The rumors of my demise have been greatly exaggerated, even though my first night of call as a sub-intern was incredibly, incredibly painful . It’s scary to actually admit it, but I… kind of enjoyed my Internal Medicine sub-internship. Yes, I know, this is crazy talk, especially having found my prior medicine months a bit slow, but the constant hypervigilance required to make sure all your patients’ labs get drawn and studies get done is, in a small, small way, similar to the constant nature of the ED.

I enjoyed it so much, and felt so comfortable managing the patients there that I even wondered for a few minutes, “Am I going into the wrong field?” Of course all my medicine colleagues asked me the same thing, and always had their own opinions about Emergency Medicine (I’m used to getting ragged on by pretty much every service by now, so it’s fine).

Calls went incredibly smoothly–probably another reason I enjoyed the month so much. We only capped (received the full number of patients we’re allowed to have) twice in the entire month, once on our first day, and the other we’d capped by 11am, since most of our patients came in overnight and were already tucked in by a fantastic night float resident (thank you, Cheryl!). Taking a note from the ED playbook, I was king of dispo, able to discharge half of my patients by post-call time! (Which often makes you wonder if they needed to be admitted in the first place.)

I definitely learned a ton, and feel comfortable writing diet and DVT prophylaxis orders now. Overall, a really great month.

I think the deal-breaker, however, is summed up today in clinic. I was reading the latest ACEP Newsletter . In the Tricks of the Trade session (written by an awesome mentor of mine, Dr. Michelle Lin!), she mentions unique uses for wall vacuum suction, including how to remove a foreign rectal vegetable using vacuum tubing and bulb suction. What other specialty talks about that in their monthly newsletter?

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Maybe this is just a west coast thing, but here’s essentially the only times residents refer to themselves as “Dr. Suchandsuch:”

1. With patients. “Hey there, I’m Dr. Kim. Tell me what brings you to the Emergency Department today?”
2. On the phone, when asking/telling someone to do something. “This is Dr. Brenner, could you connect me to the Hematology lab, please?”
3. On the phone, returning a page, because often the person that paged you only knows your last name. “This is Dr. Serfass, returning a page?”
4. Resident to intern, implying that the intern is qualified as a doctor to make a decision. “I don’t know, Dr. Walker, what antibiotic would you like to give?”
5. Resident to resident, using the term friendly and jokingly because of its importance. “I’m good, how are you today, Doctor Kea?

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Well, that was much better than last time . I went into call with one patient, came out of call with… one patient. Our team went into call with 7 patients, and came out with… 6 patients.

Thank you, gods of call. (And I got most of my ERAS application done wasting my beautiful Saturday away in the hospital!) Now just that damn personal statement.

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Pronounced my first patient just now. The hospice unit called down to our team room, so my resident and I put on our white coats, buttoned them up to look presentable, and headed upstairs.

Luckily there was no family in the room–I’m sure it would have been much more uncomfortable if there had been. Felt the patient: warm; checked for a pulse: none; saw no reaction of the pupils to light. It was very strange, putting a stethoscope to a warm, lifeless chest wall. You’re so used to hearing the rhythmic whooshing of the breath sounds or the lub-dub of the heart that it’s a little un-nerving when there’s nothing there. I moved my stethoscope to a few other places– wait, did I hear something? –but there was simply nothing there.

After a quick confirmation by the resident, we turned turned around to the nurse, looking at the clock on the wall. “Okay, we’ll call it Eight Thirty-Seven. Thanks.”

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Had my first night of subintern call last night. We capped; I admitted 4 patients.

Man it sucked.

I fully recognize it will get easier: that I will get more efficient at entering orders, more comfortable with how detailed my H&P’s need to be, and more able to focus with less sleep. But still, it sucked, and will probably continue to suck.

Now, it wasn’t particularly difficult or anything, and wasn’t far from what I was doing as a medical student on my Medicine clerkship–I was seeing patients on my own, coming up with a differential, assessment/plan, writing the H&P, deciding management, etc. But man, it’s different as a sub-I. I’m essentially being treated as another intern on the team by my attending, resident, and co-interns–which is how I should be treated, and I’m glad it’s that way. But boy, just the slight upgrade in my status and responsibility has made me a wreck: being fully responsible for a patient’s orders, making sure they’re getting the right meds at the right doses, making sure the labs that I ordered get drawn, and the studies I ordered get done is a nightmare. Especially at 2 in the morning.

