Are you there CHEST? It's me, PCCM FY1

June 30, 2015

We’re checking back in with our newest CHEST blogger, Dr. Rohit Devnani. Dr. Devnani recently began his fellowship in pulmonary and critical care medicine, and we’ve asked for a sneak peek into his journey. Here he discusses his eventful first year as a pulmonary and critical care fellow at Indiana University.

By: Rohit Devnani, MD, @RoRo_Nani

Last I left you, it was recruitment season; and since then I’m sorry to say, I have had to prioritize eating, sleeping, and brushing my teeth over writing.

This week was the graduation ceremony for the third-year class and I had the fortune of being able to talk with many of them about their journeys while reflecting back on the end of my own first year.

So instead of a play-by-play, I offer you a recap of the first year of my pulmonary and critical care fellowship at Indiana University.

The truth is, fellowship has been tiring. It’s really hard. The hours are long, the patients are sick, and many of them die. But fellowship has also been rewarding with victories both big and small. Fellowship is fun, and fellowship is annoying. Fellowship is a privilege, and fellowship is a freaking drag.

With any increase in responsibility, the highs are higher, the lows are lower, and that roller coaster is the ride of first year in fellowship. The four hospitals at Indiana University make this ride long and winding.

Roudebush Veterans’ Affairs hospital

During our first year, we spend a lot of time in the intensive care unit at the Roudebush Veterans’ Affairs hospital. Like at many VA hospitals, the efficiency can be lacking and the administration can be a nuisance. But the patients, these veterans, make it a pleasure. Despite the inefficiency that can lead to delayed and inconvenient care, I have found that they are all so appreciative.

They also bring a particular brand of durability with them. As one of my attendings noticed, despite evidence claiming the contrary, the fight in these veterans seem to help them overcome burdens that would consume the average patient. A patient of mine, let’s call him Santa Claus (because he looks like Santa Claus), came under our care after a cardiac arrest that required us to resuscitate him and put him on the ventilator.

Santa Claus’s heart, kidneys, lungs, and brain already didn’t work very well and our predictions for him, while he could recover, were of poor trajectory. Two more codes later, I had been preparing his family for the worst. Then one day, out of nowhere, Santa woke up, came off the ventilator, and went home as if nothing happened.

Short of a Christmas miracle in September, I have no explanation.

The VA also holds a special place in my heart for a variety of reasons. A major concern of mine before starting fellowship was airway management. Airway was owned by Anesthesia at my residency program, so it’s something with which I had no experience. And I was terrified. By the end of my first month, however, I was three-ways prepared, thanks in large part to Dr. Casey Stahlheber.

The truth is, fellowship has been tiring. It’s really hard. The hours are long, the patients are sick, and many of them die. But fellowship has also been rewarding with victories both big and small. 

I remember my first intubation in which I was so nervous that I was holding the blade in the wrong hand. Dr. Stahlheber asked me why I wasn’t using the Glidescope. I told him I had the Glidescope available for backup (backup…probably the most important part of airway management).  “How can you use something for backup if you have never used it before?” I hadn’t thought of that. In our airway course, the importance of backup was impressed upon us and that video-directed intubation is a wonderful backup option—if known how to use it. That part I hadn’t considered. So I used the Glidescope, learned how to intubate, and by the end of the month I was managing airways from decision to precision. 

Dr. Stahlheber is just one of the people, from attendings to ancillary staff, at the VA who have made it fun. The nurses have been particularly good to me. This group made me feel home again in Indianapolis, celebrating birthdays, blowing off steam after difficult days, and even spending 45 minutes to help me find my car keys the first month (somehow in a patient’s drawer).

I also had the pleasure of working with Dr. Irina Petrache, our division rock star and winner of the fellows’ teaching award this year. She is an inspiration as a researcher, teacher, and academician, so I took the opportunity to pick her brain. I asked her if she always knew she wanted to be a researcher. “No,” she said. “I knew I wanted to be the best.” That’s the answer she gave me. To her, the pulmonary and critical care doctors were the best, and research is where she thought she would have the greatest impact. So that’s what she did. Rock star. These are experiences from just one of the hospitals of the IU pulmonary/critical care program.

Eskenazi Health 

Across the street from the VA, at Eskenazi Health (Indianapolis’ county hospital) live the particularly vulnerable patients. They come to us poor, uninsured or underinsured—from prison, the bus stop, sometimes undocumented, sometimes psychotic, and more often than not, very, very sick.

