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“Ok ok ok ok ok, one, two, three, four now PUUUUUUUUUUSH”

As all funny stories about residency begin, it started in the Intensive Care Unit.
I’m a recently promoted second year Family Med resident who’s earned the privilege of becoming an ICU orders-bitch.
Most of the job is a mix of data-entry and the equivalent of optimizing floral designs in a funeral home on fire. I mop up the charts, correct sodium and magnesium and potassium and phosphate levels on future corpses and immobilize and anesthetize the rest.
“Mr ____ needs his restraints renewed before this afternoon.” “Mr ____ needs his pain meds renewed.” “Mr ____ needs his diet orders advanced.” “Mrs ___ ’s NG tube needs an order.”
I loathe this rotation with every part of me.
I’m working a 24. Friday to Saturday, 7AM to 7AM.
The first twelve hours aren’t so bad.
The usual morning of catching up on a baker’s dozen critically ill patients’ charts, talking to the badass ICU nurses who tolerate residents like myself well enough despite our stunning ignorance.
Were I two floors below and two weeks past this hell of a month, I’d be a normal second year, PGY-2 sophomore lieutenant guru for the Interns on the inpatient teaching service.
Were I two floors below and not isolated from my friends, my job description would comprise of Know the census, check in on the trainwrecks, maybe expedite a discharge summary if the kids are running late.
Here I’m the idiot with a couple letters after his name trying to gain the favor of the Biggest Pricks Men on Campus who you go running to when the patient has the audacity to try to die on you despite your best protracted efforts.
So it’s still morning and I’ve set up camp on the furthest left terminal on the lazily curving row of desk space facing the 20 or so ICU sliding glass aquariums of the rapidly dying and essentially already dead. Ventilators, drips, and tubes galore of Frankenstein medicine buying time for some, prolonging suffering for more, and maybe, possibly saving the life of one.
As a doctor who normally communicates with the living, you cannot imagine how annoyed I am.
The day proceeds as normal these last three God-forsaken weeks: Look up and notice the intensivist has already begun rounding without so much as tapping me on the shoulder because it’s beneath him to acknowledge me directly.
We see the rest of the patients. There’s about 15 full minutes of teaching mostly punctuated with “...which you should look up” the way old telegraphs were punctuated with STOP. He says we’ll do an IJ later today. I decline the opportunity to personally take a scalpel to an octogenarian’s neck.
No one dies during the daylight hours. No discharges or downgrades either.

Night shift.
19:00, the overnight nurses come on and my next twelve hours get more interesting.
The wisdom of modern medicine has decreed that when treating the most fragile and complicated patients, the best person to take the helm from dusk to dawn is a second year resident running on equally lethal amounts of caffeine and dread. So I’m thrown the keys to the ward and now run the show.
Time to pay attention.
The census: your run-of-the-mill hyponatremia, a few multi-organ failures w/PMH of the everything with a management goal of, “Convince the son/daughter Mom’s dying this week,” and the remaining ones trying to take me with them.
The problem makers:
65M w/PMH of EtOH abuse, paroxysmal Afib, DM2, HLD, gout, found to have hyponatremia in the one-teens. Alcoholics are easy enough to take care of. Put them on CIWA protocol, squirt Ativan into their veins every so often, we’re cool. He’s only flipped out and saw a baby crawl up the wall once today and subsequently got well and truly snowed. We’ll be fine.
87F w/PMH of stage 4 breast ca w/ mets to lungs, GI tract, and brain, presenting w/ AMS. Hospital course significant for sepsis and multi organ failure requiring ICU stay w/ central line and HD. Basically a grandma with cancer of the everything, dead before she went through the sliding glass doors after it got too hard to breathe at home, but she’s still full Code.
I had a 30 minute discussion thirteen hours earlier about her prognosis with a series of family members handing off the cell phone from one to the next about continuing this futility of care. Bright pink MOLST form still went unchanged for this half of the shift.
63M w/PMH of schizoaffective disorder, HTN, HLD, came in with AMS and found to have a CMP which competed for “most number of values incompatible with life” seen by the hospital. H&P significant for a diet consisting entirely of Chobani® Greek Yogurt - With Fruit On The Bottom (blueberry, for the record) for the last three or five years.
Earlier in the day I got pimped on this patient regarding Refeeding Syndrome by the scowling, perpetually mildly perturbed Intensivist. I failed spectacularly and retreated to my furthest-left terminal to sulk while reading UpToDate.
And beyond how terrifying managing the few-groups-shy-of-a-balanced-food-pyramid case is, I’m also on the clock to catch a kid tonight.
Continuity delivery. She’s crowning at 2AM and I’m contractually obligated to catch her kid one floor down in the maternity ward.

