Choose Your Adventure: Intern Year Edition
Lindsey Migliore, DO
PGY3, MedStar GUH National Rehabilitation Hospital
This is not what I signed up for.
The shrill screech of the night float beeper resonates through the small shared call room.
You ease yourself off of the top bunk, careful not to further disturb the sleep of the senior resident who lies below.
It’s 3:30 am, and you have been asleep for a scarce hour, long enough to have been inside REM and still confused by the fleeting remnants of a panicked call night dream, and short enough to leave you more tired than when your head hit the pillow.
Once out of earshot, you return the page while logging into the electronic medical records. Your foggy mind requires 4 separate attempts to get your password correct (which ex-girlfriend did you change it to this time?).
Mrs. Smith is hypertensive to 185/110 and is not due for any blood pressure medication.
Like the choose-your-own-adventure novels popular at elementary school book fairs in the 1990s, your choice in this moment can have a profound impact on your story.
Which of the following doors do you choose?
Door number 1: Give the 5mg Amlodipine scheduled for 6 am now.
The laziest of options, it allows you to put in a simple communication order and attempt to return to sleep before the glare of the computer screen further throws off your circadian rhythm and depletes your scant reserve of melatonin irreparably.
You glance at the vitals trend over the past week and quickly determine the primary team has been slacking. This woman’s antihypertensive management is in need of some TLC.
Door number 2: Shoot some IV Labetalol into her peripheral line.
Knock out that acute hypertension, and get the nurses off your back until she gets her morning medication. By then, you’ll be long gone, to the comfort of your own bed and some artificial melatonin induced ZZZs.
Door number 3: Increase the AM Amlodipine, and add a STAT dose of Lisinopril.
If you remember one thing from the diagrams of the loops of Henle and dark haze of boredom that were medical school nephrology lectures, it was to increase current anti-hypertensives prior to adding another agent.
The melatonin is really beginning to fade now, and your mind gains a level of clarity only owls should have at 4 am. Amlodipine will not cause any noticeable change to the blood pressure for at least a day.
You dive deeper into her chart and realize that, due to the previous sepsis-induced AKI, this diabetic’s ACE-inhibitor was held by the ICU team. Now that she has been transferred to the medicine floors, and her creatinine has returned to baseline, time to protect those glomeruli!
With career ambitions set upon outpatient physiatric practice and a possible sports medicine fellowship, the ins and outs of blood pressure management may not seem sexy.
That is what the primary care doctor is for, am I right?
You could choose door number 1 or door number 2, and push the responsibility and decision making off to another sleep-deprived intern.
You could glide through your intern year, leaving the medical decisions up to the budding nephrologists and cardiologists who sat at rapt attention while soaking up every detail about sodium potassium channels while you played Candy Crush in the half-empty lecture hall. At least you bothered to show up to class.
Or you could try door number 3.
Behind every door is the eventual end of intern year, and the start of what you actually signed up for: “actual residency.”
Behind every door is a PGY2, most of whom will be responsible for call shifts at an inpatient rehabilitation hospital. Most will be alone, truly alone in the hospital for the first time.
How will you handle that?
How will you respond to the late-night calls for hypertension, hyperglycemia or uncontrolled pain when the patient does not have a peripheral line in and there is no senior resident to make the important decisions for you.
As physiatrists, we integrate multiple specialties of medicine together to not simply add years to a patient’s life, but rather to add life to their years. We treat patients, not diagnoses.
It is the lessons you learn in intern year, on the nights when your triceps ache from performing CPR for the third time and you have not gotten non-supplement induced rest in weeks that you will draw upon when it is your turn to make the decisions, when it is your team to be the code leader.
Which door do you choose?