Admit, Monitor, Discharge, Repeat

A few months ago I did a "day in the life" post while I was on an elective. It showcased the less-stress, breezy days of residency that contrast to weeks like now when I'm pushed to my limits on our busiest rotation with a high patient turnover rate.  Every rotation of residency is a joy to me in different ways-- either relaxed enough to really soak in knowledge and move about leisurely, or be challenged, stretched, molded into a better doctor by the hour due to intensity.  I wanted to share the experience of the latter- a somewhat vulnerable display of what crosses my mind on some days.  I am lucky enough to be in a program that never violates duty hours, and has a reasonable patient census. But that doesn't mean it's not really incredibly hard to juggle all our responsibilities and wear all these theoretical hats, and come home without a heavy heart. Talking about our insecurities, of feeling overwhelmed and overworked some days is therapeutic. We're all thinking it and shouldn't be afraid to share it. So here it is-- an honest timeline of my day on telemetry packed with responsibilities and emotions.

5:30am: My alarm goes off with a serene sound and I don't even hesitate to jump out of bed. I've got my morning schedule down to such a science, my parking lot arrival has a standard deviation of about 1 minute.  Shower, eat, coffee, feed the animals, leave the house.  Play a Louisville Lecture podcast in the car (or a PaleOMG podcast on some days when I'm feeling fun..) and get parked by ~6:40.

6:45am: I roam the call rooms and CCU (coronary care unit) trying to find the night float resident so I can get sign out. I have no idea how busy the night was, but I presume it was intense (the senior at night covers both telemetry and CCU admissions, and oversees care for these patients along with the interns.)  I find her at bedside in one of the patient's rooms, discussing with the cardiology fellow what additional pressor she should add to ensure his blood pressure comes up. I don't want to interrupt but I'm anxious to start my work rounds. My co-senior has arrived as well, and presumably our interns are already buzzing around the telemetry floor examining our patients. The night float senior finally comes out of the room, hands me the call pager with a sigh of relief, and rattles off about the six new admissions she completed overnight. I quietly admire her, my peer, as she remembers small details of their stories and offers "if this happens, we should ____" plans for each of them. But they are now under our care and my own heart races with the pressure to not make a mistake.

7:15am: After jotting down a one line note on each patient, I run around the tele floor, trailing my interns to go into each patient's room and examine them myself. We have 20 as a maximum for our census, and I feel annoyed that I have to get the cliffnotes story of what brought them into the hospital. I feel sad with myself when one patient's never-ending questions starts to irritate me. I snap out of it, carefully answer all their questions, and move to the next room.  

8:15am: I've seen all the patients. Everyone looks stable, comfortable, and only mildly bothered that at least 2 doctors and a few nurses have woken them up starting at 4am. I breathe and sit down at a computer. The art of double checking everything. Every order, every lab value, every vital sign.  Subjectively calculating the answers to questions like "can i change the Lasix to oral" or "does this patient really need another stress test for their non-cardiac chest pain" and "when can this patient be discharged?" Synthesizing data alongside my co-residents, we work seamlessly, fluidly, and we're actually cracking jokes while also working so rapidly I feel this vague dizzy feeling. A nurse comes up and informs me that room 4 is FREAKING OUT that he can't have coffee until after his stress test and kindly requests, "can you please talk to him?" You can tell she's already tired too, and its 1.5 hours into the work day.  I walk to the room and my co-senior struts by and calmly mentions he'll be in room 17, her heart rate is in the 140's right now. We both put out these small fires and get back to our computers.

9:00am: SHARP. We start rounds with our attending. He acts surprised to see that the patient list looks entirely different than yesterday. "Who are all these new people? You guys have been busy with admissions, huh?" He asks calmly, knowingly. We start with table rounds, as the interns beautifully present each patient case. They arrived even earlier than me to have their notes complete before we start rounding.  I get a flashback to intern year on telemetry and quietly feel a sense of happiness that I am not them. Intern year is the toughest in terms of fatigue and getting extra work dumped on you. It's like a right of passage. I feel like protecting them from that feeling, or at least let them know it gets so much better. Harder in some ways but so. much. better. 

