Category Archives: A Day In The Life Of…

What I Do

A Day In The Life Of..., Emergency Medicine, Residency, Specialty Selection, Uncategorized

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

Stealth Medicine and Other Topics

A Day In The Life Of..., Complementary and Alternative Medicine, Residency, Uncategorized

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

Emergency Medicine Residency (Part 2: Event Horizon)

A Day In The Life Of..., Emergency Medicine, Residency, Uncategorized

(Once again, a caveat: I am a resident in a medium-sized Emergency Medicine program in an academic setting. Not as academic as Duke or USC but we have most of the players. I have never worked in private practice in Emergency Medicine so while I welcome the comments of those who have, I am describing my views of residency, not private practice. -PB)

The Spice of Life

The other night I was sitting at our PACS workstation (for viewing imaging studies) discussing a fracture with one of the orthopaedic surgery residents. In front of me were the ultrasound pictures of another patient, a woman who I was working up for a possible ectopic pregnancy. I had three charts on the table; one a lower GI bleed, one a headache (cough…drug seeker…cough), and the other a totally lame alleged intentional overdose of Seroquel. I had just discharged a four-year-old who was perfectly healthy requiring only maternal reassurance and I was keeping an eye on one of our habitual drunks signed out to me by one of my fellow residents, to be discharged when he could walk or obtain a ride home.

In no particular order, my other patients on that shift were a minor laceration to the forehead, a couple of nebulous abdominal pains, a few chest pains only one of which would probably pan out (although all were admitted), a possible meningitis requiring a lumbar puncture, a septic shock requiring the works (intubation, lines), a constipation, and a couple of drunks with whom I am on a first name basis.

That’s how I spent my night and that’s pretty typical. An occasional flat-out, full-throttle emergency, a couple of really sick people who might have become real emergencies if they had waited another few hours, some acute but non-life threatening complaints, and a whole bunch of patients who make you scratch your head and wonder what could possibly induce a reasonable human being to leave the comfort of their bed at 2AM to sit in the hall of our department eating cold turkey sammiches’. I mean, without giving too much away, let me just say that I have had vague abdominal pains at one time or another but I have never even considered calling an ambulance to take me to the Emergency Department.

So you see, while Emergency Medicine is a specialty, most of your time is going to be spent on general medical complaints, not actual emergencies. Still more of your time is going to be spent coordinating care; either referring, consulting, or admitting and a surprising amount of working up and treatment goes on before we get to that point. It is hard to get specialists and consultants to come in or admit so one likes to have a rock-solid case before calling. Not to mention that the Emergency Department has become a miniature hospital-within-the-hospital complete with admitted patients and even critical care. Consequently, the consultants and admitting physicians expect us to do a lot before we actually call, sometimes to the point of doing essentially everything for the work-up of a complicated patient including definitive care. When they start asking me the results of C-ANCA studies maybe it’s time for them to admit the patient.
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A typical shift, like March, starts like a lion but goes out like a lamb. On arriving, I grab the first chart on the rack and start the work-up on my first patient. This is the easy part. There is nothing to starting a patient’s work-up. You either have a pretty good idea what’s wrong or you can temporize by ordering studies, a tactic that will buy you anywhere from twenty minutes to an hour (one of our Emergency Departments, if you can believe it, does not have a “stat” lab and the only fast thing you can get are a few lab values off of the ABG on a critical patient). With the first patient comfortably simmering on the back burner, I pick up the next chart and repeat the process. Eventually I have a bolus of six or seven patients waiting for studies and disposition and then things slow down considerably. At a certain point you start getting close to the resident Event Horizon, that point in the space-time continuum where your efficiency drops to zero; as does your ability to see new patients without falling unacceptably behind on the ones you are following. It is surprisingly difficult to keep track of a large number of patients at various stages of their work-up.

Moving patients is complicated by the structure of residency. Our attendings, who see patients themselves, need to lay eyes on every one of our patients and approve the plan. They are as busy as anyone else so while every patient to be discharged or admitted needs their blessing, coordinating this can be difficult, particularly as our attendings are not only seeing their patients but also supervising a couple of other residents.

So if you look at a graph of my productivity, you’d probably see what looks like a huge effort towards the beginning of the shift tapering off to nothing by the last few hours. In other words, while I’m seeing my required quota of patients, once I get a certain number I lose efficiency rapidly. We typically don’t pick up charts on the last hours of our shift but by that time it’s academic anyways as most of our effort is now spent frantically trying to get rid of the ones we have. Another one of the skills our attendings try to teach us is to keep the patients moving through the pipeline without that kind of bottleneck.

Some bottlenecks, however, are unavoidable. Procedures, things like suturing or doing a lumbar puncture, can eat up a considerable amount of time if you a) are not very good at doing them and b) don’t coordinate with your nurse. Coordination is important. The nurses want to move patients as much as you do and if, for example, they have the patient moved to the OB-Gyn room for a pelvic, you need to plan to be available to do the exam when they are ready. You also need to stay on top of the labs and imaging. The sooner you can make a decision the better.
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The other unavoidable bottlenecks are critical patients and trauma, both of which can suck up large amounts of time. Critical care patients in particular, because they are not likely to be taken off your hands by surgery any time soon, can easily set you back an hour, something that many patients in with minor complaints do not understand. Reason number 1024 not to come to the Emergency Department for a minor complaint. It might seem like a good idea when you breeze through triage on a slow night but invariably there will be delays.

Contrary to the popular belief among critics and sour-grapers of Emergency Medicine, although we see some minor complaints (“I couldn’t urinate for an hour but now I can”) we do not do primary care. Oh sure, patients make attempts to get us to manage their chronic problems but you need to avoid the temptation. You cannot do decent primary care on a patient who you have never seen and will probably never see again and certainly not within the confines of an Emergency Department visit. We do not do drive-by pap smears, in other words.

Imagine how things would slow down if we did.

Just a Few Random Things

A Day In The Life Of..., Uncategorized

Fast Freddie Johnson and the Man

The patient, a young black man, eyed me suspiciously. Apart from telling me that his name was Kareem, he had said very little during the initial assessment in the trauma bay and had made it to the CT scanner and back without saying more than ten words, total, to anybody. His GCS was 15 and he was hemodynamically stable so this was initially attributed to pain and fear. Other than the obviously fractured tibia, he was uninjured but as the pain medication kicked in and things settled down he still seemed reluctant to give us any information.

A group of his friends were in the hallway outside the trauma bay and they, too, were noncommittal even in regard to his last name. They eyed the two police officers from whom their friend had been fleeing before he smashed his stolen car into a tree and elected to plead the fifth in regard to their alleged friend.

“Come on,” said one of the cops, “You hang out with this guy and you don’t even know his last name?”

Shrugs all around. They had the police in check.

“Kareem,” I said, “I’m Doctor Bear, one of the residents on the trauma service. We’re going to get the orthopedic surgeons to look at you and I imagine they’ll be taking you to the operating room to fix your fracture.

