an intern's boss.

I find it to be a hilarious perversity that I am now an Intern's Boss.

Last weekend (I think it was the weekend, anyway..), My intern paged me at about midnight about a patient that was dying. Tachypneic, Tachycardic, Hypotensive. On Death's Door. Old, demented. Let me just say it, she was a total gomer. My intern is alone, scared. He's not sure what to do, medically, ethically, or morally. She's DNR/DNI, but nevertheless in our ICU, a place known to keep people alive forever, and being aggressively treated... Should he get a lactate? Or cardiac enzymes? What if they are high? And plus we can't start pressors. She's not a surgical candidate in the case that there is an abdominal crisis brewing. She won't go to cath if she's getting an MI...Should we maybe just broaden our antibiotics...?

He's asking good questions, concrete but insightful, thinking about all the right stuff...

I am apathetic and cannot rouse myself from the couch or fully out of sleep to go and assist him this time. I trust the guy, he's smart, able, makes good decisions, and has the annoying sense of "yay! i'm a doctor!" that I find particularly difficult to be around these days.. I mumble a few tips on the phone including calling her son for an update and hang up, fall directly back to sleep. I remember thinking something along the lines of "he'll be fine, it's his turn, and it doesn't matter anyway" before fading away into a deep and peaceful slumber.

I woke up 3 hours later, which as a resident is always disconcerting. I wake up suddenly, instantly feeling PANIC with a long string of expletives racing through my mind.. f#@(!! %$!*!! da#%^&

I overslept!! (no, wait, my alarm didn't go off) --

It's dark!! (but does that mean it's still night, early morning, or night again?? crap, what was the f-ing date last time I was awake anyway??.. this military time is worthless if i don't even know the damned date) ----

I didn't hear my pager!! (no, as I methodically move across my beltline full of pagers..no new ones..) --

That patient must have died by now!! (actually, my intern probably would have called me..) --

Wow, I'm a bad resident.. (yeah, most def.. left the intern hangin, apathetic, got 4 hours of straight sleep on a call shift, and I could care less if that gomer died..) -- that last one is undeniable..

But now that I've established that I suck, which I believe I've already sort of established as a baseline on prior posts and in general with acquaintances, but let me move forward to my point.

I distinguish ethics from morality purposefully. Ethics being "medical ethics, legal rights and obligations, malpractice implications." Morality being "with what level of personal contempt directly based on your choices are you still able to sleep enough at night in order to have the energy to get up and do it all again." They balance on a fine tightrope, those two.. Or they always did. I wonder if maybe one day you reach such a point of personal contempt that you stop being able to sleep.

Interestingly, I've recently developed the Disease of Insomnia. I have never had this problem in the past, so it is a new, foreign, and extremely upsetting concept to me.. I've always had my sleep. I am the sort of person who can sleep standing, leaning, sitting across a patient in clinic who won't shut up, in a lecture, on a plane, in a car, on a boat, while eating green eggs and ham.. In residency, I developed a sort of severe "teeth-grinding phenomenon," which has resulted in me waking up with terrible face and tooth pain, but Never. Ever. Before. This. Insomnia. Never. I have always been able to sleep.

Why can't I sleep? I assume primarily because I am stressed. But who knows. I also think, as one of the superstitious folk, that I must have some serious Karma Issues.

I guess I decided long ago that the lady I referred to above would die. I'm a profit that way. She will die. (shhhh.. we all will die...). She's been in her gomer-esque state AT LEAST since I'm in residency (+2 years). She never gets out of bed. She has a Stage 4 Decub ulcer on her butt (non-medical peeps, def. n. when you probe a deep pressure ulcer with a Q-tip and keep going till you hit mushy bone. then you get really bad nausea.) She has no idea what's going on (we don't think). She has a POLST in her chart that says she doesn't want antibiotics, IV fluids, pressors, or a feeding tube. Did I mention she's in the ICU? Oh yeah, and her son, the Power of Attorney, has decided that antibiotics and IV fluids are OK with him.. So she keeps on keepin on.. and on.. and on...

We are treating a yeast UTI because we can't tell if she may in discomfort from it...

We are treating a pneumonia based on a CXR... she cannot tell us about her symptoms...

We are stressing out every day that she is so malnourished and won't eat, but she has that pesty "no feeding tube" POLST....

Hey, did I mention already that she has a skin ulcer invading itself into her SACRUM!

I bet that frieking sucker hurts.

Of all the things I've been progressively desensitized against in medicine, Decub Ulcers are things that I still have trouble with.. Just the idea and concept of an ulcer that has developed because you are no longer able to move enough to offset gravity... that is just plain something I will never be able to get over. (Or, I guess I should say that I hope I won't get over it, but I probably will eventually I guess)..

But this whole thing was supposed to be about my job as an intern's boss..

Interestingly, I have gotten good feedback about the whole thing...

Interns like working with me.

Attendings give great evaluations.

Patients ask for me.

Nurses take me out for beer.

It's too bad that I've come to hate myself and really resent my job..

..and I can No Longer Sleep...

(p.s. that patient is still alive... back to a SNF... to be continued.)

-------------------------------------------