A DAY IN THE LIFE OF A MEDICINE RESIDENT

It was a fine morning on 10th may 2022,it’s my duty day.Reaching college with lots of enthusiasm and the fear of missing my biometry.However managed to reach college by 8:02am in the morning.

There was one case in my unit of Stable angina and Haemorrhoids which I reviewed and wrote my repeat.

I went to OPD  by 9am as i usually do on my duty days and started seeing various Op cases of Diabetes, hypertension, hypothyroidism,Anemia, Gastritis, headaches,giddiness etc...everything was going fine and

Got a call from Emergency room (ER) at around 1 30pm when I was planning to go for my lunch after clearing the OPD cases of almost about 30-35cases,that a 60year male is brought in a unresponsive state.

I rushed to the ER from OPD.On my way to ER got a call from ENT OPD that a POD- 3 case of sub mandibular excision had a syncopal attack followed by one episode of ?Generalised tonic clinic seizures.So I took my junior along with me, informed my faculty and rushed to ENT OPD which is anyway on the way to ER,as her vitals were stable and no active seizure i asked my junior to shift her to ER,my junior and faculty gave her antiepileptic and ordered for few investigations.

And I found a extremely obese 60year old male lying on the triage bed with monitor showing HR-30bpm going towards brady,Bp not recordable,Grbs-400mg/dl,Not able to appreciate sats on the monitor as there was no BP.ECG done by the time I have arrived showed severe sinus bradycardia HR 40bpm,by the time I even tried to ask about the details of the patient the monitor showed a flat line.I started shouting aloud for intubation drugs and equipment, everything was made ready in few seconds,As there were no central pulses my interns already started pushing the heart hard and giving compressions.Patient was revived after 6cycles of CPR and I managed to intubate the patient with 7.5mm ET tube, although a difficult intubation in a obese patient ,somehow managed to do it with help of my EMD co pgs as soon as possible.We started to push his BP up with about 200-300ml Normal saline bolus , inotropes.Sister went running to load the inotropes.My intern took an Arterial blood gas (ABG) and rushed to the lab and came back running with the report as it was showing pH of 6.7 which is very life threatening,pco2 68.7,Hco3 6.1,St.HCo3 9.1.We started giving him inotropes and bicarb supplemention.In the mean time I counselled the attendors about all the risks and his condition and started to take a brief history.

He was a 60year old male who is a politician and a local leader and was an inspiration to many people  as what his son told me crying.He underwent nephrectomy 35years ago and his son has no idea why It was done as he was not born by then.That is when the patient was told to be having Diabetes and Hypertension.He is a person who takes his medication regularly and insulin regularly.But one month back he had acute onset Shortness of breath and was taken to a cardiologist where angiogram was done and there was no major block,mild Coronary artery disease ,he was adviced to take antiplatelets.He is a chronic Alcoholic since the age of 20-25years ,drinks daily and had a binge alcohol intake since the past 2 days.Following which he developed pain the epigastrium,severe vomitings and was taken to a local hospital,he got an USG abdomen done showing features s/o acute pancreatitis.Treated conservatively and was given oxygen in view of hypoxia.From that local hospital they started to travel to Hyderabad to some private hospital.On the way to Hyderabad the attenders found that his saturations started to fall in the ambulance,they were very much tensed and stopped at our hospital which is no the way to Hyderabad.I was standing beside the triage bed taking all this history .In the mean time patient again had a cardiac arrest, interns climbed on to the bed and started pushing hard ,giving compressions ,I took off the ventilator doing Ambu and pushing air.

Unfortunately  we couldn't make the heart to beat again.I found about 20-25 attenders waiting outside the ER for me to speak.Doing all the resuscitative efforts is of one level of experience and declaring death to the attendors is an other level of experience which I feel is much more important than even resuscitation in such a case which was very bad at presentation.I came out of ER with a flat line ECG in my hands at around 2:52pm and dull look on my face.I explained them all the events that had taken place and how hard we tried to get him back though we failed to get him back to beating heart.All the huge group of attenders started crying out loud.I came into the ER ,wrote all the death certificates and death summary notes and everything that I am supposed to do.

