Thursday, April 23, 2009

A Daaaay in the Life


Tuesday started off as the prior two days on heme-onc consults had generally started.  I looked up the overnight events on my consult patients before heading to clinic.  I had time to visit one briefly in his neutropenic precaution cave of a room.  He has a new diagnosis of AML at age 77.  He'd refused chemotherapy for days, but he seemed to be changing his mind as the new attending had explained to him, slowly and repeatedly at our 6 pm rounds the day before, the more gentle chemotherapy he could choose which would have a chance of holding the leukemia at bay for a bit longer.  He was in his bed "sleeping," but he'd hope his eyes quickly when I came in and then close them again and not respond to me if he didn't feel like chatting.  The ENT consult note for his lip lesion today used one word to describe him during their visit "annoyed."  
I rushed down to clinic, wondering if it would be like clinic the day before when I did not see a single patient for the entire three hours so instead watched the poor med student get drilled with questions he didn't know the answers to.  The attending did teach us a lot, so that was nice and sometimes I could get him talking about my consult patients long enough for the med student to google answers.

But clinic on Tuesday would be different.  The first patient I picked up had CLL stage 0 and after I'd seem him, the attending told me I shouldn't have, even though his name clearly had the word "resident ok" next to it, which I'd, foolishly I guess, interpreted as meaning I could see him.  But no.  I saw one more patient and then had a nice surprise!  One of my favorite patients, Mr. Jegan, from my intern year had an appointment that day.  I'd seen him waiting and was thrilled when his chart was in the rack for the taking.  Of course, it's not the best thing to be re-referred to heme-onc clinic at the age of 89.  He had a recurrence of his ITP, the same conditions for which he'd been admitted when we met the first time.  In the interim since then he'd been treated with dexamethasone, rituximab, and a long steroid taper which had wreaked havoc on his blood glucose control and made his neuropathy worse.

I remembered him mostly because of his blue sailors cap he always wore.  I later went back to look at the notes I'd written about him two years ago and found that I'd mentioned in there. I remembered his platlets were lower than our machine could measure but he felt well the whole time and kept wanting to go home.  And his wife was there a lot.  They were very endearing together.  And he wore the same kind of paler blue same-color jean pants that Pop used to wear all the time.  He would tease his wife and she would smile at him and go on with her concerns over his health.  She still worked and he got himself around the house pretty well.  He'd put his hand on hers--wrinkled old soft hands entwined companionably and practically. 

He'd grown weaker in the time since I saw him last.  He demonstrated how he had to stand up and his legs shook underneath him.  He was also having worse headaches.  No bleeding that he'd noticed, even though his platlets were 41 (normal above 130).

In addition, he was still on the same blood thinner that I take: coumadin (oval-shaped multi-colored devil pills that they are).  He'd had three separate instances of blood clots in his legs after his knee replacements almost 25 years ago so the was on "lifelong" anticoagulation.  Since his platlets were low, the fellow had called him on the Friday before and asked that he stop the coumadin.  We wanted to get an ultrasound of his legs to see if the clots were still there. He grumbled amiably about that saying it wasn't going to help anything.  

That afternoon, I saw a new consult: a 72 year old Jehovah's Witness (who do not accept blood product transfusions) with the hematologist's perfect storm of clotting/bleeding.  He'd come in for a toe amputation and developed shortness of breath the day after, which prompted cardiac markers with slight indication of heart attack and a relatively normal EKG.  By a few hours later when they repeated the cardiac markers, they had risen and his EKG was showing signs of acute heart attack.  He was started on a blood thinner by vein (heparin) then was rushed to the cath lab where two drug-eluting stents were used to prop open his mostly occluded vessels that take blood to the heart.  With this and evaluation with ultrasound of his heart, they also saw a big clot in one of the main pumping chambers of his heart (mural thrombus).  He was switched to integrillin blood thinner for 18 hours then back to heparin and simultaneously with coumadin to treat the clot in his heart.  And then needed clodigripel and aspirin to keep the new stents in his heart from clotting off.  Then his platlets, which for some as of yet unexplained reason live too low (around 100) began to fall.  And fall.  And fall, which gave him a large risk of bleeding.  So they tried to reverse the coumadin with vitamin K.  And heparin can often cause low platlets so they stopped that also and started him on argatroban, which complicates the transition to coumadin because it alters the test we usually use to see if it's therapeutic.  And then he started having blood in his stools, ie a GI bleed.   What a big confusing mess of confused platlets and clotting cascade in this poor man's body.  And if he started bleeding profusely, he would not take blood transfusions.  

