I feel that whenever I have a story to share from the chronicles of residency or life it is typically an outlandish outlier from the day to day events of normal life. These patient stories and tales of inpatient medical adventurism are of course entertaining to share with other residents, and useful in doing so to blow off steam. These stories are also typically the traumatic or heart wrenching memories that have a profound shaping effect on our careers and insights as physicians. But, what often gets missed I feel is the mundane days that fill the void between the outrageous tales of crazy and noteworthy patients. I also think we as health care providers get so used to this monotony that we sometimes fail to see just how amazing and equally outlandish our typical normal days have become for better or for worse.
So I feel justice should be paid to an average day in the life of a resident. One random day while on inpatient medicine I decided to chronicle the entire day. The following is the story of that day. If not for taking note of it, this day would have likely been lost from all memory and would have passed as just another drip of water on my forehead in the endless water torture that is general medical education.
The alarm on my phone goes off, I hit the button on the screen with a little too much force and it tumbles off my nightstand to the ground as is often the case. It’s often in these very fresh, cold tired moments first thing in the morning as my feet hit the ground that I curse all decisions that have lead to me having to get up so much against my will. I fumble through the morning hygiene routine always watching the clock. Over the months I’ve shaved every minute I can off the morning ritual to maximize sleep, but it comes with the cost of demanding maximum efficiency balanced with the constant pressure of trying not to feel rushed. I think the mornings would be even more cruel if every morning I woke up and immediately panicked that I was running late. Heading to the kitchen I perform the feeding and caffeinating ritual before blasting out the door for the anticipated 20 minute drive into work. The drive to and from work are the most sacred times of my day. Most of my peers lives only a mile or two away from the hospital and scoff at the idea of the drive I make each day. But, for me this is really the only protected down time there is. I mix this time with an array of music, podcasts, or just silence from the outside noise while I slowly let the caffeine build in my system for the chaos that always follows.
The three day time residents sit down with the two over night residents and they sign our patients back out to us. We sit at a large oval table that is decorated with various medical papers, half eaten bagels, and half functional office supplies. The night team watches over pages of patients they know hardly anything about expect for a brief one or two line blurb that is updated every day on their sign out sheets. They tell us about the calls they got overnight for seemingly minor complaints, or how an astute nurse decided at three in the morning she would take it upon herself to let us know about a medication she doesn’t agree with that a patient had been on for five days. This mornings sign out consisted of a mix of low blood sugars, burning urinations and positive wound cultures. Rushing through sign out the clock now starts to tick. It is 6:30am and I have exactly two hours to get through the busiest part of the day.
I have eight patients I need to round on before 8:30. This involves gathering all the data from the last 12 or so hours like vital signs, how much they urinated, what new meds were given in addition to hunting down all the labs from this morning. I also need to talk to each patient, talk to the nurse, and do a physical exam. All of this so that at 8:30 I can give a concise presentation about each patient that summarizes the last 24 hours and proposes a plan for the way forward. To get started I grab one of our new fancy computers on wheels and wheel it on up to the wards. Our hospital like all others now have gone to electronic medical charting, this means we have a multimillion dollar program that demands a nonstop keyboard pecking frenzy from me all day long in order to enter orders, notes, and whatever else the billers demand. The computer on wheels has now become the modern day clipboard for doctors. The computer on wheels were effectively called COWs for a while, until this acronym was deemed insensitive to people of larger girths, and now we are supposed to call them WOWs (work station on wheels) to satisfy the weight neutral crowd. I start with a 59 year old woman admitted yesterday afternoon. She was brought into the hospital by ambulance as her neighbors found in her house where she lives alone unable to stand from worsening weakness and confusion. She was found to have a hemoglobin of 4 and received two units of blood in the emergency department. She did have one large bloody stool in the ED and it was mostly assumed that her condition was from an ongoing GI bleed. At some point in the night she got a CT scan of her abdomen because the ED doc thought she might have been a little tender. Turns out she had about an 8 inch cancer growing in her colon and pelvis that was the likely source of her bleeding. I woke her up and her mental state had improved after getting the blood so she was now able to have a conversation with me. I went through the formalities, asked her how she felt, did a physical exam and then basically told her she had cancer. Her eyes widened in much the same way a pregnant woman eyes widen when told that her water has broken. Turns out the range of facial expression for surprise, both grim and joyous is fairly narrow. She took this news as anyone would. I did my best to console her and walk her through what the next steps would be, but I also had an eye on the clock. There are tragedies like this all day long in a busy hospital, consoling a newly diagnosed cancer patient is unfortunately not a viable excuse to not see all of my patients or miss rounds.
Moving on to the next room was a rather cooky 65 year old woman that was brought into the hospital yesterday because she was sitting hunched over at a Walmart McDonalds. She states she was just in pain from her chronic back pain she normally gets. Someone came over and asked her if she was alright, she said of course she was and snapped at them to go away. The good Samaritan wasn’t convinced and kept questioning her. She started to ramble on about her back pain and her dog she had with her. The Samaritan not seeing any dog was now sold that this lady was in pain and delusional so the ambulance was called. The ambulance then took her and her small four month old Chihuahua puppy hiding in her lap to the hospital. In the ED her story checked out, but it was incidentally found that she had an infection on her toe that was spreading up her leg so she was admitted to the hospital for cellulitis. Classic ER! I examined her foot and she did indeed have a nice spreading infection up her mid calf from it, her diabetes were not helping her wound healing. On her toe was a nice ulcer covered in granulation tissue, the sight of it made me wince a little, but being a diabetic she had lost feeling in her feet long ago and never knew such an infection was brewing. Overall I found her pleasant, a bit crazy, but pleasant.
