Winter in the Medical Unit

Wait....brace for it...I'm on call.

So I'm at State Hospital. On call for medicine. And it's like five degrees in here. I'm freezing. It's like winter or something.

It's been one of those days thusfar that's just sort of annoying in it's "hurry up and wait" -ness. Like, it's almost 1pm. I really have had nothing to do for the past couple of hours, because I've been waiting for my attending on call (Dr. Asshole. Great.) to come down and tell me what to do with this patient. I suspect? We will do nothing. Why? Because she needs nothing done. That would probably be the best thing for her. But we might give her some IV fluids, because her sodium's low. Except, she's totally asymptomatic, and I think she has too much volume on board. Does he remember that lecture he gave me about hypervolemic hyponatremia? Work with me, here, man.

I just called him to tell him her urine studies were normal, too. So guess what we're doing? We're giving her IV fluids. ::sigh::...fine....

It's like three hours later now. She's on her second liter of fluid. He says to me, "she has a history of heart failure and absolutely no edema (swelling of her legs). She must be dry." Um, well, okay. Didn't know not being in heart failure was a criterion for diagnosing dehydration, but, after all, he is a cardiologist.

So, yesterday was awful. I swear to God, I'm going to break someone's neck on that service. Soon. Something has got to give. I was there until 7:45 last night. And then I came home and worked via remote until right before I made that last post. We had a rough day...I don't even know where to start. My senior resident (let's call her Betsy) is...something else. She's a total drama queen. Everything's a catastrophe. Which feeds off my attending, whom I like very much but is currently stressed out and very high strung. Mike was not tolerating the pressure very well and looked like he was about to crack more than once. I, of course, responded to all of this by being all soothing and cooing and trying to maintain an air of overriding composure.

Except for the brief moment of Tourette's I had alone in the elevator, and the three seconds of foot-stomping and screaming "I swear to God I'm going to break someone's neck on that service!" while waiting with Fang and two of the second year residents (honestly? Whom I've met before and I like them both very much, and I don't even come close to remembering what the hell their names are) for the interviewees to show up for lunch.

Problem is, that isn't much of a relief valve, and I was under a LOT of stress yesterday.

Mike was on call, with one of the seniors whom I don't especially care for. Family call is rough. Any call is rough when you're on with difficult people. And my attending kept piling work onto us yesterday. And Betsy is really not helpful (in fact, I think she just compounds our work). She decides that I can't go to the recruitment lunch because she's got to go to clinic. Nope, sorry, I have a responsibility to my own department, here. My attendings had already given me the nod. And she freaks out, because, it's her first day, and we have to communicate or the service will fall apart, and, and, and. I'm sensing a real need for maintaining my boundaries around her, so I offer to come back early, but am very firm about going to this thing. And I leave, and she - literally - comes running down the hall after me and says that they changed her clinic time and she has to be there in 15 minutes and I can't go. So I said, okay, let's run the list. I offer her alternatives (do you want to page me when you're done?). She continues to freak out. Okay. So we run the list and I finally escape and extricate myself from her grasp and I try to put on a "I love my job (just not today)" attitude for the prospectives, and I get paged in the middle of lunch by my attending, who says, "You've got to call your patient's daughter, she's crazy."

Great.

So I excuse myself and go back and call the daughter - who is, in fact, crazy. But I think the crazy was inflamed by her interaction with my attending. So I soothe her. And calm her down. And convince her that it is indeed okay that we're discharging her mother that afternoon to a local rehab facility. And I've barely finished signing the note about this conversation when she calls me back, having a fit about some misinformation that the social worker gave her. Calm, calm, soothe, soothe, shhhhhh. And then I go talk to the patient. And then it's 4pm and I sit down with my attending again and still have way too much work to do and she gives me more and then Mike, who looks like he's about to pop an aneurysm, comes in and points out that Mr. C upstairs isn't breathing very well. So the attending says, "give him some lasix." Mike leaves, and then she looks at me and says, go with him. In essence, take care of him. Which, okay. I have more experience than Mike, I did a month of ICU back in the day, I can handle this. He, on the other hand, looks really upset. So I follow him upstairs and say, "what can I do?"

