Interns LIE!

Tonight, my CCU rotation came to an end. I had to say goodbye to the wonderful nurses, residents and fellows who made this rotation as great as it was and as magical to write about. Tomorrow, 7 am sharp, I embark on a new journey on the internal medicine floors. I will be head of a team encompassing one Attending, one Resident (me), two Interns (first year residents), one Sub-Intern/ fourth year med-student (from here on the “Sub-I”), and two third year med-students (a.k.a. “Students”).
To serve the readership yet unfamiliar with the medical hierarchy that governs today’s fine medical establishments I will now take the time to explain this ass-licking stepladder. The understanding of this is essential for our future relationship and so if you have any questions feel free to ask. I will list these from least kissed ass to practically dripping. I think the best way to explain will be to list primary goal of each, secondary goal (if applicable), friends and enemies. It is long; I am sorry for this, but essential for the upcoming month. Let us begin:

1- The Students/ Third Year Med-School Primary goal: To impress Attending and Resident with knowledge we were sure they never had. Secondary goals: To cloud a simple clinical scenario by suggesting that the patient has as many extremely rare diseases as possible, to name a disease the Resident hasn’t heard of and to send out for as many of the most expensive blood tests we have as the Resident allows. Friend: The sub-I, as he is closer to the resident and gets the scoop on their performance thus far. Enemy: Interestingly enough, they are each other’s enemy as they are always being judged comparatively to each other. This undercurrent of hate is masked very well and only Freudian understanding of the subconscious can uncover it.
2- The Sub-I Primary goal: Impress attending, Sub-I’s need recommendation letters for match so they too can be taken advantage of by residency programs and government. Secondary goal: Discharge patients, less patients less work and try not to sound like Student by naming any rare disease. Friend: Intern and Resident, possibly third year but only if they agree to do his blood draws. Enemy: Patients with extremely rare diseases (makes Sub-I extremely uncomfortable as he now has to sound like Student).
3- Intern Primary goal: Discharge patients. Intern will do or say anything to achieve this goal as he/she is usually overworked and would love to have one less annoyance. Secondary goal: Anything that ends in less patients (I cannot stress this enough). Friend: Other interns, amazing bonus point if able to really swing Resident to his “point of view” (often wrong!). Enemies: Patients!!!!
4- Resident Primary goal: To impress Attending and Chief of Medicine while also keeping Intern happy, motivated and feeling that Resident is truly on his side. Secondary goal: Constantly remember that Interns LIE! Again, they do anything to get patients out and Resident must continually double check Intern behind Intern’s back as INTERNS LIE! Friends: The Giants and other Residents. Enemies: Everyone on a certain level as Interns LIE, Sub-I wants information primarily for Student, Student wants to name rare disease and make Resident look bad. To counteract Student, Resident must immediately say “I don’t know that but why don’t you give us a presentation on this tomorrow morning” (Gotcha Ya Bastard!).
5- Attending Primary goal: Come for 2 hours in morning, teach, leave as fast as possible, keep name out of chart so no one knows who to sue later. No Secondary goal. Friend: All. Enemy: No one. Remain completely oblivious to the ass smooching going on a round you. Wipe ass off after morning round.
6- Chief of Medicine Primary Goal: Teach and run Medicine Department. Secondary goal: Absorb all ass kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school.
7- The Giants Retired Geniuses, all Ex-Chiefs of prestigious departments who don’t want to stay home because their wives will drive them nuts. We all love them because they help us and they know wayyyyy too much. They’re great!

This is the system within which we all operate. If there are any questions please feel free to ask. Tomorrow, I will do my best to avoid all questions and appease Intern to join my view of things. This will be my greatest chess match yet.

