About one week before Christmas I picked up a new patient from night float, a 48 year old woman named A.M. who presented to the hospital with a 5 day history of headaches. Her PCP had prescribed Fioricet with no relief. The admitting diagnosis was hyponatremia (Na of 126), and while she did seem confused at times and held her head at a stiff angle, she was mostly oriented x 3. I put her on NaCl for the day and later spoke with her husband by phone about what I wanted to do for her. He asked when he thought she'd be able to leave the hospital, and I said once we find the cause of the hyponatremia, maybe a few days.
The next day her sodium had dropped even lower despite being on IVF, so I consulted nephrology to evaluate her. She was diagnosed with SIADH and transferred to the ICU to get hypertonic 3% saline. I told the patient and her husband that she was not going to the ICU because she was sicker, it was so we could keep a close eye on her sodium. Even on the hypertonic saline, her sodium was slow to improve. It made no sense for a previously healthy woman to develop SIADH out of the blue, so I looked up causes of SIADH as a refresher. One thing jumped out at me: infection. Specifically, meningitis.
Suddenly everything became terribly clear. The headaches, the stiff neck, the "new" onset fever of 103 and her WBC jumping from 7 to 21 in less than 48 hours. The woman had meningitis; I was sure of it. I immediately ordered an LP, which was delayed b/c she'd been receiving Lovenox for DVT prophylaxis, but it showed a WBC of 400 and glucose of 12. Even still, her CSF didn't grow any organisms. I consulted ID, who believed that because she'd received Augmentin as an outpt for UTI, her meningitis was likely partially treated even before she came to the hospital. I explained the findings to the patient and her husband, who seemed surprised but accepting of the news. Her husband asked if he needed to be vaccinated against meningitis; fortunately the answer was no.
Over the next few days, the patient continued to spike fevers of 103 on a daily basis, but her WBC was falling and her sodium (I wish I hadn't let myself get sidetracked by the admitting diagnosis) improved. The MRI showed that her ventricles were slowly getting larger (compared to prior CT), and the ID attending warned me to be on the looking out for neuro changes. Then on Christmas Eve, her right pupil was noted to be more dilated so I called neurosurgery to see her. He didn't seem too impressed at first; except for a few instances of confusion where she asked her husband to hand her papers to grade (she was a teacher), she was fully awake and oriented. In any case, she was still getting Lovenox for DVT prophylaxis, and the neurosurgeon called me to flat-out say that "Lovenox and neurosurgery don't mix. My hands are tied." I felt horrible (you'd think I would have discontinued Lovenox after the LP), but again, the patient was stable and symptomatically improving so everyone felt that watchful waiting was the right approach. The neurosurgeon did, however, give the nurse a list of warning signs to watch for and to call him if anything changes.
That night everything went to hell. According to the RN, the patient was in her usual state of health at 10pm, eating KFC and talking to her sister on the phone. Then within 5-10 minutes she became completely unresponsive and her pupils became more dilated. The neurosurgeon was immediately called, and by the time he arrived my patient was on the verge of brain death (both pupils fixed and dilated). According to reports he immediately rushed her to the OR, shaving her hair off while doing so, and proceeded to place a ventriculostomy even before the rest of the OR team arrived. (It was very "Grey's Anatomy," as one RN put it). As he later told me, had he been even 2 minutes late in placing the ventriculostomy, she would have died. In all his years of practice, he had never seen someone decompensate so quickly; usually the neurologic changes are more gradual, easier to pick up. My partner said he was cursing himself for not putting the drain in sooner (and he even apologized to me for not doing so), but surely he'd forgotten about the Lovenox. Had he placed the drain in that morning, there was a risk of bleeding. Neurosurgery and Lovenox don't mix. There was nothing either of us could have done, yet in ways we both felt responsible (me for the Lovenox, him for believing it was safe to watch and wait, which really was reasonable at the time).
I told the husband that perhaps it was a Christmas miracle that allowed her to survive (all this happened right before midnight on Christmas Eve), but even then I didn't know how much she could improve. She was intubated and moved her arms and legs to painful stimuli, sometimes opening her eyes, but I wondered if she would recover. Most people showed signs of improvement immediately after the procedure, but she did not. I thought about her two children, one in high school, the other in college. How would they deal with this? And her poor husband, who has rarely left her side since her ordeal began. I didn't know what to say to him. I was off for five days for New Years, and I told him I would see him again once my vacation ended.
When I returned to work New Year's Day and our entire census was redistributed, I was disappointed to learn that my partner who'd taken care of some of my patients while I was gone had kept several of them, including my meningitis patient, on her service. In some ways it was better; she was more experienced than me. One of my former patients under her care actually coded and died on New Year's Day (his second PEA code in 2 weeks), and I was (selfishly) relieved that I didn't have to be the one to oversee the code. I asked her how my meningitis patient was doing, and the news was not good. Since I last saw her, she had become completely unresponsive even to painful stimuli, and both pupils were fully dilated and nonreactive. Brain death was confirmed shortly after midnight by the neurosurgeon, and after her family members gathered to say goodbye, she was extubated and pronounced dead at 0340.
