Learning, Relearning and Lessons Along the Way (In a Pre-Surge COVID Time)

We are fortunate to not yet be in “the surge” of the COVID 19 pandemic. Our hospital has patients with it. The leaders expect or at least are preparing for “the surge” like other cities have experienced. We have been preparing and ramping up for it. As a part of that we have redeployment plans in place. Those of us in cardiology are now doing educational modules to brush up on our critical care skills. 

As I thought about what to write this week it seemed fitting to go back to some memories of being a student. 

ISINLAMIKAMP

For me, this was a very important lecture. If memory serves me correctly it was Dr. Vander. We were in the 2^nd semester of our M2 (2^nd year) of medical school. We were seated in our large lecture hall that was our dwelling place for most of the year. Our professor went up to the board at the front of the lecture hall. He wrote this on the board, “ISINLAMIKAMP.” 

We were all puzzled. 

He told us that he was going to teach us about a very common condition. He said that it often afflicts medical students. He said it commonly comes on sometime about the 2^nd year of medical school and usually lasts for 15 years or longer. He reassured us that it was not terminal. We would survive it even if we didn’t like it.

He went back up to the board and wrote next to each letter:

I’m 

Stupid

I’ll

Never

Learn

All the 

Material and

I’ll

Kill 

All 

My

Patients

We all laughed a nervous laugh. We were all feeling that. None of us had the courage or perhaps the wisdom to admit that we were having those thoughts. That lecture was powerful. It made me realize that I was not alone. It helped me understand how to be a doctor.

That day I learned an important lesson.  There is so much material that it is impossible to learn and remember all of it. It is of course important to study hard and to remain as current as possible. There are some who are just so brilliant that it seems like they know everything. But oddly the ones who seem to know everything don’t always tend to be the best clinicians. More important than knowing everything is knowing that you don’t know everything.  

What do I mean? More important than knowing everything is:

1. Knowing what you don’t know.
2. Being honest and humble enough to admit when you don’t know.
3. Knowing where to go or who to ask.

What’s the Worst Thing that Could Happen?

The next story is a repeated one. It happened almost every time I was on call. 

The story starts the day or night before my call. I would think about being on call and I would feel a pit in my stomach. Even just the anticipation of being on call would bring it on. It was a feeling of anxiety and dread. Was I up to the job? Would I be able to handle everything? Most of the time, I wouldn’t even know specifically what I was so worried about. 

But I would be worried.

Every time.

I learned a technique that helped me a lot. In my efforts to try to figure out what I was so worried about I would ask myself, “What is the worst thing that could happen?” 

The script went something like this:

Me 1: What is the worst thing that could happen tomorrow?

Me 2: …

Me 1: Well?

Me 2: Well – my patient could die! 

Me 1: Yes, they could.  But if they do – then that is ACLS^[1]. And then you know exactly what to do.

Me 2: So, you are saying that if it gets terrible, then I am ok?

Me 1: That is exactly what I am saying. So just calm down and STOP worrying!

Oddly – that made me feel better. I would go and do what I needed to do. As a trainee there were senior residents or fellows or attendings who could help if I didn’t know what to do. And as an attending there were other attendings. The pre-call dread never matched the reality. 

I am not saying that it was never hard. It was. 

I can remember carrying my little green call book and managing 40+ patients on one of my rotations as an intern at the naval hospital. There were lots of times when I was really stressed. There were times when I wanted to throw my pager across the room. 

There were times when I got very tired. One night I really remember. I was so tired I struggled to finish writing an H&P (history and physical). I had to keep waking myself up. I was “falling out of my chair” tired. When I looked at what I had written in the patient chart I was horrified. There in the end of the H&P I had written part of a dream I had just had while asleep. I don’t know how I did that. It was really embarrassing! I got up and walked around to wake myself up. Then I had to throw out the paper and start writing all over again.

But no matter how bad it got, even at its worst, the worst thing that would happen is that the patient would code. And then it was just routine. Then I would know exactly what to do. We would follow the ACLS algorithms.

And even in the very hard times, I was working. I was moving. I was active. 

When I was in medical school I would read novels. Oddly they were like “sorbet for the brain.” In the midst of hours of studying I would treat myself with a few pages of a novel and it would refresh me so that I could go back to studying. One of the books I read was Phil Caputo’s, “A Rumor of War.”^[2] The book tells his story about going to serve as an officer in the Vietnam war. 

At the beginning of the book he was young, just out of college, and a brand-new military officer. He went from worrying about history and literature to worrying about dying. I could not imagine what that was like. While I was reading it, I was the same age and had just graduated college the prior year. That identification with him drew me into the book. Each page carried me with him. I came along as he arrived in Vietnam. I felt myself going when he went on his first patrol. By reading I could feel myself sitting on the helicopter heading to the drop zone. I could feel the intense anxiety and dread. I could feel him pretending to be brave for the sake of the men he was leading. He couldn’t admit it. He had to be strong. The drop zone was visible down below. As the pilot descended I could feel him asking himself if he would be able to do his job once they hit the ground. I wondered. If I was there, could I do the job? And then it happened. They hit the ground. Really without thinking they all jumped out and started charging forward shooting against enemy fire. They were just doing whatever they needed to do.

And so, it would be each time on call. The dread was the anticipation. The riding in the helicopter over the trees and then descending down to the hostile drop zone. Would I be up to the job? When we touched down on the ground would I do what was required of me? 

Then I was on call. I did the job. I handled whatever came.

In the action it was not as bad as the dread of the action.

