Thursday, February 6, 2014

Not so Emergency Rotation

This month, I am working in the emergency department. Most of us see this rotation as a sort of vacation - we only work 15 11-hour shifts in a month, plus our clinic days and didactics...which, for me, means I'll average about 55-60 hour work weeks (compared to my usual 70 hour work weeks). Those extra 10-15 hours off can make a huge difference!

The only downside of the emergency medicine month is that you're working in emergency medicine. While means in reality, I've seen about 10 cases of viral gastroenteritis, a few mild influenza, several people who fell on the ice and bruised their knee/wrist/back, and the random toothache and STD check. In short, not exactly anything I would label an emergency. In fact, I would be surprised to see most of these patients make a visit in to my clinic with these complaints - these are such mundane problems that they in all likelihood wouldn't even see their PCP for these problems. But they show up in the ED. It's so bizarre. I'd much prefer them to be in a clinic with their PCP, not only because of continuity of care and appropriate use of resources and savings of our healthcare dollars, but also because it would actually suit the patients best. The treatments I can give in the ED are vastly different than what I can do in the clinic, such as looking for underlying cause of problem and being able to treat that rather than just stick a bandaid over the wound, so to speak. It's hard to find much job satisfaction in this environment.

Only 3 days into this rotation and I'm already jaded. Despite being a "Vacation Month",  I can't wait to be back on the floors and doing what I love again.

Monday, January 20, 2014

Pulm/CC

This month I'm on the pulmonary service. The patients on this service are mostly consisting of people who were recently in the MICU, so we do have quite a few sick patients that are making their transition from MICU to hospital to LTAC/SNF/ECF/Home. Most of the patients have several chronic illnesses which are near the end-stage. I've sent several patients from the hospital to hospice, and I've sent several from the hospital to LTAC, and a few to home after hospital. One thing I'm learning from this service is the importance of good social workers (I don't know how they do it, honestly...finding a place and dealing with insurance and contacting a million people for a seemingly simple task...). I've also had a fair amount of frustration from the insurance companies.

I have a patient now who was recently shifted out of the MICU after having seizures. He's otherwise relatively healthy, but after an extended stay in the hospital, has lost quite a bit of muscle use. He needs to go to rehab. So I ask the physical therapists to see him, but its a weekend and they're short staffed- it will have to wait until Monday for a full assessment. Until I have that assessment, the social worker can't begin the search for placement upon discharge, as we need PT recommendations for subacute rehab versus acute rehab versus outpatient rehab. Once that's completed by the PT and the social worker submits information to the patient's insurance company. Again, they aren't open on holidays or weekends, so it has to wait. Once the insurance company gets the information, it can take several days for them to make a decision as to whether or not they would pay for the placement. In the meantime, they need daily updated notes and progress notes submitted to them. And before you know it, someone who was ready for discharge ends up sitting in the hospital with no reason for a week. Being someone who hates to waste healthcare dollars, this makes me so upset. Not to mention the fact that NO ONE likes to be in the hospital (and if they do, they must really hate where they live or are malingering or something). I get so frustrated.

Another patient I had came in with a hip fracture. She was completely independent at home prior to her fall, and in unbelievably good health for her age. Unfortunately, she had a complicated hospital course and suffered irreversible anoxic brain injury. For several weeks, the family insisted upon "doing everything in our power" to make things better, which we did. Everything was looking great, but when it came time for discharge, we ran into another hold up. Insurance issues. The patient was improving every day, but this patient ended up staying in hospital for an extra 8 days waiting for approval. While waiting to get out of the hospital for some rehab, she continued to lose muscle strength and ended up getting a mucous plug in her mainstem bronchus which completely made an entire lung nonfunctional. It's easy enough to remove - just a quick bronchoscopy (percussion and drainage was not working) - but it was at this point when the family decided that enough had been done, and it was time to shift our focus from aggressive treatment to comfort care. I'm having troubles coming to terms with this - there was at least a small chance that she could have make a good recovery with intensive physical therapy, but instead we elected to keep her comfortable, which will likely lead to a pneumonia, sepsis, and eventual death. I can understand comfort care with cancer, end stage liver or heart disease...but from weakness? I just can't wrap my head around it...but pneumonia is a leading cause of death in the elderly, and I am sure this is a large reason as to why. I suppose if we did the bronch and removed the plug, it would only happen again and again...which it did during the hospital course...so in a way, why prolong the suffering? It's just hard, my most difficult ethical dilemma of intern year. It just seems so treatable...but the underlying problem could really never be fixed. When I shared this information with the MICU team who cared for her, they were devastated. We all knew that the underlying problem would never be fixed (not likely anyway), but it's still so difficult to see someone we've invested so much of ourselves in to do so poorly.