I mentioned the immediate cause of death as severe metabolic acidosis with acute pancreatitis.

It was 3 :30pm ,and then... ohhh I realised that I din't have my lunch and the OPD is full of patients.I preffered going back to opd as may be , it would be difficult for my Junior and SRs to clear all the opd.We successfully cleared all the op patients by 5pm.

Found a intresting case of 45year female with ?hypothyroidism and polycystic kidney disease and admitted her to evaluate futher from OPD

At 5pm i thought of eating something as i was very hungry and to relax for some time and evaluate the female with ?hypothyroid and PkD 

That is when i got a call from ER that a 70year old female was brought in unresponsive state 

Me and my junior ran to ER from OPD with thoughts running in my head about the case that expired in the afternoon,hoping atleast this case is stable enough to be admitted and followed up, instead of experiencing death again.

We arrived the ER,there was 70year old ,very thin, malnourished lady lying on the traige bed with Spo 2- 56% at room air and bilateral crepts on ascultation,severe respiratory distress with Respiratory rate 36cpm,we started to give oxygen and nebulisations with which her sats improved to 90% (high flow oxygen) . ECG was not showing any ST-T changes.My intern took an ABG and ran to Lab. I started taking History from the attenders she was a 70 year old lady with five-year history of hypertension ,20 days ago patient had complains of giddiness and fall in her washroom following which she was admitted at local hospital .Was diagnosed with acute infarct in left caudate and lentifrom nucleus and right IT fracture .Since 15 days patient is on liquid diet from oral route with history of cough sometimes during feeding. Complains of fever since two days and and unresponsiveness and no verbal response since yesterday.With the above history I had a suspicion of aspiration pneumonia, acute pulmonary embolism secondary to right IT fracture or any central cause of hypoxia due to progression of Infarct. ABG showed severe hypoxia ,PH -7.5 PCO2 -37.3 PO 2 39.8mmhg ,HCO 3- 29.2 mmol,And I was sure that it was a arterial sample. 

I thought Elective intubation will be a better option in view of severe hypoxia and respiratory distress.

Few of my co pgs came to help as it was very busy and helped me with tackling the cases,they stayed back for some extra time helping me.

Everything was made ready for intubation ,with adequate Pre oxygenation and sedation , paralysis I intubated the case with 7.5 Mm ET tube without any difficulty.Chest x-ray was being done for the patient to check the tube position . I connected the patient to mechanical ventilator and finally went to canteen and grabbed something to eat and came back within five minutes to the case. We were thinking of shifting the ventilator case to ICU meanwhile a case of 65 year old male was brought to ER in unresponsive state. 

Me in my head -why the hell is everyone coming in an unresponsive state today

I ran to the patient and looking at the froth coming out from his mouth the first thing in my head was Seizures.E1V1M1! His vitals were stable except for his GRbs which was 22 mg/dl and bp 200/100mmhg. Everyone started searching for 25% dextrose which was not available at that time in casualty. I immediately called my ICU intern and he came running to the casualty with two units of 25% dextrose in his hands by then we already connected the patient to 5% dextrose. The patient regained consciousness in five minutes and became completely normal. Thank God, at least this case is just a hypoglycaemia ,became stable and did not need a ventilator.

At the same time a 65year old female with history of recurrent TIAs came to the ER with right hemiparesis,we did a brief neuro examination and ordered for an MRI which showed acute infarct in left lentiform nucleus.Went back to my 75year old female patient.

I wrote all the events of the ventilator case ,that had happened.Looking at the chest x ray which was showing right lung consolidations with air bronchograms and echo showing no right heart dilation my differentials narrowed down to aspiration pneumonia .I ordered for cultures and started on empirical antibiotics .We shifted the ventilator case to ICU And later I started taking history of the hypoglycaemic patient. 