In the course of the next three hours I bounced between Mr. C, a guy we were cross covering in the stepdown unit with the DTs, and my attending. Periodically getting interrupted by the senior on call who's like, why are you still here? My attending alternates between giving me more work, wondering why I'm doing Mike's on-call cross cover stuff (because it needed to be done and he had way too much to do, that's why. She thought that was an acceptable answer), and needing reassurance that Mike's doing okay and that I'm okay with helping him out and not just going out to him and badmouthing her. Soothe, calm, soothe.

Mr. DTs guy was a touchy thing to handle, and of course I also had to soothe his very nice wife. So then I went back upstairs because the nurses said they couldn't draw the STAT labs on Mr. C. Who was crumping fast, and had actually been discharged earlier in the day but hadn't yet made it out of the hospital before things started going south. So I soothed his wife for a bit, called and harassed the respiratory therapist to come help me out with this guy's breathing, and then proceeded to try and draw the blood myself. Which, let me tell you, my skill with a butterfly needle could usually make Dracula jealous. Usually I can open up a vein without so much as a second thought.

I stuck him five or six times. Blew two veins and came up bone dry the other times. Fuck. So the RT took pity on me, I think because he thought I was cute (what is it with me and RTs?), and was like, I'll get the blood. And these guys do arterial draws all day long, which are harder then venous draws. HE couldn't get blood from this guy. So I paged the IV team and assured his wife he was doing fine, that we just couldn't get the blood, and he was much better on the breathing machine, and abandoned ship to go downstairs and tie up my loose ends because I wanted to go home, where I should've been hours ago.

I woke up at three am and heard my pager beeping downstairs. It had three 911 pages on it from radiology, from midnight or one-ish, so I called them back. They were like, oh, Mr. C was down here for a head CT and we thought he was on his way out so we called you, because you ordered it. But we got a hold of who we needed. I apologized for not having heard my pager go off in the first place, and they thanked me profusely for calling back at all. And I went back to bed.

The guy died last night.

He told me he was dying. As in, let me die. I'm dying, just let me die. I shushed him and held his hand and told him he was okay, he just needed to take slow deep breaths. And we knew the guy was on his way out, just, not quite yesterday.

You know, it's funny. As soon as I checked the electronic medical record this morning to see how he had done overnight and discovered this fact, I sent Mike an email saying, "are you okay? It always sucks when this happens on your watch." I understand. I was the angel of death during that aforementioned ICU month (because I was "so good with the families", so my team would leave withdrawals of care for my night on call. It seemed like every third night for the entire month of November, 2004, I was killing someone with their family's blessing). But I didn't realize until right this moment how much it upset me.

He was a nice old man. I held his hand. He'd been in the hospital since December 14th. He's been more or less Mike's patient all through WARS. I hadn't even met him before yesterday evening. And all day today I've been going back and forth about feeling like I should've done something different. Like I should've prepared his wife better. I wasn't even on call, I didn't really even need to be there. Both Mike and my attending were in house after I left. He was DNR and going to die shortly, regardless. I still feel like I should've done something else. Something different. Like in my full day of soothing and comforting and stroking and ameliorating, I failed to smooth out the biggest wrinkle of them all.

No, not logically. But if I were driven by logic, I would've let everyone be upset and stay ruffled and put out their own damn fires yesterday. And I probably would've left at 5 and been home to let my dog out and not have called my poor mother on the way home and sobbed for 40 minutes while unleashing all my pent-up angst onto her and my poor father.

I have a story I was going to tell about one of the first patients I withdrew support on back at the Emerald Palace. But this post has already gone on too long, so I'll save it for tomorrow. Maybe I'll even have a little more commentary on this, esoterically. But right now I'm going to go be upset and knit a little and hide for a few minutes, if the pager is willing.

Thanks for listening this long, though. It soothed me.