Preface, 2008: This post was written when I was a new R3. At my residency program, the R3s were in charge of running the call team. That meant assigning admissions to the junior residents and making sure they didn't make a million mistakes, running Labor & Delivery when the intern was otherwise tied up, ensuring the attending physicians didn't get called at 3am unless there was a damn good reason, and being a general resource person to everyone else on call. It was a huge responsibility and a nasty shock after the cushy responsibilities of R2 call. The hardest part was making sure your R1 and R2 didn't make horrendous mistakes on patient orders. You had to do this without appearing to micromanage the junior residents, so either you had to see the patient before the junior and remember everything you thought was important about the patient, or see the patient after the junior had written the orders and potential mistakes already made. You ran around all night long, keeping a wary eye on your R1, who was brand new to medicine and needed whipping into shape.
At Morning Report the next day, if the attendings were critical of the R1's management of a patient, you had to fall on your sword and take the blame on yourself. "OK, that was my fault. I saw the potassium was high and it didn't occur to me to stop his spironolactone...." It was a badge of honor to deflect responsibility from the junior residents but it meant a lot of work and hair-pulling at night. I'm glad we had this ethic of senior responsibility; it taught me a lot about collegiality and stepping up to the plate. I think that's why I was so pissed off at the R2 who slept through most of Morning Report. You can't do a good job if you don't show up for the job.
The horrible confrontation between Dr. Bloody Unpleasant and the home birth patient is a telling incident in the story of my residency. We ran a pretty obstetrical Labor and Delivery service. We had to--with 270-300 deliveries every month, a lot of them high risk, we didn't have the luxury of tailoring the birth experience to each woman. I'm sorry about this but I'm glad that the vast majority of the women we cared for had safe births and went home with their babies. The downside was this awful showdown between Dr. B-U and the homebirth midwives. I remember feeling utterly powerless to intervene on behalf of the midwives, because Dr. B-U was so out of control and also because I had no experience of working with homebirths. The only thing I could do was be a calm presence in the room when I did the intrathecal.
Now I work regularly with homebirth clients. We provide parallel care to women who want to give birth at home, and I know several of the homebirth midwives personally, so there is a bond of trust between us. If a homebirth candidate decides to transfer to our hospital, there are no Bloody Unpleasant showdowns such as the one described below.
I'm on call a lot this month, dagnabbit! Here's a few highlights from Saturday and Sunday:
7:30am: I arrive on Labor and Delivery to take over the Deck. This is a courtesy the third-year resident provides to the intern on call, because both the intern and the second-year resident are probably rounding on their services in the morning. Now that the new guidelines to limit resident work hours are in effect, everyone really should be rounding on call, to minimize extra days at work. So far, the Deck looks peaceful, with only two women in labor.
9:30am: First delivery of the day, a nice boy. The intern has been working on Labor and Delivery during the week and has the routine almost down pat. She does not, however, have being on call down pat yet. At one point, she says "I like OB better than Medicine!" As nicely as possible, I tell her to get over it--this is Family Practice, and we see it all!
10:00am: For example, there's a 2-year old child being transferred from the Peds unit to the ICU for better monitoring. She was brought into the ER for bizarre behavior and "seeing spiders" and found to have a toxicology positive for multiple drugs. Now she's on a police hold and our Director of Pediatrics wants no one to see her who does not have a negative tox screen. I spend a good long while doing a Suspected Child Abuse report with the Director. You have to wonder who's been taking care of this child, to permit her to be near drug-abusing adults. Or perhaps someone gave the drugs to her deliberately, because how does a 2-year old take drugs herself? There's a lot of anger, frustration and judgement among the staff, regarding the predicament of this child....It's hard to be absoluately impartial when it comes to abused and neglected children; the least-harmful approach is to accept private judgements for what they are, but to present a neutral face to the patient's family.
