New York Times

Excellent article about patients dying and how we rush around, not allowing ourselves to react. Sorry about all the death talk, but I'm sure you can understand why this is on my mind. Although, as my fellow psych intern said yesterday, why didn't everyone get upset when my patient died? It's normal to be upset, normal to cry, so why do we push it down so much? I'm so glad she's on the service with me--it would be a lot worse if I had no one there who knows exactly what it's like to be a 3-week intern on a busy neurology service where everyone else has had at least 1 year of medicine.

Everyone Should...

...go see Batman. Now. Seriously. Heath Ledger was unbelievably amazing--he owned that whole freaking movie. Well worth seeing in the theater, if you haven't already. I hadn't even seen Batman Begins, actually, and I still really, really enjoyed this movie. Sometimes you need a little escape from reality, and this was a good one.

Really Rough

I didn't blog about all this when it happened because I didn't know what to say. I'm also working very hard to maintain anonymity (for me) and confidentiality (for my patients) on here, so it's difficult to write about things. But here goes. (Read at your own risk--this is not happy).

Friends, I thought I had killed a patient the other day.

It was a totally bizarre situation. I was just thinking to myself that she'd been in the hospital too long, and had been working with case management to get him "placed" out of there. I get nervous when I look at the roster and see that a patient's been in the hospital longer than a week, because complications go up exponentially after a certain period of time (for example, I think the UTI rate with an indwelling Foley is nearly 100% by one week). On the neuro floor, a UTI is not the benign thing it may be in other places, like an outpatient OB/Gyn clinic. On the neuro ward, a UTI can present with altered mental status or even concurrently with stroke, and can lead to sepsis before we even know the patient has a UTI, because often they can't tell us it burns when they pee, because they've had a stroke or they have diabetes and don't feel it or they have a Foley and it hurts all the time anyway.

Anyway, I'd started working on things to get her out, and then I was off part of that weekend, so someone else rounded on her. And I picked her back up Sunday, and none of us noticed that one of her medications had disappeared after Friday. I continued to say in my notes "DVT prophylaxis with subq heparin" without noticing that my med list, which is imported from the actual med list in the computer, did not show heparin. I did not have her on TED hose and SCD's simply because I didn't know you could gain benefit from using those together with heparin (heparin as opposed to LMWH because my attending likes it.) We were working hard to get her out, and we'd found a good place for rehab...

And then one morning I came in to find out there had been errors overnight. She had a vital sign in the range of "notify house officer" that wasn't reported. Cursing that morning, I ordered lab tests and x-rays, but at least she looked okay on exam, in fact slightly better than the day before.

And then her father called us in, because "she didn't look right". I went in, and indeed she did not, breathing fast and sweaty, but still awake, still trying to talk. She was tachypneic and tachycardic, so I ran to get my chief. "She's on heparin, right?" he asked me. "Of course she is, we ordered it," was my reply. Famous last words, as we looked through the med list and caught the omission. I asked the nurses, who called the pharmacy, who finally told us that heparin orders expire automatically 7 days after admission. WTF? No one knew that this was the policy, and I hadn't received a notice in my computer system, nor did the medicine show up in my "expired orders" list. It just vanished.

We got her a dose right away and started workup for PE, but not long afterwards she coded and died. I helped with the code (although I did NOT run it--I left that to a third-year medicine resident, and I did chest compressions like a good little intern), and then left to write some orders for another patient. Sitting there, out of the melee, I burst into tears. It was all my fault! I'd killed her, I was a terrible doctor, only a few weeks into my training! It was the most bone-squeezing gut-wrenching hot burning guilt I've ever experienced. It was totally intense. My attending asked some probing questions about what happened, and I told him about the heparin error. Even though we weren't sure why the patient had coded, as we had no direct evidence of PE, it loomed large in all our minds.

All night, I was miserable. The next day, I went into the autopsy I'd had to request from the parents, and was greeted with some sweet words: "there's no saddle embolus." In fact, there was no PE at all. We are still waiting on a cause of death, but it seems that my error had nothing to do with it.

Now, I'm trying to figure out how to get past this. I check and double-check everyone's DVT prophylaxis orders, and the hospital is going to revise their DVT protocol and oversight. Still, I feel some guilt, as well as just sadness and trauma from the sudden death of a patient I'd seen for over a week, who was supposed to be on her way home.

