DNR/DNI

It's been a long time since I've last posted! I've quickly come to realize that being an intern is FAR more time consuming than it was to be a medical student!

I've finished nights, worked a few shifts in the ED, and now back on the wards. I definitely love the wards the most!

I'd like to touch on a topic we discussed in conference today- the issue of DNR/DNI. For those that may not know, this is the "Do NOT resucitate/ Do NOT intubate". When a patient is admitted into the hospital, as housestaff (and I can only say this for medicine, since i'm with the Dept of Medicine), at the end of our progress notes, we put down code status. This should be in our admission notes and our daily progress notes. This is done so that we know, as well as cross covering doctors know, the patient's wishes. That being said, it is definitely not an easy task to do. Of course, if I have a younger than 50 year old patient, I automatically assume that the patient is full code. This is definitely not the right way to approach this, but for the most part, a young, healthy individual should NOT want to be DNR/DNI, otherwise, I would probably get a psych consult.

But for our older patients (and of course as the population ages and we see more in the hospital), it is not such an easy task. For some patients, it's clear that they should be DNR/DNI. Their quality of life would be so significantly impaired if they were to code and survive, although most likely, these very sick patients wouldn't survive. But for others patient's it's not so clear. And even in those that we think are "clear", we as physicians don't decide, it is left up to the patient.

So the question now is, what is the right way to approach a patient about their code status? You would hope that for older patients, especially those with multiple medical problems or end stage diseases, this topic should be brought up well in advance to a hospital admission, preferably in the ambulatory care setting, but unfortunately, this isn't always the case. I have now walked in to quite a few patient's rooms on admission, and when I asked them if anyone has ever talked about their code status, they say, "no". This puts me in a bind. This person has never met me, and here comes this young doctor asking if they want hospital staff to do "everything they can" to keep them alive. Often, patient's are not even quite sure what that means. Some even think that by becoming DNR/DNI, that means withholding care- which is definitely NOT the case.

I had a patient the other day who was quite old, more than 90, with severe COPD, diabetes, and multiple other medical problems. This kind of patient is SO common in the hospital! Well, she was definitely "with it", no dementia, very alert. So I brought up code status with her, especially since she was having a COPD exacerbation and very well may need intubation if she starts to deteriorate. She told me that no one had ever talked to her about it. So I sat down and explained to her what "coding" meant, what we do, and that she can refuse these treatments. I tried not to be too graphic, but of course, it's hard to explain to a patient what a chest compression is without actually saying that we pump the heart by pressing on the chest, likely with enough force to break the ribs. I tried to explain as non-medicalese as possible what the process what, and she could opt out if she'd like. She decided that she would like to be DNR/DNI since she would not want a tube put down her throat to assist her breathing.

How much should be told to the patient? Should we even discuss the actual process and what it entails? Or should we just discuss what their expectations of "life" is, and whether they feel that by being on a ventilator, they wouldn't not be happy living their lives the way they'd like?

I'm not exactly sure of the answer to these questions, and apparently, I wasn't the only one. Even the residents didn't have a "great" way to do this, and they've done it WAYY more times than I have. So if there are any readers out there who have any insight to this, I'd greatly appreciate it. I know there are books and papers out there on this, but I think hearing it from the public may be the best answer.

Cross Coverage?

As I mentioned in my last post, I am currently on night float, and my responsibility is to cross cover all of the patients on the floor. I've learned some really important things over this last week and a half on night float.

1) Patients, especially really sick patients, get even SICKER at night
2) My upper level residents are great and always willing to help me out no matter WHAT time I call them
3) Cross coverage can lead to many issues that remain un-resolved and may actually impair patient care

This post will focus on dealing with the last point the most. As many people are now aware, residencies are required to adhere to an 80 hr work week for their residents (thank goodness for that!) But, there are some logistics issues with this that make it difficult to come up with the "perfect" system where both the residents are happy, doing good work, and patient care is not being compromised. The way things are set up at many hospitals to make sure the 80 hr rule isn't violated is to keep residents from taking overnight call, and instead having a cross-coverage come in and watch the patients. This is not a bad system in that in decreases the work load on the residents during the day allowing them to work better and more efficiently when they are at work. Everyone needs rest. BUT, the shortfall to this system is when the patients are signed out to cross-coverage without adequate information passed along to the night float, or even any other cross-coverage that occurs on other days/weekends as well. Little things get missed and not passed on from person to person which may end up adding to a big problem. Some things are avoidable, and other times when a patient starts to crash in the middle of the night, nothing could have been done to prevent it. My point is for those situations where SOMETHING could have been done earlier.

