Serenity

Two nights into my night float and I must admit that I am overwhelmed by the serenity it has bestowed upon my soul. Having absolutely no responsibility for future results and not having to deal with the complications that will later arise has served me well. The medical admitting resident and I have become great friends. Together, we ponder over our futile attempts to divert bullshit admissions and how hopeless those attempts really are. We theorize over the judgement used by the Emergency Room doctors to rationalize their admissions and we have come to a hypothesis that it goes something like this: In a world where medical school is a business and everyone is just covering their ass is there really any room left for logical medical decision making? The answer is no.
Now, the medical Admitting Resident (AR) calls me from the Emergency Room and our conversations go something like this: (Just a general reminder, this is three or four in the morning)
AR: “Madman, I have a patient for you”
M: “Shoot!”
AR: “Ms. R is a forty year old female”
M: “With Chest pain right?”
AR: “How did you know?”
M: “I know her, I had her one my team last month. We have a documented catheterization that shows clean coronaries. She’s just a nutcase with a lot of social issues and she’s addicted to narcotics. She’s manipulative and a general liar. We practically had to get hospital security to remove her from the hospital after she wouldn’t leave on her own”.
AR: “You mean you have the report that says she has nothing in her heart!”
M: “Absolutely nothing! In general, she just wants someone to prescribe morphine and codeine and she’ll only make some poor interns life miserable for the next week”.
AR: “Well, let me talk to the ER docs and see what they say, I’ll call you back”.

One minute later the phone rings.

AR: “She’s coming in”
M: “What? After all I’ve told you she’s still coming in? Let me guess, they think she has a genetic mutation that causes her arteries to clot over days”
AR: “No, after I told them what you said they want to admit her as a social admission”

We both just started cracking up. You really can’t make this stuff up.

The truth is that at four o’clock in the morning it wasn’t as funny as when I look back on it. Of course, I punished Ms. R for the pain she would cause poor intern. I did three rectal examinations that night, just to rule out acute excessive rectal bleeding in a women with non-cardiac chest pain (hey, in a genetically mutated individual you never know). I told the intern to tell her to run up and down the halls every day for ten minutes- to prevent a venous clot. Of course, I wrote “DO NOT GIVE PAIN MEDICATION” all over my admission note.

The beauty of night float: She’s now someone else’s problem.

Not a Myocardial Infarction

There is no other job quite like the night float. It is a meaningful meaningless job of sorts. You admit, you care for patients overnight, you hand them off in the morning and forget they ever existed. Other residents depend on your impression for continued management and yet form their own impression as soon as they see the patient. From that point on they can change whatever medications they deem unnecessary and the hard work you put in overnight is instantly dismissed and discredited.
It is Friday night here and instead of celebrating my wife’s birthday I am floating the hallways, like the ghost of Halloween. My fear of impending doom does not resemble that of a myocardial infarction but still obscures my ability to enjoy this first night and I try to relax. The Emergency room is quiet now. Shortly, a chubby fluid filled abdomen will walk through the doors reeking of alcohol and asking that we end whatever misery his last bottle caused.
Here comes the news….just got a call from the admitting Resident in the ER. I have a patient waiting downstairs, my fear of impending doom grows.

Night Floating

Due to the new hours regulations in effect for all residents we now have a few weeks a year where we live for the night and exist only to admit admit and admit. This is called the “night float”.
Every day at 7 am just as our brain cells finally arrive at the realization that although we’ve been “floating” all night, our legs, arms and higher cortex neurons are damn tired, we need to present our workups to the COMMISH. Yes, sexual failure COMMISH, this should be a very fun two weeks.
I am on with another resident whom I respect. If not for his intellect, M is quite a character. He has a way of easing things up a bit. I remember the time that one of the patients in the ED took out his glass eye and rolled it on the floor just so M would pay some attention to him. M just started laughing and, picked up the glass ball and said “Don’t worry, I’m keeping an EYE on you”. I lost it.
I’ll keep you guys posted on the events of nighttime madhousing. I hope things improve for me a little, right now I don’t happen to like my life so much in many respects. This is actually my therapy and I wanted to thank all of you for keeping an EYE on me. Second year of residency certainly didn’t start the way I expected it to.

