Harder, Better, Faster, Stronger – Inpatient Teams, その1

Note – this post was originally created on October 1st but you know, residency.

Residency is no joke! Just when you think you’ve reached some understanding or gained some competency, you’re thrust into a new situation that makes you realize just how little you know. The challenge is handling those situations as if you do know what you’re doing because even though you aren’t realistically expected to know it all (at least, not by one’s senior residents or attendings), you are expected to be on top of things. On inpatient teams blocks (‘teams’ or ‘days’), you are assigned to a max of 8 patients for the duration of their hospital stay (the average pediatric inpatient stay is 2 days but can vary wildly from 1 to 21 or more) and for these patients (and their families), you are their primary physician. The expectations are as high as the turnover rate and while there is the occasional laugh to be had, there were some tense moments, some strange standoffs and (for a crybaby like me), some tears shed.

At my hospital, depending on the month there are either 2 or 3 inpatient teams staffed by residents. Each team consists of an attending, a senior resident, two interns, a junior intern (4th year medical student) and two 3rd year medical students. The day typically starts with checkout at 7:00 during which the night team residents talk about the new patients who were admitted to the team overnight and anything that may have happened to the existing patients. At around 7:30, pre-rounding takes place; during this time the residents gather numbers* and examine their patients. Attending rounds begin between 9 and 10 – the entire team goes to each patient’s room and each patient is presented to the attending. The attending performs her exam and then has the resident (who’s the primary, remember?) discuss the plan for the day and discharge criteria with the patient and their family. After rounds, residents will scurry off to order labs, alter medications and write progress notes and/or discharge summaries. Throughout the rest of the day, we continue to manage our patients: answering questions from the parents and pages from the nursing staff, following up on specialist consults and lab results, notifying community physicians and helping with new admissions to the team. On some afternoons, team members have to cover additional patients as well if a person on the team has to leave for continuity clinic or other obligations. Usually if an intern has more than 8 primary patients, the senior will take the overflow but there were certainly times that even though I was only primary on 8, I was covering 16. Between 6:00 and 7:00 pm, we report to the night team and leave the patients in their care until morning. So it goes with teams, 6 days a week (on weekends, there are no 3rd year students and usually only 1 intern per day). It’s a lot of experience and a fair bit of autonomy but boy, is it exhausting.

I felt pretty frazzled for most of the month. The fast pace of teams was nothing like the previous 2 blocks and it was a bit of a shock to the system. I remember my first solo Saturday, on which I cried 3 separate times because I felt so overwhelmed by the demands of all the patients on the team (though thankfully I broke down in the relative privacy of the resident’s area and not in front of the families). I got to perform two lumbar punctures (the first was a champagne tap!). I got yelled at by two angry parents (the first one made me cry, but I managed to hold it in until I got back to the resident area. The second one was just a jerk and the jerkiness was upsetting but not worth fretting over). I managed some pretty adorable/amazing kids and while it never seemed like I was saving any lives, I did help make them feel well enough to go home. The easiest cases were the asthma exacerbations, the abscesses and the failure-to-thrive babies for whom the treatments were clear and pretty easy to institute. The tough ones were the refractory headaches or the neurodegenerative disorders; the kids whose problems I couldn’t fix. There were a few chilling cases of neglect and non-accidental trauma that made everyone sick. I had a patient who had an ALTE and was almost transferred to ICU and another, a girl status post brain surgery who’d gone down for an exam and 20 mins later, a code blue was called (thankfully, it wasn’t actually a life-threatening event and it was on another patient but it sure took about 10 years off my life!) Teams was a block that seemed endless, even though it was only 4 weeks. What I liked most about the block was the ‘team spirit’ that developed among our group. We all cared about each other’s patients (particularly because we’d likely had to cover them at some point or another) and it was easy to bounce ideas off of each other when stumped on a management or social issue. I’ll never forget how my senior guided me through that first spinal tap and said the perfect (though slightly inappropriate) thing to help me overcome my jitters. The entire team was encouraging so even on the worst days, it never felt like there was no support.

I suppose I can see the allure of the hospitalist track. With tons of exposure to pediatric patients of all ages and ailments, it seems like there’d be enough variety to keep it interesting and yet enough continuity to make it stable. For residents however, it seems like teams blocks are some of the most challenging. Long hours, high patient flow and time management are just three of the things that make them tough. There are two more blocks of inpatient teams for first-year residents (my next one begins in January, right in the middle of RSV season!) so I guess we’ll see if I learned enough to make it go a bit more smoothly.

*getting numbers entails getting all the most recent data on one’s patients ready for presentation. This task includes obtaining actual numbers like vital signs, ins & outs and lab values, but also includes reviewing current medications (day x of y days of therapy, most recent doses and/or changes), consultant evaluations, nursing notes, etc. This info, combined with the physical exam findings, is the bulk of what is presented to the team during rounds and what is used to formulate the day’s plan.

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