PGY-?

It's July. This means it's national "how the fuck do I order that?!" month.

As a unit clerk, I dreaded July. Sure, it meant some new fresh folks to replace the ones who had been worn down and frayed by February. But it also meant too many over-eager interns and inflated residents strutting their stuff through our halls, sitting at my computer, walking off with my pen, running away with charts, and sleeping through pages. Overall, I saw July as one big pain in the ass. However, I hadn't really thought about what it meant for the patients until 1997.

Back in 1997, my brother was admitted to a big city hospital, one of those mammoth teaching/research jobs, the first week of July. Depending on your perspective, he presented either a mess or a mystery. That is, there were several paths you could have gone down to try to come up with one explanation for all the symptoms.
Here's the most obvious stuff. He was a recently HIV positive 25 year old male who came to the emergency department with renal angle tenderness, vomiting, diarrhea, fever. Oh and he was quite overtly jaundiced too. I don't know the meds or the lab values - this was years ago now and if I knew this information I've long forgotten it. Long story short - here's the important info which a good history would have elucidated. My brother had spent the weekend before this illness started at a Pride celebration which apparently entailed the mandatory drinking of many Rolling Rocks in the sun for the better part of two days. He had tried to keep up a good (non-alcoholic) fluid intake since one of his HIV meds came with stern warnings about fluids and what could happen to his kidneys if he didn't get enough with the med. However, the intentions for decent hydration were shot when he ate some bad yogurt which resulted in vomiting and diarrhea and fever. Oh and he has Gilbert's syndrome.

Needless to say, my brother's hospital stay was a fucking disaster. He was bounced from one service to the next in the attempt to come up with a single diagnosis which would account for each symptom, sign, and lab value. His primary care doc (ID) was on vacation, a fellow was covering in the office. No one knew who was authorized to talk to whom. The various services couldn't keep my brother's coverage straight, and the nursing staff didn't know which doctor was on what service and what service was on call when. Labs which were ordered didn't get drawn because they weren't ordered right the first time (and sometimes second), peaks and troughs were inverted or totally missed. Unnecessary imaging was performed, biopsies were ordered and then canceled at the last minute. Follow up on any error was somewhat expectedly poor given the many, massive cracks for something as apparently minor as bloodwork or a CT scan on a stable inpatient to slip through. Like I said, fucking disaster. But we stuck it out. We did so by constantly leaning on the primary's office, keeping our own notes about what had been ordered when, and getting to know the interns and residents really well. Yes, we were the pain in the ass family, but keep in mind, my brother's HIV status was still new and his doctors had been going down the path of kidney infection so we were scared. Eventually, the multiple, cascading causes of my brother's presentation were elucidated and addressed (more or less) and after only three false starts ("hey, he's going home today as soon as they do rounds and write the order!"), he was finally discharged.

I'd like to think that hospital and residency administrators had identified the little mini-catastrophe that a service-wide medical staff change like this causes every year, that they'd learned some tricks like staggering schedules so that radiology, anesthesia, internal medicine, surgery, emergency medicine, and infectious disease didn't all completely change staff at the same exact time, but I'm guessing this is more of my boundless optimism. I'm guessing that because my aunt just checked herself out AMA from another (different) big city hospital last night after being juggled, bounced, and rescheduled around for days. She was admitted Friday night for a Monday AM bronchoscopy (looooong history of heavy smoking - PET scan showed a mass). The scope was postponed all day Monday due to a back up. Then Monday night, the team changed its mind and decided on a needle biopsy (placement of the mass), but it was impossible to schedule with radiology through Tuesday. Tuesday evening, a nurse told my aunt "yeah, this kind of thing happens all the time". I understand why she said it, and I expect her intentions were entirely good and even sweet. Unfortunately, my aunt had been cooling her heels inpatient for too many days so she could undergo a procedure to confirm that she has lung cancer - at least this was what was going on in her mind no doubt. And while she waited, patiently or not, she was witnessing the hospital screwery that is July. I think the conversation with the nurse was the last straw and also an excuse to run away. Within an hour she had signed herself out AMA and now plans (or says she plans) to have her primary care doctor set up the biopsy outpatient through Local City Hospital, which has earned the nickname of "Local Shitty Hospital". But who knows, maybe Local Shitty (not a teaching hospital) isn't so bad comparatively speaking, at least in July.