The day after my afternoon from hell, my resident reminded me that I should ask for help if I ever felt overwhelmed by work. Easier said than done; the other MICU teams don't know anything about my patients or what tests they need. I almost panicked when my newly-septic patient was found to have pus draining from his bladder (yet ANOTHER potential infectious site for his sepsis) and I was afraid of what the attending would say once he knew of all this since he grilled me yesterday for not catching the potential causes of sepsis earlier. Fortunately ID is on the case and he's on a good antibiotic regimen until his cultures return.
I was on call overnight and didn't get much rest. We got a patient with end-stage small cell lung cancer with liver mets/failure who presented with SOB and altered mental status. His wife made him DNR/DNI, so our job was to keep him comfortable until the end. I got called about him at around 2 a.m. b/c his BP had fallen to 65/47 (and later to 55/40), and his breathing was so agonized that his entire chest heaved and there was a rattling in his throat with each breath. When I listened to his lungs, it sounded like air was echoing throughout his lungs with each exhalation. I called/woke the overnight resident asking what I should do, and he suggested calling the family. So I spoke to his son, who said that his mother preferred to remember the patient as he was and not as he is in the hospital, so they would not be coming to HUH but appreciated my keeping him updated. Later I got a call from the nurse at 5:30 a.m. saying that the patient had passed away, so the resident and I went through the steps of pronouncing him dead (listening to heart and lungs, checking the eyes, feeling for pulses). Then he filled out the death packet and called the morgue while I called the patient's wife to let her know the news. She told me that in the time her husband was at home before going to the hospital, he had spent a few good hours eating his favorite foods and watching soccer games, so she drew comfort from those last few memories of him in relatively good health. She was relieved that he's found peace.
Saturday, August 29, 2009
Thursday, August 27, 2009
MICU: The Burden of Atlas
Today was probably my worst day in the ICU to date. My team had seven patients, three of whom were very sick (one with new-onset sepsis, one who coded last night, and one with abd pain and a giant gallbladder). My resident and sub-I were post-call so they left before 1pm, and the fellow who watches over my team had clinic in the afternoon. So for one afternoon, it was just me in the unit covering all seven patients.
It was a disaster. The patient who coded had 3-4 consults I needed to follow up on. My attending was on my back to call the surgery team about two vasculopaths on our team who had an aortic dissection and no line access. I had to contact IR to ask them to put a line in our lady who coded since she had no veins. Then one of my long-term patients was found to be septic from a possible permacath infection so I had to call nephro, pulm AND infectious disease to coordinate whether they wanted the permacath removed or not (since pt was on dialysis) Then the MICU3 resident (whom my resident had asked to help me in case I got overworked, but I barely saw her at all because HER team was busy as well) got annoyed with me for not getting back to her in time about whether my patient needed a new line to get put in ("I'm not going to be here all day.") I had no time to rest. It was one thing after another, and by the time of signout at 5:00 pm I still had work to do. Then one of the fellows got mad at me for not calling IR about removing my septic patient's permacath; it was because I was calling his attendings about him until 5:30 pm and the IR department stopped taking calls at 5:00 pm.
I didn't leave until 7:00 pm (sign-out was at 5:00 pm) because there was so much to do, and I was never so exhausted and burnt out in my life. And to think I'm on call tomorrow! But hopefully things will be better then; I can't take another day like today.
(anyone want to guess what inspired the title of this post?)
It was a disaster. The patient who coded had 3-4 consults I needed to follow up on. My attending was on my back to call the surgery team about two vasculopaths on our team who had an aortic dissection and no line access. I had to contact IR to ask them to put a line in our lady who coded since she had no veins. Then one of my long-term patients was found to be septic from a possible permacath infection so I had to call nephro, pulm AND infectious disease to coordinate whether they wanted the permacath removed or not (since pt was on dialysis) Then the MICU3 resident (whom my resident had asked to help me in case I got overworked, but I barely saw her at all because HER team was busy as well) got annoyed with me for not getting back to her in time about whether my patient needed a new line to get put in ("I'm not going to be here all day.") I had no time to rest. It was one thing after another, and by the time of signout at 5:00 pm I still had work to do. Then one of the fellows got mad at me for not calling IR about removing my septic patient's permacath; it was because I was calling his attendings about him until 5:30 pm and the IR department stopped taking calls at 5:00 pm.
