Performing my IADLs

When I started internship, I knew that posting would be intermittent, but the longer it had been since I posted, the more pressure I felt to write something especially insightful. The days turned into weeks, and here we are at a whole month since my last post! I've read about this happening to other physicians-in-training with blogs, and I decided just to post about whatever comes into my head. Here we go!

The last month was fantastic! I was on an outpatient rotation, which entailed seminars and clinical experiences aimed at residents interested in primary care. While I should probably write about my excellent clinical and didactic experiences, the best part of the last month was having time for what physicians call "Instrumental Activities of Daily Living" or "IADLs". During a geriatrics conference, IADLs were jokingly referred to as "Things interns don't have time to do." It's funny but sadly true. IADLs include the following:

• Using a telephone. During my last wards month, I had many voice mails from my mother, and at one point, she called my husband to make sure nothing had happened to me. Well, internship happened to me, but during the last month, my whole family came to town to visit. Plus, I was able to chat with some old friends I hadn't spoken to in a few months.


• Grocery shopping and cooking meals. After burning myself on the oven my first month, I've not been as keen to cook. I do have a few recipes that I can throw together in a few minutes, such as fried rice or spaghetti, but after two years of marriage, my husband is now learning how to cook basically out of necessity. Plus, my stomach wasn't adjusting well to our greasy take-out diet. Over the last few weeks, I was able to indulge in one of my favorite hobbies--trying new recipes. Yesterday, I made my own pizza dough, and I put some in the freezer for the upcoming wards month along with some frozen vegetables.


• Housekeeping. During this month, my husband and I actually bought some furniture and finished unpacking our boxes from our move over three months ago. Yay!


• Laundry. If my husband didn't wash my clothes for me, I probably would be wearing scrubs daily because the hospital launders them. I hate wearing scrubs mostly because they don't fit and drag on the ground behind me, making me look like a kid playing doctor, but if my husband goes on strike, I'd wear them.


• Paying bills. Credit cards would never get paid without the automatic payment feature.

IADLs contrast with another scale used by physicians describing Activities of Daily Living (ADLs). They are things that interns (hopefully) still do regardless how busy they are, including bathing, brushing teeth, feeding themselves, dressing, and using the toilet. However, I've been known to be driving home at 9 pm realizing I hadn't been to the bathroom since the morning, and there are days when I would have starved had it not been for the granola bars in my pockets.

I really do want to write about some of my other experiences during this month, including giving a talk in front of my fellow interns and residents and learning about outpatient pain management. However, I'm basking in my last two consecutive days off until January.

My pager: Putting things in perspective

I meant to write this post last week, but I kept putting it off. Anyway, I had that really crazy week, and as my husband pointed out, it wasn't a bad week, just a very busy one. I went to the beach on my day off, and while soaking in the sun, I was able to reflect on my week.

With a little distance, I could see that I was getting overwhelmed. What I really needed to do was take a few deep breaths and tick things off my to do list one at a time. It's easy to feel overwhelmed when my pager is going off every 30 seconds interrupting my routine. Coming from the ICU, I was used to returning pages right away, but I've learned that I don't always need to sprint to the nearest phone when my pager goes off on the wards. Sometimes I should take a few minutes and finish eating or the conversation I'm having with a consultant. About 99% of the pages I receive are not urgent at all. Most of the time it's the phone number of a nurse who wants to tell me that someone didn't eat any breakfast or would prefer ibuprofen over tylenol. With anything urgent, they text message me what I need to know immediately. After figuring that out, I've managed to avoid heartburn from gobbling up my lunch in the elevator and actually sit through a few conferences.

I'm on my last week of this wards block. Tonight will be my last overnight call for a few months because I'll be on a few specialty services (cardiology, oncology) that have different call schemes. While I like admitting all my own patients, I won't miss overnight call and how it screws up my sleeping schedule for days. I can't wait for next week because I start a whole month of primary care!

What a week!

If I've been painting a rosy picture of internship, maybe it's because I've been lucky enough to have a few good weeks or maybe a bad day here or there mixed with mostly good days. This week was terrible. Everyday was a nightmare. When I tried to explain my bad days to my husband, he pointed out that nothing really bad (e.g. patient dying, giving someone the wrong drug) happened; I just had long, busy days. The wards are a crazy balancing act, and I'm working on my juggling skills. Our schedules aren't so bad if everything goes according to plan, but some things can really screw up your day:

1. When admitting, all your new patients can come to the floor at the same time. The way we're assigned patients is designed to avoid this. However, patients come from the ER, directly from clinic, transferred from other hospitals, and transferred from the ICU. Although I hear about the patients at neatly spaced intervals, through the mysteries of patient transport, sometimes they all come at once. So, I have to run around and make sure they're all stable and then try and do a quick assessment to put some basic orders in the computer (patients will complain if they don't get dinner, and nurses will complain if there are no orders in the system!). Once they're stable with dinner on the way, I have to figure out what's wrong with my new patients and how I'm going to fix them (or at least what to order to help narrow down the differential).