He Is a 65-year-old male diabetic since 20 years on oral hypoglycaemic agents-Glimi M1 BD, hypertensive since three years, He has history of diabetic ulcers on bilateral foot since two years. Current history according to the attender is that Patient felt ?anxious in the morning and went to local RMP. His grbs was 500 and the RMP has increased his oral hypoglycaemic agents to tab glimi M2BD. Patient took his morning dose of OHA and ate food , by afternoon patient started talking irrelevantly and by evening patient was found to be unresponsive lying on his bed. The attenders thought it was due to hyperglycaemia and they have pushed one more tablet of glimi M2 in his mouth.As they were told by their relatives,neighbours that it can happen even due to hypoglycaemia they started to the hospital immediately. And I suspected him to be having renal failure due to which he is having hypoglycaemia on taking a OHAs and uncontrolled hypertension.We continued 5% dextrose and ordered for hourly GRBS monitoring. We shifted the patient to ICU after taking the required samples.

Finally I went to ICU and started documenting all the events and treatment that should be given to the 70-year-old female with pneumonia and 65 year old male with hypoglycaemia patient.

2other cases in AMC (polycystic kidney disease and acute CVA) and the ENT seizures case was kept in AMC.While me and my junior were sorting out all the issues of the cases that were admitted I got a call.

Again a call from the ER intern at 8:40pm

Me-not again!

I lifted the call. 

Intern-Mam, case of 35-year-old female in unresponsive state and bp 60/40mmhg.

Me and my junior running again to the casualty

Why is this happening to us today and why is everyone coming in an unresponsive state, This is a young lady we need to Save her.

I saw a 35 year old female moderately built in the triage bed With GCS E2V1M2,Bp 60/40mmhg,spo2 96% with 6liters oxygen.

We started her immediately on dual inotropes .

I started asking the history, that attender was describing that patient was apparently asymptomatic 3days ago and she is in this bad status today. I did not understand initially what made her life to change so drastically in 3days. Her husband told us that she is been having epigastric pain since 2 to 3 days and shortness of breath on exertion since 2 to 3 days. She had history of loose tools and vomitings 15 days ago and history of fever since five days. She was admitted with the above complains at outside hospital where she was evaluated and diagnosed with anteroseptal myocardial infection with moderate LV dysfunction ejection fraction 37%,Cardiogenic shock ,?Acute pancreatitis.Treated with inotropes at outside hospital.Patient attenders came LAMA from that private hospital in Hyderabad as they are not affordable for such a costly hospital stay.He also mentioned that he spent 70,000rs in a day for her.She was Treated at outside hospital with oxygen support, anti-platelets, anticoagulants, Creat was 2.1,urea :129, TROP I: 190 IU/L +, Pro BnP 19041 Pg/ml, 2D Echo : EF: 37 % , Lateral was hypokinesia and ECG S/o ACUTE ANTEROLATERAL MI.We have done an ECG which showed qS complexes and ST segment elevation in V1,V2.

I explained the poor prognosis to the patient attenders and nonavailability of cardiologist on IP basis has been explained. Her husband was not in a position to understand and he was emotionally broken.So I spoke to her other attenders.Patient attenders were willing for admission under general physician. The patient was started on dual inotropes nor adrenaline and dobutamine and we shifted her to ICU at around 11pm,Her Bp was constantly monitored ,the systolic was never above 70mmhg and i kept on increasing the inotropes.

In view of refractory hypotension (60/40mg hg) on dual inotropes we started her on Vasopression.In view of low GCS we planned for elective intubation and everything was made ready for intubation,consent was taken. This time I made my junior nephro duty pg to do the intubation after adequate pre oxygenation and sedation at around 12 am.To my surprise he easily did the intubation without any difficulty.He has good procedural skills.We connected her to the mechanical ventilator ACMV mode with sedation and paralysis.Patient continued to have hypotension inspite of 3 inotropes.

Call from the ER intern again at 12 30am

Me -please ,not again!