Noon-ish: The OB attending has decided to perform a primary Cesarean section on one of the laboring women who has suspected fetal macrosomia, otherwise known as a Really Big Baby. As I wolf down my lunch, I review my misgivings about this decision. There is no evidence that elective Cesarean section in suspected fetal macrosomia reduces poor outcomes from complications of macrosomia, such as shoulder dystocia. The case is somewhat different for mothers with gestational diabetes, but even there, opinions differ. Today's OB attending is known to be difficult--I call her Dr. Bloody Unpleasant--so I don't challenge the decision, which the patient has already agreed with. Instead, I grit my teeth and assist Dr. B-U with the C-section--one of my new, third-year responsibilities. It's a difficult C-section, requiring extension of the abdominal and uterine incisions to delivery the baby, a boy only weighs only 8lbs, 8oz. Much less than the anticipated nine-and-a-half pounds. So much for macrosomia.
1:30pm: Dammit, is that the ER? Yep! A 70ish woman has had chronic cough for three months, and is now producing bloody phlegm. She used to smoke heavily but quit a few years ago when she discovered she had diabetes. One of those cases of too little, too late perhaps--her chest x-ray shows emphysema and a worrisome narrowing of her trachea, perhaps due to a mass in the mediastinum, the portion of the chest cavity that contains the heart and great vessels. The whole story makes me worry about lung cancer. Tuberculosis is another possibility, but the patient has none of the associated symptoms or x-ray findings. Meanwhile, she has the additional wrinkle of a very fast heart rate--atrial fibrillation, which needs treatment and monitoring in the ICU. Her EKG is complex, so all the time I've spent poring over EKGs this past month has been well-spent, because I'm able to review the EKG with the second-year resident who is admitting the patient.
5:00pm: The afternoon passes uneventfully. There's a couple of deliveries, and I get to lie down for a brief nap. There's the usual hours-long discussions about what to eat for dinner. As part of recent hospital cutbacks, the cafeteria is no longer open on the weekends. The residents are given patient trays to eat while on call, since we can't leave the building to obtain food, but attendings do not get the same courtesy. So our FP and OB attendings are being nice enough to treat us all to Chinese food, which we all enjoy together (even Dr. B-U, who is behaving herself so far).
6:30pm: Geez, there's going to be another C-section. The hospital has recently changed their policy allowing a woman to labor after a previous C-section. We were not meeting all of the stringent requirements set out by the hospital's insurance carrier, so the administration decided we could no longer assume the additional risk of permitting attempted vaginal birth after Cesarean section (VBAC). This means that all women who were unlucky enough to have a C-section for their first pregnancy now must be delivered by repeat C-section, without ever attempting a vaginal birth. The policy change has resulted in a lot more C-sections, longer hospital stays for mothers and babies, and a lot of bad feeling among those of us who believe that VBAC is an important birth option to offer to women. Worse, we were the last hospital in the county to offer VBAC, so now this option will only be open to women living in other counties, or who can travel to those counties for their care. A tragedy, in my mind, for all of these reasons AND because I now have to spend another hour in the OR doing the C-section with an FP attending who has section privileges. Because the mother had one previously, she has extensive scar tissue in her abdomen and needs quite a lot of dissecting before we can get adequate access to the uterus.
9:30pm: Now the ER has three admissions for us. One is a man in status epilepticus, or continuous seizures. This is a dangerous condition that needs intubation and high doses of anti-seizure medications. Prolonged status epilepticus can result in permanent brain damange. This patient has a history of many injuries, including one to his head which resulted in seizure disorder, and heavy drinking. I suspect his seizures may have been precipitated by alcohol withdrawl. The second-year resident comes running downstairs to talk to the patient's family, then has to run to Labor and Delivery for a meconium delivery. Meanwhile I examine the seizure patient, who is fighting the endotracheal tube, and order some sedative medications. Since the second-year is stuck in the delivery, I write orders for the man to go up to the ICU. I would prefer to have the second-year write the orders, because she's new to her role and can learn a lot from thinking through her admitting orders, but we're swamped and the patient needs to go upstairs. After he's gone, I admit the second patient, a 70-ish man with a small bowel obstruction, and call the intern to admit the third patient, a 40-ish woman with advanced cirrhosis, whose belly and legs are swollen with fluid. Cirrhosis creates abnormally high circulation pressures in the liver, which makes fluid leak into the abdomen. This condition is called ascites, and requires careful investigation, because the fluid can become infected and cause an overwhelming bacterial sepsis. This patient is very stable, however, and had been hospitalized recently for the same problem, so I'm hoping she doesn't need a paracentesis, or sampling of her ascites fluid.
