Friday, October 27, 2006


I wrote, for the first time, an order which made a nurse angry with me. The good thing about the situation is that the order was necessary for patient care, but I still felt bad doing it. I even apologized to the guy, but hey, if a patient needs an enema, she needs an enema, right?

I'll admit though, with this guy, I felt less bad than I might have with another nurse. He was the reason I started a morphine PCA on my patient. She didn't really need a PCA, but she kept getting him as her nurse, and he would take two hours to get her the morphine shot I had written for. So I gave her the PCA, with some hesitation, and though her morphine use is about the same, her mood and outlook on life is miles better.

Most nurses are amazing. Even the ones I'm not flirting with. Seriously, though physicians (and budding physicians) are great at figuring out the long term plan for a host of patients, performing complicated procedures and interventions or surgery and guiding a patient towards recovery, none of that would take place without good nursing. But like most things done well, good nursing is difficult to notice unless you are looking for it. Bad nursing sticks out like that ghastly Millenium Wheel on the Thames.

So good nurses, (which includes all those who read this blog, I'm sure) thank you. It is people like you who keep us from going completely insane when your colleagues let my patient sit with a heart rate of 160 for two solid hours before calling me.

I don't want to end this on a negative note though. With this same patient, Mrs. Dalrymple I'll call her, I have dealt with three other nurses who were absolutely amazing. Nurses who are good enough not to demand a cosignature on my orders for Tylenol. Who have the patient's vital signs ready when they page me. Who know how to draw blood from a PICC line without causing a lab error by drawing TPN into the blood tube. I'm sure there are a thousand additional thankless things you do that I never see, without which my job would become infinitely harder. You guys rule.

Thursday, October 26, 2006

Odd rewards

I guess I'm doing a pretty good job being friendly with my patients. One of them, whom we recently discharged, was so pleased with my care that he and his wife offered me a free weekend at his rental property on the coast. He told me "anytime you want it, call us up, and we'll figure out a time that works. Bring beer, bring girls, bring whatever." "Um, ok, thanks" was my response. I don't know that it is ethical to take him up on his offer, but still, it's nice to know he approved of my work that much.

So weird.

In other news, my posting has slacked off lately because I have been sicker than many of my patients. Listerine, cough drops, and orange juice are all that's gotten me through the last three days. And I'm on call again tomorrow. Hooray!

The good news is, this is my last week. If I can survive, and still make a good impression through the end of Friday, I'm free, and the easy part of fourth year starts with cardiology clinic.

Thursday, October 19, 2006

Mr. Montoya

I see the rainbow in the sky
The dew upon the grass;
I see them and I ask not why
They glimmer or they pass.

I met Mr. Montoya in the Emergency room. He was concerned about some indigestion he'd been having, and my diagnosis was an ulcer. He had some concerning factors in his history though, so we admitted him overnight for a EGD in the morning. He is a great patient, easy going, upbeat, nice to the medical student who presumes to act as liason between the real doctors and him, and with an interesting, bread and butter problem.

So I got him up to his room, checked in on him, and then went on about my business. I came and went a few more times, met his wife, his son, son-in-law, and two grandchildren. The next morning he went down for his scope, and in all likelihood, his life changed forever.

See the scope found ulcers, so I was right about that. What it also found was that the ulcers are likely cancerous. Gastric adenocarcinoma allows only about half of its victims another five years.

The tell us in med school that patients often know what is wrong with them, if you just ask. So when I gave the news to Mr. Montoya, I wasn't surprised that he wasn't surprised. He just asked me some intelligent questions about prognosis, prefacing his comments with "assuming the worst here doc..." I've told him I'm not a doctor, and he has repeatedly said "you're a doctor as far as I'm concerned." At the time, I didn't know much, as I hadn't done a lot of reading on this type of cancer. But now, having done my reading on the subject, I will talk to him tomorrow about the hard facts. This is not a conversation to look forward to.

He's been a wonderful patient. He asked me today to give him my home address so that he and his family could send a Christmas card to me. I'm praying he lives to send many of them.

But I understand why he's staring out the window at the horizon praying the rosary when I come by.

The autumn wind's
Icy morning breath
Is on the hill of Sanu.
I wish, to you about to cross,
I could lend my coat.

Tuesday, October 17, 2006

The moral of the story is...

...don't try to die in radiology.

One of the patients my team has needed a paracentesis this morning. This involves, basically, sticking a needle into someone's belly and pulling out excess fluid. Despite what you might think from the title of my post, this went quite well. I pumped about 2 liters of fluid out of Mr. Block, and he felt better immediately.