In addition to the typical admissions for COPD exacerbations, diabetic ketoacidosis (DKA) and brain hemorrhages, this hospital houses a significant number of drug overdoses. It’s as if Eskenazi ICU is a window into the social atmosphere of the United States. After admitting heroin overdose after heroin overdose, I see an article commenting on America’s latest heroin problem. After admitting the most severe case of bath salt ingestion I have seen, I read news about the latest form of bath salts coming from Florida.

Eskenazi ICU is also an exciting place to work because despite being a county hospital with county resources, there is an all-in commitment to being as advanced as any medical center in the country. 

On top of this variety of patients, every month at Eskenazi has been defined by a special case: a patient with severe toxic epidermal necrolysis who should have died but walked out of the hospital; another who had diffuse lung injury that for some reason spared the right middle lobe, later discovered to be cryptogenic organizing pneumonia (only to improve after a last ditch effort with cyclophosphamide was trialed); even a case of anti-NMDA encephalitis of undetermined etiology in an African American male. 

Eskenazi ICU is also an exciting place to work because despite being a county hospital with county resources, there is an all-in commitment to being as advanced as any medical center in the country. This includes use of disposable bronchoscopes, noninvasive cardiac output monitors, and esophageal balloon pressure monitoring.

At the center of this culture works Dr. Graham Carlos, IU Pulmonary and Critical Care teacher extraordinaire. Dr. Carlos not only serves as a major teaching attending to medical students, residents, fellows, and faculty (you may have participated in his “teaching on the fly” session at ATS) but also as the director of the ICU at Eskenazi. The atmosphere of improvement starts with him and his openness to promoting change, which I have seen firsthand.

Even as a green first year fellow, I fussed over the importance of physical therapy in the ICU. It’s been amazing to see Eskenazi’s “wake up and breathe” program (daily sedation interruptions and spontaneous breathing trials) turn into the “wake up, breathe, and walk” program.

I am even proud to say my own patient with hypoxic respiratory failure from a rip-roaring pneumonia due to Stenotrophomonas maltophilia was the first patient at Eskenazi to walk on the ventilator with an endotracheal tube in place. She left the hospital, is now my clinic patient, and has fully recovered.

Methodist and University hospitals 

The other hospitals in the IU system are Methodist and University hospitals. While we spend more time there during our latter years in fellowship, some time is spent at each during the first year. Methodist Hospital is a large multispecialty ICU tower where advanced care such as lung transplant and ECMO occur. University Hospital is the other half of advanced care with a population of bone marrow transplants, multivisceral transplants, and EBUS up the wazoo (by “up” I mean “down,” and by “the wazoo” I mean “the mouth”).

Experiences vary from a private-practice care model with Dr. Chris Naum, who works in the postcardiovascular surgery ICU, to running down a portable sleep device so our master physiologist, Dr. Mark Farber, can diagnose an extreme case of sleep-disordered breathing and hyperventilation as an inpatient. The breadth of experience turns “see one, do one, teach one” into “see plenty, do more, teach on the fly,” and there is certainly more to come over the next 2 years. 

First Year and Onward

I wish I could say the first year has been all good. I have had a heck of a time from the four hospitals, CHEST 2014 in Austin, and exciting meetings with my research mentors. So although it’s been mostly good, it’s been far from perfect.

The struggles of continually trying to establish myself, personal conflicts, adapting to new systems, and differing philosophies have burdened an already grueling year. But then there are leaders who serve as examples of inspiration against breeding cynicism: Dr. Farber who calls at night to discuss patient care issues that aren’t his own just because he cares; Dr. Carlos who ends every rotation by reminding us how much he loves his job; and Dr. Mathur, who at the beginning of the year wisely advised us that our first and foremost goal is to become excellent pulmonary and critical care physicians.

To try to be a leader I can be thankful for the good, aim to improve the bad, and hope that I leave the program having made a difference for the better and that it leaves me an excellent pulmonary and critical care physician.

Congratulations! You made it through reading all of this.

Congratulations to me for making it through living all of this (#DoctorsEgo). More time over the next 2 years means more writing on special interests in pulmonary and critical care: bedside ultrasound, end-of-life decision making, medical education, and evidence-based medicine in the ICU are just some ideas I have running through my head. At some point I will also take you through the pulmonary clinic experience, as outpatient medicine doesn’t get its due discussion, in my opinion.

Thank you for sticking with me. I appreciate the overwhelmingly positive responses I have gotten since writing for CHEST.