I didn't leave until 7:00 pm (sign-out was at 5:00 pm) because there was so much to do, and I was never so exhausted and burnt out in my life. And to think I'm on call tomorrow! But hopefully things will be better then; I can't take another day like today.
(anyone want to guess what inspired the title of this post?)
Friday, August 21, 2009
MICU: First Week
I've been in the MICU for one week, and already there are many differences from the floors here. We have fewer patients per team, but they are sicker and require lots more attention. I'm also fortunate in that there are fewer MICU patients in the summer than there are in the winter (when pneumonia runs rampant). My team currently has about 5 patients, 2 of whom have been here since July. Most of them have trachs and PEGs and just need to be weaned off the ventilator.
There are 4 MICU teams in the unit. Call here is q4 overnight; the intern from one team is paired with the resident of another team depending on whether their team is an even or odd number (i.e. I'm MICU4, so I'm on call with the MICU2 resident) so that there are doctors from two teams here at all times. Some residents cover their own teams and expect the intern to cover all the others during the night, while others will split the teams in half and say, "I'll cover 1 and 2, you cover 3 and 4." I cover all the routine calls (medications, orders, etc), but if something serious is going on with my residents' patients or if I have a question, then I call the resident.
On my first call, one of the patients on my team with small cell lung cancer/MRSA pneumonia coded (eventually brought back and put on a transcutaneous pacemaker), and there was a disagreement about which of his children could make decisions about him. One son was the power of attorney but he was overseas, and his daughter said she had papers saying that he wanted everything done (but despite being asked many times, she never brought those papers to us). It took an entire afternoon to finally reach the son with POA, and he asked if we could keep his dad alive until he got home. The pulm/CC fellow said that the patient was unlikely to survive the night, and after the son spoke with other family members (namely, a stepbrother who came to visit the patient), he told us that he wanted us to withdraw care.
The patient had his vent removed and his pacer turned off, and the nurses placed him on a drip to keep him comfortable. I poked my head into the room a few times and saw his heart rate fall to 28 while his breaths became slower. Time passed as I continued working, when suddenly I heard a loud scream. Fearing the worst, I turned and saw our patient's daughter run into his room, throwing herself over his body and begging him to wake up. Apparently the patient had just passed away and she arrived with no idea that he had been taken off life support.
One of the fellows went in the room to talk to her after giving her some time to grieve, and she went berserk on him. "Why did you pull the plug?" she screamed, stamping her foot and flinging things around the room. "You were NOT supposed to pull the plug on my daddy. He wanted everything done for him! I got papers!" And with that, she pulled out the forms that we had needed for so long, too late. "He said he wanted everything done until his heart stopped. WHO said you could pull the plug?!" I was afraid that she was going to start hitting the fellow or something like that, but he just explained that our team had directly contacted her brother who had the power of attorney, and he had made the decision along with her stepbrother to withdraw care.
"___ would never do that!" she screamed, referring to her biological brother. "And ___ isn't even his real son!" That, of course, was referring to her stepbrother. "WHY?!?" With that she broke down, continuing to alternate between screaming and holding her father, and when the paramedics came to take the body to the morgue, it took a while to get her to let go. She tried to follow the body as it was wheeled away but the security guards stopped her. "You can't keep me here, that's my daddy!" she yelled. The guards explained that she wasn't allowed to go to the morgue and she screamed they had no right keeping her here. After yelling at the guards, she turned and headed straight for the nurse's station. I was afraid she was going to find a random nurse and start screaming, but instead, she found an unguarded door leading to the lobby and promptly exited the ICU. The nurses inside the station looked started, like WTF just happened, but the security guards were alerted to go out and find her. This was sometime around 8 pm, and I was told that she was still down in the lobby at 10 pm arguing with about 5-6 security personnel. *sigh* This is why I don't want to specialize in critical care.
