Routine

Yesterday, the service was back up to its usual five consults. Most notable exception was that my patient for the day was in the ER again, a place I still like to go to. Although I'm far from being an expert yet, nephrology is already becoming a bit monotonous. If I imagine focusing on the kidney for a significant number of years, like my attending would approve, it doesn't seem like that could still be interesting then. And I don't feel like one has to be particularly smart to do it. There's a large but still limited number of diseases a kidney can have and it still holds true that hearing hooves usually signifies horses. And figuring out the occasional zebra will certainly be satisfying but rare (and we're here at a good university hospital in a consult service that deals with the cases the primary teams cannot or will not figure out - so pretty selected collective of patients already). I'd still rather be in the ER, obviously things were less repetitive in there.

That said, it's not completely boring here. Physicians mix things up by overdosing people on Lasix last night, for example, poor guy's in the ICU and probably deaf right about now. I guess I shouldn't go into details on that.

And another interesting mix-up happened .. apparently someone was very much post-call and wrote an order for DDAVP (desmopressin, basically vasopressin with an arginine attached) for a patient with a sodium of 120. Apparently they got it confused with another medication starting with "D": Demeclocycline, a vasopressin antagonist, after having been awake for too long. I guess we're all human.

(Disclaimer: These stories are needless to say purely fictional and any resemblance to actual events or persons is, of course, coincidental.)

(I started this post with breakfast in the morning. This is the third time I was interrupted and I'm continuing this draft, it's 7:30pm and I'm back home.)

So, where was I. Ah well, what does it matter anyway.

The reason I was interrupted so often today was that the two residents we had up until yesterday were done with their renal consults. We got one new resident today, but she was, of course, in clinic this morning. That left Jen and myself, Jen having a kidney biopsy scheduled. That's how I ended up with my first consult at 8:45am, when I had spent one and a half hours on it and was close to getting done she paged me again to let me know the primary team had just cancelled the consult. They'd send the patient home this afternoon. 20 minutes later I got another patient, HIV+ with PCP in the MICU. 33 minutes later, at 11:07am (I'm reconstructing this from my pager) Jen called again to inform me she was about to start the biopsy and given that this had taken more than an hour yesterday she would like me to get started on a third patient. I replied "Sure. So you're planning on rounding around 5pm, right?". I was trying to make sense of this guy in the MICU's chart again but failed miserably. He had apparently been turfed from one place to the next a lot, hitting one normal ward, one step-down service and three different ICUs in little more than a week. Naturally, they all had different kinds of flow sheets that overlapped (good luck trying to figure out ins and outs there) and medication orders were a mess.

To paint you a picture: One and the same medication, Bactrim, was showing up on the same day's medication sheet three times. Once as p.o. medication, with a "d/c'd" behind it, as in "discontinued". One more line saying "Bactrim", this time i.v. and with some number of mg/kg but no times of administration behind it. And a third line on that same page starting with "Bactrim", i.v. again, this time saying 250mg and followed by four different times of administration. Two of those time points were circled, two were crossed out, all carried some hieroglyphs around them - presumably initials from nurses but they could mean anything as long as you're not familiar with *all* of the abbreviations that could be used on these medication order sheets. It turns out that the circled times of administration are doses that are not actually given to the patient, while the crossed out ones are. And that's only one of the four different antibiotics this person has been given in the time he was there, not even speaking of the plethora of other medication this 69 y/o HIV, HepC, PCP, HTN, CRI now septic patient has been given over the past week. It took me probably about five minutes of deciphering interns', residents' and especially surgeons handwriting just to find out when the guy was intubated - namely yesterday.

I would have needed a very high threshold for frustration today, which, alas, I didn't have. It was frustrating that it still takes me forever to assemble the simplest pieces of information and I'm still not sure how I can speed it up.

The best way probably is to keep doing consults. Although it probably wouldn't hurt if someone at some point sat down with me and gave me an introduction into things like "a circle around a time point on the MAR record means that this dose was actually not given". Thank you, you've just saved me half an hour of grief and the recorded fluid intake on the flow sheet finally goes together with the fact that this antibiotic is administered in 500ml IVPBs.

You live, you learn.