To make a comparison here: at my medical school, the on-call team actually admitted patients overnight, and cared for their own patients as well, while a nightfloat took care of all the other patients on the floor. Here, at this hospital, the on-call team does not stay overnight, therefore a nightfloat covers all the inpatient teams and admissions are also done by nightfloats. Both systems have their shortfalls and benefits. First is that with the second system, residents get more time off to make sure 80 hrs is not violated, and they are well rested and in a good state of health the next day for week. The shortfall is that every night, ALL inpatients are taken care of by a night-float who is not intimately involved with the patient's care. With the first system, residents are tired the next day after being on call all night, but at least their inpatients were taken care of by the actual team making sure that their issues are well known to the team. But, on the other hand, all the other teams' patients are covered by a nightfloat, so still the same problem exists. There really is no way to resolve this issue since a nightfloat coverage is needed otherwise EVERYONE would have to stay EVERYNIGHT to cover for their patients. It seems the best thing would be to make sure everything that needs to be done, followed up, etc be done PRIOR to the team leaving and not leaving tasks like that to be done by night float. A good, informative sign-out document should be passed on so that night-float knows what's going on with the patient if he/she gets called in the middle of the night.

I wonder how other programs have addressed this issue, or maybe this is just a problem across the board now with the 80 hrs. So that's my issue for the day. Soon, I'll be back on days, and no longer have to sleep in a coffin during the day and will hopefully get to see the sunlight!

Becoming a Vampire

Well, after some time on the wards, which turned out to be a great two weeks learning experience, I have now changed my rotation to nightfloat. I essentially work 8:30 PM-7:30 AM for the next two weeks. My job is to cross cover (ie: take care of all the inpatient teams) and keep the patients alive until the primary team gets back in the morning.

My first night was from hell. The pager did not stop going off until about 3 am. And even after that, I barely had time to sit down and think. That was offset by last night which was much smoother. I had plenty of time to do the work I needed to do, respond to intermittent pages, and even do a little reading! Yes, reading up on disease management etc. is NOT an easy thing for an intern to fit into the schedule. One must be SUPER efficient to actually be able to get some reading done, or have a nice, calm, night. That being said, I hope I didn't just jinx myself.

So in contrast to my last post, where I was having difficulty deciding on whether a plan of action was just too much for a patient, I had an interesting experience from the opposite perspective the other night. One of my patients actually was going downhill, and FAST. We were running out of options on the floor, and decided the patient probably needed to be transferred to the ICU for further managment. At this point, we had to think about what was our best plan of action. This patient was 90+ years old, but the family wanted FULL CODE status. The patient also had severe dementia making it difficult for us to establish was a baseline mental status was, although according to the daughter and the nurse, by the time I saw the patient at his/her worst, he/she was apparently well below baseline. My resident and I both felt that an ICU transfer should be done since the patient was full code, but the odds were not in the patient's favor of survival. On the other hand, the family insisted we do "everything we can" to save the patient's life. I can't pass any judgement on issues such as these for a few reasons. First, I have never been a family member in this particular situation so I wouldn't know how I'd react myself. Second, I don't have enough experience as a physician to compare to other situations where another patient's status was similar, and an outcome had already been established. That being said, I felt that this patient probably would be best managed without invasive treatment, do everything we can minus full code, and provide comfort care if it came down to that. This is opposite to what the family wanted. So of course, without any other advanced directive, this patient had to be transferred to the unit and most likely required intubation and a host of other invasive treatment modalities.

That was just one piece of my first night as a night float. On top of that, this occured 10 minutes BEFORE my shift should have ended, which means I ended up staying at the hospital much later than I anticipated. I hope all turned out well for the patient and the family, but I'm not quite sure what happened.

