The Hospital Yadda-Yadda

Scene: A charting room on a medical-surgical unit in a community hospital. A hospitalist enters and consults a computerized patient census.

HOSPITALIST: [counting patients] "Two, four, six, eight, ten, twelve--shit--fourteen, sixteen--"

NURSE 1: [approaching Hospitalist] "Dr. Chan?"

HOSPITALIST: [Still looking at computer] "Hi, what's up?"

NURSE 1: "The guy in 109 hasn't had a bowel movement in four days--"

HOSPITALIST: "Who?"

NURSE 1: "The guy in 109."

HOSPITALIST: "I know, but what's his name?"

NURSE 1: "Oh sorry. Mr. Smith."

NURSE 2: [Approaching] "Oh Dr. Chan--sorry to interrupt, but the family of 120 wants to speak to you."

HOSPITALIST: "I don't even know who 120 is. What's the problem?"

NURSE 2: "They don't want him to go to a nursing home."

HOSPITALIST: "I'm sure he doesn't want to go either."

NURSE 1: [Interrupting]: "Hold on, I was first. What about 109--I mean Mr. Smith?"

HOSPITALIST: "What's wrong with--oh right, constipated. How about we give him some MOM. Does he have renal disease?"

NURSE 1: "I don't know, let me check." [Consults chart] "No, just cellulitis and diabetes."

HOSPITALIST: "OK. Just give him some MOM and I'll order a bowel regimen when I get to him."

NURSE 2: [Interrupting] "Dr. Chan, what about 120's family?"

HOSPITALIST: "Well, can you tell them I just got here, it's only 7:30 in the morning and I have to see--"

NURSE 1: [Interrupting] "How much MOM should I give him?"

HOSPITALIST: "Who? Oh, 109. Give him the usual."

NURSE 1: "Thirty ccs?"

HOSPITALIST: "Sure, why not?"

Discharge Planner enters and sees the crowd in the middle of the charting room.

DISCHARGE PLANNER: "Who's on today--oh, it's Dr. Chan! Thank goodness it's you. I left SNF orders on 120s chart, they've already accepted him and there's a bed available at 1 pm."

NURSE 2: "There's a problem with 120 going to SNF."

DISCHARGE PLANNER: "What problem?"

NURSE 2: "The family doesn't want him to go."

DISCHARGE PLANNER: "What family? I've been calling all his numbers all week and I couldn't find anyone--"

NURSE 2: "They just showed up from Arizona."

DISCHARGE PLANNER: "Oh God, they just showed up from Arizona and now they--" [Turns to Hospitalist] "Have you seen them yet?"

HOSPITALIST: "I don't even know who 120 is."

DISCHARGE PLANNER: "Sorry, it's Mr. Jones. He broke his hip and had surgery on Friday--"

The hospitalist's pager goes off.

HOSPITALIST: "Great." [Looks at number on pager] "Microbiology." [To Discharge Planner] "Hold on." [Dials phone] "Hello, it's Dr. Chan returning a page."

MICROBIOLOGY TECH: "Hello is this Dr. Chan?"

HOSPITALIST: "Yes it is. What's up?"

MICROBIOLOGY TECH: "Dr. Chan, I have a blood culture that is positive. On Mrs. Ethel Robertson--"

Overhead page: "Dr. Chan, please call star-69010. Dr. Chan, star-69010."

HOSPITALIST: "Go on, they're just paging me overhead. Mrs. Robertson?"

MICROBIOLOGY TECH: "Do you need to get that?"

HOSPITALIST: "No, it's OK. Go on."

MICROBIOLOGY TECH: "Ethel Robertson--"

HOSPITALIST: "Yes, we've gotten that far already. What about Ethel's blood cultures?"

MICROBIOLOGY TECH: "I have growth in the anaerobic bottle of gram positive cocci in clusters. So far it looks coagulase-negative."

HOSPITALIST: "Is that in both sets?"

Overhead page: "Dr. Chan, please call star-69010. Dr. Chan, star-69010."

HOSPITALIST: [Speaking to the ceiling] "All right, all right, I'm coming." [Speaking into phone] "So, is that in both--"

MICROBIOLOGY TECH: "Do you have to get that?"

HOSPITALIST: "In a minute. Was that in both sets of blood cultures?"

MICROBIOLOGY TECH: [checking micro plates] "No, just one of two anaerobic bottles growing coag-negative staph."

HOSPITALIST: "So it could be contaminated."