Intern- Mam, 55-year-old female in unresponsive state

Me to my junior-there is something fishy about today.

As we handed over the cases to ICU Pg ,me and My junior we ran to the casualty at 12:30am.

My leg are aching and I continued to go to the ER

I saw a thin built 55year old female with E1v1M1 in the triage bed with a pillow ,colourful bed sheet over her and casualty intern came to me with the vitals list.She told me that the Spo2 is only 29% at room air,But her heart is still beating at 110bpm and a bp of 110/80 ,But I saw her being not that tachypenic ,why what is wrong?is she also hypoventilating? Anyway I ausculted her lungs and there was diffuse wheeze .I immediately gave her nebulisations  and we elevated the head end.Her Sats improved to 75% with high flow oxygen.My junior took and abg and my intern went as usual running to the lab with the sample in her hands.By the time she came back I asked the attenders what happened to her.

His son came to me telling that she went into sun and that’s why she became like this.I dint get him.I repeatedly asked him what happened after she went into the sun.He was not able to speak much other than the sun thing.The person standing beside him interrupted us and started speaking-yesterday when she went into the sun,she developed giddiness.Local doctor told us that her bp is 70(probably the SBP) and started giving her IV fluids.

I asked him how much fluids were given.He immediately went to the crash cart beside us , getting a 500ml NS bottle in his hands and told me 10 bottles of this size saline was given.

I was shocked and asked him over how many hours were the 10bottles infused?

He said the doctor gave those 10 bottles over 4hours.Me thinking why would anyone do that.And that local doctor did not even give a slip on which everything is written.So there was no way they can prove me that she was infused with 5litres of saline.They also told that she had pedal edema and facial puffiness at the end of saline infusion.

The attender continued that they left that hospital and went home yesterday night.She had loose stools since today morning upto 5episodes.She even passed urine in her clothes 4 times since today morning.And at around 4pm she had Grade 4  Acute Shortness of breath so they rushed to the near by hospital and later reached to our hospital by 12 30am.He gave me some reports of the outside hospital with serum creatinine 2.5mg/dl and ph 6.7 in abg.That was the brief history .

My intern was back with the abg report picture on her phone.

Reading out loud the intern said Ph -6.84,I immediately took the phone from her and saw the abg.Respiratory acidosis!So severe!Hypercapneic encephalopathy!pco2 was 106mmhg, and po2 was 108 as it was taken on high flow oxygen,Hco3 17.4.So how do I correct the pco2 on a E1V1M1 patient.Non invasive ventilation will not help.I decided to intubate her electively. Sister was getting everthing ready for intubation.

I came out from the ER,I told the attenders that she needs to be on a ventilator immediately.Her son was heart broken.He just fell on my legs begging me to save his mother.I reassured him that I will try my level best but in my mind I know as the ph is very low she may not survive.Although , I wanted to try my best looking at his son .

I went to the head end to intubate.We started to give Ambu and push air for pre oxygenation.I noticed that her sats started to fall inspite of giving the Ambu bag ventilation properly.I cross checked the oxygen supply,I looked for any leak.Nothing was wrong ,but the Sats dropped to 30%.She started to have bradycardia,we gave her atropine before she arrested.I immediately intubated her with ET 7mm and connected the ET tube to Ambu.My junior giving the Ambu and my intern checking the carotids.Me standing at the head end hoping the heart and Sats to improve.And suddenly a flat line.My intern looking at me with tensed look telling that she can’t feel the carotids.Both the casualty intern and my intern started giving compressions.Sister was giving adrenaline.Her son noticed that something was wrong standing at the door,He came running .Standing there looking at us giving compressions ,he started crying out loud.The security dragged him out.

I think We tried our best but we could not revive her.I came out and saw him sitting on the floor with no hope left and in a shock state.I called him ,he was not responding ,he was just looking at the floor .I called him again , he looked at me.He dint even come to me as he did previously.I only went to him and explained him that I tried my best but I couldn’t save his mother.I am sorry!

