Family Centered Rounds Are Bad

Normal Rounds:

Attending: So GI recommends a neuro consult, huh? Do you want to get one?

Me: Well, the patient actually has neuro outpatient follow-up scheduled in two weeks and no acute issues. The relevant genetic labs were drawn yesterday and will likely be pending for at least a week. And after speaking to the GI fellow, I believe he recommended we consult neuro as a way of tacitly implying that he thinks the GI consult was dumb.

Attending: Neuro wouldn’t want an MRI or anything? Nothing we could do inpatient?

Me: Well, a head ultrasound was normal, all he has are diffuse LMN signs without any focal abnormalities on exam – and dysmorphism alone isn’t an indication for a head MRI, especially with pending genetic labs… so…. honestly, definitely not.

Attending: Well, at least curbside neuro – if they agree, the family can go home today.

Family-Centered Rounds:

Me: So, sounds like we’ve gotten all the worrying symptoms under control! Do you feel comfortable going home, or would you prefer to stay another night?

Mother: No, I feel great! So relieved about the new medication. My ride should be here this afternoon!

Attending: Actually, GI floated the idea that we should get Neuro involved – they might want an MRI or something! We could get that done inpatient for you. What do you think?

Me: …!!

Mom: … well, I don’t know… would it help? Do you recommend it?

Me: erm.

Attending: Well, it couldn’t hurt! Here’s how the MRI would go: he likely wouldn’t have to be sedated, cause he’s so small, and I bet we could get you on the schedule for today!

Mom: Well… okay then!

Me: :(

Status-post Family-Centered Rounds:

Neuro Fellow: Okay, so the kid has no acute issues and outpatient neuro follow-up already scheduled. What are you guys consulting us for?

Me: …. the question of whether a head MRI would be indicated.

Neuro Fellow: …

Me: Today. Stat.

Neuro Fellow: Without any focal abnormalities or UMN signs? Really? You’re consulting us for a head MRI for diffuse hypotonia?

… Hey, wait a minute – aren’t you supposed to be in our program in 2 years?

Me: …. that’s… that’s another intern. I’m someone else entirely. Please forget my name immediately, thanks.

My Suprachiasmatic nucleus is SO MAD at me right now

Assessment: 27 yo intern p/w erratic sleep schedule s/p rapid night-day scheduling shift, at risk for impending circadian failure. Post-sched-chng Day #1.

Plan:

  • NPO for AM rounds d.t. professionalism
  • Post-rounds may PO caffeine ad lib, goal volume 200 mL QD
  • Rapid caffeine taper 4 hours prior to end of shift
  • Will not monitor I&Os; could not care less frankly
  • C/s Taylor Swift for reccs on afternoon dance break
  • Dispo: neverrr

A Typical Morning Sign-Out

(Alternate title: The nurses are correct when they think we’re hopeless idiots.)

Me: Any questions on Bed 18? Great, let’s move on to Bed 19…

Pager: *BLARES*

Me: Hold on.

Pager: Bed 32 is nauseous. Can she have Zofran order before I give her her scheduled meds please?

Me: Um… hold on… we haven’t gotten to this patient yet and she really needs to not vomit her morning meds. *types in order for Zofran* Okay, back to Bed 19 – he’s here for dehydration but mom is refusing an IV. Discuss.

10 minutes later

Pager: Thank you for the Zofran order, but Bed 32 has never had an IV. Can you write it for oral?

Day resident: UGH. Okay, hold on – let me fix this. *types oral Zofran order* Where were we? Bed 25?

Me: Right. Okay, back to bed 25… gonna need dialysis as an outpatient, gotta figure out how to coordinate the gentamicin with the dialysis. Do we need to write an order? Or does nephro do it? We have to figure this out by 10am or the hospital will get dinged.

Cross-cover Resident: Um, also I just got paged that Bed 42 is vomiting blood.

Pager: THANK YOU FOR THE ZOSYN ORDER BUT SHE NEEDS ZOFRAN. AWAITING NEW ORDER, THANKS.

Me: …

Day Resident :…

Me: Can we just like, outlaw pages during sign-out?

Day Resident: Can we ignore it and hope she doesn’t call a safety event on us?

Cross-cover Resident: Let’s smash the pager with a hammer and go home.

Pager: *BLARES*

A Magical Yet Impractically Secret Phone Number

I’ve spent two days, on and off, working on that last blog entry – but somehow I still didn’t anticipate it would scare people.  I was surprised to see so many comments and messages this morning.

Turns out maybe there’s no way to write about untreated anxiety / depression in a non-scary way. Interns really shouldn’t be working 80 hour weeks with untreated anxiety. It’s a recipe for a bad time even though I feel like I’m handling it well.

(That’s usually the difference, isn’t it? We all want other people to seek help immediately, but when it comes to our own health, medical people have a deserved reputation for being dilatory as hell.)

So. Okay.

I had brunch with a co-intern who I deeply suspected had gone through the same damn thing – and luckily, I was right. He gave me the name of the NP whose job is to see residents for free and make every effort to get them into clinic at a moment’s notice. I’ll get an appointment tomorrow.

