Showing posts with label on call. Show all posts
Showing posts with label on call. Show all posts

Saturday, January 6, 2018

To OB or not to OB...that is the question

Career advice wanted

I’m having a mid-residency crisis. I’m halfway into my three year family medicine residency, which means in a year and half there will be much more independence but also much less of a safety net below me.   I want to practice in primary care - so I know that it won’t be hard to find a job, however will be much more difficult to find the right one. I’d like to continue doing underserved medicine of some variety - but not sure if that means staying in the city as I am now or moving to a rural area, possibly closer to family now that Baby is here. I’m currently ruminating on whether I’d like to continue practicing OB or not.

It was a surprise to me how much I liked practicing OB as a resident. I liked it as a med student enough (although I will forever hate ORs - I’m too clumsy with too little body spatial awareness) but doing deliveries of my own clinic patients has been so rewarding and energizing. When I find that precious time to devote to independent learning, I find myself reading OB literature (and staying awake through it) more than any other kind.

Today was the first call for a delivery I’ve had since our own Baby was born. As timing goes, it was perfect for me. I was called at 6 am, ran to the hospital, and was back after a beautiful delivery by 9 am. It was great for me - but maybe not so much for Husband. When I left at 6, Baby was just starting to wake up and Husband had stayed up late working the night before, was already awake and was very much looking forward to a morning nap. He didn’t say anything negative, but his expression was less than pleased.

...and this is a best case scenario when I got called in. Our residents are continuously on call for our own patients with lots of back up as with residency schedule we may be working nights or a hospital shift elsewhere that we may not be able to leave. My husband didn’t realize it was a possibility that I would be going in today, but the reality is it’s pretty much always a possibility as I’m usually within 2 weeks of a patient’s due date and babies don’t always come on schedule. And I think as an attending, I’ll likely be much more responsible for my own patients’ deliveries - although having adequate back up is something I am definitely evaluating as part of my future job.

So my question is... can we do this? Or more accurately, will it be worth the effort to do this? We don’t have family close. We don’t really have an emergency contact nearby who can watch Baby if plans change quick. I think I can handle the lack of sleep and unpredictable hours, but is it fair to ask my family to do the same? What about when we want to leave town and spend time with our family? Husband and I have had several conversations and will continue to do so over the next 6 months as my patients continue to deliver and we’ll see how it goes.

 I just really wanted the advice of some moms who have been practicing outside of residency for awhile. Spoiler alert: this likely won’t be my last post asking for career advice. Are you doing what you want in your careers despite a somewhat demanding call schedule? Or did you find that giving up a bit of call was worth it for a little more overall family stability?

Saturday, April 9, 2016

Being On Call

When I was a kid, my dad was on call all the time. I am not exaggerating. He was in practice with my grandfather (his father-in-law.) Nat (my Popop) had been in solo practice for years and so when Dad joined him, Dad took over call. Nat was always willing to cover if my parents had plans; mostly Dad was just - on call. 24 hours a day. Seven days a week. My mother finally forced him to take an actual vacation after eight years.

Now, Dad would be the first person to remind me that this was in the 1960s. No ICU. No CCU. No tPA. No push to get patients out of the hospital - people with uncomplicated MIs (if they survived) stayed inpatient for at least ten days. You could admit people for evaluation of new diabetes. No urgent calls on abnormal labs in the  middle of the night. And he genuinely loved his work and his patients, and he didn't need all that much sleep, and of course he had no responsibilities at home because my mother did everything. But still - on call EVERY SINGLE NIGHT. I can't even imagine it.

I'm thinking about it now because last night was One Of Those Nights. I was exhausted after a long and difficult week and I went to bed at 10:00 PM. The beeper went off at 11:00 PM, 1:00 AM, 2:30 AM, 4;00 AM and 5:30 AM. The 5:30 call was from the ED about a patient who needed urgent admission to the inpatient hospice unit, which meant three more phone calls, so I had to get out of bed. I tried to go back to sleep - and then my daughter's alarm went off at 6:10. She's away for the weekend. She didn't turn her alarm off before she went.

I think I'm too old for this. And then I think of Dad and feel like a wimp. And then I remember that he was 20 years younger than I am now, so perhaps I should let myself off the hook.

Am I the only one who has grown to loathe being on call overnight?