People constantly tell me how sad oncology is, but I'd take it any day in place of this!

Anyway...I'm officially halfway through intern year! :) :) :) :)

Saturday, January 11, 2014

Secret Day Off

Shhhh...!!! Keep it quiet, let me tell you a secret...I have an extra day off this month! Sort of. Because our patient census is reasonable and I worked an extra 6 days, my senior gave me an extra and unexpected day off today. I had no idea what to do all day, so I just kind of watched the day go by. I just got all of my errands done on Wednesday, so I didn't even have laundry to do today. I have no idea what I like to do outside of medicine (aside from running - which I did do today), so I was like a lost kid all day. ("Do I cook? I think I remember that I used to enjoy making things to eat... Should I organize some things? Maybe I'll do my taxes..." )

Something new from this week is that our students have come back on service. I enjoy teaching students, and I have a really interesting patient right now with a disease we don't see often (it's my first time seeing it as well). So when I discovered that one of the students was also going to be seeing that patient, I got excited and started asking him all sorts of questions, trying to help him learn about this interesting case. Instead of seeing an enthusiastic and interested student, I got basically silence and disinterest from him. Imagine someone being dead excited about something they've never experienced before trying to spread that enthusiasm to a wall. That's basically what was happening.

...I guess not everyone gets excited about medicine...I think this guy will find he fits right in with psychiatry, all he is interested in is stories the patients tell. Gosh, I mean, what's wrong with people?! MEDICINE IS AMAZING. duh.

I've had two separate occasions this week of nurses doing their best to report me. First one was a nurse (who I thought liked me!?) who shouted at me for not wearing a gown in a room with influenza. I had to calm her down and remind her that flu is only droplet precautions and that I did have a mask on within 3 feet of the patient. I couldn't believe it; me, who follows every rule all the time and never EVER does anything half assed. Then another nurse gave me trouble for ordering an immunosuppressant for a patient who has been on this medication for YEARS. The only reason I was dosing it myself rather than putting in a standing order was because the nurses kept giving the medication 3 times more frequently than I had ordered, causing the patient to have some undesirable side effects. Rather than slapping that info in her face, I just said to her that the patient has been taking it for a very long time and I'm giving this medication to her just as it has always been prescribed to her, and I had even double checked the dosing with her primary doctor to be sure that we were doing things correctly as well as monitoring her levels of the drug. Seriously. Get off my back!haha But it's kind of nice that they actually communicate these things with me; early in the year, nurses are a female interns worst enemy and it takes a long time for them to even acknowledge your existence. So I suppose this is a step up!

But, on a much brighter note, two NICE things also happened this week...I received a phone call from a nurse asking me to address an issue she had with medications for a patient, which she had been calling about to the other doctors for the previous two days. I was the first one to tell her why we hadn't made the changes she suggested, and she thanked me up and down (and without even mentioning my name, she knew who I was). She was happy to talk to me. I love when we can all work so well together in a team. Seriously love that. The other thing that made me blush happened during rounds. During my pre-rounds, I had spent quite some time with a patient explaining his diagnoses and our treatment plan and what our goals realistically are, etc...so when we went to round with my attending, who also is my program director, he was explaining these same things to the patient. The patient interrupted him and said "yes, I'm aware of all of this. The doctor standing beside you already told me everything you're telling me. You've got a great doctor there" and my program director just smiled, said "I know she is", and shook his hand and walked out of the room. I felt so competent, so much job satisfaction! It's nice to see the extra things I do don't always go unnoticed.