“Kareem?” said the patient’s mother who had pushed her way into the trauma bay, “His name ain’t Kareem, it’s Freddie, Freddie Johnson …Baby, why you be tellin’ them yo’ name is Kareem?”

Mr. Johnson, demoted and revealed, shot his mother an angry look and I fully expected her to deny knowing her son.

The police left after we assured them that Mr. Johnson wouldn’t be going anywhere for awhile which was probably a mistake as only one day after an ORIF (Open Reduction, Internal Fixation) of his tibia, the taciturn Mr. Johnson limped out of the hospital on his crutches and we never saw him again. I guess we underestimated his desire to evade the law. Although we never really had a conversation and he glowered at me whenever I went into his room, I can’t find it in my heart to dislike Mr. Johnson. If you have to leave Against Medical Advice (AMA) this is the best way to do it, avoiding as it does the usual song and dance, the cajoling and stroking, that these things usually entail. I have often found myself earnestly trying to persuade a recalcitrant and unappreciative patient to stay when my heart yearns to say, “Hey, if you want to leave before I can arrange to have home IV antibiotics then don’t let the door give you a staph infection as it hits you on your ass on the way out.”

Of course you can’t really say something like that.

Residency and Call Revisited.

I despise call. And I don’t care to justify my dislike for it by claiming that patient care suffers if the residents are tired. I don’t even know if I really buy into the notion that tired residents make a lot of mistakes, and frankly, I don’t care. It certainly seems like a difficult hypothesis to test and I would hate to have my sleep dictated by the results of some pointy-headed geek’s study.

No, I dislike call for the more visceral but just as legitimate reason that it is inhumane to deprive a person of sleep for anything short of combat operations or genuine medical emergencies. The problem is that everything nowadays is an emergency, even things that aren’t.

“Call” is a misnomer by the way. It’s not “call,” it’s “work.” Attendings have call. They get to go about their business until called in for an actual emergency. Otherwise they take a phone report from the resident on call and say, “Okay, admit the patient and I’ll see him in the morning.” Residents on call generally work nonstop from the early evening until they are allowed to go home the next day. If it’s not an admission in the Emergency Department it’s an issue regarding one of the many patients they are cross-covering.

There was a time, many years ago, when the whole crazy system began when resident call did not mean a sleepless night every third or fourth day. Because people routinely died from the first major illness they acquired instead of collecting them over the years and living longer thanks to medical advances, hospitals were a lot slower-paced then they are today with a more stable census for a service (as hospital stays used to stretch for weeks for things that are treated as an outpatient today) and fewer acute issues that needed to be managed. As a result, the house staff in the fifties may have stayed overnight in the hospital often but I guarantee they slept a lot more than we do today.

But, as I said, today everything is an Emergency and has to be done right away. Not only are we dealing with an older and sicker population but expectations of the public are a lot higher than they used to be. Fifty years ago it was recognized that some diseases were death sentences and the priest and the undertaker were more likely to be called than the doctor. Today, we never say die and we routinely admit, treat, and discharge people who fifty years ago could not possibly have lived long enough to acquire so many comorbid conditions. The combination, for example, of congestive heart failure, diabetes, emphysema, chronic renal failure, morbid obesity, and ischemic heart disease (any one of which was fatal a generation ago) is so common that I’m thinking of having a stamp made so I don’t have to keep writing it on the chart.

So there is very little down-time on a typical medicine or surgery service and you can count on a steady stream of admissions from the Emergency Department to keep you occupied through the night. The Emergency Department, for it’s part, is turning into a miniature and almost self-contained hospital complete with a census of admitted patients who linger in the department waiting for a bed.

What to do about it? Who knows. I only mention it because, with the exception of one month next year, this month is officially my last call month in my medical career. Nothing but shift work from here on out. Emergency Medicine, Baby!

No point, just wanted to gloat.

Letter to A Patient’s Husband
(With a nod to Scalpelorsword for the idea-PB)

Dear Mr. Jones,

I know you accused me of not caring and, on the surface, it may appear that way but I assure you the reality is more complex than that. I know your wife is morbidly obese. I know she suffers from a host of serious and eventually lethal medical conditions. I realize she was in a car accident last week but other than a few bruises, she is all right and while I can understand your reluctance to take her home, you must because she can’t stay here.

Yes, she is a big woman. In fact, she could barely fit into the CT scanner. Yes, she has trouble walking. I have had physical therapy working with here and they inform me that they have done all that they can do. I also am well aware that he has trouble breathing. This is a combination of her emphysema, her current smoking habit, and obstructive sleep apnea from her obesity. I also realize that she seems tired but as you probably noticed, she’s not getting a lot of sleep at night, particularly because she refuses to wear her CPAP mask.

Yes, I understand it’s uncomfortable. I’d hate to have to wear it myself but it’s all I’ve got in my bag of tricks.

I am sorry. We can’t keep her. She came to us in poor health after an automobile accident and she’s going to leave in the same condition that we got her because there is nothing more that we can do about her chronic medical conditions. We took great pains to rule out any occult injuries to her brain and spinal cord and she has been in the hospital on our service many, many days longer than we typically keep uninjured trauma patients, many of who we discharge from the Emergency Department after a few hours of observation.

I can understand your reluctance to take her home. I believe you when you tell me that all she does is sit on the coach and watch TV except when she struggles out of it to use the bathroom. I wish that we could send her to a skilled nursing facility but as she has no insurance and you can’t afford it, this is not an option. She may or may not qualify for Medicaid but we can’t keep her here waiting for the decision. You will just have to take her home.

How will you get her up the steps? You have two sons. I saw them here yesterday. They may live a couple of hours away but they’re just going to have to drive back to town and help their mother. She is your responsibility and theirs. That’s why they call it a family. In fact, the stability of our world depends on families acting as self-supporting units. Break the bond of family and you have either a decaying European-style welfare society dying a selfish and lingering death or a catastrophe like the former Soviet Union which proved that if everybody is responsible for everyone else, no one is.

I’m sorry to place the whole burden of Western civilization on your shoulders, what with you living in a trailer with nothing but basic cable, but there it is. She is your burden. We need this bed for the never ending backlog of patients, some even sicker than your wife, many of whom are sitting in hall beds in the Emergency Department as we speak.

So you see, it’s not that I don’t care, it’s that I can’t care. I can’t take her home with me and assign my wife as her nurse. We can’t keep her in a scarce hospital bed for the rest of her life with her own private nurses and therapists to assist her. Despite what you may have heard, we are not magicians and I we cannot cure what afflicts your wife. I’m not even sure that we could help her if she wanted our help which she apparently does not. I can’t, for example, hold the CPAP mask on her face all night against her will or force her to take insulin shots. She could have me arrested for assault. She’s an adult. We all lay in the beds we make. We’re not doing a thing for her but catering to her whims, something you might want to stop doing by the way.

