Nurse, This Patient Is Dead

Another attempt at a video. This one is somewhat more bizarre than the previous one. That may not have been the correct direction in which to go. Apologies to nurses, who are generally not like this one.

That video-creation site is kind of addictive when you don't have anything else to do when you get home, and nothing's on TV. Fortunately, it keeps crashing when I try to make a second movie. It's almost as reliable as our medical equipment.

I have an awkward situation.

We're supposed to do peer evaluations after every rotation, although half the time no one seems to do them. The system is set up such that it's supposed to be anonymous, but it isn't really anonymous because if there are two residents, and you get a peer evaluation three days after the rotation ends, guess what, there's no mystery who it's from. Also, the system doesn't let you read someone else's evaluation until you write an evaluation of them-- so if you get an evaluation you can't read, you end up figuring out who it's from because as soon as you write that person an evaluation, magic, you can read it. So, basically, the system doesn't work very well.

I got an e-mail about a peer evaluation. I assumed it was from my co-resident on the rotation that just ended. I filled out an evaluation for her. The system still didn't let me read my evaluation. So it wasn't from her.

I went back and thought about who else it could be from. I filled out a couple of other evaluations. Still no luck.

Finally, I filled out an evaluation for a resident I was on a rotation with almost six months ago, because I was running out of possibilities. It wasn't a great evaluation. I didn't think he was a great resident. There were three of us on the team, and two of us did most of the work. He was friendly and pleasant enough to work with, but he was very slow. I said so in the evaluation. It wasn't the worst evaluation ever, but it wasn't an evaluation I would have been thrilled to receive. I hadn't filled it out initially because I didn't want to give a peer a bad evaluation. And if I'd taken more time-- and if this hadn't been the fourth or fifth one I filled out in one sitting-- maybe I would have been more careful and sugar-coated things a little bit.

So I submitted it, and, sure enough, I got to read his evaluation of me. And it was a very nice evaluation, probably nicer than I deserved. Which made me feel pretty bad, on a personal level, about the evaluation I wrote.

I assume he wrote a bunch of evaluations at the same time, and a few people filled out evaluations in return.

Because I happened to run into him after our weekly resident conference yesterday, and he pulled me aside.

He asked me if I got an evaluation from the third resident on our team.

I told him I did. He said he did too, and he couldn't believe how mean she was, and he quoted back a bunch of things from the evaluation I wrote about him. So he thinks this other resident wrote the evaluation, not me. And I didn't know how to tell him that the evaluation was actually from me. And he got paged two minutes into the conversation anyway and had to race off, so I didn't have a chance to say anything even if I wanted to.

And so now I don't know what to do. On the one hand, it's supposed to be an anonymous system, we're supposed to be honest, and I feel like my evaluation was fair. And so why should I have to have an awkward conversation where I have to admit that I gave him a mediocre evaluation and have him hate me? On the other hand, it's really not cool for me to let him blame this other resident for the evaluation, and let him hate her for no reason. So I think I have to tell him, but I don't want to.

World's Worst Clinic Patient

Thought I'd try something new, just for fun. I made a video about a typical experience in clinic. Check it out.

Merry Christmas to every intoxicated homeless person who came into the hospital this weekend, and an even merrier Christmas to those of you who decided to hold off until Monday, when I'll be on an entirely different rotation.

But the merriest Christmas to my three patients who each decided they wanted to be home for the holidays so much that they would sign themselves out against medical advice and go home.

Well, the merriest Christmas to the two of them who actually made it home, and a slightly less merry Christmas to the one who got to the parking garage, fell, and had to be wheeled back in.

Merry Christmas to the nurse who brought in cookies for everyone. A less merry Christmas to the other nurse, who ate them all before any of the doctors finished rounding, and so there weren't any left.

Merry Christmas to the night resident, who came in half an hour early to relieve the day team, just because she figured she could give us a few extra minutes of holiday to enjoy.

A less merry Christmas to the chief resident, who wouldn't let us sign out a minute ahead of schedule, leaving the night resident wondering why she even bothered trying to do something nice.

Merry Christmas to the people who've been reading this.

A less merry Christmas to the people who haven't been. :)

A friend sent me a link to a column in this week's New York Times called Social Q's, where people ask advice. He wanted a doctor's opinion as to the following Q&A:

I was expecting a dear friend for the weekend. She’s been wrestling a cold for months, and is the type who works and socializes even if she’s not feeling well. Knowing that she would visit even if she were sick, I suggested that she come another time. She didn’t take my suggestion very well. But wouldn’t it have been more respectful of her to stay home and not risk spreading her cold?

Shana, New York City

The answer in the column talks about trying not to hurt her feelings, apologizing, and asking if she can pick another weekend because you can't afford to get sick right now.

Except the answer ignores the bigger issue. Your friend has a cold for months? Um, maybe your friend should see a physician. Because your friend has HIV. Or lymphoma. Or something. Maybe. It's a pretty ridiculous advice column if the advice in this case isn't to see a doctor.

I eagerly await next week's column. "I have a friend who's bleeding from the head. I have white carpet. What should I do?"

Oh, and Merry Christmas. Mine won't be so merry. I'm working all weekend. But at least there's a tree in the lobby.

The ER resident pages me--

"Hey, you've got a new one waiting for a bed. We're not sure what the issue is, but we think he's got some pain and we're working him up."

"That's vague."

"Yeah, we're having trouble communicating with him."

"No English?"

"Not sure."

"Translator phone?"

"Yeah... not really."

"Why not?"

"Yeah... we think he's deaf, mute, and maybe psychotic."

"What?"

"Yeah... doesn't seem to be able to read either. We wrote some notes and asked him to point, it's not really working. We wrote, 'point to where it hurts' and he pulled out his driver's license."

"He's deaf and mute and psychotic-- and has a driver's license?"

"Yeah, we're not sure what's going on."

"So you're basically admitting him just so you can pass him off to the floor team, and you have no idea what kind of problem we're dealing with."

"Pretty much."

"How do you know he's deaf?"

"Just seems that way."

"I'll be there in ten."

Recent Google searches leading to this blog:

"doctors office pants down"

"fired from residency now what"

"guys waking up in hospital with nurse giving him massage"

"if you want to kill and make sure doctors don't resuscitate someone"

Wednesday mornings, the attending has been bringing us bagels.

It's nice of him.

Except they're stale. Every time.

I don't know if he and his wife buy bagels on the weekend, and he brings in whatever they have left by Wednesday, or if he buys them from a place that discounts stale bagels in the middle of the week, or he buys them Tuesday night and leaves them in his car, or he's just happened to find the worst bagel place in the world, but they're so obviously stale and everybody knows they're stale, and because he's the attending we have to pretend we're enjoying them and we're grateful for them and we try to force down a couple of bites before throwing them away.

It's a nice gesture gone bad.

It makes me hate him. It's not fair, but it makes me hate him, because I know he can afford fresh bagels if he wanted to. I know he makes at least three times what the residents make, and probably a fair bit more than that. I know he doesn't have to bring us anything, but if he's going to decide to bring us something, I hate that he brings us garbage. And I hate that we're all too intimidated by the hierarchy of this place to say anything.

I mean, if he was a friend, maybe I could say to him, "hey, it's nice of you to bring in bagels-- and maybe it's the humidity in here or something, but they're always pretty stale." But he's not a friend. He's a person who has to evaluate me, and whose evaluation will be seen by the program director and incorporated into the fellowship letter that he has to write.

I shouldn't care about the bagels. I really shouldn't. I should just say I ate breakfast already, or I should take one and then throw it out if I really feel like there's pressure to take one. There are so many bigger problems here than the bagels. Like the patient we don't have a bed for, who we didn't even know existed until the ER paged me and asked why I left my patient in a bed in the hallway, struggling to breathe. And I said I don't know who you're talking about. And they said I have a new patient, and she's in the hallway and can't breathe. And that I should do something about it. So I ran down to the ER to find this patient I'd never seen before basically not breathing, and I look at her chart and she's been assigned to my team but no one told me and we don't have a bed for her, and she's just another patient who falls through the cracks and gets processed by the ER but there's no room for her, so she sits in the hall and waits and no one knows she's there and no one takes responsibility and it's only by accident that someone notices she really needs to be intubated and should be in the ICU except there are no beds there either, so she's in no-man's-land getting intubated in the hall.

