Slammed.

That's the term Jenn used after a rather relaxing morning for me. Checking up on my old patients wasn't so much work since many of the first ones had been discharged by now and I'm getting better at quickly extracting the important information about the new ones.

With Jenn and the attending at the clinic all morning and therefore completely off the radar, I was cautious though and went up to A700 early, at around 9am, to get breakfast. Because once I had that in me, they wouldn't be able to take it from me again easily. But I got to eat in peace and even had time afterwards to write a little more on the mentoring project page before the pager went off close to 10am, right before morning report.

Jenn asked me whether I felt comfortable seeing a "complicated" patient. Of course I would see that patient. It's what I was there for. Out of curiosity, I asked what would happen if I said "no". She replied that then she would see the patient after clinic and before rounds. Well, she could do that anyway in case I mess it up. So I went to see this patient in medical ICU. She was indeed not a clear-cut case, mixed connective tissue disease with idiopathic pulmonary fibrosis status post bilateral lung transplant with history of gastro-esophageal reflux disease status post multiple dilations, Botox injections and finally Nissen's fundoplication surgery that was revised a little more than a week ago. She grew partially insufficient with her gas exchange, so she was intubated, later tracheotomized. She coded for half a minute these past days. Her sputum grew pseudomonas, so they placed her on ciprofloxacin. It took me a while to gather this information from the charts and the computer. Now she was in acute renal failure, trouble was that my job was to figure out why.

Hypotension/hypoperfusion with acute tubular necrosis? Dehydration? Cipro or cyclosporin toxicity? Contrast nephropathy? The time course of her renal failure would have fit most of these causes. I talked to her, which wasn't so easy since she was tracheotomized and on a vent and examined her, she seemed pretty dry. I took a few ccs of the urine she was still making and went to dip it and spin it down. When I was just done looking at it, it was about 12:15pm, would have been just the right time to go up to A700 again to grab lunch and listen to the M&M meeting. But that's just when my pager went off, Jenn told me that we were getting "slammed" today and asked whether I could see another patient right now. "Sure", I said, not yet knowing what I was going to get myself into.

This was actually going to be a 24 year old female - I was relieved, that couldn't be too hard. So I actually went up to A700 and took about 15 minutes to munch down some very good food and listened to the middle of the M&M meeting (attendance was astoundingly excellent, by the way - 100 people easily) before going back down to see this second patient. Problem was that she was brought over from another hospital because they couldn't figure out what they should do. So they sent her over, along with records of what they had done so far in the past two weeks. She had been admitted on March 30th, so exactly two weeks ago. The records lying on the table outside her room were in three thick envelopes full of copied pages. The stack was as thick as both volumes of Harrison's together.

Splendid.

Right around that time, Jenn text-paged me informing me that we were to round at 2pm in the nephrology conference room. So I had little more than an hour to sift through this litany of photocopied partially hand-written reports, consults, flowsheets and whatnot, talk to the patient, examine her, take her urine and analyze it. Not surprisingly, that didn't work. About ten minutes to two, I had still just about covered 700 pages or so, not even seen the patient yet, I text-paged Jenn back that I was sorry and that I'd be at least fashionably late. At one point, I just gave up trying to look for everything that I'd want to know and quickly got the rest of it done, then showed up 25 minutes late for rounds with fresh urine in a cup in my pocket.

The attending didn't comment on my late arrival at all. I assume she was displeased. The new resident on the service, Tony, had also seen two new patients and Jenn managed to also squeeze one in between clinic and rounds so we had five new ones so far, with another one that Jenn was called to see but didn't have time for yet. We got done presenting the new ones to our new, very thorough attending at about 3:15pm - that's when we finally got started going to see them. Of course that meant, looking at their urines first.

Mercifully, they began rounding on a route that would lead us to my two new patients rather early. At close to 5pm we were on my second new patient's ward and went into the visitor's lounge with her three envelopes of paper. The trio of Jenn, Tony and the attending started sifting through the stuff for a while too before they declared that it looked like those people didn't know what they were doing. So they decided to re-do all the tests they did and to biopsy this young girl's kidney tomorrow to see what's going on. Which is what they have also planned for the patient I saw yesterday.

While we were rounding, Jenn got two more calls for more consults that we'd have to do tomorrow. That plus two biopsies. And normally, we start a day without any debts from the day before. That's why tomorrow is shaping up to be "another day in hell" as Jenn put it.

And she's going to be on call tonight.

Oh, and she has her parents visiting her these days.

I guess the medical profession has the same effect on your cortisol levels and social life anywhere in the world.