The last week of MICU went pretty smoothly. I got to be pretty good at transferring patients out of the unit. Two of my patients who had been in the unit since July finally got well enough to transfer to the PCU (much to the dismay of the PCU intern, who said that every other transfer note coming to the PCU was written by me) One of my calls was hectic b/c a nurse kept pestering me about a patient's BP being 220/104 (she was asymptomatic), and when I called the fellow, his response was to ask me whether I knew the difference between hypertensive emergency and hypertensive urgency. Ohh. *sigh* Good thing I called while he was eating dinner and not in the wee hours of the morning; he must have thought I was dumb.
As "luck" would have it, my very last shift of MICU fell on a Sunday, and I was overnight until Monday morning. It was just me, the overnight PGY3, and the pulm/crit care fellow for the afternoon and a good part of the evening. One of my patients developed a bad leak in her trach (which, after what happened with the patient in my last entry, had us very worried), and after way too many tidal volume readings of 50-200 ccs, we had anesthesia come to reintubate her (but not before she got bronched and had a huge mucus plug that had been blocking her left carina sucked out; that was part of the reason why her tidal volumes sucked). No one wanted to take the chance that her trach would last until morning. My PGY3 wasn't around while all this was happening, and later the fellow asked me if this sort of absence was normal. I told the fellow that my PGY3 was easily reachable by phone if I ever needed him, but silently thought, "Yes, this is normal." We had a patient close to death after her family withdrew care, and when I asked him if he wanted to be notified of her passing, he said no. "You know what to do, right?" he said. Yes, I did (he made sure to teach me when we had our first death), so I pronounced her, filled out the packet, and called the fellow when it happened. Don't get me wrong, I liked having independence in the unit, but I thought the PGY3 could have shown a bit more interest in the patients. He never even asked about her until the next morning.
Another of my patients, SS, had continual bleeding from her permacath site (oozing). Not wanting to bother Zael, I ordered thrombin spray and gave her platelets, blood, and FFP. Nothing truly worked, not even after I applied pressure for 15-20 minutes. When my resident showed up in the morning and I told him what happened, he asked if I gave her DDAVP. -__- Nope. He asked me why I didn't call the PGY3 for help or advice. It hadn't occurred to me b/c I'd asked one of the overnight triage residents for help, and she'd never mentioned DDAVP to me. *sigh* That was negligence on my part; I guess I should be lucky she didn't bleed to death or else I'd really be in trouble. I felt bad for letting my resident down; just last Friday, when I asked him how I did on my rotation overall, his only critique was that I had to know when to ask for help so that I won't get overwhelmed on the job. And what happened? I didn't ask the PGY3 for help about my bleeding patient because I didn't want to wake him up. *sigh*
Now I'm starting ambulatory, which involves spending half-days at different departments and specialties (ENT, rheum, cardio, nephrology, to name just a few) to get an idea of what outpatient medicine is like. I'll have weekends off, hours are 7:30-5:00 pm. No complaints =)
Monday, September 14, 2009
Sunday, September 6, 2009
MICU: Death on Call
When my resident was last on call, he admitted a very ill woman with a history of ovarian cancer who was dying of septic shock (I almost had to write an H&P on this woman last month, but then triage gave her to someone else. Otherwise I would have known her better). Yesterday evening the family decided to withdraw care, and after she died (surrounded by about 15-20 family members), I was called to pronounce her dead. It was very unnerving to be listening for heart/breath sounds, feeling for pulses, and checking the eyes in a completely silent room full of strangers, but when I explained my findings and said she was gone, the family took it well. After that, while the family grieved, I went to make the necessary phone calls (to admissions, her heme-onc attending, Gift of Life) before filling out the death packet. Needless to say I wasn't too amused when two of my fellow interns came into the MICU and tried to trick me into thinking that I'd be covering their patients for them tonight. Lousy timing on their part.
