Last night was not so tremendous. Going for 48 hours with about six hours of sleep gets kind of tiring. I did do something pretty dumb by the end of the night. Fortunately not dangerous, but pretty dumb. Partly, also, the night dragged because nobody got seriously sick till the early morning, so there was nothing to do but see some rather boring consults, and answer calls from the floor – never in short supply.

The high point of the night was taking a transfer from another tertiary care center at 3am. Since I had actually managed to fall asleep, at first I was rather upset. But the only thing to do really was laugh at the ridiculous situation; which I did; the nurses thought I was crazy. The patient had developed a critical lab value more than 24 hours earlier; the only evidence I had of this was a handwritten note which she was carrying with her glasses. (That was when I decided to laugh.) As the nurses observed, if we had to get an insane transfer with nonexistent documentation of gigantic medical problems, at least she was completely alert, and had a very good memory for whatever scraps of information she had been given about her condition. I think the bottom line reason she was transferred (as far as we could understand) was because her insurance didn’t like the other hospital. When she spirals and dies in a few days from the untreated condition that was ignored while she was being transferred, do you think we could all sue the insurance company for malpractice? (And do you think the tertiary hospital sent any images with her? Noooo.)

There was another patient who, on paper, looked sick enough to need a DNR order on admission. But when I went to talk to him, he honestly looked so good, I couldn’t get very far. He said the usual: I wouldn’t want to be kept alive on a ventilator, but if it’s just a short-term problem, and you think I might recover, do everything possible. I didn’t know what to say. On paper, his life expectancy is about a month. Theoretically, he could get pneumonia and have a chance to recover from that before his underlying illness kills him. Realistically, if he doesn’t sign a DNR now, he’ll end up on a ventilator when his illness catches up with him, and we’ll be stuck for several days discussing things with his family (if they turn up). But at 11pm as the intern I didn’t feel called upon to explore the prognosis of his condition; which after all he had been admitted to have a work-up for. After talking to him, I think I understand what he wants; but without signed papers, my understanding doesn’t do him any good.

I need to keep a list tonight of all the silly pages I get. (From one of my favorite nurses: “The patient’s temperature is now 100.4; it was 102 a few hours ago.” From a less beloved floor: “The patient has restless legs. I know he became delirious when we gave him any kind of sedatives yesterday, but these restless legs are really bothering him.” Which is why I’ve decided to buy Ambien’s marketing gimick of not being as mind-altering as other hypnotics; it’s a life-saver for interns. Or, “I know the patient is npo after midnight. Since it’s only 8pm now, would it be ok for him to have some dinner?”) Actually, I need to get better at filtering the important jobs from the things that can stand to wait till morning. If I had better radar, all this traffic wouldn’t be such a problem.

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