There are 4 MICU teams in the unit. Call here is q4 overnight; the intern from one team is paired with the resident of another team depending on whether their team is an even or odd number (i.e. I'm MICU4, so I'm on call with the MICU2 resident) so that there are doctors from two teams here at all times. Some residents cover their own teams and expect the intern to cover all the others during the night, while others will split the teams in half and say, "I'll cover 1 and 2, you cover 3 and 4." I cover all the routine calls (medications, orders, etc), but if something serious is going on with my residents' patients or if I have a question, then I call the resident.
On my first call, one of the patients on my team with small cell lung cancer/MRSA pneumonia coded (eventually brought back and put on a transcutaneous pacemaker), and there was a disagreement about which of his children could make decisions about him. One son was the power of attorney but he was overseas, and his daughter said she had papers saying that he wanted everything done (but despite being asked many times, she never brought those papers to us). It took an entire afternoon to finally reach the son with POA, and he asked if we could keep his dad alive until he got home. The pulm/CC fellow said that the patient was unlikely to survive the night, and after the son spoke with other family members (namely, a stepbrother who came to visit the patient), he told us that he wanted us to withdraw care.
The patient had his vent removed and his pacer turned off, and the nurses placed him on a drip to keep him comfortable. I poked my head into the room a few times and saw his heart rate fall to 28 while his breaths became slower. Time passed as I continued working, when suddenly I heard a loud scream. Fearing the worst, I turned and saw our patient's daughter run into his room, throwing herself over his body and begging him to wake up. Apparently the patient had just passed away and she arrived with no idea that he had been taken off life support.
One of the fellows went in the room to talk to her after giving her some time to grieve, and she went berserk on him. "Why did you pull the plug?" she screamed, stamping her foot and flinging things around the room. "You were NOT supposed to pull the plug on my daddy. He wanted everything done for him! I got papers!" And with that, she pulled out the forms that we had needed for so long, too late. "He said he wanted everything done until his heart stopped. WHO said you could pull the plug?!" I was afraid that she was going to start hitting the fellow or something like that, but he just explained that our team had directly contacted her brother who had the power of attorney, and he had made the decision along with her stepbrother to withdraw care.
"___ would never do that!" she screamed, referring to her biological brother. "And ___ isn't even his real son!" That, of course, was referring to her stepbrother. "WHY?!?" With that she broke down, continuing to alternate between screaming and holding her father, and when the paramedics came to take the body to the morgue, it took a while to get her to let go. She tried to follow the body as it was wheeled away but the security guards stopped her. "You can't keep me here, that's my daddy!" she yelled. The guards explained that she wasn't allowed to go to the morgue and she screamed they had no right keeping her here. After yelling at the guards, she turned and headed straight for the nurse's station. I was afraid she was going to find a random nurse and start screaming, but instead, she found an unguarded door leading to the lobby and promptly exited the ICU. The nurses inside the station looked started, like WTF just happened, but the security guards were alerted to go out and find her. This was sometime around 8 pm, and I was told that she was still down in the lobby at 10 pm arguing with about 5-6 security personnel. *sigh* This is why I don't want to specialize in critical care.
