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.

 

 

I am 7.7% done with intern year

I was surprised when I divided 1 by 13 in my calculator: it seemed like the number should be much smaller – 2%, maybe. Or 0%. (It feels more like 0%.)

The fact that it was somewhere between 3-to-infinity times larger than what I expected really tells you a lot about 1) how quickly time flies, and 2) my ability to interpret simple fractions.

(Very reassuring to my future patients, I’m sure.)

Anyway, I start inpatient wards on Monday! So I’ll magically go from being deemed capable to juggle the 2-3 patients I had as a Sub-I, to 7-8 patients as an intern. There is no possible way this can go wrong.

I’m relieved to be done with this outpatient rotation, though. It was fun and I may have learned a lot, but I never really felt like I was on anything other than a typical 4th year rotation (albeit, with an attending who was particularly lax about supervision).

Onwards and upwards.

so it begins

Quote of The Day: Oh, Come ON.

Med student: “Hey, Action Potential! Hi! Haha, funny story – I was actually just yelling at you to come over here – but it turned out it wasn’t you I was yelling at, it was actually a 70 year old woman!”

Me: “…”

Co-intern: “That’s not very funny.”

Med student: “No, no – it was! It was really funny!”

Me: “But I don’t want to look 70…”

Med student: “OHHHH, no – no, you don’t!”

Me: “Oh, good. Whew.”

Med student: “It was your hair!”

Me: …..

Med student: “Because you and the old woman had the same haircut!”

Me: …

Med student: “You know, kind of short?”

Co-intern: “Okay, okay, I think she gets it.”

5 Vignettes From My First Intern Clinic

1. Clinic: A Short Play In One Act

Scene: Clinic. Afternoon. 

Kid: Mom, why am I even taking ObscurePsychDrug?

Mom: Honey, you’re not taking ObscurePsychDrug. You’re taking CommonADHDMed. They’re completely different pills.

Me: Very true! You’re taking CommonADHDMed.

Kid: Oh. … so… ObscurePsychDrug ISN’T for ADHD?

Mom: No. It’s for… er… Oh! – the DOCTOR can explain to you what ObscurePsychDrug is for!

Me: *mild panic*

Mom: See, that’s the wonderful thing about visiting a doctor – they can explain all sorts of questions! Even about drugs you don’t take!

Me:

holy shit

Computer: *persistently refuses to allow me to google ObscurePsychDrug*

Computer: *continues to be terrible*

Mom: Okay, son, the doctor is going to explain ObscurePsychDrug to you, so STOP FIDGETING and listen. very. carefully.

*Mom attentively adjusts chair, stares at me in happy expectation*

Me: *prays to the Pediatric God that I’ll be urgently paged to another room*

The Pediatric God: *is not a kind God*

.

Me:i actually don't know what i'm talking about right now

2. My preceptor says I’m “functioning at the level of a January intern” instead of a “July intern”.

(… Is that the best half-compliment I’ve ever received, or is it pathetic and sad?)

there would be no way of knowing

3. Who the hell decided that Epic doesn’t need a “are you sure?” button to permanently sign a note?

I intended to PEND the note. I pend EVERY note before going to the physical exam. I now have a horrible, innacurate note that’s now forever in the system with an apologetic, all-caps, “I’m a stupid intern” addendum. Goddamn it, Epic.

when you make a mistake

4. The nurses like me. That’s something, right?

5. Oh god. I’m a fraud. Don’t ever visit a hospital in July, don’t visit a clinic in July, don’t step outside in July, just draw your shades and lock your doors and stay in bed and pray until this all blows over.

 

Intern Week #1: “… See, now I’m worried you’re not actually joking.”

Outpatient clinic seemed like such a perfect first rotation: Sure, the hours weren’t as cushy as I thought, but who cared? I was seeing patients! Putting in orders! Wearing a long white coat! Not getting too many things horribly wrong!

