6 months in… and a day in the life
I really apologize that this blog is pretty blah lately. Things have been incredibly busy at work. Like, I’m there for 10-12 hours daily and STILL take home some discharge summaries to finish. The hospital has been FULL. Overfull. And our hospitalist team has trouble keeping their staffing up, which means we all stretch ourselves thin to cover all the patients. But I still really enjoy my work. The days fly by. Some weeks are better. Some docs I enjoy working with more than others, but very rarely do I encounter one that I completely do not mesh with on practice styles (such as the one who thinks all maladies can be cured by becoming vegan?). 6 months in, I finally feel like I’m getting a grasp on thinks. I’ve had a few requests for my typical day, so here is today:
7:30am: Arrive at the hospital a little early in order to finish some discharge summaries from the day before. Looking through my patient list, I realize that one of my patients had died overnight. It was expected though, but I was trying to get him home with hospice before he passed. I make a note to write the death summary on him later.
8:30am: I’ve finished my discharge summaries and go through the labs and vitals on my current patients. I have 7 patients that I’ve followed previously and the docs I’m working with have added 4 more new ones. They give me a brief report on the patient, but it usually isn’t much if the patient is also new to them, as most patients are admitted by a special admissions team earlier and then “handed off” to the docs the next morning. I plan my day by triaging these patients. If anyone has abnormal labs or concerning vitals or chief complaints, then the sickest get seen first. The ICU patients are also seen early on in the day, but I don’t usually have patients there.
10:00am: I’m finally on my way to see patients for the day. Due to some abnormal labs I had to call cardiology to consult on some patients so that took up some time. I head to the orthopedics unit first to see a patient with a new hip fracture. We were consulted to optimize her medically pre-operatively. She is quite old with some dementia and new cardiac issues so I spend a lot of time explaining her risks and benefits to the family. We decide to postpone the surgery until her echocardiogram and troponin come back. I write my note on her and head to the next floor.
10:30am: I see a patient who has developed chest pain. I already called cardiology about him earlier. He’s going to need a cardiac cath. He is a known alcoholic. He tells me he uses it for anxiety and pain control. I do some brief counseling and advise him to see a therapist to discuss his anxiety but the main issue of focus at the moment is his heart. I’ve started a nitroglycerin and heparin drip with the help of my supervising MD, since I’ve never ordered those before. I write my progress note.
11:00am: I’ve got a potential discharge on my list, and if you don’t get those teed up early in the day lots of things can get derailed so I head to the medicine floor to plan the complicated discharge on my patient who needs outpatient antibiotic infusions, home oxygen, and multiple referrals placed. I make several calls to infectious disease, the social worker, and the pharmacist.
12:00-12:45: I grab a salad to go from the cafeteria and head to my desk to look up my new patients and get their notes started. I’m a dedicated chart-digger and tend to be very thorough, so new patients take me a while to figure out what other underlying issues I think need to be assessed and followed while in the hospital. I’ve got another ortho post-op with hypotension and a psych patient just transferred from the medicine floor for an overdose. I also get the orders placed for my discharge and the summary started, but there’s no time to finish it right now.
1:00: The echo and troponin are back on my ortho patient. The troponin is elevated and there’s a new abnormality on the echo. I discuss the recommendations with my MD and he agrees that she will be high cardiac risk for surgery but would be disabled without it. I see the family again and they are very indecisive. I spend a lot of time in the room. I also discuss code status, trying to guide them towards DNR, but they decide on full code. There’s a lot of orthopedic questions, which is not my forte, so I call the ortho NP and ask her to come. They decide to pursue surgery and the patient is whisked away with my recommendations to keep her blood pressure up to reduce cardiac risk. I addend my note on the patient with these updates.
2:00-4:00: I round on several other patients, jumping between floors from neuro stepdown to general medicine to cardiology. I notice my chest pain patient got an angio and they were unable to intervene on LAD lesion, medical management recommended. So I stop the drips and let him finally eat something.
4:30: I’m supposed to be done for the day but I had some busy patients earlier in the day so I find myself with a few left to see. I round on one of my “lifer” patients who’s been deemed unable to make safe medical decisions by psychiatry due to his cognitive impairment. He’s kind of been stuck in the hospital for a few weeks awaiting a guardian because he needs to be on Coumadin for a blood clot but refuses so he’s on a heparin drip indefinitely. He’s actually quite lovable and we get along well. He’s got a bad heart too so I really worry about him and his poor decisions. I encourage him to keep working with PT and review his telemetry record.
5:00: I run over to the psych unit to see a patient. She is having a cough and I see that her CXR has some questionable infiltrates. Ugh, the one patient I’d hoped would have no issues! I continue her antibiotics and order some follow-up labs for the next day.
5:30: I finish rounding on a few patients who were out of there room for tests earlier. I do some opioid conversions on a patient complaining of persistent post-op pain and realize she’s not on high enough of a dose, so I put in some new orders.
6:00: I head back to my office to finish notes and double-check that I’ve charged for all my visits and ordered tomorrow’s labs. I finally write my death summary. I sigh when I realize a bunch of prior authorization paperwork for home oxygen I ordered on a patient last week came through on the fax. I fill it out and fax it back. My docs have worked hard all day, too, and trudge into the office. I give them a quick sign-out report on all the patients and they thank me for helping out.
7:00: I finally leave the office. I’m rarely here this late and today was really long. But I feel good about the extra time spent with patients and their families. I feel like I do a good job not rushing anyone and making sure everyone’s concerns are addressed. But I certainly hope that I’ll become faster and more efficient at this in the future!