A Sunday morning bike ride isn't leisurely...

... when it's a five mile ride up and down hills after a night on call on the labor deck to get home. Here's the route, which I do twice a day (coming and going), because I have to get to work before the Metro is running. Great fun.

My night on call actually wasn't too bad. We had a fairly consistent flow of patients through triage, which is pretty much my domain. The med student follows around the second year resident to help with deliveries, and comes help me in triage when nobody is close to delivering. She was actually a huge help through call, because she was so eager to help with everything, even after I told her she doesn't have to try to impress me with anything. I think she really likes OB, but isn't really sold on the lifestyle (ie, still having to spend the night in the hospital as an attending). Since it is almost the end of her third year of med school and she doesn't know yet what she wants to do, she's thinking of doing a transitional year internship (what I'm doing this year) and then being a general medical officer for a few years. She's also getting married in a few months, which complicates matters further (she's Air Force, her future husband is Army but might be leaving the Army next year, etc).

Anyway, we weren't terribly busy, which gave me time to cyber-stalk one of my patients. One of the questions on the admission form, for some reason, is "level of education". So I looked through her pre-partum questions, and found "doctorate", which isn't that unusual, except for the fact that she was a sergeant first class, and there aren't many SFCs with Ph.D.s. I went through her medical record, all the way back to her entry physical, which listed her occupation as "Special Bandmember", and then got on Google. Here she is below (the one in the maternity uniform):

Yes, she is a professional flautist in the United States Army Field Band (one of the specialty bands, like the Marine Corps' "President's Own"). I thought that was pretty neat. And at about two this morning, they had a little girl.

So now I have all sorts of Memorial Day plans (no work tomorrow--yay!), including the Memorial Day concert at the Mall tonight. Maybe I'll get some pictures from that to share.

Air evac messes

It's been awhile since my last post, because I'm generally too wiped out to motivate myself to sit and type out what happened that day, but we had an air evac come in from Landstuhl (Army hospital in Germany) on Friday that warrants a post.

The two intensive care teams--MICU and SICU (medical ICU and surgical ICU) split the evacuees, so no team gets slammed if the Iraqis and Afghanis had a busy week. There was only one on Friday (thankfully), and we had fewer patients, so we took him. I was looking through his discharge records from Landstuhl and saw that he had facial burns, so I asked why he didn't go to BAMC (Brooke Army Medical Center, in San Antonio). Apparently, the person doing triage for the air evacs thought that his orthopedic injuries were more severe (still has all his limbs, but both of his arms have wound vacs), which is ridiculous, because they have orthopedists at BAMC as well.

Anyway, he showed up, and the surgeons (the orthopods and the general surgeons) got to work on taking down his wounds, and the general surgery chief resident said, "He should be at BAMC. He needs to get these burns taken care of." So I called the air evac office at WRAMC and explained the situation. The air evac nurse came up and handed me a pile of papers, and said, "To transfer him to BAMC on the flight at 0600 tomorrow, you need to get an accepting physician and fill these out, then contact pharmacy and get the medications for transfer sent up. Oh, and our office is closing in an hour and a half. If you don't get it done, there will be another flight on Monday." Well, burn treatments run on a tight schedule, so we knew we had to get him to BAMC as soon as possible, so we went to work, and to make a very long and complicated story short, we got an accepting burn surgeon and filled out the papers in time, and then spent the next several hours coordinating things between surgeons, with pharmacy, and filling out documentation. So I didn't get any sleep that night, but it was worth it, because I did something for this soldier that's going to make a difference to him. I'm never going to actually fight in a war; my job in the Army is to take care of those who do, and doing that is worth a sleepless night every now and then.

On-call, post-call, pre-call

When you're on call every third night, you're always either on-call, post-call, or pre-call. So I was on-call Sunday night. Things started pretty slowly--we had rounds, wrote our notes, and then kicked back and watched our patients and waited for the pages to start coming in. There were a few random pages about fairly simple problems throughout the afternoon, but nothing that took any longer than a few minutes at a time to deal with, so I was starting to get bored. I spent a lot of time in the transition year call room, where two of my fellow transition year interns (one pre-anesthesia, who is in the cardiac care unit, and one pre-physical medicine and rehab, who is on OB/GYN) were also hanging out with their equally slow afternoons. I discovered the hospital cafeteria doesn't have anything good on the weekends (when Subway is closed), and was going to order pizza with the internal medicine interns on call, but we were too late on the uptake (pizza place closed at nine, and we didn't think about it until 8:50). Then, right at nine, my resident paged me and told me to get to the ER, and things went non-stop from there.

