ON READING HARRISON’S PRINCIPLES OF INTERNAL MEDICINE FOR THE LAST TIME — CHAPTER 6
On Reading Harrison’s Principles of Internal Medicine for the Last time
Chapter 6 Safety and Quality of Healthcare
As a medical student in 1973 I believed the safety and quality of healthcare rested with the individual physician. If the physician was trained properly quality would be assured. I studied and exposed myself to as much clinical experience as I could in order to get myself prepared for a medical internship.
I learned that medical school introduces you to medicine, but that competency comes with what we used to call the internship but now the post graduate years are collectively called residency. PGY-1=internship. To all medical students worried that you are not up to the task the day you graduate from medical school you can stop worrying. You are not ready. Okay? End of story. Stop worrying. If you think you’re ready you’re dangerous. But with the correct training program you will be, and patients will not be hurt. You need graduated responsibility looking to your second- and third-year residents for guidance. Your attending physicians will not be as helpful as your senior residents. This I learned the hard way.
My first post graduate year was at a world-famous place. I thought the training would be comprehensive because a place like this could not afford to have the intern working alone in a vacuum. The joke was on me and the patients. I found myself in a frightening training program with no help from senior residents or attendings.
I went to the wards on July 1,1977 to start my internship. I reported on the first day and received my list of patients. I asked the attending who were we to go for back up? He replied we are all equal at the hospital.
“So there are no second or third year residents or chief residents backing up the interns?
“We are all equal in this system, there are no chief residents.”
“So interns, second, and third year residents all have the same responsibilities?”
“Yes.”
I learned that in this hospital there was no gradual acceptance of responsibility. Yesterday I was a medical student and today I was a doctor working without back up. It was terrifying and not fair to the interns and the patients. Patient came from all over the world to this hospital to get — me.
It was a shit show.
There were twenty-two names on my list. We only carried four or five patients in medical school.
“Excuse me where are the supervising residents?” I asked. “The second- and third-years, those with more experience?”
“They’re on other rotations,” he said. “We’re all equal at The Hospital, even on day one.”
“So, we have no backup, no supervision? Who do we go to for help?” I asked. “When you’ve left the hospital?”
My throat tightened. This could not be for real.
“You won’t need it. You’ve been selected because of your great credentials. Our reputation allows us to take the top American graduates.”
“Those are medical student credentials,” I said. “They don’t mean anything.” “Dr. Kroneman, the internship is about finding your threshold. We throw you in the deep end to see if you can swim. We’re doing you a favor.”
“Threshold?” I asked.
“Yes, threshold. If you have a high threshold for stress, you go into cardiac surgery. If you have a low one — dermatology, medical administration, or research. You will find your niche somewhere between those extremes. You know I can’t, for the life of me, figure out why dermatologists make more money than heart surgeons. It doesn’t seem right.”
“What happens to the patients while we’re finding our threshold?” I asked.
“It doesn’t seem fair or safe.”
Owens grimaced, rolled his eyes
“You will be fine. See you in the morning.”
“So you’re leaving? There is no one to help us?”
So much for being trained and mentored by season renown clinicians.
I lost the coin flip and was on call the first night. Thirty lives depended on me. I started to count my breaths in an attempt to slow my breathing. Yoga stuff. I’d try anything to avoid hyperventilation. I’ve heard of people breathing so fast they almost fainted The stricken are told to breathe into a paper bag to bring the carbon dioxide level up and restore the acid-base status of the body and protect the internal milieu so they don’t have a seizure.
I was told breathing into a paper bag would restore calm faster than Valium. I should have kept one handy. What if it happened here and I’m incapacitated? I imagined a nurse telling the patient, “See that young man over there, the one breathing into a paper bag? That is your doctor. Feeling confident?”
I was alone.
I counted breaths — one Mississippi, two Mississippi, three Mississippi… The pager screamed. I jumped. I called back.
“Dr. Kroneman, medical intern,” I said.
“This is Dr. Masters, senior on the orthopedic service. We got an old boy here, fixed his hip. Now he’s crashing. He’s trying to die on the orthopedic service and we can’t allow that. Ruins our stats.”
“I’m just an intern. This is my first night. I don’t know how to order anything. You guys keep him on your service, and I’ll write some orders. I have no supervising resident.”
I was desperate.
This wasn’t medical school; they’re firing real bullets now. I could have used a second or third year resident. Someone who’d survived the first year, the first day.
“I know,” he said. “I don’t know why they run the place like this, but they do. It sucks for you guys. You have no help. This is a famous place. If the truth gets out, they’re screwed. It’s a con game. What is and what should be are very different at The Hospital. Last year they had a suicide on the medicine service. The guy was married and had two kids. Freaked out. We’ve too much backup on surgery. We can’t cut alone. Your patient’s coming up on the elevator. May the force be with you.” (The first Star Wars had just come out.)
I needed Yoda.
A guy committed suicide last year? I felt really good now. Could it get that bad? Must have been bipolar, I hoped, and not a high-functioning obsessive-compulsive.
The elevator door opened and discharged an old man delirious and moaning. I put my hand on his head. He was hot, his skin color was fiery red.
