how can i learn to let it slide?

[GoodMonkey]

maybe i'm just a high-strung person.

i don't know what it is anymore, but i find myself getting sooooo angry with the complete asinine BS that i have to deal with. viscerally, shakingly angry.

i have 40 cross cover patients and a nurse calls me with a request for a patient and she doesn't even know what service the patient is on and doesn't know the patient's name, just a room number. no i will not see the patient until you can tell me what service the patient is on and what their name is.

i get called 4 times for temperature >101.5 on a cross-cover patient who is being appropriately worked up (pan-cultured, filmed, scanned, started on empiric abx, etc) and the nurses decide to call the senior resident because they weren't comfortable with my order for "tylenol and cooling measures" [exactly what i was signed out to do, btw, as the team knows about the fever and they're working it up currently.] so they page my senior resident [who, of course, comes back to me with WHY THE HELL AM I GETTING PAGED FOR CROSS COVER PATIENTS THAT IS AN INTERN'S JOB.]

an ED resident looks at patient from across the room and say "yeah, that looks like a trauma" and pages it out as a trauma before even seeing the patient, and then comes back about an hour later and says "so did you work that patient up? what did the scans show? is the trauma workup done?" come the **** on can't you work up your own patients? really? the woman just tripped and fell on a sidewalk - is this really a trauma patient or can the emergency department handle the workup on their own?

consult pager goes off - urgent care wants us to see someone for belly pain when they haven't even drawn labs on the patient. then they get angry when they're asked to please at least get a WBC first before calling a surgical consult.

and someone ate my treat that i had saved for my on-call night.

i'm finding myself increasingly unable to just let things go and i am getting miserable and incredibly homicidal.

so whatcha think? boxing? yoga? rocking and peeing in the corner? i'm starting to take all this negativity home with me all the d@mn time and it's making me a really miserable person. yeah - bottom of the totem pole and **** slides downhill ... i am having such a hard time just shaking things off .....

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[Coastie]

Sounds very similar to my year.

maybe i'm just a high-strung person.

i don't know what it is anymore, but i find myself getting sooooo angry with the complete asinine BS that i have to deal with. viscerally, shakingly angry.

i have 40 cross cover patients and a nurse calls me with a request for a patient and she doesn't even know what service the patient is on and doesn't know the patient's name, just a room number. no i will not see the patient until you can tell me what service the patient is on and what their name is.

i get called 4 times for temperature >101.5 on a cross-cover patient who is being appropriately worked up (pan-cultured, filmed, scanned, started on empiric abx, etc) and the nurses decide to call the senior resident because they weren't comfortable with my order for "tylenol and cooling measures" [exactly what i was signed out to do, btw, as the team knows about the fever and they're working it up currently.] so they page my senior resident [who, of course, comes back to me with WHY THE HELL AM I GETTING PAGED FOR CROSS COVER PATIENTS THAT IS AN INTERN'S JOB.]

an ED resident looks at patient from across the room and say "yeah, that looks like a trauma" and pages it out as a trauma before even seeing the patient, and then comes back about an hour later and says "so did you work that patient up? what did the scans show? is the trauma workup done?" come the **** on can't you work up your own patients? really? the woman just tripped and fell on a sidewalk - is this really a trauma patient or can the emergency department handle the workup on their own?

consult pager goes off - urgent care wants us to see someone for belly pain when they haven't even drawn labs on the patient. then they get angry when they're asked to please at least get a WBC first before calling a surgical consult.

and someone ate my treat that i had saved for my on-call night.

i'm finding myself increasingly unable to just let things go and i am getting miserable and incredibly homicidal.

so whatcha think? boxing? yoga? rocking and peeing in the corner? i'm starting to take all this negativity home with me all the d@mn time and it's making me a really miserable person. yeah - bottom of the totem pole and **** slides downhill ... i am having such a hard time just shaking things off .....

 

[Winged Scapula]

Its a common phenomenon and it either gets better as you progress up the ranks, or it doesn't. Most of the time its just different fecal matter.

As an attending, you'll have to deal directly with patient demands, the worst of which seem to come from physician's wives who try and work the system. A surgeon I know recently had a patient who called the OR scheduling desk herself to see if her case could be squeezed in (like they were lying to her) and then calls the office and demands that the office cancel a smaller case to get her in sooner.

