EDIT: This post was started at 0414 and completed at 1310 PM
Life gives you lessons. They’re not always the lessons you set out to learn, but they’re available nonetheless if you just quiet down enough to listen to them.
Tonight started off auspiciously enough. With Irene bearing down on University Hospital, I trekked up to the OB floor with two other students, one of whom had never done OB before (like me) and another of my friends who just finished OB. I quickly met the team and shadowed the intern in triage befor sign out, where I got to see my first OB exam. Man are they focused! Membranes, bleeding, movement, contractions, OB hx, maybe a cursory PMH and we’re off to ultrasound land. I don’t even know why they carry stethoscopes (in case the FHR monitor breaks?) … But it was kind of cool. Even the intern seemed like he knew what he was doing. And the attending was amiable and she even cracked a few jokes. She seemed tired, though experienced, when she dictated a discharge summary in her sleep.
I got to meet one of the moms mom, and I would check in on her every hour or two, although not much was going on with her labor (alas…). Mostly my suspicions about hospital medicine from watching Grays Anatomy were confirmed: everyone’s tired, people make inappropriate jokes all tone time, and it’s a lot of hard work. Okay, maybe that’s not what most people take home from grays anatomy but … C’est la vie.
1945: Man, the OB exam is focused. Chief Complaint? Bleeding? Membranes? Contractions? Movement? Vitals? OB/GYN History? Vaginal exam if indicated (obviously performed in an appropriate setting by an appropriately trained person)? Look at the strip. Dip urine. Send CBC type and cross … and you’re done. Of course it’s not that simple, and the art is in the interpretation and not in the procedures. But it’s so totally different from outpatient medicine. There’s no question of why the patient is here (Umm, I have this parasite inside me and if I don’t get it out within 38-42 weeks then it might kill me, but then also, we need to keep it alive cause it’s kind of important y’know?), but labor is notoriously difficult to predict.
2231: After a coupla sections, some nice work in triage by the intern and a vaginal birth, the board looks pretty clear except for my mom, two CNM moms and a mom seen by her private OB. All in all, a good night so far. Just gotta hunker down and wait to see how this one goes.
23:30 one of the fourth years comes in and asks us to go to some of the medical floors because they need help. Okay, fine. I came here to help the hospital, not just to learn, and I’ve already spent 6 hours on the floor. No, I didn’t get to do a pelvic exam, and I didn’t scrub in, but my classmates did, so that’s fine – you can’t win ’em all. Besides, I’m starting 8 weeks of OB so … off I went.
23:40 We met one of the nurse managers on a different floor. He tells us that we’re going to be replacing nursing aides so that they can go back to work on their own floors. Okay, fine. Again, I didn’t come here expecting to be first assist on a Whipple or expecting to run a code. I’m here to help. Then, he drops the kicker: these nursing aides were all on 1:1’s. For those of you that don’t know, a 1:1 is when a hospital staff member supervises a patient every minute of every day. The hospital staff member cannot leave the sight of the patient, even for an instant, unless they are replaced or have their task (very temporarily) taken over by a kind RN or staffer. The nurse tries to put some kind of exciting spin on it, saying that most of the 1:1’s (90%, he says) are for psychiatric patients. First, that’s not true. 90% of 1:1’s are ordered for dementia patients. Secondly, I’m not really sure whether that would be better or not.
My reaction at this point is basically one of incredulity. I look at the two fourth year students and the fourth year post-MD/PhD who are with me, and realize that they are basically interns. They’ve all finished their sub-Is, and only have electives left this year. Between the four of us, we have 33 years of post-secondary education, and we’re being sent to do a job that most high school students are already overqualified for. Honestly, that sounds really snotty and entitled, but that’s what I was thinking at that point in time. I recognized it, and didn’t say anything, and gamely went down to my medical floor where I met the pleasantly demented 75 year old man (“Mr. Quincy”) who I would babysit for the next seven hours.
Yes, seven hours. I agreed to stay on the floor until shift change. I don’t know why I did, but it just seemed like the right thing to do, and honestly, I figured that this dude could always find something even worse for me to do … like bedpan changes or something …
0300: And so it goes: read 2 pages of Blueprints OB/GYN, Mr. Quincy pulls out another EKG lead, consider telling nurse I changed my mind about his prn Ativan and his Vitamin H (great youtube song, BTW), decide that I can just deal with it, continue dealing with it, wipe up vomit from his face (since his hands are now restrained), refuse (again) to “go get my pretty wife” (he thought the precious aide was my wife, and apparently found her so delightful that he repeatedly propositioned her in very colorful terms. Hence the PRNs.), try to close the door just enough that he can sleep but not enough that I can’t see him (fail) try to readjust his position and blankets (fail). Wonder, loudly, often why a patient who is DNR/DNI with hx metatstatic ca and recent NSTEMI is getting serial troponins (for which we have to blow out more veins and wake him up twice each night). The night nurses are great and generally amused by the fact that I’m still here watching this guy.
420: as I’m writing this liveblog, it hits me! All I have to do is tell him to go to sleep.
“Mr. Quincy, sir, it’s 4:20 at night. Right now it’s time for you to go to sleep. I need you to go to sleep, okay?”
“mmrmrmrrhrhrhr … mmmmrmrrm … okay”
[that’s a metaphor for my neurons. Some of them are exulting in victory, while the others are completely fucking dumbfounded at what is going on around them]
WAIT WHAT?!?!? THAT ACTUALLY WORKED? What the hell kind of alternate universe am I living in? But, sure enough, he actually slept until I left at shift change, at 700 AM this morning. Drive home after the hurricane passes – some flooding, didn’t end up nearly as bad as I had thought/feared.
Conclusions to follow in the next post, this one is already waaaaay too long