2. Patients can become unstable. Nothing can destabilize my day like a call that says, "Your patient is having shortness of breath and is desating to the 80s." Yikes! People not being able to deliver oxygen to their organs is really bad, and it requires dropping whatever you were doing (e.g. rounding with the team, writing prescriptions so another patient could catch his 2 pm ambulance to rehab, eating lunch and enjoying a teaching conference, or preparing your signout to leave for the day) and running in that direction. Having been in the MICU, I have some experience with unstable patients, but I also have more patients to take care of. Once the patient's oxygen saturation has gone back up with a face mask, blood has been sent to the lab, the STAT portable chest xray team are on their way, when is it okay for me to resume my other activities? For me, not for a while. The best I can do is park myself at a portable computer outside the patient's room and try to move my other patients along, but it's hard to think about anything else except my patient possibly needing to be moved to the ICU.

3. The absence of a member of your team. I'm fortunate to be on another great team, but when one team member is gone, things can get crazy. Sometimes they're at clinic or have the day off, and in addition to my work, I'm responsible for their patients, too. Double the patients to take care of! Whenever that's going to happen, we try to make sure everyone is "tucked" (e.g. discharge summaries and prescriptions ready for possible discharges, labs ordered, consults called, etc.) but sometimes you can't predict what will happen when you're covering someone else's patients. Also, having a covering attending or resident can throw everything up in the air as he or she can have a different interpretation of events and labs and want to completely change the plan. Of course, they'll say to me, "It's your patient, and your team has a plan. However, I'm not sure why you haven't considered this possibility." Well, when you put it like that, I'd be hard pressed not to go along with their suggestions.

4. Medical students. I absolutely love having medical students and teaching them, but in the crazy juggling act that is my day, finding time for them can be difficult. As I was a student just a few months ago, I remember very well what it was like to be a med student on the wards. I try to get my students out as early as I can although sometimes they insist on staying for some unknown reason. I'll take a few minutes here or there to teach them something (e.g. reading chest xrays or EKG's, going over the differential or workup of a particular problem), but some days the best I can do is try to be a role model of a busy but hopefully intelligent and efficient intern.

What makes these crazy days better? Help from my resident and moral support from my co-interns during the day, and when I come home, a big hug and some understanding from my husband that it'll take me a few minutes to shake off my grouchy mood.

Time to go to the beach, so I can start another week rejuvenated.

Goodbye, MICU! Hello, wards!

Oh man, my last overnight call in the MICU was pretty rough. No sleep. All my other nights I slept at least 45 minutes to an hour, but the next morning I took the advice of my attending and just kept moving because if I stopped I would realize how tired I was. It's really my own fault for not getting any sleep. If things aren't too busy, I usually update future discharge summaries and note templates until 1 or 2 am. If all is quiet then, I aim to sleep between 2 and 5 am, but if a patient starts becoming unstable around then, sleep is hard to come by.

After a week on the wards, I surprisingly find myself missing the MICU. There's a wonderful sense of teamwork among your fellow interns and residents as well as with the nursing and support staff. They were all my new best friends because we depended on each other so much, and now if I pass by one of them in the hallway, we chat as if it's been years since we've seen one another.

However, there are things I don't miss about the MICU:
1. Overnight call every fourth night. It wasn't so bad at the beginning, but the sleep deprivation towards the end was making me a grouch.

2. Carrying the code pager and being on the code team. Although I had the code pager, codes were always announced on the overhead paging system first. I still get a catecholamine rush whenever there's an overhead announcement even though nine times out of ten it's something like "there will be a nondenominational mass held in the chapel at 11 am." Going to codes was fine because my role was well-defined (chest compressions, get an ABG, fetch anything that someone yelled out), but the constant state of readiness was exhausting.

3. Calling family members to let them know their loved one has taken a turn for the worse. I don't mind talking to families. I usually enjoy it, but breaking bad news isn't something that I want to do. It comes with the MICU territory because all the patients are so sick.

It's a bit of a shock to be on the wards again. My patients aren't intubated. They can talk to me, walk to the bathroom themselves, reposition for me to examine them, and often complain about the quality of the food. After being in MICU, these patients barely look sick to me, so I'm working on recalibrating my eyes. I can't say that the schedule is loads better than the MICU because some days I went home relatively early from the unit, but I can't emphasize how nice it is to sleep in my own bed more often.

Being "Doctor" Jess

One of my first nights, a patient's family member came up to me and asked if I was one of the doctors, and after a confused paused, I realized that the correct answer was "Yes!"

I haven't yet introduced myself as "Dr. ____" to anyone yet. It's still too strange to me. I usually just state my full name and then say "I'm one of the doctors in the ICU." I've only signed my name with "MD" a few times and only when it seemed necessary to say explicitly that I'm a doctor, such as death paperwork. For my charting, I just stick with "PGY-1".