Midnight: Okay, I'm officially having a bad night. There's going to be yet ANOTHER C-section! This time it's a woman who had a successful vaginal birth in the past, but whose current labor is not progressing at all. Earlier, I examined her and determined the fetus to be in an abnormal position, with the head tilted so that a wider diameter of the head was trying to pass through the incompletely dilated cervix. I asked the L&D nurses to make the patient do "labor gymnastics," moving from position to position--standing, rocking, squatting--to encourage the fetus to rotate into a functional position. No luck, so it's back to the OR for me and the FP attending...
1:01am: ...where a little girl who was trying to be born forehead-first is delivered easily from her mother's abdomen. Instead of having the typical "conehead" of an infant labored in normal position, this little girl's head looks almost square from the odd position she'd adopted in utero. Don't worry, it will look normal in a few days, now that she's out in the world.
2:15am: My pager wouldn't stop going off during that C-section. The intern needed my help writing orders on the woman with ascites, but I was tied up so she wrote them by herself. Now the ward staff is calling me for clarifications. Medical school cannot prepare a person to be an intern, only the school of hard knocks will teach a young doctor how to write good orders. I find the intern and we run through the case together. Turns out the Internal Medicine attending does want us to do a paracentesis, so that's another task we have to tackle. Meanwhile, the ER has yet another admission for us, a young man from one of the local prisons who has abdominal pain and sky-high liver enzymes--sounds like hepatitis, but the pain is in the wrong place, so he's going for a CAT scan of the abdomen, and therefore the intern and I have time to run upstairs to do the paracentesis.
3:00am: Have I ever mentioned how sneaky I am? I roll the bedside ultrasound from Labor and Delivery to the Medical-Surgical Unit so we can see where the ascites fluid is located in the patient's abdomen. A paracentesis involves inserting a needle into the abdomen, where a pocket of ascites fluid can be drained. Obviously, there's other structures in the abdomen that you have to avoid, such as intestines, a full bladder, and in this patient's case, an enormous spleen. A bedside ultrasound helps localize the fluid so you can minimize the risk of injuring these structures. I'm just glad Dr. B-U is soundly asleep in her call room, so she's not around to squawk about my pilfering. Our patient has a big pocket of ascites fluid in the right lower quadrant of her belly, which I help the intern aspirate using a small needle. Often time, ascites is drained with a large-bore needle and evacuated bottles. Sometimes 10 or more liters can be drained in this manner, but I just want to know whether the fluid is infected or not, so all I need is a quarter of a cup or so. Besides, who wouldn't prefer a small needle to a large one?
4:00am: Okay, the fluid is sampled and the intern's orders have been corrected. We both return to Labor and Delivery to find that a new patient has arrived. A woman was attempting a home birth with a midwife, but found she couldn't tolerate the pain of labor, so she came to the hospital. She has her husband, two family members, the midwife and two doulas, or professional labor supporters, in tow. Immediately there is a strange dynamic between this family and the staff. The husband follows the intern around, writing down everything she says and does. He seems to be challenging her authority--the family is not happy that the patient's care is being handled by a mere resident. The intern calls Dr. B-U for support, which ends up making everything worse, because she decides to lay down the law with an heavy hand. It doesn't help that the patient's fetal heart tracing is not at all reasurring, and she immediately needs a fetal scalp electrode for better monitoring. This is anathema to the home midwifery model of birth, so the midwife and doulas follow Dr. B-U out of the patient's room. A tense discussion follows, with raised voices--primarily La B-U's-- carrying all the way down the hall. At this moment, I decide to leave and write notes on all of the recent admissions. I don't want to get swept up in all the insanity, and this is the type of situation in which the fewer providers, the better.