9:45am: I'm on call, and luck would have it that I have not yet been paged for a new admission. This means I'm able to attend management rounds, where I sit at the head of a table with a nurse manager, social worker, and care manager to settle the nitty-gritty details of each patient's admission. I tell them why the patient is here, what they're waiting on, and their likely disposition (home, skilled nursing facility, etc.) The thought of each of their jobs genuinely exhausts me. They fight with insurance companies to get admissions paid for, and when they can't, the patient gets a larger portion of the bill to pay out of pocket. They scramble around for local nursing homes to accept patients once physical therapy has deemed they would benefit from rehab, only to find out one of my patients has gotten rejected because his drug test was positive for cocaine. "I can't place him anywhere, Shannon, he'll just have to go home." I feel defeated. That patient is basically living on the streets and occasionally living with his sister when she lets him. He's never had a chance in his life, and now he's basically dying of alcohol-induced heart failure. His functional status is very poor. But I have a census to control, and I have nothing left to offer him in the hospital. I write "discharge with home health services" under his name. We move on to the next patient, each with their own complexities within the healthcare system to address. 

10:15am: I've rejoined rounds and try to catch up on patient plans. I've missed approximately 12 messages in our team's group text-- half of them regarding tasks that need to be completed and the other half a stream of inside jokes that we've quickly developed from working a week together. I fill in the team with changes we need to make based on care management rounds.  I pull up a portable computer and start typing up discharge paperwork and sending prescriptions to the pharmacy all while still listening in on rounds. **Beeeeeep. Beeeeeep. Vibrate.** And so it begins. The hunger games with the emergency room. I call back the number and hear about a new admission for chest pain. "Is it typical chest pain?" "No.. its reproducible, but you know, this patient has a lot of risk factors and I think they would benefit from being monitored." "Are there EKG changes? Positive troponin?" "No.." the ED resident trails off. The emergency room doctors do a great job at triaging patients, but I feel a pressure to control my census for "teaching" cases or those patients who have the potential to be quite sick. I already try to rationalize how I can change this patient's disposition to the observation unit, or at least to the non-teaching team.  The truth is, I can't do any of that until I first go down and listen to the patient's story, examine them, see the EKG myself, and formulate an appropriate plan.  

1:30pm: "Shan, it's time to eat." That text message flashes on my phone screen from my co-senior. They've just finished rounding on the 20 patients upstairs while I've been down in the emergency room getting a few more additional calls for new admissions, trying to efficiently triage and send patients to the appropriate service. I've just finished placing orders for the last one, and breathe a sigh of relief knowing I can leave the ER.  The team brings my lunchbox to the cafeteria.  On a crazy service like this one, we've made it a strict rule that we would eat lunch together every day, even if it's just for 10-15 minutes. It's our little way of taking care of one another and it's been a lifesaver. Had someone not texted me, I could have easily wandered upstairs and started typing more discharge instructions, surviving off of the protein bar and cashews in my pocket (not a bad lunch if I'm being honest though.) Upstairs the rest of my team has been working just as efficiently to ensure a well-cared for patient list and to get people discharged safely.  We feel the pressure from every angle to get patients out of the hospital- from care managers, administration, from the pending new admissions sitting in the emergency room pod, to the patients themselves who want to get home. But first, we eat. And laugh. And breathe.

3:15pm: There's a few stable patients in the CCU who are ready for transfer to the telemetry floor. I begrudgingly drag myself and the intern on call over to the unit so we can get sign-out. "Can't you please find a reason to keep them for one more day in the unit?" I joke, but know that there are other patients, sicker patients, who need far more attention.  We go to the bedside of those being transferred to us, ensure that they are stable for downgrade out of the unit, and let them know their plan of care before they can go home.  

