Saturday, August 13, 2005

Call Night

Here's a day-and-a-half in the life of a doctor: a typical call day last week as a senior resident on an inpatient general medicine service.

7:00 AM Arrive at hospital, check labs quickly. Today there's only two patients in the hospital being taken care of by our team (myself the senior resident, my intern, two medical students and an attending, the boss). But we're on call today, so new patients will soon be coming our way...

7:30 Resident Report: Case presentation, reviewed recent JAMA review on the evidence for medication treatment for neuropsychiatric symptoms of dementia. Bottom line--risperidone and olanzapine have the best evidence but both come with increased stroke risk, and carbamazepine has some good evidence too. Discussion--is dementia best thought of as a terminal illness like untreatable cancers, where treatments can be used to improve quality of life even if they come with increased risk of death?

8:30 Morning work rounds: One retired physician who has been recovering from a complicated gallbladder infection is still running low-grade fevers can't go home yet, another man recovering from hypertensive emergency is now under control but we can't find a rehab place to take him that can get him to dialysis.

9:00 CODE BLUE: Patient down in hallway, we run upstairs and give ativan for apparent seizure. No airway/cardiovascular issues, situation under control, we sign off.

10:30 The attending decides to do impromptu lecture on pneumonia. He spent 3 years in Africa, and has ideas about making cheaper antibiotic choices.

11:00 My intern's off to intern report, and the students have some meeting, so I spend the usual teaching hour doing some reading on HIV dementia... Then I find out that since the non-teaching service is full of patients, we're up for admissions early. Here we go.

12:00 Noon First admission comes, a lady with Alzheimer disease and cholangitis--going straight to ERCP to look for and retrieve the gallstones. I'll see her after the procedure.

12:15 Morbidity and Mortality Conference: Over lunch, the whole Internal Medicine department gathers to hear a blow-by-blow presentation of a case from start to finish, with running commentary and questions from the professors. Traditionally they follow the format of someone's outpatient course, getting sicker, goes to 'outside hospital' but they can't figure it out so they send the patient to our academic medical center, and things either get better, or they die and we see the autopsy presentation by the pathologist. Today it was a guy with hypertrophic cardiomyopathy who they ended up doing an alcohol injection to kill off part of his heart muscle in order to improve the blood outflow tract, and he survived.

1:15 Taking admissions: A few folks in the emergency room coming to our team. One 90 year old man with an enormous nosebleed, and some blood in his stool coming in to rule out a colon bleed. Admitted to the hospital more for his physician daughter's worry more than for real medical necessity.

3:00 We're up to 5 new patients now. One is a 93 year old lady with 2 weeks of 'the dwindles'. We'll get a CT scan to evaluate some belly tenderness.

4:00 Now up to 7 new patients. We can only get up to 10, and only until 11pm, whichever comes first. The attending suggests that we try to get the non-teaching service to take 1 or 2, but I gamble that we'll get the full ten and decide to keep them so we cap early.

6:00 When the tech came to get the lady for her CT scan, the nurse hadn't yet hung her IV bicarbonate to protect her kidneys because she was always in the bathroom when she came by. The daughter is livid, and won't even talk to me, demanding the attending. Just what we need.

7:00 There's something strange about her CT scan, looks like either an infection or new cancer. OB/GYN will see her in the morning.

7:15 A man in the ER dropped his hemoglobin, probably an ulcer bleed from taking 650mg of aspirin every 4 hours for arthritis. My psychiatry training tells me he's hypomanic, but diagnosis doesn't make him any easier to deal with. He won't let my med student put in an NG tube (to suck fluid out of the stomach to look for blood) so I just do it. He'll have to learn on someone else, but he's running out of time before he rotates off the service.

7:30 My wife and daughter page me, 'any time for dinner?' With this GI bleeding guy in the ER, not really. See you tomarrow afternoon...

9:00 Up to 8 patients now, a lady with meningitis just came in.

11:00 Well, we lost the gamble, took just 8 tonight. Finally got to see the lady with the gallstones, doing OK after her procedure. On my way to see a guy with several blood clots in his lung--the intern had seen him and he was stable but we don't know where these clots are coming from.

11:45 Finally getting a chance to spend a little more time with the pleasant Christian Scientist lady we admitted for falls at home. Sounds like peripheral neuropathy, but why?

12:30 The man with the blood clots has an irregular rhythm despite his pacemaker--the question is if his pacer is malfunctioning. The cardiologists are unhelpful, just keep telling me not to worry. We'll keep a close eye on him and have the cardiology consultant team see him in the morning.

1:00am Sit down with intern to review the list of things going on, need coffee.

2:00 Reviewing the medical students' writeups of their patients. One of the patients has a heart rate of 160, but hemoglobin is down--we'll give some blood.

3:00 Get a call from the attending, review over the phone a few issues. My computer crashed, lost a long admission note I was writing. Blast it all.

4:00 Things are settling down. Will try to get a little sleep.

5:30 Get call from nurse: need to do informed consent form for a patient's blood transfusion. Can't believe it's taking so long to get the blood-- back to bed.

7:00 Rise and shine, grab some coffee, ready for rounds.

7:30 AM work rounds start, looks like we're skipping all the teaching today. Turns out the lady with peripheral neuropathy has a low B12, the neurologists are ecstatic--it's not every day they find something treatable in their specialty. The other lady still hasn't gotten her blood, we chase this problem down.

8:30 The lady with the gallstones has a low blood pressure and fever, may be crashing. Bolus fluids, constant vigilance.

10:00 Visit radiology: the guy with the blood clots may have a cancerous mass, will have to get another scan. The lady with the 'dwindles' may have cancer too, need to biopsy.

12 Noon: The MD patient recovering from his infection is better, ready to go.

2:00 The man with the nose bleed did well and is ready to go, but his MD daughter is furious that we haven't talked, but whenever we try to call her we just get her answering machine. Finally get a message she demands an ENT consultation before we send him back to the nursing home, but we don't think he needs it. We agree to 'curbside' consult them, and they recommend a brief type of exam. My intern dutifully does this. We should have left an hour ago by the rules governing resident work hours, but guilt over violating the rules is easily trumped by potential guilt over taking bad care of our patients. we work on...

2:30pm Finally ready to sign out. I give a special heads-up to the nightfloat about the unstable gallstone lady. I do a final check with my intern to make sure everything is OK and find her near tears, upset over the ENT consult incident. A little reassurance is in order, and we're outa there.

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