MICROBIOLOGY TECH: "Yes."

HOSPITALIST:  "Well, OK, thanks for telling me. Bye." [Hangs up, looks around for Discharge Planner] "Where did Maureen go?"

NURSE 3: "She went to talk to 120s family, I think."

HOSPITALIST: "Oh, good."

Overhead page: "Dr. Chan, please call star-69010."

HOSPITALIST: "Geez." [Dials] "Hello, this is Dr. Chan."

CALLER: "Hello, is this Dr. Chan?"

HOSPITALIST: "Yes, hello."

CALLER: "Dr. Chan, I have Dr. Blither for you with a direct admit, hold on a moment."

HOSPITALIST: "But all direct admits have to go through the ER--" [Realizes she is speaking to dead air] "Well, shit." [Looks over her shoulder at Charge Nurse] "Sandy, do we have beds?"

CHARGE NURSE: "I don't think so. Let me call the house supe."

DR. BLITHER: "Hello, is this the hospitalist?"

HOSPITALIST: "Yes, this is Theresa Chan, I'm the hospitalist today."

DR. BLITHER: "Dr. Cheng?"

HOSPITALIST: "No, Chan, as in Charlie Chan."

DR. BLITHER: [Obviously writing it down] "Doctor...Chan. Well, that's easy to remember."

HOSPITALIST: "Yes, isn't it? What can I do to help you, Dr. Blither?"

DR. BLITHER: "Well, yesterday I saw a really nice lady in the office. She's had her son along with her, and he's been doing just a terrific job looking after her at home, but it's just getting to be too much for one man to handle--"

CHARGE NURSE: [Interrupting] "House supe says there's no beds."

DR. BLITHER: [Blissfully unaware of interruption] "--what with the laundry, and helping her to the bathroom. So, he and his mom had a long talk and they've decided it's time for her to go into a care home--"

HOSPITALIST: "Dr. Blither, may I interrupt for a moment--"

DR. BLITHER: [Uninterruptable] "--so I called the care home and they told me I have to admit her to the hospital for three days before she'll even qualify to go there. You know, I gave up my privileges twelve years ago after I got my knee replaced--"

HOSPITALIST: "Dr. Blither, I really need--"

DR. BLITHER: [Continuing genially] "--so I thought I'd give you a call to see if you can admit this nice lady directly so we can get her to a care home."

HOSPITALIST: "That's what I'm trying to tell you, I don't have a bed for her in the hospital."

DR. BLITHER: "How's that?"

HOSPITALIST: "The hospital is full today."

DR. BLITHER: "Full? Really? I never knew that place to fill up."

HOSPITALIST: "Well it is today, unfortunately, and I should let you know that all direct admits have to go through--"

DR. BLITHER: "I'm sure you could find a spot for this nice lady. She won't need to take up a lot of your time, she doesn't really need much except some help up to the bathroom--"

HOSPITALIST: "And that's another problem, Dr. Blither, she won't qualify for a SNF if she doesn't meet criteria to be in the hospital, so if she doesn't need much--"

DR. BLITHER: "How's that again?"

The House Supervising Nurse approaches.

HOUSE SUPE: [Getting straight to the point] "No beds, unless you plan on discharging more than four today."

HOSPITALIST: [With hand over phone receiver] "I may not discharge anybody if I can't get off the phone with this guy."

DR. BLITHER: [Still talking] "I don't know what the rules are now, but in 1956, if someone needed to go to a care home, I just called the care home and that was that--"

HOSPITALIST: [Speaking fast] "Dr. Blither, if you can hold for a minute, I'll get someone on the line who can help you more than I can." [Presses hold button and looks at House Supe] "Can you talk to him? He wants me to direct admit his patient who doesn't sound sick, just so she can get to a SNF."

HOUSE SUPE: "Who's this?"

HOSPITALIST: "Blither."

HOUSE SUPE: "Oh boy." [Picks up the phone. Hospitalist cedes chair to Supe]

NURSE 3: "Dr. Chan, 117 is wondering if she can go home today."

HOSPITALIST: "Who's 117?"

NURSE 3: "The lady with the bowel obstruction. She's feeling better today."

HOSPITALIST: "Is she eating?"

NURSE 3: "Not yet."

HOSPITALIST: "Is there much coming out of her NG tube?"

NURSE 3: "Hardly anything overnight."

HOSPITALIST: "OK, clamp her NG tube and give her clears for breakfast and we'll take it from there."

NURSE 3: "Should I keep her Foley in?"