3:45pm: I jolt back over to the tele floor, remembering that I would join the intern for a family meeting.  One of our elderly patients, who exclusively speaks Haitian Creole, with a very complex medical history and a poor prognosis related to his metastatic prostate cancer (on top of having heart disease and being on dialysis) is on our floor due to a new diagnosis of atrial fibrillation (an abnormal heart rhythm that increases your risk for stroke, and often requires being on a blood thinner.) We looked at the bigger picture for this patient. What are we really doing here? Are we really addressing his medical needs? Would we really offer him a procedure to correct this rhythm? What does he actually want to be done?  We arranged a translator to be at bedside with him and his family.  We listen to them first, then carefully ensure he and the family understand his grave prognosis.  We provide options for how to approach his number of medical problems, being careful to explain both options. They decided on not wanting any invasive procedure, and also to change his code status to DNR/DNI.  They felt not ready to go home with hospice care, but we all felt it was the step in the right direction to honor his medical care choices with dignity.

4:15pm: The admission calls start to multiply, and I'm again stuck in the emergency room. My co-residents are among the very best, and seamlessly run the floors while I admit patients in peace. Did I mention there's also medical students on our service? We feel personally responsible to ensure they get a good educational experience, so in between service responsibilities, we find precious pockets of time to teach pearls of medicine along the way. They are eager, brilliant, and so willing to help. They assist the interns in some of the grunt work, for which I feel so guilty about. I remember that it's part of the experience, part of learning how to be a doctor where these responsibilities will soon fall upon them anyway. Either way, we send them home around this time to ensure they can adequately study and, you know, take care of themselves. When they ask "are you sure?" when we send them home a little early, I tell them to run :-P

5:00pm: My co-senior is not on call, so he finds me in the emergency room to hand me a fresh new patient list. I giggle at the sight of it, of how different it looks from the one I printed at 6:45 in the morning. He updates me on things I've missed to ensure that if I get called regarding a certain issue, I know how to respond. He earnestly offers to stay and help as he glances at the couple of admissions pending, but I shoo him away quickly. There are two pending because the current patient I'm seeing is complicated. I'm worried. And the minute I get the feeling that I need help, I don't hesitate to ask for it.  I call the cardiology fellow on call and explain the patient scenario to her. She understands my concern and says she'll be down to to meet me in a few minutes. I turn around and the patient looks to be in distress. Her oxygen saturation, despite being on oxygen through a nasal cannula, is still a little low. She has congestive heart failure and currently has too much extra fluid on her lungs, and she needs more support than what we're giving her right now. She could decompensate quickly, and I feel she needs to be admitted to the unit, not the telemetry floor. The cardiology fellow arrives and takes a look at her, agrees, and accepts the patient to CCU. I feel happy that my intuition is becoming stronger but also worried that this young patient will need to be intubated. She's only 42 with such an extensive medical history, now on the verge of respiratory failure. She's here because of non-compliance with medications but who am I to judge her? Who knows what terrible things she may be been dealing with this past week that kept her from making it to the pharmacy? And how devastating to be this young and live a life so dependent on medications. There are so many conflicting emotions in medicine that hit you from every angle, creep up on you or reappear when you least expect them to. I snap out of it when I get a page letting me know that bed 14 needs a discharge order, as they've just been notified they have a skilled nursing bed for the rehab center down the street. I place the order knowing that all his paperwork has already been completed by my team. 

7:00pm. Cross my Ts, dot my I's, it's time to sign out. Ok really the time is 7:30 when I actually finish my last admission but who's counting? I find the night float senior upstairs and pass off the pager with the same sigh of relief that she had given me in the morning. We laugh and banter over how the day went, I sign out the new ones to her, and she inquisitively asks about outcomes and plans regarding the patients she had admitted the night before.  

8:15pm: I walk through my front door to a dog and a husband who are very happy to see me, and two cats who really couldn't care less :-P "Did our team really do all of that today?" I think to myself. Yes, yes we did. And you know what? In the very strangest way, we had fun. I'm talking truly had fun. We learned, we accomplished, we problem solved, we took care of people. My brain is exhausted. My body is tense. I flip through a medical journal for about 30 minutes, eat some dinner that my husband had prepared a few hours before, and melt into a sense of calm. A very quick yoga session in my garage to really mellow out, and it's time for bed. Tomorrow will be no different, but I am ok with this. These are the growing pains that maybe I'll appreciate later. "Did I put in that order for morning labs?" I think as I drift to sleep. "I think so. Probably." 

Love,

Shanny, DO