Sunday, February 28, 2016

That One Time When You Unknowingly Insulted Me

It was normal Wednesday and I was staring absentmindedly at the surgery white board. I searched its unending list of procedures and "ectomies" that stretched the entire length of the wall, until I was finally able to locate my string of minor surgeries. Lost deep in thought, I wondered if there was any feasible way the labor gods would be kind to me. What were the odds my labor patient would deliver while I was scrubbed in one of my many hysteroscopies? As I came to the conclusion that once again my day was hopelessly overbooked, I sighed only to feel a hand on my back.

Turning around I saw the familiar friendly face of a charge nurse. She looked concerned.

"Dr. RH+, poor thing, were you on call last night?" she asked.

"Actually, no. I slept all night." I chirped.

"Oh....." she said as we stared at each other, slowly realizing that she had just accused me of looking like total crap.

When the awkward silence became too much to bear, I faked a page and make a dash for the locker room, where I stat ordered eye cream from one of the 200 people on my Facebook feed who try to sell me overpriced fancy products endorsed by celebrity dermatologist. Maybe I can be the next before and after picture on their web site.

Asking a doctor if they are post call is like asking a woman if she's pregnant: Just don't do it, unless you already know the answer, then think twice. The "post call" look for me often means no sleep, no shower, puffy eyes and hair style that can only be described as "Beetlejuice"-esque.

Time, stress and life itself have had their naughty way with my appearance. My running addiction is great for my legs, but my crows feet have deepened without the extra layer of fat to cushion them.

While I can't remember the last time a patient asked if I was "really old enough" to be a doctor, I also haven't had anyone question my abilities in an equally long time. At 40, I am enjoying the comfort of my own skin. My patients confidence and my colleagues respect are far more important to me than a few fine lines. I look socially acceptable most of the time (at least I hope so). I wouldn't consider trading the peace and maturity of age for a baby smooth face, but also still it's not nice to tell me I look like a tired old bag either.

Wednesday, February 10, 2016

Vomit, Poop, Snow, and Chlorine: A Week In Review*

Genmedmom here, venting.

It's just been one of those weeks. There was no one particular event. We're fine, we're (mostly) healthy, we're happy.

But, it was just one of those weeks.

I was on call for our practice last weekend. Now, our weekend calls are not that bad. We do not round on inpatients at our hospital anymore; the hospitalists care for our patients. There were not that many pages.

But, the pages came at odd hours, and in bunches. Sleep was totally disrupted. There were stressful moments. Then, we have a brand-new, very complex electronic medical record to content with. I struggled with ordering prescriptions and documenting… Again, nothing big, just, annoying.

Then, Sunday afternoon, Hubby started having nausea, and chills, and muscle aches. Ruh-roh!

Yup, we were in for it. One by one, we were felled by the GI bug. Hubby had a mild version Sunday. Minimal active GI symptoms, but, down for the count. Overnight Sunday, Babyboy started spewing. I was on bucket duty. God love him, he never missed the bucket.

Monday, Tuesday, Wednesday, all clear. Long days at work: twelve-plus hour days, mostly immersed in this new computer system. But, no one was sick at home. We all breathed a sigh of relief.

Then. Thursday evening, I started feeling a little queasy. I vasovagaled in the kitchen, caught myself. I went to bed early, wracked with nausea, chills, body aches. I considered calling in sick for Friday. But, I wasn't actively spewing, I just felt like crap.

I debated: There was going to be a snow storm. Going to work in a snowstorm is bad enough, but feeling ill, would be even worse. On the other hand, calling in sick meant I would have to contact the few early morning patients myself, to cancel. But, these patients may be canceling anyways, given the snowstorm... I just couldn't decide, couldn't even deal. It was easier to just suck it up.

Friday morning, 5:30 a.m. I shivered into the shower, bundled up in wool, and headed down. I brewed the coffee, but I couldn't stomach it.

It was just starting to snow. The driving wasn't bad. I drive to the train, and take the train into the city. For the first time since pregnancy, I had to sit down on the train.

Now, I hate when healthy, able-bodied, lazy-ass people take up seats that others may legitimately need. I felt ashamed for sitting, but at the same time, I didn't think anyone would want me passing out onto them, either.

At work, I had plain Earl Grey tea to ward off a caffeine- withdrawal headache. The snow came down. Most patients cancelled. My stomach actually settled. I felt better as the day wore on.

Friday night at home: After I picked up the kids from Nana's house, where they had spent their snow day largely outside, they helped me help shovel out our neighbor. It was after dark, and cold, but they couldn't get enough snow. I was just relieved to be off-call and feeling normal. Whew! I'll get some better sleep tonight, for sure! I thought.