Mixed Up Inside

All good things, and bad, must come to an end, or at least, should. Tonight, I wished my interns a farewell and a “good luck”. One of them I will continue to see for another two years, the other, I may see but who knows. Big H rotates through our hospital just to get a feel for medicine in a community institution. Hers is a nicely furnished private medical center more befitting people who graduated from the big H in B town.
This is a happy time for me because in one regard I would like nothing more than to put this behind me. The Real Patient incident was truly devastating and I don’t think that I recovered from it just yet. I have not had one night without images of the incident and her face on that day penetrating my deepest conscience and expressed in winces of horror on my face. Every day there is another aspect of the case I am being reminded of. If not by an interested third party then by my attending who is finally accepting that it is possible we made the wrong decision, although slowly.
On the other hand, I really liked my team and we have had an amazing month together. The tragedies have somehow brought us closer together and we have had to rely on each other for moral support. I will miss DCFA (“Don’t cry for me Argentina- the second resident, she is Argentinian) but I will get to witness her slowly growing to become a fully functional team of her own.
I will definitely miss my sub-I from the D in NC. Although having him ask me nearly everything from what to do to what he should have for lunch has gotten kind of old, he really is an amazingly hard worker and probably cares about his patients (or his grade) more than I could have imagined.
More than the others, I will miss Big H. Throughout the month we spent every call together and most of the day together. After learning a lot about who she is and some of the things she’s accomplished I am not at all surprised that the big H decided to draft this phenom. Although as an intern she is equivalent to DCFA I have to say that as a person she is one of the most amazing people I have ever met.

Tonight, after all the “Keep in touch’s” and “Good luck” with this or that we went our separate ways. We will probably all cross paths one day. We’ll have a hard time remembering each other’s names then and all we’ll say is “He used to be my resident”. We’ll remember what kind of time it was, we’ll remember if we learned anything that month. I’ll remember only one thing then: It was the worst of time and it was the best of times.

A Conflict of Interest

Unfortunately, I have noticed that hits to this blog go way up after I announce some horrible death, gross error or a particular patient who is about to code. It seems that tragedy fascinates you guys and the numbers are there to prove it.
Of course, as you may deduce, this is an unpredictable complication and one I would have never predicted in advance. As doctors and scientists (I use that term very loosely), we try not to get ourselves into such conundrums. Now as I run to a code I have to think: What will my audience want to hear, that we saved him or that he died? That we saved him and then he died anyways? That he died and then rose form the dead to sue us all? As you can see, this is a horrible conflict of interest and just may affect my performance.
The interesting point is: The more bad things happen the more depressed I get. The more depressed I get the worse I feel, the more I sexually malfunction, the less I sleep, the grumpier I get, the more I write sad depressing things and hence the more people come to the blog etc. etc. So, it may thus be deduced that in a way you animals want me to suffer and that I am powerless against it because were I not suffering who would be reading this blog?
Think about that for a while.
Let’s see how well you sleep at night.