So of course, Friday morning – as I’m settling in to read some relevant review articles on a makeshift sofa consisting largely of empty cardboard boxes – I get a call from the chief resident.

“So… there’s actually been a… scheduling issue. We need you to move to the inpatient team. Night shift. For the rest of the month.”

huh2

 

Well… so… okay.

Okay then.

That sucks. But… okay! Positive thinking! I’ll adapt! I will rise to the challenge like the flexible, go-getter, team-player I am!

(Read: I sat there, stunned, until it occurred to me that night interns get to wear scrubs.) (I’m a huge fan of anything that qualifies as Socially Acceptable Business Pajamas.)

So: I did some math: I had 3 days to adjust to a 10am – 6pm sleep schedule.

AND I DID IT. Because I am a power intern. Hoo-ah.

(Read: I did it because I really, really like staying up late. Pulling multiple socially acceptable all-nighters until I have the kind of sleep schedule that would have made my parents haul me in to see a doctor myself? SIGN ME UP. The nocturnal train is leaving the station and I am on-board.)

So I shifted my sleep schedule by 4 hours every day this weekend until, this morning, I reviewed all of my inpatient files and I fell blissfully asleep at 10am. My alarm was set for 5:30, 5:45, and 6:00pm. I was ready.

Which – as you can all guess – meant that of course I got a surprise call at 11:30am.

“So… hi. I really, really hate to do this to you… but we’ve had another intern issue. Slight scheduling change.. again: You’re back on outpatient.”

what is this jeez no text

 

“So… we’ll see you at clinic this afternoon?”

 

i quit2

 

The Last Day Of Orientation Pep Talk

Chief Resident: Each patient room has a white-board – make sure that where it says ‘Physician’ you write your attending’s name.

Me: Do we write our own name on there, too? So the patient knows who we are?

Chief Resident: Nope. The patient doesn’t need to know who you are.

Other intern: I thought the nurse said it was critical to have the intern’s name on the white-board…?

Chief Resident: Oh! Haha, I see the confusion. Okay, no – she was talking about the white board at the nurse’s station! The nurses need to know who to call.

Me: Oh. Okay.

Chief Resident: See, one of the questions on the ‘Patient Satisfaction’ survey the hospital uses is ‘Did you know your attending physician’s name?’ – so we have to write it up there so the patients will get that question right. Makes our satisfaction score higher.

Me:   :\

Chief Resident: The rest of the team doesn’t matter, you’re just free labor.

Me:   :(

Pediatric Life Support Training

EXPECTATION:

Instructor: And… begin.

Intern Leader: “Okay, look’s like the patient is in Vfib. You, please charge the defibrillator at 2 J/kg. You, please get vascular access. You two, start chest compressions and ventilation. We’ll shock, then continue with 2 minutes of CPR and reevaluate – if it’s still shockable, we’ll move on to 0.1 mL/kg of epi and charge at 4 J/kg.”

REALITY:

“Wait.. Guys, how does this thing plug in? There’s no plug for the chest pads.”

*10 panicked minutes pass as all interns independently confirm that the defibrillator does not connect to its chest pads in any way recognizable by human sight, touch, hopes, or indeed the very laws of physics*

“Hold on, let me look… I think I saw something, underneath all these cords… wait, no. That’s a lamp. But maybe…”

“IF YOU’RE HERE, WHO’S DOING CHEST COMPRESSIONS?”

“…”

*sound of guiltily resumed chest compressions*

“Let’s just.. let’s just give epi before we lose the patient.”

“Fine. I’ll draw it up while – wait, what’s the weight? “

*sound of drilling*

“GUYS, I GOT VASCULAR ACCESS.”

“… Did you just put a hole in a $1500 mannequin.”

“… for vascular access.”

“This mannequin isn’t supposed to have vascular access!”

“Um, should I still give the epi?”

“YES”

“Oh. Well, we don’t have any.”