Then Babygirl vomited on the couch.

Babygirl vomited multiple times. Despite strategically placed buckets and towels, we had to change her bed out entirely, twice. She stopped vomiting abruptly at about 11 p.m. and declared that she'd like a glass of water, please. She downed it, and another, and was fine the rest of the night.

Saturday morning, this morning, we were supposed to have a behavior therapy group session with a new family. Babyboy is mildly autistic, and needs help interpreting and managing a lot of social situations. We were supposed to bring Babygirl, too.

We debated. She'd been spewing the night before, but had awoken bright and cheerful. She had wanted warm milk. She drank it, and it stayed down. She was playing, she was smiling.

We decided to take her.

Bad call.

Ten minutes into the session (at another family's house, people we had never met before) she vomited. She managed to warn us, and we managed to get her to their bathroom, but it all ended up on the floor. I cleaned it all up, on my hands and knees, apologizing right and left.

Then, right afterwards, Babyboy had a poop accident. He's five and a half years old. We've been working on toilet training for over two years now. We'd just had a week and a half without a poop accident, our longest stretch ever. We thought maybe, just maybe, he's toilet trained!

Nope. Hubby took care of this mess, in the same bathroom. The family was so kind and understanding, but still. We were so embarrassed. You could smell it for the rest of the session: rancid milk vomitus, foul stool reek.

The kids were supposed to have their first swimming lesson today, as well. It was out of the question for Babygirl. I envisioned her vomiting in the YMCA pool… Good God. No way. Hubby took her home to watch endless Peep and the Big Wide World, all wrapped up in her pink blankie on the couch.

I took Babyboy to the Y. It was his first swimming lesson ever. I was nervous. He was nervous.

It didn't start off well. We walked into the locker room labeled "Family Locker Room". It was packed and bustling with half-dressed men and kids of all ages and moms with babies and SO MUCH NOISE in such a small space… There were changing booths with curtains on them, but I could not remotely imagine getting myself undressed and into my bathing suit, separated from the men and young boys by a flimsy curtain.

But Babyboy made the decision first: "Mommy it's too noisy in here, please let's GO…" He had his hands over his ears like they hurt, overstimulated to a painful degree.

So I took him into the women's locker room with me. We had already changed into our bathing suits when the YMCA police (or whoever she was) came in and informed me that children under eighteen years of age aren't allowed into the women's locker room. At all. Ever. And we had to leave. Now.

The lady was very stern, and Babyboy started to cry. He thought he was being scolded.

"Listen", I pleaded. "I just don't feel comfortable in that Family locker room with all those men and boys around, you know?"

The lady relented. "Well, you can use the Girl's locker room, if you like. Technically, it is for girls, but, he's pretty little…."

And so we did. Apparently, there were no girls of an age that would use the Girl's locker room around, because it was completely empty. We relocated, stuffed our winter gear into a too-small locker and entered the pool area.

Whoa! The pool was super-steamy and the chlorine odor was almost overpowering. I wasn't sure if Babyboy would be able to stand it, but he did. Other than the fact that he slipped and fell on the tiles, requiring a helpful lifeguard to get him an ice pack for his head, Babyboy enjoyed his first swim lesson, such as it was. He wouldn't get in the water without me (I had anticipated this) and there were several other special-needs kids, plus, it's the Y, so of course it was a little scattered and chaotic. But, it was fun, and he was more comfortable in the water at the end then he had been at the beginning.

Back at home, we all laid low the rest of the day. We drew, we read, we watched Peep.

Now, we sleep. I hope…

*This post was written Saturday evening. Sunday morning, our longtime pet cat passed away unexpectedly. The kids were brokenhearted. We were brokenhearted. Obviously, that event overshadowed all of the crap I've complained about here. I decided to let this post stand, however, because it's how I felt at the time. I wrote about our kitty on my own blog: The Biggest Pain In The Ass Cat You Ever Could Love: We'll Miss You, Raffy

Tuesday, May 26, 2015

My Life as a Call Girl

I spend 1/4 of my life on call. With 10 years of private practice in OB/GYN under my belt that's 2.5 years that I've been tied to my phone. Some nights I sleep peacefully through the night, but more often than not, I get to trek in at 3 am to catch a baby or two. Over the years, I've come up with my own set of on call rules to help navigate the chaos that can be a call night.


Don't dread it. Obviously, I don't wake up on my call day with a spring in my step, open the windows and shout for joy for all to hear "Yeah, I get to be on call today!" But I don't dread it either. I've learned to deal with it and enjoy it the best I can. If I didn't make peace with being on call then, I end up wishing away a quarter of my life.

