#ive never ever had good pt or ot in the hospital

[bloodanddiscoballs]

I hate you physical therapy and occupational therapy people in the hospital

[hangrypa]

s/p first year as a PA

I was hired as a hospitalist primarily for the transplant service. However, in the setting of the pandemic and staffing shortages, I am all over the place now and work in almost everything non-pediatric and non-surgical. 

In my first few months as a PA, I was incredibly overwhelmed. I went from being a learner who switches specialties every month to a fully-fledged provider making life-or-death decisions on an hourly basis. Oftentimes I’d find myself in the room of a patient actively crumping, surrounded by the patient’s family and multiple nurses awaiting instructions on what to do to save the patient. I thought that I faced a lot of pressure in school, but it was nothing compared to this. 

And just when I started to get a hang of it all, the pandemic hit. What a nightmare. As mentioned above, I was hired to work with with transplant patients. Prior to the pandemic, my transplant colleagues and I were masking and gowning for almost every patient: 1 surgical mask and 1 gown per patient and per patient encounter. But once COVID hit, we were rationing PPE. 1 N95, 1 pair of goggles, and 1 face shield for the pandemic. 1 surgical mask per week, and 1 gown only if a patient had Cdiff or a history of MDRO bacteremia.

What did the pandemic mean for our transplant patients? 

Our patients are on immunosuppressant medications to prevent transplant rejection. Unfortunately, this makes it difficult for them to fight infections. 

Our department did what it could to prevent COVID. We'd test patients on admission for COVID, regardless of symptoms or exposure history. If they were positive, they went to the COVID team and quarantined on their unit for a period of time and had to test negative before returning to our unit and being transplanted. We took many other measures to reduce COVID risk to the best of our ability. 

People still died. To see someone get transplanted successfully and then die of a virus is horrifying. Unfortunately, despite our admission tests, sometimes patients contracted COVID within the hospital. Patients would be happily FaceTiming their family one moment, telling them all of their plans for once they were discharged- then the next day they'd be intubated. We tried Remdesivir, Dexamethasone, prone positioning, etc. But the virus moved through them quickly, and these efforts often were too late. No amount of hoping and praying brought them back. 

As a first year PA, I learned to go to an empty conference room, close the door, and remove my mask before calling to the family of the deceased. This way, as they gathered around the phone in their homes, the family could hear me unmuffled as I delivered the news. Also, this way my tears didn't ruin my mask for the rest of the week. 

I learned a lot this year. It's been a mixture of crying and laughing. There are times that I question why I ever became a PA, and then there are times when this career feels like home. In addition to transplant, I’ve also been working in the  ED, IMC, ICU, inpatient hospice, clinic, and infusion center these past 6 months. I’ve learned quite a lot along the way.

Lessons learned as a first year PA:

1. Check your pager hourly: This is in addition to checking it whenever you get paged. Sometimes I’ll get paged while I’m rounding, read it, and then forget about it. Now I go through my pager at every hour to ensure that I already responded to all my pages and then answer ones that I missed/forgot.  On a semi-related note, a while back I wrote about good paging etiquette.

2. Let people know when you're out: I work a rotating schedule. As a result, it’s hard to predict when I’m in or out of the hospital. Sometimes I’ll come back on service and find urgent emails or texts that are a few days old. Now I leave an away message with my return date and my supervisor’s contact information on both email and hospital text. If someone really needs to get a hold of me, my supervisor has my personal cell phone number.

3. Be conscientious of what time you consult: I generally try to get all of my nonurgent consults done before 3pm. Many services have only 1 resident covering after 3pm, so I try not to page/call unless I have an emergency. 

4. Call the nurse if something needs to be done urgently: Being a nurse means being the ultimate multitasker. Room 5 is due for his IV Amphotericin, Room 2's Foley is supposed to come out prior to void trial with Urology, Room 1's infusion completed and is beeping, and Room 4 is a bit altered and yanked out her PICC. Now I’m placing an order for Room 3 to get IV Lasix due to concern for pulmonary edema. However, the nurse may be preoccupied with Room 4 and not see the order in the computer for some time. If I really need to the patient to get the Lasix right way, I’ll place the order through EMR and then call the nurse and see what their situation is. If they’re crazy busy with Room 4 and likely to be unable to get to the Lasix within the next 15min, I ask whether they’re okay with me asking another nurse to give the Lasix now. Usually the answer is yes.

5. Value your nurses: Nurses know the patient best. They’re the ones answering call bells, giving meds, doing dressing changes, etc. Unfortunately they oftentimes bear the brunt of everyone’s frustrations, from patients to patients’ families to attendings to managers. Not to mention, they’re the ones doing the dirty work. Bedside nurses are the heartbeat of healthcare, but they also are high risk for burnout. Always support your nurses, whether that’s volunteering to answer a patient’s family member’s 17th phone call of the day or responding to a patient’s call bell yourself. 