I spoke to my psych chief resident today, and I just have to say that they are super wonderful. I'll be meeting with them a couple of times to talk about the death, and they helped me with something I need to talk to my neuro chief about--namely, that I haven't been getting proper backup when I'm on call, despite all the rules about doing so. The chief just kept saying "we want you to feel supported through this" and I was so touched I cried (I know, it's shocking, I never cry). I just reread House of God, and Chuck's line at the end has always stuck out to me: "How can we care for patients if'n nobody cares for us?" I'm not sure if it's just my program, or others, but I feel very cared for right now, and really, really glad I'll be switching to psychiatry in January and leaving this crap behind. (Not that patients don't die on psychiatry, but I'll be getting a lot more sleep, that's for sure!)

Who Can Explain It?

What I want to know is this: why, when you're watching a really boring lecture or Grand Rounds, does the lecturer insist on referring to their boring, overly detailed, under-colored picture/diagram as a "cartoon"? Oddly, the more boring and complicated the slide, the more likely it is to be called a cartoon, as opposed to a diagram, a picture, a schematic, or anything else. It's an inverse proportion.

Seriously, a diagram of a transposon in a lecture about epigenetics? NOT A CARTOON. Unless your diagram is labelled "Transposon? That's what SHE said!", it's NOT A CARTOON. If you need to know what a cartoon looks like, I suggest you look here.

This message is brought to you by the letter "I fell asleep in Grand Rounds today", I mean "A".

What is Call?

Some clarifications, based on a question I received in comments. Call is defined differently depending on what program you're in, what rotation you're on, and possibly by what country you're in.

Currently, when I say "call" I mean "long call" or "overnight call". I get to my regular weekday shift between 6 and 7 am (right now, usually around 7--we round kinda late). If I'm on call that night, I start carrying the call pager at 4 pm, and I take in all calls for patients in the ER to admit, or consults on medicine patients who have neuro problems, until 7 am. During the week, responsibility for admissions and consults goes to the consult resident; we admit every day on this rotation. On weekends, call starts at 7 am and goes to 7 am the next day.

After I quit taking new consults or admissions at 7 am, I finish any H&P's that aren't complete, write notes for the day, and get ready for morning rounds. We only round on newly admitted or consulted patients, but rounds still take awhile, as both attendings like to lecture--so where's the lesion? What tract of the white matter? What piece of the trigeminal ganglia is affected?

After rounds, I try to finish my notes, put in orders, and be out by noon. The latest I've stayed this month is 12:45 post-call; we didn't finish rounding/lecturing till 11:30 and I still had notes to finish and residents to page about their patients.

The rule is 30 hours straight: 24 hours of taking new patients, and 6 hours to finish up with those patients, but not take on any new patient duties. In actuality, this turns into "the 30 hour rule." If I get to work by 7 am, I should be gone by 1 pm the next day. Thus far, I've been "in compliance" with this rule. (I've also worked 79 hours, which keeps me "in compliance" with the 80 hour rule. No one has asked me to misreport hours, and thus far it hasn't been a problem.)

What different kinds of call are there? I know there are night float situations, long call/short call situations, even a "rolling call" deal on medicine at my program, which I will experience in November, but I have no idea how that works. Any thoughts on different kinds of call? How long are people working? My colleagues in general surgery, who are taking q3 call, have to be working at least 90 hours per week.

Grand Rounds

Go check out the very entertaining Grand Rounds at Unprotected Text. Of course, it's awesome that my post was included, but it's just well-done over all. Check it out!

Serious Inefficiency

Last night was a seriously screwy call night, and I only had 4 patients.