Don't complain about it. When I chose OB/GYN I chose a crazy, sleep deprived life. Sometimes when I'm working postcall I will "explain" to people why I look hot mess of disheveled craziness (ie I delivered 17 babies last night). I try to keep it in a upbeat joking tone and not a "Woe is me! I work all the time" tone. We all know those providers who claim that every single call is the"Worst call ever" and that is simply annoying.

Don't indulge in the 3 am donuts. When you are up all night, the 3 am donuts can look so very tempting. Sometimes I delude myself into thinking "I deserve a treat" for having to work all night, however my 40 year old metabolism does not agree and I regret it later. I always keep healthier snacks like almonds and trail mix with me for just such emergencies.

Don't schedule appointments. After getting called in half way through a haircut once, I learned this lesson the hard way.

Don't socialize. If my leaving the event will be awkward, I won't schedule it when I'm on call; like dinner with just one other couple. If it's a bigger group of friends, I will sometimes try to go if I can. Also having people over is definitely out as well. Having to rush out half way through cooking dinner is not a great plan.


Do live your life. I can't put my life on hold completely when I'm on call. I still go to soccer games and church, I just drive separately in case I get called in. I still exercise, I just make sure when I'm running I have my phone on me and am always less than 10 min from my house. Sure this means that occasionally I have to race into the hospital all sweaty and get amniotic fluid on my Lulu tights but there are enough excuses not to exercise and I won't let call be one of them.

Do keep some entertainment close by. A lot of call can be "hurry up and wait." I often spend time waiting for an OR to open up or waiting for patient to deliver. I use this time for catch up charting and CME and reading.  This is actually my one bit of call superstition: I always keep a novel with me in hopes I won't need it.

Do Bathe. My biggest pet peeve is getting called to the hospital stat when I'm in the middle of a shower. Yes, the ruptured ectopic pregnancy is far more important than me having a bad hair day, but still it's annoying. I wish I could get away with not bathing on call but that would not be socially acceptable. Instead, I keep extra toiletries handy to throw in bag a the last minute as needed to get ready at the hospital.

Do know your limits. I am human. Occasionally, I need to ask for help. If a call is particularly awful I will get one my NPs to field phone calls. There are times I've cancelled part of my afternoon postcall to go home and rest. So no, I don't complain about every single call, but when I'm dangerously tired I listen to my body and rest.

So there are my call survival tips. I'd love to hear from the other MIMs on how they maintain sanity while juggling their pagers.

Saturday, September 20, 2014

Birthday Call: from zero to 60 and then somewhere in the middle in mere hours

40 minutes into my commute to work, I had a pseudo-melt down. As I sang “Happy Birthday” over the phone to my three-year-old, I lost it. I realized that I hadn’t kissed him on his birthday, I’d forgotten my lunch and during a 28 hour call the cafeteria food begins to make me nauseous, and that I was exceedingly anxious about all of the changes our lives will encounter over the next few months.

Needless to say, I’m in the call room after a deluge of discharges, awaiting our next transfer, feeling the urge to write and release this tension.

My Little Zo is three today. Three years ago, on this day, I birthed a fabulous little human being into the world. He’s helped me grow in countless ways. I’ve learned to let go. I’ve learned to give my all in the moment and then pass things off to someone else (to hubby O, to my parents/in-laws, to the wonderful ladies at daycare, to his Pediatrician). I’ve learned that keeping your own kid alive and occupied means breaking lots of rules (my infant slept on his belly after weeks of sleepless nights, my 2 year old ate yogurt and spinach smoothies or oatmeal for dinner on picky-eating nights) and that I am so much more capable than I ever thought imaginable. I’ve realized what’s important (playing legos and dinosaurs before bedtime and leaving my notes until he’s gone to bed, sleep, couple time, giving my all at work and not worrying about my child since he’s taken care of at all times).

In less than a year, I’ll be an Attending and yet another goal will have been achieved. I have had a few successful telephone interviews and I have my first in-person interview in October with a community health system affiliated with my medical school. This morning when I was sobbing, a great friend, KJ, who is now a Pediatrician in private practice gave me her pep-talk. We have these at least once every few months. She tells me about all of the little and big victories she has in her life after residency. She has weekends off and time to be with her boyfriend and her dog. She tells me about her quirky colleagues and her amazing patients. She tells me how different things will be in a few short months.