She can get up if motivated. I have seen her, just this morning, heave out of her bed and transfer to the bedside commode. I suggest if she asks you for some food you tell her to get it herself.

You asked if I am sending her home to die. Of course not. But she is going to die. I’d say her chances of being alive five years from now are zero as she is a setup for all kinds of medical badness. But, like I said, we can’t keep her here for the next year or two hoping to preempt the next medical crisis. Call the ambulance if there is any sudden change in her condition.

You were right about one thing. In the end, hiring a nurse to help you at home would be a lot cheaper than the inevitable hospital costs your wife will incur over the next five years as her health continues to deteriorate and fruitless regular hospital admissions turn into fruitless and spectacularly expensive ICU admissions. But I’m just a resident. I don’t make public policy. Even if I did, while your idea makes sense economically, I’m not sure I’d want to structure society to completely remove the burden of individual responsibility.

Good Luck. I wish I could do more but I can’t.

Sincerely,

Dr. Bear

Barking Mad

A Day In The Life Of..., Medical School, Specialty Selection, Uncategorized

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Sound and Fury

A Day In The Life Of..., Residency, Uncategorized

Family and Community Medicine

Latravia Kell was my favorite patient. I can’t think of one bad hand that life hadn’t dealt her but she was unfailingly cheerful, polite, and compliant with all of her treatments. I met her on my first day of family medicine clinic and saw her at least every month afterwards. I didn’t do too much for her. She had a small platoon of specialists following her various medical conditions. Rheumatology had dominion over her SLE, Orthopedics claimed her osteopenia, Infectious Disease had suzerainty over her HIV and OB/Gyn was following her for various pelvic irregularities. In fact she seemed to have all of her bets covered and I was not sure what she needed from me.

“I’m here for my Depot shot,” she said on her first visit, “All you have to do is sign the form and the nurse will give it to me.”

“Well hell, we can do that,” I said, a little relieved because she seemed a monstrously complicated patient to inflict on an intern. “Is there anything else I can do?”

“No, not really. I’m good.”

Although we later became friends and she hugged me and cried on my last day at Duke, on her first visit I think even my brief physical exam annoyed her.

Later I had to dictate our standard clinic note hitting all of the high points of the chief complaint, history of present illness, and review of systems even though these were completely incidental to the purpose of her visit. I suppose this was to give the illusion that we were actually doing something besides routing her to the shot nurse but it seemed like a lot of sound and fury for nothing. My assessment and plan was basically a list of who was following her for what condition.

But that’s family medicine, at least at a big academic medical center.

I had other regular patients. It’s not as much fun as they make it out to be and occasionally you look at your panel for the day and hope that particular patients decide to skip their appointments.

Like Mrs. Ribitz. I knew that she was old and sickly. I was aware that her bones were fragile sticks and that she had recently fallen and broken her hip and her arm. I knew that ortho had pinned and casted her and that she was in a lot of pain. Hell, she looked terrible. And she smelled like the crappy nursing home where she lived which is not a nice smell as it is basically the smell of stale urine and dried food stains.

But my God could that woman complain. About everything and everyone. After the obligatory “What can I do for you today” she would stare at me malignantly for a few seconds and then launch into a tale of pain and suffering that would have made stones weep if it was anybody but Mrs. Ribitz telling it.

And then she would cough, gasp for air, and take a rest while sucking air through her nasal cannula. Her emphysema didn’t deter her from smoking and my eyes watered in the small examination room from the fumes that permeated her clothing.

“Well, Mrs. Ribitz,” I began while her coughs subsided, “I’m sorry to hear that things aren’t going well but if you had to pick one problem to address today, what would it be?”

“My feet are swelling,” she said curtly, “And my back hurts.”

I took off her slippers and urine-stained socks to examine her feet which were indeed swollen and pulseless, an alarming finding except they has been like that since I started seeing her and no combination of medications or therapies had been able to make a dent in the problem. I threw the Doppler on her and was able to hear the faint, plaintive sound of her tired blood struggling to supply her foot with blood. It was all peripheral vascular disease and poor medical compliance (which sounds nicer on the note than saying, “Patient is an idiot.”) She had already lost three toes to gangrene and I noted that most of the rest were heading that way. There was nothing to do as Mrs. Ribitz was the poster-girl for poor surgical candidates. I confirmed her next appointment with vascular surgery but that was the extent of what I could do for her.

“Tell me about your back pain,” I said with profound regret.

The floodgates opened and I heard, for the tenth time, the story of her chronic pain (from vertebral compression fractures) which was untouched by enough narcotics to drop a small herd of elephants, after which we both looked warily at each other. A physical exam to assess her pain was out of the question. She would probably have a heart attack from the exertion of standing up, which she couldn’t do anyways because of her hip.

“I’m out of Percocet.” A statement. “I need another prescription.”

At one time Mrs. Ribitz had a pain contract but I believe by the time she had exhausted two residents the clinic surrendered and just gave her what she wanted.

“I’ll just write you a prescription and you can be on your way.”

Mrs. Ribitz grunted in satisfaction. I verified the dates of her next appointment with ortho, checked her vitals and stood up to let the nurse wheel her out.

“And don’t even start about my smoking,” she snarled.

“Ma’am. You’re 85. I’m not your father. I’m not going to lecture you but if you want to quit I’m ready to help you.”

Surprisingly, on my last appointment Mrs. Ribitz sobbed uncontrollably and told me I was her only Doctor who wasn’t a pain in the ass and that she would miss me. I guess I kind of grew to like her myself, once I realized that her visits were primarily social calls. She had the usual cadre of specialists addressing her medical problems. All I ever did for her was write for the occasional narcotic and listen to her complaints.

Not every patient was so complicated.

“I’ve got a drip,” said Mr. Ryan nervously after the nurse closed the door.

“I guess we’re not taking post-nasal, right?” I had seen Mr. Ryan several times before.

“Naw, it’s down there.” He gestured down there. “And it hurts when I whiz.”

“Sexually active?”

“Yeah. Do you think it’s the clap?”

“Could be,” I said, “Let’s take a look…yup…certainly looks like it. Tell you what, I’ll send these swabs for cultures and we’ll treat you in the meantime.”

“Hey Doc, don’t tell my wife, Okay?”

“Maybe you need to tell her. I think she needs to know.” This is one of those moral dilemmas they’re always talking about. His wife is also one of my patients.

I had seen his wife just a week before for unusual vaginal bleeding. Of course we ended up referring her to OB/Gyn, just to be safe.

The latest fad in family medicine is identifying “barriers to care.” Naturally, some of these barriers were intuitively easy to identify. Being poor and unable to afford a doctor visit comes to mind, as does being unable because of a disability to travel to the clinic. But some of the barriers are a stretch. Being angry and deciding to express this anger by not taking one’s free prescription medications seemed kind of weak to me but this was exactly the kind of barrier I was supposed to take seriously.

