Entry 2

Entry 2

Entry 2
A weeklong electronic journal.
Feb. 10 2004 7:17 PM

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I awake in a scramble to an empty bed. Half-asleep, I search frantically under my pillow for my pager and list of patients. There's nothing there, and I suddenly panic that I've slept through a code. I open one eye to see a streetlight outside. Relief: I am at home, not at the hospital. I lie still, trying to judge the time.

My cell phone says 4:43 a.m. Forty minutes before I'd planned to wake. I flip over, trying to fall back asleep, but it's futile; I'm awake, already thinking about my patients.

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I give in, get up, and crack open my first Diet Coke of the morning. I've never been one for coffee, but caffeine is key, so I drink about a gallon of Diet Coke a day.

At 4:47 a.m., I jump into the shower and realize we're out of soap. I contemplate leaving the warmth, but decide not to. This year, even tiny obstacles feel like major ordeals. During the last snowstorm, an intern friend of ours hit a snow bank on Storrow Drive, a major road in Boston. She'd just finished being on call for 36 hours and was too tired to deal, so she left the car and walked home. Another friend broke his glasses about a month ago and is still wearing them. Internship is all about choosing your battles, and the battles at the hospital trump nearly everything else.

At 5:20 a.m., my three separate alarms start ringing simultaneously, but I am already ransacking the house in search of my lucky fleece. Although we pride ourselves on being scientific, physicians are, in truth, hopelessly superstitious. On my first call, I wore a shirt with a star on it to bolster my confidence, and one of my patients had a Code Blue a few minutes after I walked in the door. For the next call, I wore my blue EMS fleece, and all of my patients did well; I've worn it religiously every since, and the thought of taking call without it sends me into a tizzy.

I reach the hospital by 5:50 a.m., grab breakfast for Ingrid and myself, and ride the elevator up to the Cardiac Intensive Care Unit. Ingrid's outside, looking exhausted after a long a night of being on call. We hug and take a minute to nestle into each other before heading into the unit together.

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Over breakfast, Ingrid updates me last night's events. She's been busy: One of my patients lost nearly 8 pints of blood. Interventional radiology stopped the bleeding by blocking the artery but found a malignant mass in his stomach, reducing his life expectancy to six months. Another one of my patients, a 21-year-old man with leukemia, died last night after a heroic four-year battle; nearly every member of our team has broken down in tears while taking care of him.

Halfway through our oatmeal, a nurse taps on the door, holding up a bucket of blood. "This came from Mr. Jones' foley," she says, referring to a catheter that empties urine from his bladder. "He wanted to make sure you saw it." Inevitably, half of my patients save their bodily fluids and show them to me unsolicited. Nothing is off-limits, including phlegm, stool, vomit, and even vaginal mucus.

Ingrid runs the board
Ingrid runs the board

We take this as a sign that it's time to start pre-rounding. In the unit, we call this "running the board," which means independently examining a 3-foot-by-3-foot paper grid that tracks each patient's temperature, heart rate, blood pressure, drips, ventilator settings, intake and outputs, lab work, and medications. It's an hourly play-by-play of the patient's past 24 hours, and it is at once sophisticated—the highest level of hospital monitoring—and also shockingly primitive since each number is hand-recorded and often illegible.

I am interrupted 17 times over the next hour by nurses with questions ranging from the simple ("His K is 3.7; how much potassium do you want to give?") to the difficult. ("The patient is breathing too fast on the ventilator: Her respiratory rate is 45, her blood pressure 190/95, and her pulmonary artery pressures 54/36—what do you want me to do?") I struggle to answer each question while trying to remain focused on recording the highs and lows of the previous day. Mrs. Smith's kidneys are shutting down, but Mr. Jones finally had a bowel movement; Ms. Brown was weaned off her diuretic drip, but Mr. Demitri is hypotensive on three mega-medicines designed to raise his blood pressure. Throughout it all, there's the steady background of the unit: the familiar wheeze and thump of the ventilators, phones ringing off the hook, and the never-ending alarm bells that sound like carnival horns.

The team debates
The team debates
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At 7:30 a.m., our team of 10 physicians gathers outside the first patient's room. We start with the new patients, and Ingrid deftly describes a man who was admitted last night with a heart attack, leading the team through a series of electrocardiograms that show the evolution of his heart attack before he was taken to the cardiac catheterization lab (aka the cath lab) to unblock his coronary artery. We go in to see him as a team, drawing the curtain behind us. Ingrid begins by shining a huge flashlight in the patient's eyes to see whether his pupils constrict; then we examine him as a team, with four of us listening to his heart and lungs simultaneously, our stethoscopes planted on his chest. He seems overwhelmed by the attention.

8 a.m. We move on to the next patient. Our co-intern, Vivian, updates the team on the strange case of her 23-year-old aerobics instructor with the massive heart attack. We can't explain why such a healthy young woman would have a heart attack, but the cath lab found large aneurysms in her coronary arteries, making it impossible for them to intervene. She is still at risk for future heart attacks and even strokes, so we decide to consult the cardiothoracic surgeons to see whether she should get a bypass.

10:30 a.m. We are still rounding and only halfway through our patients. As Ingrid presents to the team, I sit at the computer, entering orders to execute her plan—adding new medications; requesting labs, cat scans, or X-rays. I am rushing to finish before the next patient when a nurse turns to me and asks, "Why do you and Ingrid have the same rings?"

I am taken aback, suddenly unsure how to answer, although we are open about our relationship and even had a commitment ceremony five months ago. We were worried about leaving San Francisco for conservative Boston; we never dreamed we'd be moving to a more liberal legislature, where it would be possible for us to legally marry.

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"We're partners," I say, being purposely vague.

I watch the nurse's nose wrinkle. "I thought so," she responds, then adds, "That's weird." She's silent for a moment, and I turn back to my computer to finish up the orders.

A few minutes pass, and she interrupts again: "I don't think I'd like to work with my husband. We'd both be exhausted all the time and always grumpy. I'm surprised you like it." I suddenly understand and feel relieved—I'm at home again in the unit.

Ingrid catches some sleep
Ingrid catches some sleep

Rounds finally end at 12 p.m. As with any call day, I have no idea what to expect of the next 24 hours, but it turns out to be a busy night: I admit two patients, two other patients die, I perform chest compressions at two Code Blues, participate in three family meetings where we discuss withdrawing care, place two central lines—large intravenous catheters that lead directly into the heart—watch an endoscopy, and attend another set of rounds. I give up on daily rituals, squeezing in lunch at 10 p.m. and taking a break to brush my teeth at 5 a.m. There is no time for sleep. It's just another day in the unit. …

Ingrid Katz and Alexi Wright are physicians completing internships at a major teaching hospital in Boston. They are currently rotating through the cardiac intensive care unit and are the authors of Interns' Diary, an online journal.