That is a bigger problem than the bagels.

A selection of recent e-mails to the residents list:

I'm writing in the hope that someone who isn't scheduled on Christmas Day might be able to switch with me. I made plans to visit my family, thinking that I would be able to find someone to take my shift, but so far I have not been able to find anyone, and my flight is non-refundable.

The shift is an overnight call in the intensive care unit, from 7AM on the 24th until 10AM on the 25th.

I know that's a long shift, but I am willing to pay you back with either a matching shift later in the year, or two long-call day shifts, depending on what you are scheduled for when I have vacation in April. If you are willing to take my shift, but would rather have money than shift coverage, I would be willing to pay up to $50.

My patients right now are pretty stable (except for one, but he probably won't make it to the holiday), although obviously I don't know what the situation will be later in the week. I've been able to nap for most of the night, the past three nights, so hopefully you would be also.

Please let me know if you can take the shift.

You do realize $50 is equivalent to less than $2/hour, right?

Aren't we not supposed to switch ICU shifts after what happened a few months ago? The whole point of the overnight shifts is for continuity of care.

Yeah, well, I already booked the ticket, so I figure continuity of care is just something that I think is worth sacrificing in this case. And if you don't want the $50, you can take the shift coverage, like I said. If someone's really desperate and wants to take advantage of my situation, I guess I'd pay $75. But in the spirit of the holiday, I thought someone might be willing to help me out!

Why did you book a flight when you knew you were scheduled to work?

You know, for people who are too busy to take my shift, you all have an awful lot of time to send e-mails about this. You don't have to be mean about it -- I was just asking!

You were asking if you could pay us $2/hour to do your work for you -- ON A HOLIDAY! I think we're entitled to be mean about it. And you do realize you're doing something wrong if you have time to nap when you're working in the ICU, right?

Maybe I'm just more efficient than you.

Anyone who's tempted to take [name] up on her offer, I'll pay you $51 not to, just so she has to miss Christmas.

Speechless.

Utterly speechless. I have a patient battling a degenerative illness, the specifics don't matter. She's been stable, but one of her issues is a growing dysphagia-- difficulty swallowing-- so we've been feeding her through an IV. I mean, this is sort of the least of her problems, but it's absolutely a problem. But she's been doing okay given her situation, she's stable, she's breathing, she's alert.

Her family comes to visit. No one even knew her family had come-- we didn't know until someone runs into the hall screaming--

They brought her ice cream. "Oh, we knew she wasn't allowed to have any food," they said, after the fact, "but we thought a little ice cream couldn't hurt."

Uh, she aspirated. She couldn't swallow, the ice cream went into her lungs, she choked on it basically. As soon as they ran into the hall screaming, we called a rapid response, it ended up being a full code, we lost her pulse, finally we were able to get her back-- but she's in the ICU, the prognosis is not very good, whatever limited function she had before is probably not going to return.

So her family basically killed her. Oops. They're beyond distraught about it-- I've seen families who would not be distraught about stuff like this, I've seen families who come in hoping there's something they can unplug or some way to end someone's suffering-- but these people are beyond distraught, and I don't really know what to say to them.

Because they basically killed her.

Look, there was a sign above her bed. "Nothing by mouth." And the family knew she wasn't allowed to have food. We can't police these things 24/7, she was stable, she wasn't in a 1-to-1 nurse/patient situation. No one's monitoring visitors. You can go into someone's room, smother them with a pillow, and be back in the elevator before anyone will notice. This isn't prison. It would be easy to blame us for what happened-- how's the family supposed to know no ice cream-- but I don't know what we could have done differently. And it's not like they did this on purpose, but between us and the family, I feel like the blame here has to fall on them.

And they're going to sue. I'm sure they're going to sue, because the first person I saw when we finished transferring her to the ICU was someone in a suit, who I'm sure was from the risk management office, interviewing her nurse about what happened.

They killed her with ice cream. I don't know what to say. They killed her with ice cream. Speechless.

Medical abbreviations and what they really mean.


"Patient just had a BM."

BM = Bowel Movement
BM = Bed's a Mess

"This guy's DNR."

DNR = Do Not Resuscitate
DNR = Demented Nursing-home Resident

"Looks like he's acquired a MRSA infection."

MRSA = Methicillin-Resistant Staphylococcus Aureus
MRSA = Maybe we should Refill the Sanitizers Already

"I need the test done STAT"

STAT = statim (Latin for immediately)
STAT = Sometime Tonight, At the latest Tomorrow

"Another UTI for this one."

UTI = Urinary Tract Infection
UTI = Uh oh, no one Took the catheter out In weeks

"Have you been taking your pills?"

"Yes?"

"Really?"

"No."

"This is the eighth time in the past year that you've been admitted to the hospital for the same reason. When you don't take your pills, your blood sugar goes through the roof, and you end up back here. You need to take your pills."

"I was taking them, but then I was feeling better, so I stopped."

"Yes, that is the problem. The pills are what make you feel better. So you can't stop taking them when you feel better."

"But I felt better, so I didn't think I needed them anymore."

"You will always need them. Don't you see that this is what keeps happening when you stop taking the pills? You keep repeating the same thing."

"I thought this time would be different. I thought maybe I didn't need the pills anymore."

"You need the pills."

"But I was feeling better."

"Because of the pills."

"But how am I supposed to know when it's because of the pills?"

"It's always because of the pills. Can you promise me you will take your pills?"

"I promise."

"And you won't stop when you're feeling better?"

"But what if I'm really better?"

"You're not going to be better."

"Why not?"

"Please just take the pills."

I don't understand how so many of my patients exist in the world. How they function on a day to day basis. How they manage to stay alive. What happened to survival of the fittest? I don't even know how most of my patients cross the street without getting hit by a car. Or find their keys. Or refrigerate their milk. Or dress themselves. Or get to the hospital at all.

I went on a date tonight.

An early evening movie date.

Don't ask.

I'm not going to write about the date, but I will write about the movie we saw.

Why I picked a movie that's even the tiniest bit medical, I don't know...

We saw Love and Other Drugs.

And I wanted to kill myself.

I mean, part of the movie made me wonder what the hospital looked like before they banned the drug reps. I wish we had pens. We never have pens. And free food that isn't pizza. I would totally give patients Zoloft instead of Prozac if we got free food for doing it.

But most of the movie made me wonder why they couldn't have hired a medical consultant to make the doctor stuff at least seem semi-real. At one point, Jake Gyllenhaal goes into the doctor's office-- this is a primary care physician, in an office somewhere in Ohio-- and tells him he wants the names of every doctor doing Parkinson's research and access to their studies. Uh, what does he think this doctor can do for him? Is there some universal doctor beeper he can call? Guess what, he's going to Google it, just like you can. Okay, the movie takes place in 1996... so he's going to... Yahoo it. Or Altavista it. Or whatever we were doing in 1996. He is not going to have some magic book with the name of every other doctor in the country and what they're doing.

Then there's the nurse who gives Jake's character a patient's phone number. Nope, not going to happen, not even if he's sleeping with her. Unless she wants to lose her job in about ten seconds. I don't know when HIPAA happened, but surely this was a rule even beforehand. And not just a little rule. This is a big one.

I won't even get into resting tremor vs. action tremor. Or why they were recruiting for Parkinson's patients at the doctor convention across the street. Or how Prozac magically and instantly turned around the life of a homeless man. Or the entirely non-medical issue of how a car somehow catches up to and finds the very bus he's looking for on the highway when he doesn't even know he's taking the right route. Or what kind of crazy libido these people have. Or why, why, why Jake's character decides at the end of the film to go to medical school. Good grief, doesn't he know how many years of hell he's signing up for. He's not going to be a doctor until he's in his 40s. Insane. Completely insane.

I did it. Not well, but I did it. I pulled my medical student aside after rounds, and I told him we need to talk. I told him I wanted to do some mid-month feedback, just check in and see how things are going.

