The Wards – Day 12

A lot has happened since the last entry. On Tuesday night, the hallowed ER vs Medicine Hoops game went down. The format was a best of three game type – each game to 15 points, win by 2, self officiated. As I mentioned, the last match in November had the department of medicine winning, 2-0. Both were close games. We held the trophy. This time, the ER came out tough. They shot the lights out in game 1 and we lost, 15-9. The second game became a slugfest, with poor shooting on both sides. We were down 12-9 or so but then we got hot, and ended up winning 16-14. With the games tied and it getting late, several players on both teams had to leave. We were both left with 5 apiece. Unfortunately, our best player took off and it fell to me to guard the “big guy” (aka Mr. BYU, Division 1 240 lb 6-6 guy), who had been tough to stop all day. This proved difficult. The game was long and tiring, and in the end, we lost. 15-13. The ER now has the trophy. Boo that.

On Wednesday, my team was pretty manageable, and by the end of the day we got our census down to 4 patients! (this is amazing). Wednesday I got out of the hospital around 3:15 or so and drove 2 hours down to Portland to see my friend Alexi from med school. He had flown in for a couple of days so he could interview with OHSU’s cardiology fellowship program. I got there around 6 pm or so and he, Leah, and I went out to this amazing sushi dinner (I now have a new favorite sushi place in P-town). It was good to see old Alexi, whom I hadn’t seen since graduation. He’s a funny bastard and the 3 of us (including Leah) were busting up left and right at dinner and having a good old time. Hopefully he’ll be interviewing up at University of Washington as well in the next couple of months. Sadly, I had to take off after dinner. This was about 10:30. I drove the 2 hours back up toward work and crashed at my friend Pete’s house (he lives close to work) so that I could be closer the next day. I got to bed around 1 am. Got up at about 5:45, took a shower, and headed to work. It was a call day. I should have gotten more sleep.

Yesterday was crazy (as these call days tend to be). I got to work about 6:45 and was handed 3 patients from the night float check out. I took the sassy MOD pager from John (the night float) and pretty much didn’t stop moving until about 8 pm that night. It was a wild and interesting day with a lot of phone calls, a lot of scurrying around the hospital, a lot of patient work-ups, and finally a lot of paperwork and loose end type stuff to finish at the end of the day. All on about 4.5 hours of sleep. I downed a ton of coffee and diet coke all day to keep moving. There was a tragically unfortunate black lady who is 35 years old with metastatic breast cancer who came in with what looked to be a blood clot in her lungs. The tests proved negative, but we confirmed in the process that she has metastases in her brain. This is horrifically depressing. Her prognosis, with two daughters, 8 and 12 years old, is terrible. There was another guy who is 53 years old who came in with severe abdominal cramping and peeing blood. Some lady from the clinic with diabetes had been throwing up all week. Another 83-year-old lady with dementia and about 7 other medical issues had been found wandering outside of her house in the neighborhood with minimal clothing on and without her supplemental oxygen on. She was a mess. Another 45-year-old man had intractable nausea and vomiting for unknown reasons. Another huge diabetic woman had passed out and been found with a heart rate of 30 at home (this is really low) – she went to the ICU. Near the end of the call, I had to work up this 44 year old alcoholic, schizophrenic guy who had this nasty rash all over his body – it was a red flaky, dried out, oozing sort of thing that was nasty beyond description. And it was everywhere. I walked in his room and he was picking at it while taking in a few pieces of fried chicken. Nasty. All these, and a few more patients, and at the end of the day I found myself staring at “the board” (the big dry erase board where all three medicine teams have all the names of their patients written) and under my team there were 12 patients. Knowing I had today off, I stayed really late (Until 10:30 pm) and finished up a ton of work, mostly paperwork, after we were off the clock at 6 pm that night. That’s a busy 16-hour workday on 4.5 hours of sleep. Got it.

It is really hard to describe the chaos of a call day to someone who doesn’t do this sort of thing. There is absolutely no stop in the madness until some point late at night. As I concentrate on doing one task, there are three or four more tasks piling up and the end of the line. Rinse, repeat. Finally, at about 6 pm, tasks stop piling up and you can finally buckle down and grind out the last things on the list and see where everything settles out.