At any rate, we've all been there and have used various coping mechanisms to deal. Some drink (obviously not healthy), overeat, have lots of indiscriminate sex, etc. One former intern of mine actually used the gym as a way to destress...very healthy, but something that never worked for me. So try and find something which not only relieves the stress but doesn't hurt you or anyone else in the process (I don't recommend venting to an SO unless they are also in medicine, and even then you should think twice about doing so). The BS will continue throughout your practice and you'll have to find a way to manage the stress it causes you.

 

[gasnewby]

maybe i'm just a high-strung person.

you're not. the stress is enough to make anyone insane.

i don't know what it is anymore, but i find myself getting sooooo angry with the complete asinine BS that i have to deal with. viscerally, shakingly angry.

have you considered a beta blocker? your heart rate won't go up, anyway. it will blunt some of that sympathetic response. try inderal 40mg

i have 40 cross cover patients and a nurse calls me with a request for a patient and she doesn't even know what service the patient is on and doesn't know the patient's name, just a room number. no i will not see the patient until you can tell me what service the patient is on and what their name is.

"are they bleeding or coding? No? ok, please page me back with the patient's name and service and i'll be more than happy to help you. goodbye."

i get called 4 times for temperature >101.5 on a cross-cover patient who is being appropriately worked up (pan-cultured, filmed, scanned, started on empiric abx, etc) and the nurses decide to call the senior resident because they weren't comfortable with my order for "tylenol and cooling measures" [exactly what i was signed out to do, btw, as the team knows about the fever and they're working it up currently.]

make sure they understand why you aren't "working up the pt." they go by pattern recognition. if there's a temp, knee-jerk is response is to do a fever w/u. they aren't going to check the computer for the guy's last cxr or to see if he's been cx'd in the past 24 hrs. i know it is annoying but they're trying to make sure you're doing the right thing for the patient. if they really keep paging you, have the nursing supervisor paged and ask nicely if they can help you communicate with the floor. they don't like getting bothered either.

an ED resident looks at patient from across the room and say "yeah, that looks like a trauma" and pages it out as a trauma before even seeing the patient, and then comes back about an hour later and says "so did you work that patient up? what did the scans show? is the trauma workup done?"

this is a resident talking to you like that? wtf?! i prefer the withering look and silence. they soon slink away. or "what did you think of the CT scan? you seem really interested in the patient...you didn't look at it? oh, well check it out and then let's talk. it's really cool." they'll be way too lazy to do this.

consult pager goes off - urgent care wants us to see someone for belly pain when they haven't even drawn labs on the patient. then they get angry when they're asked to please at least get a WBC first before calling a surgical consult.

my favorite question: "what makes you think the patient needs an operation?" and for fun there's always "is he heme-positive?...well please check your patient, it's very important! jeez, did you even examine him?"

like the boss said, most residents binge drink, overeat, and sleep around.

read through the other intern threads
"stupidest thing a nurse has ever paged you for"
"call stories"

you're not the only one going through this. it's a really crappy rite of passage. it will always be stressful but you learn to deal with it better every month. try to keep ahead on call nights with your caffeine intake. the more tired you are, the less self-control you have and the more likely you'll snap on some nurse with a chip on her shoulder.

 

[Pir8DeacDoc]

At any rate, we've all been there and have used various coping mechanisms to deal. Some drink (obviously not healthy), overeat, have lots of indiscriminate sex, etc.

Well if the gym didn't do it for you, then you're either a boozer or a touch promiscuous. Or maybe both?!


NICE

 

[GoodMonkey]

make sure they understand why you aren't "working up the pt." they go by pattern recognition. if there's a temp, knee-jerk is response is to do a fever w/u. they aren't going to check the computer for the guy's last cxr or to see if he's been cx'd in the past 24 hrs. i know it is annoying but they're trying to make sure you're doing the right thing for the patient. if they really keep paging you, have the nursing supervisor paged and ask nicely if they can help you communicate with the floor. they don't like getting bothered either.

oh i went through it with them a few times, even pulled up the culture results and labs and read them back to the nurse. (cultures were drawn on this guy's watch the day prior and he forgot they were done.) i actually spent a good deal of time on the phone (while i was in the ED CT scanner with a trauma patient on the table) explaining why i - as the cross cover and as a physician in general - wasn't going to do anything further than what is already being done.

and they called my junior and senior anyway.