The next patient was tragically obese woman that toped in around 400 pounds. She came in because her failing heart couldn’t handle the sodium load from some Chinese food days before and she swelled up as fluid backed up into her lungs, and basically all throughout her body. For three days we were giving her medicine to make her urinate fluid out. At this point we had got about 13 liters of fluid off of her and she was still swollen. She was very nice and always greeted everyone warmly. To me though there was something not quite right about her warm affection. She had completely betrayed her body. She couldn’t walk, stand or even get out of bed because of her obesity, and her organs were now failing one by one, yet she seemed almost indifferent, chipper even. Part of me was saying “good for you, your powering through this adversity with a positive attitude”, but another part of me, the part that educates patients about weight loss, about healthy eating and exercise felt irritated by her positivity. It was as if I knew her whole life she probably smiled and joked her way through doctor after doctor appointments warning her about what she was doing to herself, trying to motivate her to take care of herself and she had never cared or listened. I felt irritated because I knew I have so many patients like her that I’m trying to turn around, but ultimately won’t be able to.
Next was a women that presented to the ED because she was having some very clear acid reflux, but she also had almost every common chronic disease and a medication list that could have been the sole subject of an entire semester of pharmacy school. So the ED being full of the skittish little creatures they are admitted her for suspected heart attack. She was fine, and was going home today.
There were two gentleman in their late 80s that were equally pleasantly demented that needed placement in some kind of long term care facility as they were no longer safe to live at home and had been in the hospital for weeks waiting on beds. There was a pleasant woman with pneumonia that still required oxygen. Finally there was a rather cranky schizophrenic middle aged woman that was living in an assisted care facility when she fell and broke her hip. The medicine service was taking care of her because Orthopedic surgery was not comfortable managing her stable schizophrenia.
I wheeled the COW back to the resident workroom where we all gathered again. Our program is too small to have daily morning report like most big programs do, so instead we have something known as “interesting cases” where people smarter than us lowly family medicine residents come help us with tough cases we have. It’s actually always pretty helpful. Today we discussed my lady with colon cancer and where the cancer might be coming from and the workup that should possibly follow.
I want to poop, but there isn’t time. For the next hour and a half I round with my attending and we again roll the COW around the hospital going to each patients room. I give my presentation about each patient in the hallway and then we both go in and chat with them about what we are doing, and why while attempting to answer any questions. Most questions have nothing to do with the reason why they are there, they want to know when they can eat, have various complaints about the food, or want to complain about how the bed is hurting their back. It’s just me and my attending rounding which is unique for a residency program. In most major teaching hospitals a resident inpatient team rounds with a cloud of white coats consisting of at least six or seven bodies, another plus of being in a small program. We trudge slowly from room to room debating the merits of different treatment methods in the hallway while he quizzes “pimps” me on various medical guidelines. Ah, isn’t education great. I just want to poop!
It’s time to go to the resource management meeting that happens every day. The various hospital teams line up outside a small conference room and go in one by one. Inside are about a dozen “resource managers” they consist of case workers, physical therapists, hospice nurses, dieticians, and pharmacists. My attending and upper level residents never want to go, so I usually go in by myself. I sit at small table in the middle of the room and talk about each of my patients briefly and then I ask for their help with each patient. Maybe my lady with the broken hip needs more physical therapy. What is the status on placement with the two demented gentleman? Will the hospice nurse go meet with the family of the newly diagnosed cancer patient? At first I was intimidated and nervous by this room, as it feels a bit like a firing squad. But, now it is one of my favorite points in the day. Turns out part of me likes being the center of attention, and enjoy a room full of people that seem to laugh at most of my jokes.
We continue the slow drudge of rounding. Thankfully the ED hasn’t tried to admit any new patients yet, and I finally got to poop!
Rounds are finally over, I now have 8 notes to write and about 4 discharges to do. My attending however would rather we go back to the woman with the infected diabetic toe and pair down the granulation tissue off her ulcer so that it will heal better. Kneeling on the hard floor next to her bedside I start slowly scrapping away her thick toe with a scalpel. Most people would be nauseated by this, but it’s strangely making me hungry. I remember in med school we all used to get hungry in anatomy lab, the cadavers smothered in formaldehyde clearly were not appetizing, but the tissue sure did look like some good brisket. As I’m scraping her toe away she feels none of it. In the background the volume of her TV is turned way up and Fox news is going on about the violence at a Donald Trump opposition rally. She starts telling us her stance on Donald Trump, the ulcer is now juicy and well exposed ripe for the healing to begin.
Back in the resident work room I sit with the two other residents in silence as we peck away at our notes. Sometimes I feel that all I do is feed the EHR words like it’s some kind of sacrificial ritual I do all day everyday to keep the beast at bay. The phone rings and one of the residents answers, it’s a family member he has been trying to get ahold of. He talks at length about how the father isn’t doing well and eventually convinces the family member that the best thing to do is put him on comfort care hospice as he is dying. The other resident is on a different phone call discussing with DHS how she is worried one of her pediatric patients is being exposed to meth at home. Suddenly the lullaby tune plays overhead signaling a baby has been born. Nobody seems to take notice to these three conflicting streams of reality. The work continues.
The ED finally decides to wake up. We get three calls at once requesting admissions. I take one of them, a 70 year old male with a recent upper respiratory infection that kicked off his COPD and now he needs breathing treatments and oxygen. A fairly easy rubberstamp admission any other day, but of course he also has a med list a mile long for a slew of other unrelated conditions and his records are scattered across three different EHRs that requires time to hunt down.
Sliding into the finish line I finish my notes on time for sign out for what was otherwise a fairly easy day. We sit back down and the round resident table with the night team, and sign our patients back out to them for safe keeping overnight, I debate about taking a bite of the bagel of unknown age, but pass, maybe tomorrow..