One of our initial clinical assignments was to visit a patient at their home and identify their “barriers to care. My patient was an obese, pleasant, single mother of two with the usual comorbidities, all complicated by medical non-compliance. We weren’t actually supposed to say “non-compliant,” instead substituting the more optimistic and non-judgmental phrase “pre-compliant.’

Having lost her Section 8 housing because of some fraudulent activity which involved subletting her subsidized apartment while she lived with her mother, she lived in a small but adequate house, the rent for which ate up most of her meager income from the public treasury. The first thing she complained about was the poor upkeep of the house and asked me what she was expected to do about it. The social worker who accompanied me nodded empathetically as if to say, “Here, you newly minted doctor and representative of ‘The Man,’ here is a barrier to care. How will you help her over it?”

In my written report I suggested that this was a matter far beyond our scope of practice, something best worked out between the tenant and landlord either amicably or in the City small claims court. Besides, this in no way effected her access to our clinic as her visits cost her exactly nothing and a broken window and leaky faucet are not exactly homeowner’s emergencies.

My wife and I managed a housing project years ago (before my wife quit after discovering a dead tenant which is another story) and we used to get calls at 3AM demanding that we drive across town to unclog a toilet. The helplessness of the dependency class does not admit to any effort, no matter how small, to take responsibility for anything in life. The typical response to the natural question, “Do you have a plunger?” was, “I’m not sticking my hand in the toilet.”

I once got a frantic call from a tenant’s whose apartment was on fire.

“Did you call 911?” I asked.

“No. Do I need to?”

“Not unless you think I’m going to get in my private fire engine and drive over there.”

But I digress.

I also pointed out in my report that despite her claims of poverty, the patient must have had other income. She had furniture, the babies were fed, there was a large (but not extravagant) entertainment center in the living room, and I saw no signs of deprivation of any kind. The children also looked clean and well-cared for. She even had a working automobile.

Apparently her mother helped out.

Lack of daycare was another barrier to care, as it prevented her from coming to clinic even though my wife sometimes has to drag all four of my kids to her doctor’s appointments. I discovered however that while the baby-daddy’s mother, the baby-granny, wanted to take an active role in caring for the children, my patient had refused her access to her grand-children until she bought them expensive clothes as a propitiatory gift. My patient bragged about this. Apparently greed and arrogance were also legitimate barriers to care.

It turned out that she was angry. Yes angry. Angry that when she came to clinic no one listened to her concerns and nobody explained her treatment regimen in a manner which she could understand. Nor did we respect her sensibilities as an independent, intelligent African-American woman.

“I just don’t feel like you take me seriously,” was her explanation as to why she didn’t take her insulin as directed. The social worker soothed her ruffled feathers and I held my tongue. I was not kind to her in my written report. She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care.

Her anger, I wrote, was a form of transference. Impotent and ineffectual in every other aspect of life, she gave herself the illusion of control by making her social worker and the physicians at the clinic jerk like puppets to her whimsy. The clinic, after all, was probably the only place in the world where she was taken seriously. In every other venue she was just a fat, dumb, single mother without the sense to take advantage of the help she has been given by the State.

Tragic, perhaps. A crying shame and a waste of her potential, no doubt. But not a medical problem.

This report was not received well by the program chairwoman. As if I was a third-grader, I was asked to rewrite my homework, not once but twice, in order to please the sensitivities of the program. And the second rewrite wasn’t good enough either. I was asked to write it again but decided to blow it of and never heard about it again.

Mr. Smith Has an Epiphany

A Day In The Life Of..., Articles You Must Read, Emergency Medicine

I’ve got Your Back

It’s my wife. The pager displays our super-secret marital code for “Everything is all right. I just want to see how you are doing. Call me at home.”

“Hey baby,” I say when my lovely wife picks up, “How’s everything going?”

“I’ll be home in another hour. Sorry. Things are kind of busy tonight and I have a couple of patients I can’t sign out just yet…OK, I’ll see you when I get home…I love you too…bye.”

Mr. Smith sits in his hall bed and gapes.

“Don’t gape, Mr. Smith. Even doctors have families. Hard to believe, huh? You probably think that we live here which is understandable because we’re never closed and there’s always someone here when you come in with one bullshit complaint or another. It’s not like you’ve ever been turned away when you come looking for narcotics. You might not get them every time but somebody always takes you back, treats you with more respect than you probably deserve, and listens intently to your latest drug-seeking gambit.”

“In fact, I even like to go home at a regular hour if you can believe that. Sometimes I can’t because in this department we try to get a disposition on everybody before we leave, something I had almost accomplished until I made the mistake of picking up your chart. But why should I mind? My children will get to bed tonight just fine without me and I certainly spend too much time watching TV with my wife anyways. The importance of your chest pain, on the other hand, does not diminish just because you’ve been here six times in the last two months with a similar complaint. I’m pretty confident that you’re going to be just fine but I’d feel bad chasing you out if this time, and I’m just talking here, it was a real heart attack. I don’t see how the world could get along without your vibrant soul.”

“Oh no. Don’t get up. Sit. Stay a while. I’m on a hunt for cardiac enzymes and this time your blood is going to score! The normal EKG was disappointing, I’ll admit, but your constant “ten-out-of-ten” chest pain radiating up your neck encourages me. This could be the big one. You’ve just got to believe, Mr. Smith.”

“Are you falling asleep? Brave soul! Your pain is so intense that it is no wonder you seek the oblivion of slumber. It was even untouched by the morphine I reluctantly gave you before I realized who you were. I’d give you something stronger but I’m at a loss for what to give except that we both agree it probably starts with a “D”. How can you expect me to remember its name if you can’t?”

“I understand what you mean when you say that you have no power and the man is sticking it to you. On the other hand, here we are. I have a college degree, two years of graduate school, a medical degree and two years of residency training. My attending has all that plus a few years of a fellowship. You may have not graduated from high school and be the most hard-luck guy in town but you have the power to make us dance like trained monkeys just by uttering three little words:”

“My chest hurts.”

“Now that’s power. Not to mention our highly skilled nurses cleaning up your urine and the fine technicians in our lab feverishly analyzing you blood as if you were the great Tsar of Russia himself.”

“So no, I don’t mind seeing you. The paper work is not too bad. I feel kind of silly writing out your discharge instructions seeing as we’ve done it exactly the same many times before. I know you get a good laugh out of “Return to Emergency Department if pain returns and is not relieved by nitroglycerine.” I think it’s funny too. Especially that part about following up with your primary care physician. That guy is always out of town. How on earth can you follow up with him?”

“Don’t worry, Mr. Smith. I got your back. You’re covered. Sleep, gentle spirit. When you awake I hope to give you the good news that your heart is fine and Motrin, not narcotics, will ease the pain.”

Spectator Medicine

A Day In The Life Of..., Emergency Medicine

Emergency

Mrs. Jones looks like a cadaver. Her bony yellow legs stick out of the bottom of the gown. A pack of relatives clutch at each of her claw-like hands and stare confidently at the monitor over the bed.

