How It’s Done: Part One

A Day in the Life of an Intern.

Medicine Rotation. Two weeks down, three to go. Saturday morning. Today is “long call,” meaning that we will be here overnight as opposed to “short call” where we are the admitting team until two PM.

0530: I have the alarm set for 0545 but why bother? My eyes are open and if I go back to sleep I might sleep through the alarm and I’m not even sure if I turned it on last night. Had a dream that this was a day off and I could sleep in a little. Maybe until eight which I haven’t actually done since we had our first child almost nine years ago. Very disappointed when I realized that not only was this not the case but that this going to be a long day. Shower, shave, brush teeth. My black lab Persephone stumbles off the bed and lays down on the bath mat outside the shower as she does every morning.

0600: Check my email. My program is always sending threatening emails. I need to submit my duty hours for the last two months but the online software for this is pretty crappy and to enter my hours will take an hour or two which is why I haven’t done it. To hell with it. I’m certainly not going to do it now. Why are they bugging me about all the bureaucratic stuff anyways? I’m starting my new program in three months. What does it matter? Persephone has followed me downstairs and lays at my feet. My wife walked them (I have five dogs) at around four so I don’t really need to let her outside this morning. It’s raining anyways.

0610: Grab my pager, PDA, keys, straighten my tie, grab a couple of bagels and Cherry Diet Coke and head to work.

0630: Time to run the list. Only seven patients on the census this morning. we cap at seven admits. ICU admits, handled by the third year resident, count as two. Theoretically the list could get as high as fourteen but we have a few we can discharge today and a few rocks who are stable but immobile (with no expectation of discharge) and whose notes and plan should be easy to manage as it is essentially the same from day to day.

Mr. Smith, an incredibly emaciated man suffering from cancer who was admitted for pneumonia fell out of his bed ten minutes before I arrived I am informed by the on-call intern during a brief sign out for my team. Neurologically intact. Nasty knot on his forehead. He just bought himself a head CT. Do I need contrast? How is his renal function? Doesn’t matter. Non-contrast is indicated here. Renal function excellent but we have to supplement his mag and phos probably due to refeeding syndrome.

Mr. Jones liver function enzymes are normalizing. Liver biopsy tomorrow. Many nodules on his MRI suspicious for malignancy. Mental status at baseline which is not good. Still in restraints. Electrolytes OK. Renal function improving. Pneumonia, his presenting complaint buried among his competing co-morbidities is resolving. Still in respiratory isolation because once you start working somebody up for TB you have to carry on to the bitter end.

Ms. Green can go home. She has ruled out for an MI.

Ms. Black, still NPO. Fluids still running. Pain control. Treatment of choice for acute pancreatitis. Where does she get the money for her booze and heroin? We’ll start her on a clear diet today and advance to a regular, optimistically low fat, low salt diet if she tolerates it.

Mr. Good, you had us worried for PCP what with your HIV and an unknown CD4 count. It was nothing. Just Community Acquired Pneumonia. I’m not surprised you can’t afford your prescription for moxifloxacin. The remaining ten tablets will cost you close to thirty bucks which will seriously eat into your cocaine money. Don’t worry. We’ll hook you up. We always do. You have never, apparently, accepted responsibility for anything in life and it would be negligence on our part to expect this of you now.

0700: Meet with third year resident in charge of my team. The team consists of me, a medical student, a PA student, and the resident. Four teams, of course, as we are Q4 call. We run the list looking at everyone’s labs, vitals, and meds. On the computer, believe it or not, so I don’t have to run around collecting data. My resident is very thorough, very knowledgeable, and a pleasure to work for. Very efficient, too.

0720: Time to start seeing patients. There are two admits in the Emergency department already. This is goods news. Maybe we’ll cap early, like in the afternoon. This means that we might get some sleep. My resident goes to admit them, I start pre-rounding. The medical student and the PA student are each going to pick up one of the admits. I have five notes to write and one to co-sign. Not to mention new orders, as appropriate.