HOSPITALIST: "God, no. Take that out and let her move around."

Hospitalist consults her census list and is trying to make a game plan, when Medical Staff Coordinator approaches.

MED STAFF: "Good morning."

HOSPITALIST: "Are you sure about that?"

MED STAFF: "Not having a good morning?"

HOSPITALIST: "I've got seventeen patients to see and I can't get out of this charting room because I keep getting stuck on the phone."

MED STAFF: "So I take it you're not coming to Med Exec meeting today."

HOSPITALIST: "What?"

MED STAFF: "Med Exec."

HOSPITALIST: "Why would I go to the Med Exec meeting?

MED STAFF: [Patiently] "Because you're the Secretary."

HOSPITALIST: "I am? That started already?"

MED STAFF: "It started three months ago."

HOSPITALIST: "Shows you how much I know. Well, I'll try. Time?"

MED STAFF: "Twelve-thirty. Lunch will be served."

HOSPITALIST: "OK." [Sees Charge Nurse approaching] "Well, now what?"

CHARGE NURSE: "There's someone from the funeral home who needs you to sign a death certificate."

HOSPITALIST: "Who died?"

CHARGE NURSE: "Mr. Souza, yesterday."

HOSPITALIST: "I wasn't on yesterday. Who--oh never mind, I'll sign it anyway. Can you bring it in?" [Charge nurse leaves, Discharge Planner enters]

DISCHARGE PLANNER: "I talked to 120's family. I think it's going to be OK, but they want to talk to you."

HOSPITALIST: "What's the problem with--" [Charge Nurse re-enters with death certificate. Hospitalist signs.]

CHARGE NURSE: "ICU wants to talk to you."

HOSPITALIST: "Great."

DISCHARGE PLANNER: "They just want to hear it from you why he's got to go to SNF. They got the wrong idea from last night's nurse--"

Phone rings.

CHARGE NURSE: [Yelling from outside the charting room} "That's ICU for you."

HOSPITALIST: [Picking up phone, looks apologetically at Discharge Planner] "Hi, it's Dr. Chan."

ICU NURSE: "Good morning, Dr. Chan!"

HOSPITALIST: "That's the second time I've heard that. What's up?"

ICU NURSE: "Bed Three's troponin is back--"

HOSPITALIST: "Hold on, who's Bed Three?"

ICU NURSE: "Oh, sorry. It's Mr. North, with the NSTEMI."

HOSPITALIST: "And his troponin is what this morning?"

ICU NURSE: "Seventeen."

HOSPITALIST: "And what was it yesterday?"

ICU NURSE: [Obviously turning pages in a chart] "Twenty-four."

HOSPITALIST: "So it's going down?"

ICU NURSE: "Yes."

HOSPITALIST: "Well, that's good. I'll come see him soon, thanks." [Hangs up phone, turns back to Discharge Planner] "Sorry about that."

DISCHARGE PLANNER: "This is how it's going to be all day, isn't it?"

HOSPITALIST: "I have a sinking feeling it is."

DISCHARGE PLANNER: "Well, before anyone else calls you, please go an talk to 120's family and straighten out this mess so we can send him to SNF--apparently someone told them last night that he was going there to die and they're upset."

HOSPITALIST: "Great." [Thinks for a second] "Is he going there to die?"

DISCHARGE PLANNER: "We're not sending him there to die, but he's 85 and he broke his hip and he's not in great shape."

HOSPITALIST: "OK, I'm going."

Hospitalist leaves charting room, gets past the nurse's station when someone calls out behind her.

VOICE: "Dr. Chan!"

HOSPITALIST: [Talking over her shoulder as she walks towards 120] "Can you wait a minute, I've really got to--"

VOICE: [Who is speaking from next hallway] "Really quick, can I give 104 some Narcan?"

HOSPITALIST: [Stops in her tracks] "Why does 104 need Narcan?" [Sees a whole stream of nurses heading towards 104] "Geez."

Overhead page: "Code Blue, Room 104....Code Blue, Room 104."

HOSPITALIST: [Heading toward 104, sees Discharge Planner] "Don't worry, if we can't get room 120 to SNF today, I'll go myself." [Disappears into room 104]

Comments

[ZMD]

Reminds me of why I went into anesthesiology. Couldn't stand all the interruptions during the day from the nurses, family, other docs, etc.

[Chantel]

I need a nap!

