First, twists in diagnoses: our drug addict with meningitis: we got a new attending today, and he decided that before he would sign off on the discharge of a man who continued to have fevers and white blood cells in CSF after a good while on antibiotics, he wanted an MRI. Well, lo and behold, there’s an abscess. Very bad. And, we realized today, we totally neglected to check HIV in this patient; weird meningitis = we ought to have done that long ago. But it gets better: with a brain abscess, you need several weeks of IV antibiotics. And we don’t dare discharge a known drug user with an indwelling iv line; so he needs a nursing home. But for some reason it will take two weeks to get him an admission. The nurses are already fighting to avoid having to take care of him; and the residents roll their eyes every time his name comes up. He is definitely not winning the popularity sweepstakes; I’d bet even money someone comes up with a way to discharge him, despite the current parameters.Yesterday I didn’t get to write anything because 1) we were on call and 2) I used up so much emotional energy I didn’t have anything left to write. For one thing, I feel like my residents have no use for me – which is quite probable, but I still don’t like it; they keep neglecting to page me for new patients, and they keep losing me on work rounds. So I got very worked up about that, and then didn’t dare say anything to them, because I would have said more than I should, once I started. Later in the day I persuaded the resident to show me how to write discharge orders. Then I went to go get a head start on today’s discharges, and started writing out an antibiotic, when the attending came by, looked over my shoulder, and observed that I was writing for ten times the proper dose. I don’t think he was very impressed with my protestations that a) I had asked the resident twice about that dose, and b) I was still concerned enough that I was just looking it up in my PDA. I keep falling down in front of this attending, and I’m beginning to get seriously concerned about my grade from him. Not to mention the fact that I just barely missed injuring the patient. Bother!

Later on in the day there was a code blue. I actually arrived simultaneously with the intern and resident, but since it was in the ICU, by that time there were already some 20 people (literally) on the scene, and none of us did much except watch. It went on for about 15 minutes, without much prospect of success. If it were one of my patients, I would feel guilty for having wished for such an incident. As it is, I will just stop wishing. But now I have a question: did the man die when his heart first became irregular, and the code was called, or when his heartbeat completely disappeared, during the code, or when the doctor in charge called the code? When did his spirit leave?

This morning the intern was very busy, and finally told me to go get started on the discharge orders for an elderly lady. I was overjoyed. Finally, one of them spontaneously offered me a useful activity. I rushed off to look for the chart, and, not finding it, stepped into her room to see if it landed by her bed. (I don’t know what made me think it would be there.) The lady’s daughter all but pushed me out of the room, and began demanding to know my name and the name of everyone on the team, and all their phone numbers, and insisting that no one should talk to her mother any more, only to her. I hadn’t been following the patient, so we hadn’t met before. Her demands were quite reasonable, really, but she was very angry, and I was startled. I gladly retreated to the shelter of “only a student,” and promised that the intern would come talk with her. I tried to work on the chart, but she was still angry and in tears, talking to the nurse, so after a minute or two I just plain ran away. The intern did come talk with her, and behaved admirably. He listened nicely, agreed that there had been miscommunication (besides internal medicine, renal and surgery are also consulting on this lady), promised to do better, and refused to say anything to her direct criticism of the resident.

Then we went and found the social worker, and she said there are three children involved, some not as much as others. So we figured between three children and three teams of doctors, it’s no wonder a few statements slipped. No sooner was that taken care of, than another patient’s family turned up wanting to talk to the “doctor” right now. The poor intern. At least they were only curious, not upset – yet. So what with one thing and another, I never managed to do those orders.

It must be so confusing for patients and families in an academic medicine setting. It took me a couple months to figure out the hierarchy of attendings and residents and interns and nurses and social workers, not to mention the way we switch coverage around without hardly warning anyone, and consult all kinds of people, whom the uninitiated can’t differentiate from the primary team. I’m sure it wouldn’t have helped that lady at all, or in fact improved the confusion we had given her mother, to say that our team is almost as frustrated by the difficulty of communicating with our consultants. When they do write notes, it’s illegible.

On the plus side, we have the new attending, and he seems much more interested in teaching. This morning he was quizzing us about differential diagnosis of a very interesting case of abdominal pain. He was asking the intern, but I knew the answers. I feel a little bad for making the intern look bad, but I think I needed the right answers more than he did. The new attending is younger, and remembers his residency more vividly, so he announced his intentions of avoiding various annoying practices. I hope I wasn’t nodding agreement too vigorously. . .

Lastly: Overnight a lady I know from psych here turned up with an overdose of one of her seizure medicines (see here, here, and here. She was being violent, threatening, and suicidal by turns, and of course got herself heavily loaded with haldol and ativan. So when I went to say hi early in the morning, it seemed prudent not to wake her up. Later on, when I was sent to go write the shortest-possible-note (because we’re sending her up to psych tomorrow), she was awake, cheerfully eating spaghetti, and demanding to go home. She remembered me (not sure that’s a compliment), and wanted to know if I would send her home. I decided discretion was the better part of valor, and did my physical exam quickly before advising her that if she would stay away from the police, she would end up in the hospital less often. She responded that she hadn’t called the police, and she didn’t know what they were doing at her apartment. The sitter (who was keeping an eye on her) and I both thought that was quite funny.

This is already a huge post, so let me tack on one other observation in my developing relationship with nurses: I don’t know why, but they keep asking me what to do. This patient has morphine showing up on his med list, and he doesn’t need it, what shall we do? This patient is agitated, what shall we do? This patient keeps asking for pain meds, what shall we do? I’m rather pleased with myself for no longer trying to persuade them not to ask me. Now I look serious, ask precisely what the problem is, and then say, “What would you like us to do?” And then they say, order ativan, or make the pain meds scheduled, not by request. So I go tell the resident, and he does it. But I think it’s funny that they ask me. Probably because it’s less bothersome than asking the resident directly. This way makes me the one who badgers the resident. Sometimes I even come up with an answer on my own, and if it’s not major, they settle for that.

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