Two unresponsive patients came in within five minutes of each other, which is never a pleasant situation. One just had surgery three days before, so the surgery team came and handled him and ended up taking him to the SICU (surgical intensive care unit). The other had been in asystole (flat line) or PEA (pulse less electrical activity; electrical impulses go through the heart, but it can't contract enough to push blood through the body) for 45 minutes, which is a pretty bad situation. We ended up getting a pulse again and getting him on the ventilator before moving him up to the MICU, where they had to get him somewhat settled in before going down for a head CT. Since I knew that that would take an hour or so, and it was already 1:45am, I reminded the nurses to page me when they were ready and went to lie down in the MICU call room. Then an hour later, it was time to take him to CT (with me ventilating with the bag-valve-mask as we rolled him down the hall and into the elevator), and then back up to the floor. The whole process took about an hour to get a five minute head CT (which was pretty ominous looking when we saw it at rounds on Monday morning). Then when I got back, I had to deal with being sleep-deprived and trying to explain the events of the night to the family. It wasn't until I finally got to lie down again that I realized how scary this must be for them; for me, it was another random unresponsive victim who came in and will never wake up. For them, a few hours before, he was walking around and talking, and now he's in the ICU, on a ventilator and all sorts of IVs, and some doctor they've never met is trying to tell them bad the situation is.

It was a banner night. Then I went back to bed until the pages with the morning lab values started coming in.

At rounds on Monday, I was grilled about the electrolyte abnormalities in the acute kidney failure of one of my patients (and stumbled through the answers), and then after writing my notes, was out of there. I decided to hit the base gym before going home, which was a really good idea--it completely woke me up so I could drive home. Then I made lunch, did some cleaning, and went down to the pool, where I promptly fell asleep. I probably would have stayed that way (ending up rather burnt) if one of the general surgery interns hadn't paged me asking if I wanted to do dinner. So I changed, took the Metro into Bethesda, and enjoyed the 1/2 priced bottles of wine at Olazzo (their Monday happy hour special) with some surgery interns (I spend a lot of time hanging out with surgeons, for some reason). And then it was back home, where I went to bed early in anticipation of getting up to go in for a "work day" today.

"Work day" means you go in, see your patients, learn everything that's happened to them in the last 24 hours, and then round (which took forever today, for some reason, but I did get to look impressive by properly interpreting an EKG), and then write notes and get to noon conference (which was cancelled today). After leaving the hospital, I met with one of the fourth year preventive medicine residents about on-going research projects that I could join, and then headed home for a run. I've just been lounging around since, will probably go to bed early again tonight, because I'm pre-call.

Three down, 362 to go

Yesterday I started my first shift as a doctor--in the MICU (Medical Intensive Care Unit)--and today at noon, that shift ended. Nothing like a 30-hour on-call shift to say, welcome to the field of medicine.

On Wednesday night, I got a call from the on-call resident saying that since I was on-call on Thursday, I didn't have to worry about showing up until 8. So on Thursday, I got up, showered, dressed in civvies, and headed for the hospital, where I changed into scrubs and my white coat (a long white coat now, which is a little weird), which is my 'uniform' while I'm in the MICU. Since it is a uniform, uniform standards apply, which means that my hair had to be up, etc. It also means that for some guys, they have to shave their five o'clock shadows while on-call.

Anyway, so I arrive to the MICU around 7:30, to discover that I should have been there at 6, because I was assigned a patient. Fortunately, my resident bailed me out and went with me to see the patient while explaining how things work in the MICU.

Rounds, of course, took forever. It's internal medicine; they like to round. And they like to throw around big words and quote studies and whatnot, so after a year of living the easy life as a fourth year medical student, it was feeling rather intimidating. After rounds, I asked one of my fellow interns if I could go somewhere and cry. He laughed and said there was too much to do to have time for that (which was true). We also have a Oral/Maxofacial Surgery resident (dentist) on the team, who is somewhere between an intern and a resident in terms of responsibility. It was pretty funny; at one point, I asked him what sort of clerical error allowed me to earn an MD, and he replied that at least I spent the last four years in medical school, and that I should just imagine doing all of this after four years at dental school. He had a good point.