“She’s doing better, right?” Her blood pressure had been coming up steadily. A great-grandson reads the numbers to the relatives standing in the hall who nod in relief.

“We’re giving her fluid. She was pretty dry when she came in.” I am not nearly as optimistic.

Mrs. Jones came to the Emergency Department from her nursing home. According to EMS a nurse had noticed that she was looking more cadaver-ish than usual and became alarmed when she couldn’t get a blood pressure.

“Her doctor said not to give her fluids.” The daughter is the spokesman for the relatives. “He said it would flood her lungs.”

Mrs. Jones’ medical history reads like a pathology textbook. Her congestive heart failure is the least of her problems at this point as it’s competing with severe hypovolemia, probably from diarrhea over the past several days.

“Her lungs sound pretty clear. We’re waiting for the chest x-ray but I’m pretty sure she can tolerate a lot more fluid than we’ve given her. We can always take some of the fluid off later but her organs need fluid now.”

The daughter holds up her hand.

“We want to speak to a real doctor. Our doctor told us to keep residents away from her.”

“I am a real doctor,” I say pointing to my ID badge. The family looks suspicious.

“The other doctor who was in here said she didn’t need that,” says the daughter pointing to the small bag of levophed dripping into her central line. “He said it will make her lungs fill with fluid.”

That must have been my medical student. Or maybe one of the janitors. They clearly don’t buy my explanation of the role of pressors in shock. The daughter throws me a dark look. I promise to get a real doctor to answer their questions.

Several hours later and Mrs. Jones still looks like a cadaver. According to the monitor Mrs. Jones is doing fine though she clearly has one foot in the next world. Her daughter who has become adept at reading the numbers is annoyed that we have not stopped the pressors and have not removed the endotracheal tube, something she insists we do immediately. I don’t think she’s going to be very receptive to the discussion of code status once her mother gets up to the ICU but the prognosis for her mother is grim, cheerfully normal vitals notwithstanding. Mrs. Jones is fighting myelodyplastic syndrome which has converted to leukemia, something I only discovered when I browsed through her old records.

“Why does she need to go to the ICU?” asks the daughter.

“Because she’s dying. The only things keeping her alive are the fluids and the ventilator. I hate to be blunt but surely you are familiar with her medical history.”

“Her doctor said she still had at least six months. You’re not even a real doctor. What do you know?” Some of the relatives look embarrassed. The alpha-relatives, however, are clearly not impressed with me and mutter darkly about a second opinion.

“Let’s get her up to the ICU and you can talk to her oncologist in the morning.”

Mrs. Smith has fibromyalgia. I have hardly introduced myself before her husband mentions this twice. My attending laughed when I picked up the chart. Mrs. Smith is well known to the department. A quick check of the computer shows fifteen visits in the last year for similar pain. She writhes in agony on the bed.

“How long have you had the pain,” I ask, grimly determined to think the best of her.

“Since last night…I’m paining real bad…All Over.” By this time she has learned not to point to a specific spot as we have a distressing tendency to take people at their word and order all kinds of inconclusive and painful tests and studies.

“She gets like this a lot,” says her husband, clearly distressed, “You guys never do nothing for her.”

Normal physical exam. Mrs. Smith has still not caught on that when I am listening for bowel sounds I am actually palpating her abdomen with my stethoscope. Sometimes you have to distract the patient. Neither is there anything unusual in the review of systems or the history except for pain.

“What do you take for your pain?” Her old charts record a bewildering array of pain medications. “Let me try you on some Motrin.”

“I want to speak to a real Doctor,” she says.

The nurse mentions to me that “pain lady” was sleeping soundly just minutes before I opened the curtain.

Mr. Simon’s mother hold the basin as he heaves and vomits a large quantity of red-colored fluid, spits to clear his mouth, then lays back in the bed and continues to curse at the nurses. I’d ordinarily be alarmed but the paramedics told us that his neighbor thought he was hypoglycemic and force-fed him a bottle of fruit punch. His vitals are stable and he’s not tachycardic. On the other hand alcoholics are susceptible to upper GI bleeds from ulcers, varices, and esophageal tears. We send a sample of his vomit to be tested for blood and I make sure to order a type and screen but I don’t think he is bleeding. His blood counts come back normal a few minutes later and his vomit is negative for blood.

“If you stick me again I’m going to kick your fucking ass,” yells Mr. Simon to the respiratory therapist by way of introduction. Aside from being drunk, diabetic, and high on heroin, Mr. Simon’s immediate medical problem is the inability to maintain his oxygen saturation without supplemental oxygen. When he takes off his mask, his oxygen saturation falls to the high seventies. Mr. Simon is only 29 and a heavy smoker but this is definitely not normal. I want to get an arterial blood gas on him. If he thinks the respiratory therapist is hurting him he’s going to enjoy it even less if I have to stick him.

“Stop cursing at the nurses, Mr. Simon,” I suggest gently, “They’re trying to help you.”

“I’m paying your fucking salary,” screams Mr. Simon. “I don’t need this shit from you.” Mr. Simon is what is optimistically known as “self pay” meaning he wouldn’t pay his medical bills even if he had the money.

According to his mother he went on his current binge after being dropped by his girlfriend. He had stopped taking his insulin a day before and his presenting blood sugar was too high to be read by the glucometer. The complete metabolic panel pegged it at 769 which is pretty high but everything else wasn’t too far out of whack. He also had a normal anion gap which was unexpected as the assumption was that he had diabetic ketoacidosis. His potassium was normal so we started him on a modest insulin drip.

Mr. Simon is a mystery. A rancid, abusive, tattooed enigma. His chest films are normal, his respiratory rate is normal, and his GCS is a solid 15. His ABG confirms both a mixed metabolic and respiratory acidosis and a low oxygen saturation. Pulmonary embolism? His D-dimer is low so he’s not making it easy for us. Aspiration? My senior resident starts him on clindamycin as a precaution but would he really be so hypoxic so quickly? Physical exam pretty normal too except that he feels clammy.

Maybe it’s cardiac but unfortunately is EKG is normal. Maybe the cardiac enzymes will give us a clue. I ask him about chest pain but as Mr. Simon answers some variation of “fuck you” to every question, the review of systems is probably going to be a little sketchy.

“Yeah my chest fucking hurts,” He says.

Surprise, surprise. “What does the pain feel like, Mr. Simon?”

“Have you ever had your heart chewed up and then spit back into your chest? That’s what that bitch did to me.” (He points to a scruffy looking young lady who has crept into the room and now shirks against the wall.)

“Not recently. Listen, is it some kind of metaphorical pain or does your chest really hurt?”

“Fuck you. I need to take a crap.”

He’s stable for now although it’s a struggle to keep his oxygen mask on. He keeps pulling it off and threatening to leave. While this isn’t a prison, he is drunk and high so I could restrain him if necessary. He definitely needs to be admitted and I ask the unit coordinator to break the good news to the medicine intern

Mr. Simon was admitted but bolted a few hours later before the source of his hypoxia could be identified. I imagine he is in some hole shooting up with his insulin money.