On a happier note, I did get to go to the Charles River to watch the fireworks display last week! It was beautiful. Even despite the rain, and the cold weather, we managed to have a good time and enjoy the company around and the show. Boston truly has some spectacular scenery. I also got to spend some time out by the pool on Sunday on my day off. That was nice. During the end of my last year of medical school, I managed to spend many hours by the pool, or on the beach in the carribean, and 3 weeks of work in the hospital under flourescent lights has already managed to rid me of my tan and make me look like a ghost, or better yet, a vampire since I'm now awake all night- and sleep during the day (but I promise I do NOT sleep in a coffin!!!)

When is too much really too much??

When I was a medical student, I felt that my "job" really consisted of 2 things. 1) I was responsible for talking to a patient. Getting to know them. Taking a great history, doing a full physical. Trying to gather EVERY single little piece of data possible to try to figure out how our team could possibly help this person suffering from whatever ailment they would have. 2) I would put the above information together, and come up with a differential diagnosis, diagnostic studies, labs that needed to be ordered, as well as come up with a treatment plan based on what I've learned in the countless hours I've spent reading books, notes, journal articles, etc. What I never really had to do as a medical student was actually IMPLEMENT most of what I would write down as my plan. We have the luxury of putting all types of treatment, no matter how invasive or possibly unnecessary it was. All it was for us was a learning experience, and it was to help us think of all the possible options.

Now as an intern, things are definitely different. First thing is, I don't have NEARLY the amount of time I used to have as a medical student to spend time chatting with my patients, gathering every piece of information I could possibly gather, and doing a COMPLETELY thorough physical exam. Of course, I will get as much history as I can, especially the information that would be pertinent to the case, and I do a complete physical, but focus it primarily to those organ systems involved with the disease process for each specific patient. ll of this while being paged by the nurses that someone's heart rate is in the 150s and someone else's potassium is too high. Then comes the diagnostic imaging, labs, and treatment plans. Cost is now something that I need to think about too. Before, it didn't matter what I wrote on the chart really, but now, when I order something (radiology, blood work, etc), someone's got to pay for it. This makes me think of the best approach to take, without wasting resources to come to a diagnosis. As for treatments, some patients should not have the most invasive procedure available just because it's an option, but rather based on each clinical situation.

Case in point. I will change some of this information around so that I don't violate any HIPPA rules here. Plus, I'll be vague. A patient that I'm following is nearly 100 years old. Although there are medicines that treat his/her condition, he/she seems to be failing these treatment options currently, and I'm starting to feel like I'm not getting anywhere. I've spent HOURS researching his/her disease, coming up with treatment options, deciding what path is next, discussing the options with my resident and attending, and even the patient's family. Of course, there is some definitive treatment, BUT it's highly invasive and for this patient, it just may not be appropriate at 100 years old. Plus, there is the whole issue of DNR/DNI. As a medical student, we learn about these ethical issues, but we don't need to actually DEAL with them. Now, I'm being faced with making some decisions of whether taking more invasive routes with this patient is really worth the risk. Of course, as an intern, I'm NEVER left alone to make these kind of decisions (THANK GOODNESS!!) and I have an extremely supportive resident and attending to help in this process.

The question becomes, when do you just cut your losses and decide that enough is enough?? Is the right thing to just try and manage this patient with medicine, despite the fact that it hasn't worked as well as we had hoped so far, and just see what happens? Also, there's the issue that the LONGER a patient like this stays in the hospital, the more likely they are to get sick with some kind of infection, pneumonia, etc.

Needless to say, this patient is very cute at around 100 years old. I've had this patient since my first day on service as a real doctor. Losing him/her would probably be a big blow for me, considering how much time I've invested in the treatment, planning, discussions, and research for the best option available to him/her. Our team is doing our best to help this patient get back to him/her previous status, but it seems like a rough road so far. We'll just see what happens....

And in response to the comments left by Paul, I am VERY careful when I cross the street at Brookline and Longwood :) I find that despite the "walk" signal across the street from me, I still dodge traffic every time I cross the street! Also, yes, the CIO must be great!

First Day of Work!

Wow! That 3 letter word just about sums it up. What an experience! Being an intern is extremely different from being a medical student. People actually EXPECT you to DO stuff for them, like give pain meds, talk to families, etc. Things that medical students weren't paged for before.