Shortly before midnight I got a call about a patient named Melvin whom the nurse suspected had aspirated on tube feeds, so I got a CXR that turned out to be normal. Several hours later the nurse called me again saying that he was making gurgling sounds in his (relatively new) trach (he had end stage HIV and was completely out of it mentally). Since it was close to morning at the time, I said I'd pass the news on to the R3. Everything was fine until around 7:30-7:40 a.m., I was writing notes on another patient when one of the nurses asked me to call surgery because he was really having trouble breathing. I got the pager number for the surgery intern/resident on call, but before I could do anything with it, I heard a lot of people saying that he was bradying down and someone called for the crash cart. Oh #$@%!!
Even though I'd already handed my code pager off to Dave, I was close to the room and immediately went to see what was going on. The overnight R2 was giving chest compressions and I immediately went to help him out. This was my first time doing compressions and the fellow said I wasn't pushing it deep enough. "Don't stop, keep compressing! One inch depth!" he yelled. It was a messy code. There was a lot of moving and shifting around as the patient had his trach changed (assuming it was the trach that caused his intial hypoxia), and then anesthesia came to intubate him. The table was too high and I had to stand on my toes to do compressions, and even then I knew my compressions were subpar. At one point the nephrology attending (who just happened to be nearby when the code happened) had to do compressions while I had to move to the other side o the bed. The fellow kept yelling for someone to call the code officially so that more housestaff can come and assist (the R2 and I each got tired out pretty quickly), but unfortunately no one ever called the code. Surgery did arrive because he got paged overhead, and then he and the fellow got into an argument about whether or not the patient was shockable or not. "He's in asystole!" the fellow yelled. Surgery yelled back, "He had a shockable rhythm!" Fellow: "That was with compressions!" Surgery: "No, it wasn't!" It went like that for a while, and despite the injections of epi, bicarb and more, the patient was still in asystole. Now that was definitely unshockable Finally the fellow said, "Any other ideas?" The surgeon shrugged and said, "I'm ready to call it if you are." Time of death: 8:06 a.m.
The atmosphere in the room was grim as we left, and I couldn't help wondering if there was more I should have done overnight aside from ordering a CXR on him to rule out aspiration. Later the fellow asked me if I'd done codes before. I told him that was my first code, and he said he was sorry that had to be my first one. "That was a very disorganized code," he said. "It was never called out, so it was just you, me and R2. There should have been 4-5 housestaff here. And I shouldn't be trying to keep the airway open, look at the monitor, and give orders at the same time; I should have been at the foot of the bed keeping an eye on everything going on." It made sense. Afterwards, it took about 2 hours for anyone to get ahold of the patient's family and inform them of the patient's passing (apparently they didn't visit often), but in the end, they came. Thank goodness for that.
That was more death than I wanted in one night. Thank goodness I have Labor Day off.
Shortly before midnight I got a call about a patient named Melvin whom the nurse suspected had aspirated on tube feeds, so I got a CXR that turned out to be normal. Several hours later the nurse called me again saying that he was making gurgling sounds in his (relatively new) trach (he had end stage HIV and was completely out of it mentally). Since it was close to morning at the time, I said I'd pass the news on to the R3. Everything was fine until around 7:30-7:40 a.m., I was writing notes on another patient when one of the nurses asked me to call surgery because he was really having trouble breathing. I got the pager number for the surgery intern/resident on call, but before I could do anything with it, I heard a lot of people saying that he was bradying down and someone called for the crash cart. Oh #$@%!!
Even though I'd already handed my code pager off to Dave, I was close to the room and immediately went to see what was going on. The overnight R2 was giving chest compressions and I immediately went to help him out. This was my first time doing compressions and the fellow said I wasn't pushing it deep enough. "Don't stop, keep compressing! One inch depth!" he yelled. It was a messy code. There was a lot of moving and shifting around as the patient had his trach changed (assuming it was the trach that caused his intial hypoxia), and then anesthesia came to intubate him. The table was too high and I had to stand on my toes to do compressions, and even then I knew my compressions were subpar. At one point the nephrology attending (who just happened to be nearby when the code happened) had to do compressions while I had to move to the other side o the bed. The fellow kept yelling for someone to call the code officially so that more housestaff can come and assist (the R2 and I each got tired out pretty quickly), but unfortunately no one ever called the code. Surgery did arrive because he got paged overhead, and then he and the fellow got into an argument about whether or not the patient was shockable or not. "He's in asystole!" the fellow yelled. Surgery yelled back, "He had a shockable rhythm!" Fellow: "That was with compressions!" Surgery: "No, it wasn't!" It went like that for a while, and despite the injections of epi, bicarb and more, the patient was still in asystole. Now that was definitely unshockable Finally the fellow said, "Any other ideas?" The surgeon shrugged and said, "I'm ready to call it if you are." Time of death: 8:06 a.m.