So, on Little Zo’s third birthday, I went from zero (dragging myself out of bed after an exhausting month on inpatient service during asthma season), to 60 (sobbing in the Starbucks parking lot), to somewhere in the middle. I am thankful for three years of motherhood. Thankful that Zo is vibrant, healthy, active, super-smart, and super-sweet (when he’s not biting or hitting). Thankful for only 3 more days on inpatient service before 2 months of elective and that I've been able to do great work this month and keep folks' babies alive and healthy! Thankful for friends like KJ who understand the struggles of residency-based medical practice. Sad that I wasn’t at home snuggling Zo and our visiting family members. And hopeful of life after residency.

Happy birthday to my little roaring dinosaur - Mommy loves you!

Wednesday, May 7, 2014

Mommy Call

After my six-week maternity leave was over, I showed up to work after having been up all night because my Doll must have felt the change coming--she didn't sleep a wink!  And I was up with her, trying to soothe her back to sleep.

I was quite embittered (is that  word?) that I was scheduled for a 24 hour overnight in-house call just 4 days later, as I thought there was an agreement that I would not be on call for at least a month after returning.  That night on call was a particularly slow night, and I was called by the nurses only about twice.  One of the calls required me to handle a situation on the floors, and as I was writing my evaluation note, one of the nurses said to me, "it's nice to get some sleep while you're here, huh?"

No, it's not.  I would have rather been up every night all night with my Doll than sleep all at work.  That's how I felt then, and that's how I feel now, 9 months later.

It is finally May.  I see the light at the end of this very long tunnel!  Two more months until what seems now to be the golden year of residency.

Monday, March 31, 2014

Keeping it moving on an overnight call

5 admissions, 4 discharges, PICU transfer. That sums up my night.

I could dwell on the negatives (exhaustion, cold under-heated hallways with headache-inducing fluorescent lights) or I can focus on the positives.

The positives. We managed the craziness with style and grace. No one died. Though one Nurse did come down with something and ended up in the Emergency Department. We (Interns and I) learned many things about patient care and prioritizing. I learned that even though my eyes are burning and my reaction time has slowed down considerably, I know enough to keep patients alive, manage a variety of conditions pretty darn well, and even alleviate some parental anxiety. I can successfully perform a lumbar puncture even after the Intern is unsuccessful and I have to bust through the big ole’ hematoma he left behind. Bammm how do you like all those red blood cells?!? What lab representative, red blood cells aren’t good?!? Of course I know that but at least I have enough cerebrospinal fluid for a gram stain and culture. Could you run those STAT please?!? I can scrounge up a makeshift meal (cereal, graham crackers, peanut butter, diet Coca Cola) to avoid my own hypoglycemia in spite of the fact that due to budget-cuts the cafeteria now closes at 8pm. I can snuggle sick babies and help position them so that they don’t become hypoxemic at 2:30am. I can make my exhausted Intern laugh at our horrible night. I can make my Nurses feel appreciated and not hate me even though they are ready to label me a “Black Cloud”.

And just to cap the whole night off, after a particularly crazy admission where we were all unknowingly exposed to some infectious respiratory goobers, we exited the room quickly, donned our masks and proceeded to do a modified line-dance down the hallway back into the room where we provided judgement-free exemplary service.

At this point, I just want to curl up in the call room, but there are far too many labs to follow up on and kiddos to check up on.

So to those out there in call-land, keep it moving and keep those patients alive! Cuz’ you know I will :-)

Thursday, August 8, 2013

First Call

It's my first overnight call in the hospital. It's 7pm and I've been at work for 13 hours. There are 16 more hours to go. My arms are halfway through the portholes of an isolette and my hands are cradling the tiny hand of one of my patients who needs a blood culture and screening labs. I am shush-shush-shush-ing the baby as I choose my spot, swab it with alcohol, and pierce the skin quickly and definitively, trying to cause as little pain as possible. My pager phone is buzzing and beeping against my hip, the nurses are mobilizing, talking, helping each other do all the things this sick baby needs done, but for the moment it is just me and this hand and the artery that is hidden a few milimeters beneath the skin. After a few adjustments of the needle, the red arterial blood flashes into the needle, travels up the tubing, and begins to fill the syringe. My shoulders start to unknit themselves and I take what feels like my first breath in a while. Thirty seconds pass as the syringe slowly fills. There's nothing else I can do for the moment but stand here. I haven't stopped moving and doing and thinking and worrying for the past 13 hours, so this feels like a break. The baby is chewing on his pacifier, looking around for the source of the sting, and our eyes meet for a moment before the blood hits the 2cc mark and I retract the needle into its hub. "Thanks, little man," I whisper to him softly, grateful to have gotten the blood, grateful that I don't have to cause him more pain with a second stick, grateful that I don't have to call the fellow to come and help me, grateful for the couple of breaths I took and whatever small thing passed between us. In the time it took for the stick -- no more than three or four minutes -- four new pages have come through and I am needed in four places at once and I don't breathe again until well after midnight.

