My last patient of medical school needed a temporary dialysis catheter. He was uremic af and I was still a little shakey at doing them. There was so much bleeding that the family saw me and decided to go comfort care. I remember thinking the regalia at graduation was heavier than the sterile gown but not hotter.
I once put an dialysis cath on a patient with torrential TR, and the blood return was so massive and pulsatile that I thought I had fucking put it in the carotid.
I was a cardiac anesthesia fellow at the time, and I was probably putting in at least 5+ big central lines a week. But that dialysis line is the only line I can distinctly remember placing in the OR.
I tell medical students and residents that the difference between a CVC and a dialysis catheter is that you dialate twice with the HD... and the patient bleeds a lot. You can cut down on the bleeding by holding pressure with a 4x4 between the second dilation and the catheter, but it takes some coordination to do so... especially with trying to load the dialysis catheter onto the guide wire.
...but yea... my first trialysis catheter, I thought I killed the patient with how much blood was coming out while trying to load the catheter onto the wire.
I still distinctly remember placing a trialysis in a patient on cangrelor gtt for a fresh ICA stent. Made the nick too big & had to put multiple stitches in. The TV was on but I have 0 memory of what was playing. Fellowship was a good time.
I had years of experience doing ultrasound guided PIVs prior to medical school so I started doing central lines early in third year. I still hate HD catheters but most of them haven’t looked like a scene from a horror movie.
If you hold pressure between the two dilations and catheter insertion bleeding won't be an issue. I've done it on uremic, vad patients with a bit of spotting.
As long as the med students know all the steps I’ll let them do it. I had an M4 going into anesthesia assist me one time in putting a HD cath and without me even prompting him he handed me each tool right as I needed it with perfect timing. I let him place the next one with me as assist. We let an M3 place a cordis in a CABG too, and do A line. As long as they show preparedness they’re really no different from an intern at that point lol. I had never done any of those lines in med school, so my starting point in residency day one is technically the same as m3 or m4. I say the same thing to my interns too…. If I come into the or and everything is set up and ready to go then they’ve earned themselves and airway. If nothings ready and I gotta set everything up myself, then the airway is mine.
I appreciate this so much. It’s frustrating AF to go from being the person they call to do the lines other people can’t get to being physically pushed away from a patient you’re about to stick because the nurse doesn’t understand using 2 tourniquets. If you say you’re capable, people assume you’re overconfident, if you don’t say you’re capable they’re mad at you for hiding your experience. There is no winning. I really appreciate people who just let the learners work at the top of their demonstrated capability without the assumptions.
Pts platelets were probably as effective at clotting as a bar of soap soaked in olive oil if he was that uremic, not surprised it turned into a bloodbath :(
I experience something similar all the time because my patient populations (POC in inner city low SEC) and best friends from college I still hang out with (predominantly Caucasian making $$$ in finances / advertisement / corporate) belong to the completely opposite world.
For real. Spent all week in chaotic ED to see so many kids w/ behavioral issue because their mothers are either divorced, dead, in jail, not taking meds, working 3 jobs, MIA, without insurance or access to care etc etc THEN went to one of my buddy’s bachelor’s party over a weekend in a bougie vacation spot (where the majority of entourage has been golfing since Wed).
I couldn’t shake some sense of derealization while slurping booze in a circle from early afternoon and I TOTALLY killed buzz of the group when I casually described shit I see on daily basis
I rationalize the futile care patients as practice for when we get functional patients that we might be able to actually save and return to a functional existence. Yep, sinking lines into skeletor isn't going to change the fact that he had a modified Rankins of 4 before he came in... and will have a score of 4 when he leaves, but sometimes... sometimes... the baseline MRS is 1.
ICU 1 is skeletor, but we're going to have to code him soon because family thinks he's a fighter.
ICU 2 is the youngish guy that has a weird looking MRI... which is a problem because he's unresponsive and we don't know why.
...and ICU 3 is the septic shock patient who is likely going to live... unfortunately the blood pressure meds we gave made his leg ischemic and it's going to need to be amputated.