Not So Crazy

On my service there is a lady from the local psychiatric hospital. For the last few days she has been driving my intern crazy. Her pager hasn’t stopped and every time that she gets called it’s usually because the patient is throwing some fit in the hallway, yelling at the nurses and the staff. Her (The patient’s) mental capacity is obviously altered due to her frequent hallucinations and so we really can’t be too upset (although we are!).
During the weekend, I am on with only one of my interns, the other one! So today “Big H” (The other intern) gets called for the nutso yelling in the hallway. I decided to take a walk to entertain myself (It was slow).
It seems that she was insisting she be transferred and cursing at the staff. I suggested that instead she should write a note of her complaints on a piece of paper and that I will hand this paper to the hospital management. I figured this would shut her up for a few hours. What came next honestly surprised me.
The following is a list of her complaints: (in her exact words)
1- The smell of shit perculates through the entire hospital. (I usually call this “Eau De Residance”).
2- The food is nasty and tasteless.
3- Patients are ill and depressing.
4- I cannot identify with the staff.
5- My doctor lied for the last 2 days.
6- Staff clerk- told me to go “s--k my d--k!” and pointed to my vagina.
7- I don’t like the me me me stuff.
8- I want to get out of HERE.

The strangest part of it all: I cannot deny that on some level I feel the same.

So who’s the crazy one? Oh, and about that mental status…

A Fart in the Wind

Throughout this month Attending Giant has mostly taught us about common sense. I have found it somewhat frustrating that in the way of actual medicine he is not as well informed as I would like and that I find myself making very difficult clinical decisions on my own. Possible that at this age he has found that his greatest contribution would be just plain old common sense and a fifty year retrospective on the experience of caring for people. I have been amazed by his ability to connect with patients. He speaks their vernacular instantaneously and seems to have dealt with each particular patient for years.
Lately, you must have noticed that I have hit some rough patches. I continue to question the work I do and the reasons that I chose to do it. Did I really need to work this hard? Did I really need this level of stress and responsibility? Finally, what is there in all of this for me? As if he could hear the thoughts that cross my mind, today Attending Giant told us a story, he was speaking to me directly and I knew it.
It was about an old patient of his. The patient had passed three years ago but to this day Giant remembers the funny times they had together. His face lit up when he talked about him and he began to laugh to himself and tears almost swelled in his eyes. He told us this patient was a very funny man and that each time he saw him they would lock themselves in the exam room and laugh for an hour, exchanging dirty jokes. Days before the patient died he visited Giant at the office. He talked about how badly he felt. “I feel like a fart in the wind” were his exact words. When Giant told this to us he couldn’t stop laughing. He felt it epitomized his friend. Giant paid for his funeral and even wrote a eulogy for a prominent newspaper in the area, titled appropriately “Fart in the Wind”.
Attending asked me today to think about the definition of the word “Doctoring”. This was before he told me this story. I am happy to say that, although I can’t possibly put it into words, I know exactly what it means now.

Glucometers for Everyone

Two weeks into the current rotation I find that the hardest thing about being a resident is keeping all these different patients and all their coexisting medical conditions straight in my head. As we round each morning through twenty to thirty patients for whom I am personally responsible, they all seem to blend together and become one big mega-patient. This one has Diabetes, this one has hypertension (high blood pressure), MS (Multiple Sclerosis), Chronic heart failure, chronic kidney failure, chronic chronic chronic. Whatever they have, it’s chronic!
To counteract the onslaught of mega-patient I have developed a new and seemingly effective “pre-emptive” response.
I now assume everyone has Diabetes, Hypertension, Hypercholesterolemia (high cholesterol) and snorts cocaine. The reason for this is obvious: Every patient in this hospital HAS Diabetes, Hypertension and Hypercholesterolemia and nearly everyone has snorted cocaine or is currently shooting it into their IV line. If they don’t have these conditions, then I’m sure they will at a later time anyways. This effectively cuts short the list of diseases and addictions I have to remember by four and usually will leave only one to two additional conditions.

