Overheard

Overheard in the hallway of one large academic medical center this week:

Me: "Hey Intern Year."
Intern Year: "Ya?"
Me: "Suck it!"

Dancing With The Morons

The hospital, when flowing smoothly, is beautiful to watch. The elegance with which teams of doctors, nurses, pharmacists, techs, and other staff work together is something so remarkable, so coordinated, so intricate, that is so closely resembles…a dance. Yes, just as B and C list celebrities have proven time and time again, a well-orchestrated dance is simply magical, especially when you are paired with a half-naked dancing goddess in heels. And just like in those dances, the hospital carries with it a unique array of dances, some dazzling, some romatic, all strangely metro. So please, learn these moves, dazzle your family, friends, and lovers, and just be careful. After all, wouldn’t want you breaking anything, because before you know it you’ll have me dancing around you…and as anyone who was at my bar-mitzvah can attest to, it ain’t pretty.

The Icky Shuffle

With apologies to the original Ickey Shuffle, a fond form of entertainment from my youth, this one is starkly different and, in my opinion, vastly more challenging. Your partner in this case is an ED exam room covered in blood, vomit and feces, all deposited by the charming young alcoholic in the center of the room. You must briskly hop, skip, and jump across these assorted piles of excrement, urine, and lord knows what else, for if you slip that is not only a ten point deduction, but also a memory no amount of showers will wash away.

By the way, those extra blue dots in the corner aren’t just for a hopping sequence involving your left foot – those are just tears. Lots and lots of tears. Lets move on.

The Intern Code Special

For this dance, you (in blue) are the intern on the ICU Code Blue team, paired with a high-powered group of medical professionals. At any moment an overhead page will holler “Code Blue [location]”, repeating over and over again. One second you’re trying to stay awake during noon conference, the next second that voice emerges from the monotony – you, along with the other members of the code team, bolt from your chairs and charge towards the crashing patient at full speed. Hilarity ensues, at your clueless, dumb-ass expense. This may or may not be based on a true story…I’ll let you decide.

The There Is No Way In Hell I’m Getting Anywhere Near That Guy

There is something about drug seeking behavior and body odor that makes for a very intimate, albeit distant tango of passion. And by passion I mean a foulness that would burn the inside of your nose much like the cocaine burning the nose of this guy right now!

The Shadow

Paired with a ballroom trainee (in green), otherwise known as a medical student, watch as she follows your every move. Literally. The only thing more annoying is that Hello Kitty pen she carries with her as she scribbles down every worthless thing you say.

Hey, you. Ya, you. Med student. How about instead of following me into the bathroom you do a literature search on staying away from my balls? Thanks a bunch.

The Eye Pass

The most seductive of dances, this one involves the lowly intern, downtrodden but still yearning for the higher echelons of care, catching the glimpse of the Hot Nurse, she who bestows upon the lucky housestaff an image of perfection behind her oddly form-fitting scrubs. He makes a pass, then walks away, then another pass, and another. He knows she dances for him, that their connection is true. She, on the other hand, knows he’s a douchebag. And one who makes less than she does.

Higher Power

As a medical student during your clinical years, you are generally expected to take a lot of time to get to you’re your patients intimately, to spend long amounts of time with them, to truly know them. After all, on most rotations you are generally only assigned one to three patients at a time, so there is often ample time to give them the attention they, in most cases, deserve. So much of healing seems to revolve around the simple act of sitting down next to a patient at the bedside and listening (although a squirt of antibiotics or a snip of an appendix can help from time to time as well).

Which makes it all the more ironic that perhaps the greatest challenge in the transition from medical student to intern (or resident, or attending for that matter), is that the precious element of time is taken away from you and you have to deal with it without compromising patient care. What started as a 30 minute to one hour encounter progressively shrinks, to the point that at peak efficiency any self-respecting intern can probably limit actual face-time encounters with a patient to less than one minute and still extract enough information (along with the time you spend getting labs, vitals, etc.) to guide the course of therapy and interventions for the day.