*sigh* no win.

 

[Winged Scapula]

Well if the gym didn't do it for you, then you're either a boozer or a touch promiscuous. Or maybe both?!


NICE

Maybe, maybe.

Nah...I hardly ever drink...just don't really enjoy the taste of it...and I had an SO all through residency. One was enough.

I like to destress by reading trashy magazines like People, US, Star, etc., and reading about celebrities lives and how they've F'd them up, despite fame, money, beauty, etc. I also watch a lot of movies when I have time (esp Zoolander...makes me laugh after all this time).

 

[Winged Scapula]

oh i went through it with them a few times, even pulled up the culture results and labs and read them back to the nurse. (cultures were drawn on this guy's watch the day prior and he forgot they were done.) i actually spent a good deal of time on the phone (while i was in the ED CT scanner with a trauma patient on the table) explaining why i - as the cross cover and as a physician in general - wasn't going to do anything further than what is already being done.

and they called my junior and senior anyway.

*sigh* no win.

Its early in the year. They'll learn to trust you but by then there will be a new intern crowd.

 

[kamehame]

It's OK to get angry, just as long as you make sure the other person goes home with a large ulcer in their stomach, as well. See, everything you said in your post is due to everyone else being lazy and trying to make you do their work. It's that simple. We can dance around the issue and pretend there are other reasons, but that's to spare feelings.

If a nurse doesn't know the patient's name or vitals or any information you want, you simply tell (not ask) her to get it for you and then wait. If she hangs up, you report her because that's reasonable information to request. It's that simple. She won't learn to have the information ready because she's not that smart, but she'll learn that she'd better get it for you when you want it.

If you get paged for a febrile patient and they won't accept "do nothing," then make them do everything. Do a complete work-up, throw in an EKG, have them do overnight chest PT, and so on. If you dislike that approach and they call your senior and your senior calls you, you go to the floor, sit in front of the nurse, and answer the phone in front of her. You talk about how she doesn't know anything and everything is being done appropriately. At the end, you just laugh and go, "yeah, she is" (this is the best because she then assumes the senior is saying she's a ******, but she doesn't know).

You can't do much about the ED because they're an instutition of laziness. That's their entire culture. The best you can do is bounce work back at them. If you want scans, tell them to get them. They have to because it's still "their" patient. If they ask you for the read, you just tell them to call Radiology and you'll see the patient again once the read is available (obviously if this is not an emergent case). If you're not busy, you can help them out, but if they're just scutting you out you can return the favor. The biggest incentive for them is just for you to say "we'll figure out what we want to do once we have the information" and leave it at that.

 

[Tired]

RN: I'm calling about Mr. Jones.
Me: What service?
RN: Um . . . General Surgery.
Me: Which Gen Surg team?
RN: I don't know.
Me: Well, I have five pages of Gen Surg patients, and I need to know which team.
RN: Sorry, our board only has one color for Gen Surg.
Me: Then look at the orders which list the team, and call me back.


Here's what I'm learning: There are two irritating phone calls. One type is just irritating on a personal level. I'm getting better at letting these go. Then there are the type that are actually potentially threatening to patients. These I will not let go. Never.

A few months ago I got trashed by Apollyon for being too angry and hostile and rude. He had something of a point.

But I still believe that when meds aren't being given, or the patient isn't being taken to CT scan, or abnormal vitals aren't being reported, then you should never ever let it go. You have a responsibility to pursue and correct these issues.

Some of the most liked interns in my hospital are the ones I hate signing out to, because anything that gets done (or doesn't get done) is just fine with them. In my mind, those are the worst interns around.

 

[kamehame]

The people who never get angry are the ones who don't really care. They're not better people, they're much worse. They're like bureaucrats. They've learned how to excel in office politics and get along and they also happen to not do much of anything around the hospital.

 

[gasnewby]

i don't even bother answering a page unless i'm by a computer and logged in (if you have computerized orders). you don't have to flip through a bunch of sign-outs, and half the time, the answer is "tylenol prn (or fill in the blank) was ordered four days ago. anything else?" you can end the call in 15 seconds and avoid a lot of frustration.

 

[gasnewby]

weekend ER consult:

ER: we have a 54 year old female down here with abdominal pain. she's already been to CT scan. she's being admitted to medicine. blah blah blah.

i look up the labs, all NL. "and...you want a surgery consult?"