What made it so bad?
1) One of my patients was seriously sick. Big, bad stroke, initially not seen to be so large on the CT scan (which aren't very sensitive for acute ischemia, but are mostly used to rule out hemorrhage); after obtaining MRI/MRA and seeing how big it was, and the occluded carotid that likely caused it, we had to transfer him from the neuro floor to the ICU. This was a lot of work and worry, as I was afraid this guy was going to code on my floor with only a few nurses and me to save him. Fortunately, he's still doing okay.
2) Another patient had the possibility of going to medicine or neurology. In order to determine where she'd go, we obtained a stat study. And then I had to help wheel her to the study, wait with her while the contrast went in, wheel her back to the ER, and wait for the radiologist to give me a prelim report. I couldn't get started on her note because I wasn't sure it would require an H&P-titled note or an Inpatient Note-titled note. This makes a difference in the template used in the computer, and it's not terribly easy to cut and paste between the two.
3) Medication reconciliations are impossible to do when the patient doesn't have a list, doesn't have the meds, and does not have the stuff in the computer. Yet, I have violated the "rules" by not completing it until this morning, and could receive another lecture about "being in noncompliance."
4) I had one patient whom I called "my pager magnet". Literally, every time I'd go into his room, my pager would go off. I cleared out 18 pages about halfway through the night, and had received another 5 more before morning. This doesn't count all the repeat pages from my upper level, the neuro floor, and the ER. I'm really not that surprised that his H&P took over 6 hours to complete, as I never received more than about 5 minutes of consecutive exam time.
5) Doing things on the weekend made all of this much more miserable. I needed STAT carotid and vertebral imaging on my big stroke patient. Unfortunately, he was unable to have a CT Angiogram with contrast dye, which is usually the study of choice on the weekend or at night. I attempted for an hour to get him a STAT carotid ultrasound, but was told that a) radiology doesn't do them on the weekend, vascular does and b) vascular had no idea what the hell radiology was talking about. The ultrasound tech from radiology was actually present while I was doing all this futile calling, and could have run the study in less than 30 minuts.
6) Fortunately, the MRI tech came in from home to run a STAT MRI/MRA for us. I had to be present for this study as well, since the tech was by herself.
7) The rest of my night was mostly spent at the phone: returning pages from my anxious upper-level ("do you have that read yet??? I know you said you'd page when you got it, but you haven't paged in 30 minutes!"), returning pages from radiology, me PAGING the poor radiology resident (who was also new), fielding floor pages, consult pages, pages pages all I saw were pages.

I really miss having a text pager. It would be so much nicer if I could receive a text page with "Mr. Y has arrived on the floor" than have to go through the whole interrupting the patient interview I'm doing to find a phone and call back, not knowing whether the page I'm returning is vitally important or totally banal. The pager shows no mercy.

4 down, 2 more to go. Next call is Thursday, and I didn't realize I was still q4 until yesterday. It was awfully hard to keep going yesterday. Thank goodness I'm done with weekend call and will have two full days off this week.

Functioning at the Level of an Intern

A few of my med student rotation evals commented that I was "functioning at the level of an intern." Now that I'm an intern, I'm calling bullshit. There's just no comparison between being a medical student doing an inpatient rotation or a subinternship and actually being an intern. I predicted back in January that I really had no idea what it was going to be like, and I'm learning that I was entirely correct (and I called this, too).

• As a medical student, I carried a pager, but I received fewer than 3 pages per day on average. Often, they were just from other med students, telling me we were rounding or asking if there was food.
• As an intern, I am currently carrying 2 pagers (and I haven't yet been assigned a personal pager, but I'm trying to put that off as long as possible). When one goes off, I often can't tell which pager is beeping, so I usually check them both. One week in, and I hate being paged more going to the dentist. I'm developing a visible twitch and am prone to cursing outbursts when I get paged with my hands full or in the bathroom--perhaps I have Tourette's.
  
• As a medical student, I was able to see all my patients, write beautiful H&P's and progress notes, keep track of my patients' to do lists, help my residents, and even read up on issues (gasp--learning!). Without sounding too conceited (I hope), I can say that I was a pretty good medical student.
• As an intern, I feel like I barely have time to see my patients and put in their notes. When I get them in, I find myself making errors that I would have pointed out as a student. Patient A didn't get put on DVT prophylaxis. Patient B is on a zillion anti-cholinergic meds and is confused (not ordered by me, but not discovered initially). In completing Patient C's negative workup for stroke, we discovered a past medical history totally unknown to me (and indeed, the rest of the team) that actually explains his symptoms better. I forgot to order Patient D's nebs, until I listened to their chest this morning and thought Oh geez, they sound like junk. The errors are multifactorial: I'm new, the team is new, I don't know the computer system, half the time I didn't admit the patients and the error began in their admit orders, I just didn't catch it, I'm exhausted, etc. I feel responsible for it all, though, which I have to watch out for. It's useful to be responsible for my patients and be thorough, and learn from my mistakes; it's not useful to get so upset about minor things that I get flustered and forget big things.
• As a medical student, I could get the history and physical and defer all questions of workup or treatment to the doctors.
• As an intern, I AM one of the doctors, and it sounds weirder to say I'll have to go talk to the OTHER doctors first. It's like I'm saying, I'll go talk to your REAL doctor. I'm only pretending.