I bring this up because over the course of intern year, one thing has become alarmingly clear: namely, that an increasingly large number of patients are distrustful, antagonistic, doubtful, and angry with health care providers. I can rattle off a lengthy list of patient encounters that involved stacks of (often false) information patients printed out from the Internet, the patient angrily shaking the papers in the doctor’s hands when what the doctor says does not agree with whatever crap some quack on the Internet typed up. Then there are patients that repeatedly insist on seeing only specialists and/or attendings even though they know they are at a teaching hospital and have absolutely no choice about whether the putz intern or medical student rounds on them every day (unless the patient happens to be a prince from any number of middle-eastern countries needing a transplant of one organ or another…but that’s for another day). And I think a lot of these encounters can be easily fixed, but the system no longer allows us to spend the time necessary to do so, and as a result this contributes to the declining respect for physicians in our society.

I have not thought much about this until today, because until today I really had nothing to compare it to. However, this afternoon I met a very pleasant and exceedingly tragic young man who is dying from cancer. Stoic and occasionally tearful, he ended up in our hospital after vomiting blood at the airport shortly after arriving from his home country of India on a business trip. My encounter with him was somewhat standard; yet, it was my encounter with his mother, who hopped on the first plane to America upon hearing her son was in the intensive care unit (likely at some obscene financial cost, no less), that was so remarkably unusual. After discussing the case with the patient and his mom, the mother started talking about her concerns regarding his health, repeatedly invoking the notion that God will help her son, that God will cure his cancer, that God will ease his pain. After a few minutes of this monologue, she turned to me and said, “And honestly, we both know that God is too busy to meddle in the day to day health of all the souls on this Earth. That is why you are here…you are the hand of God, to do his bidding…you are God.” She grabbed my hand and repeated, “You are God.”

I smiled, held her hand for a few moments, and after a brief discourse walked outside of the room and took a deep breath. I instantly remember thinking that that had to be one of the most, if not the most, awkward patient encounter I experienced in my budding career, more frustrating than drug addict who called me a “pain medicine Nazi” (just a note to all you pain seekers out there: most things probably don’t rile doctors up, but before you call someone a Nazi, make sure they aren’t Jewish and descendants of Holocaust survivors, because when you say things like that you don’t get your pain medicine…just a tip), more embarrassing than the prostitute that screamed through the halls of the emergency room, “You can’t handle my pussy with your peppercorn dick!” (seriously, how did she know?).

I’ve spent most of the year being reminded by patients of how idiotic I am, how incompetent the hospital staff has become, and how incomprehensible the system shall ever be, and here I am being proclaimed a God so matter-of-factly, so nonchalantly, by someone who held her oncologist from India in the same regard and also does not appear to understand that neither one of us was going to be able to cure anything her unfortunate son had anyways.

At first, after walking back to the resident room, I recall thinking, “Well it’s about damn time someone appreciated what I do all day!” It was so refreshing to be put on that pedestal, because, obviously, there is no other pedestal that quite matches up to the one God is on. But it was only a few moments later that I started feeling extremely uncomfortable. Would a physician prefer the current state of medicine in our society, one rife with distrust, conflict, and frustrations, or would a physician prefer to return to the extremely paternalistic state, one in which the physician was king, immediately trust-worthy, the ultimate arbiter of life and death?

