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.

Scrubs

An interesting article in the New York Times sent to me by my mother-in-law:

In case it won't let you read it, here it is:

Should hospital scrubs be worn in public places?

That’s one of the questions asked by my Well column this week, which looks at the role clothing may play in the spread of germs by health workers. The issue of scrubs on the subway and other public places has been raised often by readers of the Well blog.

“I cringe every time I see a medical professional on the subway in their scrubs, which is a regular occurrence,” writes reader A.K.

“What drives me crazy is the sight of someone wearing scrubs while shopping for groceries, going to the post office, picking up their kids from day care, and so on,” writes Jenny, a nurse. “Someone wearing scrubs has been around germs all day. That person is too lazy to keep their patients’ problems away from you, and now they’re handling the apples and cereal boxes that you or someone you love may handle next.”

As my story explains, there’s no evidence that wearing soiled scrubs out of the hospital poses a threat to the public, but part of the problem is that the issue of physician attire and germs hasn’t been well studied. To read more, read the full Well column here, and then post your comments below.

I think the best part of the article are the comments below it from readers - not surprisingly, I agree and sympathize with the doctors. If you work in an operating room, or somewhere that requires clean clothes for the patients' sake (for example if they are all immunocompromised), even if you wear scrubs to work, you have to change into new clean scrubs at the hospital, which you take off before you leave. Otherwise, scrubs are no different from other clothes (for example a suit) that you wear to the hospital. It's really just a public perception that they are dirty - people wearing nice clothes touch the same patients, do the same procedures, go into the same areas of the hospital as people wearing scrubs. From my own perspective, if something happens to a patient and we have to do something emergent, or there's some blood spilled during a procedure, it is easier to clean scrubs than it is to clean a suit or a nice blouse, not to mention that scrubs are often much more comfortable and allow me to do procedures without restriction or care about my clothes. Although not relevant to the safety issue, I also agree with some of the other comments saying that many non-medical personnel wear scrubs too just because it's convenient, and these people often include janitors, technicians, medical students, researchers, etc. In the end, I guess what would be needed to settle this point is a study looking at people wearing scrubs in the public compared to other medical and non-medical people wearing regular clothes and seeing if there are any differences in "germs", and moreover, even if there were differences in amounts or types of germs, if this actually made any difference in terms of infection rates of people they came into contact with. I doubt anyone is willing to spend thousands of dollars to find something like this out.

Steps involved in medical care

I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.

A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).

At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).

Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).

After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).

Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.

As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.

The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.

LuBang! horah video

Well, it took long enough to upload, but here is the ever-anticipated Lubang horah video. I think the highlights are the parents.

God and medicine

I'm not particularly religious, but I know many patients and doctors are. Although I don't believe in the same thing they do, I feel that I have plenty of respect for their beliefs and don't usually have a problem with it. However, I have a small pet peeve about something I hear a lot of patients say. It's not a big deal, really it isn't, but I dislike it when there's a test or therapy patients don't want to take and they say "it's in God's hands." I completely respect patients' wishes (and sometimes agree with them) when they don't want to take something or do something - it's their right. However, I have a problem with them using God as an excuse. I'd rather them tell me they just don't want to do it, even if it's against all logic, than use what I call the God excuse.

For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.

But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.

Medical Time Suck

I cannot believe the time I spend doing non-medical things for my medical patients. Some of course are necessary, for example - speaking to patient's families. In a way, you can consider that part of a patient's health, especially if they partially or completely depend on their family for assistance at home or for their medical care. However, I would bet that the majority of my time is spent doing non-medical tasks. Let me give an example.

Today I had a patient who was admitted several days ago from a shelter for fainting and having chest pain. At first it sounds serious, but it turns out he probably is an alcoholic and "passed out" after drinking too much, and his chest pain looked clinically like a mild rotator cuff injury. Moreover, he had no idea what his medications were, which shelter he lived in, what kind of past medical history he had (cardiac or otherwise). For this patient, not only did I spend hours on his medical care, but I also spent hours calling 4 or 5 different shelters trying to find out where he lived and what medications he took. I called his health center many many times trying to get a hold of his doctor, and when I finally reached her, she didn't know anything about him. I spent time talking to the medical records department of another hospital, getting the patient's authorization for medical record release on paper, faxing it to the medical records department, and then waiting for them to fax me the studies he had when he was admitted there. Then finally, it took quite a while to get him discharged as we had to involve social work so that he could get sent to a shelter using a cab voucher and could get medical follow-up (which he probably will not do) with our cardiology department.

These are all very frustrating things, and unfortunately it's the poorest and neediest patients who often need all this extra attention. Sometimes they come in to the hospital partially to find a warm, dry place to sleep, a place to clean themselves, and 3 meals a day in addition to medical care. I think a lot of doctors and nurses often take a look at these patients and brush them off since they don't have a good medical reason to be in the hospital or sometimes are actively lying and trying to deceive us in order to stay in the hospital. However, I see it like this - if you spend the time on them now, then hopefully they will have good medical follow-up afterwards and won't get to a state where they have to be admitted to the hospital again, thereby decreasing the amount of our work. Of course, some patients are just hopeless - they're well known to the Emergency Department and the medical staff, and I guess that's just something we all have to accept.

Attitude

The longer I live, the more I realize the impact of attitude on life.

Attitude, to me, is more important than facts. It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do. It is more important than appearance, giftedness, or skill. It will make or break a company ... a church ... a home.

The remarkable thing is we have a choice every day regarding the attitude we will embrace for that day. We cannot change our past. We cannot change the fact that people will act in a certain way. We cannot change the inevitable.

The only thing we can do is play on the one string we have, and that is our attitude ... I am convinced that life is 10% what happens to me, and 90% how I react to it. And so it is with you ... we are in charge of our attitudes.

-- Charles Swindoll

This is what I need to think about when a patient complains to me for 15 minutes about how horrible the hospital system is and then refuses to let me examine him so that I can admit him to the hospital.