I didn't learn that she died until this morning from my partner who had taken over her care, and we were both saddened by the news. "That was a crappy case of meningitis," said my partner. I was slightly relieved that she passed overnight; I don't know I would have been able to look her husband in the eyes after everything that's happened. To think she came in with headaches and hyponatremia (in a bitter twist of irony, her sodium had shot up to 160 the day before she died), only to be diagnosed with meningitis with the worst possible outcome. I think both the neurosurgeon and I will be haunted by this case for a long time, if not for the rest of our professional lives.
Wednesday, January 2, 2013
Wednesday, December 26, 2012
Burnt Out
I just finished working 17 days in a row. It wasn't entirely by choice; I was supposed to have Christmas off and work over New Year's, but when one of my partners quit and left on December 13, that left one person short to cover the hospital during Christmas. That meant 7 doctors for as many as 240 patients. I was supposed to work the night shift over New Year's (which I did not feel ready for), so I volunteered to work over Christmas. That way, with 8 hospitalists, the average census per physician would be 20-25, which was much preferable to 30.
The drawback, of course, was that toward the end of my 17 day stint I felt like I was losing my mind. I was averaging about 5-6 hours of sleep per night, and during the last week I was taking call from 5 to 10 pm every other day. This was a mistake on the scheduler's part; she'd originally put me down for three 5 to 10 pm calls in a row, which is straight-up suicide. There was a time when I worked back-to back 5-10pm calls, and I am never doing that again. Let me tell you, Q2 call is not fun at all, especially when most nights I wasn't physically able to leave the hospital until around midnight. And it was during one of these 5-10pm shifts that I experienced my worst call ever: 10 patients in 5 hours (capped out). Neither my partner or I left the hospital before midnight that day.
Christmas Eve was bad. There were lots of patients anxious to go home before Christmas, and I broke yet another record by discharging 9 people in one day. I couldn't even see all my patients on time because I had to see the imminent discharges first, and by the time I saw them and did all their paperwork, it was already very late. I'd had plans to have Christmas Eve dinner at a family friend's house at 6:00 pm, but I wasn't even able to leave the hospital until 6:30pm (still had 5 pts to see at 5:30pm, but I rounded extra-fast). Fortunately my friends had just started eating when I arrived, and the beef tenderloin, homemade mashed potatoes, red wine mushrooms, pomegranates, and cabernet sauvignon soon made me forget what a horrible day I had.
Christmas Day itself was better; I was still happy and smiling from dinner the night before (it was just the breather I'd needed), and I discharged two patients that were more than ready to go home. But a few bad things happened, too. A woman who had meningitis (I'll have to write a whole post about her in the near future) needed an emergent ventriculostomy for rapidly progressing hydrocephalus (went from AOx4 and talking to fixed pupils in 30 minutes), and another patient developed massive hemoptysis and went into PEA arrest during a bronchoscopy. Needless to say it was the Christmas from hell for the covering pulmonologist (who works every Christmas because he's Jewish); to quote him, this was his fourth massive hemoptysis since he first began practicing in the 1980s, and it put him in a foul mood for the rest of the day. Needless to say the pulmonology director had a lot of apologizing to do for his disgruntled colleague when he returned from vacation today; doctors, nurses, and even patients and their families complained about the other pulmonologist's unprofessional behavior. Thank goodness he's usually at another hospital.
The day after Christmas (today) was another day from hell. I'd barely seen 4 of my 22 patients when they announced "CODE BLUE, ROOM _____" (this hospital never says "Code Blue;" they use another term), and I immediately recognized the room number of one of my patients. He was an 86-year-old man who came to the hospital with a pathologic hip fracture from metastatic prostate cancer, and he'd been doing pretty well post-op. Just yesterday I was telling him that the Christmas cookies his family had brought him looked delicious. As I soon found out, PT had found him pulseless and unresponsive. The poor man had at least 2 shocks and 15 minutes of CPR (plus epi, amio, bicarb, atropine pushed into him), and when we reached the family, they asked us to keep him alive until they got there. Fortunately after the amio and the 2nd shock we got a "strong pulse" and we were able to transfer him to the ICU. There, his pressures were in the 50s-60s. I wanted to start pressors, but one of the nurses (wisely so) told me to talk to the family first. I met with the family and explained the situation, asking how aggressive they wanted to be. Fortunately they were very reasonable and his daughter said she didn't want any aggressive life-saving measures to be done. "We just wanted to see him," she said.
To me, the timing could not have been better. I would never want anyone's last memory of their loved one to be of doctors and nurses pounding away at their chests and shocking them to keep them alive. My patient had regained a pulse long enough so that his wife and children were able to see him lying peacefully in bed. They had enough time to summon a chaplain to the bedside, and they were together when the patient was extubated and eventually died. It was a good, peaceful death, which is what I wanted for him.
Of course, the whole case with this patient took up a good hour of my time, so I spent the rest of the day struggling to see the rest of my patients in a timely manner. And honestly, between the death of my patient and the fact that this was my 17th straight day of work, I was in a pretty foul mood. I told my colleagues that I felt like death, could barely keep my head on my shoulders, and was at the point where I simply did not care anymore. I spent 17 days taking care of other people, but never had time to take care of me. I didn't leave work until 6:45 p.m., and I am pooped.
Thank goodness it's over.