Other weird things:

I often find myself prescribing things to patients I don't know when I'm on call. I field questions like Mr. G has constipation, Mr. X has nasal allergies, Mr. Y is on heparin drip and has a PTT of 75, should I bolus? It's totally bizarre to me. If my husband asked me for medication for allergies, he can go to the medicine cabinet or the store and get it himself. In the hospital, we take that away from patients, and they're totally dependent upon those of us with those magical "MD" initials that give us control of their allergy medicine, Tylenol or Advil for headache, and the all-important constipation meds.

I gripe about the constipation thing, but actually, every patient in the hospital is likely to have trouble going poo. Hospital food isn't well-known for its high fiber and whole grain content, we put patients in bed and restrict their fluid intake, and tell them they can't get up to walk without assistance, lest they fall and break a hip. All of these factors = no poo. Honestly, if I were doing a better job of prevention with stool softeners and ambulation orders, I might have fewer problems with this. What I just find truly odd is that these pages are so frequently timed at 2-3 am. Seriously, I have never been so constipated that it woke me from sleep in the middle of the night. (Now, if they have insomnia, AND coincidentally feel constipated, that I can fix). I can give medication for constipation, but unless I write for an enema it's not going to magically produce poop within minutes. I still think that unless the patient is having pain, or is post-op from belly surgery, there's no reason for the 3 am constipation page, so long as the patient is clinically fine.

Also, this morning I got a page at 6:30 am for ordering air mattresses for two patients. Again, this was for patients whom I didn't know, and the page came in on the call pager, causing me a brief heart attack as I woke up and imagined a tPA candidate in the ER. I helped take care of it, and I was as nice as I can be when I'm awakened (I would have been getting up within about 5 minutes anyway), but I just have to wonder--isn't this an issue that is better taken care of during the day? It's not like the air mattress people are going to arrive any earlier than 8 or 9 am to examine their consult requests. No, I'm not bitter. At all.

I told my dad earlier, being an intern is a very odd combination of having supreme responsibility and having no responsibility (where being a med student, you really have few responsibilities). On the one hand, all my plans come straight from an upper level. I don't know diddly squat, other than to say "uh, stroke labs and an MRI?" On the other hand, I get paged about heparin drips and people seizing and I'm responsible for making spur of the moment treatment decisions, often with no warning. Do I give Ativan to the guy seizing in the EMU, even though his seizure is over and he's off his seizure meds so that they might record his seizures? Do we give the heparin bolus prescribed by the protocol, or do we leave it alone on the drip? I make these decisions all night and I have no idea if I've made the right decision. I just try to use common sense (what little I have).

I'm down 3 calls, 3 left to go. I'm so glad that after Sunday, my calls start spacing out further, because I'm effing tired. In fact, I'm going to bed.

Sanity vs Insanity, Part II

During our lecture today, we spent a long time discussing the paper I wrote about yesterday. It was a great discussion, led by an instructor who's obviously used this paper to teach his points for years. I'll see if I can recap a few of the different views I now have about the paper.

1) (This analogy was given by the instructor) If you were to walk into a neurologist's office and complain of crushing, throbbing unilateral headaches accompanied by photophobia and phonophobia, and you were to be admitted to a hospital for workup, at the end of which they found nothing wrong with you, and you had no headaches in the hospital (and indeed, never had headaches), wouldn't their diagnosis still be migraine? And if they found you out to be lying in the first place, wouldn't their diagnosis be malingering? So, if you come to a psych ward and lie about your symptoms to get in, then have no more symptoms inside, you are actually technically meet a diagnosis of malingering. Therefore, instead of "sanity versus insanity", what we're actually having a tough time diagnosing is "psychosis versus malingering", which apparently is true. It's pretty easy to fake psychiatric symptoms (Oh, I'm hearing the voices now!) and then when you get what you want, not hear them anymore. I worked on a "forensic unit" in a psych hospital, which accepted patients from the local jail. It was amazing how many of them heard voices in jail, but not in the hospital, at least not until the night before they were to be discharged.