I'm seeing this consult and the attending, who is perhaps the most thorough I have yet met, is going through his information and I know he's going to find more than I can in the short amount of time.  And he does, which if fine, since he's the expert and he spend a lot of time worrying and telling me about special antibody tests we can run to see if it really was the heparin that's the problem and we talk with the cardiologists how need the plavix to protect their stents and the patient's heart and we talk more and we think more and we talk and talk. 

And then we to go tumor board for two hours where they present the lung cancer patients first, who all have grim prognoses and for whom they try to figure out how to at least minimize symptoms.  And then we talk about the other cancer patients and whether surgery or radiation or chemotherapy is the best approach.  Or maybe everything. Or maybe some.  I find it all sad and elusive as they bat around idea about chemotheraputic drugs I don't recognize and flash pictures on the wall of lungs obliterated with cancer.  Or look at the microscope pictures of the malignant cells that have returned.

And then we finish and we still have to round on the inpatient service.  So we talk and talk and think and talk.

Then I get a page about Mr. Jegan's blood clots in his legs.  One of them which had gone away at one point was back.  Crap.  And we had him off of his blood thinner because of his low platlets.  Did we restart it?  Did we switch him to one that was more easily reversible.  Did we need to bring him back in that night to be admitted?  I didn't have the answers, so I asked the heme-0nc fellow.  He wasn't sure later so, fortunately, though it was 7 p.m. by then and we were still working on our notes, our attendings were there--both the one who had seen Mr. Jegan that morning and the thorough clotting specialist.  

The big danger with blood clots in the venous system of your legs is that they'll break loose and get pumped through your heart and end up trapped in your lungs where they block blood flow there and can cause death.  We did not want that to happen to Mr. Jegan.  So we talked and we thought and we worried and we talked.  We ended up calling him and asking him to come in the next day to start intravenous treatment for his low platlets and subcutaneous treatment for his leg clots.

Then I went back to finish my notes.  When I went to the ICU at 8:30 pm to get the most recent vitals on Mr. Perfect-Storm, our attending was still up there talking to him.  While I had learned a lot that day and knew he would probably have something new to share, I was tired and left before he came out of the room.  

Mom was home when I got there.  Bryce is somewhere on his way to Colorado with his friend, Hayden who just spent a couple weeks with us.  I warned her how tired and hungry and grumpy I felt and ate and went to bed, sorry that I'd signed up for moonlighting that night as I set my pager by my bed and switched it from vibrate to sound.  

I laid there for 15 minutes, almost fell asleep when it went off: "Shawna, I have one patient on the floor for you, gastroenteritis, and three in the ER so far. Katy."  What?!  Being called in so early on a week night in April is quite unusual.  And I was so tired!  When I called her back to let her know I was on my way, she was all discombobulated with the speed with which she'd just heard about the 15 new admits in the last 6 hours.  From being on her side, I knew that the beginning of my shift was a relief for her at least since she could pass off the insistent admit pager.  I changed from my pjs to my scrubs, put on my clogs on the way out the door and was glad I had started to keep two white coats in my car, one for my day adult job at the VA and one for my night moonlighting job at Children's (with the heavy otoscope in one pocket and Harriet Lane in the other, it was by far the heavier of the two).  The last few times I'd moonlit, I'd even started taking a blanket and pillow from my bed since I could usually catch an hour's nap in the limo-tinted back seat of my car before having to be back at work at the VA in my other coat. 

There are parts of moonlighting I really like.  And on nights when I'm no so utterly exhausted before I even start, I actually look forward to it.  I like being able to think independently about what to do with the patients.  I like working with the nurses as a team.  I like the relative peace of the hospital at night.  I like the surprise of not knowing what is next.  I like the variety.  I like the challenge of managing so many patients so quickly and I like it when it's a little slower and I can read and think a bit more about the ones that I do get.  I like being the first to see them on the floor and trying to anticipate their hospital course.  I like the experience.  I like the extra funds it provides.  

I don't like doing it when I'm already tired.  I decided I don't like doing it much when I have to work the next day.  I don't like not being there in the morning to see what happens next.  I don't like not getting any feedback from people about the choices I make in the middle of the night, besides what I can glean from their records and discharge summaries.

Anyway, in I went.  I realized on my way there that I'd forgotten my blanket and pillow.  But I had a beach blanket and a fleece in the trunk that would do.  