The drawback, of course, was that toward the end of my 17 day stint I felt like I was losing my mind. I was averaging about 5-6 hours of sleep per night, and during the last week I was taking call from 5 to 10 pm every other day. This was a mistake on the scheduler's part; she'd originally put me down for three 5 to 10 pm calls in a row, which is straight-up suicide. There was a time when I worked back-to back 5-10pm calls, and I am never doing that again. Let me tell you, Q2 call is not fun at all, especially when most nights I wasn't physically able to leave the hospital until around midnight. And it was during one of these 5-10pm shifts that I experienced my worst call ever: 10 patients in 5 hours (capped out). Neither my partner or I left the hospital before midnight that day.
Christmas Eve was bad. There were lots of patients anxious to go home before Christmas, and I broke yet another record by discharging 9 people in one day. I couldn't even see all my patients on time because I had to see the imminent discharges first, and by the time I saw them and did all their paperwork, it was already very late. I'd had plans to have Christmas Eve dinner at a family friend's house at 6:00 pm, but I wasn't even able to leave the hospital until 6:30pm (still had 5 pts to see at 5:30pm, but I rounded extra-fast). Fortunately my friends had just started eating when I arrived, and the beef tenderloin, homemade mashed potatoes, red wine mushrooms, pomegranates, and cabernet sauvignon soon made me forget what a horrible day I had.
Christmas Day itself was better; I was still happy and smiling from dinner the night before (it was just the breather I'd needed), and I discharged two patients that were more than ready to go home. But a few bad things happened, too. A woman who had meningitis (I'll have to write a whole post about her in the near future) needed an emergent ventriculostomy for rapidly progressing hydrocephalus (went from AOx4 and talking to fixed pupils in 30 minutes), and another patient developed massive hemoptysis and went into PEA arrest during a bronchoscopy. Needless to say it was the Christmas from hell for the covering pulmonologist (who works every Christmas because he's Jewish); to quote him, this was his fourth massive hemoptysis since he first began practicing in the 1980s, and it put him in a foul mood for the rest of the day. Needless to say the pulmonology director had a lot of apologizing to do for his disgruntled colleague when he returned from vacation today; doctors, nurses, and even patients and their families complained about the other pulmonologist's unprofessional behavior. Thank goodness he's usually at another hospital.
The day after Christmas (today) was another day from hell. I'd barely seen 4 of my 22 patients when they announced "CODE BLUE, ROOM _____" (this hospital never says "Code Blue;" they use another term), and I immediately recognized the room number of one of my patients. He was an 86-year-old man who came to the hospital with a pathologic hip fracture from metastatic prostate cancer, and he'd been doing pretty well post-op. Just yesterday I was telling him that the Christmas cookies his family had brought him looked delicious. As I soon found out, PT had found him pulseless and unresponsive. The poor man had at least 2 shocks and 15 minutes of CPR (plus epi, amio, bicarb, atropine pushed into him), and when we reached the family, they asked us to keep him alive until they got there. Fortunately after the amio and the 2nd shock we got a "strong pulse" and we were able to transfer him to the ICU. There, his pressures were in the 50s-60s. I wanted to start pressors, but one of the nurses (wisely so) told me to talk to the family first. I met with the family and explained the situation, asking how aggressive they wanted to be. Fortunately they were very reasonable and his daughter said she didn't want any aggressive life-saving measures to be done. "We just wanted to see him," she said.
To me, the timing could not have been better. I would never want anyone's last memory of their loved one to be of doctors and nurses pounding away at their chests and shocking them to keep them alive. My patient had regained a pulse long enough so that his wife and children were able to see him lying peacefully in bed. They had enough time to summon a chaplain to the bedside, and they were together when the patient was extubated and eventually died. It was a good, peaceful death, which is what I wanted for him.
Of course, the whole case with this patient took up a good hour of my time, so I spent the rest of the day struggling to see the rest of my patients in a timely manner. And honestly, between the death of my patient and the fact that this was my 17th straight day of work, I was in a pretty foul mood. I told my colleagues that I felt like death, could barely keep my head on my shoulders, and was at the point where I simply did not care anymore. I spent 17 days taking care of other people, but never had time to take care of me. I didn't leave work until 6:45 p.m., and I am pooped.
Thank goodness it's over.
Sunday, December 9, 2012
I Need a Dreamcatcher
It seems like death just can't leave me alone in my dreams. Last night I dreamed that a childhood friend whom I haven't spoke to in years threw himself off a tall building to his death, but not before calling me on the phone and saying, "You ready?" just before the fatal jump. What I remember most vividly from the dream was hearing his voice on the phone, then the horrible silence that told me he'd jumped, me screaming, and then the accusations that followed about who was to blame for his death.
It's strange that I dreamed about this particular person, whom I considered a close friend in our teenage years, but we grew apart after high school when he became a complete rebel. He couldn't seem to stay in school and became a gay porn model (not joking) for some time. Fortunately, from what I read on FB, he's turning his life around and making a name for himself in other ways. But still, maybe it was because of his troubled background that had me dream of him throwing himself off a building. The first thing I did when I woke up was check FB to make sure nothing had happened to him. He was fine.
But seriously...what's with all these dreams involving death? Is something horrible about to happen?
It's strange that I dreamed about this particular person, whom I considered a close friend in our teenage years, but we grew apart after high school when he became a complete rebel. He couldn't seem to stay in school and became a gay porn model (not joking) for some time. Fortunately, from what I read on FB, he's turning his life around and making a name for himself in other ways. But still, maybe it was because of his troubled background that had me dream of him throwing himself off a building. The first thing I did when I woke up was check FB to make sure nothing had happened to him. He was fine.