Shock the Crap Out Of'em

Three days left in my CCU. Yesterday was my only day off per week. They do this so that we don’t have any more incidents where residents jump off the roof of the hospital to their death. I am pretty confident that had there been no casualties we would still be working 24/7. They tell us it’s better for our education to work the long hours. “Care continuity” is the magic word around here and every time us residents hear it we begin to feel our peristaltic waves changing direction as the food slowly makes it’s way up our esophagus.
There are fresh new faces here and more tragic stories. A Few Updates, Ms. R with the widow maker is doing quite well and maybe, contrary to our medical opinion, she may actually one day make it out of this hospital. “Paranoid deluxe” went upstairs to torment another resident who will undoubtedly attempt to take his own history. “Dah” is still here and heading downhill, his kidneys, after realizing that his cerebral cortex had royally screwed up, have decided to shut down for a while as they mourn the passing of normal cardiac function. He started dialysis yesterday and all of us are waiting for his kidneys to recover from their loss and get back to work.
Mr. C is new, he is a poor soul who ran into an overzealous EMT responder who decided to shock him three times so that his heart would come back to life. It did, and now Mr. C is intubated in my CCU with practically no brain function (there was no oxygen going to his brain for a long time). He has absolutely no medical chance of recovery and now can depend on a life hooked up to a machine that will help him breath when all he wants is to stop breathing. The intern who saw him overnight decided to place an external defibrillator on his abdomen just in case he codes again. We were all very happy to know that if Mr. C codes he we would send enough voltage through his bowels that we would shock the crap out of him (literally!). At least he would die on an empty stomach.
As medical management I recommend no more medical management. We should let him go to the BUS peacefully but instead we will treat every single abnormality we can and prevent him from doing just that. Welcome to the world of legal medicine. As my favorite teacher used to say "currently we are rearranging the deck chairs on the titanic”!
At least, he won't need any stool softeners.


Question to Readership: I started this blog to convey the general experience we face as residents in a city hospital/any hospital. I am unsure if you would like me to include my patients or the medicine involved in these discussions. What are your opinions? Comment or email me, I would love to hear from you.

Widow Maker

Upon arrival to my CCU I was introduced to a young 58 y/o female currently walking the tightrope between life and death. Earlier today she was admitted with a new onset MI (heart attack). She was rushed to the angiography lab where one of the critical arteries supplying blood to the heart didn't appear on the monitor- it was horrible clogged.
The “widow maker” was so affectionally named due to it’s effectiveness at doing just that. It is a commonly fatal stenosis of one of the critical arteries that supplies the heart and usually affects fifty something year old men, fatally, making their wives widows. Ms. R had no idea of this horrible monster that was forming in her arteries and now it threatens to end everything that is her life.
I had to talk to her family earlier tonight and tell them how grim the situation looks, they cried, I had nothing to say to comfort them at all. I don’t really think I should, she has a very slim chance of survival and they better be prepared. At the moment she’s nearly maxed out on all the possible medication we could give her and the only thing standing between her and the BUS (Big Unit in Sky) is the love of god and a resident with 14 months of experience.
I am scared.
Back to work!

The Night Crawler

It’s 3 am in my CCU. Lady with dig toxicity and 1 vein and the prior two bleeders went upstairs today while I was passed out at home. By Upstairs I don’t mean the Big Unit in the Sky (BUS=Heaven), I just mean to the medicine floor. Still no CCU patients hitting the BUS on my watch. One should code any minute since I just wrote this. At least my overwhelming paranoia thinks so. The two new admissions are mysteries in and of themselves. “Dah..my heart is ballooning” guy and “paranoia delux” chick.
The first to check in was “paranoia delux”. A relatively young lady in her late 50’s who had the unfortunate circumstances of having her second MI (Myocardial Infarction= Heart attack) in as many decades. She also had a long history of paranoid schizophrenia, let’s concentrate on this. To those who have not had the privilege to talk with these patients then let me describe the experience. It’s kind of like talking to a wall, except, the wall could probably hold up a better conversation. It’s quite painful, kind of like, running into that same wall over and over, at high speed, head first, no padding, steel wall.
The following is an excerpt from our conversation:
Me: So tell me what brought you to the hospital today Ms. P? (notice the open ended question form)
Ms. P: The ambulance. (me: aha….)
Me: Well, why did you call the ambulance?
Ms. P: I didn’t, my husband did.
Me: Why did your husband call the ambulance, were you having pain or anything else? (open ended #3)
Ms. P: yes.

This went on for a long time. An agonizing looonnngggg time.

Then came “dah, my heart is ballooning” guy (From here on, just plain “duh”). “duh” was here before, approximately a few months before this admission. During that time, someone happened to do an Echo and mention to him that his heart had ballooned to the size of a watermelon and that it may…just may…could possibly…cause him to have horrible heart failure and die real soon!
You’d think this would maybe make an impression, possibly scratch the surface, maybe even it would be something that you would like to follow up on. Therein lies how “dah” earned his title. Now with full blown CHF and a spec of hope for a possible transplant “dah” is back in full force. Updates to follow.

Topic of Title: It’s 3 am in my CCU and I am wide awake, unable to sleep but maybe because I switched my biological clock to nighttime now. So, technically, what is this called? It’s not insomnia because I intentionally did this. Rules. Well I’m climbing the walls, as I like to say, so for tonight I am the night crawler.

