Night Coverage

Clearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.

Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.

It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes can be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes can be made (again, not that they are common). This would be an argument for the second system.

In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.

Night Float

What can I say - I've been on it this month and it sucks. Let me count all the reasons why:

1. You're taking care of 12 interns (plus or minus some medical students) worth of patients at night, which is up to 120 patients. All the little (and big) crap that interns normally get called about during the day gets funneled through to night float. Depending on the intern, sometimes they don't do a very good job of taking care of issues before they leave for the day, so then you have to deal with it at night.

2. You're exhausted. At Pennsylvania Hospital, we work from about 5pm until 7:30am for an average of 3.5 days a week. If you say that's about 15 hours a day, that averages 52 hours a week, which isn't bad, but the timing is horrible. Usually we work 3-4 days in a row. For those days, I usually get home around 8 or 8:30am, shower, maybe get something to eat. I finally get to sleep around 9 or 9:30am, and then get some bad sleep before getting up at 4pm again to go to work - even if I sleep the whole time (usually I waken quite a few times, sometimes for more food), that's barely 7 hours of sleep, and it's never good sleep.

3. You feel very isolated and you never seen anyone. You're completely time-shifted and if you live or have a significant other, you often leave for work before they get home, and you often get home after they've already left for work. So if you work a number days in a row, you might not see them for quite a while. Moreover, you work during the nights half the time, and the other half the time, you're exhausted or recovering from working multiple days in a row, so you never see your friends since they all get together during the evenings. You don't even see your colleagues much - you see most of them for signout when you get there and before you leave. You really only see a couple of people throughout the night, many of whom are also busy. So you spend much of the time alone - it's very isolating.

4. Nighttime is generally a bad time for patients - for whatever reason, if patients start to deteriorate, they often do it at night, so you deal with a lot more critical issues and patients whose hearts may stop beating or who stop breathing. There are many fewer doctors and nurses around at night, so you have less help and have to make many more crucial decisions on your own, which can be daunting at times.

5. The food is horrible. I basically eat cafeteria food around the clock when I'm working, so I usually get cafeteria food only for 3 or 4 days in a row. It's horrible. Although one saving grace is the pancakes on the weekends. Sometimes residents will order out, but unless they take care of it, I often don't have time. Plus that costs a lot of money, so I don't want to do that too often.

One more week to go.

Drug Dinners

In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."

I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.

The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.

On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.

I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.

All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...

A lesson well-learned

The call system for Pennsylvania Hospital is a little different from other hospitals. I won't go into it now, but suffice it to say there are three types of calls - short call, medium call, and long call. Over the last 3 weeks, on medium call, I've generally been able to get out at 6 or 6:30. So I thought yesterday would be no different. In fact, we had already bought tickets to go to a large music festival with the rest of our friends. The plan was for me to get out, Pete would pick me up, and we would go directly there to join everyone around 6:30 or 7. It was a pretty crazy day and I picked up the max number of patients I could possibly pick up (which has been the case for the last 6 calls I've been on), and there were some complications with other patients. I didn't get out of the hospital until close to 8:30pm, at which point, not only was I exhausted, but I hadn't eaten, and we would only get to enjoy about an hour of the music festival by the time we got there. So I just went home.

The moral of the story? Don't buy tickets, especially expensive ones, ahead of time unless you are sure that you will get out in time.

First Call - to Code or not to Code?

I had my first overnight call as an intern. It wasn't too bad. Pennsylvania Hospital is actually pretty nice to their interns. Typically, interns stop admitting around 1 or 2 am if they're on overnight call. Which means they probably get 3 or 4 hours of sleep, which is great! Of course, I spent about 2 hours with my resident doing a paracentesis (sticking a big needle in somebody's abdomen - you usually do it when fluid is building up abnormally in a patient's abdomen, making it all poofy. Yes that's a medical term. Poofy.) and trying to get IV access and blood drawn from a very difficult patient. So I didn't even start admitting until around midnight, and I felt bad, so I ended up doing 4 admissions, which lasted until about 4:30am. Plus there was a code - which is the thing I actually want to talk about that happened that night. I ended up getting only about an hour of sleep.

So the code was interesting - a resident and I are doing admissions in the ED, and suddenly a code call goes out across the hospital-wide PA system. "CRT... CRT... " and it told us the location. Apparently that means somebody was going through cardiac arrest. I found out later that this patient had been doing fine after his surgery and was being monitored by telemetry. That's where they attached a lot of electrodes to a patient's chest, it monitors their heart, and somebody in a centralized location watches a lot of monitors 24-7 to make sure all those hearts are working properly. This person noticed that at 1am, this patient's heart suddenly stopped working for some unknown reason and called the code. When my resident and I got in there, there were 4-5 people already there working on the patient and giving CPR. It turns out giving CPR (which at its most basic is simply chest compressions and giving breaths) is the most important thing in bringing someone back from the dead and giving them the best chance of survival afterwards. Somebody had already gotten IV access, and he was being pumped full of fluids, they were attaching a monitor to his chest. His heart was in ventricular fibrillation, which is a type of arrhythmia, that if left untreated, usually leads to death. They shocked him, and he immediately went into PEA, or pulseless electrical activity, which means the electrodes were sensing electrical activity by the heart, but it wasn't actually pumping, and the patient was pulseless. At this point, shocking doesn't help anymore, and you basically continue CPR and start giving all these different types of medications meant to jump-start your heart.