Things I am sadly but quickly learning:

1. Take nothing for granted. Assume nothing. Even though they’re called “orders,” not “suggestions” or “pretty please requests,” it’s amazing how most of the ORDERS I wrote for (mostly labs that weren’t at scheduled lab draw times) didn’t get done, were completely just ignored, and I wasn’t even called about it. (It doesn’t help that labs on the computer system that have been drawn are described as “active,” whereas ones that are being ignored are labeled as “pending.”) So I wake up this morning, expecting my patients to have finished their rule-outs, since I scheduled their troponins x3 q8hr, and hey, they were never even drawn.
2. If you don’t do it, it’s not going to get done. Sure, I have a fantastic resident who’s standing on the sidelines making sure I’m not forgetting anything, but it’s not like I have an intern co-following like you do as a medical student. If you meant to write for the daily chest xrays, or the stress test, and you just forgot, it probably won’t get done, and that means another day in the hospital for your patient (which is good incentive for you to not forget these things in the first place).
3. It’s much easier to remember what we did for a patient when I’m writing the orders. When co-following, you’re kind of out of the loop on things. There’s this big stream of information that’s constantly going over your head, and when you go off to class for an hour or two as a med student, things can greatly change and you don’t really know about it until the next morning. But when you’re the one thinking, “Okay, what all do I need to do for this patient,” and you actually think it through and write or click which orders you want, it helps. A lot.
4. My team is really trusting me with these patients. I know it’s just a month trial run, but when you look up on the floor whiteboard with patients names and the assigned intern name and pager number after it, it’s “Walker p11028,” not my resident or another intern. Yes, it’s annoying that I still need to call my resident to sign/co-sign any orders that I get called about, and that I can’t just give verbal orders, but while it’s still a Medicine rotation, it’s markedly different from the one you do as a non-sub-intern.

I think I hated mostly the fact that I didn’t feel like I was doing a very good job, on account of my lack of sleep. I really pride myself on the fact that I really try to do my best, and that I’m almost always on top of everything. But during call, I just felt the constant onslaught of work prevented me from having a chance to really think about the patients, read up about them in detail, or even really go through the differential. Most of my patients were pretty straightforward, so it wasn’t much of a problem, but I felt so pushed to constantly be getting orders in, and then seeing the next patient that I wasn’t able to really solidify patients’ stories in my head like I normally am. My presentations the next morning weren’t where I’d have liked them to be, forgetting small bits and pieces and having to go back. Perfectionist, guilty as charged, but I don’t like the feeling of being unsure if I’m providing the 100% best care to my patients, only providing good enough care to get them admitted, stable, and start initial treatments. (Maybe this is just the way call days work, I’m not sure.)

Old school docs and your ragging on the 80-hour work week be damned: interns on little sleep who’ve admitted patients all night, who are writing orders at 2 or 3 in the morning is, in the best of worlds, sub-optimal, and in the worst of worlds, dangerous. Having run around all day and night long, with patients’ stories and allergies and medications confused in your head, and then trying to write orders on them is awful. The mental poop that was coming from my brain was so foul and uncontrollable that it took easily twice as long for me to focus and concentrate to think through my patients. After 3 hours of sleep, the fog and haze was truly no better: I would sit down at a phone, desk, or computer and stare blankly, trying to remember what I was supposed to be doing. I wasn’t particularly sleepy or tired, just with a profound inability to focus. I hated being so out of control of my head, since it’s normally so easy for me to power through things.

It’s not the workload of the resident that’s the taxing part–all of us have pulled our all-nighters, with diminishing returns as the night carries on–it’s the frequent interruptions and constant shifting of attention. If you could just focus on admitting one patient at a time, it’d be great. But at the same time you’re admitting one patient, you’re gearing up, overhearing that your next one has just arrived in the ED; you’re getting a page that a patient needs pain medications when he’s already written for them; you’re trying to ignore your stomach that’s asking to please find something to feed it, while trying to concentrate and remember which is the antibiotic that covers urinary tract infections and which is the one that doesn’t.

I think I can see where Panda is coming from sometimes now. He writes about his frustration with patients, hospitals, and residency training, and from my N of 1 call night, I kind of get it. (Now, this does not mean that I agree with his solutions or placing of blame, of course–it’s not a patient’s fault that the system is messed up, or that they got sick at 4am–but you go through this and think, “God, there has to be a better way.”)

Enough bitching and ranting, as I’ve already talked several people’s heads off today, and now yours, too. Time for bed, and to hopefully work on getting my two other patients discharged: I’m on call again on Saturday.