But seriously...what's with all these dreams involving death? Is something horrible about to happen?
Thursday, December 6, 2012
Mortality Bites
I rarely remember my dreams more than a minute or so after I wake up, but last night's dream (more like a nightmare, actually) was on a whole new level. I think it began with me being in the hospital, knowing I was ill (cancer, maybe?) and with a limited time to live. I remember looking in the mirror and seeing my face appear gaunt, with hollow cheeks (which has never happened; I've always had a round face), and having friends and family take me home, asking me what I wanted for "after I go." I distinctly remember being in a room surrounded by familiar things, looking through them, and telling my next door neighbor (whom I've known since he was a baby) I wanted to be buried with my childhood journals. It was around then that I woke up, a good 30 minutes before my alarm was set to go off, and no matter what I did, I couldn't fall back asleep. I just lay in bed, feeling uneasy.
As a hospitalist, I'm no stranger to death. Fortunately my white cloud has prevailed as I've only had to sign 3 death certificates so far since starting my job in September. Even still, I've been working three weeks straight with only 1 day off in the middle, and in these past three weeks I've seen a lot of depressing things. For example, a patient with metastatic esophageal cancer came to the hospital and decided the following day he wanted hospice. He even knew which hospice facility he wanted, and knew he wanted to be comfortable in the end. His oncologist told me 1 week later that he'd died peacefully after several days in hospice; that same oncologist also said he'd lost several patients in the past 2 weeks to terminal cancer. I had another patient with ESLD who got a TIPS in hopes that it could curb his ascites. It didn't; one week after I sent him to rehab, I ran into him in the hall on the way to IR to get a paracentesis. He'd gained 27 lbs in 1 week. "Doc, I can't do this anymore, I want to die," he'd said, "and I don't want to die at that place (rehab), I want to go home." Because we were in the hall, the only thing I could tell him was to get the paracentesis, then talk things over with his gastroenterologist and sisters.
I don't think my dreams are prophetic, but there have been a few instances in life where I had a twinge of deja vu and thought, "I think I dreamed of this before." A few dreams I recall that (fortunately) did not come true include a childhood friend being wheeled into a hospital with a needle in his arm (ironically, he's now working as a nurse in Seattle) or me being pregnant and not knowing who the father is (which will never happen if I can help it). But this dream with me dying of cancer? It could happen. I've seen young people in their 20s and 30s be diagnosed with leukemias, sarcomas, and everything in between. Some (a 31-year-old woman with ALL, a 32-year-old with metastatic rectal cancer) are most likely dead now. I've been extremely fortunate to be healthy all my life, but who knows? That could change in a blink of an eye.
Death is not something I try to think about. I've watched my parents grow older these past few years, and I dread the day I have to bury them. I hate it when my dad makes comments like, "Oh, I've probably got about 10 good years left," but the truth is he might be right. And who knows how many years I have left? Everyone would like to grow old and die peacefully, but those of us in medicine know all too well that it rarely ever ends like that. Anything can happen. I can only hope it won't be anytime soon.
As a hospitalist, I'm no stranger to death. Fortunately my white cloud has prevailed as I've only had to sign 3 death certificates so far since starting my job in September. Even still, I've been working three weeks straight with only 1 day off in the middle, and in these past three weeks I've seen a lot of depressing things. For example, a patient with metastatic esophageal cancer came to the hospital and decided the following day he wanted hospice. He even knew which hospice facility he wanted, and knew he wanted to be comfortable in the end. His oncologist told me 1 week later that he'd died peacefully after several days in hospice; that same oncologist also said he'd lost several patients in the past 2 weeks to terminal cancer. I had another patient with ESLD who got a TIPS in hopes that it could curb his ascites. It didn't; one week after I sent him to rehab, I ran into him in the hall on the way to IR to get a paracentesis. He'd gained 27 lbs in 1 week. "Doc, I can't do this anymore, I want to die," he'd said, "and I don't want to die at that place (rehab), I want to go home." Because we were in the hall, the only thing I could tell him was to get the paracentesis, then talk things over with his gastroenterologist and sisters.
I don't think my dreams are prophetic, but there have been a few instances in life where I had a twinge of deja vu and thought, "I think I dreamed of this before." A few dreams I recall that (fortunately) did not come true include a childhood friend being wheeled into a hospital with a needle in his arm (ironically, he's now working as a nurse in Seattle) or me being pregnant and not knowing who the father is (which will never happen if I can help it). But this dream with me dying of cancer? It could happen. I've seen young people in their 20s and 30s be diagnosed with leukemias, sarcomas, and everything in between. Some (a 31-year-old woman with ALL, a 32-year-old with metastatic rectal cancer) are most likely dead now. I've been extremely fortunate to be healthy all my life, but who knows? That could change in a blink of an eye.
Death is not something I try to think about. I've watched my parents grow older these past few years, and I dread the day I have to bury them. I hate it when my dad makes comments like, "Oh, I've probably got about 10 good years left," but the truth is he might be right. And who knows how many years I have left? Everyone would like to grow old and die peacefully, but those of us in medicine know all too well that it rarely ever ends like that. Anything can happen. I can only hope it won't be anytime soon.