"Oh, they're going great. Thanks."

"No, I want to actually sit down and talk. How do you feel like this is going so far? Are you learning? Are you feeling like a part of the team?"

"Oh, definitely. I think you're great. I talk to some of my friends, and their residents seem really terrible. They're making them stay late, they're giving them all sorts of stupid stuff to do, they're really torturing them. I feel like I got really lucky, and you've been really cool about not keeping me late and staring over my shoulder the whole day."

"Yeah. Great. I appreciate that. Because, you know, I'm just a few months into residency and I'm still learning how to manage the interns and the med students, and it's not always the easiest thing. I don't know that I did a great job of setting expectations at the beginning of the month, and really laying out what everyone's role on the team is."

"No, no, it seems like the interns really like you."

"Yeah, thanks, but that's not-- look, I think there are things you've been really good at. On an interpersonal level, everyone likes you. You're friendly, the patients seem to like you, the attendings haven't said anything negative-- I think sometimes there's a problem with med students who come in and think they have all the answers, and try to show off in front of the patients or the attendings, and that can be frustrating and really hurt the team. And you absolutely haven't done that, and I think that's definitely something you should be really happy about."

"Thanks. You know, I know I'm still a student, and I'm still learning."

"Yeah, exactly. But I think, along the same lines, I think you are probably more competent than you give yourself credit for, and you can take on more responsibility than you let yourself. [I really wanted to make 'you are lazy' sound as positive as I could.] The one big thing I would say you need to work on is taking ownership of your patients, and not just waiting for me to give you things to do, but to be proactive about figuring out what needs to be done, and doing it on your own."

"Yeah, I didn't want to get in the way or anything..."

"And I think that's part of where I failed to set the right expectations. As a med student, you're not just helping out-- you're an actual part of the team. And so you should be the expert on your patients. That means getting in early to pre-round on them every day so you can report to the rest of us--"

"Yeah, I keep meaning to, but I feel like I've been confused about what time rounds are."

"7:30."

"Yeah, but they haven't been that early every day--"

"No, you haven't been on time every day. But every day we start rounds at 7:30. Every day."

"Okay, I'll try to remember."

"It's about more than trying to remember, and it's about more than rounds. Like yesterday, when I asked you about the latest lab work, and you told me you didn't know if the patient had his blood drawn at all. It should be your job to check and make sure that happens, and then follow up to get the results, and then report those results back to me. It's not enough to wait for me to ask, and then tell me you don't know. You need to actually make sure it gets done, and then take the next step and make sure you are an expert in whatever's going on with your patient."

"So you want me to, like, and I don't mean this in a bad way-- you want me to do your work for you on my one patient."

"No, that's what I'm saying-- it's not my work. It's our work, as a team. You're part of the team. This is your patient. You're not just shadowing us. This is your patient. You should be responsible for your patient."

"But I'm just a student. I didn't want to get in the way."

"You're not getting in the way. And you're not making decisions on your own, or left to do anything you're not capable of. My job is to be here to help, when you need help. But you should be the one asking me, not the other way around. I want to be able to trust that you know that patient as well as I do, and you've taken the history, you've checked in on him, you're following up on the tests, you're monitoring what's going on. And then you're reporting back so we can all talk about treatment."

"That makes it seem like I'm the resident."

"No. That's the role of the student. You're training to be the resident, which you will be, in not that many months."

"So you want me to not just ask you what to do, and hope you say nothing so I can leave, or whatever?"

"Yeah. That's what I want."

"Really?"

"Yeah. That's what I need from you."

"Starting tomorrow?"

"No, starting now."

"Oh."

Three post requests from the comments-- I'll knock them all out right now while I wait for my attending to show up (she's having "car trouble," which may or may not mean her alarm clock didn't go off this morning). [See, in most jobs, you can be late -- especially if you're the boss -- and it's not really something that going to cause someone else's entire day to get messed up. But here, you're late and that means I could have gotten up later and gotten an actual night's worth of sleep, plus we're going to start the day later which means we're going to end later which means I'm going to miss sleep on the other end. So if you're my attending, and you're late, while for you it's no big deal, for me it's a huge aggravation and I want to murder you.]

"Describe a colleague who seems to thrive on this stuff, and what you think is wrong with them."

Okay, I dispute the premise of this question. I don't think I have any colleagues who *actually* thrive on this stuff. I have colleagues who think they do, who think they're awesome and are in fact racing through their to-do lists and leaving a lot of important things unchecked, failing to follow up, failing to call the proper consults, failing to really serve their patients in the best possible way. I do it too, absolutely-- there are things that somehow never make it onto my list and then they don't get done until I happen to remember hours later, or someone else happens to ask-- fortunately nothing with any consequences, at least not yet, but for anyone reasonably responsible, the worry is there, the worry that you're missing something. And for the people who don't have that worry-- who "seem to thrive"-- they're almost certainly only thriving in their own heads and not in the heads of the colleagues who have to clean up their messes. There is too much to potentially do for each patient that you simply can't not get overwhelmed sometimes. You are missing something if you are always on top of everything, every hour of the day. That's all there is to it. So the people who seem to thrive are deluded. Period.

"Who's your wackiest coworker?"

Wacky?? This isn't a sitcom. I wish I had wacky co-workers. And maybe at 40 hours a week, some of these people would be wacky. At eighty hours a week, you're either extremely competent or you're extremely frustrating. And if you mean wacky in their personal lives, I don't know that anyone has time to be. I have a co-resident who gets crushes on half the PAs and techs we deal with, and I guess that makes her wacky, or insane, or desperate, or something like that. I've had a couple of interns who were thinking of dropping out and doing something else with their lives-- wasting the past 4+ years of education-- which would be pretty wacky. And there's a guy who wears suspenders. Which seems pretty wacky to me.

"Got any good med school stories?"

Nope. Med school sucked and I hated everyone there. And I probably should have blogged about it, but I didn't, so all of those stories are lost to the universe. Okay, I'm being glib here. I'm sure I have some good med school stories, but I can't think of any of them as I stand here in the only part of this unit I can get decent phone reception and write this. I'll put the question on the back burner and see what I can come up with.

Asked a nurse to come help me put a catheter in a patient. I go in and get started, she comes in a couple of minutes later.

She walks in, takes a look at the patient.

Who is awake and alert and not demented, just FYI.

The nurse takes a look specifically at the patient's penis, and makes a gesture with her pointer finger and her thumb.

"So small..." she says, with a sad face.

"So small."

We need a national initiative to educate people as far as what it means to choose between full code and DNR status (do not resuscitate).

The truth is, it's a messed up question. No one wants to tell a doctor to let their loved one die. And very few doctors are even asking the question until we're at a point when we think the patient should be DNR no matter what the family says.

But somehow-- and I assume it's through the popular culture and what we see on TV and in the movies-- it has percolated through the patient population that there are gradients of care, and that it's meaningful to say things like:

"No heroic measures"

or

"She wouldn't want to live like a vegetable"

or

"Do CPR, but no paddles, no breathing tubes"

or

"Paddles are fine, but that's it"

These are not answers. And unless someone has watched a code happen, I don't know how we can expect them to know these are not answers. It's not a continuum. It's yes or no. Maybe we wish it wasn't, but in practice it is.

We're not intubating someone because we want to. We're intubating because we have to clear the airway. We don't know if CPR is going to work. We don't know how much function will be lost. Once we start, we're going for it. There's no point where you can reasonably stop and say, hey, the scale has tipped, at this moment we've found the spot on the gradient that matches the family's wishes, and we should stop.

It doesn't work like that.

I think there's a fear that no code means no care, and being DNR means you're signing an order to die. I think patients don't realize that when your heart stops, that's really bad news. People in good health, who are doing well, don't normally have their heart stop. They just don't. DNR status doesn't come into play when someone comes into the hospital with the flu, or a broken leg. DNR status comes into play when someone is dying, regardless of what we do.

So on the one hand, I feel like patients underestimate what it means to have a code event. But on the other hand, I feel like they overestimate what we're likely to accomplish in the event of a code. Much of the time, the patient is going to die anyway. And in most cases when they don't, they will not come back to the same level of function they had before. Nursing home care, loss of brain function, all that fun stuff that people don't actually want to happen, but are quite likely to.