I wrote a note on Facebook about my on-call experience. Because I'm too lazy to type it twice, I've copied and pasted it here:

So here are a few things I learned in my first on-call night as an MD:
1) After four years of wearing a short white coat and knowing that everyone around you knows that that means you have no responsibilities, it's a little weird to be in a long white coat. It took me a few hours for it to actually sink in that that's what I was supposed to be wearing and that nobody was going to get me in trouble for impersonating a doctor.
2) For military personnel, scrubs are a uniform while you're in the hospital. That means hair must be maintained to uniform standards (short for guys, above the collar/in a bun for girls). It also means that when on call, a lot of guys have to, at some point in the night, shave.
3) After the fiftieth page about blood pressure, you start to feel comfortable handling that alone without calling the senior resident.
4) ICU-trained nurses are AMAZING. I'm serious. When a patient was beginning to circle the drain, it took me about three seconds to realize that my job was to stand out of the way, and when the nurses asked, "Ma'am, do you want to give _____?" the proper response is, "I'll go put that order in right now."
5) Non-ICU trained nurses working in intermediate care, on the other hand... not so amazing. See point three about answering pages about blood pressure.
6) Doctors at Walter Reed wear their pagers clipped to the front of the scrubs top instead of at the waistband of the pants. This isn't to look cool. It's so when you're getting these constant pages, all you have to do is glance down to see what number you need to call back.
7) You very quickly learn to recognize the phone numbers on your pager of the units/nurses that will keep you up all night. See points 3 and 5.
8) At WRAMC, they have a policy where patients who are on a monitor must be accompanied by a doctor whenever they leave the floor. All ICU patients are on monitors. That means that when Mrs. X is going down to her MRI at midnight, the intern gets to go with her and sit there until it's time to go back.
9) The computers in the MRI suite don't have the program necessary to write patient notes. So while sitting there while Mrs. X is getting her MRI, there's nothing to do (assuming she doesn't suddenly crash), and notes that have to be written aren't getting written.
10) It's not Gray's Anatomy (well, I knew that point already). The on-call rooms are used for sleep, storing things in lockers, and grabbing thirty seconds to wolf down a meal at 0300 that was supposed to be dinner the night before. Nobody has the time or energy for sex while working. At least, I hope not. I caught an hour and a half of very interrupted sleep (see points 3, 5, and 7) on one of the very uncomfortable beds in the Transition Year call room, and I don't want to even think about when the sheets were last changed.
11) Brownies stolen from the Internal Medicine work room at 11pm taste really good at 4am.
12) White coat pockets are large for a reason. That way, in addition to carrying around reference books and patient notes, you have room for food, gum, chap stick, and a water bottle. And a stethoscope, if you get tired of wearing it around your neck.
13) After awhile, answering the phone, "This is Dr. Hesse, I was paged," loses its novelty.
14) You realize, sometime around 0200, that you almost know what you're doing, and maybe you didn't waste the last four years of your life in med school after all.

A few other things that I didn't add to the list that I just thought of:
1) Leaving the hospital after being indoors for 30 hours makes you feel like Rumpelstiltskin. You have no idea what day it is or why it's sunny outside.
2) When you don't know what day it is, it makes getting around a military base a bit difficult. This really only applies to today. Since the 4th is a Saturday, the 3rd is a training holiday, which meant the hospital gym was closed (and thus, there went my plans of working out after work), the road from the parking garage to the main gate was closed, and the 16th Ave gate, which I usually take, was also closed. To get from the garage to the main gate on a weekend or holiday (the only gate open), you literally have to drive all the way around base, and for everyone who has ever driven on a military base, you know that that's easier said than done--roads aren't gridded, they're narrow, and there are stop signs and speed bumps in seemingly random places. Now imagine doing that after working for 30 hours (when you're as impaired as someone who is legally drunk). All sorts of fun.

Anyway, that was my first day as an intern. I have tomorrow off (I'm planning on watching the fireworks from the Washington Monument), and then I'm on-call again Sunday (another 30-hour shift... yipee). Only three weeks of this, and then it's onto general medicine wards (which I'm not thrilled about, either).

