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.

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.

Disorienting Orientation

Is it just me, or is the word "orientation" completely abused nowadays? It seems like it should be applied to a process which helps you know where you are, keeps you from getting lost, puts your head back on your shoulders and find your way around. Right?

The problem is this: has anyone EVER been actually oriented during a session called "orientation"?

Yesterday, I went to the program's session, where we received a very thick binder full of papers. During the course of the morning, various people filed in and added even MORE papers, including some we'd already been emailed (and so, of course, your OCD-highness here had already printed them out). Statements in the binder conflicted with the verbal statements of the program directors on very important subjects, like parking, so much time was lost in working out the nitty gritty details of parking at multiple different clinical sites (how much does it cost per day? per month? will I be reimbursed? how far will I have to walk to the site?--etc.)

Today's was far worse. We arrived at the Very Large Hospital and eventually found the conference room (helpfully titled "6B-183", but located on the 6C wing), only to find that none of the people orienting us were present (and I was 10 minutes late, due to an alarm clock malfunction and lack of parking spots). We spent awhile filling out paperwork, then were led to a 3 hour computer orientation on the very-complicated EMR system. (On the way to the computer lab, our leader, who WORKS IN THIS HOSPITAL, got lost. And when she asked for directions, two different employees had no idea what she was asking about. This does not bode well for me--I have zero sense of direction indoors). The computer session was awful. The woman leading it had a mild speech impediment, yet spoke rapidly. I would look at my screen for 5 seconds, look up, and she'd be on a whole new window, but I'd have no idea what she'd clicked to get there. About an hour and a half in, I gave up and surfed the Web (conveniently NOT restricted on that computer) until it was over.

Lunch was yet another boxed sandwich meal. I don't mind them, but honestly, why would you put tuna and chicken salad sandwiches on a catering menu? You know those sandwiches were delivered up to an hour or so before we got to eat them, and who knows how hot the delivery driver's car was (it was in the 90's here today). I ate warm chicken salad until I couldn't stand it (it also had pineapples or somesuch in it--yech), and then survived on potato chips and a granola bar until dinner. Nothing like a little warm mayonnaise to breed a little staph food poisoning.

After lunch, the real crap started. The lady led four of us to Human Resources to get our badges. We signed in and proceeded to wait. Eventually, the rest of the group came into HR, but we original four were still waiting. Now there were 15 or so of our group, plus other new residents who were there before us, all crammed into a tiny waiting room with about 6 chairs. They started calling us out one at a time. I went, and found that one woman, by herself, had to verify ID, fill out the form, take my fingerprints (twice), take my picture, upload the picture, copy my documents, and lead me to the exit. It took her about 10 minutes to complete my paperwork (and she wasn't lollygagging, either). I then had to go to another office where they actually printed my badge; the whole thing took me an hour, and I was the first done. They scheduled our group to finish this in 2 hours.

After waiting for another hour, our lady came in with some forms to sign and get notarized, and then we waited some more. I tried to go get my parking decal, but the office closed at 3:30 (we went at 3:39). Eventually, our last (and reasonably important) lecture started late and ran long (naturally), and I spent what was probably the most important time of the day trying not to fall asleep or let my stomach growl too loud.

Tomorrow, I have stuff in the morning, then a break of several hours, then more stuff from 3:30 pm on. Our schedule says "dinner" (another box, from the looks of it), with no end time given, so for all I know I'll be in the Very Large Hospital all night. I'll have to try to go get my PPD read, since the occupational health people aren't going to take my word for it that it's flat without erythema. One of my classmates said "Well you know, MD, you need that LVN to read that PPD." (My med school's clinic just let us call in with the results if it was negative, hence the confusion).

At this point, I have one ID badge (out of 3 I need), 0 passwords/logins (out of 3 I need), 0 pagers (out of 1 needed--I'm not in a hurry for this) and I have not seen my call schedule for July because apparently the neuro department is known for not getting it done until 2-3 days before the month starts.

So now I've finished my little temper tantrum, and I've finished compulsively typing in the entire year's lecture schedule into Outlook, so I think it's time for bed. I'm still reading The Devil in the White City, which is really interesting and more than a little creepy. Nighty night from a tired, cranky TS.

The Rot Slowly Sets In

3 calls down, 4 to go. After only two weeks of q4, I feel like my grip on things is slipping. Out of four days, I'm either on call, post-call, in clinic, or out by 1-2 pm (in that order). Today's clinic unexpectedly lasted till past 5, and I had to tutor at 7, so there was no time to go to the gym. Fortunately, my lovely hubby made dinner, and brought me flowers to boot. He is such an amazing man!

q4 is not the most grueling call schedule possible by far. The schedule I described is not the worst I've ever worked. As the days go on, though, I'm getting progressively more sleep-deprived. I'm getting a few hours on call, so I generally don't sleep post-call until nighttime. I wake up every day around 5 am, and I find it difficult to get to bed before 10 pm. An hour or two of deficit here, an hour or two there, a talk on UTI that couldn't be started till 8 pm, etc etc, and it adds up. Again, it's not the worst I've ever worked, and the rotation is largely easy in terms of the workload (almost ridiculously low), with the exception of clinic requirements (every other day) and mandatory noon conference on post-call days. Maybe I'm just getting softened up by fourth year (very likely), maybe I'm a wuss (very likely), or maybe q4 call is actually somewhat difficult (likely).

Add to all this that my husband and I are working on a large life transition (no, not a baby) that has me all stressed out, and the fact that I was going to have 2 more baby blankets made by now for babies due in February, but I don't (and don't have the time to work on them), and that I just started tutoring this block, yada yada yada, I'm feeling a little stressed and worn out. Fortunately, tomorrow is my day off (I worked all weekend), so I can get a little more sleep, hopefully go to the gym, maybe go get my bangs trimmed, and crochet till my wrist falls off. It actually sounds very nice.