Mrs. Jones died in the ICU that day.

Mrs. Smith got six vicodin and left gravely disappointed.

Pulmonary Consult

A Day In The Life Of..., Articles You Must Read, Futile Care

Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.

ICU

A Day In The Life Of..., Futile Care, Residency, Uncategorized

Waiting for a Miracle

“You understand that if your father’s heart stops we’re going to be pounding on his chest and shocking him to try to get it started,” I say to the family of Mr. Green, “There will many people in the room who you have never met inserting lines in his veins and arteries, drawing blood, giving him fluids, and it will be controlled chaos. If we get him back he will just be even more critically ill than he is now and the next time his heart stops we will repeat the same routine.”

Mr. Green is eaten up by cancer which has metastasized everywhere including his brain. It seems difficult for the family to understand the connection with this and the large fungiating, bloody melanoma on his right big toe. (“Can’t you just amputate his toe?”) He is on the ventilator and is also on a pressor drip (levophed, or epinephrine) to maintain his blood pressure. To say he is not doing well would be an understatement.

“We understand that, Doctor, but we’re praying for a miracle.”

This is by far the worst part of this ICU rotation. Everybody likes to deliver good news but in the ICU it is often necessary to concede defeat. Resident or not, whatever your level of experience you become the point-man of the whole medical profession and it is your job to explain that whatever propaganda the family may have heard, there is no cure for death and when it’s time to go, it’s time to go.

“I’m a religious man myself,” I begin, carefully choosing my words, “And I believe that God watches over all of us and will not abandon us in our time of need. But I also know that any further treatment for your father is only going to put off the inevitable. I can’t tell you how long he has. It may be twenty minutes, it may be a week. I don’t know. But I can say with certainty that we have come to the limits of our ability to do anything but briefly prolong his and your suffering.”

Distressed look from the family.

“So I believe that the best thing to do is to keep him comfortable,” I continue, again choosing my words very carefully, “Trying our best to preserve his peace and dignity.”

“Do we have to decide right away?” asks Mr. Green’s oldest daughter, “We would like to get more of the family involved.”

“Please, take all the time you need. Have the nurse page me when you come to a decision.”

The decision is to change his code status from “full code,” meaning that every effort will be taken to restart his heart and support his breathing, to “Do Not Intubate/Do Not Resuscitate (DNI/DNR).” A simple decision from the point of view of the physician and nurses but incredibly painful for the family who have a lifetime of history with Mr. Green.

A critical care physician once related to me the story of a patient of his who at the age of 82 and after a lifetime of diabetes had developed renal failure requiring dialysis three times a week. He was completely blind, a triple amputee, unable to speak as a result of throat cancer, and had right-sided heart failure from COPD. He had recently undergone a partial colectomy for ischemic bowel and had a colostomy. He was fed via a PEG tube (Percutaneous Endoscopic Gastrostomy) and breathed through a tracheostomy on supplemental oxygen. As one last insult he had recently suffered an MI which burned out a significant portion of his left ventricle dropping his ejection fraction, already low from the right sided heart failure (which drops cardiac output by decreasing amount of blood to the left side of the heart) to something barely compatible with life. But he clung to life and communicated that he wanted every measure taken to keep him alive.

“You know,” The physician said to me, “In Europe they would have let this guy go five years ago. There’s no way they would expend the kind of resources we have to keep him alive.”

“What do you think about it?” I asked.

“I think it’s a tremendous testament of the will of the human spirit to live and I’ll do everything I can for the guy.”

So there’s the problem. When do you keep a patient alive even when treatment appears to be futile? In the case of a patient who can make his own decisions the answer is clear. You do what he asks. When the family acts as a surrogate the decision is a lot more complex. In the case of Mr. Green, the oldest daughter took me aside and confided to me that her brother and her father had had a falling out several years before and had never patched things up. The brother was the strongest advocate for taking all possible measures to keep his father alive.

It would not be too much of a stretch to believe that guilt played some role in the son’s attitude towards his father whose death would leave a lot of important things unsaid, perhaps an apology and a reconciliation.

But that’s how it goes in the ICU. Some patients get better. Some get worse and die despite your best efforts. And some come in and make you wonder why they were admitted because nothing can be done beyond comfort measure.. The ICU shouldn’t be a place for hospice or palliative care but it is sometimes used for this purpose.

How It’s Done: Part Two

A Day In The Life Of..., Residency

A Day in the Life of an Intern

Obstetrics Rotation. Week Two. An eternity ahead of me.

4:10 AM: Good God. It is early. Early by anybody’s standards. Even the dairy farmers must cringe from this early hour. And yet my eyes have been open for the last twenty minutes as I fight off sleep knowing that I’ll just have to get up in twenty minutes. Now fifteen. Now ten. Now five.

4:30 AM: Holy crap it’s early. Wasn’t I just awake? Didn’t I just do this yesterday? Of course I did. But I am only two weeks into this rotation with two more weeks staring me in the face. Now is the time to suck it up. No sense getting demoralized now. The funny thing is that no matter how bad you feel about a rotation in the beginning, towards the end and once you have gotten the hang of things it never really seems that bad. I’m counting on this but OB might be the exception to the rule.

On paper the rotation doesn’t look too bad. Four weeks of 12 hour days with two full two-day weekends at the end of the second and the fourth week. Not to mention only two call days on the two Saturdays when I do not have the weekends off. Let’s just call it Q14 call which is almost like not having call. Still, if there has been one rotation that has made me regret my burning desire six years ago to become a physician this is it. It is just so wrong to be up this early. Even Persephone my faithful Black Lab seems confused.

4:35 AM: Mouthwash is my total morning hygiene package. I shower, shave, and brush my teeth the night before to save the fifteen minutes that this usually takes me. I lay out my scrubs, shoes, pager, keys, pens and my PDA the night before as well because from the time my alarm rings I have thirty minutes to get to the hospital and every second counts. I guess I could get up at 4:15 AM but this would be wrong. So wrong. So very wrong. I fantasize about my old job when I worked for myself and set my own hours. Why, I sometimes didn’t get up until eight o’clock…and once I even slept until nine.

Have I mentioned anything about OB yet? No. Here is an important philosophical point. I know that our purpose as residents is to learn medicine and that this requires a certain level of enthusiasm. If we were perfect people we would look at the long hours as just another opportunity to live our dream, something we swore we were passionate about in our AMCAS personal statement. The reality is that medical training pretty much sucks and it is endured, at least in intern year, rather than enjoyed. Naturally you learn a lot but almost any intern would cheerfully sacrifice some of his training time for more sleep and a day off here or there especially since so much of residency training is ridiculously inefficient.