As hesitant as I am to shout from the rooftops that I'm a doctor. I'm realizing how much I love being one. My worst experiences in medicine have been when I just followed orders instead of questioning the plan set by my residents and attending. In the ICU, I'm on a great team that values my opinion. When I say I'm concerned about my patients, they listen, and we discuss the best course of action. It's hard to believe that I only have two calls left in the ICU, and then I'll likely be on the wards, which will present a new set of challenges.

Outside the hospital, I've been making an effort to see my husband and friends. There have been definitely sacrifices, such as missing a friend's out-of-town wedding and not seeing my husband everyday. However, this week after my usual post call nap, I went to see the new Harry Potter movie and have a delicious meal in Chinatown. Despite the constant exhaustion, I never regret going out. It makes me feel like a normal person for a little while. Even working up to 80 hours a week (and it's pretty close to that), I haven't had to sacrifice all the joys in my life. My Tivo keeps all my favorite reality TV shows, such as So You Think You Can Dance, for me, and I've been rereading my Harry Potter books in my spare time.

It's taken me three times as long to figure out what to say in this post. What am I really trying to say? I'm surviving, and it's not so bad. It's actually pretty darn good.

As the sleep deprivation sets in

I woke up this morning and thought, "I can't believe I'm on call again tomorrow. Wasn't I just on call the other night?" Yes, I was just on call Saturday night and again tomorrow night. That's the beauty of a q4 call (every fourth night). On my noncall days, I used to stay in the MICU an extra hour to do paperwork--update notes, discharge summaries, or the signout, but now when the resident suggests I go home, I say thanks, grab my bag, and run out the door.

I now recall during intern orientation an excellent talk about sleep deprivation. The presenter said that trying to judge how impaired you are when sleep deprived is as accurate as doing so when you're drunk. During one of my first post call days, I woke up from my nap and tried to cook some dinner for me and my husband. I thought I was fine after my nap, but I ended up burning my arm on the oven door! How bad was my reaction time? I have a very nice, painful, second-degree burn to remind myself that I'm a poor judge of how impaired I am post call. We eat out now on post-call days!

I'm going to sleep earlier and earlier every night trying to remedy the sleep debt, but the truth is I'm just plain tired most of the time. I have 3 more calls in the MICU but I honestly don't think being on the wards next is going to be any easier on my sleep schedule or social life. All I'm thinking about now is seeing the new Harry Potter movie on my post call day. Just one more 30-hour shift until the movie and a day off!

And on the seventh day ...

I'm resting. There are so many things I could write about because this week has been full of firsts and emotions. Off the top of my head ...

I did my first procedure this week. I was finishing up my work at the end of the day when my resident text paged me, "Get over here. You're doing a lumbar puncture." I had never done one before, but I had seen a few. To make a long story short, I did it! What I felt when I saw the cerebrospinal fluid coming out from the needle in my patient's back was disbelief. I couldn't believe I had done it. My resident was like a proud father running around the ICU telling anyone that would hear that his brand new intern did her first lumbar puncture on her first try. It was pretty cute. I got a lot of pats on the back, and I'm pretty sure that's the closest I'll ever get to feeling like a rock star.

The down side of my rock star moment was that I was very late for my friend's birthday party. I was also dead tired and barely able to hold conversation with an awful tendency to talk about my lack of sleep and little else. I felt terrible because we had purposely arranged the dinner for the night before I was on call (logically known as the "precall" night). Typically your team tries to get you out early on your precall night so you can get a good night's sleep before your overnight shift. What my friend and I hadn't anticipated was my co-intern being off on my precall day, which meant that I was covering the whole service by myself, and things were pretty busy.

As I enjoy my day off, I know that my co-intern is now feeling what I went through on Thursday and Friday (his post call and off days). While the time off is well deserved, it comes at a price. Someone has to take care of my patients every minute I'm not in the hospital. At night plus my post call and off days, one of my co-interns is taking on my load so that I can enjoy my time out of the ICU. I do the same for them. We are all dependent on each other, and I'm with a great group of interns in the unit. We're still trying to find out the best ways to help each other because we're all new at this, but we are all helping each other. This dependency on my teammates is something new for me. As a medical student, sometimes you're a bit extraneous. You're there to learn, and if you can do some work to help the team, then that's great. However, the team can run well (and likely more efficiently) without you. You're sent home way before the rest of team because you have books to read and tests to study for.

After my call yesterday, I got home and slept until 5 pm. My husband and I went out for a wonderful dinner outside on a restaurant patio. I enjoyed actually being outdoors, and he and I talked for hours with each other. There was so much to catch up on! I have no definite plans for today except to relax and maybe read a little bit about ICU management of patients. I want to cook a meal in my lovely new, under-utilized kitchen, call my mother, and deposit my first paycheck. Otherwise, I'm a little surprised at how ready I feel to dive back into work tomorrow morning.