Tuesday, November 20, 2012
Discharging the Drug Seeker
When I went to discharge my pain-seeking patient yesterday, I picked up her chart and saw a sealed envelope taped to the chart addressed to me. "For Dr. ____ Only" it read. I wasn't sure what to expect, but what I pulled out were four stapled sheets of notebook paper, both front and back filled out, and consisted mainly of a list of grievances that the patient felt had been committed against her since her thoracotomy two weeks ago. Mostly, she was furious that I'd called an "MD" (her name for the pain specialist) who was "disrespectful" and "power hungry" and did nothing to try to help her pain (as she believes a pain specialist's goal is the comfort of the patient). She also described the increased "suffering" she endured from not being able to talk to me over the weekend (it was my weekend off) and accused me of forgetting our "good relationship built on trust." She felt I put my trust in the wrong person (the pain specialist), and in her words, "I suffered since you left me and in my book and most others that is not very thoughtful practice." My mental response when I read that part: What. The. F***.
Maybe she thought that she was speaking to me as one health professional to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.
When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.
Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.
Maybe she thought that she was speaking to me as one health professional to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.
When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.
Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.
Saturday, November 17, 2012
Master Manipulator
One of the biggest challenges I've found with being an attending is learning to deal with drug-seeking patients. I had plenty of those throughout residency, but I was protected because I didn't have a DEA number and therefore couldn't write prescriptions for narcotics. If they needed pain meds, I just said, "Talk to my attending" and left it to the attending to decide whether or not to write for narcs. Now I am the attending, and I have to deal with these narc seekers directly. Sometimes it goes well, other times not.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
Thursday, November 1, 2012
A Day in the Life...
Now that I've been working for over a month, life has settled into something of a comfortable routine. In some way, since the hospitalists work independently of each other (unless we're on call), I am my own boss. I set my own hours, decide when to come to the hospital and which patients to see first, and leave when my work is done. Most days I come to work between 6:30am - 7:00am in hopes of finishing earlier (so that I can get out of the hospital sooner), but if I worked a 5-10pm call shift the night before and didn't leave the hospital until 11:30pm, then I'll usually come to work later, like 7:30a.m. (try to give myself at least 5.5-6 hrs of sleep a night). Or if I need to be somewhere by 4 pm and I have 15 patients to see, I'll come at 6:00 a.m. to give me plenty of time to work. No one ever yells at me for being late, and no one tells me how to practice medicine. I just hope that I know what I'm doing.
In the mornings, depending on how high or low my census is, I can usually expect to get some extra patients who were admitted overnight. Or, if one or two of my partners has decided to take the day off, their patient lists are split amongst the rest of us. The only rule regarding taking days off is that 10 hospitalists have to be present on any given day, so some partners use this to their advantage (i.e. take every Friday off). I once took a day off to attend hospital orientation, but since I got out in 4 hours, I ended up taking back my patients and working a regular day anyway. This is why I try to come to the hospital early; yesterday I ended up with four new patients on top of the others I already had. My "desired" patient cap is 15, so as long as my census is less than 15, I can almost always expect to get new patients every morning.
The general rule is to see the ICU and IMC patients first, and since the IMC is on the top floor of the hospital, proceed with gravity rounds. I usually stick to this rule, but there are times where I will skip a floor (i.e. if the patient's a rock) and go to a different floor where I know I have pending discharges to do. We try to discharge patients as early as possible, and those take up a LOT of time (paperwork plus dictations). I once spent almost an hour dictating a patient who'd been here for a month and miraculously survived everything that got thrown at him (GI bleed with simultaneous MI, gastrectomy, post-op CVA, etc), and that delayed time in seeing other patients. On a good day I can see 4-5 patients in an hour if they're not too complicated. The ICU/IMC patients usually take up a good 30-40 minutes per visit.
Food is free for physicians in the hospital (awesome perk!), and is usually not that bad. I've even stopped making my own breakfast of oatmeal and eggs b/c I can get the same at the hospital (plus extra fruit and bacon I wouldn't otherwise eat....) The menu has both healthy and greasy options, though my biggest weakness so far is helping myself to a chocolate chip cookie for dessert at lunch. I never ate cookies in residency b/c I had to pay for them (which I refused to do), but when the cookie is free, then all that goes out the window. So needless to say I've gained some weight. =P
Overall, more good days than bad on this job. Can't complain about that one =)
In the mornings, depending on how high or low my census is, I can usually expect to get some extra patients who were admitted overnight. Or, if one or two of my partners has decided to take the day off, their patient lists are split amongst the rest of us. The only rule regarding taking days off is that 10 hospitalists have to be present on any given day, so some partners use this to their advantage (i.e. take every Friday off). I once took a day off to attend hospital orientation, but since I got out in 4 hours, I ended up taking back my patients and working a regular day anyway. This is why I try to come to the hospital early; yesterday I ended up with four new patients on top of the others I already had. My "desired" patient cap is 15, so as long as my census is less than 15, I can almost always expect to get new patients every morning.
The general rule is to see the ICU and IMC patients first, and since the IMC is on the top floor of the hospital, proceed with gravity rounds. I usually stick to this rule, but there are times where I will skip a floor (i.e. if the patient's a rock) and go to a different floor where I know I have pending discharges to do. We try to discharge patients as early as possible, and those take up a LOT of time (paperwork plus dictations). I once spent almost an hour dictating a patient who'd been here for a month and miraculously survived everything that got thrown at him (GI bleed with simultaneous MI, gastrectomy, post-op CVA, etc), and that delayed time in seeing other patients. On a good day I can see 4-5 patients in an hour if they're not too complicated. The ICU/IMC patients usually take up a good 30-40 minutes per visit.