And, yeah, it's probably better to regret coding someone instead of regretting not coding-- but the point shouldn't be to minimize possible regret. The point should be to figure out the patient's wishes and what they want to happen.

This is not a rant against full code. I absolutely want to be full code. Hopefully for a long, long, long time. I'm healthy, my odds are probably as good as they can be in these kinds of situations. But if I'm frail and demented, have virtually no quality of life anyway, no hope to recover to any sort of quality state, then I don't want to be coded.

And the silly part is that we go through pains to ask patients or their families what they want, we try to talk them through the options, we try to make them understand what they're choosing between... and then we do what we think we should do anyway.

I don't mean to be flippant about that. I haven't seen anyone truly subvert a family's wishes-- if you insist full code, if you are clear and definitive about it, you're getting the full code, I have no reason to think anyone is going to fight that. But if you think you're somewhere on the continuum, and you've given us some wishy-washy answer about no vegetable, yes paddles, no breathing tube, like it's a menu of lifesaving options you're choosing from, and your father is 103 and doesn't know who he is, then the attending is probably going to do a slow code, and basically just go through the motions.

But the real solution should be education. And I don't know how to make that happen. There are so many things so many patients need to be educated about-- nutrition, preventive screenings, when to go to a hospital and when not to, etc-- but this is a reasonably important one.

New patient, has a bunch of issues, thought I'd call her primary care doctor to get her records and make sure we're treating everything we need to be treating.

Easy enough, right?

Three rings, then a recording:

"The doctor's office you have called will be closed until further notice. Thank you."

No contact information, no nothing.

All in a day's work.

Thanks for the advice regarding my medical student. I'm sure he's not reading this blog, but he did somehow seem better yesterday. Maybe it was some sort of psychic energy I was giving off, after venting about him on here. I don't know. I don't want to jinx it. But I guess writing this post is probably jinxing it.

Ever see a bladder explode? You don't want to.

Feels like it's going to be a slow day. Which, again, I don't want to jinx, but I'm jinxing. Taking a risk here, but I'll take post requests in the comments if there's anything anyone wants me to write about. Reserving the right to pass.

Sad about Elizabeth Edwards, incidentally. I saw the articles on Monday, and any time doctors are stopping treatment and saying any further action is likely to be futile, it is not a good sign. From my rotations in the cancer wing, I saw patients getting treatment long after any objective third-party would say that the treatment was hurting more than it was helping. That's not to criticize-- if death is the alternative to treatment, then it's hard to fault someone for doing everything he or she can, even if the odds of any sort of success are dwarfed by the likely pain and loss of quality of life for whatever time is left. But it's just to say that stopping treatment, in most cases, isn't something that's done when there's a lot of time left on the table, or there's even any longshot reason to hope.

And that goes double-- triple? quadruple? orders of magnitude higher?-- when you're talking about someone with access to absolutely anything that might be out there, the money to pay for it, and the connections to know that no stone is going unturned. It is hard to imagine that there could have been anything untried in this case-- having had years to find the best doctors and the newest treatments, and the money to pursue anything that might plausibly help, it's really just reinforcing the lesson that we can't beat this yet. I feel like this is the same kind of statement about metastatic breast cancer that Peter Jennings and the quick course of his illness was for lung cancer. It doesn't matter if you have access to everything-- this stuff still gets you, and not that slowly.

I think, to some extent, it's easy to lull ourselves into a false sense of health-related security sometimes. There are a lot of diseases that society has pretty much eradicated, at least among people who aren't living in poverty, who have health insurance, who have enough food. But there are still a lot of diseases that don't discriminate, that don't care how good your doctors are and how much money you have. You still lose. And it's scary, and sad. I saw it most often when I was in the cancer wing and had young patients who had done nothing to deserve their disease, but I see it in every rotation. And it's why it's absolutely harder to emotionally deal with those patients than with the drug abusers and alcoholics who, to whatever degree you're comfortable believing, have some culpability. There are reasons what's happening is happening. We can trace the origins. It's easier, to be blunt, to watch someone die when you can trace the origins of what's happening and assure yourself that this could have been avoided. It's much more frightening to deal with things that can't be.

My med student sucks and I think it's my fault.

I can't deal with him anymore. I tell him things, and he doesn't listen. It would be easier if he wasn't there. He's supposed to help ease the load on me and my intern, but mostly he just creates more work.

It's not that hard to be the med student on a team. We give you one or two patients to follow. You pre-round on them-- you come in at 7:30 or so and check on them before we do group rounds at 7:45, so you can give a two sentence report about how they're doing. You listen to the rest of rounds. You check in on your patient a few times during the day. You write a note at the end of the day, that I take a look at and then rewrite for the attending. Throughout the day, you keep alert for ways you can help, and I give you some relatively straightforward-- and, unfortunately, usually boring-- tasks to do when we need another pair of hands. You read up on whatever your patients have, so you can understand the conversations. And when there's the opportunity, I teach, or I have the intern teach-- I bring you in to watch a lumbar puncture, or I explain why we're giving this medication or that one. You ask sensible questions, or you don't. That's pretty much the role.

And, yeah, when I was a med student, there were rotations that were fine and ones that were really boring-- and I definitely didn't want to stay later than I needed to, and I didn't always know what the residents needed me to do-- but there's a baseline level of competence that I hope I had, a baseline level of "at least I'm not making their lives more difficult," that I don't think my med student this month has. At all.

And I want to give him a terrible evaluation, but I worry it's my fault for not setting expectations, and for not teaching enough. It's a one-resident/one-intern team, so there's not a lot of time to teach.

But here's the problem. He doesn't really understand that the patients I assign him are his patients, and he should feel some responsibility for getting to know them, checking in on them, and reporting back to me about how they're doing. He doesn't come in early enough to pre-round, and he doesn't seem to care-- "Oh, I didn't see him yet. You wanted me to see him today?" "I want you to see him every day. We round at 7:45. You need to come in early enough to see him beforehand, at least for a few minutes."

He doesn't read up on what the patients have, so he can't follow anything we talk about. So he doesn't have opinions, or questions, or ideas, or anything at all to say. I ask him questions and he never knows the answer-- or at least if he would realize he doesn't know the answer, and say he'd look it up, or he'd make sure to try and learn some more about it. But, nope, never. And I give him things to do, and they don't get done.

"Can you ask the nurse if she ever sent off the blood sample?"

"Sure," he says, as he continues to text on his phone.

Ten minutes later I ask him he checked with the nurse.

"Oh, not yet. Did you need me to do that soon?"

"Yes. I needed you to do it when I asked you to do it."

"Oh. Okay."

And then he does it, but doesn't bother finding me to tell me the answer, and I end up asking the nurse myself.

I asked him to run down to CT scan when the tech wasn't picking up the phone, to see if anyone was around, and when they could take our patient.

He disappears for 45 minutes, comes back with a snack.

"Can they take him?"

"Oh, the tech wasn't sure. There's a backup."

"Did he say when we could send him down?"

"No, I don't think so."

"Can you call him and see?"

"Now?"

"Yeah, now."

And at 5:00 on the dot, even if we're in the middle of running a rapid response, he's got his backpack on and he's out the door. Half the time, without writing a note on his patient.

I want to ask him-- "How do you think this is going? What are you getting out of this rotation? How can I help you get more from this / be more engaged / care a little bit?" But I don't feel terribly confident that I know how to have that conversation. Because maybe it's my own fault for not sitting down with him on the first day and being really explicit about all of this. I thought I was, but I also figured he's now four months into the year and has had other rotations already and should be slightly more used to this process than he seems to be. And maybe it's less my fault than the resident who preceded me-- the med student came on four days before I started, and I don't know what the last resident had him do. Maybe she had him do nothing, and he figured that's what this rotation is, you do nothing and everyone's fine with that. But I feel like I keep having the same conversations with him. "I need this done." "Okay." "Did you do it?" "No." And so I want to kill him.

This is why a lot of being a resident has very little to do with how much medicine you know or how good of a doctor you will be. It's about being a supervisor and a manager of people, it's about being a boss.