Morning rounds now go something like this:
Intern: “Ms. D is a 34 year old woman who came last night complaining of severe pain in the abdomen, we think she has a urinary tract infection”.
Me: “What are we giving her”
Intern: “Bactrim” (A type of antibiotic).
Me: “How much insulin is she getting?”
Intern: “She’s not diabetic”
Me: “Won’t the Bactrim interfere with her Hypercholesterolemia?”
Intern: “She has a normal lipid panel, she’s doesn’t have high cholesterol”
Me: “Even with her Diabetes?”
Intern: “She doesn’t have Diabetes!”
Me: “What’s she getting for blood pressure control?”
Intern: “She’s not hypertensive!”
Me: “Even with her Diabetes and Hypercholesterolemia she’s not hypertensive?”
Intern: “Stop it”
Me: “Have we talked with her about rehab?”
Intern: “How many times do I have to tell you that she doesn’t do coke!”
Me: “Oh yeah, what’s that white stuff under her nostrils?”
Intern: “That’s a milk mustache from breakfast”
Me: “Who gave her cocaine for breakfast?”
Intern: “I give up”
Me: “It's about time!”

Poor Big H, she's a burning match in a world without oxygen.
She’ll understand next year.

BUS (Big Unit In Sky)

Today I found myself running between two rooms. In a day I’d like nothing more than to forget I went between a patient with dismal disease and one with horribly dismal disease. In one room, I told a patient’s family and him that he had cancer, that it is very advanced, that although he is still walking and feeling ok he probably won’t be for very long. In the other room, I was trying to convince a family to sign a DNR order on a patient with advanced cancer of a different type. The patient is going down the tubes as we speak and will very likely jump the BUS very soon. There is nothing I’d like more than to let her do that and not end up on some ventilator wasting away.
I find that this month I have had more than my share of tearing people’s heart out. I’ve watched husbands nearly collapse at the news of possibly losing their wives. I’ve watched old ladies cry to me to save their husband.
In a world where doctors are supposed to be perfect and everything is supposed to be curable there are just dismal diseases that we have no answer for, at least not yet.
After these last two weeks I find I am getting more comfortable with the word “Cancer”. I am no longer affected by its consequences. It’s true meaning as it relates to my patients lives and to their family’s life elude me now. I have become automated, a sort of desensitized machine. At the same time, I have trouble falling asleep at night. I find that I try to avoid seeing my dying patients. Even consciously knowing what I am going through is really not helping me cope with it much. They are not necessarily my failures but they ask for help every day and every day I have to remind them just how helpless I am. There just is no cure, not for them. Whether I am still able to save myself remains to be seen. In this world where doctors are perfect and are able to cure everything. Who is here to care for the doctors?

Rule No. 1

As doctors we try to follow at the minimum one rule: First, Do No Harm. So it was especially tragic for me when I received a phone call today telling me that Mr. E had died.
He was a 95 y/o man whom I cared for during the week on the medicine floor. He had severe dementia to the point of being nonfunctional. He had severe congestive heart failure and a host of other debilitating conditions. He wasn’t able to move around and was pretty depended on machines and family for life.
After some time in the CCU, he was stabilized and sent to the medicine floors to prepare for discharge. After evaluation, I believed he was relatively stable and that there was nothing more we would be able to do and had discharged him the following day to go home with his family.
Two days later I find out he died the following evening. His family, when I met them, had expressed their wishes that he die in his sleep and that he that his suffering would end. Part of me is happy for him and happy for them.
Still, there are the doubts and the guilt that plague my conscience. Could it be that in my hastiness I broke Rule No. 1?

Procedures and Complications

For the most part, the most exciting time for a medical resident is when he/she has to perform a procedure. It’s the time when the medicine residents can pretend to be surgeons who actually know how to read an EKG. So when a fellow resident’s intern approached me to supervise her Central line placement I had no trouble with it. Her resident was supposedly not certified as of yet and so could not yet supervise her. What she forgot to tell me (“forgot” is a relative term) is that she never told her resident that she was placing the line.
A bit of hospital politics: Since all residents have to perform a number of central line procedures to be certified and since all have a three year residency, the general rule is, senior gets the procedure, unless resident is already done enough procedures. It’s a dog war out there.
To make a long story short: Intern scrubs in, Intern preps area, Intern breathes deeply and begins to hyperventilate, sticks in BIG ass needle, pokes around for a really annoyingly long time. It gets interesting: Resident (Her own) happens to walk by, storms into room yelling that he is the one supposed to do procedure, Intern gets flustered and yells at her resident calling him “Big Baby”, Resident and intern continue to yell at each other (Patient not under general anesthesia and is now threatened by BIG ASS needle in PISSED OFF intern’s inexperienced hands), and me watching everything. Intern stops procedure and storms out of room, panic ensues (my own!), Resident storms out to continue yelling at Intern, I do my best to finish procedure, I keep my name out of patient’s chart to avoid impending law suit. A quick lesson: Procedures have complications, even those we would never think about