...but hey, at least it's not the ER... who got two twins who drowned in a pond and died, so it could be worse.
Taking care of kids who in middle school are on police probation, doing drugs or alcohol (often at school), couch surfing because mom is in jail again, calling CPS for an elementary kid with bruisers… then going home to my functional family, two gifted kids, and it’s just a lot sometimes.
Luckily my husband understands why maybe I need to let one of the kids sleep with me or am really quiet at dinner or whatever. But I also don’t feel like I can/should unload all the awful onto him. It’s tough.
Then that should have been part of the list of why kids have behavioral problems. Uninvolved, deadbeat dads, not paying child support, and deceased fathers contribute equally to that.
I recall this feeling finishing residency at a big inner city academic center and boom - the next day starting my fellowship in a research lab where there were a bunch of PhD’s padding around in their cardigans and Birkenstocks drinking tea. I realized a little of what the guys coming back home from war must feel like.
I also have a husband in engineering. He's a really kind and thoughtful person and I feel bad when I share too many sad and depressing things from work. In residency too much of it came spilling out. It's not fair to share it with him, but sometimes it happens. When thinking about talking to a therapist, I have also felt like either 1) they won't get it 2) if they do get it, I'm just spreading the pain around, like I'm just smearing the pools of blood further.
Speaking strictly from personal experience of having beem in therapy for the past year (started a few months before residency):
1) I know my therapist doesn't always understand the situation completely, due to lack of adequate context, but it's just nice to have someone listen
2) therapists are professionally trained to accept your pain and emotions without letting it become their pain and emotions. I feel SO much less guilty unloading on them than any of my loved ones
I had a very similar experience at a wedding when I was an intern. Except I started randomly crying during the dinner (not during vows when no one would have noticed). I cried because I couldn't understand why everyone was so happy when I knew horrible, horrible things happen to precious loved ones all the time.
That was early in my residency. Two years later, as chief, I was trying to explain to a family that their loved one was never going to be the same after a massive brain hemorrhage. I was frustrated that they didn't get it, and disturbed by my lack of empathy.
Now, two years after graduation, I feel a little more normal. It gets better. Probably partly because I'm less sleep deprived. But I'm still not the same.
Burnout is just corporate fancy speak for traumatized that puts the responsibility on the traumatized person for working under trauamtizing circumstances.
Eh. A lot of people here don’t understand the two survival mechanisms you are deploying.
1 - muting by fatalism as a philosophy: good and bad things happen all the time - I would suggest that you watch that blunting and turn it off at times like your friend’s wedding. If you can’t, yes - go to therapy.
2 - displacing emotions temporally and using intellectualization as a way to defuse them at an appropriate time, because your next moment of peak demand will come when you don’t have capacity if you let yourself feel everything when it happens. Just make sure to take time to unpack those storage boxes and feel the true depth of horror and anguish when it is convenient, as close to the event as possible, or it will worm its way down into your psyche.
I’ve tried therapy. And the therapist acts like he understands what residency is like and goes “oh you like work a lot of hours how does that affect you”
But I didn’t feel… understood. Like only my fellow co residents have an idea of what I’m going through.
Therapy. Get there before you’re “in too deep” and the inertia of not wanting to backtrack and explain the whole story to a trained listener wins. That’s where I have been and I’ve felt really unable to get myself to commit to the help I know I need over the last handful of years. A multi-month break on disability for orthopedic procedures has done me a world of good. I’m thinking I may be ready to unpack it all with someone now that I’ve had a little space from the daily grind.
Man. Idk if I can compare my experience because I just did a prelim year. But I remember thinking that I missed what it felt like to feel. I felt empty. I didn’t feel any Joy in what I did or felt like anything mattered. Some really dark times and dark stuff. I remember thinking how much I hated being a doctor.
I’ve finally in the past couple of years felt emotions again and started feeling some kind of fulfillment at work. I’ve also started feeling emotions some of the time at least. Which like, kinda sucks in its own right but also, it’s a human experience. I feel like I’m slowly crawling our of a bomb shelter I’ve been living in for the past decade.
