Black cloud, white cloud

[nightengalesknd]

The PICU attending yesterday says he doesn't believe in "white clouds" even though he is known for being one. He believes we make our own luck by our own thinking. I'm known as a white cloud as well, and as reasonable as it seems, there's a certain flaw in his logic where my luck is concerned. Because there's a reason in medical school I called my cloud an "on call jinx" - I don't like it! And I refuse to believe my subconscious is so twisted that I've been doing this to myself for two and a half years.



The "black cloud" is the resident (or less often, attending, nurse or student) who makes bad things happen. He or she does not do this through lack of competence. No, he or she does this just by showing up. The black cloud is the resident who pronounced four NICU babies dead one month. (The white cloud may never have done so. The white cloud may never have even been in a code.) The black cloud is the resident who almost never gets to sleep on call, who admits the sickest patients, who routinely gets seven or eight admissions on a call. The white cloud may get more sleep on call than she does at home. The black cloud's clinic is full of complex patients who need three referrals apiece. The white cloud's clinic is full of patients who don't show up.

What finally got me to believe in the power of the black cloud was one resident I worked with last year. One month she was working in the clinic but covering call in the PICU every fourth night (as I am doing this month.) She admitted a patient one night who had fallen and had a head injury. Over the next few days, the PICU team took care of the patient while she was in clinic. Early in the afternoon the day of her next call, she looked on the computer and noticed that patient was still admitted. She had thought he would have been discharged by then, and said to herself, "I wonder if he's having seizures." About an hour after that, the child, who had never had a seizure before in his life, before or after his fall, had a seizure.

You have to give some serious thought to someone who can cause a seizure from another building, just by thinking about it.

In medical school, about halfway through third year, I developed what I called a "jinx." I was doing internal medicine and taking call every fourth night. I was supposed to admit patients when on call and then follow those patients I admitted through the rest of my rotation or until they were discharged. It's a good teaching technique. Whoever does the initial history and physical of a patient knows that patient best. That student or resident gets the story "fresh" and has the chance to think through a plan of diagnosis and treatment. I loved to admit patients.

My first month on internal medicine was just slow. My second month, though, was when the jinx became evident. I had something like five consecutive calls where I only did three admissions and accepted two patients in transfer. When you accept a patient, from another service, most of the thinking and diagnosis has already been done. Sure you get the joy of taking care of a patient, but it just isn't an adequate substitute for doing the admission yourself. But what could I do? When I took call, there were just no patients. I began to refer to this as "patientopenia," where "-penia" means a deficiency of some sort.

Insult was added to injury when I started asking how my classmates' call went. I got one of three answers: Great I didn't have admissions and got to go home early! Great, I got to do X procedure! Terrible I got admissions and had to stay the whole time.

They got admissions and didn't want them. I wanted them and didn't get them. You see why I resent the implication I'm doing this to myself?

After internal med I did pediatrics, three weeks in clinic, two inpatient, one in the nursery. Clinic was slow because there were attendings on vacation, so I mostly followed the residents around. I get to the inpatient unit on a busy children's hospital and - shut it down. Oh, there were patients, all right. But not during the two nights I was permitted to take call. Due to transportation reasons, I even spent the night on call instead of staying until 10 like the other students, and still didn't get patients. Oh, one night they did get a patient at 2 in the morning, but the resident disregarded my before-bed pleas to call me if there was an admission. I was required to be observed doing one admission as part of the rotation and finally did get one - at 2 PM my last day of the rotation.

Next I did rehab medicine. Part of studying rehab medicine is watching a patient progress over time. I had a 6 day rotation and was given a patient to follow the first day, with the expectation that I'd get to admit another patient and follow them as well for the rest of my time there. The spinal cord injury service got one new patient during my six days - 3 PM on my last day.

Neuro didn't have that many patients on service either, and my experience there was compounded by the residents trying to send me home at 1 PM every afternoon. I broke down in tears and begged them to let me stay. There weren't very many patients, but at least I could have spent more time with the patients we had?