Then, we started ending the procedure. This involves pulling the needle out and putting a band-aid over the hole. Seriously. But we also packed gauze under the band-aid to absorb some fluid. So, thinking one band-aid was not enough, I asked the tech for another. But we were in the radiology department. And the tech wasn't able to find one.

Now I have heard that the two toughest things to find in a hospital are aspirin and band-aids, so I tried again.

"Have you any tape?"
[tech leaves
[tech enters
"No, we don't."

I was a bit surprised, but perhaps naively so. A procedure clinic without dressing tape? What is up with that?

Also, I came up with a few witticisms which are probably way funnier since I've spent the last thirty-four hours without sleep:

A hospital is a lot like a casino, because in both a)time has no meaning, and b)the only people doing well are the ones working there.

Also, you might be a med student've ever needed to check your cell phone to tell what day it is. Apparently it's Tuesday.

Sunday, October 15, 2006


So my interviews for this residency site are complete. As usual, I find it difficult to judge how well or poorly I did. Fortunately, I didn't get the worst question ever: "Tell me what you see as your greatest weakness?" I did, however, get a difficult question which, though better from the point of view of the interviewer, can be awkward and off-putting: "Tell me about yourself."

What do you say when pressed with such a question? I've often thought how I would try to define myself in a few words or phrases, but I'm not concise enough to do so. I don't know that anyone really could. And when it's asked as the first question in an interview, I'm not nearly warmed up to the interviewer enough to give an answer I'm happy with. What is it that defines a person? Where you're from? What you do? How you spend your spare time? Do you answer honestly, even if that means "I've been so tired lately my spare time when I'm not asleep has been spent sitting on the bed in the hotel room thinking I should just turn off the TV and go to sleep?"

For I have known them all already, known them all:
Have known the evenings, mornings, afternoons,
I have measured out my life with coffee spoons;

Probably I'm just frustrated. I was recently discussing my situation with a classmate, also in the midst of applications to residency, and we were both remarking upon how it has taken a lot of effort and drive to get where we are in life. But the end is not in sight, and if anything, it is harder work to move ahead now than it ever was before.

Which is why I don't know that I'd recommend a medical career to anyone asking me for advice. Fewer than ten percent of applicants to medical school are accepted, nation-wide. But that's not the end of the bottle-neck. The competition you see and participate in before medical school only gets worse. Before medical school, you can pretend that it's only a facade, it's not really you, the competition is just a phase.

But it's not. You become that person, and if you don't, you fail. Two of my classmates actually dropped out of school, because they saw that. One is now a weatherman, and the other drives an armored truck. Mad props to them both. (Sorry, dated reference)

So, who am I? I'm a guy who doesn't mind working hard, but is tired of making life about a competition, who wants to help people, but doesn't want his life completely subsumed in others. Maybe that means I won't be a great doctor. But if being a great doctor is defined by the number of textbooks I've authored, I don't think I want that. At least, I didn't back when I was sane. I don't know.

Dang, that's what I should have said.

Worth checking out

Regina Spektor
I just got this album. I had to. Two separate people recommended it to me within a week. I've not been disappointed. I'm tempted to write a review, but I'll just say I recommend clicking on the link above, listening to the track and then buying the album.

Friday, October 13, 2006

Because I'm too tired to write anything serious...

I think it should be illegal to ride an elevator down one floor if you are able to walk and aren't pushing a gurney or cart.

Especially in a hospital. Come on people. Take the stairs and work off that plastic packaged 1000 calorie, 22 gram of fat cinnamon roll you're munching.

This is odd

Apparently, if you are making an offering to a heathen wight, you should use whole milk, never 2% or skim. Seriously. Scroll down to section V, "Calling and Speaking with the Wights."

I guess Thor doesn't like Jenny Craig.

Back to work...

Saturday, October 07, 2006

First page...and second.

I've gotten paged before. But never before have I been expected to act as the intern and decide what to do about a patient at 2am. I still remember the conversation, which is good. I had just laid down to sleep (how typical, I'm thinking) when I got the page, and calling the phone number, I rang a nurse who told me that "Mrs. Wright has a diastolic blood pressure of 109, and I rechecked it manually and got 101, and though she's asymptomatic, I'm worried about her."

At this point, I was probably sweating. All of a sudden, I didn't know anything. What the heck is blood pressure anyway? Luckily, I managed to keep my head a little, and asked the question "she's asymptomatic?" despite the fact that the nurse had just answered it. Then I said "I'll come see her."