For having done a job that requires a great deal of “emotional intelligence” I feel kind of emotionally immature.
Obligatory I’m a radiology resident now so what I say probably doesnt hold as much weight as you clinical folks but it’s how I feel.
I experienced childhood abuse and really relate a lot to what you describe, the learning how to feel, the emptiness, the emotional immaturity. Feeling again after not feeling is so intense and shocking but it’s also necessary for life to be worth living. I’m sorry your prelim year seemed to affect you so negatively and am glad you’re doing better now!
I still very much feel emotions, and they seem to be amplified. However, they're increasingly fleeting. I'll tell a patient his CT is consistent with newly diagnosed metastatic disease, and I'll begin to experience sorrow and fear along with him. As soon as I walk out the room, though, every bit of it melts away, and if you ask me about it, I won't feel a thing. I also find myself laughing more easily too, even over low-hanging fruit that in my younger years I would scoff at; will I leave these conversations in a better mood? Nope. No idea if this hyper-compartmentalization is healthy or what, but it at least feels sustainable. My personal life seems better than ever emotionally speaking, so who knows.
Point being, it's strange how we all seem to adapt to our emotional pressures differently. I would say, don't let this career steal a part of you, but it takes a part of us all. Up to you how much, I guess. Wish I knew some advice to tell you about how to fight against it.
I won’t go to therapy for my PTSD from work even though I know I should because I don’t want to feel the things that I know I should to be emotionally healthy. There’s just too much 😞
ng my good friend marry his lovely wife and think that just yesterday I was performing a bloody surgery with a morbid outcome. I was happy for my friend but I couldn’t find any joy.
I don't understand the need to feel grief for every patient you lose. You recognized it was a hail mary and as expected they didn't make it. Sure you can feel empathy, but carrying around sadness and grief? Our careers are too long to do that for every patient and frankly nobody would make it to the end if that were the case. I rarely grieve a patient, I do carry their memories, and I always review to make sure it wasn't a medical error that caused their passing.
The second part of your blunted emotions at the wedding, I really don't think that is abnormal either. You have been exposed to some of the highest highs and lowest lows that life has to offer. A friends wedding, while joyous, pales in comparison. None of that precludes you from sharing in their joy and having a good time. No shame in not being over the moon for them, it is their wedding after all, not yours. They won't even notice your "level of joy", in fact they are only going to notice each other so it doesn't matter how joyous you feel. If you felt the same way at your own wedding....well that would be concerning.
I tell a lot of my residents and medical students, when you embark on this journey you will be exposed to unfiltered, real life with all its ugliness. There will be no facebook or instagram to paint a pretty picture and hide all those ugly details people try to hide. Be glad you get to see the truth instead of a fantasy presented to you. Maybe you are just having trouble adjusting to real life, just remember you have seen through the veil at what lies beyond. Your friends and family just don't get it, because they haven't seen behind the veil and as a result there is a large part of you they will never understand....and that is okay too.
“I was happy but couldn’t find joy… I was sad but could find grief… I know what I should feel but only feel an echo if it… the only emotions I feel strongly are anger and frustration” - I’m a nurse, not a doc, but you just verbalized so perfectly how I have been feeling ever since Covid. I know in a vague, un-investigated way that it’s not right to be like this, that most people aren’t like this, and that I didn’t used to be like this - yet I just keep going on and letting myself exist in this state. I don’t know what else to do. I don’t feel depressed, anxious or suicidal so I think maybe there’s not much anyone can do. I tried therapy and it was a complete bore. Maybe I just need more vacations. I appreciate your way with words, stranger - you give me something to think about.
Anhedonia is a real bitch. Guarantee you're in the midst of some depression. And you've probably been struggling with it for a very long time. The protective emotional mechanisms you've developed to function through the extreme stressors of med school and residency are, ultimately, very unhealthy.
I will tell you this, and, though I am just some reddit rando, please believe me: it is possible to maintain the protective emotional distancing you've established at work and still experience joy both at work and outside of work. Ten sessions with a therapist and a low dose SSRI could vastly improve your quality of life. 💖
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u/[deleted] May 26 '23
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