2) The study really isn't very rigorously scientific. It is, however, a fascinating social experiment, which I think still renders it valid. It also gives us fascinating insights into the treatment of patients within a psych hospital, which were some of the most appalling points of the paper.

3) Today, you would not likely be admitted just for saying "I hear voices." 35 years ago, the diagnostic criteria for schizophrenia were much broader. I'm still not sure why that symptom alone was enough to get all these people admitted--a patient needs to be unable to take care of themselves, or decompensating rapidly, or a danger to self or others usually to be admitted like that. Maybe that's a difference with time? I'm not sure.

4) The author's claim that the pseudopatients acted "normal" in the psych ward wasn't entirely true. They never told the doctors they'd lied, they never told anyone they were in an experiment, etc. As far as the doctors and staff knew, these patients had honestly heard voices (eg, exhibited psychotic symptoms) and were currently asymptomatic. The doctors weren't given all the information, and certainly psychotic patients can hear voices one day and not the next.

5) Finally, the author's conclusion was essentially that the category of insanity is bogus because we can't reliably tell it apart from sanity (although he really meant we can't tell psychotic from non-psychotic). Is hypertension a bogus diagnosis, even though you might get a reading that is 135/85 and some books say "normal" and others say "pre-hypertension" and others say "hypertension", and some authorities urge you to treat it and others say don't worry? (I exaggerate in this example, but you get the point.) I personally think, and thought yesterday, that he's throwing the baby out with the bathwater, so to speak. Perhaps it's easier to recognize abnormal, maladaptive behavior in the "sane" world than vice versa, but this is the world most of us live in, where such behavior gets us in trouble.

The important take home points of the article, according to the instructor (and I touched on this briefly yesterday, but not in a very organized fashion):

1) It's very important to have reliable categories of diagnostic criteria that lead to valid predictors of outcome (which was the point of the lecture).

2) The second experiment, where the doctors rated whom they believed to be pseudopatients, likely shows either a high rate of malingering patients or a high rate of very high-functioning patients (or both) who weren't particularly bothered by their symptoms, although that begs the question why were they in a psych hospital.

3) The way patients were treated by staff was a valid observation by the pseudopatients. They were able to take detailed notes without anyone caring, because they were believed to be crazy. They were able to document abuse by staff of some of the patients, when said abuse would stop when physicians entered the unit, because they were not "credible witnesses"--after all, who'd believe a psych patient? They also experienced the depersonalization that happens on a psych ward--there's little to do but watch TV and wait for meals, you're not in your own clothes, you can't go to the bathroom in peace because there's often no door, you can't have your own belongings with you, and your room and personal items may be searched at any time. Also, the segregation of staff and patients holds true today, for sure. Most of us get a little prickle of fear the first time we walk into a locked psych ward. After all, if we lock them in, these guys must be dangerous! But how, then, do we strike a balance between keeping the patients safe (and keeping those few patients who are dangerous safe) and allowing personal freedom and rights?

It may sound like a non sequitur, but I'd like to conclude with an observation I made in China in a locked psych ward. The air was fresh, because small windows were open to allow air circulation. I'm not sure if the building had central air conditioning, as the majority of buildings in Beijing did not. It was just so refreshing to enter various hospitals and find open windows allowing in fresh air. In America, I doubt there's more than a handful of psych hospitals that have windows which open. As a result, the air quality on most psych wards is ridiculously stale--rather like the jail I worked in last year on OB. The air in this Beijing psych ward was fresh (or as fresh as air in Beijing ever is!) Perhaps one small difference we could make for our patients is a little fresh air. After all, they're not inmates (usually), they're just people with problems that they wear on the outside where everyone can see them, as opposed to inside.