*          *          *          *          *

The most recent change in the ACGME medical training rules happened when I was a fourth year medical student. At the time, all the protest over the limitation of interns to 16 hour shifts seemed silly to me. How could anyone protest a seemingly more humane schedule? What was the big deal? Then I got to intern year and began to understand the widespread dissent. The day-float, night-float system featured constant signout -- on long call days, I would spend 2-3 hours of my day signing out. I worked 13, 14, 15 hours six days a week, enduring the pain of long separations from my child, often staying up late working on notes and discharge summaries -- and still there was never enough time to see patients, with rounds and conferences and notes and sign out and the endless to-do lists. Most disturbingly, I felt like I wasn't learning as much as I expected. Admitting a patient was more a matter of administrative work. There was never the opportunity to travel with the patient through the process of diagnosis and treatment. At best I would put in the initial orders, then sign the patient out to the night person. Nights were a little better, with more opportunity to actually see patients and think about them, but six consecutive 15 hour days left me feeling exhausted and was hugely disruptive to my family. I began to feel resentful all the time. Worse, I began to forget why I went into medicine in the first place.

As second year neared, I was filled with both apprehension (would I actually be able to function for 30 hours in a row?) and excitement for the switch to a Q4 overnight call schedule. What was I looking forward to? The time to actually see patients. The chance to spend at least one out of every four afternoons with my daughter. The chance to admit and then follow my own patients instead of picking up overnight admissions and shuffling patients when one or another team member switched to nights. The sense of mastery that would come with being able to manage patients by myself overnight. I was hoping to fall in love with medicine again.

*          *          *          *          *

It's 3:30am and even though I should be trying to catch a little sleep during a lull, I am worrying about sodium. One of my patients has a sodium of 129. It's not low enough to panic, but it's not normal. It's not low enough to call the fellow who has probably already gone to lie down but it's low enough to make me lie awake in the dark, wondering if I should intervene or not intervene, wondering if I should call the fellow or not, feeling like this is the kind of problem I should be able to solve on my own. I get up and turn on the light in the small call room and set about reading about neonatal hyponatremia, which confirms that the baby is not in danger. I could go down on his fluids, but he is losing more than the typical amount of fluid through his unrepaired myeloschesis and there has been concern all day for poor urine output. On the other hand, it's hard to imagine that he is fluid down with a sodium of 129. I go around and around in my head, weighing the sodium level against the risk of insensible fluid loss. I decide to recheck a level in the morning and leave the fluids where they are. It's a small decision but it keeps me tossing and turning for the interrupted hour and a half I have to rest before the morning work starts. When the BMP pops up at 6am, my heart catches in my throat for a moment. What if his sodium is 121? It's 130. On rounds later in the morning, we decide to leave the fluids where they are. For the team it's a small decision -- no one even notices -- but for me it's the end of an arc of learning: how to tolerate the anxiety of uncertainty, how to make a clinical decision when there are no protocols to follow, how to think through a problem and come up with a safe solution. If I had been there with a senior resident, I would have just asked them and they would have changed the fluids or not changed the fluids. I would have slept better. But I would have been no farther along in my ability to take care of patients independently.

Post-call rounding is a whole new experience. I know all the patients and what has happened to them over the past 24 hours. I was there yesterday when decisions were made on rounds and I watched these decisions play out. I have listened to these lungs, stared at these monitors, felt these bellies all night long. I am the one who was here. For the first time, none of the patients on rounds are new to me -- they are all mine. I have the opportunity to get feedback from the attending about my overnight decisions, learning that will stick with me forever. Even though I am exhausted, it is exhilarating. I go home, sleep for a few hours in the afternoon, then have the incredible treat of going to pick my daughter up at day care, something I could almost never do on the intern schedule. I have a normal evening with my family, full of all the quotidian details of dinner, bath, and bedtime that are my secret paradise. By the next morning, I am ready to dive back in.