Mollaret's Meningitis

Early in the morning on Monday (when I had been awake for 24 hours already and had another seven left to go before I went to bed), we had a new patient come in through the ED with viral meningitis. When we went through her old ED records, we found out that this was her fourth hospitalization for viral meningitis, which we thought was a bit odd. So we searched online and discovered a disease called Mollaret's meningitis, which is recurrent aseptic (non-bacterial) meningitis, most often caused by HSV-2 (the herpes virus that causes genital herpes; HSV-1 is cold sores). Interesting enough, most people with Mollaret's meningitis report never having genital herpes. So we sent her CSF (cerebrospinal fluid, from the lumbar puncture) to the lab to be tested for HSV-2. It's a test that takes a couple of days to come back, so we didn't have an answer yet when we discharged her today. Well, it came back positive this evening, which confirms Mollaret's. No treatment is required, since it's a self-limiting course (translation: lasts 2 days with treatment and 2 days without), but since this is her fourth hospitalization for viral meningitis, my attending is going to call her in a prescription for Valtrex (herpes medicine; you might recognize it from the commercials: "I have genital herpes." "And I don't." "And now we're doing something about it." etc).

So that was my fun discovery for the day (and since I was the one who told my attending that we should check for HSV-2 to see if this is Mollaret's, I now look really impressive). It's pretty rare, so it's kinda cool that now I can say that I've seen it.

Last call as a med student!

Yes, that's right--it's my last call as a medical student. The next time I spend the night at a hospital, I'll have real responsibilities. That's kinda scary.

Not much has happened so far today (yesterday? I guess it is technically Monday now). We had one discharge and one transfer from the ICU today, which left us open to one new patient during the night, and what a new patient. I still can't figure out why he's on the ID service. He's here for altered mental status and really has no infectious issue at all. And because he has altered mental status and came from an outside hospital, we had no OSU records, he couldn't give a history, and all we had was a stack of records from the other hospital. They didn't include anything useful, of course, just endless copies of his med lists and his lab reports. Wonderful. And then the intern had me staff the admission (phone the on-call attending about it so he can decide what to do). Fortunately, I had worked with that attending before, so it wasn't a nerve-wracking experience.

Anyway, my resident wanted me to stay awake all night (so I can experience getting 80 IQ points dumber by staying awake for 30 hours?), so right now I'm just trying to find something to do to stay awake between pages about blood pressure and foley catheters. Only ten and a half more hours, and then I will never again have to experience med student calls. That will be a great feeling.

My post-callness

Being post-call is kinda nice, if you ignore the whole being-completely-exhausted thing. Actually, last night wasn't too bad. I went to bed a little after midnight, and didn't get any pages until about five. It was so strange that I asked the intern I was working with if nurses were bypassing me and paging him directly, but he said that he thought I was just doing a good job of triaging pages and didn't need his help.

I did get one page that turned out to be a problem, the one right before midnight. A nurse paged me saying that one of our patients was spiking a fever, which was new, and rather worrisome considering the fact that he was already on two broad-spectrum antibiotics. He has a spinal abscess (blog of infection on his spine) that was biopsied yesterday afternoon, so I was imaging all these scenarios of bacteria spreading throughout his bloodstream and him becoming septic. So I asked the nurse for the rest of his vitals, which were vastly different than his previous vitals, and really made it look like he was septic. So I told her that I would be ordering a fever workup (blood cultures, urine culture, chest x-ray) and that I'd be up to see him in a few minutes. I called the intern, who agreed and told me to add a bolus of fluids (one liter of normal saline in an hour), and said that he would co-sign the orders as soon as he was done admitting a patient to another service.

So I went to the patient's room, and found him sleeping rather comfortably. Confused, I checked his vitals chart, and everything was completely normal. So I tracked down the nurse and asked her what was going on, and she was rather confused by the normal vitals as well. So I found the PCA (the person taking the vitals; don't ask me what it stands for, because I don't know), and he confirmed that my patient's vitals were normal last time he checked. I decided to check the vitals sheets on the other patients in the room, and discovered that a roommate had a fever and the vital signs that the nurse read to me. I informed her of the error and called the intern and told him to cancel the fever work-up and explained the situation.