At first the answer may seem obvious to those of us currently operating under the current mode of existence. Frankly, the next time a patient comes in with a stack of information printed out from some quack website, questioning my every move and shoving those pieces of paper in my face, I may simply say, “Fine, if you want to take the Internet’s advice over mine, that’s OK; just never come to see a doctor or go to a hospital ever again.” (Right before I take their stack of papers and throw them down the hall.) Fortunately we don’t have to imagine what that might be like, we have the vast majority of modern medicine to guide us. After all, the Tuskegee Experiment and the Nazi medical crimes were both done under the guise of the all-knowing, all-powerful physician. Yet, those are admittedly extreme examples that are perhaps more a reflection of the stunning depths of humanity and not a particular aspect of paternalistic medicine itself. At a much smaller but more practical level, it is important for me to express the intense discomfort that soon swept over me shortly after that patient and family encounter. Yes, I was initially feeling pretty proud of myself, but I shortly started feeling rather uncomfortable. Because before I became a doctor, I went through an incredible series of silly hoops, whether they were exams, activities, or hours upon hours with incredibly obnoxious interactions with awful people. In fact, I think I’ve made it pretty clear that my education over the last four years does not exactly prepare one for…well…much of anything, as it turns out. And I feel very confident in saying that nothing I went through actually amounts to any true higher stature, and surely no true higher power.

Most importantly, however, I learned that it is far better to be humiliated, scorned, and untrustworthy in the current medical system than to be falsely idolized in the older model. So much of this past year has been accepting failure, whether it manifests in the cancer-ridden body of a previously healthy 40 year old with a wife and two young kids, or in the glazed eyes of the same crack addict with a habit I will never break. In the wake of these perpetual failures, the notion that physicians are somehow elevated in society holds no ground, and I think it is silly for any physician to attempt to embrace this role. This is something medical students are now taught to varying degrees, but my hunch is these lessons last as long as it takes for most newly minted doctors to find themselves in a similar position to that I just experienced, weighed down by a year’s worth of sometimes literally being shit on only to be elevated to God-like status by some kind (if misguided) patients, and enjoying the latter role far more than the former. The attitude starts there, and only grows.

Where to go from here? As with most things, moderation seems like the key. I think most doctors would willingly give up a fair amount of the hero-worship they currently enjoy from the minority in exchange for a little more appreciation and respect, along with a large disposal of the unwarranted distrust that is currently sweeping through this country, from the majority. It doesn’t seem like much to ask to me.

And what of the family I spoke about? Sadly, the patient quickly succumbed to his disease two days after I met him, no miracle cure to save him from the terminal cancer he was suffering from. Yet, I was told he died in peace, without pain and with family at his side. Something God would be proud of, no doubt.

Pages From The Dark Side

There are many reasons why I have disappeared (see below for a more serious account). Yes, there are many. I could go on and on (and on and on) listing all these reasons, a diatribe on intern year...but I feel like that's been done before (see House of God), and I'd hate to shamelessly rehash material that has already been discussed ad nauseum. After 9 months of some of the hardest work I have every done, often under utterly absurd circumstances one could only describe as Kafka-esque, I have emerged. In other words, the last nine months have been a total shit show, and I've been just too freaking tired to do anything other than work, eat, poop, and occassionaly sleep. So, umm, sorry?

But with clarifications in mind, I thought I'd touch on one of the biggest parts of my intern life: my pager. Back in medical school (about 86 years ago, or so it seems), I touched briefly on the fears I had about receiving my first pager, even then sensing that something rotten lurked underneath that plastic shell. Two years later, wrought with many a prank page from the likes of Dr. Jablomie (first name Haywood) and Dr. P. Tang, I actually developed a soft spot for my pager as a form of divisive medical student entertainment. After all, when you are a medical student with zero responsibilities and a lot of free time to screw around with an electronic toy that all your friends are also carrying, life is good.

But then this year happened.

Like the cigarettes and lighter rammed up one of my more memorable patient's rectum (I’ll let you decide if I mean that the patient himself was memorable or that it was the unique qualities of his rectum that emblazoned themselves in my brain - I already know you're going with the latter), I have been subject to what amounts to a pounding of putrid pages that would make the most sane of men crack. (Was the "rectum" and "crack" in the same sentence shtick too much? It's been so long, I have a lot of things to flush out of my system...OK OK, I'll stop. Woo!) So, naturally, I would like to celebrate the best pages of the year, and what better way to do so than to hand out all sorts of awards that make no sense.

