Last night I got definite proof that all the rest of my fellow interns have forgotten the prime directive, which is to plan ahead to prevent calls. I think every single person who was allowed to take anything by mouth developed a headache, and didn’t have any tylenol ordered. (OK, there were other pain meds, but the nurses and patients and I all agreed that they were overkill for a headache.) Of course, none of them did it at the same time. The nurses were calling me literally every ten minutes – starting, of course, only after I decided to try to sleep.
After an hour or so of that, the ER called me. The poor intern down there started off to give me a complete history of the patient, starting with the symptoms that had caused him to be admitted two weeks ago. “Bill. Stop. He’s in the ER now? What room?” On the way down I considered explaining to him that I’m pretty much useless with a case of abdominal pain in the ER when the labs haven’t come back and the CT hasn’t been done. (Academically, I would like to be able to diagnose the majority of things based on history and physical. But my senior is going to be very unimpressed if I wake him up without those results, because the attending doesn’t want to hear anything till all the data is in, unless it’s a true emergency.) Several flights of stairs let me wake up enough to remember that a) this patient belongs to the paranoid attending, who really does want to know if his patients are in the ER, even if they don’t need to be admitted, and who wants to hear the moment they’re there when they do need to be admitted (bariatrics, so there are some peculiar complications that might not be recognized easily), and b) I’ve heard enough stories of patients languishing because nonsurgeons just don’t recognize surgical diseases as fast as surgeons do, so I don’t want to go discouraging the ER from calling us. A few months back there was ruptured AAA which they didn’t know was ruptured, and one of the senior surgery residents caught a glimpse of the CT from the hallway, went back to look, and kidnapped the patient to the OR. (Or at least that’s the version of the story among our residents; I admit that it sounds pretty far-fetched. Probably the CT had just been done, and the ER was on the verge of calling us. But still, when a guy with a known AAA comes in complaining of back pain and is borderline hypotensive, you should get a CT without dawdling, and call surgery at the same time, so that we can get the OR set up.) (The guy survived cleanly, to the amazement of all.)
Then later, just when my call was technically over, and I was past due to go round on my own service, one of the nurses grabbed me: So and so is having chest pain, come help. For a minute I tried to dodge, but no other residents seemed to be visible or answering pagers, so I gave up on rounding. The patient was stable, but very uncomfortable. I ran through the basic workup, and reassured the nurses. That’s the funny thing about surgical floor nurses (as opposed to ICU). They know what to do with blood gushing out of a wound, or vomit or stool all over the patient and the bed, but chest pain and rhythm strips make them panicky. I was happy with myself because I wasn’t particularly spooked, and did all the right things. Then the senior resident showed up, and looked as though he thought I was over-reacting. I had to run see my own patients, so I’ll have to ask him tomorrow to explain the algorithm for deciding when not to take chest pain that seriously. (It wasn’t heartburn, but the vital signs were completely normal, and so was the EKG.) But the whole episode was worthwhile for me, because it let me see how much I’ve learned in just the last few months. Even back in October I would have been a little scared by that; but now I know everything that could be done, it’s just a matter of figuring out how much of it to do.
I got out in time for church, but slept through the sermon. So far, I am very determined to go to church whenever I’m not absolutely required to be in the hospital. Being sleepy shouldn’t make a difference. I hate it, though, when the sermon verses are splendid, and the pastor is making very helpful points, and I can’t keep my eyes open. At least I wake up for the singing.