This has a double purpose. One, it's what we're trained to do, as it's the right thing to do, since you can't make a decision about someone without seeing them. At my level anyway. Two, it allows you the time it takes to walk to the patient's room to think about what you might do.

In my case, it didn't matter. I still had no clue when I reached the bedside, so I gathered some information and paged my resident. Of course, while talking to him on the phone, I felt like a complete idiot, as he rattled off questions I hadn't asked, including basic ones like "what is the ranger her blood pressure has been running?" Mortified, I set the phone down and ran over to grab the patient's chart, and we figured out what to do.

I returned to bed about ten minutes later very angry with myself. I had completely failed to add anything substantive, and had needed to page my resident over a really simple problem.

Half an hour later, I got a chance to redeem myself. I was paged again, on another patient. This time the question was simpler, but I hurried downstairs and clarified medication orders, wrote telemetry orders, and had, in general, a minor success. Very minor.

An hour later, I seriously redeemed myself. I got another page on Mrs. Wright, and this time, I asked the nurse the questions my resident had asked me, then went and saw the patient, and then made a treatment decision on my own. I decided not to page the resident, as I was now comfortable with handling the problem.

It struck me, as I decided it was now too late to go back to bed and I started my morning rounds, that this is probably how most learning takes place as a resident. Seeing an example, and next time, not needing to call.

The end of the story is that my resident was impressed at rounds this morning. I hadn't realized, but I admitted more patients last night than either of the real interns, and I only needed to page the resident once. I feel almost like a doctor.

Wednesday, October 04, 2006


The rotation I'm doing now is an official "subinternship," which means I am to act as much like a real doctor as possible, clearing all my decisions with my resident, but writing all the orders, all the notes, and in general "carrying" the patient. I get paged by the nurses with questions and requests for clarification of orders. I talk to the subspecialists for consults.

I love it, I think. In part, what I do is just glorified secretarial work. I file papers, review papers, summarize papers. The fact that three years of med school is necessary to file these papers doesn't really seem to matter. It is here, in the headaches of paperwork, that the dehumanization begins. Patients become numbers, become diagnoses, because we see a stack of thirty pages about them more than we see them in person. In "The House Of God" the Fat Man comments that it is never necessary to actually see a patient, and in modern medicine, that's probably true. There are so many notes about the patient that it is possible to write about them, make decisions about them, and even cure them, without setting foot in their room.

That's the part I don't like.

So today, getting bogged down in phone calls and the elaborate system of documentation necessary to comply with the often whimsical requirements of HIPAA and JCAHO, I took a break and actually went to see my patient.

She's a wonderful woman, unfortunately without a bright future ahead of her. But she's come to terms with her poor prognosis and speaks quite frankly about her decisions. She doesn't want resuscitation, doesn't want surgery, and (a bit frustrating to the medical team) she doesn't even want a surgical biopsy of what we think is cancer, because she doesn't want to go through the treatment. She realizes she's old(er) and probably dying. Unlike Mr. Ashman, she doesn't have a family to support her, and after seeing her husband die of cancer a few years ago, doesn't want to go through treatment without support. All in all, a wise decision, if not an uplifting one. But we still managed to chat amicably for a half hour or so. She's from England originally, so (working from past experience) I got her talking about tea. Brits love talking tea, and she's no exception. It is a bittersweet conversation, since she has a nasogastric tube and can't drink tea right now. She may never again. For reasons much more aesthetic than mine her one wish now is to be able to drink coffee once more, "because though I do like tea, I fancy a spot of coffee now and then." It's maybe a bit odd that such a phrase can bring tears to my eyes listening, and now again while writing.

So then I went back to my papers, back to the headaches, back to the phone and pager. But now I'm not just trying to get my work done. I'm trying to help an old lady return to drinking tea, with a spot of coffee now and then.

Tuesday, October 03, 2006

Extreme, but he has a point

The New York Crank: Necessary and urgent, but political poison: Why the United States needs to restore the draft

One of the great things about fourth year is being able to read and write non-medical stuff. In the former of those categories fell this blog, whose author has an excellent point. One I can't agree to without caveat, but something worth considering.

I love this place

Another day, another hospital. I'm now in my rotation at my number one choice for residency, and I am reminded regularly of why. Everyone is happy here. The patients are similar, the workload is, if anything, greater, but the people are uniformly happier to be here. I don't really have a great explanation for the difference. I just really like it here.