Saturday, October 27, 2007

Goal Met

Today is my third day off of the month, and I have tomorrow off too. It's an amazing feeling. I really have no plans aside from errands (and Reformation Day Party at church tomorrow evening). I was going to do a lot of non-medical reading and possibly Stargate Atlantis watching, but I have been somewhat thwarted--my netflix account has sent me the third disc but not the second, so I am faced with the dilemma of either watching episodes out of sequence which is a pet peeve of mine, or waiting until next week to watch them at all. Similarly, I requested from the county library system the first three books of a series I am about to start, and I got an email yesterday informing me that they are holding the second and third books, but don't have the first yet. Annoying.

My call night on Thursday was the best call night of any rotation I have been on. Our only admit (who could totally have gone to a regular floor) was a bronchiolitis kid with no significant medical history and on no medications. I staffed him by 10:00, then went to my call room. I had to watch for some labs which were back by 11:20, then I went to bed. And didn't get another page until 3:45! I was able to take care of it with a phone call, went back to bed, and got up at 6:00. I saw the senior resident a little later, and he told me that nights like that never happen. Of course, the night wasn't as restful as it sounds as evidenced by the fact that I still came home and slept six hours straight before going to bed for the night. Call night sleep is very superficial and interrupted--one is constantly waking up, checking the pager to make sure one hasn't been paged and slept through it, checking the computer to make sure there aren't any crazy lab values that no one has told you about, waking up to FYI pages from the nurses, as well as going over patients constantly in one's head to mentally check and re-check that one hasn't missed anything. But I'll still take a night like that over a night like my first and second call nights any day (or night, as it were).

Yesterday I finally achieved my highest goal for the month--I discharged the last of my original patients.

Tuesday, October 23, 2007

6 down, 2 to go

This rotation is winding to a close--technically, I have a week with two call nights left, but since I get the weekend off (!!!) it seems like less. As I have said, this has been a very valuable rotation for my over all development as a physician, but it is somewhat exhausting.

We've had some very sad cases recently. One is a 3 month old boy who underwent horrible parental abuse that left him severely brain-damaged. My last two call nights I've been called to see him several times for trouble breathing/low oxygenation. Sunday night was particularly bad, and after several hours during which time we had to call the critical care fellows and attending in to see him, he was finally transferred to the PICU. Unfortunately, he will likely continue to worsen--what makes it particularly sad is that his mother (father is in jail) refuses to look at the situation realistically and thinks that the infant will heal completely. Underlying this denial is the fact that if the infant dies, her boyfriend will be tried for murder instead of child abuse. His grandmother is very on top of things and is in the room constantly--she is trying to reason with his mother.

The saddest case so far is an 11 month old I admitted last week. She had a heart defect which had been stable for the last couple months. She developed mild shortness of breath a couple days before her admission. Her parents had decided to transfer her care a month ago, so rather than go to the hospital at which she was established, they came here. She was very stable, and didn't seem to be very bad off. The cardiologist decided to do an echo in a couple days. I left Friday night, everyone thinking she was fine. When I came back Sunday morning, I found out that out of the blue she had suddenly worsened Saturday evening, was transferred to the PICU, and then died early Sunday morning. I can't imagine how devastated the parents must feel.

On a happier note, the little girl who has been here for months is going to get a new heart tonight.

On a different note, for some weird reason I just cannot stop eating on this rotation. Usually my diet is pretty healthy, but these last few weeks I have found myself with an insatiable craving for greasy food. It's worst on call nights, which I think is reasonable as my body is unusually stressed and fat has the most calories per gram. However, today for instance, I had lunch, then went to the resident lounge to get coffee and a danish. After the danish, I ate a donut. Then I came home and ate a chocolate bar. I'm really going to have to watch myself in residency.