Food is free for physicians in the hospital (awesome perk!), and is usually not that bad. I've even stopped making my own breakfast of oatmeal and eggs b/c I can get the same at the hospital (plus extra fruit and bacon I wouldn't otherwise eat....) The menu has both healthy and greasy options, though my biggest weakness so far is helping myself to a chocolate chip cookie for dessert at lunch. I never ate cookies in residency b/c I had to pay for them (which I refused to do), but when the cookie is free, then all that goes out the window. So needless to say I've gained some weight. =P
Overall, more good days than bad on this job. Can't complain about that one =)
Monday, October 15, 2012
Loss of a Classmate II
This afternoon I checked Facebook after work to learn that another of my med school classmates, John M., died earlier today after a battle with cancer. It seems so surreal that less than four years after our class lost Kasha, now we've lost John, too. I'd be lying if I said John and I were friends in med school; we sat in different parts of the classroom and never did any rotations together. My six weeks in Corpus Christi was the closest I got to spending time with John and the rest of the "Corpus crew;" I still have pictures of us TCOMers hanging out at Sue's July 4th BBQ or Utopia (which is now closed) for happy hour. When I look back, he was probably one of the shining stars in the class, because while I've forgotten the names of classmates with whom I barely interacted, I've never forgotten him.
One of the things I remember most about John is his smile. He had a great sense of humor, and there was something about his smile that made me want to smile as well. Once during our first year, Erwin was showing me the recently-released "Ms. New Booty" music video (I am not making this up) during a break in class, and John, who was sitting several rows behind us, saw what we were watching and started laughing, too. I was initially mortified, but soon realized that John was laughing with us, not at us. His laughter was contagious, and he was no stranger to poking fun at himself on occasion. The too-small Batman and Robin costumes that he and Tony wore to the 2005 Halloween party attest to that.
I didn't know John had metastatic cancer until several months ago, when I heard the news through the TCOM grapevine. I was told that not many people knew of his diagnosis, and out of respect for his privacy I kept the news to myself. I can still remember how my mother didn't want others to know when she was diagnosed with breast cancer, preferring to go on with her life and not let cancer knock her down. John, as it turns out, was no different; after his diagnosis he continued working at his residency for quite some time. It's a question I've asked myself before: if I was diagnosed with a deadly illness during residency, what would I do with the time I had left? The selfless doctor in me would probably wish to continue my training so that I can become the best doctor I can be before I depart this world, but the larger, selfish part of me would want to quit residency, spend time with family, and travel to Japan, Paris, and other places I've yet to see. So when I heard what John was doing, I couldn't help but admire his strength and courage.
Even if I didn't know John had cancer, I could guess from his Facebook pictures that something was different. He'd lost his hair, and his face had that hollow look that I'd seen so often in my cancer patients. The only difference: in his pictures he was smiling. There were times where I thought about writing on his wall to tell him I was thinking of him, but never did, as most likely I wasn't even supposed to know he was sick. News of his death today still came as a shock to me, as it tears my heart whenever young people with their whole lives ahead of them have their lives cut short.
Goodbye, John. You will be missed.
One of the things I remember most about John is his smile. He had a great sense of humor, and there was something about his smile that made me want to smile as well. Once during our first year, Erwin was showing me the recently-released "Ms. New Booty" music video (I am not making this up) during a break in class, and John, who was sitting several rows behind us, saw what we were watching and started laughing, too. I was initially mortified, but soon realized that John was laughing with us, not at us. His laughter was contagious, and he was no stranger to poking fun at himself on occasion. The too-small Batman and Robin costumes that he and Tony wore to the 2005 Halloween party attest to that.
I didn't know John had metastatic cancer until several months ago, when I heard the news through the TCOM grapevine. I was told that not many people knew of his diagnosis, and out of respect for his privacy I kept the news to myself. I can still remember how my mother didn't want others to know when she was diagnosed with breast cancer, preferring to go on with her life and not let cancer knock her down. John, as it turns out, was no different; after his diagnosis he continued working at his residency for quite some time. It's a question I've asked myself before: if I was diagnosed with a deadly illness during residency, what would I do with the time I had left? The selfless doctor in me would probably wish to continue my training so that I can become the best doctor I can be before I depart this world, but the larger, selfish part of me would want to quit residency, spend time with family, and travel to Japan, Paris, and other places I've yet to see. So when I heard what John was doing, I couldn't help but admire his strength and courage.
Even if I didn't know John had cancer, I could guess from his Facebook pictures that something was different. He'd lost his hair, and his face had that hollow look that I'd seen so often in my cancer patients. The only difference: in his pictures he was smiling. There were times where I thought about writing on his wall to tell him I was thinking of him, but never did, as most likely I wasn't even supposed to know he was sick. News of his death today still came as a shock to me, as it tears my heart whenever young people with their whole lives ahead of them have their lives cut short.
Goodbye, John. You will be missed.