Excuse Me

Hi Guys:
I just want to apologize for the lack of trackbacks and all the other jazz that goes along with having a blog. I am still trying to even come to terms with what all this stuff even means. Not to mention installing any of it which at the moment is a little above my current comprehension of computer systems. I need the idiots guide to just above everything here.
If anyone has any suggestions please feel free to email me. Excuse this post as a sidenote of my ineptitude. It is not the topic of this page, read below.

Limitation, How Beautiful

Fourth night call. We’re maxed out on patients, or rather, we have no more beds. Currently, everyone is stable. In spite of this my paranoia keeps me awake. Like rafting in a river with a waterfall except you don’t know where it is. Actually, it’s more like swimming in water with a loose shark. I find myself looking through everyone’s labs and checking on them constantly, afraid I may have missed something crucial, something that will hint the next coder. Having no room for more patients is comforting of sort as I always prefer the devil I know.

The interns are back at work now doing what they do so well. At times I find my paternal instinct kicking in trying to protect my interns from attending’s wrath. Attending has been kinda nonchalant about this whole rotation and he’s barely teaching anything.

For fun I make it a point to strike up a conversation with at least 2 members of every team in the CCU. For those who don’t know, on any given day CT surgery (Cardothoracic Surgery) team, the Critical Care team, the Internal Medicine team and the nurses are all the CCU at the time. Here’s the interesting part, they don’t talk to each other. It’s not a rule, but somehow, before I got here, it became a tradition of sort. I find myself being upset with the rest of the teams for no apparent reason. I guess even unfamiliarity breeds contempt. I asked other residents at different hospitals and I find it’s like that in most places. It’s a little of hospital politics that patients rarely learn about. One that really only exists in the US.

Different Topic: the LOL’s in NAD (refer below) made it through the CCU without dying. The one remaining vein still functions. The lady with the excessive digoxin concentration continues to survive. Her heart is being really obnoxious about it and refuses to let go, good for her!

Topic: avoid the hospital in JULY and AUGUST. Can’t elaborate, just trust me!

Topic: We have a few patients here being evaluated for cardiac transplantation. I had to break the news to one of them that he’ll need a new heart. Actually, no one bothered to tell him and he found out after psychiatry came by to evaluate. Poor guy, it was such a surprise. It was also a surprise for the psychiatrist who was really pissed at us for not telling him about this ahead of time. I was pissed at CHF service for not telling him and they were pissed at the patient for having a shitty heart. We’re all a little pissed.

The Night Owl

The first night in the CCU went uneventfully. I had to torment a bunch of LOL in NAD’s (Little Old Ladies in No Apparent Distress) because they decided they needed to come to the hospital for a pain in the leg and the shoulder, respectively. Both were found to have an arrhythmia which could possibly kill them. Except, they’ve probably been walking around with this horribly deadly arrhythmia for quite a long time and now they met a resident who will probably kill them. Never before have they ran into the medical madhouse where interns stick you with needles and residents on call have to punish you for coming to the hospital in the first place. One of the LOL’s needed to get a blood draw every 2 hours. She had one vein left in her body and it was hanging on by a thread. I managed to collapse it at several different points just for good measure. She should be in systemic shock at some point this morning.
To make things worse, the LOL shouldn’t have been getting the medication she was getting that forced me get her bloodwork every two hours. It was a cardiology fellow screwup and he refused to fess up to it in front of the attending making the rest of us look like jackasses. I managed to pretend not to know who ordered it and audited the order system in the computer. His name came up, mysteriously. Wiseass!
Different topic: Some time off in the night allowed me to read an article in the NEJM about how residents and medical students are getting screwed by the match and the hospitals and the government. I often think that it would all be totally worth it if I thought that my patients really appreciated what we go through to take care of them. 4 years college, 4 years med school, 3 years residency, 3 years fellowship, thousands of dollars in debt. Where I learned medicine patients families brought food and cakes to the department every day. They said thank you endlessly. They really made me happy to be there. I would love to say that it is the case here in NY but it isn’t even close, maybe in other areas of the US. If you have any insight feel free to add your two cents. If you have any idea on how I can pay all this debt back please feel free to add your donation (just kidding).

Why Me?