(By the way, what follows in no way suggests that we interns don’t contribute our fair share of complete incompetence that royally pisses off our nursing and pharmacy colleagues, because we do all sorts of stupid things that make their lives hell, things that I am sure I will touch upon in the near future. So I hope I do not offend anyone, specifically health care personnel or people easily offended by poop jokes - of which I predict there will be many - as it has already been established that the intern is the lowest form of scum known to man.)

Outstanding achievement in complete horseshit goes to…the 3 AM poop special
Picture it: It’s 3:00 AM. You have been working since 7 AM the day before, tirelessly, sometimes helplessly. You have finally finished up all your work and are just about to crawl into the stinky, steaming call room for a glorious 2 hours of sleep before you have to run around like a madman seeing all your patients before morning rounds. You lie down, close your eyes, start to dream about – ah shit, your pager just when off. You call back and are greeted by a cheery night-shift nurse, who poses the following question regarding one of your long-term players:
“Umm doctor? Patient _____ has not had a bowel movement on my shift and needs more meds for constipation now.”
Seriously? I mean, seriously? You’ve got to be kidding me. After nine months gentle restraint, I’m letting it all out right here, right now: PEOPLE DO NOT CRAP AT 3 IN THE MORNING, SO STOP PAGING ME ABOUT THIS!
Wow. I feel much better. Actually no I don’t. But I just cannot fathom why any rational human being would be compelled to think the middle of the night is the time to evaluate whether someone needs to drop a deuce. If anything, you’d think it would be more page-worthy to inform me if someone was dropping the kids off at 3 AM, because I’d want to start eating whatever they are eating as I bet it’d make me feel a lot better.

Best unintelligible performance goes to…*239
This page beat out some of the other contenders (namely, 33011053 and 2) for reminding me that people generally aren’t just stupid, they are also stupidly persistent. Imagine you’re me (sorry!) for a moment and you get a page that reads “*239”. Knowing that your hospital functions on 5 digit extensions and that your pager functions on 4 digit extensions, you disregard this page as an error on the hands of the person that pages you. Except 2 minutes later you get another page that reads “*239”. And then another. And another. And then you start getting paranoid, wondering which one of your patients is coding without you knowing about it, all while getting another three pages that reads exactly the same as the first. It isn’t until two hours later that, while walking down the hall, you run into the cardiology fellow, who cusses you out in front if your peers for not returning the five pages she sent you. It is also about that time that you realize your life sucks. Ladies and gentlemen, intern year!

Outstanding effort in existentialism goes to…the insulin form pages.
What follows is a roughly verbatim transcription of a telephone conversation I had with a nurse at around 3 A.M. regarding a two page insulin form (one page for when a patient is eating, another for when not eating) at my hospital:
Me (sleepy): “Hello?”
Nurse: “Umm doctor? Can you please come up and clarify insulin form?”
Me: “Now? Seriously? What’s wrong with it?”
Nurse: “The two pages have different times at the bottom.”
Me: “Well ya, because you made me fill out the second page 3 hours after I filled out the first even though the patient never actually needed the second page in the first place.”
Nurse: “Yes well they have to be timed at the same time.”
Me: “Why?”
Nurse: “Because otherwise they do not match up.”
Me: “What does that mean?”
Nurse: “They do not exist unless they match up.”
[I should remind you that we had this conversation on hour 22 of my 30 hour shift]
Me: “What does that mean?”
Nurse: “What do you mean?”
Me: “How can it not exist, I filled it out with my pen!”
Nurse: “It cannot exist if it is not filled at the same time.”
Me: “So nothing exists unless it occurs at the same time?”
Nurse: "What?"
Me: "You're telling me that these forms don't exist, that my writing doesn't count, unless they exist at the same time right?"
Nurse: "Right, they don't exist because they are timed differently."
Me: "So if they don't exist, I never filled them out in the first place. How could you be calling me about something that I never did?"
Nurse: “I don’t understand – you come fill out form now OK? Bye!”
Click.

