Life at Grady: Internship/Residency Chronicles, Pt 1

The following post, by Kimberly Manning, FACP, first appeared on the blog Reflections of a Grady Doctor.

Beep beep. . . .beep beep. . . .beep beeeeep. . . .

I wish there were a way to describe the sound of the pager we had to carry when taking call as the AMO, or admitting medical officer, during my residency. It was one of the most heinous calls we took as upper-level residents. This one pager number--1181 (I still remember it)--sealed your doom for the night. The pager itself was tossed from one resident to another like some horrible, searing, hot potato.

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The AMO had the great fortune of being paged for every single medical admission to the hospital between 5pm and 8am--regardless of acuity--and then triaging to the appropriate floor. The AMO was also responsible for running all codes on the medicine service, seeing all medical consults from non-medical services (like surgery or psychiatry) overnight, assisting with all needle sticks and exposures (random, I know!), and even backing up any resident or intern covering a floor who couldn't seem to pull his or her weight. The AMO was the destination for advice calls, hospital transfers, and the default for nurses that didn't know who else to call--especially if they knew you.

"Hey, Kim. This is Alice in the CCU. I think one of the techs has pink-eye. I saw it was you on call and thought I'd call you to come and check it out...."

No kidding--once someone paged me to ask directions to Jacob's Field for an Indians game. That pager was like 411, 911, and 0 all rolled into one tiny black box. And that heinous little black box! It went off all. night. long. What made it worse was that some kind of wire was loose in it, so instead of beeping, it sort of bleated. A slow, nauseating bleat in an escalating, nasal, milquetoast pitch....Ugghh. I feel sick just thinking about it right now; the same Pavlovian response I had back then.

The AMO call night from hell

It was a cloudless spring night in Cleveland, Ohio. The kind of weather that made being in the hospital overnight just that much worse. The hospital was busy and full. . . .but not full enough to be closed to new admissions (which was music to an AMO's ears.) This particular night, the patients were sick. Not just sick . . . .but sick-sick. The bleating pager was unrelenting.

I remember getting the calls, seeing the admissions as quickly as I could, and then calling the resident covering the floor to which patients would be triaged. I'd already seen over twenty patients that evening; I knew this because for every patient I saw, I stuck his or her identification sticker on the right leg of my scrub pants. By 2:30 am, my right leg was covered with labels. Twenty-six to be exact. I'd already run two codes, dealt with a needle stick, and helped the residents covering the ICU place and arterial line. Then, twenty whole minutes went by without the pager making a bleat. Could it be? A moment to sleep...perchance to dream?

I made it to the 9th floor and into the call room. I kicked off my clogs, dived onto the scratchy sheets, and, just before closing my eyes, yanked my pagers off of my waist and placed them onto the dreadful hospital issue pillow right beside my head. (Every good resident knows the danger of sleeping through pages when you're exhausted.) Within two seconds, I'd fallen asleep. The time stamp on my pager read 2:50. Zzzzzzzzz. . . . .

Beep beep. . . .beep beep. . . .beep beeeeep. . . .

"Please no," I said aloud to God or anyone else who might be listening. My eyes flew open and looked at the ceiling, which had some kind of disgusting water stain on it. The impatient pager began bleating again. I repeated, "Please no." I was so tired I could vomit. Have you ever felt that way? So tired you could vomit? If you haven't, I hope you never do. This is exactly why folks always advised against trying to sleep on busy call nights. The only thing worse than no sleep was this: the sleep tease. It was now 2:57 am. This absolutely qualified as a sleep tease.

I looked at the pager and. . . .whew. . . . breathed a sigh of relief. It was a number I recognized, and most important, it wasn't one from the Emergency Department. Even better, the number was followed by an asterisk with four more numbers--our way of adding our pager number or "signature" to let the person being paged know who was calling. At the very worse, it was a sick patient. At best, it was a someone asking a clinical question. I rolled over and dialed back the number.