I awoke today only to find out that today I go to night shift. This means that I now go in at 8 pm to my CCU while my co-resident goes to days. I will be working from 8 pm to 8 am. While switching my biological clock at the drop of a hat is a routine familiar to me it is by no means an easy one. Some of the ways us physicians achieve this: (warning: Those who respect their private physicians please read no further)

1- Sleep very late the previous night or wake very early on the day you begin working at night. Hope you are very tired in the afternoon and you can maybe catch a nap.
2- If fatigue does not set in drink a beer. Drink two then three, whatever it takes!
3- If fatigue still does not set in then have sex with wife (possibly, anyone else)…hope this will knock you out. No wife or anyone else…you know what to do.
4- If you’re not yet counting sheep then go to work at eight pm, bloodshot eyes, tired, cranky, upset, pissed you chose this career path. Now you’re a real doctor.

Night CCU promises great adventures. No interns around, no fellows, no attendings, just me and my thoughts and my codes and my insecurities. Here we go.

I Hope to Be Pleasantly Demented

Fourth day on the job after the long vacation:
One of the patients in my CCU is bleeding. We're hoping she stops bleeding but for a a good while it looked like we were going to have to rush her to the OR. This time I managed to keep calm and actually sounded like I knew what I was talking about. Maybe next time I'll actually even sound confident.
Well, to the point. It was during my internship when I noticed that there are two types of demented elderly. There is the angry demented elderly and then there are the pleasantly demented elderly. The angry demented just about upset everyone they know. Family never visits, no one ever calls, the home health aids are constantly changing because they are just so hard to deal with.
Then there are the pleasantly demented ones. They are always smiling, even during codes, even during their own codes. I love them. It's almost a blessing. They don't even know how much they don't know or how slow they've become or how incontinant for that matter. We love them because they make us feel like we're doing something for them, even when we're not.
I've resigned myself to a future of Alzheimer's. My memory is horribly bad and if I don't get alzheimer's then we can pretty much junk the whole disease-progression theory.
I just hope to be Pleasantly Demented.

For Whom These Bells Toll...

I am writing from the confines of my ICU. The machine bells create a certain melody I cannot easily describe. It's amazing how heart rates set to music can sound so beautiful and so scary at the same time.
I returned yesterday as per previous post and already had a big scare when in the first hour one of the patients crashed. She quickly recovered but not before my knees nearly gave out. If anyone saw the episode of scrubs where that intern is running towards a code and hide's in the closet then that's kind of what felt like except there was no closet to be found and everyone was looking at me to shout out some instructions. Three months off practice can play with the memory. Luckily the atropine kicked in pretty quickly and saved me from looking like a huge moron. It's coming back very quickly though and I am very impressed at how fast I am picking it up again.
It is also my first rotation as a second year resident and so the responsibility of supervising interns is also new to me. I am having a lot of trouble ordering people to do things and find myself always saying "if its' no trouble....". Although my interns won't hate me I am starting to wonder if it will cause a rebellion in the ranks as they begin to think that their resident is too nice and start walking all over me. I'll make sure to stick a few "do this" and "do that" before I leave today, get them back in line. Overall, I am impressed with myself and I'm amazed at how little they know and realizing that it was me about one year ago. The learning curve on this job is very steep.
Otherwise, I like rotating here because there are a few cute nurses. In our hospital you'de have a hard time finding a good looking female. Although my wife hates when I say this, it never hurts to have something easy on the eyes around all this misery. Not to mention....the medical students ;-}

Rusty

Two weeks ambulatory, two weeks vacation, one month research elective, another month research elective, two more weeks of vacation, tomorrow…CCU. This was my schedule for the last 3 months. I started ambulatory at the end of my intern year and went directly (post 1 week in Puerto Rico) into vacation, research for two months and vacation once more. All in all, three months off clinical practice of any kind.

While most would salivate for this schedule I’ve come to realize something about myself which apparently everyone else already knew. I can’t stand having more than 2 weeks with nothing to do. As my wife puts it “I have a chilly pepper in my ass” (It sound better in Hebrew).

Well, to the point. Tomorrow I return to my first day as a second year resident. My first rotation is in the CCU. It’s one of our two rotations a year that we spend at a private hospital. And while floating the floor is usually misery personified, being in this hospital’s CCU is like a wet dream come true. Nurses are motivated and practically run the place, residents get to sleep and when they wake up they’re given a list of orders to enter in the computer. Stuff the nurses did all by themselves overnight because they didn’t want to wake you up. God bless their souls.

I’m rereading, for the fourth time, the complexities of a code. I remember nothing. RUST! And as the metal slowly creeks and the brain function returns and neurotransmitters begin to form once more I realize I am facing an uphill battle. Wish me luck my friends. Over the next 2 weeks my supratentorium should come back to life, who knows, maybe it’ll help make my blogging a little more interesting.