Monday, October 15, 2007

To sleep or not to sleep

This was my black weekend (on call Saturday therefore no days off). It really wasn't too bad, we had an unprecedented one admission which came early in the night. At nine, I realized I had nothing to do, so guiltily went to my call room and laid down, pagers by my head, hoping that no admissions would come in--and none did! I still did not get to sleep, as I was paged continuously about issues. Most I had to go see the patient for, thankfully most of those ended up being nothing I couldn't quickly handle. A couple of the pages I could handle over the phone without even getting out of bed. So I spent much of the night in a half-awake/half-dazed state, getting up about every 30-60 minutes. Even without sleep though it was much superior to admitting people non-stop. There was one patient that was a problem throughout the night--he was persistently bleeding from his mouth and nose--most likely from a high flow nasal cannula. It looked a lot worse than what it was, and the nurses were getting a little tense, particularly after his O2 saturation dropped into the 20s. This however, is not uncommon for him, and he came right back into the 90s by the time I got to his room.

When I left the hospital, I thought that I would likely not need to sleep as much in the afternoon since I had had a peaceful night. Ha. I started dozing after I had lunch and went to bed a little before 2pm. I woke up and looked at the clock--it was 3:30am. I slept more until 5am when I got up--that's the first time that has happened to me, usually I get up for a couple hours in the evening. So my n=1 study seems to indicate that constantly interrupted half sleep is not as restful as no sleep at all.

My patient with heart failure, now improved, failed her swallow study. Was scheduled to get PEG tube (tube that goes into the stomach for feeding) last (I think) Wednesday, consents were signed. The anesthesiologist however, wasn't comfortable putting her under anesthesia without talking to the mother. Problem is that mom's a flake and it's impossible to get a hold of her. So the procedure was postponed until tomorrow. This morning she spiked a fever. She's fine, but anesthesia may not want to put her under. The biggest issue is that the only reason she's still in the hospital is that she is waiting for a PEG tube. Frustrating.

Friday, October 12, 2007

The saga continues

I'm pretty tired. My last call night was just non-stop, I admitted four patients, all of whom required about two hours each just to read through their charts. One was a four year old boy who had just gotten a heart transplant, and was transferring out of the PICU (where he had been for three months previously). One was a girl with a super-rare genetic disorder who was admitted to the PICU in heart failure, and transferred to us when she was stabilized. Four of the six patients I talked about in my last post are still here.

I have mixed feelings about this rotation. In general, I do not like it, but I can't put my finger on why. I'm not a big fan of being awake for 30 hours straight, but have been on other rotations without too much trouble. I think the biggest thing is that these patients have very complicated, chronic conditions that are generally beyond my level of understanding. Rounds in the morning are also painful, being hours long, but I have to pay close attention because one out of four nights I'll be watching over all the patients, and on the weekends I'll be rounding on some of the other interns' patients. That all being said, I have to admit that in the long run I think this rotation is going to be very good for me in many ways. First, patients with issues like heart transplants are very intimidating to me, and this rotation has been helpful to make me realize that the basics of medicine still apply to them. Second, I am forced to follow more patients than I ever have before more closely than I ever have before, and I have to keep a lot of information in my head about each one. Third, it makes me have to put into practice all the things I know in theory--like what to do if someone spikes a fever, or has decreased urine output. At this point I put things into practice very badly, so it is a good thing that I have a senior resident take call with me to sign all my orders and step in when I am clueless. Also, I never fully realized how many stupid little details have to be managed and ordered.

I'm starting to feel like I have a better grasp on things, particularly since I am now only following five patients instead of nine. I felt better after I asked the interns what they thought of this rotation compared to others, and they told me that they had similar frustrations to mine.

I'll be on call tomorrow--then I'll be halfway through my calls! And once this rotation is over, I'll have ER for a month (shift work!) then two months totally off (except for interviewing)!

