AMH 3: Looking back

Yesterday I finished my last floor month of intern year (not counting CCU in June, which is strictly a unit month), and boy was I glad to be done. The service was pretty full the entire month; the lowest my census ever got was 7 (cap was 14). Even worse, this was the only service where I went home worrying about my patients' well-being, because they were that sick. When I took a day off to attend a convention, I sent the intern covering for me a long email telling him everything he needed to follow up on and later called him to make sure everything was fine. For the most part the service was evenly split between general medicine patients (university) and heme-onc patients, but both sides had several rocks that, for various reasons, wore me down both mentally and emotionally.

On the medicine side, we had a man admitted for nausea and abd pain with bilirubin levels that rose from 12 to 18; we were just watching him turn more yellow each day. Liver biopsy just showed EtOH disease, and surgery said his GB was fine and didn't need to be removed (patent bile duct). When I left the service they still didn't know what to do for him. Then we had a 20-year-old girl with a horribly displaced hip due to Legg-Calve-Perthes dz that ortho won't operate on b/c she's too young for a hip replacement, so she's here for pain management and inpatient rehab almost indefinitely b/c her insurance won't cover acute rehab. They both wanted answers as to what would happen to them next, answers I did not have.

The heme-onc side was no better. One patient who's been on the service longer than me was a 35-year-old woman with metastatic breast cancer. She has jaundice, massive ascites, and major LE edema due to her liver mets, not to mention horrible back pain, but she's fighting the cancer the best she can for the sake of her husband and two kids. Her support system is excellent, as she always has either her mother, husband, or sister at her side, but when I see her CA27-29 rising week by week I know the chemo is not working. Then there was an older woman with CLL and extensive lymphadenopathy who'd been spiking fevers of 101-102 almost every day for the past week or so, and every night we drew cultures on her only for them to be negative. My last day at work, she was frustrated with the daily lab draws and was refusing further cultures. She accused us of causing her nothing but more pain ever since she was hospitalized, and I always dreaded going to see her because she would always accuse me of not doing anything to help her (whether it was making her LE edema go away, help her cure her constipation, etc). Every time I left her room I felt like I just took a beating.

To make things worse, the last week of this rotation I became sick with what started as nasal congestion but later progressed to full-blown sinusitis. I constantly felt feverish (even though my thermometer kept claiming my temp was 97.7 at the max) and kept wads of tissue in my coat because I couldn't breathe. Nyquil and Dayquil did nothing to help, though Sudafed helped a lot. My resident could tell I was miserable and once told me to lie down in the call room while he took my phone (we carry SpectraLink phones at this hospital so we can be reached easily). That gave me about 30 minutes of uninterrupted sleep, which I desperately needed. I ended up writing myself a script of Amoxil (signed by a fellow intern), which I believe is working, but what I really needed and could not get was sleep. While I was sick, I kept waking up in the middle of the night to either blow my nose or because I was too hot. The night before I had overnight call, I woke up with belly pain and ended up throwing up (mild food poisoning). Fortunately that was a one time thing.

I ended my last week on a black weekend, with overnight call/night float this past Sunday. And that was when everything went to hell. My CLL patient developed yet another fever but had such a bad case of rigors, shaking, and tachypnea that I was afraid I'd have to send her to the unit (especially after her CXR came back reading "mild failure"). Fortunately the rigors subsided and she fell asleep, but damn that scared me. Then my other patients all wanted to "talk" to me, and I wondered why they couldn't ask to talk to me during the day rather than at night. Sometime around midnight, I developed a headache and felt myself getting warm again (see what no rest will do to you despite being on antibiotics?), and I was afraid the hell would never end. Fortunately I only got about 4-5 phone calls after 1 a.m. and got a few hours of sleep. The overnight resident took pity on me and didn't call me for any admissions (to which I'll always be grateful to him for), but did snag me and the intern at 1:30 a.m. to teach us about how to manage hyperkalemia. In that case, the teaching was warranted (I had a pt with a K of 6.1) and helpful. And once my shift ended, I went home and spent most of the day in bed, relieved to be done.

Now I have 2 weeks of heme-onc elective ahead of me, and I think this will give me a chance to see if I really like heme-onc or not. If my last month was any indication, I don't know if I can deal with the emotional burden that comes with being an oncologist. But the interest is still there at least.