The atmosphere in the room was grim as we left, and I couldn't help wondering if there was more I should have done overnight aside from ordering a CXR on him to rule out aspiration. Later the fellow asked me if I'd done codes before. I told him that was my first code, and he said he was sorry that had to be my first one. "That was a very disorganized code," he said. "It was never called out, so it was just you, me and R2. There should have been 4-5 housestaff here. And I shouldn't be trying to keep the airway open, look at the monitor, and give orders at the same time; I should have been at the foot of the bed keeping an eye on everything going on." It made sense. Afterwards, it took about 2 hours for anyone to get ahold of the patient's family and inform them of the patient's passing (apparently they didn't visit often), but in the end, they came. Thank goodness for that.
That was more death than I wanted in one night. Thank goodness I have Labor Day off.
Saturday, August 29, 2009
MICU: Time of Death
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.
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.
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.
Monday, July 27, 2009
Yellow: First Night Float
One rule at this hospital is that night float interns work Mondays through Saturdays but get Sunday evening off. On Sundays, whoever is the overnight intern has to do double duty as overnight intern (admissions) and night float (cross cover). It's been called "Black Sunday" and was supposedly the worst night of any intern's life. Guess who had Sunday overnight call yesterday? Me.
I started getting sign-outs from the other teams (I covered a total of eight teams, the 4 Yellow and 4 Green teams) shortly after noon. For the most part things were calm until around 5 pm. Then the calls started from nurses needing orders for their patients. I let my MS3 go home at 7 pm so that she could have dinner with her husband (on top of that she had nothing to do). Shortly after that I got my first admission: a patient of Dr. RRR's with metastatic colon cancer who had exquisite abdominal pain. All I did was brush her abdomen with my stethoscope and she pushed my hands away. She wasn't really able to give me a good history because of her pain so I had to ask the ER attending what was going on.
While I was down in the ER presenting to the triage resident, I suddenly got bombarded with pages and ignored them to finish my presentation. The bottom line: this patient was not well enough to go to the floors; MICU or surgery would be a better bet. Then I got a call on my cell phone from a very impatient nurse on the 17th floor (when I didn't answer her pages, she called the operator and asked for my cell phone) practically demanding that I put in some orders for her PRONTO. Even though my note wasn't completely written (didn't elaborate on the assessment and plan), I went to the 17th floor to see what was up.
"Four things," said the nurse. "___needs a Foley renewal. ____ needs to have tube feeds held after midnight. ____is vomiting. And I need to know whether or not to give this patient (certain cardiac drug)." When I asked the nurse what indications were for giving the drug, she rolled her eyes and said she didn't know. Um, what? I looked through the sign-out list and the patient's chart and learned she was being given the drug for A-fib, and the resident had a note saying "QT < 450." Did that mean I should give the drug as long as the QT was less than 450? The QT was 380, so I told the nurse to give the drug. It wasn't until the morning, when I spoke to Alan, that I realized that the drug was known to cause QT prolongation and that it was safe to give as long as it was less than 450. Whew. Looks like I made the right choice this time around. Even still, I felt really stupid when it was all said and done.