27F G3P2 w/ no significant PMH about to pop. She’s one sprinting floor down the stairs. I’d been getting progress texts all night: station and dilation and effacement all now pointing towards if you want credit to graduate, get down here immediately.
There’s a rule in my Family Medicine program that in order to become an independent, grown up doctor, one must catch exactly five (5) or more kids whose mom the Resident has seen at least three (3) times for routine prenatal care.
I had seen Ms ___ well above three times for prenatal care and would not be denied my trophy.
Saw Mom since her first you’re-sure-I’m-pregnant? clinic visit. Was there the first time we picked up the kid’s heartbeat on the Doppler.
I’ll trade however much they pay to do a colonoscopy or a cath just to keep being around a happy mom’s experience listening to her next new kid’s first heard heartbeats.
The tocodynamometer’s peaks confirm the texts and I take note at the wails of this suffering, sweating goddess who’s now both parts future of humanity and possible minor surgical emergency.
My physician’s mind calmly regards my patient’s genitals leaking blood and shit and a baby’s crowning skull as something equivalent to an art piece recreation of the War In Vietnam and I assure you I don’t freak the fuck out at all.
Unrelated, most of my time before this was spent on checkups of healthy third graders or managing hypertension in otherwise healthy adults a few weeks before this.
The Family Medicine Intern on overnight Obstetrics, Dr ____ and I stand shoulder to shoulder at the business end of a uterus so we can get both get credit for catching this kid. No time for booties for me, I’m lucky to have had the handful of seconds to put on a mask and splatter-resistant gown.
The L&D nurses and the Midwife play overenthusiastic cheerleaders at the crest of each contraction wave.
To be honest, they’re doing the majority of the work.
Push push push push push push annnnnnd BREATHE!
They hold her hands, they help fight her agony.
Then, a miracle occurs.

I’ve been told this is one of the happiest moments of your life.
The culmination of so much worry, and want, and love on a level no one understands until they see the face of their first child the first time.
For me, Mom’s blood is puddling against my black Chucks and I’m dreading playing tug of rope with the afterbirth then shakily stitching Mom’s perineum / boink bridge flesh wound back together.
Labor for a Resident is so much more than just catching the kid.
Still work to be done even after the small triumph of not fumbling a newborn’s head onto the tile despite having zero training on playing quarterback to a hiked football covered in lube.
Labor stages have a second half after you’d think the shift should be done.
Stage 3 of 4: After the baby is born, you continue to have contractions so that the placenta can be born.
Stage 4 of 4: The two hours after birth when breastfeeding can be established. Contractions continue as the uterus will shrink.
I clamp off the umbilical cord twice a couple inches apart but neglect to milk the center of the tissue outwards.
Professional OB/GYNs, please don’t spoil the ending.
I create the anatomical equivalent of a pressurized blood balloon. Which I then proceed to cut, sharp end of the scissors directly anatomically inferior to my face.
A miniaturized Bellagio fountain spray of cortical blood unleashes upward, making a splattered streak of red from my right cheek to my glasses to my forehead to an already-red single curl of my hair to the fucking ceiling.
None of that is a lie, none of that is an exaggeration.
The cleaning crew had to replace a ceiling tile after my handywork.
The L&D nurses got a good laugh that pre-dawn.
I’m too punch drunk from lack of sleep to do anything but laugh along and think of course.

I take the stairs double step back up to the ICU.
I taper off the adrenaline rush for an hour checking in on my ICU patients’ charts. Everyone is still alive, no reports of toddlers tapdancing on the ceiling, Cancer of the Everything’s still breathing, Chobani’s labs are looking better. I crash in an unused ICU bed in the furthest possible left-most side of the unit.
Smells like plain hospital detergent and hospital plastic, feels like scratchy hospital linen and a flat hospital pillow. For all I care, might as well be like slipping into a warm hotel bed with a fiancé.
I’m vaguely aware of the electric bed inflating at odd places from time to time to save me from bed sores.
I awake to my phone’s alarm exactly one hour and seventeen minutes later for morning sign out.
I take pride in reporting my patient census is one higher than it started 24 hours prior.
submitted by madfrogurt to u/madfrogurt

Follow up protocol

Hi everyone, for those of you who ho are practicing in the US and working in Rehab/subacute facilities: how often do you follow up on your new admission? I know it depends on their Dx and factors they might be at risk of, but let’s say on someone with wounds, ESRD HD, TF how often do you write f/u notes during for example 2-3 wks stay? What about ortho pts with common Dx HTN, HLD, CKD, DM,...? Do you know what’s the actual CMS protocol on how many f/up they needs during their stay? Thank you in advance for your response.
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