I started this blog not as a medical source but more as a chronicle of our exploitationa dn as a place that we can bind together and rant and rave and mumble anything that comes to mind. To all who enter feel free to give your experiences, as yours are certainly different than mine. To the interns out there we know you are angry, feels free to rant, we understand!

MEDICAL INVESTIGATION MY ASS!

It takes a lot to move me to write. In my nature I am quite passive, being very content in letting the world do as it may in front of my eyes, be it wrong or right. But I draw the line here. During the 10 seasons of ER, I had my moments when I was ready to blow but last night topped the charts. I am speaking of the new NBC Thursday show “Medical Investigation”. A new, exciting, thrilling, mind blowing load of shit.

Let’s take it from the top:
1- I don’t know a doctor that is that high strung, let me rephrase, I don’t know a GOOD doctor that is that high strung. In my opinion, the only medical mystery this guy needs to figure out is where his valium is. He also needs to stop using Crest strip teeth whiteners…I can’t see the patients due to the reflection of light emanating from his mouth.
2- The NIH doesn’t send out helicopters to get anybody. They barely have enough funding to embezzle.
3- Osteogenesis Imperfecta is one of the main DD’s (Differential Diagnosis) for suspected trauma. The fact that he took a helicopter to another state to make the diagnosis of an obvious disease only further explains why the NIH doesn’t have enough money! ;-} It also says we need to be teaching actors playing pediatricians better. Since they can’t rule out an obvious diagnosis. Let’s open a fund to help actors playing pediatricians.


Let me clear things up. I loved ER, BUT, I really hated the med students. I celebrated when they killed Lucy, or when carter screwed up. Enough…as a general rule in emergency rooms:

1- students DO NOT intubate. As a more realistic rule, students should be NO WHERE NEAR THE VICTIM in the case of trauma.
2- Students DO NOT know everything, like those geniuses on ER. God I wanted to puke every time they got another answer right.
3- Doctors don’t fight on the floor.
4- Helicopters don’t crash through ER walls.
I could go on forever. Feel free to contribute as I’m sure your pet peeve’s are bigger than mine.

My Retrospect on being the LOWEST rung on the totem pole

I only found Blogger one year into my residency, September 9, 2004, today. One of the main reasons, well, let’s face it, the main reason is because for the past one year I’ve been the lowest form of being in a city hospital, the INTERN, and way too busy to be surfing google. Along the way I’ve learned all the essentials of being a wonderful intern: scut the students, avoid the residents, avoid giving excessive information as it will inevitably lead to more work for ME. In addition, never disrespect the nurses as they run the hospital, have plenty of chocolate in your pocket for bribing tech’s and secretaries, AND don’t ever be shy about bribing the secretaries and techs with chocolate. I’m ready for my second year now. But before I go on (never start a sentence with “but”…yeah I know) I thought I would take some time to look back at some of the wonderful times that happened, usually at 3 in the morning, this past year. Times I will never forget, mostly because they are etched in my mind, along with the wonderful patients that in their innocence and ignorance and well cuteness…made this past year a ride to remember.

I started the year in the CCU (Coronary Care Unit) a frightened little intern only protected from the world by a white coat that says that I know what I’m talking about (Not for sure) and my resident who I now realized didn’t really know too much at that point but sure did pretend to know it. I remember Mr. Weiss, wonderful Ashkenazi Jew and unbelievable stereotypical. I say it as a compliment. Anyways, to the point, Mr. Weiss, an overweight 64 year old man walks 12 blocks through scorching sun to buy 10 bottles of ginger ale. Yes, TEN bottles (each 2 liters) of ginger ale. Because? Waldbaums was having a special of ginger ale at 25 cents a bottle. This is where it begins…but it gets better!

Anyways, as you imagined he carries these 10 bottles through the heat and has this massive heart attack. He then enters a pharmacy and sits in a seat next to the door. The pharmacist growing wise figures out this guy had a heart attack and offers to call EMS. Here’s the twist, Weiss tells him to call his wife instead.
The wife understands what happened and says she will be there soon as she can catch THE BUS!!!! One hour later she finally arrives. The pharmacist offers to call EMS again, however, the wife states that she looks like a MESS and can’t go to the ER looking so schlumpy. You heard right…a MAJOR heart attack.
So they go back home. One hour there…she changes clothing and then, you guessed it, they wait for the bus again and finally head to the hospital. When he arrives we realize he had a major heart attack and he gets admitted to the CCU.