The calls kept coming throughout the night; at best, I lay down for 10 minutes. Several of the heme-onc patients had problems, especially one from the other team who was tachypneic and agitated after getting a breathing treatment. The cafeteria was closed on Sunday nights (much to my dismay) so I ordered takeout Chinese and ate it when I had a spare minute. I also didn't eat anything after midnight until around 6:30 am when I quickly ran down to the cafeteria for breakfast. I was surprised to see medical students at 5:30 a.m.; they were on their surgery rotation and seeing patients right before their surgeries. Finally 7:00 a.m. came and I had to sign out to a new group of residents, including my own. Residents switch services one week after the interns do to give the interns a week to adjust to a new team (and pass on words of wisdom). My new resident was kind enough to let me go home at 11:30 am, but man...I hope I don't have another Black Sunday for a LONG time.
I started getting sign-outs from the other teams (I covered a total of eight teams, the 4 Yellow and 4 Green teams) shortly after noon. For the most part things were calm until around 5 pm. Then the calls started from nurses needing orders for their patients. I let my MS3 go home at 7 pm so that she could have dinner with her husband (on top of that she had nothing to do). Shortly after that I got my first admission: a patient of Dr. RRR's with metastatic colon cancer who had exquisite abdominal pain. All I did was brush her abdomen with my stethoscope and she pushed my hands away. She wasn't really able to give me a good history because of her pain so I had to ask the ER attending what was going on.
While I was down in the ER presenting to the triage resident, I suddenly got bombarded with pages and ignored them to finish my presentation. The bottom line: this patient was not well enough to go to the floors; MICU or surgery would be a better bet. Then I got a call on my cell phone from a very impatient nurse on the 17th floor (when I didn't answer her pages, she called the operator and asked for my cell phone) practically demanding that I put in some orders for her PRONTO. Even though my note wasn't completely written (didn't elaborate on the assessment and plan), I went to the 17th floor to see what was up.
"Four things," said the nurse. "___needs a Foley renewal. ____ needs to have tube feeds held after midnight. ____is vomiting. And I need to know whether or not to give this patient (certain cardiac drug)." When I asked the nurse what indications were for giving the drug, she rolled her eyes and said she didn't know. Um, what? I looked through the sign-out list and the patient's chart and learned she was being given the drug for A-fib, and the resident had a note saying "QT < 450." Did that mean I should give the drug as long as the QT was less than 450? The QT was 380, so I told the nurse to give the drug. It wasn't until the morning, when I spoke to Alan, that I realized that the drug was known to cause QT prolongation and that it was safe to give as long as it was less than 450. Whew. Looks like I made the right choice this time around. Even still, I felt really stupid when it was all said and done.
The calls kept coming throughout the night; at best, I lay down for 10 minutes. Several of the heme-onc patients had problems, especially one from the other team who was tachypneic and agitated after getting a breathing treatment. The cafeteria was closed on Sunday nights (much to my dismay) so I ordered takeout Chinese and ate it when I had a spare minute. I also didn't eat anything after midnight until around 6:30 am when I quickly ran down to the cafeteria for breakfast. I was surprised to see medical students at 5:30 a.m.; they were on their surgery rotation and seeing patients right before their surgeries. Finally 7:00 a.m. came and I had to sign out to a new group of residents, including my own. Residents switch services one week after the interns do to give the interns a week to adjust to a new team (and pass on words of wisdom). My new resident was kind enough to let me go home at 11:30 am, but man...I hope I don't have another Black Sunday for a LONG time.
Friday, July 24, 2009
Yellow 3: Getting started
There are 16 medicine teams at HUH, four in each "color" of red, blue, green, or yellow. Red is a strictly cardio service. Blue is strictly general medicine. Green is half general med, half nephro. Yellow is half general med, half heme-onc. I was assigned to Yellow 3, one of the two heme-onc services, and I wouldn't have had it any other way.