"Hey, Kim . . this is Mark, the intern on 9B."

"Hey Mark," I replied trying to sound as chipper and welcoming as possible despite the lingering nausea I felt from the sound of the pager. "Is everything okay?"

He let out a nervous laugh. "Umm. . . . well, yes and no." Mark was an excellent intern. He was mature, organized, responsible and a great independent worker. I knew I could trust whatever he said, and could count on him to follow through with my directions. "Ummmm. . . .so, I've gotten 5 admissions tonight, and they're all fine. . . .but. . .uhhh. . .I, like, haven't seen my resident. . . . .since. . .I don't know. . .like 9:30?"

I bolted upright in the bed. "What? That makes no sense. I've called all of the admissions to Nick directly. How have you even known about them?"

"Well, that's what's weird. He's called me with the admissions and that's it. I haven't seen him otherwise."

"Whaaat?" I asked again. This was crazy. The drill was simple. I get the admission. I go see the admission. I decide if the admission should go to the floor, the ICU or telemetry. I call the resident covering the floor. The resident calls the intern and they go see the patient. The intern writes the orders, and both the intern and resident write admit notes. Simple enough. "Who's seen the patients with you?"

"I kept thinking he was going to come, but he hasn't. It's really odd," he replied, "I did take an EKG to him to look at in the call room. I mean, I'm really comfortable with each patient, but I've managed them on my own."

"What the. . . .?" I muttered under my breath, deciding against the expletive. "Give me a couple of seconds. I'm coming over there to help you." I slammed down the phone and jammed my feet into my clogs. I was so tired. Too tired for some drama, which is exactly what this sounded like. I picked up the phone and paged Nick. Two seconds later, I was startled to hear his pager go off in the call room right next to my own. The dude was right beside me. Despite realizing this, I still leaped when I heard the phone jingling on the nightstand right beside me. Well, at least he was answering pages.

"Uhhh. . . .Nick?" I answered.

"Hey Kim, what's up?" Okay, I could hear him through the receiver and the wall. Sounding all chipper and wide awake. I smacked my palm over my face and shook my head. This was the "What's up" of a person who had nothing unusual going on. Before I could even say anything, he said, "Got a patient for me?"

Was he kidding? I was too tired for this. I had no idea what to do, so I said, "Hold on for a minute." I lay down the receiver and looked at my leg full of patient labels. I smacked my hand over my face again, and began patting my foot to release the mounting anger. Here's the thing: Nick was covering not only Mark, but also Jeannie on another floor. She'd been given four admissions in addition to Mark's five. If this dude has not seen any of these nine patients, I am going to have to kick his a**, I thought. (I wish I could say this violent thought did not cross my mind, but it so did.) I marched out of my tiny room, walked next door and banged on Nick's call room door. Hard.

Either he was slow or hard of hearing. Nick opened the door like he was expecting to see housekeeping with new towels. He jumped back when he saw me. "Oh, hey Kim!" he said wiping the sleep from his eyes. His thinning hair was standing all over, screaming "bedhead". You have got to be kidding me.

I scanned the room. TV was on. VCR player in the room with VHS tapes FROM BLOCK-fricking-BUSTER sitting on the nightstand. An empty Diet Coke can and half of an eaten stromboli lying in an open box. A honey bun wrapper, a crumpled bag of microwave popcorn and some coffee that appeared to be from hours earlier. It looked like a hotel room with excellent room service. In other words, this dude had been CHILLING. All. Night. Long. I placed my hand firmly on my right thigh, to keep me from, literally, kicking his a** right then and there.

I wasted no time. "Nick, Mark said you haven't seen any of his patients. What's going on, man?"

"Oh, I knew I hit paydirt tonight. Mark and Jeannie are strong. Those guys are on auto-pilot, man. I told them to call me with questions, so as you can see, they didn't need me!" He gestured to the rock star suite behind him. Was he serious? At this point I crossed my left leg over the right, as surely he was about to catch an Inglewood style beatdown in the call room threshold.

