Getting out on time

The rule in medicine is that you're not supposed to work more than 30 hrs straight. That if you worked overnight and are still at the hospital at 1 pm post-call, the residents will do whatever they can to help you out so that you can get out of the hospital in time. They have your back.

Lies.

There's only so much that residents can do to help their interns leave on time. They can see a patient or two for you and write notes. They can put orders in the computer or call social work for you. But they can't fill out discharge forms or transfer forms for patients that aren't their own, because they don't know the patient like the primary team does. During the weekday it's not bad, because the resident can help the intern get out on time. But during the weekend, when there's only one intern/resident per team seeing anywhere between 6-14 patients and hoping to get out by 11-12 pm (the earliest time you can sign out on weekends), the intern really doesn't get much help from the other residents. For the most part s/he's on his/her own.

I was overnight last night, and ended up not getting any sleep because one of the night float interns had an emergency and had to leave the hospital for about 4 hrs. I had to cover his half of the hospital until he returned, but thank goodness I only got about 4-5 calls in that time. It could have been much worse. I also had one patient who had both elevated cardiac enzymes and Strep/Serratia sepsis so I was keeping an eye on her for most of the night anyway. And while I saw all my patients and wrote all my notes on time, there were a lot of things keeping me from leaving at noon. I had 3 patients being discharged. One patient needed neurology follow-up, and when I paged the neurologist on call, he said the patient wasn't on his service and told me to read the last neuro note. "Maybe you should check the chart before calling me, that's just laziness," he said. Well, excuse me for being post-call. As it turned out, I'd paged the wrong neuro group anyway, and the pt's neurologist was a much nicer person. The second discharge was a patient we'd had for 3 weeks who had a very caring/overbearing wife, and when she found out we were discharging him, she insisted on making sure all his medications would be ready at the nursing home before they left the hospital. The attending originally asked me to call the nursing home with his (very long) med list, but I think he sensed I was swamped and said he'd make the call instead (thank goodness).

On weekends, we are technically not allowed to leave until we round with the attendings on each patient. The problem was that in geriatrics (my current rotation), different patients have different attendings rounding on them, so I had to touch base with about 5-6 attendings before leaving. Some were nice and responded immediately to my pages, others never returned my pages and I was sitting there wondering what to do. If we don't follow the attending's recommendations, they can call us up on it, but I didn't want to stay late and wait for the attending to arrive. Not when I was post-call. On top of that, the hospital I'm rotating through is huge; it takes aout 5-10 minutes to run from one side of the building to the other. And I did a lot of running around, i.e. I forgot to put a script in one patient's chart on one end of the hospital, then had to run back to the opposite to do a discharge form. It was miserable to say the least.

It's not to say that the residents didn't offer to help out. The two 8 pm residents called from time to time to see if I needed help, and one of them ordered morning labs for my patients for me. But they could not do the things that were taking me the longest to get through: fill out discharge forms, touch base with the attendings, making my sign-out sheet for the night floats. That was all on me, and at one point I got so overwhelmed I had to hide in the bathroom to catch my breath and keep from losing myself completely in front of the nurses, patients, and families. It didn't help that at 1:00 pm, the triage resident called me and asked if I was almost done. I felt like screaming, "NO! I am not done, and no one is helping me either!"

One resident told me to stay where I was and that she was coming over to help, but when 10 minutes passed and she still didn't show, I gave up. I was through with counting on residents to help me out, so I just did what I could and signed out to the night floats. I won't say what time I left the hospital, but having skipped lunch aside from a granola bar, I was both exhausted and hungry. Someone expressed concern about whether I could drive home (it's a 30-40 min commute), but I assured him I'd be fine. As long as I could get away from the hospital and get some freaking sleep, I knew I'd be fine. It had been a rough night and morning, and it didn't help that I'd been working every day since October 18 (2 weeks straight) and was very burned out.

Two months ago, my MICU resident told me that I should never hesitate to ask for help when I need it, but after today, I know all too well that help doesn't always come even if you ask for it. Feel free to comment on this, but for all I know, no one reads this anymore.

It's the little things that matter most

Normally I don't watch Grey's Anatomy on Thursday nights, but since this week's CSI was a rerun I switched over to ABC to watch Grey's for the first time in ages. And the episode was a very good one: a woman suffering from burns dies in the ER and the events leading to her death are seen through the eyes of all the doctors who were working with or beside her (in flashback form) in order to figure out how and why she died. And in the end, we find out that the woman died because the doctor who examined her forgot to look inside her throat. And because of that, no one saw that she had soot in her throat from the fire that later compromised her airway and set off the chain of events leading to her death. The doctor was then fired for her negligence.

That episode shook me to the core, because this is something that can easily happen in real life. As an intern, I've made my share of mistakes whenever I had to fly solo and didn't have a resident around to help out (whenever he/she was in clinic, post-call, or taking an inservice exam). I once didn't think to order blood cultures on a feverish patient while I was overnight, and the next morning the resident asked me why I didn't do so. To this day I'm convinced she thinks I'm a dumb intern. Another time I didn't order a CXR on a patient who sounded wet (even though the attending later said that was her baseline CHF), and more recently, I ordered a lidocaine patch on a patient without checking to see if she was allergic to it (she wasn't). But looking back, there are many ways in which those things could have gone wrong. The feverish patient could have been septic. The patient who sounded wet could have developed ARDS. And if I'd given my third patient morphine without checking to see if she was allergic to it, and she was, she could have died.

Which makes me wonder, how well are we protected by the hospitals that we work for? Would my program be quick to fire me if I accidently prescribed a patient allergic to sulfa some Bactrim and he went into anaphylactic shock? I'd like to think no, since the program is so dependent on its residents that if one resident leaves for any reason, things become way more chaotic (the current R3s are having this problem since one of them didn't pass Step 3, and now people are getting pulled left and right to cover her duties). But what constitutes as an unexcusable mistake that would cost a resident his/her job? The scenario from Grey's Anatomy seemed a bit unrealistic, to fire a resident after one mistake, because what would happen to that resident after that? Would she never be able to complete her residency because no one would take her into their program after she made a single deadly mistake?

If I learned anything from watching this episode, it's that you can never be too careful.