#im going to eventually post a big write up on my thoughts about diabetes in thedas but thats going to come later

[rozzwil]

A whole lot of thoughts and sketches on Isha’s T1D supplies and how he manages his diabetes day to day 💉🩸

[therunningpa]

New job & night shift novella

So I’ve been at a new job the past 6 weeks. I’m still a hospitalist, but I’ve moved to night shift. It’s a long story for another time, but basically I was getting burned out and it was either change shifts or move to a different department altogether. Because I love IM so much I am desperately clinging to it for the time being. In my current role, I only do new admissions and consults.

Since I only post now, like, once a year I figured I might as well write a nice long story for you guys! Because also, when have I kept things short, ever?

So, here you go, a narrative of my day (night?).

I leave my house, clutching my tote of Campbell’s Double Noodle soup cans, rice crackers, and Gatorade. I kiss my husband, tell him I love him, and remind him to please finish cleaning the kitchen for me. He needs a lot of reminding. I need a lot of therapy. We’ve had a lot of therapy. It’s been a year sober for him and the anniversary has been hard, bringing back the guilt big time. It’s been more down days than usual the past month and as I leave the house I can only hope I won’t get any liver patients or alcoholics tonight.

I pull in to the hospital, badge in through various doors, end up in the office. The day shift is coming to a close. “Hey!” my coworkers greet me, “Feeling better?”

“Tons! Not a hundred percent but good enough for active duty.”

My terrible med seeking external ED dump patient from earlier this week had given me her norovirus. I’d spent the previous night out sick, puking and near-syncopizing. (FYI- use the bleach wipes next time!!)

I check in with the three physicians I’m working with that night. One, a seasoned night shifter, a quiet man I dub “The Machine” because of his deftness and ease at admitting patients. One, a seasoned nocturnist, another quiet and confident man who could run a thousand codes without screaming “fuck!” not even once. The third, an exceedingly nice new residency graduate who recently started with us and is probably reconsidering the job after his first week on nights. They have a lot of patients coming from outlying facilities, but no one arrived yet.

I sit around for an hour and a half, check emails, clear my inbox of the previous day’s results and check up on a few of those patients, eat a cup of noodles, rub my belly, think about how I shouldn’t have had coffee, then, all at once, I have 3 admissions I’m called to see. Yes, it’s true, they really all do come at once.

I triage them, and go see first an unfortunate lady who is bleeding and clotting. Or rather, likely to bleed. She has a genetic disorder predisposing her to clots and bleeding, and has come in with chest pain. The chest CT showed a pulmonary embolism, one in each lung. I’d hoped they’d be subsegmental, but they weren’t. I meet with her, spend a long time talking. I tell her I’ll call the hematologist and get back to her. I put out a page.

I jump up to the orthopedics floor to see my next patient, a 73 year old lady with COPD and osteoporosis who fell down the stairs at home and probably broke her sacrum. She’s straightforward enough, other than saying she’s intolerant to everything IV opioid except fentanyl. Which she’s not going to get outside of the ED. I write for oxycodone and IV ketorolac and pray her pending labs show normal renal function.

The hematologist pages me while I’m writing patient 2′s note. He recommends a heparin drip, so it can be turned off quickly if patient 1 starts to bleed. He also says he has no idea what to do with her after that, as far as a long term plan. I text my attending and let him know the plan for tonight. While I’m finishing my note, he texts me back an SOS that patient 1 is refusing heparin because she’s afraid of bleeding.

I go back to the ED, I print out UpToDate, visit the poor lady with the PEs again. I talk about risks and benefits, types of heparin. She has some cognitive impairments from a stroke, but she gets it enough that she has capacity. She still declines the heparin, wants us to “watch her” overnight in the hospital though. I check in with bed control, ask for an IMCU bed since she’s refusing blood thinners, and am told there are no ICU beds left. She’ll have to go to the regular floor.

My third patient is a prisoner with history of peptic ulcers and GI bleed coming in with worsening anemia. Actually, he never shows up from the outside hospital because of some officer conflict. His name gets handed off to the next shift.

Fourth patient shows up in the IMCU, from an outside hospital. The notes he comes with are scanty. Acute on chronic hyponatremia, ?dementia. Hypotensive. Weak. I hope he can give me some history. When I walk in he tells me he’s in a hotel in a different state and doesn’t remember how he got here. He denies any symptoms or concerns. It’s 11 pm, but I dial his elderly wife and bless her, she’s up, and gives me the full scoop. He ends up with a slew of labs, head CT, cardiac echocardiogram.