"Are you serious or are you joking? Have you not seen the NINE patients I've called to you?
What the hell is wrong with you?!"

"It's May. They are almost residents," Nick replied with a shrug.

"But they AREN'T residents," I shot back unable to hide my anger. "Dude! You're supposed to see the patients and review their orders and also write your accept note--you know that! What the hell, Nick?" I couldn't believe this. Sure, everyone knows that some residents and doctors can be a little bit shady. But this was so egregious. . . hands down, the shadiest, laziest thing I'd ever seen. I was so tired and I knew what this was about to mean. It meant I would be seeing and reviewing all of the orders and writing all of the notes. (Back then, residents wrote an accept note or mini-history and physical to accompany the intern's note.) This would have me working at a breakneck pace until morning report. I was so, so tired. I wanted to throw up. On him.

"You're overreacting," he retorted nonchalantly. "Bet you didn't know that the attending bills from the intern note, not ours. We don't even need to write a note technically." He smiled all wide with his big yellow teeth.

"I should kick your a**, Nick," I growled. (This was before we taught about the importance of professional peer interactions, too.)

I couldn't take it anymore. If I didn't get away from him, I'd be arrested for assault and battery of a lazy classmate. I spun on my heel and left without another word.

I walked briskly from hall to hall like one of those mall powerwalkers. For the rest of the night, I did Nick's job and mine. I answered random pages and reviewed orders, plans and findings with interns. I did not sit down for more than 5 minutes for the rest of the night. It sucked.

The following day was Thursday--my clinic day. As a combined Internal Medicine/Pediatrics resident, every Thursday afternoon from 1-5pm, I alternated between my Internal Medicine clinic and my Pediatrics clinic. Whether I was on call, post-call, no call, or any other state you could think of. Any chance of leaving the hospital early was out the window. Despite my night from hell, this was just the way it was before duty hours reform. This sucked, too.

Post Call Clinic--going on 34 hours straight of working:

At about 3:45 p.m.,I was sitting across from my attending telling her about one of my patients that I'd just seen in clinic. All of a sudden, I felt someone shaking my shoulder and heard my name.

"Kim! Kim!!"

I jerked awake and immediately realized that my mouth had been wide open. Hanging from my glistening lower lip was a long piece of drool that had collected into an unattractively large puddle on the desk and all the paperwork in front of me. The pen in my hand had captured writing that had gone from sloppy, to tiny and not discernible, to one flat, diagonal line across the encounter form. Nice.

"Go home," my attending spoke with a mix of concern and disgust. "In fact, go to a call room until you can get someone to give you a ride home." It was one of the kindest yet simultaneously mortifying moments I'd experienced in my entire 4 years of training.

I can't promise you that I went to a call room to sleep. If I recall correctly, I had two shots of espresso, rolled down the car windows and smacked myself in the face repeatedly while reciting "Rapper's Delight" all the way home.

Two days later, I was AMO again. Great.

***
So the good news is that this horrid work-fest would never happen now under the current resident duty hours regulations. And to that I say "Hallelujah." Drooling all over a desk when you're old enough to vote is not good.

Okay, so I bet you're wondering what happened to Nick. Well, I told the chief residents, who thanked me for stepping in. I also told my residency friend and confidant Tracey H., who said what became one of our most classic exchanges ever:

Tracey: "I could've told you that dude had a shady bone in his body!"
Me: "Not just any bone, but a big bone, man. This was not like a shady metatarsal...this dude had like...a shady femur."
(Nerdy, I know. But still something that makes Tracey and I laugh until we feel sick.)

I suppose somebody scolded that guy Nick at some point, but in the end, he smiled and received his residency diploma right along with the rest of us. Now he's probably somewhere doing who knows what....

I knew I should've kicked his a** when I had the chance.

Labels: internship, Life at Grady, residency training

posted by Jessica Berthold at 7:00 AM