Sane in Insane Places

I have my first set of psychiatry didactics tomorrow, called "seminars" at this institution. I've been having trouble with my email, so today I finally received the reading material for tomorrow's talks. Some of it was pretty dry, but buried in the PDF's was an article which I'd imagine is required reading for all psychiatry residents (and if it's not, it should be):

On Being Sane in Insane Places
D. L. Rosenhan
[Science 1973;179:250–258]

35 years ago, this author posed the question, would psychiatrists recognize normal? We all think we can recognize abnormal out in the land of the normal, but would we see normal in the land of the abnormal? To answer his question, he and seven other volunteers became "pseudopatients": they "snuck" into psychiatric hospitals, using the key phrase "I'm hearing voices", and then tried to convince the staff they were sane to be let out. Other than the voices, none of the 8 fabricated symptoms or history; they told their own stories. (None of the pseudoopatients had any psychiatric diagnoses, and all were highly educated, high-functioning members of society). Once inside, they said "I'm fine, I have no symptoms anymore" and behaved as they would in any other situation.

So what happened to the pseudopatients? Did psychiatry recognize normal?

It turns out, some people were very good at detecting the sane: the insane. Or at least, the hospitalized patients in the psychiatric hospitals. Pseudopatients were often questioned as to whether they were journalists or professors (they took notes on the wards), but only by patients. Psychiatrists, nurses, and staff never questioned the admitting diagnosis of schizophrenia; even behavior that was normal was seen as pathological. If the patient was seen writing, it was "patient is engaging in writing behavior". When patients were discharged, they were diagnosed with "schizophrenia, in remission".

One hospital, hearing of the results, took offense. That could never happen here, they said. So a second experiment was arranged. The hospital was warned that in the next 3 months, one or more pseudopatients would be sent to try to gain admission. Psychiatrists and staff were asked to evaluate every patient on the ward and presented for admission, to see whether they might be faking their symptoms. Of 193 patients evaluated, 41 were suspected strongly by 1 psychiatrist of being fakers; 19 were suspected by 1 psychiatrist AND 1 staff. In fact, the author did not send any pseudopatients within the three months.

The author hypothesizes that barriers to recognizing sanity were multiple. 1) In medicine we prefer false positives to false negatives; it's better to overdiagnose cancer than underdiagnose it. He believes that this should not be true in psychiatry, because 2) Psychiatric diagnoses carry stigma, even among mental health professionals. He presented multiple studies of people treating others very differently in the psych ward than out in public. 3) The multi-tiered structure on the psych ward keeps psychiatrists, with the most training, furthest from the patients, and staff, with the least training, closest to patients. 4) All staff is somewhat segregated from the patient populations, hiding out in glass "cages" (in other hospitals I've been in, they're called the "control towers"). Interaction with patients is limited. 5) Not many mental health professionals recognize the dehumanizing forces at play within a psych ward. He makes the obvious next step: if these "sane" people went undetected, then how many "sane" people are even now locked into psych wards, saddled with diagnoses that will keep them labelled for life?

I had many feelings about this article. First, I was rather amused that the author pulled this off, and showed up the doubting hospital. Second, I was horrified that this used to happen. Third, I was appalled that this probably still happens every day. Fourth, I vowed to reread this article frequently during my training, lest I forget.

I will say that in my experience last year, we admitted several patients to the pediatric ward at the insistence of parents/law enforcement, etc, only to discharge them the next day or within 2 days because they were fine. Often our history at admission was from the parent or other family; even when it conflicted with the patient's words, sometimes the kid would get admitted anyway (especially if a warrant was involved). Then, with the parents out of the room, we could usually get a good story of what was going on. So, why did we believe the parents more than the kid? Was it the fact that a kid is a minor, and the parent is in charge? Or was it that the kid was accused of being a psych patient, and therefore we didn't trust their story initially? I'm not sure.

This article is over 30 years old, and I hope that things have improved dramatically. I also hope I can help things continue to improve. I'm a little unsettled, though, which is an odd place to be the night before I start attending lectures in this field. I will take hope from the fact that I'll be receiving lectures from an attending discerning enough to have us read this article in the first place.


Added 7/8 at 2054: I just posted a sequel to this post, written after my lecture today on this article. Check it out here.