And that was my second very important lesson: The anticipation is worse than the execution.  At its worst, it is ACLS.

The Person Who Taught Me How to Manage DKA

I was a brand-new intern. I had “MD” written on my lab coat and people called me “doctor” but I still had a lot to learn. 

I had been taught about how to manage diabetic ketoacidosis (DKA) in medical school. I had been a part of managing it several times. But as an intern it was different to be the person who was writing the orders. It was a whole series of things – the fluid – the timing of the insulin – the management of the electrolytes and the anticipation of the rapid shifts in electrolytes, etc. I was anxious when I did my first DKA admission in internship. 

And then I discovered a secret.

The nurses had managed it a gazillion times! As I was writing the admission orders, my patient’s nurse was there. She looked to make sure that I was not missing anything. Then she would conveniently page me every time I needed to make a change. “Doctor, would you like to do xyz?” “Why yes, nurse, I think I would like to do xyz! Can you take a telephone order for that?”

The truth is that the person who really taught me how to manage DKA was an RN.

This was my third important lesson: Healthcare is a team effort.

It is not the all wonderful and all knowledgeable doctor dictating everything that is done. The doctor is not like a puppeteer who has to control all the elements. It is a team. There are multiple layers of professionals. 

In safety we talk about the “swiss cheese” effect. That is the idea that for every error that reaches a patient, it is actually the result of multiple failures. Each failure could have but didn’t catch the error. It is as though you stacked a bunch of slices of swiss cheese and all the holes lined up perfectly to allow the error to pass through and get to the patient.

We talk about the swiss cheese effect, because the vast majority of the time, the swiss cheese effect works to our advantage. We end up doing the right thing because of the integrity of the entire team.  Gaps in one of our actions are compensated for by the others.

In training there are multiple layers. As a medical student there is the intern. As an intern there is a resident and the other interns. As a resident there is the attending and the other residents and the interns. 

But there were also nurses. The nurses trained me in ways that I couldn’t learn in books. There were respiratory therapists. They taught me about ventilators. The unit secretaries taught me how to handle the paperwork and what orders to write to get things done.  The pharmacists taught me about drug interactions and drug dosing and pharmacokinetics. The list goes on and on.

The point is that if we are smart we treasure the integrity of the entire team.  It doesn’t mean I don’t take ownership for my responsibility and my actions. I push myself to know as much as I can and to always always always do the right thing. But I do that in the context of being a human being. That means that I am fallible and will make mistakes. When I inevitably make a mistake, it is the integrity of the team that catches the mistake and stops it. It is easily corrected. It does no harm.

 The dangerous physician is the one who is arrogant and thinks that he has to do it on his own. The wise and safe clinician is the one who values and empowers the team. 

What about now?

I am so sorry for everything that is happening in Italy and New York and now on the southeast side of Michigan (and multiple other areas). They are living through very challenging times. 

The data suggests that it is coming to us too. We have been given the blessing of some extra time. It doesn’t seem especially fair that we get this and they didn’t. But who ever said that everything in life is fair? And who ever said that anything about this COVID 19 pandemic is fair? 

But we have been given time to prepare. It feels a little bit like we were given 2 extra weeks to study for final exams. In that studying it makes us feel anxious. Part of us just wants to put away our books and march in and demand our chance to take the exam. But wisdom tells us that these extra days are a precious commodity. Our colleagues in other areas would have loved to have had this time and more of a chance to prepare and plan.

And so, we prepare. We plan for redeployment. We brush up on clinical skills that we have not used in years. And we remember lessons we learned early in training:

1. ISINLAMIKAMP: It is ok to not know everything. As long as you know that you don’t know and are wiling to ask.
2. The anticipation is worse than the execution. When the time comes we can do the jobs that we are needed to do.
3. The team: We are not going into this alone. We have a lot of talented people around us. We will be going through this together.

How about for those of you non-medical readers?

1. ISINKEIWTKIDKWTB  (I’m Stupid, I’ll Never Know Everything I Want To Know and I Don’t Know What To Believe): We all feel like that sometimes. We don’t have to know everything. We just have to use our best judgment to find experts that we think are credible. At the moment,  smart people are telling us to stay home, wash our hands, and to slow the spread. That is enough.
2. Sitting and doing nothing is hard. That is human and natural. I hope it helps just a little bit to know that? Anticipation is hard to handle because you can’t just “do”. Many are going to get this illness. Some of us will just go through it without problems. Some will feel awful and then recover. We may lose some people we love. That is the essence of the dread that many of us feel. I am in no way looking forward to any of that. Maybe I should be telling everyone that the frustrated feelings they have inside at the moment are not valid? Maybe I should be telling all of you to just be happy and that you have things “good” sitting safely home at the moment? But honestly I find myself feeling the “pre-call dread.” I am back to figuring out how to deal with that. Please know this: In the worst of it, human beings – you – have a deep strength. That strength comes out when you need it. Are you up to what is going to be required of you? When the doors open and the helicopter hits the ground and the bullets are flying around you, you can and will jump out and charge forward and do whatever job is required of you. You might not like it. But within you is the strength to do it.
3. The Team: Remember that in medical education the learning comes from all directions. It is never just “top down.” Maybe in this time also we can take encouragement and support from all directions? If you have children in your life, maybe this is the time for them to teach you (to remind you) how to play? We are all in this game of life together. None of us are perfect. Fortunately, we do not have to be. Even if we are physically separated we are still going through this together. Together we are strong.

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^[1] ACLS = Advanced Cardiac Life Support

^[2] Caputo, P. (1977) A Rumor of War. Holt and Company, Henry.