*          *          *          *           *

The new duty hour rules were well intentioned, designed to keep patients safe and minimize the ill effects of sleep deprivation. But I think there needs to be some consideration of what may have been lost. The danger of sleep deprivation has to be balanced again the the burn-out associated with the relentless march of long days without the high-yield learning and sense of connection to patients bourne of the shared journey of an entire day. Being awake for 30 hours is hard. But feeling like a mediocre doctor while seeing my family for an hour a day for most days every month was much, much harder.

I'm curious to what other people think about the "new" (now not so new) duty hours.

Tuesday, August 2, 2011

Not just us anymore

I had planned to write about my first post baby overnight call which occurred a couple of weeks ago. Long story short, I survived, hubby survived and my little peanut survived. I felt good to be back in the hospital and thankfully it really was like riding a bike, everything came back to me (FYI - I actually can’t ride a bike, but that’s another story). I may still write about it later, because I did gain some nice insights, however, now as I get ready for my next overnight call and a potential procurement call, I decided to write about this new feeling of accountability.

I have one more year left in the lab and I just started taking overnight ICU call twice a month in order to keep my feet wet. Last week I was asked if I would like to to cover some organ procurement calls as well. Initially, I wanted to jump at the opportunity (I’m interested in transplant surgery). However, when thinking about the burden middle of the night procurement puts on my hubby (especially with one car), I decided to table it unless they were really in a bind. Then, I kept thinking about it. And suddenly I was paralyzed about the thought of getting on a random, unregulated jet in the middle of the night with a baby at home. I’ve flown on a number of procurements in the past and I love riding in the jet. I love the free meal we get on the ride over, the much needed nap on the way home, and the urgency of getting organs back to help save someone who has been desperately waiting for them. However, now all I could think of was the danger of these jet journeys. What if I crashed? How could I be so frivolous with my life and safety? Even while on call, I find myself being a LOT more diligent about wearing my PPE and more being careful when putting in lines. A fellow resident is currently suffering on antiretrovirals after being stuck with an open bore needle of an HIV patient - one of my biggest fears. Now, these fears which were sort of trivial, in the background, part of the job fears have moved promptly to the forefront of my mind. I now feel as if I’m not just taking risks for me and my grown adult husband. Now the risks affect my innocent child.

I don’t really know how to deal with this new feeling of accountability. Specific to the risks of being a transplant surgeon (flying and Hep C) I plan to follow one of my husband's suggestions of finding Pauline Chen and asking her! (Yes, he, the non-medical one, knew about Pauline Chen!) I enjoy my work and I fully understood that there were some occupational hazards when I signed up. However, in the meantime, I wonder how others feel about the things we expose ourselves to at work and how that affects our children.