[The Happy Hospitalist]

To those who keep saying it's like being an intern. It's hardly like being an intern. It's called hospital medicine. When you're caring for 15 in patients and cross covering for 50 or more, you're going to get pages. Interns don't know what they are doing. I do. I have never felt like an intern working as a hospitalist. Being available is part of being a hospitalist and why we are so sought out. We have a great working relationship with all the staff. When we find we are starting to get abused in certain regards, we reestablish the guidelines for contacting us and not contacting us. A while ago we established guidelines on when to call and when to wait until morning for our night shift folks. It has worked wonders to reduce unnecessary night pages by 80% or more. I suppose it's easier when you are a private practice as opposed to a hospital owned position to set your own rules.

[mufffinrn]

Just wanted to give a few details from a nurse. First, we are required to call all critical labs to the Physician. Second, we are required to speak of patients using room numbers due to HIPPA. However, a smart and kind nurse will use the patients name when calling the Doc. Third, please please don't get mad and yell at us nurses for doing our jobs. I hate when I have to page a doctor for something stupid, but it still has to be done.

[Dr. Dredd]

And this is why I'd sooner shoot myself in the head than become a hospitalist. It's like being a perpetual intern, albeit with a MUCH higher salary.

I think I'm having a post-traumatic flashback to residency...

[Mayhem]

You're way more patient than I am. I'd have lost my temper right around the time ICU called to interrupt.

[Kim]

Holy cow!

(a) It sounds like what an ER doc has to put up with for 12 hours!

(b) I am going to be extra nice to the hospitalists - especially the ones who manage to smile through all this.

(c) Yikes, the use of room numbers instead of names is scary!

I need a nap after reading that! : D

[Theresa]

Hi Everybody,

Thanks for the kind comments. Yes, it is like being an intern again, except I'm better at it. And it pays slightly better than being an intern.

Dr. Levin, I wish we could hire an NP, but this program barely pays my salary...

[Leigh Ann - My Family Doctor Mag]

You should write for ER! Oh, wait ... they're going off the air. OK, House then.

[Gary Levin M.D.]

How much medicine do you actually do, as compared to all this. You need a NP to do this scut work.
Or just go back to being an intern

[Carolyn]

Flashback to my internship!

I wonder if the MCAT's should be testing future physicians' ability to multitask effectively rather than their knowledge of organic chemistry, etc.

[Jonathan Dee]

Reminds me of residency. I second secretwave's sentiment.

[Dragonfly]

Yikes.....

[Beth]

That was great. My night was very similar to that at the start. I came in at 5:30 PM and was on the phone for a solid hour...and that was BEFORE the day team even signed out to me! There was a metric ton of BS to clean up after that. We managed dinner at a reasonable hour and then I sent my intern to bed around midnight. Five more hours to go and it's not looking too bad. Hope your day went better after that code!

[SeaSpray]

Hi..I really enjoyed your post. You couldn't even get out of the gate...gee! Time must fly. :)

[secretwave101]

The only problem with your post is that it was so true-to-life and so well written that I'm all pissed and uptight now.

[Kate]

This is good; really good. Although I'm not a Hospitalist, I know what it feels like to walk in cold on a dozen inpatients (not as many as Dr. Chan had...) and to have so many interruptions that it's impossible to have any kind of orderly approach to anything. "Ping-Ponging" from this to that. OMG. Well written. I'm going to send it to my hospitalist colleagues; they'll have a knowing chuckle out of it, I'm sure.

[Medicine R2]

I hate getting called with "critical" lab values (calling with the troponin that's trending down, calling re: the bicarb on a chronic CO2 retainer whose bicarb has been > 40 every single day, etc.).

[Peggikaye]

Well ... if nothing else ... it kept you thinking and gave you a blog post???

*ducking and running*

oh wait, maybe I just need to duck cause you don't have the energy to run after that.

Here ...how bout a nice cup of cappacino!

[Happy Hospitalist]

That Sounds About Right.

[Dr. Rob]

EXACTLY why I don't do inpatient any more. My life is hectic in the office, but at least to some degree I am still the boss.

At least I pretend to be.

[Xavier Emmanuelle]

Wow, I must say that even though it sounds stressful and sucky for you, that was REALLY fun to read :)

[Mary]

Wow! I almost considered using sock puppets to keep track of all that action! Sounds exciting! Well, exciting in a "I'm sorry you had such a busy morning" kind of way. Haha, wow. And LOL at the part where you forgot you were secretary of the Med Exec meetings. Hahaha. Very nice post. I'm gonna print it out!