Fifth patient was not supposed to be admitted. Just discharged 2 days ago with COPD flare, end stage COPD on home oxygen. I read the ED notes in the chart, indicating the family demanded the patient be admitted because they are unhappy and that we are being investigated for discharging her too soon, or was it the nursing home was being investigated for not taking care of her the past 2 days? Or both? The discharge summary from my PA colleague indicates the patient refused hospice the last stay. Awww nawwww. I go and see her. It’s late and at least that means the angry family has gone away. I sit with the patient, she’s very anxious, I’ve taken care of her before. I listen for a long time, answer questions, sometimes the same question over and over. She eventually admits her memory ain’t so good anymore. She then marvels “you’ve asked me more questions than anyone else has today”. I hope that’s a good thing. I go through her extensive workup and again conclude that “I am so sorry, but what you have is not fixable. I think we need to focus on trying to get your symptoms better, but we can’t cure you”. She agrees to at least have a palliative care consult. She grumbles about her bad nursing home experience and says her family called to have the bed held for the following day. I waggle my eyebrows at her “You know, if you don’t hold the bed they’ll give it up and then you’ll have to be here through the weekend and then we can see if your preferred nursing home has a spot now, But, you didn’t hear that from me!” She beams. Somewhere, a social worker has rolled over in their grave and pledges to haunt me in my dreams tonight.

I run up to my office again and eat some more noodles, drink Gatorade, rub my gastroparetic-feeling tummy, and finish up my notes just as one of the physicians strides in with a cardiology consult for a patient who just had a STEMI, now in the coronary ICU. They were found to have multivessel coronary artery disease, received a stent. “Should be easy” he says, “Cardiology has done everything!”.

Except, they haven’t. Patient is from outside our system. Needs an entire medical record update. I also notice his blood sugar is > 300 and there’s no insulin ordered. I add “Type 2 Diabetes” to his problem list. I go in and see him, expecting him to be asleep at 1:30 in the morning, but he is wide awake and surrounded by family. He’s a good soul, we have a long talk about diabetes. His wife has a lot of cardiac questions and try to answer as able. His nurse pops in. “His blood pressure is greater than 150 and they want him under that post cath. There’s no medications ordered”. I step out, sigh. Honestly, I have no idea what cardiology does or does not want for an antihypertensive in their post cath patient. I have a sneaking suspicion it also varies widely by the cardiologist. I wish they would order this shit on their people already. I’m just here for the diabeet-us. Gah! 

“What do they usually do for the post cath protocol?” I wonder out loud.

“How about some PO metropolol?” a nurse asks.

I make a face “Really? They do that?”

The nurse looks horrified “Um, yeah, all MIs should be getting that!”

I shake my head “No, I know that, that’s not what I meant, I just mean it’s not going to act rapidly and it’s not going to do much, I mean maybe IV metoprolol but-”

She looks further horrified “No, they never do IV!”

I wanted to say “but I would never give that”, finishing my thought, but instead I shrug and give up. “I’ll ask the attending.” 

I don’t work in the ICUs that often, and I especially don’t know the night crew being new at this job. It’s true what they say, sometimes you need to earn your stripes with some ICU staff, especially if you’re a PA. Also, goddammit cardiology, order your antihypertensives! And beta blockers! And statins! (Also, I love you my cardiology people out there, please don’t take my 2 AM thoughts too seriously to heart, ok?)

I trudge back to my office, finish writing notes and checking labs and imaging that have come back. The demented hyponatremic guy does not have a brain bleed. The COPD flare bounce back has a normal procalcitonin. The untreated PE has normal blood pressures. Broken sacrum indeed does have normal renal function. I order new labs for the day crew. I report out to my docs. Around 3:30 AM I hang up my coat, collect my soup and Gatorade cans to recycle, and stumble out the cold wintry parking garage. I cast a few glances, good, no creepers trolling about, get in my car, and drive home.

I drive through the industrial part of the city and through spotlights and fog I see that the operations are already going at this ungodly hour. Backstreet Boys is playing on the radio. I pull into the back alley outside my house. I tentatively feel my way through the backyard, trying not to fall on my ass on the ice over our sidewalk, like I did the other night. I slip inside, and am completely delighted to see that not only has the kitchen been cleaned but there’s a loaf of homemade banana bread sitting out, steaming a little still. I hear a soft pitter-patter and my puppy steals down the stairwell to greet me. She wiggles from head to toe and jumps on me, playfully stealing my lanyard of keys and running away, shaking them. I took her home one day from a rescue this past summer, pretty much against my husband’s will, and I secretly believe she at least 75% the reason his depression lifted. He now agrees. I let her out to pee, then tread upstairs and wash my face and put on my pajamas, kiss my sleeping husband. I’m too wired to sleep though, maybe because I spent the last day and a half sleeping off the norovirus, so I go back downstairs, eat some banana bread, and start to write.