5:00 AM: Post-partum intern work rounds. An exercise in inefficiency if there ever was one. I am covering half of the floor, pre-rounding on the women who have given birth and seeing how they are doing. It is inefficient because I have to transcribe vitals, lab values, and anything else pertinent from the computer to my rounding sheet. This is 2006. You’d think gathering this information could be automated. Maybe you who are still dreaming of medical school will be the first to experience the truly paperless hospital. For now we scribble away like Mesopotamian scribes. At least we don’t have to wait for the clay to dry.

Welcome to the world of abbreviations. Even in the medical profession where abbreviating is a way of life OB/Gyn carries the practice to the very limit of practicality. Here’s my note on Mrs. Smith in room 5704:

29 y.o. G4P1122 POD 2 s/p PLTCS for pre-X @ 34/3 wks EGA c/b FGR, non-reas FHT A+/RI/RPR NEG/pap neg/M/no circ/bottle/IUD/DCHD No n/v/HA/SF/VB uo 1200 ml p/MN AVSS BP 130s/80s Tmax 36.9 HR 80s ABD: NT fundus firm incision c/d/I w/o s/s inf CV: RRR 2/6 ESEM RUSB RESP: CTAB EXT: no LE edema A/P: doing well. D/C tomorrow.

Which any fool knows means “Mrs. Smith is 29 years old, has been pregnant four times, has had one term birth, one pre-term birth, two abortions (either spontaneous or “therapeutic,” and two of the births produced live children. She had her current baby at an estimated gestational age of 34 weeks and three days and was delivered by primary low-transverse ceasarian section because of preeclampsia. The baby has fetal growth restriction and the delivery was expedited because of non-reassuring fetal heart rhythms. Mrs. Smith has a blood type of A pos, is rubella immune, has a negative syphilis screen, and her last pap smear was normal. She had a boy, does not desire circumcision, would like an IUD (six weeks post-partum) for birth control. She will bottle-feed her infant and will follow up at the Durham County Health Department for her post-natal care. Denies headache, nausea, vomiting, subjective fever, and vaginal bleeding. Her urine output was 1200 ml since midnight. All vital signs stable. Blood pressure was in the 130s/70s. She was afebrile and non-tachycardic. Her abdomen was non-tender and her fundus was firm. The incision was clean, dry, and intact without signs or symptoms of infection. Her heart rate was regular but she has a mild early systolic murmer hear best in the the right upper sternal border. Her lungs were clear to auscultation bilaterally and she had no lower extremity edema. She is doing well and we will discharge her tomorrow.

0545: Data gathered, rounding sheet organized I start seeing patients. “Habla usted English? No? Not even a poquito?” Goddamnit. At least half of the patients here at Duke are illegals. Probably one in five speaks English. I understand from my Spanish PA student (from Spain and therefore not Hispanic) that their Spanish isn’t that hot either and even she has trouble communicating. Cultural competency blah blah blah. It still wears me out because I am an American and was raised speaking English. (Although we once had a Greek patient. I speak Greek. The patient spoke English so it was a bust.). I could use the blue translation phones but that takes a lot of time to get set up.

“Dolore?” Blank look. I point. “Dolore?”

“Ah, Si! Jabber jabber jibber ga-jabber dipthong jabber jabber!”

“Uh, Okay. Feivre? Nausea? Vomito? Commida?”

“No.”

“Qualle anti-contepcivo quierres?” I ask. I’m trying to find out what birth control she wants but by the look I get I think I just asked her if she wanted cheese fries with her ferret. “Pastilla? Patch? Depo?”

“Ah! Si! Pastilla.” Pill, I think, and it will be micronor because God bless illegal immigrants they at least have the sense (or lack the money) to breast feed their babies.

Well. Preliminaries out of the way I motion that I’m going to feel her abdomen and listen to her heart. The husband looks on disinterestedly. I woke him up too. Sorry Amigo, this isn’t a hotel.

Everything fine. Answer of “No” to my question of “sangre?” with pointing to region of her vagina. No vaginal bleeding. Post-partum day two so we will discharge her today.

On to the next patient, Mrs. Walsh, cradling her dead baby which died early this morning in the NICU from a congenital heart defect except I don’t know this at the time. I have never seen Mrs. Walsh before and everything I know I learned from yesterday’s progress note by another intern. The ideal they teach you in medical school of following every patient from admit to discharge is just an ideal. On a large volume, high turnover service like OB as an intern you will follow many patients who you know nothing about until you round on them for the first time. Mrs. Walsh’s note said “G2P2002 s/p RLTCS @ 33/5 for pre-X c/b fetal CHD” but since the baby died only hours ago there is no mention of this in the note.

Still, something tells me not to make the usual polite comments about the baby. The mood is somber. The mother has a puzzled look on her face as I introduce myself. The baby is wrapped in a blanket and I think to myself that he doesn’t look very healthy. (No kidding.) I ask the usual questions, complete my exam, and before I go on to the next patient look through the pediatric notes (something we almost never do on OB) to see what is going on.

More patients. The interns are responsible for post-partum patients. The upper levels round on the ante-partum. The other intern is OB/Gyn and like me is at the end of her intern year. Unlike me she has been doing nothing but OB for the last eleven months so she knows a tad more about the field than I do this being my first OB experience since the beginning of third year in medical school. She seems exasperated both at my lack of knowledge and at my unfamiliarity with her department’s procedures. This highlights one of the drawbacks of training as a generalist, namely that you jump around a lot never really getting the hang of anything. She’s nice enough but tends to talk down to me, something I tolerate because as I mentioned earlier I am starting my Emergency Medicine residency in June and I just don’t care. I have two weeks left at Duke and as much as I dislike it I have been nothing but affable and polite the whole time and I’m not going to change this winning strategy now. Still, it’s easy to be an expert on a couple of pelvic organs. I’m sure I’d be pretty handy to have around if, oh I don’t know, somebody was having a heart attack or a stroke.

0710: Formal rounds. Basically a conference where the antepartum, intrapartum, and postpartum patients are reviewed. The interns review their patients last in as an efficient manner as possible. This procedes quickly as OB is a very busy service with a lot going on and they don’t have the luxury to debate the causes of a patients hyponatremia like they do on a medicine service. The upper levels leave to scrub in on their scheduled cases. The other intern goes to clinic. I go to triage where I will spend the rest of the day.

Triage is the point of entry to the OB floor. Although there are a few direct admits, most patients come through here to be assessed. As the emergency department sends up every pregnant patient who is not spurting arterial blood, it also functions as an obstetrical emergency department. They also answer phone calls and handle telephone triage. (“Hello, I think my water just broke.”)

During the week triage is supervised by nurse-midwives. For those of you who don’t know it, nurse-midwives are nurses who undergo approximately two years of intensive obstetrics training. They are pretty well trained and qualified to handle all but the most difficult of vaginal deliveries. It’s a pretty good arrangement if you are just rotating on OB because OB/Gyn residents are notoriously clique-ish and it is very easy to get ignored during your entire rotation. Not that this would be a bad thing you understand but we are here to learn how to deliver babies and manage common obstetric problems. The midwifes are a lot friendlier and more willing to teach than the residents if only because the residents work pretty hard and don’t have time for your incompetence especially if you are not an OB/Gyn intern.