Maybe I'm just worried that once I tell him he needs to stop texting and stop surfing the web all day, he will start watching me, and every time I check my e-mail, or go to the bathroom, I will feel like I'm doing something wrong. And this way, I can be slightly lazy because I know he's incredibly lazy and so I'm awesome in comparison.

But it's not like I'm being lazy. I'm getting everything done, my patients are okay. It's just that in a lot of ways I still feel like the med student, and I don't necessarily want to be watched like a hawk and micro-managed. I don't want to be the resident who makes the job suck for my med student. But that only works if the med student doesn't suck. He sucks. That's all there is to it. I wish I could trade him in and get a new one.

Someone tell me why I'm still watching Grey's Anatomy.

And especially at 8AM on my only day off of the week.

Okay, I don't need you to tell me, because I know. I'll watch anything. What else am I going to do at 8AM on my only day off? My body can't sleep past 8 anymore. I'm lucky I can even sleep this long. I had a dream about my patients. I'm always having dreams about my patients. Nightmares, really. I forget to put in orders. I get in trouble. People die because of me. And I wake up panicked until I realize it was only a nightmare.

So, Grey's Anatomy. I can't do it. I can't sit through an episode without wanting to pick it apart, every little moment that makes. no. sense. if you've ever worked in a hospital. Or even been in a hospital.

If you don't want to be spoiled about the plot, stop here-- this is this week's episode, from Thursday, that I'm writing about. And I'm not even giving away any of the real plot, just the stupid medical stuff that's really incidental to what the show is actually about. But I don't care about Christina and Derek and whether Christina's ever going back to work-- as if a residency can just lose a resident mid-stream without repercussions, and as if they would really hold a spot for her-- and as if everyone would care! How do they have time to care? They're surgical residents!

But that wasn't the point I wanted to make.

First of all, scheduling same-day hip replacement surgery for a patient who walks in to be checked out. Nope. Never. No way. Makes no sense. No pre-surgical testing? No advance notice to book an OR and get a team together? No fasting for the patient? Etc. No way. Nonsense. And then he goes and gets a second opinion-- again, the same day!-- and then comes back to have the surgery, because of course her calendar is still open and there's still an available OR. They compressed a couple weeks of time into what we're supposed to think took half a day. Insane.

Meredith at one point says she spends her days off in the hospital. I had to pause and go back for a second. She says "I have days off, but I spend them here," or something like that. Nope. Sorry. What do you do, wander the halls distracting the people who are working? Do you have so little going on in your life that you can't bear to actually take your days off and sleep, or don't sleep, or-- anything-- but there is nothing for a doctor on a day off to do in the hospital but get in the way. So that's insane. Moving on...

The nurse who seems to know everything about post-op complications. I'm not going to argue with the idea that a nurse can be competent and know things the doctor doesn't-- nurses can be good, sure. But no patient is a particular nurse's patient, no nurse would be there to monitor a patient from surgery until five days post. They're on 8-12 hour shifts, they work 3 or 4 shifts a week, any particular patient is rotating through a number of different nurses, and it makes no sense to be able to say that all of the patients of nurse X do well because nurse X knows what he's doing. Great if nurse X is there when something's happening, but nurses Y and Z are going to be there too, and they're probably going to listen to the doctor even when the doctor wants them to do something bad for the patient, and it'll probably get done.

And attendings don't know nurses, or care. Nurses deal with residents, residents deal with attendings, the equivalent of Dr. Bailey would not be able to say something like, "sure, none of my patients who you're the nurse for ever have a complication," because Dr. Bailey won't have any idea what nurse is doing what, and she won't care.

What else? Doctors offering to marry patients without health insurance... and apparently there is no public hospital where the uninsured guy can get his surgery, I guess. Public hospitals exist. I'm there every day -- this month, at least. It may not be luxury, but we do treat patients. Patients who don't have insurance.

Okay, that's all that's coming to mind. I'm sure there was more, but I didn't take notes. Tune in next time, when I work myself up over the lack of hand-washing we see from television doctors when they enter patient rooms.

"No, I'm not letting her in the CT scanner," said the tech.

"She may have had a stroke," I said. "We need to do a scan."

"But she's got that rash."

"Yes, she has a rash. But she still needs a scan, now."

"I don't want her mucking up the machine and giving everyone else that rash."

"There's paper on the machine."

"Yeah, it's just paper. It's going to rip, or move, and she's going to rub against something else in here, and then whatever she has is going to spread. I won't take that risk. She's not getting a scan."

"I need to see if she had a stroke."

"Not in my machine."

"You want me to call the attending?"

"Fine. I'll tell him the same thing. You're worried about the one patient, but I'm worried about everyone else. And I don't want to touch her myself either, to be honest."

"Put gloves on!"

"Yeah, like that's enough."

"SHE NEEDS A SCAN."

"Wouldn't do it now even if I wanted to. I'm on break."

"Doctor, quick question-- I was having a debate with some of the other nurses. When we give [certain drug we give many patients every day], does it make the blood pressure go up or go down?"

"Down. You really didn't notice that?"

"Oh, no. I never really paid attention."

"Oh. Well, it's down."

"And you call that lowering the blood pressure, not raising it, right?"

"Yep."

"Okay."

"Did you win the debate?"

"No."

"Okay."

Here's a story:

Patient is brought in by the cops, barely able to stand up by himself, completely drunk. Blood alcohol level is almost 300. [80 is legal limit for drunk driving in most states.] Why we have to babysit drunks who don't actually have a medical problem we can treat is the larger question, but anyway...

We keep him overnight, next morning he's belligerent but doesn't seem drunk anymore. We're trying to discharge him. He doesn't want to be here anymore. We don't want him here. We're getting the papers together. We tell him it'll be an hour. He calms down.

An hour later, my intern goes to deal with the discharge. Comes back and tells me he doesn't seem right. Slurring his speech, can't sit up straight, etc.

I go and check on him. Yeah, he seems drunk again. We run his blood alcohol level again, and it's actually higher than when he came in, pushing 350.

We call hospital police to search his room. What did he sneak in here, and how?

They find nothing.

So we're baffled. My intern asks if something else might be going on, and I don't really have an answer. I don't know.

By habit, I squirt some sanitizing foam on my hands as I leave his room...

There's no foam in the dispenser.

It takes me a second.

No, can't be.

We look, shoved behind the door, the squeezed-dry, empty bag of hand sanitizer.

Alcohol-based hand sanitizer.

He drank a bag of hand sanitizer.

Awesome.

Happy Thanksgiving.

I was working, of course.

I thought the ER would be empty on Thanksgiving. Or if not, that I would at least get some funny stories out of it. But no such luck. Just the normal assortment of alcoholics and the uninsured.

My ER rotation ended yesterday; today I started back on the hospital floors. I've got two interns and a med student under me... and no one between me and the attending. So I may actually be able to accidentally kill someone this month. You'll have to stay tuned.

Another resident and I are going out for a belated Thanksgiving dinner tonight, since we were both working last night. I think he's even more jaded about this place than I am, so conversation should be spirited.

"What's that smell?" asked the nurse.

"I don't know."

And we scanned our wing of the ER for a few minutes before determining that, yes, our drunk 21-year-old had gone to the bathroom in his pants.

Again.

We gave him three new pairs of scrub pants, over the course of four hours.

He kept soiling himself.

He kept apologizing for it.

And then he kept doing it again.

How much did he drink? We don't know.

Is this the first time he was drunk? Maybe.

It was the first time he'd been to our ER.

***

"I need you to remove my hemorrhoid," said the 50-year-old postal worker.

"Sir, we don't do that in the ER. You need to make an appointment with the clinic, or with an outpatient specialist. It's not an emergency, and it's not something we can spend the time doing here."

"Doctor, I've been to three different ERs this past week trying to get someone to take care of this, and every time I've been turned away."

"Yes, exactly. That's not something anyone's going to do for you in the ER. You're wasting your time. You need to make a clinic appointment."

"I'm not coming back again. I've already wasted three days on this--"

"Yes, you're wasting your own time. You will have to come back again, but not to the ER. You need to go to the clinic."