He had broken out in a sweat, so did I.
“The man has a fever,” I said.
“Brilliant,” the orderly said.
The nurse laughed.
“We’ll get the old gomer in bed, then you can examine him.”
I waited outside the room. They were waiting for me to call the shots. I thought back to medical school lectures. It must be an infection and shock. But what if it was a blood clot in the lung? That happened after hip surgery. I reviewed my medical notes.
Why was there no one to help me? This was human life for God’s sake.
I tried to get a history, but all the old guy could do was mumble. I put him on nafcillin and gentamicin, the antibiotics we used back then when we didn’t know what we were treating. But he could have had a blood clot, so I put him on heparin to thin his blood. I did it all in thirty minutes, during which time I answered calls from nurses asking for aspirins, laxatives, and sleeping pills for their patients.
I sat alone. I took a few deep breaths. I just took care of my first patient. I did okay. What if something more challenging came in? I was the person responsible, and I couldn’t call for back-up. There was none.
I started to get nervous again. It was ten o’clock, ten hours to go.
Perhaps my first night’s trial was over. That was enough for me. I wanted to go home.
The beeper screamed, sending a bolt of adrenaline through my body.
“Dr. Kroneman here.”
“This is Dr. Jaworski from Lance Community Hospital; got an eighteen-year-old girl. She’s just delivered a baby. She’s toxic, blood pressure’s over two-fifty systolic. We got to get her to you guys. I can’t stabilize her. I can’t get her pressure down. She’s gonna have a stroke.”
Oh no, please no.
“Can’t you keep her till the morning, when our staff comes in?” I asked.
“No, we’re not equipped to deal with this sort of thing.”
“How long have you been in practice?” I asked.
“Fifteen years,” he said.
“Well, I’ve been a doctor for a day, and I’m really not comfortable with this.” I also wanted to tell him I might hyperventilate myself into a seizure. I had not brought a paper bag. Then who would take care of the girl?
“You have infrastructure; it’s a bad case. I’ll probably get my ass sued for being at the wrong place at the wrong time. I switched calls. You’ll get help. Besides, you have insurance; I’m in obstetrics, I’m bare, no insurance. If you don’t get her blood pressure down, she’ll bleed into her brain.”
“No, I won’t get any help. This place isn’t what you think. You don’t understand what’s really going on here.”
He hung up while I said, “We don’t have infrastructure, we don’t have shit, it’s just me.”
Just me, doctor for a day. I hadn’t even taken part three of the National Boards.
The beeper sounded. More laxatives, aspirins, and sleeping pills. A nurse called me for an IV start.
“I’ve only put in two IVs in my life.”
I went to the patient’s bedside. The patient had a blood disorder, she’d hemorrhaged into her brain and was in a coma. No hope. I called the surgical resident. He arrived and was not happy.
“What’s this all about? I’m trying to sleep. I have to operate tomorrow. Damn interns.”
“You mean hold retractors,” the nurse said. “They don’t let you guys do squat. That’s why if you train here they won’t let you go on the attending staff.”
“The patient’s line came out. She needs a new one, and she has no veins,” I said.
“I’ll throw in a central line,” the resident said.
“Her blood won’t clot,” I said. “A central line’s too dangerous. She could bleed to death. We should do a cut-down on a vein in her arm, we can control the bleeding. You put an IV line in her neck, and we’ll never control the bleeding.”
“It’ll take too long, I need to get some sleep. I’m putting in a central line.”
“I think that’s a mistake,” I said.
“You’re just a July first intern. Let me handle this.”
He opened the central line kit and went to work. I wanted no part of it.
I left for the cafeteria, but it was closed. It was now two in the morning. No food. It was okay because I was too nauseated to eat. No sleep; I was wired anyway. I didn’t count my breaths for a while; too busy. I didn’t have time to think about having a panic attack. I had a headache. Headache plus nausea meant a migraine was coming on.
Too much was going down. As long as I was in motion, the panic wouldn’t come. When I stopped to think about what I did or what I might have to do, I got nervous. I was doing okay. No major disasters. But I had this girl coming in with high blood pressure. I had never managed high blood pressure in a pregnant woman. I didn’t have a supervising resident, so I went to the library, I needed information. It’s locked. I started to breathe fast. The beeper sounded and snatched me back from hyperspace.
“Code blue on the general medical service, room 779.”
I had to run to a code, even though we had not been instructed on how to manage a patient in cardiac arrest, we had to go anyway.
I arrived first. Damn, that was a mistake. Should have run slowly or backward.
A nurse shoved me into room 779. The patient was not breathing. Eyes opened, mouth opened. He turned blue.
“Call anesthesia,” I shouted
They followed my orders, that surprised me. Now what? We hadn’t had CPR resuscitation training, that was next week. Now, I had this blue guy in front of me. I’ve only resuscitated rubber mannequins. It’s how we learned mouth-to-mouth resuscitation.
