A Day in the Life, Part 1

My editors here at The New Atlantis suggested I write about what a day is like for me and other members of the medical team. What exactly (aside from
rounding) do we do all day? When do we have to be in? When do we leave? What goes on when we’re not rounding?

We can divide the third year of medical school into three distinct categories of rotations. There are inpatient weeks (hospital work), outpatient weeks
(doctor’s office work), and the Emergency Department, or ED. The roles differ as do the schedules. I have already described a bit about how the ED works here. The hospital is for patients who need urgent medical attention or
medical procedures. If a patient is having a heart attack, for instance, a cardiologist in the hospital will make sure the patient does not suffer
complications from the disease process. Outpatient work, by contrast, involves less urgent medical problems, like adjusting blood pressure medications or prescribing antibiotics for an ear infection. Let me take you through a day on inpatient and outpatient medicine.

Inpatient

On an inpatient service the interns arrive at approximately 6 a.m. or, if on a surgical service, at 5:30 a.m., and print out a patient list from the electronic
health record. This list of patients contains the patient names, chief complaints, possible diagnoses, ages, and other basic information of the patients we
need to see. It contains a summary of tests and test results as well. It may seem a bit silly that physicians need a reminder about which patients they are
taking care of; however, the hospital experiences quick turnover. A patient may be present for only a couple of days before leaving. Then, a new patient
with a new history and a new problem takes his or her place. Additionally, when there are sixteen patients on the list it is difficult to keep up with
every story.

Medical students arrive shortly after the interns (the residents are a bit like our supervisors, letting us know when we can leave and when we ought to
come in). Given how early in the day we usually have to be in, there is little time in the morning to do anything but eat a quick breakfast while
bleary-eyed before driving to the hospital in the dark. If we’re there early enough, we receive checkout from the night intern. The night intern goes
through each patient on the list and discusses the latest news on each patient. Did the patient vomit? Did he or she have trouble breathing? What
interventions, tests, or treatments were done? Additionally, if the night intern admitted new patients overnight, what is the story behind the hospital
admission? These questions are vital to the care of each patient. If the day resident does not know, for example, that a patient was having trouble
breathing or received an imaging study then the resident does not know to look at the results of that study, potentially missing a life-threatening problem
like a collapsed lung or a heart attack. In an ideal world, the transition between resident shifts is so seamless that it is as if the day resident took
care of or admitted patients during the night.

Subsequently, the interns assign medical students to “follow” one, two, or three patients (depending on how far along we are during our third year). Following a patient
means knowing the vital signs daily and keeping up with the results of x-rays, CT scans, and lab tests. It also means we come up with a plan for that
patient’s care and propose it to the attending and residents. In truth, the residents and attendings already know what they are going to do for the patient
and our proposals are merely an exercise for our own edification.

After these assignments, we go through the chart on the electronic health record and read about the patient’s history. We read the night intern’s note on
the patient and we look at the labs (tests) that the intern ordered. These notes give us a sense of what the residents or attendings thought the patient had and
needed. For example, if the patient came into the ED with a fever and a cough, the notes will usually mention a workup and treatment for a possible pneumonia, or lung infection (which includes a chest x-ray, sputum culture, and
empiric antibiotics). More importantly, students and residents look at the vital signs of the
patients we follow. These indicate if the patient needs immediate treatment. Is the blood pressure too low with a fast heart rate and a high body
temperature? This indicates a possible blood infection and we take blood cultures and administer antibiotics.

Despite the fact that the sun has not yet peeked through the hospital windows, we subsequently visit patients in their rooms to do a physical exam. We look
at new rashes that patients have, listen to hearts and lungs with stethoscopes and perform neurological exams. We target our exam at the patient’s
presenting illness. For a patient with pneumonia, we listen closely to the patient’s lungs for abnormal breathing sounds due to the infection. All this, of
course, entails waking the patient up. And since residents, appropriately, will come in after us to make sure that we have done the physical exam correctly
and that the patient is in no distress, we unfortunately wake the patient up at least twice during the early morning hours. This is separate from the
instances where the nurses wake the patient up to draw blood for morning labs. Such is one difficulty of being a patient at a teaching hospital, something
I will discuss in future posts.

Image via Shutterstock

Once we’re finished seeing the patients, we have a little bit of time left before rounds start at 8 a.m. We look up information about the illnesses our patients have. We also write down the information we will need to present the patient to the attending physician on rounds. I’ve written a bit about
patient presentations in this post, but in sum,
our presentations report the relevant medical information and treatment plan in an organized and concise matter.

At 8 a.m., the attending arrives and we round on patients. Aside from the few patient presentation(s) we do for the attending we remain silent and watch and
learn as I’ve described previously. Once we finish rounding
we go over the patient list in the physician work room. We make sure that we all agree on the plans for each patient for the rest of the day. Some patients
need to leave the hospital. Some need more IV fluids or medications. And some need an imaging study or a blood test.

After we’ve confirmed all of this, the residents write “notes” about each patient for the electronic health record. A note is similar in format to a patient
presentation. It contains a brief history of the patient’s chief complaint and illness as well as the blood test results, imaging test results, diagnosis,
past medical history, and past surgical history, as well as the treatment plan for the patient. These notes, though incredibly time-consuming, serve a
valuable purpose. First, legally, the note can help protect a physician from future lawsuits. The note documents a physician’s train of thought and
actions. It justifies the tests and treatments which patients receive in the hospital. Second, it is used for billing purposes by documenting what was done
for the patient. And third, when the patient goes for a follow-up appointment with another physician in clinic, the note acts as a standardized form of
communication to update the clinician on what was done in the hospital.

At lunchtime, medical students usually receive a lecture from a physician in the rotation. In pediatrics, for instance, we may listen to a lecture on
pediatric respiratory complaints from a pediatrician. Meanwhile, the residents remain in the workroom or, if they’ve finished with their notes, they can
grab a quick bite to eat in the cafeteria. Sometimes, though, the residents are swamped. They carry around pagers or phones, and nurses and other physicians
page or call throughout the day with questions about specific patients. A patient may get a headache or feel nauseous and the nurse may page the resident
to ask if it’s okay to give pain medication or antiemetics (medication for nausea or vomiting). Given
that there are a limited number of residents, if multiple patients fall extremely ill and need medications, it can be difficult for the residents to
respond to other more minor complaints. A cardiac arrest on the floor, for example, may prevent the resident from ordering pain medication for a patient
with a headache.

More on a day in the life, in a bit…

How the ED (Emergency Department) Works

Ambulance image via Shutterstock

The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines
whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by
ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness
of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring
the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart
rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a
patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls
for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the
hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent
as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with
computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each
other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them
onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We
have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily
systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do
in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about
a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long
conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we
must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive
regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school
or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year
about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the
ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening
illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then
sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the
resident executes it. All this might be clearer with an example from my own experience.

During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the
stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is
extremely difficult and can even cause the observer to feel pain. And
there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining
him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and
frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto
the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the
interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the
signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for
instance, had a differential diagnosis list as follows:

1. Kidney stones

2. Herniated disc

3. Pulled muscle

4. Kidney infection (pyelonephritis)

5. Spinal abscess

6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A
practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical
exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this
pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians
present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of
the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a
concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back
pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to
his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen
earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient
is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis,
herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the
patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for
when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar,
for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If
the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine
physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they
don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological,
psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems
that they can treat.