There are three attendings that cover Yellow 3, along with one heme-onc fellow, one resident, one intern (me), one sub-I, and one MSIII. We have one attending MW, the other TTh, and the other Friday, and then they take turns covering the weekend. The MW attending just finished fellowship so he's really fun and cool, as is the Friday attending, who completed his fellowship at HUH and still wears the white coat he wore as a fellow instead of an attending's coat. The TTh attending has been on the service the longest, as she used to run Yellow 3 alone. From the first day, my resident warned me that she was everything I should strive not to be (an opinion shared by most of the medicine residents and attendings). I soon found out why. She answers personal phone calls in the middle of talking to patients ("Oh, you saw___? What was he wearing today?"), she admits patients directly to the hospital without telling triage (which confuses the heck out of them and messes up the census), and she doesn't communicate that well with her partners about treating certain patients. Not the best example of professionalism.
The rest of my team is pretty cool. The fellow's really nice and approachable, my MSIII is one of the sweetest people ever (and very helpful, too), and my sub-I puts me to shame because he's so smart and hardworking, doing all the consults and discharge forms. My current resident is a PGY-3, and he took it upon himself to tell me what was expected of me as an intern and train me to become an active member of the team. "You're running the floor," he said. "The med students and I are here to help you, but this is your service." Lots of responsibility, wow. I actually get a new resident next week (they switch a week after interns do), and this one will be a PGY-2. He was an intern just one month ago, so I imagine working with him will be different from working with the PGY-3. I just hope we won't BOTH be clueless.
Now that I'm out of the ER, I also have clinic every week. My clinic is located across the street from the hospital. So far I have 2 patients per afternoon, though I expect that number to increase with time. For now, no complaints =P
There are three attendings that cover Yellow 3, along with one heme-onc fellow, one resident, one intern (me), one sub-I, and one MSIII. We have one attending MW, the other TTh, and the other Friday, and then they take turns covering the weekend. The MW attending just finished fellowship so he's really fun and cool, as is the Friday attending, who completed his fellowship at HUH and still wears the white coat he wore as a fellow instead of an attending's coat. The TTh attending has been on the service the longest, as she used to run Yellow 3 alone. From the first day, my resident warned me that she was everything I should strive not to be (an opinion shared by most of the medicine residents and attendings). I soon found out why. She answers personal phone calls in the middle of talking to patients ("Oh, you saw___? What was he wearing today?"), she admits patients directly to the hospital without telling triage (which confuses the heck out of them and messes up the census), and she doesn't communicate that well with her partners about treating certain patients. Not the best example of professionalism.
The rest of my team is pretty cool. The fellow's really nice and approachable, my MSIII is one of the sweetest people ever (and very helpful, too), and my sub-I puts me to shame because he's so smart and hardworking, doing all the consults and discharge forms. My current resident is a PGY-3, and he took it upon himself to tell me what was expected of me as an intern and train me to become an active member of the team. "You're running the floor," he said. "The med students and I are here to help you, but this is your service." Lots of responsibility, wow. I actually get a new resident next week (they switch a week after interns do), and this one will be a PGY-2. He was an intern just one month ago, so I imagine working with him will be different from working with the PGY-3. I just hope we won't BOTH be clueless.
Now that I'm out of the ER, I also have clinic every week. My clinic is located across the street from the hospital. So far I have 2 patients per afternoon, though I expect that number to increase with time. For now, no complaints =P
Monday, July 20, 2009
EM: Finale
Wow...these last few days in the ED were definitely memorable, as were the patients. One of them, a guy in his late 30s with a history of DVTs, had a note placed in his chart requesting confidentiality from his own family members, which didn't make much sense to me. When I spoke to him alone, he was really friendly, but when I tried to ask him more questions while his wife and son were in the room, he looked horrified and asked me to come back later. "Everything is confidential, right?" he asked. I didn't understand what he meant until visiting hours were over, and he confessed that his wife was not aware that he was HIV positive (which was written in his chart). Apparently he tested positive soon after they were married (about 5 years ago), and the most likely carrier was a woman he had a relationship with before he met his wife. At any rate, that's why he requests patient confidentiality on all his files, and why he didn't want to talk to me when his wife was in the room: he'd thought I'd ask about his CD4 count and other things. He stated he takes all his HIV meds faithfully and has a undetectable titer. His wife keeps a copy of his medications with him, and I saw that beside the usual HIV drugs it said, "Antiviral medication." I wonder if his wife questions just what kind of virus he has. Maybe she thinks he has hepatitis or something. My attending later commented that his wife can have him arrested and prosecuted for lying about his HIV status, but hopefully it won't come to that anytime soon.