I did the only thing I knew how to do: mouth-to-mouth resuscitation. I didn’t stop to think if he had a communicable disease or not. The patient came first. He started to pink up. I was surprised how well you can inflate another person’s lungs with mouth-to-mouth. You got a pretty good seal. I was breathing life into the guy. Resurrection. The CPR team and anesthesia showed up. The surgeon looked at me. It was the same one who put the central line in the other dying patient.
“Cut that out,” he said to me. “That’s the nurse’s job.”
Then vomit splashed my face.
“He got ya. See, I told you that’s the nurse’s job. Get out of here. Take a shower.
Don’t ever do mouth-to-mouth again. It’s not worth it. It’s disgusting. What if he has TB? They always vomit. They didn’t tell you that in med school? God, everybody wants to die tonight.”
I kept my head down, turned off my pager, and headed for the shower. I didn’t care who would call for what. I had to get clean. I opened my mouth and let the water pour in. I showered and toweled dry. I put on surgical scrubs.
I checked the beeper — nine unanswered calls. One stat, logged in ten minutes ago.
I called the floor. The nurse is screaming, “Kroneman, where the hell have you been?
That lady he put the line in is bleeding. There’s a lump the size of a golf ball in her neck.
You told him not to do it. It’s not your fault.”
I raced to the patient.
I entered the patient’s room. There was a mass of blood around the inserted central line. I placed my hand over the line, applied pressure, but the bleeding continued.
“What’s her blood pressure?”
“Ninety over sixty. I’ll open up the saline, give her a ton of fluids and page the surgical resident.”
“They really never let a surgical resident who trains here go on the attending staff/”
“Never,” she said. “They say it’s to prevent inbreeding but it’s because their program sucks. It’s on probation.”
“At the World Famous Place?”
“Yep.”
I counted the monitored mechanical pings of the patient’s heartbeats. After 187 beats the surgical resident appeared.
“Now what?”
“Look.” The nurse pointed to the patient’s neck. The mass of blood grew to the size of a softball. Her head was turned up and to the left. Then a loud, grating, snoring sound.
“Shit, the blood is collapsing her airway. She can’t get any air,” the surgical resident said. He looked worried, no longer self-assured, cocky and confident. He was frightened. The young surgeon looked like I felt.
The wet, snoring sound grew louder.
“We need to put her on the ventilator; get a tube down her.”
“She is not to be resuscitated. She’s terminal,” I said. “We’re not to put her on the ventilator.”
“I can’t listen to that noise,” said the nurse. She left the room.
“I won’t listen to that,” the surgeon said. There was a tremor in his voice.
He took an endotracheal tube and placed it into the woman’s windpipe. The snoring stopped. He should not have done that. He should not have put that subclavian line in her either. He should have done a cut-down on her vein like I told him to. He wasn’t very smart. The patient was not to be resuscitated. No tubes. No respirator. But I was glad he did it. I couldn’t stand that noise either. He attached her to the ventilator.
“Damn, we need to crack open her chest and tie off what’s bleeding,” he said. “Get the transfusion ready.”
“Blood pressure?”
“None.”
Then the shrill whistle signaling that the person was dead. You had five minutes to do something. I definitely was not going to do mouth to mouth resuscitation. Those of us who have done it understand “one and done.”
“Call a CPR,” the surgeon said.
“No, you don’t,” the nurse said. “She’s a no CPR. You’ve done too much already.”
Her blood pressure was zero, her eyes fixed and dilated in death. The three of us stood there like gawkers at a car wreck.
I broke the silence. “I guess I should pull the tube out of her mouth, take her off the ventilator.”
“You can’t,” the charge nurse said. “She still has a heart rhythm.”
She pointed to the metallic green heartbeats that snaked across the monitor. She turned on the volume — blip, blip, blip.
“But that’s just an agonal, useless rhythm. She is dead,” I said.
“As long as she has a heartbeat, you can’t pull the tube out unless your attending supervising professor is here. If she goes flat line, you can pull it.”
“Let me get this straight. I’ve worked all night, flown by the seat of my pants. I’ve had no help with the living patients. Now I’ve got a dead patient on a ventilator and can’t take her off without my attending here? That makes no sense,” I said.
“That’s the way it’s done at The Hospital.”
The patient was dead, but the machine continued to move her chest up and down.
She still had a heartbeat that was imitating life. The respirator didn’t want to give up. I did. Ventilating a dead person was eerie. The breaths are slow, steady, and peaceful. I admired the peaceful rhythm. My breathing subconsciously became in sync with the dead patient. I started to count the patient’s breaths rather than mine. The dead patient was helping me; a final good deed. She slowed me down. I was calm. The dead really taught us, sometimes too late.
We had her set for twelve breaths per minute, that’s 720 breaths per hour; my attending would be here in two hours. I would count 1,440 breaths, then my attending would arrive, and she could be removed from the ventilator.
The young pregnant woman arrived after eight so I would not have to be her doctor.
That was a relief.
* * *
I lasted one year and got the hell out of the World Famous Hospital. I am amazed to this day, almost forty years ago that they could run a training program as they did. Some of the patients I took care of all alone as an intern would make me nervous today.
I’m proud of the young doctor who stuck it out but was smart enough to go to University program with appropriate responsibility the following year.
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