I should feel relieved.

Instead, I’m honestly a little irritated that our hospital employees medical professionals explicitly for this purpose and then makes it impossible to find out about them. (Short of having a terse, scary meeting with the Program Director – which is how my co-intern got the numbers in the first place.)

Why make this so hard? How counter-productive is that? Why are hospitals so universally dumb?

… speaking of healthcare being dumb, I’m going to be a little crass and direct you guys to my brilliant friend’s new healthcare and public policy blog.

Because as much as I’m excising my irritation with The Man / The System by complaining about the problems, Mark’s actually working on current efforts to solve them.

And you know, someone has to.

You could cut the irony with a knife

I’ve been off my Lexapro for a month and it turns out that’s bad.

Sometimes my patients have crippling anxiety.

When they do, I’ll take a few minutes to rule out other causes, report it to my preceptor, and they’ll breezily tell me “Fine – write a prescription for Zoloft, Lexapro, or Prozac – whatever you feel comfortable with. Do you know the dosing?”

Lady, you have no idea. By the way, I would also like a refill for myself.

… but for the life of me, I can’t find someone to take 10 seconds to write one for me.

I don’t feel it’s alarmist to say this is a problem.

I’ve been pretty open about my anxiety / depression. It’s been a non-issue for the last 4 years because my med school had outside psychiatrists.

But I’m not in med school anymore, and there are only a certain number of times you can refill a prescription from out-of-state without a visit – and I’ve gone way beyond that.

So now what?

I could set up an appointment at my current hospital, but I have to do a psychiatry rotation with these same attendings, so that seems… short-sighted.

I could call around at one of the competitor hospitals, but they’re all far enough away that I’d have to ask off work for “medical reasons”, which is a bit of a death knell. And why would they even accept our health insurance?

They probably don’t.

(Or maybe that’s just me making lame excuses? I honestly don’t know. My anxiety has ramped up to the point where the thought of just finding a phone number and calling someone is so mentally and emotionally exhausting that it’s impossible to tell.)

The thing that kills me (and the reason I’m writing this blog post at all) is that I know I’m not the only resident with this problem. I can’t be. Depression and anxiety are way too common – and the 80-hour work week and infeasibility of accessing your own hospital’s psychiatrists have to make this a global problem.

In the mean-time, there I am: taking a total of 10 seconds to jot down a prescription, then sitting in the corner anxiously twirling my pen and grinding my teeth.

Medicine sure can be stupid.

I mean, I celebrated last week because I got an article accepted to Gomerblog

You know how there’s a lot of German words for complicated emotions?

  • Schadenfreude: The pleasure you feel at someone else’s pain.
  • Schleppen: The labor at carrying a heavy object a very long way.
  • WanderlustAn impulse, longing or urge to go for long walks or hikes, or to travel
  • Zugzwang: A situation in which you have to make a move, but any move you make will be disadvantageous to you, whereas if you did not have to move, you would not be at a disadvantage.
  • WeltschmerzSentimental pessimism or melancholy over the state of the world

Do you know if there’s a German word for the emotion “my peer just had a 1st author paper accepted for publication to Cell and I’m simultaneously incredibly proud but also – good god, I need to seriously re-evaluate my suddenly wanting life?”

… asking for, um, a friend.

Edit: 15 minutes after posting this, one of my friends got a write-up in the New York Times. I’m officially having a small but incredibly selfish and confusing personal crisis.

I admitted 10 patients last night

Back in med school, I wondered how the interns wrote so many notes so quickly. It took me hours to do a good H&P, and in the process of writing it I would always remember something I forgot to ask or elicit.

Luckily, I’m now an intern, so I know the secret to writing lots of notes quickly:

Intern notes suck.

Even the best notes are only technically ‘good’ because we spent a couple extra minutes synthesizing the assessment and plan. Because, hey – the bright side to notes that suck is that nobody’s going to read a 3 paragraph HPI or a 4 paragraph history of someone’s back pain, and everyone’s just skimming your ROS and examination anyway, so what the hell, it’s okay that your family history consisted of two words.

(I used to bold the pertinent positives and negatives of the ROS and exam, but then one of my preceptors told me to knock it off because she likes to use bold for her own addendum. Which, okay, fine – I guess this way, at least no one will notice I didn’t check for cervical adenopathy in the kid with mono.)

The downside to notes that suck is that your original note will be repeatedly quoted in every consultant and social worker’s HPI, word-for-sucky-word.

I really can’t get over the fact that people actually read my notes now. (Or at least, copy and paste them). After 4 years of medical school, having a consultant specifically reference aspects of my HPI or assessment feels… wrong. And guilt-inducing.

Don’t you want to do your own assessment? Are you sure you want to rely on mine? I wrote this H&P in-between a rapid response, 3 “urgent” pages, the surgical fellow tapping his foot impatiently at the door, and sign-out.

But anyway, there you go: It used to take me 4 hours to write my weekly H&P, which would inevitably get ripped apart by the preceptor for not including tactile fremitus, CVA tenderness, a gait exam, and fifty additional ROS questions. This H&P would never, ever be read, because I was an M2.