That being said, my first day went by great! I have a phenomenal resident who took the time to sit down and go through EVERYTHING with me. Everything from how to use the computer, manage my time efficiently, and even what to say/do for the pages I got as the cross-coverage intern (covering other teams patient's after they left since I was on call). Surprisingly, we made it home by 11 PM, MUCH earlier than expected. I even ended up doing 2 admits, AND two discharges along with all the other work for the day!

Some things of note.
1) The computer system is AMAZING!! Everything is efficiently at your fingertips. All the systems seem to complement each other, data is constantly saved, and putting in orders for your patient are easy as a few clicks. Even printing out prescriptions is automatic, I just click the print button, and sign away!
2) Ancillary and nursing staff are second to NONE! They truly are the backbone of this hospital. If the physician wants ANYTHING done, he/she can put the order in, or tell the appropriate person, and it's DONE! This is definitely something that wasn't as easily done back down south. Although, of course, this has something to do with personnel staff, and sheer numbers of them.

Well- apparently internship also causes a person to not be able to complete posts!! So now, I've basically gone through a whole cycle on the wards, gotten a better grasp of the computer system, and trying to improve my clinical knowledge!

Some interesting differences between my new hospital vs my old is the way the teams are made. At my medical school, once a patient is admitted to a hospital inpatient service, that patient is now the patient of the ward attending. All the residents, interns, medical students, etc all work with only that ONE attending on the service. This makes things much easier. My understanding was this hospital that I am currently at was more or less like that system as compared to an older system where many different attendings could admit to a ward service. I guess my assumption was incorrect. Although MOST of the patients on our service does get covered by our firm attending, despite them having an outside physician, there are still some patients who are followed by an outside attending which means I've got to call them and inform them of the status of their patient. THAT'S annoying. I don't feel like I'm learning much on those patients from the attending. I'm teaching myself about those patients and their conditions, and of course my superb resident who is also a great teacher teaches me as well.

Oh, one last thing, the upper level residents I've worked with so far are AMAZING! Their clinical knowledge is phenomenal for their level of training... I am very impressed. And, this also makes me hopeful that one day, I can be like them!

Hello Bean Town!

So I'm finally here! It's definitely been a huge adjustment to move up here from the south. First thing to note is... last week, on thursday, it was in the upper 50s!! For the middle of June, that's downright insane! And, of course, I don't have any clothes for that kind of weather with me here such as a light jacket... oh well. It's better now.

Living in the city has been great. To be able to walk everywhere, use the T, and to have the whole city just under your fingertips is absolutely amazing. What a great concept! Of course, being a southerner, I could not part with my car so I've left it with family in the suburbs. Although I don't expect to use it much, when I do, I will be grateful to have it and not rely on public transportation to take me from state to state.

The hospital is amazing. That being said, the whole medical/academic area in Boston is amazing! To have that many hospitals, higher education schools, and research centers jammed into a 3 block area is fascinating. The work that comes out this area is simply phenomenal, and blows my mind away. The hospital itself is impressive. Although they are older hospitals, there have been many renovations, new buildings, improvement, and countless pieces of technologies built into the system that makes it truly a first class hospital. Everyone that I've met so far has been very nice, welcoming, and seem to be great people to work with. Although I haven't actually started working yet, that will start this coming weekend.

My apartment is perfect from the hospital. Less than a 10 min walk! Now THAT'S a novel idea. I would never have had that luxury in Louisiana where I had gone to medical school, or even to the ones in New Orleans. Living within a 10 minute walk of either location is probably not the safest places to be. To make things even better, at nights, I can hear the crowd at the Red Sox games!

Well, that will conclude this post for now. I will add more as we get deeper and deeper into the hospital and orientation wraps up. Oh, just a side note, we have been asked to choose our "benefits" package. For me, this is a first. I've never held a job where I've had to do that... what a strange concept! It REALLY is a REAL JOB! Which also means, I've got to become a REAL doctor soon enough!!!

hiatus

Sorry- have been MIA for a while. Will be on vacation for at least a week. I expect to have some new topic probably after I get back!