The Resident I Hate

I am fast becoming the Resident I hate. You know the one. He thinks he knows everything, he assigns presentations left and right, he doesn’t remember what being the medical student was like, never ever helps with intern scut and, of course, never helps with intern scutwork. This was my nightmare as an intern and now I am my intern’s nightmare.
After my three month hiatus from the medicine floor I have quickly picked up where I left off. The cocky, arrogant, knowledgeless shit is back, but now I get to boss other people around. Maybe the power went to my head. Every time I even think about helping intern I am reminded of my last year and think “leave them alone, they need to go through this to learn”. Of course they don’t, just don’t tell me that.

CSI Madhouse

This morning I was assigned a forty year old man who recently came into the Madhouse with a horrible cocaine overdose. So horrible, he laid on his floor for so long that much of the muscle tissue in his legs began to break down, causing his kidneys to shut down in protest. We had to put him on hemodialysis and keep him on it for over a month. Not to mention the two operations he had to endure just to try and save his leg. We finally discharged him one month later with one barely functional leg. He had only recently been discharged from jail.
This time he nearly did it again. Found on the street with his face in the concrete he was saved from a horrible life threatening arrhythmia seconds before it would have ended his life. His urine was positive for drugs. When I finally saw him he was stable and able to talk and breath. All I wanted to do after seeing what he did to himself was knock his teeth out and choke him. I wanted to shake him and say “WHAT THE FUCK ARE YOU DOING????” Instead I asked him what happened, how, why? Etc. etc. etc. The whole time thinking “idiot”.
It is not becoming of a doctor to speak such filthy language, at least not to patients. So it was very amusing to see Attending Giant walk the team over to the patient’s bed, approach the patient, smack the patient and then turn to us and say “Here we have a forty year old man who is ROYALLY FUCKING UP HIS LIFE!”
PGY50 (Post-Graduate Year 50), it takes time to be that good.

Different Subject: Over the course of the last month we have had over ten patients who have recently snorted cocaine and came to the hospital with heart rates in the 30’s. It appears that there is a bad stash of coke being sold in the area. We recently began asking our patients to bring in the cocaine so that we can get it analyzed. I wonder if they think we are taking it for ourselves.

If My Aunt Had Balls She’d Be My Uncle

I know I’ve been kind of slow with the blogging recently but it’s mostly because of my overall exhaustion. As you know, last week was really difficult. I was finished with the first CCU rotation of the year and started my rotation on the medicine floors. I figured I would take this opportunity to update everyone on the current ongoings inside the Medical Madhouse.

My Team: As I previously outlined, my team is made up of one Attending, Resident (me), two Interns, one Sub-I, and two Students (check prior posts for further explanation of goals). I’ve been with them for almost one week so far and have slowly developed into a team leader. A highly indecisive, paranoid, self-conscious team kind of leader (I guess…). One of the Interns is from that amazing medical school from Boston, the big H, rhymes with “Harvard”. The Sub-I is from the big-D in NC, rhymes with “Luke”. Every day as we round I try to teach the students a little something. Every time, these other two try to chime in with one of their New England Journal facts. I think next time on call I will ask the admitting resident for a patient who needs emergency dis-impaction. A little present from the big R (that’s for "your RESIDENT") for being way too smart!