Sunday, September 30, 2012
Now the Real Work Begins
I've been working as a hospitalist for two weeks now, and I think I've settled in pretty well. During the first week I bumped my cap up from 5 to 12, and more recently bumped it up to 14. The most number of patients I've had to see so far on any given day is 12, but even that was manageable. The real challenge is going to be the weekend, when each hospitalist has to see 25-30 patients; I'm guessing I'll be at the hospital until 5 pm. The other hospitalists in the group have been very helpful and supportive in giving advice or providing me with contact information for the various specialists in the hospital. Probably one of the best parts of being an attending is that no specialist will give me crap for a consult. A surg-onc didn't mind the prospect of doing a Whipple on a Saturday when I told him about a pt with resectable ampullary CA. I had to consult one heme-onc attending twice in one day because her number was the only one I had, causing her to stay at the hospital until 7-8 pm, but when I met her in person she was gracious and thanked me for the consults. I was giving her business, after all; one of the consults was for a newly diagnosed colon CA.
One of the oncologists commented that being a hospitalist at SAMC is not all that different from residency, and in ways she is right. Because we don't do the 7-on, 7-off schedule, we can leave the hospital as soon as our work is done on non-call days (for me, that's probably around 2 pm for 10 pts). That means a certain number of people have to stay later at the hospital each day to take call and do admissions. There's two people on call between 12-5 pm, two people between 5-10 pm, and then a designated night float who does all overnight admissions. On average I take call twice a week. Some people will even volunteer to do extra calls so that they get more patients (apparently H&P's bring in the most money), a concept that's still foreign to me. I only need to support myself, and was able to do so on a resident's salary, so right now I don't feel the urge to work extra shifts for extra money. Of course, if one of the partners becomes ill and needs someone to cover their shift, I'll volunteer as long as I don't have to do two calls in a row.
This sort of schedule works well for me because I like leaving the hospital as soon as my work is done (I always hated the 7am - 7pm shifts and vice versa when doing triage/MAR in residency), and I wouldn't know what to do with myself if I had seven days off. I suppose I could moonlight if I wanted to; one of the hospitalists said that he used to work at a 7-on, 7-off hospital and would moonlight on his weeks off for extra money. Plus, at least in Austin, there's a whole lot you can do for your week off. Personally I think I'd get burned out too quickly if I had to work seven 12-hr shifts in a row that involved both admitting new patients and taking care of old ones. At least now I don't have to admit everyday.
My two week adjustment period is over. Starting tomorrow, I'll be working almost every other weekend, taking call 2-3 times a week, and seeing well more than 10 pts a day (which I've just become comfortable with). Weekends have become more precious than ever. I never did like working black weekends in residency, but that's part of the package in this hospital. As long as I make my golden weekends worthwhile, then I hope things will be okay.
One of the oncologists commented that being a hospitalist at SAMC is not all that different from residency, and in ways she is right. Because we don't do the 7-on, 7-off schedule, we can leave the hospital as soon as our work is done on non-call days (for me, that's probably around 2 pm for 10 pts). That means a certain number of people have to stay later at the hospital each day to take call and do admissions. There's two people on call between 12-5 pm, two people between 5-10 pm, and then a designated night float who does all overnight admissions. On average I take call twice a week. Some people will even volunteer to do extra calls so that they get more patients (apparently H&P's bring in the most money), a concept that's still foreign to me. I only need to support myself, and was able to do so on a resident's salary, so right now I don't feel the urge to work extra shifts for extra money. Of course, if one of the partners becomes ill and needs someone to cover their shift, I'll volunteer as long as I don't have to do two calls in a row.
This sort of schedule works well for me because I like leaving the hospital as soon as my work is done (I always hated the 7am - 7pm shifts and vice versa when doing triage/MAR in residency), and I wouldn't know what to do with myself if I had seven days off. I suppose I could moonlight if I wanted to; one of the hospitalists said that he used to work at a 7-on, 7-off hospital and would moonlight on his weeks off for extra money. Plus, at least in Austin, there's a whole lot you can do for your week off. Personally I think I'd get burned out too quickly if I had to work seven 12-hr shifts in a row that involved both admitting new patients and taking care of old ones. At least now I don't have to admit everyday.
My two week adjustment period is over. Starting tomorrow, I'll be working almost every other weekend, taking call 2-3 times a week, and seeing well more than 10 pts a day (which I've just become comfortable with). Weekends have become more precious than ever. I never did like working black weekends in residency, but that's part of the package in this hospital. As long as I make my golden weekends worthwhile, then I hope things will be okay.
Tuesday, September 18, 2012
First Day of Work: Plagued by Doubts
Yesterday was supposed to be my first day on the job, but since I wasn't assigned a user name for computer log-ins until the morning (apparently someone forgot to sign my credentialing papers on Friday that would have allowed me to start work on time), I had an extra afternoon off. My morning, instead, was spent familiarizing myself with the layout of patient charts and learning how to use the EMR at this hospital. Some of the attendings suggested that I could shadow someone for the day, but I respectfully declined. These guys had patients to see; I didn't want to take away from that time by having them babysit me.