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Started my Medicine Sub-I today; anyone have advice for the sub-intern (or intern, for that matter)? Tips and tricks appreciated.

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Found this “Guide to Being an Intern” online –it’s for UMich residents, but has some good little tips that I’ll definitely be referring back to when I hit my SubI and finally graduate.

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Now would be a good time to wrap-up my long two months on my Internal Medicine clerkship, seeing as though I start Pediatrics tomorrow, which totally scares me because kids definitely don’t get my wry sense of humor and frequent pop culture references. In no particular, bullet order, because I’m just not in a paragraph writing mood tonight:

• After ranting for 20 minutes to my parents about how much I hated it, medicine turned out okay in the end, probably because I had a fun team and better attendings my second month. And okay, fine, I learned a lot, despite my best effort.
• No wonder people specialize. There’s just too much to freaking know.
• Man are we obsessed with data and risk and studies and evidence. Trial X found a Y% drop in Z when using Drug A dose B compared to Drug C dose D. This is the reason medical research and spending will always have a rationale. There will always be something a liiiittle bit better than the last breakthrough. Or sometimes studies suggest something reeaaaaally expensive for milllllions of patients. Are we really going to put pacemakers in everyone with heart failure?
• We spend an awful, awful lot of money on really, really sick patients, and often we spend huge sums of money on people in their last 6 months of life. In one study in LA, almost 50% of patients were seeing more than 10 doctors in their last 6 months of their lives. Is that how they really wanted to spend their time?
• Can someone please, please explain to me why nurses record a “normal” respiratory rate as 18 or 20? Because it’s not. It’s like 12-14.
• As a patient, don’t piss off your nurse, because if you’ve got an unprofessional one, he or she will turn all passive-aggressive. If this happens, tell your doctor; if nothing improves, go to the Patient Advocate.
• There is a nursing shortage in this country. If you need something as a patient, obviously ask for it, but try to be reasonable. A hospital is not a hotel. Try to make sure your loved ones are reasonable too. This will be help avoid the preceeding statement.
• As a patient, you will have better, more efficient medical care if you know the names of your medical problems and the names and dosages of your medications. A list is even better.
• Kate has been writing about medical malpractice and there’s been a lot of discussion about practicing defensive medicine, and their associated costs, but I would not be surprised if a large amount of spending is also devoted to repeating tests that have been done at one hospital but are not available at another. This is INSANE. I can now pay people money with my cellphone , but I can’t see images or lab values from a hospital 5 minutes away? You’ve got to be kidding me.
• For people that take multiple medications, automatically assume that they forget to take them. Ask: “How often do you miss taking these?” It will make patients feel less worried about trying to please the doctor.
• Trying to please the doctor is a normal human reaction. It’s why you brush your teeth extra well and floss before you go to the dentist. Just be honest, that’s the most important thing.
• I will never ever ever be an oncologist. They save so many people that they think everyone can be saved, and often lose sight of the fact that everyone dies. I don’t know how often patients were encouraged to undergo another round of chemo when it was obvious to everyone else they didn’t have much time to live. Then again, hindsight’s 20/20.
• Giving people a comfortable, safe, and supportive place to die is one of the most compassionate things one can do for another.
• The surgeon’s 30-day mortality statistic can lead to some pretty perverse incentives to keep patients alive.
• Many of the problems in modern medicine, like most other areas of life, are due to laziness. As my surgery resident told me: “You’ve got. To do. Your job.”
• There was a NYT article last week talking about how doctors are on such a different playing field from their patients that they seem like they’re from a different planet. I would have to agree.
• I came in thinking the differential was kind of silly, like that more cases than not are cut and dry. I now know why doctors are so damn skeptical and suspicious and often agnostic or atheistic. They’ve been burned too many times assuming one thing when it turns out to be something else entirely, or have been sure about a diagnosis, and then they find that they’re wrong.
• You really do need to understand the physiology to understand the pathophysiology to figure out the treatment. This makes it hard for me to believe in new agey healing stuff.
• Want to know why doctors are so unhealthy? Because we spend so much freaking time taking care of patients that we eat crappy food at the hospital and don’t have time to get to the gym. Also, because we are hypocrites. Or at least, that’s my excuse. Feel free to use it if you like. I seriously should go ahead and start a thiazide and a statin.
• Interns get freaking worked . I am trying to vigorously avoid this from happening, and am hence taking a year off to do “research.”
• More bullets to come.

