Monday, July 28, 2008

a little endogenous beta agonism

I can tell I'm getting more anxious about starting my new job, because I've started having anesthesia dreams again.

When I started my anesthesia residency, I had anesthesia dreams for about six months straight. Some of them were clearly efforts to process what I was learning--some dreams were purely sensory, hearing alarms, pulse ox tones, that kind of thing, or brief motor sequences of me drawing up meds, spiking med bags, doing my machine check. And some dreams were nightmares.

Gradually, as I guess I became more comfortable with my job, as I learned the routines, I started having these anesthesia dreams less, and by my last year of residency, I don't think I was really having any work-related dreams at all. This respite continued until about a few weeks ago, when I had this dream about securing a difficult airway, after which point the patient started talking around the tube, causing the medical student I was working with to freak out and dislodge the tube entirely. Another night, I had a dream about a difficult case, and not being able to find the equipment I needed. I don't think it takes a Freudian to figure out that I'm feeling a little nervous about the new level of responsibility that I'll be facing, combined with learning the ropes in an unfamiliar work environment. (Though it probably would take a Freudian to tell me that the dislodged endotracheal tube represents my CASTRATION ANXIETY.)

I would not be nearly as nervous if I were starting a job at Columbia, where I trained. In fact, I think I would barely be nervous at all. I know how the system works there. I know how the ORs are laid out, I know the names of all the nurses, I know the surgeons, I know what to do when the shit hits the fan. Systems-based familiarity is so much comfort.

I started making preparations for starting work in a week. Giving our new nanny and Cal a full day together without me lurking downstairs like some damn stalker (THE CALL WAS COMING FROM THE BASEMENT!!), I set out for a full day of grown-up work this past Friday and practiced my commute on the subway. (Whatever, "MARTA." I will be calling it the subway for a long, long time, so just get used to it. I was in Boston for four years, and outside of a handful of occasions where I was really making an effort to be correct, I don't think I ever called the train system there "The T.") It seems straightforward enough, but the real test is making sure that the commute is as reliable at 6:00am as it was at 9:30am. Still, 45 minutes door to door for a commute that distance isn't that bad, and certainly shorter than the commute I've been making for the past five years.

The other thing that's feeding into my anxiety is the fact that my last day at work was June 29th, which means that by the time I start, I will have been away from the ORs for more than a month. Again, not as big a deal as when I was a first year (as a first year, even being off for a week vacation would completely throw off my game, exacerbated by the fact that I was inevitably on call my first day back) but still, it feels like a substantial amount of time away. I just have to hope that my game reflexes are still intact, though I'm not naive enough to think that I won't be a little rusty. It's just a little nerve-wracking to feel like you have to find your A-game again while starting something completely new, in a hospital at which you've never worked, where you know no one and you have no reputation to fall back on, and where you're taking care of real patients with real problems who don't care that it's your first day on the job, they need you to be good and fast and make the right decision NOW.

And honestly, even though I have given anesthesia to hundreds and hundreds and hundreds of patients at this point, never has the act of inducing anesthesia seemed so fraught with gravity. I am giving medications to induce unconsciousness, that will drop my patient's blood pressure, that will paralyze them, after which point it's up to me to secure that airway, or...what? Or they're dead. No ventilation, you're dead. Forget B and C when you can't even get the A. Usually, the process of securing the airway is so straightforward I don't even really think about it too much anymore in routine situations--unless the patient looks especially difficult, it's a procedure that I will easily cede to the medical student, to the ER rotator, to whoever wants to give it a try--but we've all had difficult intubations, we've all had patients that are difficult to ventilate, and there is nothing that jacks up one's sympathetics more than that unholy combination of the two. See, no kidding, my heart rate is going up right now, just thinking about it. But as a resident, there was always the attending there, standing behind you. Not that attendings are infallible, and not that all attendings can secure an airway that an experienced third-year resident can't, but they were there. That was comforting. They were in charge. When the shit started hitting the fan, if you had a good attending, you could always (though as training progressed, I was more and more loathe to cede control) throw up your hands and defer to them to step in and save the day. Sometimes they couldn't. But they were there.

One of my attendings once told me that the learning curve my first month of being an attending would be steeper than anything I had ever experienced before during medical school, residency, ever. Initially, I thought he meant that I would learn a lot in the process of supervising others, learning to trust the hands and judgement of other people as opposed to putting my hands on everything myself, and bailing people out of difficult situations once they'd gotten to the shit/fan interface. But now I realize that he meant more than that.

As an attending, at least for the first few months, I will exclusively be doing all my own cases, which really isn't all that different from what I was doing as a resident. But I'm not a resident anymore. I'm an attending. I'm the bottom line. There's no one to fall back on. There's no one to bail me out. (Well, if there is a real emergency, obviously there would be 20 people rushing in the room to help, but let's all hope it's doesn't get to that point all too frequently.) Everything has more meaning, is more fraught with potential for the worst case scenario. I'm thinking harder about everything, even things I was cavalier about just a few weeks ago. The medicine is the same, and yet everything is somehow different. Your job is different. Your responsibility to the patient is different. You are different.

So I'm a little nervous about starting work, is what I'm saying.