"But I'm here now."

"And I can't help you now."

"Then I'll wait."

"Sir, this isn't a problem we are going to take care of in the emergency room. You should leave, call the clinic tomorrow, make an appointment, and then come in when they tell you to come in."

"No. You're going to do this now."

"Sir, I'm not."

"Then I'll wait."

"I don't want to have to call security."

"Does security know how to remove my hemorrhoid?"

"I can certainly ask them to try."

"While I'm here in the ER anyway, will you..."

No. No, I won't. I won't check your cholesterol. I won't give you a colonoscopy. I won't renew your birth control pills. I won't give your husband a drug test. I won't fill out your son's school physical form. I won't call your boss and tell him we need to keep you overnight (even though we don't). I won't give you a box of band-aids. I won't check your vision. I won't tell them to go ahead and put breast implants in your wife while they have her chest open anyway...

The emergency room is not your one-stop medical clinic, to deal with all of your problems at once. You're here for a reason. Hopefully. We're going to deal with the reason and then you're going to leave so someone else can take your place. We're not going to go through your file and do all of your outpatient checkups, renew your medications, and look at the bruise on your leg. Go to a doctor. Go to a clinic. If it's not an emergency, do not ask me about it. This is the emergency room. For emergencies. Not for elective medical care, maintenance, follow-up checks, or workplace physicals. This is for when you've been shot or you're having a heart attack.

Or you've tried to kill yourself and failed.

And maybe this is a controversial point of view, but I don't really understand why we're making people who actually want to live wait around bleeding to death while we spend our energy trying to save people who want to kill themselves.

We're saving them so they can try again. Or we're saving them but now instead of just being depressed, they're going to be depressed and in a nursing home, painfully recovering-- or not recovering much, and having minimal brain function for the rest of their lives.

If you're a 92-year-old with terminal cancer who swallowed a bottle of Tylenol PM hoping to end it, why are we fighting to bring you back, to a vegetative state, so you can linger for a few more months?

While we leave the guy in the car accident on a stretcher, waiting for a doctor to be free to deal with him.

And, no, I won't clip your toenails while you're here anyway. Go away. The ER is terrible.

"Mr. Walker said he thinks I'm an incredible doctor."

"You realize Mr. Walker also called the meat loaf incredible, right?"

***

Oh, come on.

Give me one moment to believe I can do this.

Give me one moment to forget about the sixteen times I stuck someone with a needle looking for a vein, lying to him through the whole process, telling him this was normal, telling him it takes every doctor this many jabs to get blood.

Yeah, every doctor who doesn’t know what he’s doing.

"This makes your veins healthier."

"I’m just trying to air out your skin."

"These holes will make it easier for you to breathe."

Believe me, it’s hard to keep a straight face. But this is the job. Stabbing sick people, fruitlessly, over and over again, without laughing.

And then the attending has to go and ruin what I'm pretty sure is the only compliment I’ve been given by a patient the entire month I've been in the ER.

Argh.

"I am right," said the attending, to a room full of residents at the annual lecture on professionalism and effective patient care.

"See, before you’ve even asked me a question, I’m already telling you I know the answer. Say it with me. I am right. Make it your mantra. You can’t be afraid. All we have is our authority, and as soon as we start letting any doubt creep into our patients’ minds, we’ve lost our power completely. This is what separates us from WebMD. This is what keeps us in business. This is what their insurance companies are paying for. Confidence. Decisiveness. Answers. I am right. I am always right. I am right, I am busy, and I don’t have time for you.

"That last bit is especially important. Patients are expecting more and more from us. 24-hour access. Calls back when they leave a message. An answering service that actually answers. E-mails. Web chats. Doctors on demand. They’re starting to forget how the system has always worked, and who holds all the cards in the doctor-patient relationship.

"Be upfront. 'I don’t have time to hold your hand and walk you through it.' Leave them wanting more. Whether they’re asking about their prognosis, or they’re asking where the bathroom is. You are the one with the information. You are the one with the power. Yield it only when you have to, and tell them only enough to get them to the door. You tell them too much, and they get greedy and want more. And pretty soon you’re spending your whole day explaining the pros and cons of eight different kinds of birth control when really you should just be sterilizing any patient who dares even ask you a question.

"They want second opinions, let them try. But don’t make it easy. 'You can look for other answers, but you’ll only be wasting your time. There are people out there who will tell you anything. There are always going to be people who will prey on your vulnerability and give you the answer you want to hear. They’ll drag you down a path of false hope and wishful thinking, dead ends in the maze of life, until you finally get back to the very same place you’re sitting right now. And we’re just talking about directions to the bathroom, which, as I’ve already said three times, is only for doctors and hospital staff, and we really can’t have you using it.'

"People have forgotten that we’re the ones who went to medical school. Ten years ago, would anyone even think of bringing in a printout of a medical study and asking us to look at it? Not a chance. They would accept whatever disease we’ve told them they have, and learned to deal with the consequences. If your doctor didn’t know something, that piece of information simply didn’t exist for you. We can’t know about every new protocol, every new treatment, every new cure. But the way to learn is not from people handing us pieces of the Internet. It’s from drug reps or the natural course of information-sharing. They can’t expect to have every chance to survive. They’re lucky we give them a fraction of the medicine that’s out there. And we can’t let them forget that.

"Don’t admit mistakes. Blame the patient. Pretend you have to leave. Create a distraction. Hide the ball. Instead of dwelling on the cancer, and how you should have seen it on the previous scan except you never even looked at it before it went into the file, berate the patient for having the nerve to keep you waiting. 'Why people like you don’t go to the bathroom before you come see me will never make any sense. I kept you in the waiting room for an hour and a half. Surely at some point, it could have crossed your mind that you’d be better off going to the bathroom now than waiting until I’m ready to see you. But, no, let’s waste my valuable time—and the less valuable time of everyone else still sitting in the waiting room. I know, it’s too late for this visit, but maybe you’ll remember next time. If there is a next time. The cancer’s inoperable, and I don’t know how much longer you’ll live. So this may be the only time I see you. Thus my last time to teach you this lesson.'

"'Although I’ll try to squeeze in another appointment, since your insurance has an unusually high reimbursement rate.'"

I think I raped a patient last night.

Okay, that's an exaggeration-- maybe-- but to the patient, who knows.

Elderly man who spoke a language I'd never heard of (and virtually no English). Comes in, seems to have a fever, but we can't understand what he's trying to say. Finally we figure out what language and get the right interpreter on the phone. We think. But it doesn't seem to be going well.

We're trying to see if he's oriented. We ask him what year it is. The interpreter says he didn't really answer the question. That he just said something like, "I'm an old man." We ask if he knows where he is. The interpreter again says he said, "I'm an old man." Finally we figure out he's got chills and some other vague symptoms, some bleeding, possibly some urinary symptoms, it's not entirely clear.

The attending is getting frustrated with the pace of the translation, finally gives up and disconnects-- so we're just left with this guy who's fairly confused and definitely doesn't know what we're saying.

And the attending tells me we need to do a rectal exam. Tells me I should do a rectal exam. Tries to explain to the patient what's going to happen, but the patient pretty clearly isn't following and has no idea what we're saying we need to do.

I'm trying to go slowly and explain, with reasonably-appropriate hand gestures, what we need to do. The attending is looking around at the backlog of patients, clearly wants me to hurry up. Finally just tells me to do it. He yanks the patient's pants down, and tells me to do it.

So I do it.

And the patient just stares straight ahead, this look of shock on his face. As in, "what is going on here? what is happening to me?"

And I don't even really know how to say, "I'm sorry," or "This was important," or "You can pull your pants back up."

And the attending heads back to our alcoholic homeless patient, and I hear just the tail end of their conversation-- "You really want to know in the METRIC SYSTEM how much alcohol I drink? You think I know the METRIC SYSTEM?"

"I have a neck injury from an accident I had three days ago. I need some pain medication. I've taken Vicodin in the past for similar and that seemed to work. Can I have some Vicodin?"

"Did you see a doctor after this accident?"