The jinx wasn't too bad for my electives senior year, but did come out in full force duirng my inpatient sub-I. Admittedly I did this rotation in a children's ward that only had 7 beds, but the maximum census the entire month I was there was four. And this was November, so excuses about low-census times of year didn't hold water.

I held out hope my jinx would break when I left medical school and started my residency. It was hard to tell the first few months. The nursery census was low but not alarmingly so. I got admissions during my NICU calls although others often got more. There were a couple of call nights I got 5 or 6 hours sleep.

Clinic is what clinched it though. Now it didn't help that my first month in clinic, there were six residents. There's enough of a workload for two busy ones or three relaxed ones. I was desperate for patients. But it was August and everyone said clinic is slow in August. My second month of clinic there were again six residents. And it was March. Kids get sick in March. Except in our clinic.

I've had my busy calls and my busy times. I got seven admissions and no sleep two calls in a row in June, and that's with laryngitis. I've had NICU shifts where I got two admissions during a required lunchtime lecture. And I've had clinics where I didn't have a chance to sit down for hours. But overall, I've been "lucky."

So far as a senior, I've covered two calls in the NICU and two in the PICU. The first NICU call, we had no babies until 5 AM and I got a full night's sleep. The second one, we had three deliveries of four babies between 4 and 7 AM, so things were bonkers for awhile but still, I got a signifigant amount of sleep. My first PICU shift I got one admission. My second PICU shift, I got none.

Well I'm in clinic this month, with only 4 residents instead of six. I've seen up to four patients in a day, which is sort of like molasses in January. Thing is, though, we have a scheduling snafu tomorrow. While there are four residents to see acute patients most days this month, on Thursdays three of us have our own clinics and one has to attend required lectures. We tried to get some help but for tomorrow, there aren't a lot of choices. One intern (and she's an August intern, remember) and I, with the help of the attendings, are suppose to cover our own patients and any acute patients who arrive. It would be a good day to have no-shows and a generally low census.

So here's the question. Will my White Cloud Superpower work tomorrow if we count on it?

Comments

[mst3kforall.livejournal.com]

So here's the question. Will my White Cloud Superpower work tomorrow if we count on it?

I hope so! I am always afraid about things like that, though.

My first thought was that perhaps you tend to get scheduled on nights that are not the most statistically active nights for people to have problems... but if I correctly understand "every fourth day", it would cycle through all the days of the week (e.g. if Monday first, then Friday, Tuesday, Saturday, Wednesday, Sunday, Thursday, Monday (lather, rinse, repeat)

[nightengalesknd.livejournal.com]

Yes "every fourth night" does cycle through like that. It's so no one gets stuck with all the weekends, and every fourth night is vaguly humane and takes only 4 people. Every second night is illegeal, every third night is inhumane, and every fifth or more means finding more people to help.

And my first call in the PICU was a "full moon Saturday night," which, if we're going to believe in superstitions, is known for being bonkers. The ER was bonkers, but we only got one admission from there. I think it's me.

[aries11.livejournal.com]

If not tomorrow, then I hope your White Cloud moment comes soon. :)

[nightengalesknd.livejournal.com]

We need it to work tomorrow! After that it can go rain somewere else. . .

[queenlyzard.livejournal.com]

I find it fascinating how every profession and every workplace has its own particular traditions and mythologies.

[nightengalesknd.livejournal.com]

Yup. I'm actually very superstitous at work. For instance, never say the word that begins with "q" and rhymes with "diet" in the hospital unless you WANT all hell to break loose!

[queenlyzard.livejournal.com]

*grins* I find it entertaining to see that streak of superstitious behavior in someone as down-to-earth and reasonable as you.

[nightengalesknd.livejournal.com]

But you are assuming these are irrational notions.

I have very carefully observed what happens when the Q word is spoken, and have found that avoiding it is the only reasonable solution.

Another is not dating the discharge paperwork. You can write up the entire discharge sheet of instructions and information. But don't ever ever ever date it until you are 100% positive the patient is leaving that day. Otherwise, you will go to discharge the patient, paperwork all sealed, only to find there is some reason the patient can't go.

I've been burned by that one. . .