Every year as we transition from an intern to a second-year, to a third-year and so on, we abruptly level up. After twelve strange, grueling months as an intern, I just leveled the heck up and, while I don’t have the words to describe exactly how it feels (kind of great! kind of horrible!), the green-faced puke Emoji best captures the day-to-day sentiment.
Suddenly the job that I spent a year figuring out how to do is no longer mine. There are new fresh-faced interns stepping in to replete patients’ electrolytes and answer 6,233 questions (the exact number of pages I received as an intern). Now, I have new tasks, new responsibilities, and new expectations to meet — or fall shy of. Unfortunately, there’s no orientation or crash course in managing sicker patients or speaking with greater authority. We just have to figure it out and, frankly, fake it a bit as we go.
I started my second year in the Surgical ICU (SICU), taking 28-hour calls a few times a week. For all of intern year, the SICU was a safe haven, a mysterious space a few floors below, where my sickest patients would go, relieving me of the stress of having to work them up and manage their ailments. Unlike my pages, I can’t count the number of times during my intern year that a patient looked terrible, and I had to wake up a sleeping chief resident or go down to the operating room to share my concerns, and the chief said, “Just call the ICU.” It happened not infrequently and after I summoned the ICU, a huge wave of relief would wash over me as the critical care fellow arrived at my patient’s bedside and, like the queen conferring knighthood, deemed the patient sick-enough to transfer to the land of intensive care. Suddenly, the responsibility fell on someone else’s shoulders — the shoulders of a smarter, wiser second-year resident.
Now, I’m on the receiving end of that interaction, but I’m no wiser than I was as an intern a few weeks ago. In the SICU, we deal with machines and medications, and even pathophysiology that I hadn’t seriously encountered before. Many of our patients are on ventilators pushing air through their lungs at different settings and modes. Many receive a cocktail of sedating medications and have drips of drugs that clamp down their arteries, increasing blood flow through their bodies. None of these things are brand new to me; as a medical student, I rotated through the Medical ICU (MICU) in the midst of COVID, but I’ve never been responsible for thinking through how to manage patients this sick, and on such little sleep.
In the SICU, we take 28-hour calls that are notoriously grueling. I did plenty of 24-hour shifts intern year and truly thought I was ready for anything, but on most of my previous shifts, there was always a moment to close my eyes — even if leaning back in a desk chair — or some time to grab a snack and take a lap around the halls. In the SICU, the pace is relentless. I’m in a hyper-vigilant state for what feels like days of my life. Even though I’m mostly just staring at one computer screen, I might as well be looking at 20 patient monitors at once. At all moments, you’re expected to track the slight variations in each patient’s respiratory function, blood pressure changes, and medications. You have to stay on top of a million tiny details, while also fielding constant questions from nurses, performing bedside procedures, having conversations with family members, making decisions about patient care, and meeting and admitting new patients who arrive — sometimes on the brink of death — to the ICU. I found myself literally gasping for air at points, feeling a perpetual queasiness, while my heart raced for each second of the shift. One shift I forgot to pee for the first 10 hours, too preoccupied to recognize my own discomfort.
“How does anyone do this?” I asked myself in a voice memo after my first 28-hour shift, “I’m worse than drunk.” Sometime after midnight on those shifts, I would begin to feel like I could barely walk in a straight line let alone do procedures and take care of critically ill patients. Standing became burdensome. But sitting could be dangerous: several times I found my eyes closing against my will only to jerk awake as my head hit the keyboard or encountered the airspace behind my low-back desk chair.
And yet, somehow, I got through each shift on a combination of adrenaline, sugar, and caffeine sustaining me like the infusions keeping my patients alive. I got through each shift with the support of a fellow looking over my shoulder, picking up my slack. After each shift, I’d return to my quiet apartment, scrub the smell of the SICU off of me, and collapse into my bed to sleep through the entire rest of the day, before waking up just to eat something, and return to bed to prepare for a 6:00 AM start the next morning.
I have no great conclusions to these descriptions, no big lesson or takeaway, other than to capture what I’ve done here. I’ve learned a lot on each of these shifts about how to manage the sickest of patients. I’ve called Time of Death on complete strangers, placed catheters into patient’s neck veins to give them medications, watched a man bleed out after surgery and return to the operating room right away, saw a kid who had a bike accident recover without the brain injury we expected, made decisions I felt good about and those that I doubted. I’ve picked my battles, read up on studies, admitted to my shortcomings, fought back tears.
It probably doesn't have to be quite like this, so scary and sleepless. But it is what it is, and my job — sometimes a joy, sometimes a burden — is to keep up and level up. I'll keep going from here.
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