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Well- I've just about finished/survived my first month as an intern. On the main medicine ward, its been Team 'A', 3 interns, a junior resident, 2 first year Harvard med students and a fourth year student sub-intern. It has been the busiest July at the Mass General in recent memory. Averaging 5 admissions per call per intern on the public service. Every third night call comes around quickly, especially if you've left the hospital pre-call the night before at 11pm, and are returning the next morning for another 30 hours.
Unlike most traditional ward medicine teams, the MGH Bigalow public service is more team oriented, where we all follow patients. Every third day you are on call for your team, writing progress notes on all the patients (we usually have between 23-28 patients), and admitting patients new patients to the team from the Emergency Ward, or on transfer from one of the Intensive care or step-down units. Usually don't sleep on call, trying to write admission notes, running the cases by the one junior covering all four medical teams (A-through D), and keeping the teams' patients alive and kicking until morning.
Post-call days one's job is to stay awake on rounds and present the new patients. By noon its a sense of relief and off to home to sleep (or try to enjoy the day- I made it sailing on the Charles river once with one of my clinic attendings I ran into while rollerblading home down the Esplanade, and also went to my first Red-Sox game (though I slept through a couple of innings). The 3rd day you are the "Swing" intern, and the job is to get all the scut done for the day- calling the consults, getting the tests run, checking the labs and reading the charts, writing all the orders, dealing with decompensating patients, chest pain etc. Its a crazy, hectic, stressful job.
We round as a team each 7:30 am. We meet with the attendings, have X-ray rounds, and go over and see new and talk about old patients from 10-noon. Then noon conference marks the end of the formal day (gotta get there early to get food- often pretty good Indian/Mexican/ or greasy pizzas). Then its trying to get the work done and get home (averaging around 10 PM) when on swing duty, to come in the next day on call.
Some of our current patients...
Ms M is starting the IV Morphine drip to oblivion. The family is pushing it. The nurses are pushing it. Nothing more done. Diagnosed with metastatic lung Ca after being admitted for TB and diarrhea. Dwindled fast. Always looked like shit. Now she is sure, wants it done and over. No hospice for her. 45 pack year smoker she is 52 for a while longer.
Declared my first patient dead the last call night, or was it morning around 5:30. Much of the extended family was there, which was nice , but painful as they watched their sister mother, grandmother on the C-PAP positive pressure breathing mask, taking her final breaths over a 16 hour period. The ravages of advancing rheumatoid lung despite high dose steroids. Each night it was getting harder to keep her sat above 80%, to high flow to CPAP. A Do Not Intubate (DNI) declared. In on rounds she was struggling... a blood gas came back with a CO2 in the 70s. Called the family in. This time she wasn't going to pull out of it. Filled out the forms. Called the admitting office for the discharge to the big man upstairs...
Mr D. left today. Our Jovial overweight, Italian chef had pancreatitis, despite the fact that he doesn t drink. His lipase, amylase were down, and he'd stopped spiking temps. We "The A Team" now have a gift certificate to his Italian restaurant.
Mr M., some excitement the other day on call, when he had elevated S-T on his ECG. Big MI? ... all leads. Turns out to be pericarditis. Good thing we didn't heparanize him. The echocardiogram confirmed it. His chest tube is in place and draining what is probably a malignant effusion. Seems like we have the lung cancer ward this month. Nice Italian man. Family there to translate. I'm getting better at my, Bonna Sera, and converting my Spanish to Itanglish.
Drawing blood on the neurotic woman from NYC with an infected vein graft harvest site, 3 months out from her quadruple bypass CABG. A real laugh riot.
4am- taking Mrs. M, a 75 yo women with metastatic angiosarcoma to the MRI to r/o cord compression as mets to her spine rendered her acutely nuerologically impaired. Had to snow her with over 30 mg of Haldol to get her through the scan.
Mrs. S, 48 yrs old rom the Hills of Maine, who let an ear infection with puss coming out his ear brew for a month until he developed facial palsy, and osteomyelitis of his skull- comes to us from the ICU, for hyperbaric oxygen and antibiotics.
Mr Joe . Our team's darling mascot. Very pleasantly, and most amusingly demented, and always pulling out his suprapubic catheter, he is full of congenial confabulations to the questions we pose to him. He returned to us from the nursing home after a fall. Doesn't eat much but chocolate Ensure and sit, poseyed to his chair by the nursing station so we can keep an eye on him.
Timmy, the 23 year old chronic vegetative state patient transferred over a month ago from rehab with pneumonia, status post MVA (car vs. pole), now ventilator dependent. The parents take shifts, and one is always there... since April. Poor poor prognosis. Poor family.
The end stage AIDS patient transferred from the ICU with an almost brain herniation from a large brain mass, either toxoplasmosis or lymphoma. Comfort measures only. Though now he is coming out of it a bit, despite being on a morphine drip at 10mg an hour. Barely touches this heavy IVDA heroin user. No brain Biopsy... like our other similar patient a week or so ago. Went for brain bx. Showed lymphoma, STarted radiation treatment. but why. Had a huge GI bleed. Died that night. The first death for our team. Not unexpected. Not too tragic?
Got AIDS from a needlestick working in a lab. Does that make it any more tragic at 42 yrs old?
Signed out tonight at 10pm . Tomorrow on call. Never-ending.
Next week. Its on the to the Intensive Care Unit.
Ciao for now-
Daniel
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