Sunday, August 16, 2009
Yellow: Finishing Heme/Onc
I had a "black weekend" this week since I was on call Saturday and post-call today. I do get a golden weekend NEXT week so in the end it balances out. Today was my very last day on the Yellow 3 heme-onc team, and I have to say it was a good learning experience. It wasn't overwhelmingly busy for a floor month, but I feel like I got enough out of it to know what to expect on other floors. I also got along pretty well with my resident (who actually stayed late on an 8pm call day to help me organize a presentation I had to do for intern report; not many residents will do that), my med students (never worked them too hard, to my knowledge), and the fellows. I actually got my heme-onc fellow and MSIII hooked on Hi-Chew, so that was another fun thing we shared as I always kept some in my pocket (and there's plenty of Hi-Chew to be found in Philadelphia since HUH is only blocks away from Chinatown)
Most people get out around noon on Sundays, but I stayed until 3:30 pm b/c a patient I admitted yesterday had a distended bladder after not voiding in 24 hrs and no one could get a catheter in him. I, myself, have never cathed anyone and neither did the Yellow 1 resident who was supervising me (my resident had a golden weekend), so we had to call the surgery intern on call (who was also covering urology) to use a special Foley (with a tilted Coude tip). It took the surgery intern 1.5 hrs to get to the floor, but once he was there and the Foley was in, my patient drained 500 ccs of urine on the spot and felt instant relief. Thank goodness.
Tomorrow I start MICU, which will probably be another hospital culture shock since the unit is so different from the floors. But I look forward to it.
Most people get out around noon on Sundays, but I stayed until 3:30 pm b/c a patient I admitted yesterday had a distended bladder after not voiding in 24 hrs and no one could get a catheter in him. I, myself, have never cathed anyone and neither did the Yellow 1 resident who was supervising me (my resident had a golden weekend), so we had to call the surgery intern on call (who was also covering urology) to use a special Foley (with a tilted Coude tip). It took the surgery intern 1.5 hrs to get to the floor, but once he was there and the Foley was in, my patient drained 500 ccs of urine on the spot and felt instant relief. Thank goodness.
Tomorrow I start MICU, which will probably be another hospital culture shock since the unit is so different from the floors. But I look forward to it.
Wednesday, August 12, 2009
Giving "The Talk"
At some point or another throughout med school, residency, and beyond, we get pulled aside by someone above us (resident or attending, right now), for private chats which usually leave us feeling bad for a good part of the day. I got my first one-on-one back when I was a MSIII during my ob-gyn rotation, when my resident told me that I was too timid after I froze during a delivery and he had to take over. Fortunately by the time he saw me again as a MSIV during my ICU rotation, I was more sure of myself and actually asking to do procedures. More recently, I got pulled aside by an ER attending who berated me for attempting a certain procedure without supervision (even though the patient was fine in the end). In that case the fault was entirely mine, though I felt like crap for a good 2-3 days afterwards. It only made me dislike ER more, though I've since seen that same attending in the ER and we're on good terms as though nothing ever happened. I still worry about seeing him/her sometimes though.
I was the overnight intern yesterday, and after doing 3 admissions from 6 pm to 2:30 am, I was looking forward to lying down and getting at least 2-3 hours of sleep. Unfortunately it didn't happen. Just as I finished my lastest admission and was about to call it a night, the ER called me and told me that there was a patient coming to my service who had an incomplete H&P and had essentially been forgotten in the ER. "There's no admission order, no call to case management, nothing!" I remembered the triage resident telling me that the overnight sub-I was doing the admission for my team, and when I went to see the H&P, I saw that he had only filled out the history, med list, labs, and review of systems. Everything else--the physical exam, the assessment and plan--was missing. There was nothing there. This patient could have been sent to the floors hours ago, but apparently the sub-I just stuck the H&P in her chart and went to bed after the interview without telling ANYONE that he saw her.
I couldn't believe it, and worse, I was pissed that because of the sub-I's incompetence, I would now have to stay up even later to see the patient, examine her, formulate a plan, and then call the heme-onc fellow to let her know what was going on (and I really did not want to page her at 3 a.m.) Needless to say it was close to 4:30 a.m. by the time I finished my work, and I was exhausted. A part of me wanted to page the sub-I, yank his butt out of bed and demand an explanation for what happened tonight, but I decided to wait until morning. Either way, I knew that I had to talk to him, and give him one of those "chats" that I myself dread receiving.