Back in February I accepted a contract from a hospitalist group that works in various hospitals around the city; I would be spending most of my time in one particular hospital, the SAMC. The SAMC has only 200 beds, but our group cares for the majority of the patients. There are about 15-16 hospitalists at SAMC, and each one sees 12-15 patients daily on average. Fortunately for me, the "pod leader" of the hospitalists was going to start me off with 5 patients, and no call for the rest of September until I learn to do things around the hospital. That's more than kind. One of the hospitalists (who shares my last name) made a point of taking me to different nursing stations and introducing me to the nurses, for my sake as well as his (i.e. please specify which Dr. ____ you need, the male or the female). Most of the nurses knew of my arrival and were both welcoming and happy to see me. "You guys just keep hiring!" one charge nurse commented; before I arrived, another woman started in July, and several people started working in February.
After 2.5 months of "freedom" from medicine (1.5 of which was devoted to boards), I was eager to get back to being a doctor again. Five patients doesn't sound like a lot, but on the first day, I probably averaged 45-60 minutes per patient because I wanted to be thorough. The safety net I had as a resident is gone; there is no attending to tell me what to do because I am the attending now. Sure, I can ask my more experienced colleagues for help, but I need to show them I can stand on my own two feet. Fortunately I was given relatively easy cases (nothing in the MICU): three chest pain rule-outs (one went to cath, two got stress tests), one rhabdo, and one N/V with elevated troponins.
Even though I was pretty sure I knew how to take care of my patients, even after I went home, a lot of things nagged at me. My rhabdo guy also presented with sky-high LFTs; was it safe to attribute the LFTs only to the rhabdo when the RUQ U/S just showed a fatty liver? At the hospital I was able to justify not getting GI involved; at home, I wonder if I am doing the right thing. I also noticed his chloride was creeping up, possibly due to all the NaCl I'm giving him, but how high is too high? One attending suggested I treat him with a bicarb drip because his CK exceeded 50,000, but his bicarb and creatinine were normal and CK was falling with fluids so I chose not to do so. Then one of the nephrologists called my cell expressing concern that her patient was having worsening back pain and may need an MRI (despite negative films). A cardiologist paged me at 6 pm to let me know one of my chest pains had a negative stress test; had this been hours earlier, I might have discharged her. Another chest pain just needed his cardiologist's input as to whether he can go home; I asked the nurse to call me once they had an answer; they never did. I just know I'll feel really bad tomorrow morning if I find that one of the on-call partners had to discharge my patient for me.
This is probably the toughest part of being a brand new hospitalist fresh out of residency: even after I go home, I find myself worrying about whether or not I did the right thing for my patients. Some of this may be attributed to lack of confidence; I was never the smartest resident in my class, but I tried to make up for it with being hardworking and responsible. I imagine it'll take some time before I'm truly comfortable being a full-time hospitalist, but for now, I'm willing to take things day by day.
Back in February I accepted a contract from a hospitalist group that works in various hospitals around the city; I would be spending most of my time in one particular hospital, the SAMC. The SAMC has only 200 beds, but our group cares for the majority of the patients. There are about 15-16 hospitalists at SAMC, and each one sees 12-15 patients daily on average. Fortunately for me, the "pod leader" of the hospitalists was going to start me off with 5 patients, and no call for the rest of September until I learn to do things around the hospital. That's more than kind. One of the hospitalists (who shares my last name) made a point of taking me to different nursing stations and introducing me to the nurses, for my sake as well as his (i.e. please specify which Dr. ____ you need, the male or the female). Most of the nurses knew of my arrival and were both welcoming and happy to see me. "You guys just keep hiring!" one charge nurse commented; before I arrived, another woman started in July, and several people started working in February.
After 2.5 months of "freedom" from medicine (1.5 of which was devoted to boards), I was eager to get back to being a doctor again. Five patients doesn't sound like a lot, but on the first day, I probably averaged 45-60 minutes per patient because I wanted to be thorough. The safety net I had as a resident is gone; there is no attending to tell me what to do because I am the attending now. Sure, I can ask my more experienced colleagues for help, but I need to show them I can stand on my own two feet. Fortunately I was given relatively easy cases (nothing in the MICU): three chest pain rule-outs (one went to cath, two got stress tests), one rhabdo, and one N/V with elevated troponins.
Even though I was pretty sure I knew how to take care of my patients, even after I went home, a lot of things nagged at me. My rhabdo guy also presented with sky-high LFTs; was it safe to attribute the LFTs only to the rhabdo when the RUQ U/S just showed a fatty liver? At the hospital I was able to justify not getting GI involved; at home, I wonder if I am doing the right thing. I also noticed his chloride was creeping up, possibly due to all the NaCl I'm giving him, but how high is too high? One attending suggested I treat him with a bicarb drip because his CK exceeded 50,000, but his bicarb and creatinine were normal and CK was falling with fluids so I chose not to do so. Then one of the nephrologists called my cell expressing concern that her patient was having worsening back pain and may need an MRI (despite negative films). A cardiologist paged me at 6 pm to let me know one of my chest pains had a negative stress test; had this been hours earlier, I might have discharged her. Another chest pain just needed his cardiologist's input as to whether he can go home; I asked the nurse to call me once they had an answer; they never did. I just know I'll feel really bad tomorrow morning if I find that one of the on-call partners had to discharge my patient for me.
This is probably the toughest part of being a brand new hospitalist fresh out of residency: even after I go home, I find myself worrying about whether or not I did the right thing for my patients. Some of this may be attributed to lack of confidence; I was never the smartest resident in my class, but I tried to make up for it with being hardworking and responsible. I imagine it'll take some time before I'm truly comfortable being a full-time hospitalist, but for now, I'm willing to take things day by day.
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