Donning my pediatric cape, I swooped in to write admit orders at the speed of light.  The charge nurse caught me on my way in and informed me that another one was on the floor. And was I admitting the 6 month old with congenital glaucoma?  And she'd just called in all their on call nurses cause the ER was packed (which I'd seen as I drove in).  I caught up with Katy and she already had five that she knew of either there or shortly arriving (and one she told me about later that's she'd forgotten the first round, the 6 mo with glaucoma).  And so I started admitting.  Priority went to getting all the orders in and I had my routine: 1) patient has arrived to room page from nurse, 2) call nurse to make sure patient looks stable and let her know how long it may be before I get there, 3) get to patient, 4) review ER notes or outside hospital notes, labs and former dictations in the computer, 5) interview patient and family, 6) physical exam, 7) decisions about what to do, 8) tell them what they might expect, 9) write orders, 10) scribble a few reminders of their story on the history and physical form (which will have to be finished and dictated later), 11) NEXT.  Depending on the complexity it takes me anywhere from 30 minutes to an hour per patient, and longer if I have time to review their past information more or fill out their growth chart.  

And so the night went: an 18 month old with gastroenteritis, a 6 month old with congenital acute angle glaucoma, two teenage boys with pneumonia, one recently out of juvenile hall, a four day old with slow heart rate, two babies with increased seizure activity, a 9 year old with a liver transplant that might be failing,  a 9 year old girl with possible small bowel obstruction, another baby with a fever without known source.  Then one more.  

The last one of the night, at 4:30 am, arrives from another hospital just as I get a page about three more in the ER and hope that they won't get a room until after I have passed off the hot-potato pager.  It didn't sound that bad in the report I got: 11 day old with a fever.  We call these "rule out sepsis" or ROS, and baby under a month get the full court press of antibiotics until the cultures from the blood, urine, and spinal fluid are negative for two days.  Pretty standard stuff and the babies usually have a virus and look like a peach while we treat them just in case it's something worse.  

So I was surprised when the nurse stuck her head in as I was finishing up with one of the other patients, "Room 246 is here."  And again a minute later, "She doesn't look good."  Uh oh.  I remember telling Ali on my way in that I hoped I didn't get anyone really sick because I too tired to manage.  I rushed over to the room which was packed with nurses and one worried grandmother.  Running through my head what I'd heard about this baby, "fever, mother with possible syphilis, mother in jail, other prenatal labs normal."  The baby looked bad.  Grunting is never good and she was grunting and mottled (which is when the skin starts to get pale with red blotches).  She was working to breath and the nurses already had extra oxygen on her and her saturations weren't coming up.  And, they informed me as I hurried in, "She has red jelly like stuff in her diaper."  What could it be?  While I was trying to think, I asked for a blood gas to see if she was acidotic and a sugar level.  Her peripheral perfusion was awful as I touched her cold feet so asked them to give her a 20 ml/kg bolus.  I listened to her heart and had trouble hearing it well over her noisy breathing.  He lungs didn't sound wheezy but they didn't sound good either.  I couldn't hear bowel sounds much.  I rifled through her papers from the outside hospital: her spinal fluid looked okay so far, her white blood cell count was high in her blood (possibly sepsis), her chest x-ray was clear, but her heart looked a little big.  I wasn't sure what to make of the red stool yet, so ordered a STAT abdominal x-ray.  And she already had antibiotics in, but no antivirals, so I wanted some of those, too.  She still didn't look any better after the bolus and the VBG came back with a pH of 7.11 (normal is 7.4 and it's very tightly controlled and important).  The x-ray techs still weren't there.  Her breathing was worse if anything.  I checked who the PICU fellow was on that night and it was one of the senior fellows who'd taught me a lot on my month with them.  I paged him and explained the situation and what I'd done.  "She just looks bad," I concluded.  He would come right down.  

When he got there, he wasn't sure what was going on either, but he asked for all the same things I'd already done and said it made him feel worse that that had all been done and the baby still looked so sick.  He took her upstairs to the PICU. He paged me later to let me know they'd intubated her shortly after and that one of the senior surgeons was taking her to the operating room right then to see if her gut was partially dying or dead already.  

I still had to write all of the history and physical forms for the other 10 patients I'd admitted before I needed to pass them off to the other teams at 6:30 am.  I wrote frantically and finished 8/10 before I went to pass them off, which took about 20 minutes.  I then wrote the other two and started dictating them all back to back, talking as fast as I could and marking the dictation priority so they would be in the computer by the time someone needed them that morning.  I ran around putting the finished paperwork in the charts and finally I was finished with the night.  Sigh.

I had been starving for hours so went to the hospital cafeteria, wondering on my way over what percentage of my meals are prepared and/or eaten in a hospital.  Probably 66% at least.  I indulged in hash browns and eggs and sausage with ketchup and then went to my car to sleep a little.  The trick was getting into the back seat before anyone came along and thought I was leaving and waited for my parking place.

