It is important that I get out on time tonight, O Best Beloved, and not because I plan to drive back to my Angel (I left my cell phone in FW this morning, and my new notecards. Poor me. It is important that I get out on time because the Family Medicine residents have invited me to their volleyball party tonight. There will be food, and company, and I will be getting out and doing things rather than sitting in my apartment by myself with my dial-up connection, getting my tail spanked by Keeper Asmodeus (I love Dungeon Keeper 2, but I cannot beat this level) and missing my Angel.
"My medical student is less trouble than my intern."
Things I have learned by overhearing conversations between S and a terribly unsure-of-himself intern on his first ward month as a Real Doctor:
When one is treating an elderly uroseptic lady (chemical code only, no shocking or intubation) who is in the process of trying to die slowly on you, do not order for 2-4 liters of normal saline every 2-4 hours. That's a morphine drip order (only mg instead of L), not an IV fluid order. It's nurse mix-and-match, 2L every 2 hours, 2L every 3 hours, 4L every 2 hours, whatever. Furthermore, the human body contains about 5L of blood. The elderly person with impaired renal function is going to drown in 2-4L of fluid. Saying "The PDA told me to do it" is not an acceptable excuse, and only underscores the vital importance of using clinical judgment and everything you learned in medical school to modify what the PDA tells you to do. The PDA is only a reference. That's why you are a doctor. This careful consideration will prevent your resident from being paged at 10 PM by the nursing manager, and will smooth things over for you to get some sleep.
When one is not sure of what to order, there is no shame in calling for backup. But if you call for backup, have a pen ready so that you do not have to call backup five minutes later to ask "What did you say to do again?"
Do not lose the card on which you wrote the information for your ward transfer patient. The medical student who paged you after the ICU intern paged her, she didn't keep her paper with the information because you were responsible for the patient and not her. That's what the AO said. Medical students keep many things. Don't count on them being useful.
Don't try to get out of writing daily notes on your patient, and never be caught admitting that you are completely unaware of any information at all on the patient you have been following for ten days now. They will notice.
S has a bad case of CYA syndrome (that's cover-your-tushy, if you didn't know). Every sentence he utters regarding a patient involves "Make sure to document" or "if you got called to court", some days. He had a brush with malpractise once already in his career, I don't know the details, and it's scared him. But I'm not sure I can practise his kind of defensive medicine. And it frightens me that as I begin seriously to face the future I will have as a physician, that I may have to be able to practise defensive medicine. I write careful notes. I try to have a good relationship with my patients (although my ICU transfer gentleman hates everyone; he's a little demented and insists that he was kidnapped to the hospital, despite the life-threatening sepsis that wracked him from a perforated bowel) and I try to do what's best for them, to explain what's going on and why we're doing what we're doing. And it terrifies me that that might not be enough.
All my notes were done, two and a half hours after I came to the hospital. I was leisurely, came in and chatted with patients, saw my gentleman in the transitional unit for a social visit (he's doing much better, and furthermore has graduated from calling me "baby" to calling me "doc". He even told S I was a genius, and he was blessed to have me as his doctor. I went home with a warm heart from that remark.), I explained test results and gave nurses backrubs and spread around the good cheer.
I feel like there is something I should be doing, like I am not busy enough. Without residents and staff and conference eating the first few hours of my day (8-9, morning conference; 9-10, staffing; 12-1, noon conference) I have completed things at least 2 hours ahead of schedule, and I am hoping I have not forgotten anything.
I called Pulmonary to ask if they wanted to see my latest admit, who is a 174-kg (yes, O Best Beloved, 385 pounds) gentleman in his early twenties with a pulmonary embolism. Lives at home, unemployed, mother takes such good care of him. You know the stereotype, and it is so hard to see the human being underneath two hundred extra pounds of flesh, but I am trying. Coumadin and Lovenox (I didn't realize Lovenox was a kind of heparin until today, I thought it was just Lovenox, magic drug) for anticoagulation and no consult, he's stable. The nurses are going crazy, the boy is so whiny but I am polite and forthcoming with him, he is polite and listens carefully, and we get along. At least I think we do.
I begged the nurse to make sure my patient with the diabetic third-nerve palsy got seen by optho (S this morning, "Please make sure there was a consult, and if not, call $eye_clinic, and if they refuse, call $doctor and say I asked you to call" - there was a note on the chart after all that work) and I explained to her our precarious situation, that I wasn't sure she needed to be in the hospital, we weren't doing much that couldn't be done outpatient, and she said she'd think about that.
I talked to a diabetic with chest pain and a normal stress test about staying in the hospital to start insulin. We want her to stay, but not at the risk of keeping me at cap so I don't get admits, and she wanted to go home anyway. She'll start it as an outpatient. I was secretly sorry; she was a nice lady and I liked her. The nice ones always go home. The compliant patients, the good patients, the happy patients, they go home quickly and leave you with the cranky demented noncompliant patients. I look for the good in the cranky ones too, and, surprisingly or not-so, I find it.
I was flagged down by Social Work on the top floor of the hospital. "Hey, wanted to let you know." The gentleman with abscesses, the one with the history of drug use and noncompliance, whom we sent home with a PICC line, that one? It seems I put the fear of God, so to speak, into him. He's been completely compliant with his outpatient antibiotics, for fear of losing his leg. He's following doctors' orders. Good.
I am woefully incompetent in managing post-surgical patients, but I am instructed only to write notes on my post-surgical patient, not to write orders. Critical Care is still following him, let them make the decisions. I am not comfortable in that role. It is more a problem of not knowing why I am seeing the man at all than of not knowing what to do with him. I wrote a note. "Patient confused again this AM. States he was "kidnapped"."
I signed out, and I was invited to the volleyball party. I want to go, relax, have fun. S stressed me out this morning, with his lists of things to do and check up on and make sure I wrote for this and that and the other and S, it's okay, I did all that yesterday. I've got it under control. The more he worries, the more I worry that I don't have it under control, and the more I find myself wanting to abdicate responsibility to someone else, someone with all the answers. It's too bad that in the end, none of us have all the answers, and the the thousand-item differential for nausea and vomiting has at the bottom of it "idiopathic" or "we don't know why".
This, O Best Beloved, is why we only practice medicine.