So this morning, I talked to my intern and told him what happened, and we decided that even though nothing happened, I should write up an incident report. It's not tattling on the nurse, but simply pointing out a 'near miss'. If I hadn't been on, the page would have gone to the intern, who would have ordered the same workup. But he wouldn't have seen the patient for at least half an hour, until he was done admitting the other patient, and by then, the fever work-up would have been done for nothing. This kind of things are how medical errors happen.

Anyway, after that whole debacle, I came home, crashed for about an hour, and ran all the errands I don't have time to run any other time. Not quite relaxing, but I did get a lot accomplished, so I guess that makes up for it.

Another night of call

I just realized that the last time I updated this was the last time I was call. Oops. I guess while I'm a captive audience here in the hospital with nothing better to do (such as watching tv, going for a run, or sleeping) is the only time I remember that I actually have a blog. Sorry about that.

As far as what's happened since the last night on call... not much. See patients, see patients get better, send them home, repeat. I took off early on Friday to head down to southern Indiana for Adrienne's bridal shower and bachlorette party, which was a lot of fun (the bachlorette party more than the bridal shower). She has a fairly large extended family, and at one point, one of her second cousins or something made a comment to me about how strange I must find it that Adrienne knows all of her extended family. I said not really. It was nothing new to me!

We went to a dueling piano bar for the bachlorette party--lots of fun. I'll leave it at that.

And then Sunday was Easter and Easter dinner with Adrienne's immediate family (plus future mother-in-law) before we loaded back into the car in time to take her sister to the airport (her younger sister is a grad student at Harvard). Then it was back to Columbus, where I went for a quick run, ate dinner, and went to bed (after forgetting to call my parents--sorry) fairly early in order to get up at my usual 4:30 for another fun and exciting day as a sub-i.

Standard stuff for the last few days. Most of the patients are fairly simple--cellulitis, give them a couple of days of IV antibiotics before sending them home on pills. Right now, most of our patients are pretty stable, but we have room for three more on the census, so I might have to deal with admitting three new patients from the ED. For the meantime, though, I'm going to be looking forward to this:

In case you can't read that, it says "You are no longer covering for IM Infectious Disease Pager (INF). That is the best page one could ever receive. It means no more random pages about a patient's perfectly normal temperature or mild hypertension, and a few hours of sleep are on the horizon.

Anyway, now that I'm done eating dinner, I should probably go find my intern so we can pull a dialysis catheter out of a patient's femoral vein (ah, I bet you wish you had my life...)

On-call again

Yes, I am on-call again... ugh. Tonight I have (almost) real responsibilities, though, so it's a much better experience. The infectious disease pager was forwarded to me, so now every time a nurse has a question about vital signs or medications, I get the page. Most of the questions thus far have been fairly simple--so far I have gone and talked to a patient about why he needs to take his medications, told a nurse reporting that a temperature had a fever that he can have Tylenol (I talked that over with the intern first; I can't just arbitrarily prescribe medicine, even Tylenol, and had to defend why I didn't think the fever was a sign of serious infection), and turfed a question about pain medicine on to the resident. At some point, we'll probably have a slew of admissions (we discharged quite a few people today), so that'll keep me busy, but for the meantime, I'm debating whether or not I should go find a call room and crash until the pager goes off again.

Other than the multitude of discharges, it was a fairly typical day. I arrived at 6:15ish, saw my patients, and we did the whole rounding thing. My patient with the reaction to Bactrim was officially transferred to the burns service today, because they finally realized that his HIV wasn't really an issue, at least compared to fact that his skin was falling off. He was by far the sickest on our service. The man who is growing fungus out of his lungs is now also growing mycobacteria (the same group of bacteria as tuberculosis and leprosy, but it isn't TB or leprosy), so I decided that he's just cooking up a microbiology lab in his lungs. Thoracic surgery was going to take him to the OR today to cut out the fungal badness, but they had too many emergent surgeries today, so now our patient is on their schedule for early next week. He is not happy about having to wait around in the hospital that long (and because he's on IV antifungal meds, he can't just go home and then come back next week). Other than that, everyone was fairly stable--improving, but not quite ready to go home. I also got to show off my future-preventive-medicine-ness: our patient with TB finally had three negative screens for TB, which means that we were able to take him out of isolation. He said he had done this before, but the Ohio Department of Health didn't have records of it. So I called ODH, informed them of the situation, got their fax number, and then called the microbiology lab at the hospital and asked them to fax the microbiology reports to ODH so that they were aware of the situation. It was a proud moment for future preventive medicine physicians everywhere, I'm sure.