0740: Mr. Smith’s G-tube was pulled out as he fell. Did they save it? No. It’s in the trash. Rats. They should have tried to reinsert it immediately. Now the fistula has closed and the not even a narrow feeding tube can be inserted. Oh well. He will have to wait until Monday to eat because today is Saturday and interventional radiology will not come in today to replace the tube. Now I have to switch all of his “VT” (via tube) medications to IV. And there are quite a few. It’s things like this that eat up time. Fifteen minutes here, fifteen minutes there. Pretty soon it’s time to round. Surprise. Interventional is in house for an emergency and they will take Mr. Smith after they are done.

0900: Rounds. Sit down rounds in the resident’s work room. The best kind. We quickly review the old patients updating the attending on changes n condition or plan. The team going off call presents their new admits.

1000: Rounds. Only the interesting patients. Nine of us in the patient’s room while the medical students present. Mr. Clark with alcoholic pancreatitis which is being conservatively managed. NPO (no food, no water), IV hydration, and pain control. Mr. Marks with altered mental status, two year history of dementia who was finally LP’d (lumbar puncture, that is, a spinal tap) on this visit to the ED and who’s spinal fluid was VDRL positive leading to the diagnosis of neurosyphilis. How often do you see that? Penicillin in huge quantities has almost cured him. It’s miraculous, really.

1200: Work Rounds: Time to make sure all of the new plans for all the patients are implemented as orders to the nurses. New lab values and imagining needs to be followed up. Some patients can be discharged. The case managers are worth their weight in gold and you find yourself shamelessly kissing their asses as they alone can arrange skilled nursing care without which a patient like Mrs. Doe who has been on the floor for 170 days will never leave. You try to be compassionate but some patients overstay their welcome. You get tired of writing the same note every day and doing the same physical exam with the same findings. Can we make a big rubber stamp with the entire daily note and I can just pencil in the date. “Plan: discharge pending placement in skilled nursing facility.”

1400: Does every patient have a note? All are the labs ordered for tomorrow. Have all the labs been checked from yesterday? Anybody’s ions low? High? If so, why? Supplement the usual electrolytes for the gentleman detoxing up on the seventh floor. Slightly shaky but no real tremors. We had him on the alcohol withdrawal protocol and I guess he doesn’t really need the ativan but he is kind of squirrelly so we put him on standing ativan orders anyways. We will wean him tomorrow, or rather he will wean himself after discharge if he follows the instructions on the prescription. Either that or he will sell the ativan to buy booze. He complains about the ten bucks per month his blood pressure medicine will cost him. Ten bucks? Come on. That’s two bottles of Mad Dog.

Miss Purple, I know you don’t feel like going home but this is not a hotel. Of course we won’t just throw you out. The social worker has a taxi voucher for you. I’m sorry your life is a mess but nobody holds a gun to your head and makes you smoke crack. You’ve been off it for a week here recovering from your mysterious CVA-like episode so you obviously can do without it.

1500: Two new admits in the emergency department. The first has an impressive GI bleed. Shall I check his stool for occult blood? Couldn’t hurt…but he has passed about a 400 ml of blood in the thirty minutes he’s been down in the ED. A hematocrit (percentage of red cells in the blood) is 12. 40 is normal. The technetium scan showed an upper-GI source. But this is wrong because a later arteriogram showed a diverticular bleed which will be embolized by interventional radiology shortly. Young guy, too, so while diverticular disease is a possibility he may also have AVMs and we will work him up for this as soon as he is stable.