Here is what one admission to the hospital entails:

A patient walks into the ER. They are sick. The ER does all the initial work up. They talk to the patient (quickly), begin to get preliminary tests, studies, etc. They page me. I get the name and social security number and they tell me that they want me (i.e internal medicine) to come see the patient. I am being consulted. So, we hang up – they keep doing their thing. And I start digging into records. I look up the patient, all their past medical history. All their labs and studies from recently to years past. All their clinic notes. Unarchive all their last several admissions (some people have many, some have none). This takes about 10-30 minutes, depending on the patient. Then I go see the patient. In the ER, I take a look at all their paper work. I look at the EKG, then the chest X-ray (good thing they’re all digital now). Then I talk to the patient, make them repeat themselves and tell me the whole story. I spend time confirming their past issues as well. I write down their medication list. Finally, I do a physical exam and lay hands and all that. All the while I’m thinking about what is going on and what sort of problem they have. Then I decide if they need to be admitted (i.e. get them into the hospital overnight). If that’s a go (and it usually is if I’m consulted), then I start writing orders (all their meds, what happens to them on the floor, how often I want vital signs checked, what daily labs they need drawn, etc). I page the hospital bed manager to reserve a bed. I finish the orders and hand them over. Finally, when I have time, I have to sit down and write a “History and Physical” which is a big long document describing the patient’s story, labs, and exam. It always ends with the “assessment and plan” which is sort of me saying what I think is going on and what I’m going to do about it. To write one of these, it usually takes a good 20-60 minutes depending on the patient.

So all of that is to admit one patient. Now, on a call day, as I’m working on the first patient, my pager keeps going off. I usually have to stop and answer the page. (I try not to do this while actually talking to the patient). New patient consults are added on. Sometimes radiology calls me to tell me the results of a certain scan, or whatever. I may get 3 more patient consults while working on the first one. This ends up creating a whole long chain of work that seems insurmountable until finally I am “off the clock”. So I keep grinding through patient consults all day. At some point, I have to page my staff physician and tell him about the patients too. Sometimes he’s in the ER with me to help admit them. At my side are two trusty interns who help me do a lot of this work. Often they will write the History and Physical which also saves me time. But I have to write notes on every patient. And I still have to see every patient (obviously), as I’m sort of their supervisor. And at night (when I’m on call overnight), I have no interns helping me. So all that work is on me.

On top of all this, I still have my regular (non-call, everyday) pager on as well. This thing goes off everyday – usually it’s the nursing staff, the social workers, the ward clerks, the pharmacy, radiology, the clinic, or other residents calling. While we admit new patients, the old ones are constantly requiring attention and problems arise. Little fires have to be put out. The interns help with this as well. But it can get crazy. When both pagers are going off and 16 tasks have to get done and you just keep adding tasks to the back of the long line. Sometimes there are inappropriate consults, which are frustrating. Sometimes it’s not the ER but other services (i.e Surgery, or OB/Gyn, or Orthopedics) who consult you because one of “their” patients has an internal medicine type of issue that needs addressing. Occasionally there are emergencies, i.e. a patient stops breathing or goes into a cardiac arrest. A “Code” is called overhead and you stop what you’re doing and run over there and work on that until things stabilize (or the patient dies, sadly). Then there are lectures and conferences scattered about the day you are supposed to attend (luckily we’re excused from most of these on call days). At some point all of this becomes comical and you start high-fiving your fellow residents in the hall and laughing about everything.

We have a little “medicine resident area” with a bunch of computers and our desks. We do a lot of paper work (and our typing) there and so at the end of the day there are a bunch of residents sitting around, typing stuff, laughing or bitching about things. At the end of the day, I throw off the scrubs, put on my clothes, and stalk out of the hospital. It’s a lot of work, but right now I’m doing OK with it, I guess. I surely can’t deny at the end of these days that it feels like I’m making good use of myself and my time. Even as frustrating and stressful as it can be some days. There really is no better feeling than getting home after a super long day, cracking a beer, and throwing the Beatles on or something. Ah, the wards.

Anyway, that’s a little piece of what I do, at least on call days. On weekends, I stay overnight one of the three days. (Sunday night this week). Today is my second day off (of four). I woke up at 12:30 pm today. (Apparently my body needed sleep). My next day off is not next Wednesday but the Wednesday after that. That will be a painful stretch.

Anyway, I guess that’s the way it goes.


“Woke up….fell out of bed…dragged a comb across my head…went downstairs and drank a cup, and looking up, I noticed I was late…”