Best attempt at unintentional comedy goes to this text page:
”Doctor, patient _____ reports that he fell out of bed last night because of the ghosts and goblins in his room. Pls call to confirm. Thx, RN”
OK maybe it’s not so funny now, but I got this page at the tail end of a 30 hour shift and it seemed like the funniest thing at the time. But I’m not sure what’s more ridiculous, what the patient told the nurse, the fact that the nurse felt like text-paging me about it, the fact that the nurse thought the information was so important he wanted me to call back just to make sure I got it, or the fact that the only thing the goblin in my room keeps telling me is that I'm paler than he is. Just making sure you are paying attention.


Outstanding achievement in clarification goes to…the All-Caps Pharmacist:
“ATTN: RE PT _____, PLEASE CLARIFY ROUTE FOR COMPAZINE SUPPOSITORY, CANNOT GIVE MED UNTIL CLARIFIED.”
(I should remind you that these are all real pages I have received.) Yes, I would love to clarify the route for that suppository. In fact, why don’t I walk over to the inpatient pharmacy and just show you where that suppository is supposed to go, but instead of a suppository how about I use my pager instead? Hey, I’ll even set it to vibrate for you. And while I’m at it, this pharmacist must be the last person on Earth to know about that whole caps = screaming rule that everyone else learned in some shady Internet chat room with their dial-up modem 10 years ago. What's next, is this guy going to tell me to start buying my pet food on the Internet? (By the way, does anyone miss the crazy buzzing sound those things used to make when logging on? No one? OK I guess it was just me.)

Best performance in shorthand goes to…the Night-time Telemetry Tech.
At the beginning of my cardiology rotation, I started receiving all sorts of pages from one of the nighttime telemetry technicians (the folks who took at patients heart tracings and inform us if anything bad is going on) that would generally read something like “GMD, VTx3 BTS for ACS PT”. It took me weeks to figure out that “GMD” was “Good morning, Doctor”, “VT” was “ventricular tachycardia” (OK that one was kind of obvious) and “BTS” was “beats.” Well, here’s my reply: “WTF? It DM, SPMWTC”. (Loosely translates to “What the fuck? It doesn’t matter. Stop paging me with this crap.”) And by the way, it’s not a good morning if you’re paging me about something that doesn’t matter at 4 AM.

Outstanding effort in night float angst goes to…bed 14.
Night float refers to the gloriously appreciated (cough) job of the intern who has to cover all of the patients over night (except for the admitting team’s patients), which usually consists of anywhere from 50 to 70 patients on any given night. Your job is to make sure that everyone’s patients remain alive through the night, fielding pages from nurses at all corners of the hospital in rapid succession about everything from the scary (“Hi Doc, patient hasn’t been breathing for about 2 hours”) to the mundane (“Doctor, patient's blood sugar is 120, what do we do?!?!?!”). However, nothing is more maddening than this page, which I have received in various forms about 800 times this year: “Umm…doctor? Patient in bed 14 sick. Please come.”
Bed 14 eh? No name? No team? Not even a floor? Let’s think about this for a second. There are roughly 7 patient floors at my hospital, each with two wings. Each wing has a room 14, and each room has two beds. Multiply that by the stack of papers with each patient’s information, and you get 458. Why 458? Because that is the amount of hairs that fell off my head trying to figure out who the nurse was referring to.

Wow. Well, it was a really exciting year for all the winners and the nominees. I hope the winners realize how lucky they are and, more importantly, how many months they have taken off my life. I look forward to yet another year fielding next year’s candidates for the most asinine pages of the year! Now if you'll excuse me, I have about fifteen pages to return.

Tired.