The second patient is 95 years old. In surprisingly good health until recently. No real medical history except an appendectomy back in the Truman administration. Had a fall. The EMTs reported slurred speech but once he gets his dentures in he’s perfectly coherent. Swears he tripped over his bedside commode. The usual syncope work-up, of course, including a head CT but the real concern is that he lay on the floor for twelve hours before he was found by his daughter. His serum myoglobin and CK are sky-high from rhabdomyolysis. A big risk to his kidneys so we will gently hydrate him with IV fluid. Gently because he has some congestive heart failure, undiagnosed until now, but revealed by his distended jugular vein and “pitting” edema in his legs. His lungs are clear so we’re not that worried about giving him too much fluid. Dialysis will kill him even if he is a candidate so we elect to “risk” the fluids to preserve his renal function. His seventy-five-year-old-daughter can’t care for him any more and he knows he is getting weaker so we will place him in a nursing home on Monday.

A lot of paper work. History and physical. Orders. Eats up the time.

1600: The other three teams have given up their pagers so now I am cross-covering for everybody. They have signed out a few key things to watch for in their more unstable patients but nothing really serious anticipated. Still, for the next 16 hours one pager or another will go off every ten or fifteen minutes with some routine (hopefully) question about a patient who I have never seen. “Sleeping pill? Sure!” “Restraint order? Why not.” The patient in 7117 just spiked a fever. 38.3. Is that high? I have to convert to Fahrenheit. Yes. Okay. Blood cultures, urine culture, chest x-ray. Otherwise patient doing fine.

1900: Grab something to eat from the cafeteria just as it closes. Not much of a selection but the server gives me a couple of extra pork-chops for free because they are closing.

2000 to 0500: A couple more admits. Small bowel obstruction. Obvious on the KUB (Abdominal film) as large, dilated loops of bowel. This is really a surgical patient but we will admit and they will follow. A naso-gastric tube to wall suction brings almost instant relief. Her vitals and appearance improve drastically. But still dangerous.

Many, many more pages during the night. Just enough to preclude the possibility of any real sleep. Still, it’s a slow night and with the exception of some chest pain nothing really serious. Just annoying. Can so-and-so have a laxative? Can you come talk to the family of a patient you know nothing about. Nurse annoyed that I know nothing about the patient. I explain cross-cover to her. “Is that safe?” she asks.


Speed read the chart so I can sound authoritative. “Doctor, we’re not happy with the care our 76-year-old (demented, quadriplegic who should have been allowed to die peacefully after his third stroke) father is getting and we’re thinking of taking him to UNC in the morning.” You’ll make somebody on team 3 very happy if you do. Of course I don’t say that.

Respiratory therapy does not provide routine trach care. Can you please put in an order for the nurses to clear the patient in 4113’s airway every four hours?

0600: Start pre-rounding on my patients. Everybody’s vitals stable. Nobody’s labs too far out of whack. Write a few notes before rounding with my upper level at seven.

0700: Round with the upper-level who has had to mange our MICU patients most of the night as well as supervise the admissions. I always seem to miss something. I’m family medicine so we don’t spend as much time on the wards as the internal medicine interns.

0900: Attending rounds. Rounding on the new admits. Present the interesting ones at bedside. Time drags on. Enthusiasm for the minutia at it’s lowest ebb. Important to stay focused and answer the attending’s questions intelligently. The student’s presentations are maddening in their thoroughness. Look, it was just exertional chest pain of sudden onset relieved by rest and nitro. Do we really need the detailed description of the patient’s home life? This is why I am going into Emergency Medicine. Thirty minutes is just too long to talk about one patient.

1100: Now the mad dash to finish up all the work and tweak the plans for the new patients before 1:00PM when we have to be out of the hospital. The day float helps. We have thirteen patients now and there is a surprising amount of work to do. The new admits need brief notes. All the labs have to be checked and the imaging reviewed to make sure that everyone is lined up for Monday. It is Sunday morning and nothing routine will get done. Just emergencies but don’t hold your breath. Don’t get sick on a Friday at a community hospital.

1315: Everything done. Signed out to the on call intern. Out the door into the blinding sunshine. Short drive home. Kids watching cartoons before church. Maybe I’ll skip today and take a nap. Persephone brings the Frisbee to me so I have to go throw it for her in the front yard. She’s a real Frisbee dog and can catch them in mid air. The kids think she is a wonder dog.

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