The Weekend From Hell

Anyone who follows me on Facebook knows that I'm not the type of person who posts every day. This weekend was the exception. After returning home from 2 weeks of traveling in Sapporo, Bali, and Seoul, I was assigned "pit boss" duty, meaning that I take calls from the ED from 6am-12pm and distribute admissions among my partners. It also meant that on Monday morning I had to redivide our ENTIRE weekend census in order to even out everyone's census (since the total number of hospitalists rose from 8 on the weekend to 12 on the weekday). That was my first time "making the list" and it took me a good 2-3 hours (got to the hospital at 4:45 am, didn't finalize the list until after 7 am), but in the end I was satisfied with my work. Some of my partners have done a crappy job of dividing the list (where half of my patients from the previous week went to other people), but most of us who are off for the weekend want our old patients from the previous week back. I, of course, had a brand new census of people whom I'd never met before, but fortunately the average census was 14-15 people. I even took an extra  admission on Monday because I had room to spare (my "desired" census is 15 people/day) Stupid me, I thought being the pit boss meant I had to physically be in the hospital by 6 am (not true), and when one of my partners finally told me on a Thursday morning, I thought, "Oh, then on Friday I'll come in at 7:00." Big mistake.

Normally our group has a rule that there has to be ten hospitalists rounding on any given day so as to not overwhelm anybody. On Thursday there were 11 hospitalists; two were "charity" helpers (one was from another hospital, another should be post-night float but chose to work to earn extra money) and deserved to be off. The other, one of the senior partners, gave no notice except for a note on the board: "Off 3/1, back 3/2." Incidentally, the census at the hospital exploded to maximum capacity. So we went from 11 hospitalists to only 8 hospitalists (which is the number that typically works on weekends), and our individual census rose ridiculously high. I had left the hospital on Thursday with 13 patients; on Friday I had 22.

Some of the remaining partners were pissed, and rightfully so; one had only 11 patients left on Thursday, and she'd made a doctor's appointment for the afternoon. Another had just worked 2 straight weekends and was hoping for a easy Friday. Never mind that I was on call at 5 pm. The lowest census anyone had was 22. This was, essentially, a 3-day weekend type of census. It took me until 7 pm to see my inpatients and 1 consult, and then I got 7 admissions from the ED. In my six months here the hospital had never been so busy before, even during Christmas. The ED was holding 12+ admissions in their rooms because there were no more inpatient beds available; there were even stretchers in the halls, which almost never happens. I didn't see my last new admission until 11 pm; by that time I was pooped. Most people try to dictate their H&Ps while they're in the hospital, but I was so tired and sick of work I went home, showered, and then dictated from home. Then did my billing for the day. I didn't go to bed until 2 am. That day I saw 30 patients.

I need at least 4 hrs of sleep to function, so I woke up at 6, drank coffee to stay awake (which was against my better judgement; coffee in the morning makes me ill), and rolled into work around 7 am. Because I was tired, I wasn't able to keep up my usual pace, and by noon I'd only seen 11 of my 27 patients (including one new admission, which fortunately for me was straightforward syncope.) Of course, of those 10 I'd discharged a few, and discharges always slow me down. As expected the coffee gave me an upset stomach, so I was pretty much in misery the entire day. I didn't see my last patients until 7:30-8:00pm, just in time to hear one of my patients complain that he hadn't seen me all day. Total census that day: 28 patients. I discharged 7 and got my census down to 21.

Fortunately the admissions slowed down so that I only got 1 new admission overnight. I felt much more refreshed after getting 6 hours of sleep (rather than 4), so I was a bit faster. By noon I'd seen 13 patients and discharged 4. The call was not bad either; only 3 new patients. The problem was that a lot more patient families were visiting on the weekends, so I had to take time to speak with them (which sidetracked me), so I didn't see my last admission until around 8pm (again). I discharged another 7 patients and got my census down to 18. When I got home, I calculated that in the past 3 days, I'd worked 44 hours, examined 83 patients, and never saw the sun except from inside the hospital. Wow.

Residency nowadays cannot prepare future hospitalists for this kind of work. Not with patient caps of 14-16 and duty hour rules where an intern cannot work longer than 16 hours at a time. Now I understand why my pod leader looked concerned when I told her on my interview day that I never saw more than 14 patients on any given day; she was probably afraid I wouldn't be able to handle the workload here. I think she took quite a leap of faith in deciding to hire me, and I'm glad to say I made sure she didn't regret her decision. I heard her tell another interviewee that she thought I'd have trouble because I was "green" (complete rookie with no real life experience), but that I learned very fast and was doing pretty well. My other partners, too, have told me I'm doing a pretty good job, and one of the cardiologists told me that they missed me while I was on vacation ;). "You're a workhorse," he'd said. Guess that means I contribute to the group =)

Fortunately this month I'm based at a nearby rehabilitation hospital, which promises to be easier. Hope so.