The holiday season can be tough in any setting, but for residents it is especially difficult. Most residency programs setup the schedule so that each resident will either get a week off for Christmas or New Years. This means that during Christmas and New Years, half of the residents are on vacation while the other half are working at reduced staff (WARS) meaning an increased workload amplifying seasonal affective disorder by one hundered fold.
Last year I was on a general medicine service during Christmas. We admitted patients every day, and it was not uncommon to come in around 6:30AM and be told by night float residents that there are 2 patients in the ER waiting to be seen on top of the 6-8 inpatients that I needed to preround on.
I remember caring for a recovering alcoholic who went into fulminant hepatorenal (kidney and liver) failure. He kept moving in and out of the ICU, and became hypotensive during dialysis. He needed a kidney and/or liver transplant, but could not get either because of his history of prior alcoholism. His climbing urea and ammonia levels impaired his ability to think, and the ICU team quickly decided that his code status was DNR because the patient was unable to clarify. By the time he came to the floor and was dialyzed, his mental status cleared a little bit, and he was able to communicate that he wanted to live and move forward with dialysis, but he would get hypotensive in dialysis. His low albumin levels from his liver failure prevented him from being able to keep fluid in his intravascular space. Our primary team sat down with the nephrologists and hepatologists to discuss how to proceed. Here is a man who has verbalized that he does not want to die, but his blood pressures drop dangerously low when he received dialysis and he was not a candidate for organ transplant. We chose to respect the patient's wishes and move forward with dialysis. Midodrine and albumin eventually was added to treat his hepatorenal failure. Unfortunately this was not helpful and he continued to become hypotensive in dialysis. The patient eventually passed away on comfort care measures.
And then there was the nicest little old lady I had with systemic scleroderma and sarcoidosis. She kept on developing recurrent pleural effusions where fluid would accumulate in the space surrounding her lungs, so the interventional radiologists placed "pigtail catheters" in her pleural space to drain her effusions and help her breath. This worked well for several weeks, but the effusions kept on recurring. This patient reminded my of Billy Madison's grandmother, so sweet, so patient, and asking for so little. Eventually, she chose to ask for a second opinion at Duke. Our attending obliged her request and called a rheumatologist at Duke who agreed with our current treatment. In spite of our best efforts, she kept on reaccumulating pleural fluid. Eventually I would go off service on vacation to my sister's wedding in India... Several weeks later I asked the pulmonology fellow how she was doing, and was informed that she had died from complications from a pleural biopsy. I could tell that he had not wanted to move forward with this procedure but that the decision was made at a higher level.
Today I have just returned from West Chester, Ohio back to Carrboro after enjoying a wonderful Thanksgiving vacation. I met with my parents, sisters, cousins and brother in law and enjoyed a great meal with friends and family. My cousin and I rented a log cabin and went hiking in the caves of Hocking Hills in Ohio.
My schedule through the rest of November and December is difficult. I have multiple Saturday 30 hour calls and I'm on night float for neurology wards during Christmas. As a second year resident, now I have more autonomy and decision making ability. I'm the one who will get called in the middle of the night if someone has a stroke or seizures. I'll be the one making decisions on who can get discharged from the ER or who will need to be admitted to the neurology service. I have plenty of backup from upper level residents and attendings who I can always call if I have questions I don't know the answers to, but the volume will be high so efficiency is a must. As 2012 winds down, I know that the next month will be a time that shapes my career and will provide ample opportunities to significantly help people with real neurologic pathologies while simultaneously being the oncall neurology resident who speaks with patients about their tooth pain. What a unique experience it will be!
