Diary of an Intern On Her First All Nighter
by Hope Olzewski
First Night Shift on Family Medicine Inpatient Rotation at Arrowhead RMC
(Note, not all nights have been this challenging, and this is an abbreviated form of the entire night.)
I printed copies of an updated patient list for my team and self. I am on Team C, and you had better make sure your residents are ready with lists for sign-off.
Other family medicine teams sign off to your team for the night so that you can be on call for their patients overnight. They give pertinent patient information for events that could happen for the night, ex: follow up on MRI that is about to be done on a patient.
After sign-off, Team C residents tell me and another medical student which teams we have to hand write progress (or SOAP) notes for due to some teams being off the next day. A progress note always has to be written for a patient daily. No exceptions. We also write progress notes for our own team’s patients.
Go see all the patients that you have to write notes for the next day. Ask them about acute events or concerns that they may have and perform a brief, focused physical exam. It is best to see all the patients (6 this night for me) right away so that you don’t wake them in the middle of the night and so that you can be ready when there is an admit from the ED for the rest of the night.
I checked in with my 3 patients from my team and wrote down concerns and nurse reports regarding the patients. I admitted these patients from the ED some time in the previous week. Therefore, I knew their history, and they knew me, which made it much easier.
Patient 1 Progress Note and Physical for other Team: (meaning I have to learn about the patient just before I see them)
Patient 1 was diagnosed with small cell lung cancer with metastasis to the brain and liver the previous day. Hospice had already been contacted, and they were just waiting on the patient to become more stable before transport to his home for care. This was my first week at ARMC, I had never spoken to a recently terminally diagnosed patient before. I realized I had to be careful in how I phrased my questions and in my demeanor. I was not going to ask him how he was because well that seemed like a ridiculous question to ask a terminal diagnosis patient. Instead, I carefully asked about specifics, like nausea and vomiting control over the past day and performed my focused physical exam.
Patient 2 Progress Note and Physical for the other Team: (meaning I have to learn about the patient just before I see them)
Patient 2 was a 25 y/o F with a past medical history of osteogenesis imperfecta and was presenting with loss of vision in her left eye. The MRI showed signs of left optic neuritis. Neurology had been consulted, and they ordered a lumbar tap for the next day as to rule in or out multiple sclerosis, as the patient seemed to have one of the classic initial presentations of MS. Another patient, where I knew I needed to be careful with my words due to an eminent MS diagnosis. I knocked and opened the patient’s door and saw a 25 year old girl with blue sclera all alone in her room looking worried, understandably so. I asked all the questions I needed to and then asked if she had any concerns at that time that I could help out with. She began expressing her concern over the lumbar tap process, and asked how much it would hurt. She asked if there could be any other diagnosis besides MS that could be causing here optic neuritis. I began really feeling sorry for this patient. I answered her questions, and she responded with “I love when I’m able to connect with doctors. It’s getting more difficult to do that.” I was honored to have been able to provide some relief even though it was impartial and temporary. Normally I don’t stay with patients extra time, but I ended up staying with this patient an hour to try and help settle her concerns and just so she would have someone with her.
Patient 3 for the other team was a stroke patient. I was not going to wake him up at this hour, so I waited until the morning. Even though I am interested in neurology, the thought of performing a neuro exam on a patient with a previous day ischemic stroke was daunting.
Hand write progress notes for patients.
We got called for an admit from the Emergency Department. The 34 y/o F was admitted for diarrhea and hypokalemia but with stable vitals. My residents were wondering why we were admitting her, and they told me to go start the admit in the ED. I walked into the patient’s room and immediately knew there was more to the patient history than had been described. The patient was sitting up with her feet on the ground and rocking back and forth. After completing ROS questions, the patient told me that her boyfriend takes her at the beginning of the month when she gets a check for her medical illness. She said that they go to a house where a lot of people have sex, and her boyfriend makes her use methamphetamine daily. He also beat her when she tried to leave. This time she escaped.
After hearing this and trying my best to keep a poker face, diarrhea seemed somewhat trivial on this patient’s problem list. I performed the physical, and the residents came in to check on the patient. I then looked at the patient’s EMR information and saw that she had a past diagnosis of schizoaffective disorder and was currently taking antipsychotic medications. She was unable to tell me this information when I asked about past medical diagnoses and medications. I then filled out the history and physical for admittance note in the EMR. This patient who was being excessively taken advantage of was my first psychiatric patient.
I quickly ate a snack and went to the restroom while we had time. I had been up since the previous morning at 8AM and was also pretending I wasn’t tired. It is challenging for me to flip to nights the first night so I end up staying awake for a long period of time.
We are called for another admit in the ED. The other medical student on our team took this admit. I was relieved because this patient was presenting with chest pain. A few days before, I helped admit a patient presenting with chest and back pain. After I, the residents and the nursing staff saw the patient, the patient coded and passed away in the ED. I had never seen a code in real life before, yet alone watch a code that was unable to resuscitate a patient, our patient. Therefore, I was still nervous about a patient coding while I was in the room from this experience. Even though I knew the procedure if a patient started coding while I was in the room, I still had an irrational fear of not being able to help the patient in time.
My job was to gather background information on the patient in the EMR this time to help the other student. (The other student did this for me while I was admitting the patient with diarrhea and psych hx.)
Patient 3 Progress Note and Physical for the other team. This 54 y/o M patient had a past medical history of ETOH abuse, meth abuse off and on and HTN and presented ischemic stroke the day before. I am interested in neurology in the future. However, I didn’t feel ready to perform a neuro exam on a patient in the stroke unit, but I performed the exam anyway. The patient’s last progress note showed that he had a left sided facial droop, slurred speech and left sided weakness. I woke the patient up. He was very groggy but came to. I asked him questions, but he only nodded yes or no. He would not speak. I asked him to, and he dejectedly shook his head no. I said okay. Don’t worry. We are here to get you better. I completed the neuro exam and physical. The patient’s facial droop was gone. (I was very surprised by this during the physical and made him smile big 3 times. I’m sure he loved doing that.) He still had left arm and left leg weakness. I began my progress note.
Eat breakfast with the team and hand over progress notes for the residents to read through.
Round with the attending regarding our team’s patients.
I presented my progress notes and admittance note for the new patient to the attending. He then signed my notes. We then went and saw my patients and the other medical student’s patients.
Update our patient list information according to changes that the attending confirmed.