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And so the morning routine begins, checking morning labs. I turn on the computer, login to the medical record system, and up pop a bunch of lab results for my favorite patient–he’d been transfered off my service to the surgeons, but I liked to keep an eye on him and his labs (I’m very protective), and I had forgotten how to turn off his lab notifications, anyway. I had just seen him the day before when I stopped by to say hello just briefly.

He has abnormal labs every day. A high blood sugar from his diabetes, a moderately low sodium, an elevated creatinine from his chronic kidney disease. I skim them again today. That’s weird. A critical result?

I double-click the chemistry panel. It’s probably just a high potassium before his dialysis.

CO2 9 L
RESULT RE-CHECKED AND REPORTED TO NURSE.


My heart skips a beat. What the hell? 9? That’s too low. Wait, CO2, that’s not pCO2. That’s bicarb. Bicarb is supposed to be 24. Oh shit. What the hell is going on?

I move the mouse over to the Notes tab of the system to get more information. I’m overwhelmed with the slew of the last 100 notes written on the patient. The most recent one is selected automatically.

Pupils fixed and unresponsive.

No! What the fuck. Wait, does that mean coma? What the hell does that mean? My eyes somehow skip ahead to the last line of the short note, as if they’ve already read the conclusion before my consciousness has.

Patient pronounced dead at 9:40pm.

I go back to read the lines again. Pupils unresponsive. No sign of breathing. No pulse or heart beat. This can’t be happening. Tears wet my eyes. I read through the last 5 notes. ICU transfer accept note. Pt found unresponsive, E-team notified. Patient intubated, blood pressure stable on pressors. Family arrived. Discussed patient’s status, and care was withdrawn. Pt extubated, put on comfort care.

I’m just stunned. That’s not how things go, I tell myself. You don’t go from smiling and with it and happy and you don’t just go see your favorite patient one day for 20 seconds, run off to do your work, and read that he’s dead the day you come back. You don’t die that way in a hospital. You die a long, protracted course in the ICU, where we throw everything but the kitchen sink at you. And you get better. And you get worse. And then you get better again, and then you get really sick. You don’t just fucking die like this.

I went up to the ICU to talk to the intern about what happened. Luckily I knew him, and luckily he’s a very outdoorsy, in touch with his feelings kind of guy, so I wouldn’t feel stupid to ask him what happened, and how the patient died, and if he was comfortable, and if his family got to see him before he passed, and what we tried to do to save him. He explained everything to me, and my mouth kind of did that little involuntary frown thing it always does when I feel just really sad and like I want to just lose it but I have to fight back the tears. He could tell I was upset. But it was okay to be upset.

So I walk back to the team room to finish my work on both my patients who are cranky and crotchety and tell one intern about it, and there’s not much reaction. The patient wasn’t his. I understand. I assume there will be a larger showing of grief with the other intern–the one seeing the patient with me. She finds out, and there’s a minute of a surprise, and sigh, and a discussion of what happened. But then it’s business as usual.

Both are incredibly caring people and will be wonderful, compassionate physicians, but more than anything I fear–no, I know–that this will become me. That I’ll have so many patients die on me that often their deaths will be only a minute of my time. Now maybe I’m wrong, maybe they grieve privately, on the inside, like I am. Or maybe not.

I guess I’m mainly so torn up about this patient because he was mine. And maybe it’s some sort of screwed up egotism. Or just that his death was so unexpected. Or that I spent so much time fighting for him, worrying about him, and trying to make sure he got his surgery and his studies as soon as possible. Or that I feel guilty for only giving him a casual Hello, how are you today as our final words. Maybe that’s all our relationship was to him to begin with.

But I think, most of all, I was upset was because he treated me like his doctor. I was the first one to greet him every morning. I was the one that helped him put in his hearing aids and change their batteries, getting his ear wax all over my hands time and time again. I was the one that always complimented him on the really great deep breaths he’d always take so I could listen to his lungs. And no matter how often I corrected him, he always called me Dr. Walker. He was the one that woke up one day, confused from getting too much medication, and didn’t understand he was in a hospital. He cursed at me, and I told him we were all here to help take care of him, and he groggily but immediately said he wanted a second opinion, as if I was his first.

After he was transfered over to the surgeons for his operation, I visited him every day, and he told me how much me missed my morning exam, and how much he loved hearing me encourage his deep breaths. He had gotten in the habit of mimicking me, without his hearing aids, to the point that he was practically yelling to the entire floor.

“Wonderful, just wonderful, Dr. Walker,” he used to say.

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My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.

I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead ( Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud . About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.

A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s ), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.

Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.

“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.

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