Category Archives: Residency

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.

Yes, the Hours Still Suck

Residency, Uncategorized

There is No Prize for Sucking it Up

Residency entails long hours. You may as well accept this and prepare for it. Up until very recently however the hours were much, much worse and it was not uncommon for residents to all but live in the hospital except for the polite fiction of being allowed to go home infrequently for sleep. These were the bad old day, only a few years ago, when you worked at the whim of your program with no recourse other than to quit if you didn’t like it.

These kind of hours were insane. Nobody can function on three or four hours of sleep every other day, at least not in something as complicated and intellectually demanding as medicine. As a young Marine I regularly went several days without sleep but while being a Marine requires considerable skill and intelligence, it’s nowhere near as demanding intellectually as medicine. You really do stop caring about things as you become sleep deprived. Everything requires more effort. Concentrating on routine (but important tasks) becomes impossible and it is only the occasional burst of adrenaline that makes functioning as a sleep deprived Marine or a physician possible.

In the old days when most of your older attending were residents, things were considerably different. It’s true that they spent long hours at the hospital but the pace was a good deal slower on the wards as there were both fewer interventions and a much slower turnover of patients. These were the days when the hospital course for someone with a heart attack was three weeks. Today it is usually two days, sometimes even one if the heart cath was done early in the morning and the patient is in otherwise good health.

It is one thing to be on call on a service with a census of patients most of whom are long term and stable boarders, it is another thing to be on call on a service with rapid patient turnover and a completely new census every few days. There is simply more work to do, especially when it comes to admitting patients.

“Admitting” is the process of working up the patient when he presents to the hospital and involves the history, physical exam, assessment, and plan which we discussed in a previous post. It is also as you can imagine a tedious paper-work grind at almost every hospital as previous records are tracked down, numerous forms are filled out (many of them redundant and mainly serving the purpose of lawyer-appeasement) and extensive notes are either written or dictated. It is not as tedious in private practice as the economics of paying a physician to waste time come into play but no such restriction apply at a typical academic hospital. Not only will you shoulder the burden of this work but you will also have to clear every decision through either your upper level resident or your attending.

This is the way it needs to be, of course (I mean except for the lawyer protection paperwork) but as a typical admission on a medicine service can take hours in the case of complicated patient you can see that with the rapid turnover in today’s teaching hospitals a few admissions a night will prevent you from getting any sleep when on call. In fact, most teaching services are “capped” or limited on the number of admissions they can take in recognition that learning is impossible if you are treated as cheap labor.

So I don’t want to hear the sanctimony from the old-timers about how much harder they had it back in the day. Fewer admissions and more stable patients lead to a more stable census and more time for rest. Sorry. The trouble was that as medicine became more complex and demanding, the treatment of residents lagged far behind almost as if it were in a different century. Residents working in modern, high-turnover hospitals were treated no differently than their more relaxed collegues from the fifties and sixties.

After several important papers were published detailing the risks to the safety of both patients and residents from sleep deprivation, the Accreditation Council for Graduate Medical Education (AGCME) mandated that all residency program restrict the work hours of residents to eighty hours per week averaged over four weeks. This is a good start but it’s still only a start.

The fact that many in the medical community think it takes eighty hours per week to train you in a medical specialty reflects the general inefficiency and poor organization of medical training as well as a reluctance of some to let go of old, outmoded methods. Eighty hours is better than 120 of course, but it’s not a pleasant way to spend three to seven years of your life.

Let’s look at a typical Q4 call schedule. This means that every fourth night is overnight call. You will work three 12 hour days. On the fourth day you will work through the night until one in the afternoon (you must be released by this time according to the rules). Since you got no sleep on call your half-day is pretty much wasted as you sleep most of it. You must be allowed one 24-hour period per week free from all clinical duties but sometimes this entails being allowed to go home in the morning after call which means that your day off is abbreviated to 20 hours or so.

You will usually end up working 85 hours a week if not more because some people will not let go of the old ways and as they have no life outside the hospital have no incentive to be efficient or decisive. Your time is not valued in the slightest because anybody who cares is paying the same whether you work fifty hours or a hundred.

The worst thing is that most of your time will be spent wrestling the incredibly inefficient paperwork system which is endemic to every American hospital. You will spend most of your time as an intern filling out some sort of paperwork or another. That’s why they still call your intern year a “clerkship.” Trust me, you will spend the majority of your time wrestling with the paperwork. Important or not, there is a huge quantity of it.

So eighty hours does make for a long week and a long month. It is a violation of an unwritten rule of residency to complain, of course. The tradition is to suck it up and not look weak. Still, it is a lot easier to spend your life at the hospital if you have no life outside the hospital which is more the case than you imagine. I had a third year resident on a medicine rotation who regularly rounded in the evening on non-call nights after every other team had gone home sometimes until seven or eight with me and the medical students as her entourage. The on call team was also in the hospital handling all of the new admits so we weren’t really doing anything. She just was just very dedicated but more importantly had nothing better to do with her time.

Patient care is important. On the other hand if you can’t manage twelve patients on your service from six in the morning until six at night then you have a problem with efficiency. All your over-night orders should be written well before normal quitting time and the nurses are more than capable of following them. The labs will cook without you and all of the consultants have gone home and will only suffer to come for an Emergency, delegating their interns to cover things. The on call team, for its part, is there for Emergencies and to follow a few key items for you which you relate during sign-out.

You can go home already.

The best part was that at the start of the rotation the resident lectured me that medicine needed to be my first priority and family and personal life a distant second. This attitude is incredibly patronizing. It is just a job and like most men of my age and upbringing I take work very seriously. I’ll do what needs to be done but medicine is not the military and it should not be necessary to sacrifice one’s family life to its service. Spending time with the wife and children is not a privilege, a reward, or something for which we have to beg.

So you’re not supposed to complain but I think as more and more non-traditional students matriculate into medical school and then into residency training there will be more complaining as the older you are and the more experience you have outside of medicine the less tolerance you have for chicken shit…which is what a lot of the antiquated customs of residency are.

I think the first thing that needs to be done is to eliminate or greatly curtail call. Everybody deserves to get a good night’s (or day’s) sleep. It should also not be a privilege to get some rest. Some call is pretty benign of course. Urologists pull call but there are few real urological emergencies so they sleep pretty well. Specialties like medicine need to go to a shift system. Either that or have a night float system where one week out of the month you work at night and sleep during the day.

Another thing that can be done is to add to the length of residency training. Maybe sixty hours a week isn’t enough time to train a medicine resident. Medicine is inherently inefficient as it deals with inefficient human beings so a lot of the wasted time is hardwired into the system. Add a year. Increase the pay a little and pay overtime for anything over forty hours like anywhere else.

Research any residency program thoroughly. Talk to the residents when you interview. Get a good idea of the call schedule and the hours because some programs are more benign than others.