Now I can write 10 H&Ps in a night, all of which will be quoted extensively by consultants who are relieved they don’t have to take the history themselves!

Something, something… patient safety.

I Ordered A Blood Transfusion Today

I’m not comfortable with the fact that this was, somehow, allowed.

And blood transfusions are really the WORST example, because there’s so many safety checks between the blood bank and the nurses – but even so, the fact remains: I have waaay too much responsibility.

And it’s not the “so many things I have to do!” kind of responsibility – it’s the “so many things for which I am legally and morally culpable!” kind of responsibility. And I am not used to that.

Med school does not prepare you for that.

Today I carried the other intern’s patients, because she had continuity clinic. And I got a page about a patient with, say, pancreatitis. “Still in pain after I gave tylenol dose. Can you put in an order for motrin?”

… Can I?

Sure, I checked up on the patient first. But even after that, it took me at least 5 minutes of research to feel confident that motrin was definitely okay in pancreatitis. (Why wouldn’t it be? Shit, I don’t know. Stomach ulcers? I just had a general feeling of unease about it).

Then it took me 10 more minutes to figure out how to prescribe it, because of finicky things with dosing and formulations. And then I was unsure if I maybe overprescribed it, so I had to call the pharmacy to double-check.

The nurse was not amused by the delay.

So yes, you could say intern year is going great.

I got another page today: “Patient ‘TotallyStable McHomeSoon’ is desatting to high 80s on blow-by, sBPs in 80s. Please come to bedside to assess.”

So I jogged over, assessed, gave a few obvious orders (Nasal canula, 1 L. …. Nasal canula, 2L… albuterol on stand-by…), came up with a reasonable assessment and plan, and left the nurse at the bedside so I could quickly update my senior resident.

I figured she’d probably be okay with my management, but might be deservedly annoyed I didn’t inform her sooner. I mean, this kid was initially unstable.

But she just said “Right, I heard about that patient’s desats,” – and with great restraint and calculated patience, she continued: “They told me first. So I told the nurse to page you.”

Which… what? Excuse me?

WHY WOULD YOU DO THAT.

So I went back in the room, kept managing him – and the patient turned out fine (eventually stable on room air) – but I do not like that kind of pressure.

Even worse, one of the things on my differential was that I had recently reconciled all of his many, many medications – and some weren’t on formulary, so I had to call the pharmacist – and… maybe I made a mistake? Maybe this was pharmacologic respiratory depression? He had just gotten his morning medications, after all.

So for at least 5 minutes, I was seriously considering the fact that I might have made an inadvertent error that could have seriously hurt someone.

I didn’t. Turns out it was something else entirely – but… the bright feeling of “Whew, I didn’t make a mistake!” is being tempered by this inner voice that’s adding “This time” to the end of that sentence.

Why would anyone WANT this kind of pressure? Who the hell decides to be a doctor? Who wants to reconcile outside medications, knowing that there’s a chance you’ll make a minor error, and see a patient in acute respiratory distress?

(Again: I was not the cause. I reconciled perfectly.)

(… this time.)

We had a code today, too. I was ecstatic that – despite being disturbingly close by when the code was called / the alarms went off – I still somehow managed to be too late to be of any use. (YES! The holy grail: responding emergently like a responsible person, and not being needed.)

Still, I stuck around with about 10 other residents / attendings / nurses in case they had to go to chest compressions and needed the extra help.

Chest compressions, I can do.

This day-to-day “ordering potentially life-threatening medications under my god-given name” thing? That’s much harder.

Sign-out really needs to happen more than once a day

Our attending’s goal is to make rounds fly by as quickly as possible, with a bare minimum of any actual HPI or physical exam findings.

Our Sub-I’s goal is manage their patients by themselves, as an actual practice for residency.

Our senior resident’s goal is to discharge / transfer people out as quickly as possible, because she has one foot out the door.

And the night intern just wants to get a sign-out from us that doesn’t suck and addresses all their questions so they can take care of like a million kids.

I get up early every morning to review the list of kids on the ward (all of them, not just the ones I’m assigned) because I hate getting called to the bedside of a kid I don’t know. (Rounds are supposed to mitigate this kind of thing, but we go so fast – and our turnover is so high with all the discharges, that it usually doesn’t help.)

Yep, I’m the intern. Nope, nobody told me that this patient even existed. No, I can’t believe it either. The lack of communication here is stupid, dangerous, and totally unnecessary.” <– is what I don’t say. But it’s true.

The sign-out list I’ve been carting around is now no longer relevant and so I page the senior. Maybe she gave the patient to one of the Sub-Is? Maybe she’s been managing that patient herself because she wanted me to finish discharging my other kids? Maybe a ghost put in the admit orders?

So I show up to the nurse’s call, make sure the kid isn’t actually coding, make a couple minor interventions to bide some time (Let’s stop the feeds and try some blow-by even though I don’t know the patient’s history!) and page the senior.

Today the medical students looks at me sadly like, “You couldn’t even handle that yourself?”

Nope.

You could actually see the respect draining out of their eyes.