"No. The pain wasn't so bad right afterwards, so I didn't see a doctor. But I feel the pain now. And it's pretty bad. Can I have some Vicodin?"

"Sir, we should really do some tests to get a better sense of your injury. Can you show me where it hurts?"

"No. It hurts too much to start showing you. Can I have some Vicodin?"

"Well, we're definitely going to need to do some lab work before we give you a prescription for anything."

"No. Why would I need lab work? I'm fine except for the pain. Can I have some Vicodin?"

"No. You may not."

Which is the fake ER patient?

1. Woman comes in saying she tried to commit suicide, took 25 sleeping pills, mixed it with alcohol. She seems normal and alert. Blood alcohol comes back negative. She says she actually thinks she only took 10 pills, and no alcohol. Still no evidence she actually took anything. We tell her to rest for a bit and we'll check on her later. She screams as we walk away. "Aren't you going to give me something to help me sleep?"

2. Young guy comes in with a friend, drunk, says they're from a local college. ID badge says he's 25, so I ask if he's a grad student, says no, he's an undergrad. Looks young too. We let him sober up, seems like he's fine so we're doing the discharge paperwork, and his friend says wait, that's not his name on the paper. So I'm thinking uh oh, someone screwed up the ID badge and got him mixed up with someone else. Nope-- the same fake ID he used to get the alcohol, he used in the hospital. So he got admitted under a fake ID, is really an 18-year-old freshman. The nurse tried to get hospital police to scare him but they said that if we got them involved they would have to actually arrest him and didn't want to bother. So the nurse just pretended she was some kind of hospital administrator and gave him a stern talking-to (and took away the fake ID). I'm just glad the friend was stupid enough to screw it up for him, because otherwise we've got records under a fake name, no way to bill the patient, etc. What a mess.

3. Obese woman comes in with a varicose vein that literally burst. She is dripping blood from her leg, it's coming out in spurts. And she also has a bunch of bedsore-like ulcers all over her leg-- basically big sore holes. I nearly passed out, this was seriously disgusting. I've never seen anything like this before, but the attending said it's not that uncommon. Still disgusting.

4. Elderly woman comes in, quietly pulls me aside. "I'm itchy." I step back. "I keep seeing bugs on me." Scabies. I begged the attending to give her to the other resident. He liked me, so he did. I do not want scabies. I do not do not do not want scabies.

Give up?

So do I. They're all real, and they're all from one night. Along with a dozen of their compadres. Welcome to the emergency room.

Last night, a drunk guy comes in-- belligerent, reeking of alcohol, vomit all over his clothes. He's refusing to answer any questions, insists he isn't "some homeless bum," and finally we end up just letting him sleep it off.

I come around in the morning, wake him up, to try and figure out if we're just going to discharge him or what. And he opens his eyes, and politely inquires-- with a British accent--

"Excuse me, where might I be?"

"Wait-- what--? You have an accent?"

"Excuse me?"

"You didn't have an accent last night. Where are you from?"

"London."

"You came in here last night, drunk, and you did not have an accent."

"How odd."

"Yes, it is. Are you sure you have an accent?"

"Yes."

"Hmmm. Haven't seen that before. Do you remember what happened last night?"

"I gather I had a little too much to drink."

"Look at your shirt."

He sees the vomit. "Oh, dear. I'm terribly sorry for any inconvenience I may have caused you."

"Do you have a job? Where do you live?"

"Of course I have a job. In fact, that's how I got here."

"What?"

"We had a work party. I guess I should have been more careful."

"You had an absurd amount to drink at your party."

"I guess it seems I did."

"What kind of work do you do?"

"I'm an accountant."

"Oh. Wild party for accountants."

"You have no idea."

I am getting used to crazy people.

Patient comes in last night after falling and hitting his head. Seems a little altered although his girlfriend says this is his baseline. Standard next step is CT scan. Patient starts freaking out. "No, I won't let you put me inside a machine, no, no, no, no," he starts screaming. We explain that we're just trying to rule out a brain bleed and the test will be quick, won't hurt, finally he agrees. The attending has me go with the patient. We get there and he starts freaking out again. Gets off the stretcher and pulls off his gown and starts running through the halls of the hospital, naked, screaming. I call the attending, who is now even more insistent we do the scan because the guy really does seem altered. The attending chases him down the hall and corners him. The patient eludes him and ends up inside a supply closet, locks it from the inside, refusing to come out. We get hospital police, who aren't real police but just basically thugs with a uniform, who get a key, unlock the closet, and carry the patient out, force him onto a bed, and my attending injects a sedative into the patient and puts him to sleep. This morning, he is calm and has no memory of what happened.

Two gunshot victims.

And, no, they didn't shoot each other.

The homeless lawyer I'd seen a few weeks ago returned, with no real medical problem but he'd figured out the system. If you get arrested, and you tell the police you have some sort of medical issue, they take you to the hospital instead of jail. Buys you a little time. Gives them a chance to decide to forget about it. He was caught shoplifting over-the-counter medicine to sell to other homeless people. He told the police he was having a seizure and needed medical attention. He wasn't having a seizure. But they didn't know, so they brought him into the emergency room just in case. He didn't remember meeting me.

I feel like the whole night was a bit of a dream. As a person, I feel so removed from this world I see as a doctor. I don't know criminals and gunshot victims. I don't travel in these kinds of circles. I went to a good college, a good medical school, I know lawyers and marketing directors and account executives. I know people who aim to one day live in the suburbs and be active members of the PTA. I don't know drug dealers. I don't want to know drug dealers. I don't want to know police officers. I don't want to know that the world is pretty messed up.

But at night I see people who don't know doctors. Who don't know lawyers and marketing directors and account executives. I'm as foreign to them as they are to me.

One of the gunshot victims died. I didn't even get to know his name. Shift was over before they looked for any ID.

Well, that settles it.

I have no desire to work in the emergency room.

I knew it, but now I really know it.

I've also forgotten how to put in an IV, can't draw blood, and don't know the first thing about giving someone stitches. It's amazing how two weeks of vacation can wipe the slate clean.

We had a homeless guy brought in, "passed out on the street" with a bottle of rubbing alcohol. Everyone's so judgmental. "What a pathetic guy, drinking a bottle of rubbing alcohol until he passed out."

Well, it turns out he was sleeping on the street, and he used the rubbing alcohol to clean himself. And there was no reason for him to be in the emergency room.

Except that they cut his sweatshirt off of him when he got here -- more clothes are cut off people in the emergency room than I'd ever realized, and in most cases it makes no sense. You can pull someone's boxer shorts off. There is no reason to destroy them just because there's a pair of scissors you're allowed to use. I don't know why, with all of the fancy machines and tools we have access to, everyone's running for the scissors and can't wait to cut people's clothes off them.

Anyway, now he has no sweatshirt, and that sucks for him. I tried to find him a hospital sweatshirt to replace it, but I couldn't. Then I tried to get him a pair of scrubs -- just so he'd have something to go back out into the world wearing -- but the scrubs are dispensed from a machine that hates me, and I tried to trick the machine into giving me an extra pair (we're allowed two pairs -- when a pair is dirty, you put it in the machine, type in your number, and exchange it for a clean pair -- so I put the scrub top in separately from the pants, hoping the machine would think it was two different pairs -- except the machine is smarter than that, voided the whole exchange, and now they're saying I have two pairs of scrubs out when really I only have one, and I was wearing them, so I couldn't give this guy anything).

Also, don't tell a doctor someone hurt you unless someone actually hurt you. That was an hour and a half with a social worker when it turned out two kids were just pushing each other in the playground.

Back to work.

Today I'm starting a month in the emergency room.

Day shifts, night shifts, all sorts of shifts that together make up a schedule I'm not particularly looking forward to. 2PM to midnight one day, back at 8AM to 9PM the next, then 24 hours off and working 9PM to 7AM the next day. It's as if the point is to disorient us and mess up any hope of a real sleep schedule. But that can't be the point, can it?

