Entry 3

Entry 3

Entry 3
A weeklong electronic journal.
Feb. 11 2004 5:04 PM

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Fighting Infection for JCAHO
Fighting Infection for JCAHO

We're all on edge today, anticipating the hospital review. Inspectors from JCAHO, the Joint Commission on Accreditation of Health Care Organizations, are officially here. They're crawling through the halls, rifling through drawers, and stopping us at random to quiz us on regulations. The hospital higher-ups have been anticipating this for months, peppering our inboxes with daily reminders:

3 Days until the JCAHO survey! Relax. Don't be alarmed if you don't know the answer to a question posed by a surveyor. Simply explain to him or her that you would ask your supervisor for the answer.

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It's hard to pay attention to much when you're in the middle of the unit and alarm bells are screaming (signaling a patient is unstable), patients stop breathing, and you haven't slept for 30 hours. We worry about intubating patients with respiratory failure, shocking people in cardiac arrest, or supporting families who are letting go of their loved ones. These are our emergencies, and everything else—from fire drills to waste disposal—we learn on the fly, when we need to.

2 Days until the JCAHO survey! Be Courteous. If you are too busy with patient care responsibilities when approached by a surveyor, politely ask if they could come back in a little while. However, keep in mind that he or she will indeed come back.

The review used to be a bureaucratic thing—a few suits combing through the books—but now the inspectors are following our patients from admission to discharge, watching us every step of the way. It's particularly tense this year because of the new regulations limiting resident work hours. Hopkins nearly lost their accreditation because they made residents take call every other night in the unit. Technically, we are only allowed to work 30 hours straight, take call every third night, and work a total of 80 hours in one week. It's hard to believe that 80 hours, nearly twice the average American workweek, is reform, but it's amazing how challenging it is to implement. There are a fixed number of residents and a growing patient population. Add to that physicians' inherent perfectionism, and it's a miracle we ever leave the hospital. Most programs are trying to comply—switching call schedules, rearranging teams, and hiring more physician assistants—but it remains an uphill battle. Ingrid and I have fallen asleep in some strange places this year—in the shower, in restaurants, on rounds, and once, while driving home. Fortunately, I awoke before a major accident could occur, when I felt the car bump the median.

1 Day until the JCAHO survey! Final Prep. Do one last scan of your work area for general cleanliness, clutter (old newspapers), etc. Also, remember to take down and put away all posted JCAHO prep materials and checklists.

Reading a cath film
Reading a cath film
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As interns working in the cardiac intensive care unit, we're under special scrutiny. At dawn, the unit fills with cleaning carts and men vigorously vacuuming the corners and behind the refrigerators. The unit is scheduled for a visit at 8:30 a.m. As rounds start, we all look around: It's never been this clean. It feels like we're getting ready for a persnickety set of in-laws.

In the middle of rounds, one of the nurses snaps at me for leaving my papers in her workspace. "I hope you get cited by JCAHO for being messy," she says. Before internship, Ingrid and I were warned about working with nurses and told that many are sexist and treat female physicians worse than their male counterparts. Despite this, my experiences have been overwhelmingly positive; the unit nurses are truly exceptional. Almost daily I turn to them to ask: "What do you think? What do you usually do when this happens?"

Medicine is fundamentally a team endeavor. I'm convinced that half of us would have been professional athletes if we'd had the physique for it. Each person on the team has a special role: The attending physician (aka the "attending") is the coach, running the show; the fellow, who is completing specialty training after residency, acts as the assistant coach; the resident is the quarterback making the calls; and the interns are the lineman, blocking for the rest of the team—all guts and no glory. In cardiology, this is particularly true—it's a testosterone-driven field, as reflected by the clinical trial names—GUSTO, TACTICS, TARGET, COMET, and CADILLAC to name a few.

Education happens at every level. As interns, we learn from the nurses, each other, the residents, the fellows, and our attending. The formal teaching usually comes from the coaches, but a lot of the key learning happens at night when we're alone with the residents on call. That's when we learn how to perform procedures, manage critically-ill patients from minute to minute, and interact with patients and their families. It sometimes feels like a strange sleepover party when we're all up together, taking care of patients and wandering the halls late at night. As the hour gets later and later, more levels of authority peel off: The attending usually leaves by 8 p.m., the resident goes to bed whenever the patients are stable, and we, the interns, are left alone with the nurses to manage the unit. There's always backup (from the residents, fellow, and attending) available 24 hours a day, but we try to handle things independently; we have to learn, because someday we'll be the coach calling the shots.

Raj and me
Raj and me

Every few weeks the teams change—attendings "go off-service" (they return to their labs and clinical research), residents switch to other specialties, and we swap positions with our co-interns. Each team has a unique feel, a gestalt made up of individual personalities, and once a team dissolves it's never the same; the magic is all memories, and we each move on. Today our residents change again, and I am sad because I've spent the past two weeks working with a wonderful resident named Raj. I met him before internship started because he's close to my best friend from high school. At the time, we were both medical students, and he wore a short white coat that looked like a flak jacket, covered with buttons. He had a pin for every cause—HIV, breast cancer, domestic violence, and even intersexual rights (for children born with ambiguous genitalia). Now he's lost the white coat, but he still wears his heart on his sleeve and treats every patient like his own parent. I'll miss working with him. My next resident has big shoes to fill.

Ingrid Katz and Alexi Wright are physicians completing internships at a major teaching hospital in Boston. They are currently rotating through the cardiac intensive care unit and are the authors of Interns' Diary, an online journal.