I slept for about an hour before my phone alarm startled me awake and I crawled into the front seat and tried to make sure I didn't have any blanket marks on my face before driving to the VA.  

At least there wasn't any clinic that morning.  Just my two patients to visit, review their overnight events and check to see of any new consults.  No consults.  Just as I was about to start my notes for my patients in preparation for rounds, Mr. Jegan showed up and the fellow had to go off to do something then get ready to do a bone marrow biopsy.  He asked if I could see him.  Of course.  

They were glad to see me again, though not as excited to be back so soon.  Since they were there earlier than expected we could get chemotherapy started.  I visited with them and got them set up in the infusion center and let them know I'd come back to see them.  We took guesses at what Mr. Jegan's platlet count would be that day.  I like them.  Their grandkids are lucky to have them.  

I thought about Pop.  He was a great patient.  All the nurses in the hospital loved him.  No matter what was happening, he always had a smile, or a joke, or a friendly word in his warm Rhode Island accent with a big-man's gentle pat of his worn hands.  Even when he was tired or in pain, he hardly complained.  I remember after he'd had his open heart surgery when he was 83 and I stayed with him for hours in the hospital until he could come home and I took care of him there, he was so glad to see me and have company.  He slept part of the time I was there.  I encouraged him to eat.  His doctors and nurses and physical therapists visited.  I bed they thought I was lucky to have him, too. I know I was. 

There are certain people in your life who you just know are good.  All the way good.   People you trust completely with everything that you have.  People who will love you no matter what you do.  Grandparents are special that way.  I was thinking today that we are all allotted a few of those people.  And they are peeled away by age or distance or circumstances and then we are left alone.  Or with memories of them.  And perhaps the ability to meet new ones, but it's not the same as the core people--the first people--the ones who made you who you are and about whom you dream and who you feel even when they're not there.  Those are special people.  

I could tell Mr. and Mrs. Jegan were those kind of people to those they loved the most.  I'd like to be one of their circle, but I'm not and that's the way it should be.  I'm their doctor and that will have to be enough.  At least I'm lucky enough to be in a position to help them and know them in some semi-intimate way.  

So, while waiting for his platelet count to return, I worked more on my notes, went to noon conference cardiology review and then we waited for the attendings to show up and they didn't until late and there was some miscommunication and we looked at blood smears then, and bone marrow smears, and talked and talked and thought and talked.  Then they had to go a meeting that would last an hour and then round after that, at 4 pm.  I was not going to make it that long and we'd already decided what to do with my patients so I asked the fellow if I could go.  I'm not sure if he was happy about it but I was too tired to care.  I'd been working for practically 35 hours in a row and I was too tired to care.  

I stumbled home, changed, put in my ear plugs and fell asleep.  The deep solid sleep of exhaustion.  Dreamless sleep where you wake up in the same position in which you passed out.  Sleep that feels like it could go on forever.  Sleep that only ends when you get too hungry to even lay still or when your bladder reaches critical mass.

I woke up at 9 pm and remembered I was moonlighting again that night and glared at the pager on my night stand, dreaming of the day when I would not have to dread waking up to the harsh "beep beep beep."  And praying that I would not wake up to it later that night.  I got up to go to the bathroom and take my medicines, realizing moments after I swallowed them that I'd taken my morning pills instead of my night pills. Oops, those included the prednisone.  I didn't think the measly two milligrams that I take now would affect my sleep, but it's hard to tell.  I found the cookie jar full of fresh-baked chocolate chip cookies and blessed my mom while eating three of them for dinner with a glass of lactaid milk before stumbling back to bed.  Unable to fall back asleep, I fretted and fumed about nothing, tossed and turned, then read my book, "Hannah's Dream," for a while.  The main character reminded me of Pop again, the way he called those he loved, "Shug" like Pop had always called me.  The pager was still quiet.  

I tossed and turned a while more.  My feet were aching.  Finally I must have fallen asleep.  My pager woke me up, but it was light outside.  I'd survived the night without getting called in.  It was morning and the page was reminding me of our morning teaching conference.  I was pretty sure I was going to be late.  But finally, I wasn't tired.

2 Comments:

Anonymous Anonymous said...

wow you are truly amazing!

quick question, aren't you in violation of acgme work hours if you spend almost 2days/nights working?!

9:21 AM, April 26, 2009  
Blogger S. said...

Yes, it's kind of tricky; we have to have ten hour off in between shifts, which would have happened if I had gotten out of work in time the day before and been called in at not such an absurdly early hour that night. Well, at least it would have been closer to okay.

I'm not sure it's amazing so much as overly ambitious planning, but thank you!

10:35 PM, April 27, 2009  

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