Just finished five night shifts at St. Charles. I like working nights, once I'm in the same time zone, which always takes a couple days to adjust. The hospital is quieter, the pace less frantic, and often there are a few minutes here and there to get horizontal. I laid down on the window seat in the hospitalist office, since the call room was in some far-off corner away from the action. The big picture windows brought in a lot of cold, but a friendly nurse gave me a couple blankets, toasty from the blanket warmer. You're on your own at night...most specialists don't want to get out of bed, though they're usually willing to talk on the phone. And you hope the three daytime docs tied up all the loose ends on their patients so you don't have to. The pace was steady, and the Emergency Room was crowded a couple nights this week, which usually means plenty of business for me. No one knows why the number of patients fluctuates so much from night to night.
As a regional referral center for all of eastern Oregon, St. Charles has a "transfer center", which pages the nocturnist hospitalist about possible transfers, usually very sick patients. It's pretty exciting to be managing the care of a really sick patient over the phone with another doctor at a tiny rural hospital hours away. I had a midnight call from a doc in Burns who wanted transfer an elderly semi-comatose quadriplegic woman with pneumonia and sepsis. But after he told me the story, I asked him to do a few things to stabilize her before the three hour road trip. Due to the weather air transport was not available. She had a very high serum potassium (6.7) and a very low serum sodium (115) with lowish blood pressure, so I asked him to give hydrocortisone, since this could indicate adrenal crisis. I also asked him to check blood gases--even though her oxygen saturation was okay: turned out her carbon dioxide level was high, so she needed BiPap, if not intubation. He told me she did not have a fever, but a further check, inspired by the mention of adrenal crisis, showed she was hypothermic, with a rectal temp of 90. So she was covered with a Bair Hugger, a warming blanket with circulating hot air, and given warm IV fluids. (I always thought Bair Hugger was spelled "Bear Hugger".) We discussed antibiotic choice--their miniture hospital didn't have the one I wanted, so he substituted another. The woman finally arrived at the end of my shift, but I had her admission orders all written and waiting, so the ICU team could get right to work. Her doc called a couple days later to inquire about her condition, and say thanks for the help. I congratulated him on putting in that central line, which he hadn't done in years, but did successfully in this big pinch.
The morning after my last night, I signed out to a new group of hospitalists I hadn't met before. One arrived a little early, and started telling me about local politics. I knew of three hospitalists who were planning to leave, mostly women who were excellent doctors, but couldn't juggle the twelve hour rotating shifts with having young children at home. But now I heard two of the male doctors were leaving too. It turns out Bend Memorial Clinic, the big multispecialty clinic in town, had hired their own hospitalists, which decreased the work available for the local ICU intensivists. The intensivists, in turn, decided they wanted a "closed" ICU so only they could work in the ICU, excluding the hospitalists. (And here I had been trying to protect the sleep of the intensivist by managing that patient from Burns through the night...even gave him time to take a shower in the morning...my hospitalists told me not to bother in the future.) The arrival of the BMC hospital group (whose medical director suggested I call him about working there in the future), also decreased the census of my Sound Inpatient Physicians hospitalist group, but SIP planned to make up the difference by doing all the medical work for the local psychiatric unit, Sageview. There was also disgruntlement over salaries and management. Every hospitalist program I've worked in (this is #5) has had politics, and usually locum tenens positions (like mine) are needed during such times of upheaval. My plan is just to enjoy the work, and try not to get wrapped up in the politics. It's hard to see good people struggle with these issues when their energy is better focused on patient care.
One of the "benefits" of being a referral center is seeing unusual or interesting cases. I admitted a young man with hypokalemic periodic paralysis. His serum potassium was 1.6 and he could barely move. I had never seen anyone with this diagnosis before, and had to look it up online on UpToDate so find out how fast I could replenish his potassium. He was discharged the next day, so I guess my orders did the job.
I'm also struck by how much alcoholism there is here. I haven't seen many patients admitted with chest pain from cocaine, as in southern Delaware, but here there have been a lot of alcoholics in need of detox, and suicidal drug overdoses, or both. Perhaps having a psychiatric facility here changes the mix seen in this emergency room, but I suspect Bend's being especially hard hit by the recent economy meltdown has increased the amount of alcoholism. The unemployment rate here is especially high. The real estate market bubble was especially large, with housing very overbuilt, and one of the most overpriced markets in the country. Apparently the population of Bend has shrunk 30% in the aftermath of that bubble bursting. There are lots of people down on their luck, if they even stayed in town. It's no wonder I could get this nice two bedroom apt for 3 months for only $850/month. But now that winter is here...cold and dark, with barely nine hours of light each day, the rate of alcoholism is worse than ever.
So I finished my stretch of nights, got a little sleep, and headed to Portland to see a couple friends before my sister and I head south to visit our other sister outside Sacramento for Thanksgiving. The road check showed it was snowing heavily in the mountains with chains required, so I took the hour longer route north to the Columbia River Gorge, then west to Portland. There was a little snow, but not enough to need chains. And I always enjoy driving through the Columbia River Scenic Area, even when the sky is dark with clouds. But the winding roads reminded me to be sure to take this trip back to Bend during daylight hours. When the weather is stormy, it's very dark at night out in these lightly populated areas.
No comments:
Post a Comment