ER: yes

i'm pulling up the CT while we're talking..."ok, what does the CT show?"

ER: i don't know. i TOLD you she's being admitted to medicine!

"i don't care that she's being admitted to medicine. this CT was done almost two hours ago. you don't know the read??"

ER: what do you want me to do, there's no read on it.

"the radiology residents have pagers, don't they? the reading room is down the hall from the ER, right? she has completely normal labs and a normal CT, from what i can tell. why does she need a surgery consult?"

ER: blah, blah, blah (i forget what was said, but it was really whiny and annoying)

"ok, i noticed you didn't get LFTs, amylase/lipase or a UA. how about getting those, as a STANDARD WORKUP for abdominal pain"

ER: well, i don't think she needs them

"i don't care if you think she needs them! get them!"

ridiculous. this consult goes way down on my priority list. eventually i make my way to the ER and ask the admitting medicine team if they really want a surgery consult, in light of her normal wbc/ chem7, normal CT, and hey guess what, +UA and elevated ast/alt! and btw, there was a memo on the CT stating that it was normal when the ER resident called me, but i was too distracted and PO'd to notice.

the medicine team thankfully decide it's not needed and say they will call if they have questions. the ER resident didn't even bother documenting that surgery was called. hopefully too embarrassed, but probably too incompetent and lazy.

BS, but it did get my heart rate up.

 

[kamehame]

ER: what do you want me to do, there's no read on it.

You made the mistake of actually trying to reply reasonably. You should have just paused for a long time and then said, "yeah, what was I thinking, that's an unsolvable situation" and hung up.

 

[GoodMonkey]

i don't even bother answering a page unless i'm by a computer and logged in (if you have computerized orders). you don't have to flip through a bunch of sign-outs, and half the time, the answer is "tylenol prn (or fill in the blank) was ordered four days ago. anything else?" you can end the call in 15 seconds and avoid a lot of frustration.

the gang pages come more often than not when i'm down in the ED bending over and taking it on trauma call (when i also have consult responsibilities and all the cross cover.) i'm at a gun-and-knife club county hospital. no luxury of the above. alas.

 

[Blade28]

To the OP, believe me when I say that we all feel your pain - internship and junior residency can be particularly brutal in General Surgery. In addition to the advice already given in the thread, do you have a good outlet for talking about these work issues? A close friend, significant other, close family member, roommate, co-intern/co-resident? You'll find that a significant portion of your social life (at least early on during internship) consists of cathartic venting over dinner/drinks, and while too much can be a self-destructive thing, we all need to destress.

I agree that sports, exercise, etc. is helpful to blow off steam. Or sometimes just having a glass of wine and vegging out in front of the TiVo helps too.

 

[Faebinder]

Its a common phenomenon and it either gets better as you progress up the ranks, or it doesn't. Most of the time its just different fecal matter.

As an attending, you'll have to deal directly with patient demands, the worst of which seem to come from physician's wives who try and work the system. A surgeon I know recently had a patient who called the OR scheduling desk herself to see if her case could be squeezed in (like they were lying to her) and then calls the office and demands that the office cancel a smaller case to get her in sooner.

At any rate, we've all been there and have used various coping mechanisms to deal. Some drink (obviously not healthy), overeat, have lots of indiscriminate sex, etc. One former intern of mine actually used the gym as a way to destress...very healthy, but something that never worked for me. So try and find something which not only relieves the stress but doesn't hurt you or anyone else in the process (I don't recommend venting to an SO unless they are also in medicine, and even then you should think twice about doing so). The BS will continue throughout your practice and you'll have to find a way to manage the stress it causes you.

Try this one...

A radiologist from a different hospital called my PD straight to the OR and told him he is coming in and he is getting admitted under my PD's service and that this time he thinks he actually needs the NGT (and wants to put it in himself like he did the last time before we+he discharged him).

 

[gasnewby]

we've had PATIENTS do that too (self-administered ngt). didn't believe it until i saw it.

 

[Tired]

we've had PATIENTS do that too (self-administered ngt). didn't believe it until i saw it.

I once saw a drug addict put down her own NG tube.

Then I saw the xray, and was able to explain to her why she developed a cough right after.

