Medicine service is brutal - on the one hand, I enjoy the new 7a to 7p call because there is an end in sight; on the other hand, it means that there are no days off. If I am not on call, I have afternoon clinic, extended hours from 1 to 4:15, now that I am a second-year. If it is the day after a call day, we have successfully lobbied to make our clinics from 2 to 4:15 instead.
One of the residents is on indefinite leave and we are all covering her messages and patients in shifts. This last week, I sorted my own box, answered my own messages, and then delved into the backlog that is her box. All this after completing my EMR charts, because I haven't stopped to make templates and do all the little things that would make my life easier. Angel keeps me company. I come in at 0615 to pre-round and leave at 1930 or so most days, and there is still work undone - work that needs to be done.
We have a patient - I have a patient - who is suffering from acute on chronic craziness, in addition to his medical problems. He got drunk and ran his motorcycle into something, had to have his knee repaired, went home and came back a week later with miserable abdominal pain. Turns out, he's infarcted part of his left kidney. Turns out, he has lupus anticoagulant syndrome and should really be on Coumadin forever. I've called just about every specialist in the book and recommended that his abdominal pain be looked into by a GI doctor over the weekend when I don't have to explain myself to someone for the 435345346th time. We have performed not one but two different interventional radiology studies involving catheterizing the femoral artery to examine the vessels leading to his internal organs. We have CT'd, PCA'd, PRN'd and given stupid quantities of miscellaneous drugs, in addition to letting him determine his own dosing schedule for his Seroquel and Effexor. (As an aside, I want you to know that I adore Seroquel as an antipsychotic.)
We're doing a million-dollar workup on this man who is probably (a) crazy and (b) constipated. (And according to abdominal flat-plate he is, in fact, exactly that.) He needs a hefty dose of high colonic and I think that his fear of rectal intervention is keeping him in the hospital. He also needs to have his Foley catheter removed, but he's afraid that the morphine won't let him pee and we'll put it back in.
He lives in his own reality. In this reality, Coumadin always kills people, nobody pays to sit in the hospital and get therapy they could easily be getting at home, and I am the only doctor who can be trusted to take good care of him. In this reality, discharge is an option and not an order. In this reality, he has still not gotten over the fear that somehow the blood clot on the arterial side of his kidney will somehow filter through the vessels, reconstitute on the other side, travel through the veins to his heart and kill him - but he is certain that if we thin his blood he will die. It is a struggle to be kind to a man I want to strangle daily.
Research grant proposal is due in electronic format by 13 October. I think I'll have it done, but it's one more thing keeping me up and shorting my sleep. And the value is in writing it, right? Regardless of whether or not I actually get the money from the AAFP for the project (which I want to do!) I'll at least have written a real grant proposal...
I'm breaking down a little bit, here at home, O Best Beloved. Nobody at the hospital notices, nobody in the clinic seems aware of this - but the hours and the lack of sleep and the total absence of any meaningful break are starting to wear on me, and Angel comes home to find me avoidant at best, dismal and tearful more evenings than not. Medicine lasts only a week and a half longer; I'm tired of rounds from seven to eight-thirty, skipping breakfast to write notes on eight complex patients every morning and fighting to finish up by one PM so that I can go to clinic. I'm tired of trying to maintain the reputation for excellence that I've been granted when excellence means working so hard on every single patient, and when that means that complex patients get entrusted to me.
But I want to know, when I am alone in practice, that I am qualified to care for people. And I want these people to get better. And I want to feel like everyone sees me, quick, bright, and compassionate.
But O, Best Beloved, I am so tired...