0810: 25 y.o. G1P0 @ 38/4 wks for SROM. (Spontaneous rupture of membranes) Thinks her water broke but isn’t really sure. Has some leakage of fluid but not enough to soak her panties. (Yes, this is an important part of the review of systems.) A sterile speculum exam shows no pooling of fluid. The nitrazine paper does not turn blue (amniotic fluid is acidic) and there is no “ferning” on the slide. Her cervix is one centimeter dilated, slightly effaced (I say about 10 percent but hell, what do I know?) And anterior. She can go home.

0840: 17 y.o. G3P0020 @ 36/3 wks for EOL. (Evaluation of labor.) Said she has a “boogery” discharge two days ago which was probably her mucous plug (which seals the cervix) and is now has contractions every five minutes or so. Denies ROM (rupture of membranes.) Her cervix is 5/50/-3 or five centimeters dilated, fifty percent effaced (or thinned) and I just tack on the -3 station because while I feel her membranes in the os (or mouth) of the cervix I don’t feel any baby parts. The midwife assures me that the baby is cephalic. She shows me the Leopold maneuvers to verify this and I politely nod but admit that I can’t tell the difference. I get the ultrasound machine and correctly identify the head pointing down. The midwife laughs good-naturedly and I accuse her of being a witch (which many superstitious people still believe about midwives). Five centimeters is the definition of labor so we admit her. Nice contraction on the monitor and the baby’s heart rate is normally reactive.

0920: 29 y.o. G2P1 @ 22/3 wks EGA with placenta previa for vaginal bleeding. This is a potentially serious problem so I call the upper level resident after I get a quick history. It was not much bleeding. A little less than a light period. The patient is on strict bed-rest at home and apparently this is not an alarming finding. Under no circumstances does anything get get inserted in her vagina blindly. The resident does a careful speculum exam and sees no blood at the os so she is sent home with pelvic precautions. (No sex, among other things.)

0940: Called to a delivery. The usual cheerleading for the mother. The nurses labor the patient and only call the intern when they think the baby is ready to come. Nothing to it, really, from our point of view if everything goes well. A couple of pushes, one hand on the perineum to support it and help prevent tears and one hand on the baby’s head to prevent it from popping out, also to prevent tears. The usual gush of fluids as the head appears and restitutes (or turns). Gentle traction down on the head to clear the presenting shoulder and then up to clear the posterior shoulder and the baby is out. A little bit of suction and if the baby cries put it on the mother’s chest for a few seconds so she can see it. In a normal birth there is no need to rush to cut the cord. The OB/Gyn residents are more business-like and clamp and cut immediately. The midwives often let the mothers hold the baby for several minutes (if the baby is breathing and looks good) especially if pediatrics has not arrived yet at which time they will usually demand the baby. If there are any problems the resident is paged and takes over. No lacerations so after the placenta delivers I congratulate the mother and go back to triage.

1020: 37 y.o. G1P0 @ 38/6 wks for EOL. Large woman. My fingers are either not long enough or her cervix is in some weird position. I’m not that great at cervical exams. It does take practice. The first twenty or so you do all you can really tell is that it’s warmer in there than it is outside. I can usually find the cervix and I can tell you with confidence if it is closed, long and high (or normal) but after that we get into the realm of subjectivity. Some of the time I can say with confidence the degree of dilation or effacement but if I’m not sure I ask the midwife to check behind me (which she usually does anyways).

1130: 24 y.o. G2P1000 @ 27/6 weeks EGA c/b PIH (Pregnancy induced hypertension) with bilateral lower extremity swelling and pitting edema (a finger leaves an impression). Her history is troubling as she reports a two day history of headaches, seeing spots, and swelling. Naturally the concern is for preeclampsia. Her blood pressure at presentation is 160/100. She gets a stat preeclampsia work-up which shows protein in her urine, a high serum uric acid, and a protein to creatinine ration of 426. Her liver function labs (the LFTs) are normal as are her platlets so she doesn’t have Hemolysis, elevated liver-enzyme levels, and low platelet count (or HELLP) syndrome. She is admitted and placed on a magnesium sulfate drip for siezure prophylaxis and hydralazine for blood pressure control the goal being to avoid ecclampsia, fetal death, and end-organ damage. If everything goes well she will be delivered at 30 weeks.

1240: Phone triage. G1P0 @ 12 wks EGA with spotting after intercourse. A lot of spotting? No, much less than a usual period. I fight to keep a level expression as I ask if her husband is a large fellow. Yes. Sometimes it hurts. Use a good lubricant. I think you’ll be all right. No need to come in.

1300: G11P5328 @ 24/4 wks EGA with chest pain. Yes. That’s right. Eight live births none of which she ever cared for as she is a prostitute and not a very smart one at that. Extensive and varied social history as well including most of the major illegal drugs. Now chest pain I can handle and happily work through something I am familiar with for a change. Happily, none of the midwives or residents are very good at reading an EKG so I have a chance to show that I am not a total idiot. Eventually three sets of cardiac markers will come back negative. The EKG is also negative. It is just GERD which I knew two minutes after meeting her. Still, you can’t be too careful. She signs the papers for a BTL (Bilteral Tubal Ligation) after her delivery scheduled for 40 weeks and the nurses and midwives do the wave (silently).

And so it goes until 1800 when the night float intern shows up and we find the chief resident to do our checkout. During the entire day I have also been covering the post-partum patients. As most of them are pretty healthy (because pregnancy is not a disease) this doesn’t involve too much work. The standard orders on every patient cover almost everything and I probably only get five or ten calls from the floor in the entire day. I have to do all the discharge paperwork for our mother who are going home of course which I fir in while I handle triage.

Not much to it. Like I said, technically this should be an easy rotation. It’s busy but not crazy busy most of the time. The day does go by quickly. The residents are friendly (mostly) if a little distant and the I get along very well with the nurses and midwives. But I don’t like OB in the slightest and this makes all the difference. Not to mention that by a twist of fate I haven’t had a day off in nearly three weeks (I was post-call the day before I started and had call last Saturday) and I am kind of worn out in general. I usually get out around 1830. Trust me. Two weeks of 14-hour days will wear you down.

1845: Home, finally. Obligatory Frisbee with Persephone as my kids tell me about their day and my lovely and long-suffering wife updates me on the sale of our house which is not going well. I have to be up in the great frozen tundra in five weeks and it looks like I’m going to be living alone up there until the house sells. Like most residents with families, we are living on the brink of financial disaster and we can’t afford two mortgages. Still, we just had our fourteenth wedding anniversary, our children are healthy and happy, and we have prospects for the future.

How It’s Done: Part One

A Day In The Life Of..., Residency

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.

“No.”

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.