6. Know how to get a hold of someone quickly: It’s less than ideal to page someone repeatedly. At my hospital, if I need to talk to an attending urgently, I call the operator and ask them to connect me directly to the attending’s cell phone. If a patient is crashing and we’re not in the ICU, I dial the emergency number and call a rapid response, which sends people running into my patient’s room. 

7. Plan your discharge meds from Day 1: The goal of every admission is to treat the patient and then discharge them safely. Send medications early for prior auth and call the pharmacy to make sure that they have medications in stock. (One time a patient’s insurance didn’t cover Levofloxacin, of all things.) 

8. Keep social work and care coordination aware of all needs from the start: Does your patient looks unsteady? Place a PT/OT consult and let social work and care coordination know that the patient might require home therapy services and/or DME so that they can start looking at services and companies that may be covered by insurance. Does your patient have a central line? They’ll likely need a home health service to teach them how to care for it daily at home. Do they seem to require frequent transfusions? They’ll probably need labs on discharge. Is the patient’s living situation safe (no heat/AC, possible abuse at home, financial difficulties, etc)? They may need alternative housing.

9. The attending is not always right: Generally speaking, the attending has the last say on how the team manages a patient. However, I’ve come across situations in which an attending’s decision put a patient in more danger. Sometimes asking them about their decision can help steer the care plan toward better patient care. Other times you just have to stand your ground and be okay with being on the receiving end of an attending’s misdirected rant. Report these instances to your manager and to other higher-ups.

10. Always have gloves in your pocket: You never know when you’ll find a mess. Or which part of the body someone asks you to examine. Or how hygienic a person is (or is not).

11. Verify weird vitals: I was very new when I walked into work, opened a patient’s chart, and promptly bolted down the hallway when I saw a patient’s O2 sats recorded as 15-20s. I found the patient sitting up in bed, eating breakfast, and bewildered by me bursting into the room. Turns out that overnight someone mistakenly recorded his respirations as the O2 sats.

12. Remove whatever tubes you can: Anything entering the body is an infection risk. Does your patient still need that Foley placed by the surgery team? No? Yank it (don’t actually yank because ouch). Is your patient A&O and able to eat without aspirating? Remove the NG tube. Does your patient have good veins and require infrequent transfusions/labwork? Pull their central line.

13. Take a buddy with you to emergencies: Two heads are better than one. Even if you’re a seasoned provider and well-equipped to manage an emergency, you might need another body to help with performing CPR, making urgent calls, grabbing supplies, etc. 

14. Ask your patients about premeds for procedures: We all have different levels of pain tolerance. A procedure goes far more smoothly if your patient is comfortable. Note: if you’re going to premed with Ativan or an opiate in the outpatient setting, make sure they have a driver.

15. Be good to your charge nurse and unit secretary: I don’t know how they do it. If I had to manage the unit’s signout, patient complaints, calls from other floor, being yelled at by providers, verifying paper orders, and finding beds for incoming patients- all at the same time - I’d lose my mind. 

16. If your patient is mad, just shut up and listen: There are many things that you can’t control: the time it takes for a patient to get a room, the temperature of hospital food, the dismissive attitude of your attending, etc. And oftentimes the patient knows this. My reflex is to want to apologize for things and overexplain why different things are happening. But sometimes the patient just needs to rant. Take a step back and just listen. That can make all the difference.

17. Fact check your notes: The framework for your progress note often is the note from the day prior. It sounds obvious, but make sure that you go through the note and make updates and changes accordingly. If today is 01/15, there’s a good chance that the Fungitell from 12/31 is not still pending. 

18. Try to learn some nursing skills: This is one of the areas in which I most envy my NP colleagues. If a patient’s IV pump is beeping or their central line need to be flushed, I oftentimes awkwardly step out of the room and look vacantly into the distance for a nurse. I’ve finally figured out how to spike a bag (albeit I do so very slowly, and it certainly makes the RNs giggle some). I talked to our unit’s nurse manager, and she’s willing for me to learn some nursing skills from the staff during a slow day- we’ll see when thing slow down!

19. Be kind: Generally speaking, being in a hospital is stressful. Patients are feeling out of sorts, and staff are working with constant dinging in the background. I rant plenty on this website, but I’m kind to everyone at work (with few exceptions) because it makes things more comfortable for everyone. Additionally, if you are always kind to your patients and colleagues, your reputation will speak for itself. One time I was walking down a hall with poor reception while on my ASCOM with a notoriously standoffish nurse from another unit. My phone cut out. She called my unit’s nurse manager to complain, and the nurse manager told her that I would never hang up on purpose. My interactions with the nurse going forward were always more pleasant in nature.

20. Support your team: The best colleagues are not the smartest colleagues; the best coworkers are the ones who have your back. Whether it’s a medical emergency or just a strange situation, it’s important to be supported and to give support.

I know that I’ve learned a lot more than this, so I’ll likely be adding to this throughout the year. Happy Snow Day, all!