Soon after meeting Mrs. Pello, a middle-aged man, who had collapsed at home, was brought into our ER and placed in the room next door. His right side was completely flaccid (no muscle strength) and he had a facial droop. An obvious stroke. A stroke alert was called and we emergently intubated this gentleman, hooked him up to a ventilator, and aggressively treated his escalating blood pressure. This patient was critical.

And then, suddenly, in the midst of treating this crisis, there it was. "Yoo-hoo. Yoo-hoo." It was clear and resounding. Everyone who was involved in treating our stroke patient did a quick pause. "Yoo-hoo." Mrs. Pello had added another one for good measure.

"Come on, people, back to work," I said, reminding them of our task at hand.

"What the hell was that?" the neurologist and neurosurgeon asked me, intrigued. "You really don't want to know," I said, grinning. My ER team, including Victoria, was shaking their heads, obviously trying to stifle their laughs. Swiftly, we transferred the stroke patient to the OR for emergent surgery after his CT scan revealed a large hemorrhagic stroke--blood on the brain.

Unfortunately, treating the stroke patient delayed Mrs. Pello's own head CT and she continued to sit in her room, waiting. "Yoo-hoo." Yep, about every five minutes.

At another point, as a family passed by Mrs. Pello's room while being escorted to their treatment room, she started screaming out "Help me! I need help." The family's eyes widened from fright. The staff, immune to the cries, didn't even budge to help, which I'm sure thoroughly impressed this family. They had to have thought of high-tailing it and heading to another ER. Someplace where the doctors and nurses cared.

Eventually, though, Mrs. Pello went over to the radiology department for her head CT. We all cheered, looking forward to a few minutes of silence. Unfortunately, not even five minutes had passed before we got an urgent call from the CT tech. "Can someone come over right away? Mrs. Pello is screaming for help." Oops, someone forgot to warn the tech of Mrs. Pello's outbursts.

She returned from her CT scan and, thankfully, all of her workup was normal. She had been in our emergency department for approximately four hours. Well, not approximately. More like exactly! Even those of us not involved in her care were celebrating her finished work-up and immediate plans to be transferred back to her nursing home. However, due to several ongoing emergencies, it would be one more hour of waiting until the ambulance service arrived to take her back. "Yoo-hoo."

Even though I wasn't treating her, I couldn't help but go into Mrs. Pello's room several more times to make sure she was comfortable. You see, not only did her "yoo-hoo" trigger a wonderful childhood memory of that coo-coo clock, but Mrs. Pello herself reminded me of my grandmother, an amazing and fiercely-independent woman who also was stricken with dementia.

Victoria was dead-on right. After five hours of "yoo-hoos," Mrs. Pello's voice had lost most of its charm and smooth, mellow tones. Now, her cries were simply annoying. Our staff gave her a wonderful farewell, lining up in the hallway to witness her be escorted by the ambulance team back to her nursing home. I think they were just making sure that there would be no screw-ups--that Mrs. Pello was actually leaving. Do not pass go. Do not collect $200. Just get the heck out!

Me? Well, of course, I was missing Mrs. Pello and her "yoo-hoos" five minutes after she was discharged. It was too quiet! And truth be told, I don't think I was alone. I think we all were suffering from yoo-hoo withdrawal.

So, I took a deep breath, calmed my fears, made my voice smooth and mellow, and did it.

"Yoo-hoo."

Update: One week later...
Good news...you can hardly see my black-eye anymore. I just wish someone had warned me that Victoria knew karate!

As always, a big thanks for reading. The next post will be Monday, February 15. Happy Valentine's Day to all of you...

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