At 6:15 a.m. (which I felt was a reasonable time to wake up), I paged the sub-I and asked him to meet me in the lounge so that we could go over his note. Fortunately the room was empty so we could talk in private. When he arrived, the first thing I asked was whether he told anyone (namely, triage) about the patient after he saw her and whether or not he did an exam. He immediately realized what he did wrong and apologized, saying that he wasn't sure whether he was allowed to write on the H&P or not. That was reasonable, so I explained to him that after seeing a patient, he's supposed to present the patient to triage so that triage can decide where to admit the patient, rather than have him/her sit in the ER for nothing. I further noted that I know he's just starting his sub-I (med students switched services last week) and that everyone makes mistakes (me included), but next time, make sure this doesn't happen again. He again apologized, both to me and the patient, and I accepted his apology. When I let him leave, however, I couldn't help but feel bad for him. Did I completely ruin his day by giving him "the talk" that he needed to hear? I hoped not.
As far as I'm concerned, the talk we had was between us only. I don't know who his resident is and even if I did, I wouldn't say anything to get him in trouble (though the triage resident, who was with me when I started ranting in the wee hours of the morning, might say something). Having been an MSIV once, I don't want this one mistake to affect his entire grade for his sub-I. Since I'm not his resident, I don't have to grade him or tell the med student coordinator what happened, and I think it's better that way. As long as he learned his lesson...just as I learned that giving one of these "chats" is just as hard as receiving one.
I was the overnight intern yesterday, and after doing 3 admissions from 6 pm to 2:30 am, I was looking forward to lying down and getting at least 2-3 hours of sleep. Unfortunately it didn't happen. Just as I finished my lastest admission and was about to call it a night, the ER called me and told me that there was a patient coming to my service who had an incomplete H&P and had essentially been forgotten in the ER. "There's no admission order, no call to case management, nothing!" I remembered the triage resident telling me that the overnight sub-I was doing the admission for my team, and when I went to see the H&P, I saw that he had only filled out the history, med list, labs, and review of systems. Everything else--the physical exam, the assessment and plan--was missing. There was nothing there. This patient could have been sent to the floors hours ago, but apparently the sub-I just stuck the H&P in her chart and went to bed after the interview without telling ANYONE that he saw her.
I couldn't believe it, and worse, I was pissed that because of the sub-I's incompetence, I would now have to stay up even later to see the patient, examine her, formulate a plan, and then call the heme-onc fellow to let her know what was going on (and I really did not want to page her at 3 a.m.) Needless to say it was close to 4:30 a.m. by the time I finished my work, and I was exhausted. A part of me wanted to page the sub-I, yank his butt out of bed and demand an explanation for what happened tonight, but I decided to wait until morning. Either way, I knew that I had to talk to him, and give him one of those "chats" that I myself dread receiving.
At 6:15 a.m. (which I felt was a reasonable time to wake up), I paged the sub-I and asked him to meet me in the lounge so that we could go over his note. Fortunately the room was empty so we could talk in private. When he arrived, the first thing I asked was whether he told anyone (namely, triage) about the patient after he saw her and whether or not he did an exam. He immediately realized what he did wrong and apologized, saying that he wasn't sure whether he was allowed to write on the H&P or not. That was reasonable, so I explained to him that after seeing a patient, he's supposed to present the patient to triage so that triage can decide where to admit the patient, rather than have him/her sit in the ER for nothing. I further noted that I know he's just starting his sub-I (med students switched services last week) and that everyone makes mistakes (me included), but next time, make sure this doesn't happen again. He again apologized, both to me and the patient, and I accepted his apology. When I let him leave, however, I couldn't help but feel bad for him. Did I completely ruin his day by giving him "the talk" that he needed to hear? I hoped not.
As far as I'm concerned, the talk we had was between us only. I don't know who his resident is and even if I did, I wouldn't say anything to get him in trouble (though the triage resident, who was with me when I started ranting in the wee hours of the morning, might say something). Having been an MSIV once, I don't want this one mistake to affect his entire grade for his sub-I. Since I'm not his resident, I don't have to grade him or tell the med student coordinator what happened, and I think it's better that way. As long as he learned his lesson...just as I learned that giving one of these "chats" is just as hard as receiving one.
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