My Attending: As luck would have it my Attending this month is one of the Giants. Known for his total disregard of conventional medicine and an odd view of the way we do things. He likes to discharge patients, specifically, patients with life threatening conditions. Over the last week I’ve admitted multiple patients just to see them go home the following morning. Great for Intern, as Intern’s mission is auto-accomplished and no lying necessary, but bad for Student and Resident as I now have to work harder to teach.
Last night, I admitted a patient who’s suddenly started vomiting at 6 o’clock in the morning. I was pretty sure during the night that this woman had a small bowel obstruction and that her condition was somewhat severe. This morning, Attending convinced me that this is in fact Not Small Bowel Obstruction. His explanation: “If my Aunt had balls she’d be my Uncle”. Considering his standing as one of the Giants, I am thoroughly convinced that this in fact is pure genius. I just haven’t figured it out yet. I’m sure that with a little more sleep deprivation things will begin to make sense.

Chief Of Medicine (from here on “COMMISH”): In my last post, I touched on how the Commish embarrassed Resident MaDmAn in front of everyone and questioned the MaDmAn’s commitment to hard work and excellent patient care. I had trouble sleeping that night. Considering, I really took it kind of hard. It was really surprising how Commish got into Resident head. So bad, that during that evening Resident had achieved total failure in bedroom with wife because Commish’s face kept popping into Resident head. Thus achieving failure in multiple aspects of life. Came to work the next day kind of cranky (you think?).
I was determined to do an absolutely fantastic job of admitting last night and presenting this morning and I believe that I did. Commish had no great comments, but at least no bad ones either. MaDmAn junior is back. “Oh honey…?”

By the way…if anyone figured out that “My Aunt had Balls thing” feel free to clear this up for me.

This “May” Be Consistent With My Therapy

As I write this I am crying. Honestly.

It has been a very rough week. The first day I was picking up the service and on call at the same time, had 2 patients on the floor crashing while I’m trying to admit eight more, figure out the patients I am suddenly managing and trying to teach two relatively new interns how to do anything. Left very late at night and presented my patients to the Chief of Medicine in the morning. Who made me look like shit in front of nearly everyone. The week went downhill from there, until today. But after this afternoon, I am broken.
On my first night I admitted a poor (very poor) fifty something y/o man. He had no medical history, because he never goes to doctors, because he can’t afford it and he has no insurance. He had some smudge on his x-ray way up on the top left side of his lungs. To quote the radiology resident’s report this smudge “may be consistent with cancer”. This was as “may be consistent with cancer” as a Ferrari “may be consistent with an expensive car”. It was cancer, it was horrible cancer, it was inoperable cancer, and it’s the angel of death on an x-ray.
In today’s medical world radiologists, and just about everyone else, covers their butt by using words like “may be consistent with” or “cannot exclude”. This x-ray should have been dictated the way it was dictated back in the 50’s: “C.A.N.C.E.R.!!!!CANCERCANCERCANCERCANCER!!!!!”
I think in a way that it would be more humane if it just was!

Before I left I had to tell his wife that we need a biopsy to check if this could be cancer. I was lying because I know it is. We have to confirm it anyway. She cried. She has no one else in this world. She has no money, they don’t have a real place to live, she barely gets by with him and now she will have to get by without him. I nearly broke down in tears right in front of her and had to leave the room as fast as possible. I locked myself in the on call room and cried. I’m still crying.
My message to the tobacco industry and the great CEO’s of the past (and present) who found ways to play with people’s brains and make them believe they were somehow better for smoking: Thank you very much for your wonderful gift. So many people dead, dying. So many residents crying, so many wives watching their world crash around them. Thank you so very much. I hope one day you’ll have something that would be “consistent with a conscience”. Maybe we should tattoo it on your forehead, but only the way they used to do it:
“KILLERMURDERERKILLERMURDERER”