Post-call

I was on call last night. Never a fun situation. I really don't like being on call.

The day started fine--all of our patients were either getting better (as is the goal) or staying the same, and several had improved to the point that we were comfortable discharging them. Unfortunately for me, all of those were patients I was following. It's unfortunate because it meant that not only did I have to fill out their discharge paperwork (I can't fill in discharge medications, but I can write summaries of the hospital course and lists of the procedures they had had while hospitalized), but that I had room to pick up more patients once they were gone. I was sure that meant that I would be up all night admitting new patients.

We did learn a few things about the patients during the day as well. We decided to take a field trip down to the radiology reading room to see about our TB patient's CT scans from the hospital he was at (they had sent a CD with the scans) to see if his disease was getting better, worse, or staying the same. We decided that his TB is getting better (his lungs were showing signs of healing), but he currently has a pneumonia, so it's not exactly an ideal situation. He's still hanging out in the isolation room until we can clear him. Another one of my patients had a new read on his lung culture. It turns out he's growing two different kinds of fungus in his lungs. One we knew about and have been treating him for; the other was a new discovery, and not a good one. For starters, the anti-fungal medicine we have him on doesn't cover the new fungus. For two, that particular organism is a pretty ominous sign in someone with cancer (he has chronic lymphoma), and the medicine used to treat it (amphotericin B, for anyone out there who watches House) is pretty hard on the kidneys, and his kidneys were already not doing great. In other words, this guy is a train wreck, and doesn't even realize it (he's always cheerful and comfortable when I come in and chat with him): he has cancer, kidney failure, fungus in his lungs, vasculitis in his skin, atrial fibrillation in his heart... The list goes on and on. He's being followed by infectious disease (my team), pulmonary (lung docs), nephrology (kidney docs), thoracic surgery (lung surgeons), rheumatology (for the vasculitis in his legs), and hematology (for his lymphoma). That's a lot of doctors for one guy.

Anyway, our census was pretty low at the beginning of the evening last night. We can have up to twelve, and we had eight, which meant that we had room for four more. We heard fairly early in the night about two that were supposed to come in: a woman with meningitis and another with possible TB. Neither of them came. We did get a guy from the ED with a newly diagnosed sulfa allergy, though. He had just been hospitalized, and during his last stay, it was discovered that not only was he HIV positive (with a CD4 count of 49--normal is about 1200, and AIDS is anything less than 200), but had two opportunistic infections. He was sent out on Bactrim, a sulfa antibiotic, to treat those infections, and came in with a massive rash and swelling in his face and airway. He didn't need to be intubated, but did get steroids and benedryl in the ED for the allergy. So we had to admit him to watch him and change up his medications. He's doing fine, although is still quite swollen and completely covered in this rash. Apparently, sulfa allergies aren't uncommon in HIV positive patients, which is unfortunate, because most get Bactrim to keep from getting the types of infections that HIV positive patients get.

As far as the calls from the nurses, allergies seemed to be the special for the evening. We have a girl (OSU undergrad) with bacterial meningitis who had been getting ceftriaxone for the past week. Well, last night, right after she finished her dose of IV ceftriaxone, her face got pretty swollen. I got the call from the nurse, who tried telling me that that was a medication for her, despite my insistence that she had been getting it for the past week. Well, we went in and saw her and, sure enough, her face was pretty swollen. We can't figure it out--most allergies would present a long time before a week after the medicine was started--but we gave her some IV benedryl, and she's looking better now. We're going to try to give her benedryl before the ceftriaxone for her next dose, and if that doesn't work, we're going to have to change her to another antibiotic that doesn't have as much data for bacterial meningitis (all of the studies on treatment of bacterial meningitis show that ceftriaxone is the best antibiotic for it).

I did manage to grab a couple of hours of sleep (on the world's most uncomfortable beds, in a room I shared with two other med students on call), between admissions and calls from the nurses, but I was still pretty out of it during rounds this morning (I'm fairly worthless when I'm post-call). Three more nights of call as a med student left, and after that, the next time I'm on call, I'll have actual responsibilities... kinda scary.