The rule of thumb is that you don't continue to code a person past 10 or 15 minutes because (1) the chance of survival is way too low after that period of time and (2) even if you bring them back to life, they've been "dead" for too long, and their functionality is horrible. There's a good chance they'll code and die again before they leave the hospital. However, in reality, codes often go on for 20-40 minutes, especially in patients where it is unexpected. Time goes super fast in a code, and people are reluctant to give up. This code had gone on for about 17 minutes... people were starting to give up, they'd loss IV access (I actually managed to put a new one in on the foot that lasted about 2 seconds). And then all of a sudden, someone says "I've got a pulse." Crazy. This guy was dead for 17-18 minutes, and then all of a sudden his heart starts working again. And the monitor shows that his rhythm, although not idea, is a workable rhythm, and he's "alive" again, and somewhat stable. All this activity starts up again and he eventually gets intubated (a breathing tube shoved down his throat) and transferred to the ICU. I don't know what happened to him after that - I guess if you follow statistics, there was a good chance he coded again and died.

Afterwards, I finally found out the rest of his story. This patient has esophageal cancer, one of the worst cancers to have. The treatment is surgery - they take out your whole esophagus, which is an extremely hard surgery to live through. Then afterwards, many patients have to go through chemotherapy and radiation, which is definitely no joke either. And after all of that, there's a good chance of it coming back anyways! So even if this patient lived and was stabilized, first of all, he would probably have little to no brain function since he got very little oxygen to his brain for 17 minutes. He'd be a zombie, on life support, for the rest of his life. Even if a miracle happened and he woke up, he'd die of his esophageal cancer pretty soon, or have to go through chemotherapy or radiation, which might kill him too.

So my question is... should he really have been coded? If I were the patient, I would not have wanted that. But not many people think of these things when they're going in for surgery anymore. In many countries, they trust the doctors to make these decisions, but in this country, and in the era of litigation, that's just not possible. Because of this, we waste millions of dollars on codes and life support and everything else. But more importantly, it leads to horrible situations that families have to deal with.

The first day of internship

Today was my first day of internship at Pennsylvania Hospital! There were a few hitches - we didn't have our own long white coats (the universal symbol of being a doctor), so we had to borrow other people's. Not a big deal - we put tape over their names, which are stitched over the pocket. A few of us also didn't have our logins or passwords to one of the main computer programs used in the hospital. Without it, we couldn't enter electronic orders, or really check labs on patients. It took a couple hours to sort it out, so that definitely ate into our working time. Also, I still don't have my email account. Oh well - hopefully nothing crucial was sent to us! All this was a little annoying, because you would think these things would all be taken care of weeks ahead of time, since we found out we were going there in May. But it's not a big deal.

Despite it being the first day, I think it went relatively well! I had 7 patients to start, and 3 of them were discharged. My resident helped me out, as well as the other intern on the team quite a bit since we didn't know these patients at all. We were also lucky - my co-intern (Christina) and I both know the programs and the system relatively well, so we were able to do things much more efficiently (I imagine) than some of the other new interns. Some of the newbies definitely had frazzled looks on their faces. :)

Tomorrow will be much harder for us - we're on call. Christina has to stay until 10pm, and I am staying overnight until the next day at 1pm, and we are taking patients during most of that time. That means not only will we be busy with the patients we already have, but we will also be admitting patients from the ER, which takes on average 1 - 1.5 hours per patient. We can each take up to 5 new patients, in addition to the ones we already have. It's gonna be interesting!

The beginning of intern year

Yesterday marked the beginning of my intern year at Pennsylvania Hospital. I haven't done anything clinical really since September when I was in Botswana. I guess I took a radiology elective, but really, I didn't work too hard. I had to get up at 6am! I know, it's a tough life. I'm hoping to be able to blog about life as an intern throughout this year with some stories and insights into hospital life, but this being intern year, we'll see how much time I have for that.

For these first two days we have ACLS training. That is, Advanced Cardiac Life Support. We learn to run codes, which are when somebody suddenly dies, and you go through the appropriate steps to try to resuscitate them. Have you ever seen an emergency situation on a show like ER? And they yell out orders and give medications, and maybe eventually shock a patient with electric paddes? It's like that. Exactly.

It's actually pretty complicated. Depending what's wrong with the patient, you have to give different medications, treat them differently, order different labs. CONTRARY to what you do see on ER, you don't shock every patient and not every patient gets epi (epinephrine, also known as pure ol' adrenaline). And everything is happening pretty fast - the patient is getting bagged or intubated (getting a breathing tube shoved down their throat), they're getting put on the monitor, somebody is inserting an IV or two into the patient, someone else is drawing labs, someone is giving medications, someone is giving CPR and doing chest compressions, someone is monitoring their heart rate, blood pressure, and a few other things. Not to mention all the bystanders there either just looking on, or trying to be available to help. So there are probably 10-20 people crammed into this small room with the leader yelling out instructions, and sometimes it can be pretty difficult under pressure to remember all the things you have to do, and to communicate effectively with all the people.

That's what all the new interns got certified in today. This is certainly not an unknown issue, but it's a little scary to think of new interns practicing a medicine, much less running a code. I don't think we would be bad, but almost certainly slower. But interns have a huge learning curve. I think by the second week, people are usually up and running, and while the knowledge base is still building, interns can get things done pretty effectively.

I think I would feel relatively confident running a code. Maybe not perfect, but ok, and I'm sure that will improve. I think many of the interns were a little worried or scared about running a code. Thankfully, usually it is a senior resident (a 2nd or 3rd year resident) who runs a code. The interns usually just help out, and when they have enough experience, then they run the code. I know this is a horrible thing to say - I guess that's why I'm in medicine - but I'm a little excited to take part in my first code! Look at it like this - I don't want anybody to die, I just want to help bring someone back to life! :)