Sunday, October 07, 2007


I started my sub-internship in the intermediate intensive care unit at our children's hospital on Monday. It's been...intense. Today is my only day off for the first three weeks of October. I take call every fourth day. Monday I admitted three patients overnight, and rounded on them in the morning. At noon Tuesday I found out that I would have to round on four new patients Wednesday in addition to my patients. Essentially, it meant that Wednesday morning I had to round on six patients, all very complicated, four of whom I knew nothing about. My presentations were shaky at best. I stayed two hours late that day to go over their charts (some had been in the hospital for several months) which aided considerably in rounds the next morning. Friday I took call again--I admitted 5 new patients overnight, giving me nine patients total. As these patients are all far more complicated than any patients I've taken care of before as a third year medical student (virtually no real responsibility) it's been challenging. I've been told that I'm doing well fortunately, and I think the fact that I'm working hard even though I'm not going into peds helps my reputation as a sub-i a lot.

Some of my patients over the last week:

1) Ten year old boy w/new onset diabetes presenting in diabetic ketoacidosis. Gave him a lot of IV fluids and IV insulin, sent him home two days later.

2) 18 yo girl with Charcot-Marie-Tooth disease (neurological disorder). She's ventilator dependent, but very stable. We have her because there was a question of negligence on her parents' part--they are fighting to keep her. Lot of messy social stuff, but my gut feeling and the feeling of the attendings is that her parents are being unfairly judged, and she will most likely go back to them, hopefully this week.

3) 3 yo girl with history of congenital heart disease, underwent repair several years ago, here with heart failure. Worsened after tonsillectomy. Slowly improving, though has a lot of stuff going on and will need to be very closely followed when she leaves.

4) 3 yo girl with congenital heart defects, needs a new heart. She's been here for months just waiting. A few nights ago I started praying that she would get a new heart, but then suddenly realized that for that to happen, a healthy child somewhere is going to have to die. Very sad situation.

5) 10 yo girl with extensive medical history, had a bilateral lung transplant several months ago. A couple of her labs from home were a little off, so she was admitted with the concern of a line infection. She's completely asymptomatic, but as she is immunosuppressed there is still a concern. Hopefully the concern is baseless and she'll go home soon. Interestingly, she has an incredibly bizarre diet in which she eats horrendous amounts of food, but remains a normal-sized ten year old. Apparently, she eats every couple hours, and will sit down and eat five hamburgers at a time, or will order 75 pieces of salami and eat them in one sitting, dipping each piece in salt, etc. There's a suspicion that she may have a biotinidase deficiency.

6) 4 yo girl with neurologic devastation after complete cardiopulmonary arrest a year ago (she was totally normal before), believed to be secondary to parental abuse (also has history of a couple broken limbs which is a serious red flag). She is trach and g-tube dependent, has spastic limbs, cannot communicate, and has a seizure disorder. She's in foster care now--her parents legally have custody, but are not allowed to be alone with her. She had an episode the morning of her admission in which she stopped breathing, was bagged for five minutes, then revived and has been fine since. We think that her trach was momentarily clogged with a mucus plug. Her mother came to spend the night in the hospital with her, and acted like a concerned parent--her foster mom told me that despite the fact that her parents have full visitation rights, this was the first time she had met the biological mother. I didn't have a lot of sympathy for the biological parents, and had to bite my tongue when I heard the biological mother complain on the phone about the court system.

And I have several more. The vast majority are far more complicated than I am comfortable with, and honestly I have a very limited understanding of what the full scope of their disorders are. This is a pretty intimidating rotation, and even though I know I'll learn a ton, and I'm grateful for the fact that it really pushes me to be far more efficient than I've ever been before, and to know my patients well, I can't help wishing every once in a while (usually at 2:00am when I've done 3 admissions and have two more coming) that I did the family practice sub-i instead, which caps at two admissions a night and has patients with simple problems:). I have learned that I really prefer to deal with patients with one acute problem, with maybe the occasional well-controlled chronic problem as opposed to here where patients have 5 medical problems and take 30 medications every day. Maybe that will change over the years as my knowledge increases and my general competency improves. One really weird thing about this rotation is for the first time I am the first point of contact for my patients for the nurses--they ask me questions about what they should do, and expect me to have an answer. This is particularly difficult at night when I am covering almost 30 patients, and don't know most of them. Thankfully, there is a senior resident available who has to sign all my orders, and is available if I need help with something.