Sunday, March 27, 2011

Pager Anxiety*

I was on call for 7 days starting last Friday. My mother watched Babyboy all day until I got home from work close to 7 pm. My husband was traveling. Mom and I had a bowl of soup together, and then she went home. I was thankful knowing she would be on duty for me Saturday and Sunday so I could go in and round on my patients. Babyboy and I set about our usual Friday night routine: he sat on my bed supported by pillows as I got my pajamas on; then we did tummy-time for a bit and sang songs for a bit. As soon as he started to rub his eyes, I darkened his lights, set Sleep Sheep on “rainfall”, and gave him a warm milkie bottle. And as per usual, he conked out.
Time for Mommy to conk out. I set my pager on the bedside table, turned out the light, and nestled down for the night. Then, “Bip!” the pager went off. I startled and turned the lights back on and fussed with my glasses and looked at the page text: an urgent page from someone with a sore throat. Sigh. I got up, logged into the computer, pulled up the patient’s chart and called her. A young new mom, her baby is in daycare and is on his 3rd course of antibiotics for an ear infection. Now she’s had a very sore throat and fever over 101 and difficulty swallowing. She knows she should have come into the office, but between work and the baby, she couldn’t. She’s miserable, she’s pretty sure this is Strep, can I help her? Sure. We chatted, she was very gracious, and I felt good to be able to help her out. I called in her Amoxicillin and that was that.
I again set the pager down on the bedside table, turned out the light, and settled down to try to sleep. But how could I sleep when I kept worrying and fretting that the pager would go off again?
Sigh. This has been an ongoing issue since residency. As a resident, when you’re on call, you’re in the hospital, often covering more than one service. As an example, when I was on Pediatrics call, I sometimes would cover two floors: toddler and school age. Back then, each floor had their own pager. Then there was the clinic pager. This in addition to my own personal pager. So it was not abnormal to be wearing 4 pagers. I had to double-knot my scrub bottoms so they stayed up with all these pagers clipped to my waist. It was a feat to use the bathroom and not lose one down the toilet!
And they beeped. A lot. I remember being on call one overnight at a satellite hospital. I was the resident covering the Peds ward, admissions, and backup for labor and delivery. I was paired with an intern who was thankfully a smart and cool-headed guy. For most of the night, we were working with a newly admitted teenager in diabetic ketoacidosis. The teen was on an insulin drip, and their blood sugars, electrolytes and acid/base balance had to be watched carefully. We were being paged so often about the teen that we decided to just stay up there. But, BEEP! A code in the ER! An 8 year old in status epilepticus. We ran and got there at the same time as the on-call anesthesiologist. We decided to sedate and intubate the boy, give as much Valium and other antiepileptics as we could and call for transport to the Main hospital. Then, BEEP! we were STAT paged to a delivery. The resident covering Neonatal was already in a delivery, and there was another imminent delivery that required Peds presence: premature TWINS. They were 32 weeks, which is little but not too too little. They would need to be in the NICU (Neonatal intensive care) for a few weeks, but they were fine. The whole time there were numerous other pages: issues with the admitted children on the ward, beep beep beep; some new admissions to go and see, beep beep. We split up to try to cover it all.
That was a pretty bad night on pediatrics, but it wasn’t abnormal. Medicine codes were much more common, and arguably worse, because people died more often. The medicine code pager, which went off if there was an adult in cardiac or respiratory arrest somewhere in the hospital, had the loudest, most obnoxious sound: “REE-OO-REE-OO-REEEEE”. If I’m in my hospital now, and someone’s pager is set to that tone, I get so uncomfortable. I want to run, or hit them.
I now have my pager set to a sound that isn’t at all like the ones I had in residency. It’s a little “Bip!”, almost a chirp, really. And it never means I have to run anywhere. I only need to be able to pick up the phone and talk, and think. But when that thing goes off, I might as well be back on the floors again. I’m like a returned soldier from ‘Nam, man. Just a tad PTSD.
There was even one holiday weekend, a Fourth of July, where my office was closed on a Friday. I was on call starting that morning. It was a beautiful day, sunny and warm. But the pager went off every five minutes for the whole day. I was planted at my desk, fielding calls, reading charts, looking up answers, trying to keep track of all the issues. The calls piled up. People were annoyed that the office was closed, and that I took so long to get back to them. I went into a full-fledged panic attack at one point. I can now tell my patients with panic attacks that I really do know what a panic attack feels like.
And so, a week ago Friday, there I was, in bed and trying to sleep, in the safety and comfort of my own bedroom, and I couldn’t sleep, after just one benign page. I even started drifting off to sleep, and hallucinated that the pager beeped. I woke up and turned the lights on and stared, but there was no blinking callback number, no message.
I finally fell asleep. Then, at 4:30 a.m., “Bip!” From the deepest sleep, I startled, turned the light on, fumbled with my glasses, and looked at the message. An urgent call for nausea, vomiting. I sighed, pulled myself up and to the computer, and dialed. The lady had school-aged children. She couldn’t keep anything down. I talked to her husband. We agreed that he would take her into the emergency room. I called the emergency room to let them know she was on her way and that I suspected Norovirus, that she would likely need IV fluids. I typed a brief note. I went back to bed.
Two hours later, I was still awake.
*originally posted at March 19, 2011

Monday, August 25, 2008

Tucked in

As a resident running the family practice ward, I would come up to the unit in the evening to finish dictations and complete paperwork. At the end of the evening, I'd ask the nurse if there were any patients she was concerned about or orders she wanted written. Having tied up all the loose ends, I'd head to the call room.
I distinctly remember how I felt walking down the corridor at eleven at night. The ward was hushed and still, with the patients' lights off and just one or two staff at the nursing station. Heading back to the elevator, past rooms of four beds apiece with patients curled up under blue cotton blankets, I felt maternal. Or how I imagined maternal would feel, as I hadn't had a child yet.
It was a powerful emotion, a combination of affection and respect for my charges, the satisfaction of having managed the day's problems, the weight of responsibility, and humility and gratefulness for my own position.
These days, as I round on my own children every night before bed, the flood of feeling as I adjust the covers over small sleeping bodies is remarkably similar.
And I realize now that those late nights walking down the corridor of 7B, the sense was of having tucked the kids in for the night.