Fifth of July

Last night, I had a moderately bad call night. I say moderately, because it could have been worse (that's the mantra for this rotation--it could always be worse.) All day, I was slammed with pages for consults from the ER and the floor, and was trying to wade through them with the help of the team's chief. He's a little ADHD, so when I try to ask him about management it is often a few minutes before he remembers that I asked a question in the first place.

Add to this the craziness that is the Fifth of July in the ER. Everyone gets sick on the Fourth, but no one wants to miss out on the barbecue and fireworks, so they wait to come in on the Fifth. Every service was slammed--medicine had a ton of MI's and rule-out-MI's, one of my fellow psych interns was totally overloaded with people driven crazy by fireworks, booze, and other substances external and internal, and neurology had the joy of receiving consults from a totally worthless PA. Seriously, dude, "sleepy" or "drowsy" does not equal "stroke" or "other neurologic condition." Especially when you ask me to see the patient BEFORE obtaining any labs to rule out metabolic or pharmacologic causes of drowsiness/confusion. Now, if you don't know HOW to work up drowsiness, then fine, make that your consult question, but don't just say "well, it might be neurological" when you don't even know whether the patient is high as a kite, dehydrated from the fine jungle summer weather, has a raging sepsis, or is just drunk. GRR!

Other than that, we were just plain busy. We had patients with dizziness, we had patients with sleepiness, we had seizures and strokes and hallucination/seizure/nightmare/flashbacks-induced-by-loud-fireworks. I'd staggered to the call room praying for some sleep, but received a page probably 30 minutes after falling asleep, so I was extra-groggy for that one. And immediately after writing down that first mid-night consult, I got a page for another. And a page from the floor for a fever, could I write the patient some PR Tylenol instead of PO? I dragged myself downstairs to see the patients, anticipating the long neurological exams I'd have to conduct and dreading them (I just don't enjoy the neuro exam).

This morning, after handing off the call pager, I would start twitching every time it went off, forgetting I wasn't wearing it anymore. I'm going to join my PTSD patients before long. Not to mention I was having word-finding difficulties, left-right confusion, memory loss, and disorientation to place (couldn't find elevator) this morning, putting me right on par with most of my stroke patients.

But the thing that made it all suck, the thing that nearly broke me last night...

THE VENDING MACHINES ONLY CARRY PEPSI PRODUCTS.

No Coke, no Dr. Pepper, only Pepsi. I tried to buy a bottle of water from several machines, but they were all broken. I gave in and tried to buy a can of Pepsi, but the machine was "sold out" and refused to give me back my $0.75, so I ended up drinking Mountain Dew. Which I hate, but it was better than root beer (which I despise). It gave me tachycardia, which made it hard to sleep even when I went to bed. (I could have just gone thirsty, but I was really, really thirsty. Trust me.)

I'm a southern girl. I use the word "Coke" to describe all soft drinks in general, and then name the specific drink I want. Not "soda", not "soft drink", not "cola", but "Coke." It is just not right that every single freaking vending machine in this hospital is Pepsi.

This morning, bleary-eyed, I poked my head in the back door of the cafeteria. The lady said they didn't open till 8, and I nearly cried I was so tired. (Not drinking coffee is not so handy sometimes.) She took pity on me and let me sneak in and pay her cash for a Coke from the fountain.

It was delicious.

Primer Noctem

So last night was my first call as an intern. I survived, and it really wasn't that bad, thank god.

Things that happened overnight:

• At one point, my upper-level gave me a pack of "brownie bites". I was walking down the hallway with the pack, and at some point I realized that it was not closed, like I thought it was. I was dropping little brown squares, like a trail of bread crumbs, from the ER back to the neuro callroom. And from a distance, they did not look like brownies. Heh.
• Raise your hand if you've ever in your whole life been so constipated that at 3 am you feel the need to call out for help. Anyone who wasn't a post-op abdominal surgery patient? Anyone? Anyone? Bueller? Yes, I got that page at 3 am. The nurse had tried to use the PRN meds ordered, but the patient refused. He wanted some "lemon-tasting stuff" he'd had in the past. The nurse decided that equalled mag citrate and asked me to order it in the computer. I complied, and figured that he probably knew what he was in for, or at least hoped I wouldn't get called to clean up the mess.
• I got paged in the ER while I was on the phone trying to call someone else. As I was trying to juggle the phone and check the pager, the pager slipped out of my hands and fell straight into a styrofoam cup of coffee on the counter. Ker-Splash! Coffee went everywhere, including my brand new white coat, the phone, and a nursing note. A nurse grabbed a towel and started mopping it all up while I was still trying to talk to the doctor on the phone. The call pager ended up smelling pleasantly of coffee for the rest of the night. Sadly, it continued to work.
• After dropping the pager, I cursed (after I hung up the phone). The nurse next to me started to laugh, because my patient's wife was standing not too far away (I didn't know who she was) and SHE started to laugh. I apologized to her repeatedly for my unprofessional behavior--I make it a point not to cuss in front of patients, and I was more than a little embarrassed. She thought it was hilarious.
• It is possible to have close to 5 hours' sleep on call (or at least, that's how long I was in the call room) and still feel exhausted in the morning. I'm not complaining about getting sleep on call--the girl on the night before didn't even get to go FIND the call room--but there's something less than refreshing about sleeping in your dirty scrubs with 4 different alarms set (I'm notorious for sleeping in) and getting paged all night.
  
• I ran into a fellow psych intern who was taking psych call. She had been having a slow evening, but was praying the suicide pager wouldn't go off. I'd forgotten that in 6 months, I'll have to carry that same pager, and I'll absolutely pray it never goes off. Or that whomever it goes off for is not ACTUALLY committing suicide, but just needs someone to talk to. *shudder*
• I discovered that there is a wireless internet connection (or is it Bluetooth?) between my pager and my ass. As in, the moment my ass connected with a toilet seat, the pager went off.
  
• Finally, I'm only one call into the month (5 more to go) and I'm convinced that pagers are the spawn of the devil. They are truly instruments of pure evil and must be destroyed.
  

I'm on call again Saturday, because we swapped some stuff on the schedule. It makes the next few days suck, but my last call will be nearly 2 weeks before the end of the rotation. Thank goodness I'm off for the Fourth! Have a happy holiday!

I Almost Forgot

Two tales from yesterday.

1) We went in a patient's room and needed to turn off the TV so we could hear ourselves talk. The TV's are mounted on the wall right up by the ceiling. I looked up and figured I wouldn't be able to reach it, but then my attending looked over at me and asked me to turn it off. I stood on my tiptoes and pressed the button with a pen held in my hand--it was that high for me. The attending busted out laughing, laced his hands together, and offered to give me a boost.

2) That first order I signed yesterday? The social worker walked me through every step and dictated to me what I should write. I also signed an order for a wheelchair that PT put in the computer for me. Really, I did very little on my own yesterday, which was kind of a relief.

First Day

First off, I think everyone should read this post at Mothers in Medicine: "Cry". As a person who cries very easily, with pretty much every major emotion (happy/sad/mad), I can really relate to this post. I have come to see my teariness as just a part of me, not a weakness or a problem. It can be inconvenient, like when my patient died on ICU and after I'd done compressions and been relieved of duty, I found myself with nothing to distract me, so I ended up crying in the bathroom. And then rounding for the rest of the day with the pathognomonic red eyes and nose.

_________________________________________

Today was my first day as "Dr. TS." I actually answered a phone that way once, and I did not refer to myself as a med student all day (although I did look up when someone else said "Students?"). I totally freaked out when I wrote my first order in the computer; it popped up, I signed it electronically, and it showed up with MY name on it as provider. OMG!!!!!!! I turned bright red and announced to the room, "That was my first order!" I have hereby saved the world, people, because my first order was a referral to outpatient physical rehabilitation. WHOA!

Seriously, I flipped out.

A third year med student looked at me with envy. "I can't wait to do that! Is it awesome to wear a long white coat?"

I told him the truth: "It's scary as hell."

And I kept looking down at my legs all day, wondering what the hell was flapping against my shins?

It was totally bizarre, I must admit. Tomorrow night: First Call!

Good luck to all my fellow new interns, whether they've started already or are still waiting. We'll get to the good stuff eventually. For now, it's learning how to write Colace orders.