The easy, quick explanation for why I have waited so long is, quite simply, this one: I'm tired. Yes, the 80 (and sometimes more than 80 – shh, don't tell anyone) hour work weeks, the 30 hour shifts, the two week stretches without a day off…they’ve been piling up fast. So fast, in fact, that I only notice anymore by monitoring how soon I go to sleep. Let’s just assume for now that your average ridiculously handsome but still charmingly shy 26 (or even 27) year old heads to bed anywhere between 10:30 and midnight on any given night. In August, I was usually in bed 11 PM at the latest. By December, the occasional "in bed just before 10" was not that surprising. But now? I've caught myself crawling into bed at 8:30 PM, which basically makes the only non-work but still awake time of my life that glorious dinner hour and the four minutes I spend on the toilet in the morning (and just because I have no shame whatsoever, that four minutes used to be fourteen when I had more free time and could sit triumphantly on my throne, but now are only fourteen if I accidentally fall asleep while on the pooper).

However, there is more to this notion of being tired than what I have just described. Because, in all seriousness, this job has weighed on me so heavily that I have found myself beaten down, succumbing on a daily basis to many thing. Just tired...

Tired of the perpetual stress – of course every job has it’s stress, but I can only now grasp why the life or death aspect of medicine sprinkles in that extra pinch of chaos when compared to other jobs to make sure that, as the lowly intern, you are always one slip of just about anything (whether that be a needle or your pen) from killing someone.

Tired of the system – one of many systems where hyper-educated individuals are routinely thrust into a system that, at a local, state, and national level, is so beyond fucked up there is really no way to grasp the magnitude of it. But while inefficiencies in other fields may hamper your taxes, your business, or your local schools, it seems especially upsetting that inefficiencies in this system have killed, are killing, and will continue to kill on an alarmingly regular basis your grandmother, your friend, or even you. At least, as a once and future consumer of health care, it is upsetting to me. But to also know that some of the solutions are so simple (umm, national computerized health record please?) but so impossible to achieve in today’s reality for reasons beyond my control makes things all the more maddening.

Tired of the position – here’s where the intern-specific whining comes in, and yes I know that all of my superiors had it worse and blah blah blah I don’t care: being an intern has to rank up there with cleaning up the elephant poo at the zoo as one of the worst jobs on Earth. There is nothing quite like being caught in a tug of war between demanding attendings who require a long list of things to happen for a patient, nurses who actually have to do those things (take a deep breath…ok), and patients who half the time seem hell bent on refusing what we want to do but refusing to leave. Multiply that by 10-20 patients, 5-10 nurses, 2-3 attendings and 30 hour shifts…and then do all that while this thing attached to your hip keeps vibrating over and over again with new and different requests from any of the aforementioned parties and you’ll have a small idea of how painful intern year is for the schmuck intern caught in the middle of these forces. Something tells me I’ll have more to say about all that before this is through.

But mostly I’m just tired of the reality. Being confronted with society’s ills, in every sense of the word (because it turns out this job encompasses the literal medical ills, the economic ills, the social ills, etc., which is a lot more than what they advertise in medical school), on a daily and nightly basis is like (warning: over-used cliché alarm) being forced to push an immeasurably heavy stone up an unbelievably steep hill…only that the stone keeps getting heavier and the hill keeps getting steeper on a daily (or even hourly) basis. There is absolutely nothing more tragic to me than telling a sweet seemingly healthy middle-aged women that she has inoperable metastatic lung cancer to her brain, and then walking to the next room over and get cussed out by an otherwise healthy crack addict trying to abuse the system for pain medications, knowing that the former will probably never walk out of the hospital but the latter will keep leaving and coming back over and over again to abuse every last resource she can get.

It is this daily tragedy, unfolding before my eyes, that has been building up inside of me for the last 9 months, sinking me in and out of a mild depression each and every day, making it harder and harder to get any sleep at night, but forcing me to try to go to sleep earlier and earlier.

It is also why I have decided to start writing again…because for whatever reason, I feel better after writing about this, even if I’m usually not writing about why it is so catastrophically depressing all the time. If that means forgoing a bit of sleep to whine endlessly to myself, then so be it. Better than becoming so tired I cannot even function at all, I suppose.