 

[GoodMonkey]

To the OP, believe me when I say that we all feel your pain - internship and junior residency can be particularly brutal in General Surgery. In addition to the advice already given in the thread, do you have a good outlet for talking about these work issues? A close friend, significant other, close family member, roommate, co-intern/co-resident? You'll find that a significant portion of your social life (at least early on during internship) consists of cathartic venting over dinner/drinks, and while too much can be a self-destructive thing, we all need to destress.

I agree that sports, exercise, etc. is helpful to blow off steam. Or sometimes just having a glass of wine and vegging out in front of the TiVo helps too.

thankfully (no offense meant,) i'm only gsurg-ish for one year. i'm a categorical ortho resident ... when i see some of the **** that even the upper level gsurg residents take around these parts, i am amazed at the tenacity they have to stick it out.

my poor bf - yes, i have a venting outlet. i try to keep it to absolute essential vent, though, as nice people in non-medical fields could never deal with the endless stream of BS that would come from my mouth should i vent about everything i seethe about regularly.

my shameless outlet of late has been playing this glorious mind-suck while drinking a beer: http://www.mylifetime.com/games/lifetime/game.php?game=tiara that, and i run. a lot. i've taken to biking to work more often (it's 6 miles and i'm in socal - no weather excuse for not doing it) for a multitude of reasons: eco-friendly, a work-out, and stress relief.

 

[Blade28]

Sounds like you have some good mechanisms for dealing with the daily grind and BS of a tough internship.

But as always, feel free to vent here on SDN!

 

[Tenesma]

as an intern i had most of my patients place their own NGT - there was SOOO much less fighting - all I did was spray benzocaine on the back of their throat and place some phenylephrine gauze in their nostril --- lubed it up really good, explained to them how they should do it... and while they all tear up a bit, it usually goes down quite well...

the ones that are tough are the demented severe parkinson patients ---

i agree with phone calls... but don't do any work... let them do all the work...

also figure out ways to keep the patient and the RN safe and happy until the day-team comes back in...

 

[gasnewby]

as an intern i had most of my patients place their own NGT - there was SOOO much less fighting - all I did was spray benzocaine on the back of their throat and place some phenylephrine gauze in their nostril --- lubed it up really good, explained to them how they should do it... and while they all tear up a bit, it usually goes down quite well...

do you have them drink while they're doing it or just tell them to swallow it?

do you make the phenylephrine gauze? how? i like that idea, especially if they're anticoagulated.

interns, it's pretty late in the game but if you're cross-covering and you get a call that the ngt "fell out," don't automatically replace it! every year we get somebody s/p gastric bypass or billroth who gets the ngt replaced by a busy intern. let your upper year poke it through the fresh anastomosis!

 

[Pir8DeacDoc]

interns, it's pretty late in the game but if you're cross-covering and you get a call that the ngt "fell out," don't automatically replace it! every year we get somebody s/p gastric bypass or billroth who gets the ngt replaced by a busy intern. let your upper year poke it through the fresh anastomosis!

Agree with above completely. It happened once at my place last year. Luckily the patient didn't perf. Uggh that would have gotten ugly.


Also, if you can (i.e. patient able to answer) ask about past surgical history. We had a very competent fellow who attempted to place an NGT in a patient who had previously had transsphenoidal surgery. The patient became apneic and died. Not the outcome you hope for when trying to decompress a stomach or relieve some nausea.

 

[gasnewby]

god, that poor fellow...i'm sure he carries that around.

just thought of another disaster narrowly averted. i almost dropped an ngt to lavage a guy with ugib, hb~6. turns out he had esophageal varices. not such a smart idea unless you have a blakemore at the bedside and know how to use it! my chief stopped me, luckily. let GI get out of bed and scope the guy. the ngt's not going to stop his bleed anyway.

 

[Blade28]

just thought of another disaster narrowly averted. i almost dropped an ngt to lavage a guy with ugib, hb~6. turns out he had esophageal varices. not such a smart idea unless you have a blakemore at the bedside and know how to use it! my chief stopped me, luckily. let GI get out of bed and scope the guy. the ngt's not going to stop his bleed anyway.

That's a tough one. It's so easy to reflexively think "NGT lavage" when you see an upper GI bleeder.

 

[Doowai]

and someone ate my treat that i had saved for my on-call night.

Damn, the straw that broke the camels back. Time to go postal.