5:00am: The ER patient is back from CAT scan. There are some interesting findings on the scan, suggesting gallbladder disease, which is interesting. Gallstones and their associated findings are often best seen on ultrasound, not CT, so the ER wants the man to undergo this study as well, and has contacted the surgeon on call for consultation. Originally I wanted the intern to do this admission, because it's an interesting case and she could learn a lot from it, but in light of Dr. Bloody Unpleasant and the recent midwife-vs.-OB conflict, I think it's better for her to stay near Labor and Delivery. I don't want the intern to get into trouble with Dr. B-U for neglecting her responsibilities there, so I admit the patient to the Surgery service.
6:00am: I'm finally done with my notes and reviewing the second-year's admissions. I catch a few of her errors and write some orders. This is the hardest part of being a third-year resident. No longer are you responsible for your own admissions, you have to check the junior residents' work as well. Hopefully you catch their oversights and help them learn from their admissions, without actually spending as much time on the administrative part (paperwork, communication, etc.) of the admission itself. And yet, it seems like I'm doing more admissions now, not less, because I have to go over all these details.
6:20am: The Mental Health Unit is calling to tell me about a patient in seclusion. They need me to make sure the patient is safely confined, and sign the seclusion order. This is really a bother, because it's not as though I'm not in the middle of anything else at this moment, is it? I tell them I'll be there as soon as I can, with the idea that I can get down there as soon as I've checked in to see if the Deck is under control....
6:50am: ....Which is not the case, since about three new patients have arrived since I was last there. Two of them are in labor, and need to be admitted. The intern is still finishing up other work, so I volunteer to admit one of them. While I'm interviewing the patient, the intern informs me that the failed home birth patient would like an intrathecal, or spinal analgesia. The intern isn't signed off on this procedure yet, dammit. I am sorely tempted to call the anesthesiologist to do this one, but the patient's nurse talks me into doing it. I spend a long time explaining the procedure to the patient, whose husband is hovering nearby. I decide to ignore him completely and concentrate on the patient, because I believe a lot of the complicated dynamics in the room have to do with everyone else--doulas, midwife, family, husband--imposing their wishes upon this patient. Not that neglecting the family is a good thing to do, but sometimes you just have to put the patient, not her family, first. The patient agrees to the intrathecal, but needs a new IV, so I'm stuck waiting for the nurses to place it. I'm getting nervous, because it's almost time for Morning Report and I can't be late. Of course, I have a hard time getting the intrathecal in, but eventually the forces of good prevail and the patient gets some much-needed pain relief.
8:00am: Morning Report! I round up all the X-rays and the intern and I present our cases. Where is the second-year? I have her paged, but she still does not appear. Finally, I start presenting one of her admissions, and she arrives mid-way through the presentation. Twenty minutes late. Slept late. I'm on my last nerve by this point, so after everyone else is gone, I tick her off fairly sternly for not showing up on time. (She's not our strongest second-year resident, to be honest, and needs to do simple things well, like show up on time and present her cases competently.) Besides, I don't want to get stuck presenting all of her patients--not very considerate to a colleague, to be late! We have a good discussion and part on good terms, which I consider a small triumph because I was feeling pretty scaly about the whole thing.
8:50am: Dammit! I never went to Mental Health. The incoming third-year wants to take pity on me and go to see the patient, but then gets swept up into a delivery. I don't want her to have to leave Labor and Delivery when it's so busy, so I trudge down to MHU to see the patient, a young man who thinks he is God and refuses to eat or drink. The psychiatrist wants me to evaluate the patient for dehydration, but the patient won't let me examine him. He is, however, standing up steadily, has normal vital signs, and is reported to be urinating regularly (in bed, unfortunately), and makes a pretty convincing dash for the door while I'm there, so I write a note documenting the likelihood that he has adequate hydration status, and hope that he starts drinking some water soon--he thinks it's poisoned.
What a joyous way to end a truly appalling call night. At least no one died, or even got close--and none of us got in trouble with Dr. Bloody Unpleasant, other than the poor midwife.