I was surprised to see him not crying , but then he was not even speaking a word to me and was looking at me with anger in his eyes.I can understand his emotions but I tried to save her.He should’nt be angry with me.right?

I explained the other attender also and went inside to give all the death care and for the documentation.

I just sat to write the death certificate in a depressed mood as it was second death since morning.Wrote the cause of death as type 2 respiratory failure and hypercapneic encephalopathy .I wrote the death certificate  ,I took the file and was recalling all the events to note down in the file.

Got a call from the icu Pg

Mam ,the patient you shifted to ICU got arrested .Trying to revive her!

I thought the case with aspiration penumonia got arrested.I just left the ER writing nothing in the file,running to Icu.

By the time I reached ICU ,CPR was going for the young lady with refractory hypotension.I was informed that even on 3 inotropes her bp continued to be low and got arrested suddenly.I took on the CPR started to push her heart.

This should not happen to her ,she is very young.

We could not revive her.

3Deaths in a day!

This is so depressing

I went to the attenders , I got the same angry look from her husband and the others were crying.

It was 4 15am by the time I declared her death.

I sat to write down all the events and death summary.I completed writing notes for the ICU case by 5am and went to ER to write the notes for casualty death case.Completed all my documentation by 6 30am.

Was thinking to have rest for sometime.Came out from the ER and shocked to see that it’s morning already.I looked at my phone to see the time.1 and Hf hour more to go .

I first went to ICU at 6 30am

I was very tired !

Realised that I was left with the intubated case of aspiration pneumonia and recurrent hypoglycaemias in ICU and 

AMC cases of hypothyroidism with PKD,Acute CVA case,the ENT case which had ?Syncope?seizure. 

Had a look at all their reports till 7 30am

Finally I got 30mins left to sleep.Woww !

I slept for 30mins ,me and my junior went home and came back by 9am after fresh up.

We both started discussing the remaining cases and their treatment plans,wrote repeats

We attended the faculty rounds.

All the cases were getting sorted out slowly.

At around 11am I was in AMC discussing the history of the female with ?hypothyroidism and PKD,ICU intern came running to me and told me that a case got arrested in ICU.

I was going to ICU,praying in my heart that it should not be my case of aspiration pneumonia (though itseems selfish)

As there was an other case in ICU on ventilator,I entered into ICU with a positive hope that the case which got arrested might be the other case on ventilator.

By unfortunately it’s my patient again.CPR was going on,she was doing well on ventilator since night,I was tapering her fio2 based on her spo2 since her admission.Morning abg was fine.Having no idea why she got arrested I climbed the bed doing CPR with a depressive mood.I told my intern to continue the CPR and I went to the attenders to explain.Patient’s grand son holding my hands and crying to save her.I told him the same thing that I told to every attender “I will try my best”.He told me that he is getting married in 3days , The marriage hall is ready,wedding cards were already distributed and this is what happened just before the marriage.He told me crying that If his grand mother expires that would be emotionally and financially a big loss to their family and also the brides family. He can’t get married till 1year after a death in their family according to the rituals they follow.

She expired!I was left again with a flat line ECG in my hands as usual.I explained the attenders and declared the death.I got a same angry look in return.

I feel Experiencing 4 deaths in a day is not a easy thing to take even for a doctor .

Although the cases may be bad since the presentation,it was hard for me to accept all the deaths

The hardest part is consolling myself that I did my best at the end of the day.

I took a pain killer and slept on my post duty at around 10pm.

It was very depressing anyhow I enjoyed the medical part of it.

But I Came back the next day morning sharp at 8am with smile on my face ,taking care of my remaining patients.

It’s not very easy to accept all the deaths but had a good experience in critical care and counselling ,declaring deaths,talking to people,listening to various stories of each patient .

Life is such a valuable thing!

But I finally understood that as a resident,my highest ideal is not saving lives,everyone dies eventually but guiding a patient or a family to an understanding of death and illness!

#A DAY IN THE LIFE OF A MEDICINE RESIDENT