For my last ever ER shift, I had to work from 11 pm to 7 am, and then run up to the 12th floor lounge at 7 am to pick up my patient list and immediately start working on the floors. Thank goodness Dr. PB was willing to let me go at 6:30 am so that I could start on time, and that I was allowed to leave the hospital at noon as though I was post-call. I saw only three patients, and they were all trainwrecks. Two of them had ESRD and their electrolyte levels were outrageous (potassium of 6.8!) The third was a cachetic man dying of terminal lung cancer who was in hospice care, but his wife brought him to the ED after he stopped eating and became less responsive. She was supposed to call hospice before bringing him to the hospital, because hospice patients are discharged from hospice once they're admitted to the hospital. I had to get on the phone with hospice to try to figure out what we could do for this patient, and that took up a huge chunk of my time. Even worse, all three patients had crappy veins, and we couldn't get blood from them without the help of ultrasound-guided line insertions, which could only be done by the third year resident (I knew nothing about using an ultrasound machine). Needless to say I felt useless in the ED and was all too happy to sign out to the ER intern and haul my butt up to the 12th floor, where I once again exchanged scrubs for business casual.
I immediately went to the heme-onc floor (15th floor) to get started on seeing patients. There were currently 5 in the service, not a bad number at all, and I was able to see them all and get notes written on them (with some help from my med students) before the attending arrived. Steve went to morning report but gave me his cell phone number in case I needed help. So far so good. There were three attendings who rotated through our service, two males and one female. The female doctor was in charge of the service; the other two are fresh out of fellowship and therefore more "cool." One of the male attendings came to round with us today and introduced himself to us as "Mickey." Mickey loves to teach, and we spent a good 20 minutes talking about breast cancer and its prognosis based on ER/PR/Her2-neu status. Pretty interesting stuff.
As promised, I got to leave at noon and slept for a good chunk of the afternoon. Hopefully I'll be able to fall asleep tonight.
For my last ever ER shift, I had to work from 11 pm to 7 am, and then run up to the 12th floor lounge at 7 am to pick up my patient list and immediately start working on the floors. Thank goodness Dr. PB was willing to let me go at 6:30 am so that I could start on time, and that I was allowed to leave the hospital at noon as though I was post-call. I saw only three patients, and they were all trainwrecks. Two of them had ESRD and their electrolyte levels were outrageous (potassium of 6.8!) The third was a cachetic man dying of terminal lung cancer who was in hospice care, but his wife brought him to the ED after he stopped eating and became less responsive. She was supposed to call hospice before bringing him to the hospital, because hospice patients are discharged from hospice once they're admitted to the hospital. I had to get on the phone with hospice to try to figure out what we could do for this patient, and that took up a huge chunk of my time. Even worse, all three patients had crappy veins, and we couldn't get blood from them without the help of ultrasound-guided line insertions, which could only be done by the third year resident (I knew nothing about using an ultrasound machine). Needless to say I felt useless in the ED and was all too happy to sign out to the ER intern and haul my butt up to the 12th floor, where I once again exchanged scrubs for business casual.
I immediately went to the heme-onc floor (15th floor) to get started on seeing patients. There were currently 5 in the service, not a bad number at all, and I was able to see them all and get notes written on them (with some help from my med students) before the attending arrived. Steve went to morning report but gave me his cell phone number in case I needed help. So far so good. There were three attendings who rotated through our service, two males and one female. The female doctor was in charge of the service; the other two are fresh out of fellowship and therefore more "cool." One of the male attendings came to round with us today and introduced himself to us as "Mickey." Mickey loves to teach, and we spent a good 20 minutes talking about breast cancer and its prognosis based on ER/PR/Her2-neu status. Pretty interesting stuff.
As promised, I got to leave at noon and slept for a good chunk of the afternoon. Hopefully I'll be able to fall asleep tonight.
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