I'm scared. I haven't missed work these last two weeks. And I feel like that's a problem. If this is what I'm going to be doing for the rest of my life, shouldn't I miss it when I'm not doing it? Shouldn't there be some part of me that wants to go back? And maybe that's too high a standard to hold myself to -- it's been so many months since any kind of a vacation, why do I feel like it's so wrong to have a vacation and not think about work and just take the days off and be off? What is wrong with enjoying not going to work?

I think the problem is that I'm still trying to come to terms with the idea that most jobs are just jobs. I feel like I used to picture this as a calling. I used to look at adults and think their jobs were a big piece of what defined them, and of course they must enjoy their jobs because otherwise they would be doing something else. And that life was about finding a rewarding career and the rest of the pieces could fall into place after that.

But the more adult I get, the more adults I meet, and the more I realize that very few people find that calling. And for the rest of us, it's a job, and most jobs aren't so awesome. There are good things, there are bad things, but it's just a job. And if it's just a job and not a calling, we're allowed not to like it, and we're allowed to enjoy being on vacation.

So it's not so much that I'm annoyed that I don't miss work. It's that I'm annoyed to finally be realizing that I'm going to spend my life with a job, and not a calling.

But at least there'll be a paycheck.

I didn't mean to take such a break from the blog.

But I just spent a week taking an actual-- much-needed, I think-- vacation, and I stayed as far away from the Internet as I could.

Didn't check my work e-mail.

Which has turned out to be a bit of a disaster now that I'm back.

"Fall Performance Reviews" said one e-mail, requesting me to write back with some available dates and times.

"Fall Reviews -- Please Respond"

"Fall Reviews -- You Must Reply"

"Fall Reviews -- IMPORTANT"

"Please call the program director ASAP"

Five e-mails over the course of the week, each more urgent than the last, making me feel like my "fall performance review" will be taking a turn for the worse and they'll say there's an expectation that I should be checking e-mail regularly even while on vacation. Which maybe there should be, but I was hoping that one of the things that makes this career better than some others is that when you're off, you can really be off. People know when they're on call, people know when they have to work. When I get a vacation, I don't want to think about work.

And the dates they gave me for the review are all vacation days too! I certainly don't want to have a performance review over my vacation! It's supposed to be a vacation. An actual vacation.

I was afraid that I'd encounter a medical emergency while I was away and have to act. Or lie and say I wasn't a doctor. Fortunately nothing. A sort-of choking at a breakfast buffet, but the guy figured it out on his own before I needed to intervene.

More once I catch up on sleep. I still have another 4 days off before going back this weekend, and I plan to sleep a lot. And I have a week of e-mail to catch up on.

My two-week vacation starts Friday.

Not a day too soon. Clinic patient today. Came in last month for a checkup. He has hypothroidism, and his lab results were too high. I took a quick look at his chart, saw that he takes 100mcg of his medication, so I upped it to 125 and told him he really needs to take it.

He comes in today, lab results are even higher. "Why aren't you taking your medication?" "Oh, I am, I try, almost every day. I am taking it." "It doesn't seem like you are." "Oh, I will be better, I will, I am trying." Okay, whatever, everyone says they take their medication even when they don't.

I take another look at the chart.

And I notice that I didn't read quite so carefully last month. Because he'd actually been prescribed 2 of the 100mcg pills daily. 200 mcg. And I'd dropped it to 125mcg instead of bumping it up.

And so he'd probably been taking the medicine. He just wasn't getting enough of it. Because I am a terrible doctor.

Or at least a slightly careless doctor. Sometimes.

No long term issue, he's on the right dose now and he'll be fine. But, uh... oops?

I saw eight patients in clinic today, and I didn't care about any of them.

I know it's terrible to say that, but it's true. I don't know if I was unusually tired, or these patients were unusually awful, or I'm just a bad person, but they came in, I listened to their problems, I prescribed some medication, made some referrals, wrote some notes, and really didn't care about any of it. Just wanted to be done with it and come home... come home to nothing, really. The Braves-Giants playoff game on TV, I guess. Me and some Kraft Macaroni and Cheese, the Braves-Giants game, an empty e-mail inbox, and very few thoughts about these patients I saw today.

I know I complain about inpatient rotations when I'm on them, and I say I want to do outpatient work, but, man, outpatient work sucks if you don't have a life. If you have a life, it seems pretty great. You go to work, you have appointments, you come home, you make pretty good money and get to live the rest of your life. You're on call sometimes, sure, but you can own the time you're not working, and the time you're working isn't so terrible, it's pretty chill to see clinic patients, you see the same five problems, you refer the rest. But if you have nothing to come home to...

At least the insane hospital schedule lets me forget I don't have a life. How can anyone have a life working eighty hours a week, overnight every x nights, weekends, 16 hour shifts, on your feet, running codes, watching people die. You can't. You can get wrapped up in the work-- you have no choice but to get wrapped up in the work-- you can't have a life even if you want one.

But then I'm on outpatient and all of a sudden there's time to breathe, the days don't run into each other in quite the same way, I have weekends... and I have nothing to do and I realize that this can be my life if I don't do something about it. Go to work, come home, watch TV, go to sleep, do it again, and have absolutely nothing change, ever.

That's the thing about this job. Other jobs change over time. You have business trips, you work on new projects, you have things to look forward to, things to plan for. This job, you see patients. And then you see more patients. And then you see more patients. You see patients, you get paid. You sit on your couch, you don't get paid. There are no special days, there are no new projects, there are no new challenges. There are just patients and whatever they're sick with. And if I'm bored 16 months into residency, what's going to happen in five years?

Doctors don't blog. I can't quite figure out why. There is no community. There's Kevin MD and a few others, but there's not much with any real traction, at least not that I've found. Doctors write books, a few of them, Atul Gawande, Jerome Groopman, but for the most part doctors are not telling their stories. No one at work even remembers their patients from one day to the next. I feel like a lot of my co-residents wipe their memory clean every day. They barely remember each other-- or at least they barely remember me. No one reads the newspaper, no one sees movies, no one else is probably even watching this Giants-Braves game. It was like that in medical school but the excuse was medical school is insane. Now there's less of an excuse. Doctors are boring. I'm boring. Life is boring. This blog is boring. My patients are boring. Two flu shots, a urinary tract infection, bronchitis, and two referrals. Boring.

Ah, patient histories. Consider this a crash course.

"So, what brings you in?"

"I've been getting up every 45 minutes or an hour to urinate during the night."

"You get up five, ten times during the night to go to the bathroom?"

"Well, maybe not five or ten. Three. Two or three. Most nights."

"Okay. How long has this been going on?"

"The past couple of years, maybe four years."

"Wow. That's a long time. What brings you in now, specifically?"

"Oh, I have a rash."

"You have a rash on your--"

"No, no, not there. On my stomach."

"And you think this is related to the nighttime urination?"

"I don't know."

"Okay. Let's talk more about the rash. How long have you had it?"

"About a month."

"And you're first coming in now because--"

"I had microscopic blood in my urine."

"Microscopic?"

"Yes, very small amount. I could barely see it."

"Okay, that's definitely concerning. And this was this morning?"

"No, no, 1996. It was because of a weight loss pill I was taking. I stopped taking it."

"Okay. So what changed today that you came in to see me?"

"My sleep has been very poor."

"Because you keep having to get up to use the bathroom?"

"Yes, and because of my leg."

"What's wrong with your leg?"

"Well, I think have the rash because I'm not showering as much as I used to. I have trouble balancing in the shower. So I think I keep getting food on my stomach and that is causing the rash."

"And the trouble balancing--"

"That is my leg."

"So you're having trouble balancing, or trouble standing?"

"Yes."

"Which one is it?"

"I don't know. My mother had an infection on her leg a few years ago."

"Okay."

"Do you think I could have the same thing?"

"I don't think you caught an infection your mother had a few years ago, no. Whether you have an infection in your leg is something I can't tell without examining you. I'm just trying to isolate exactly what's going on now that we need to be most concerned about. Is the trouble balancing a new thing?"

"No."

"Is the leg pain new?"

"I don't have leg pain, no. I have a rash."

"On your stomach?"

"And my leg."

"Okay."

"And it burns when I urinate."

"Now?"

"It does not burn now. Only when I urinate."

"When is the last time it burned?"

"In the night. I don't urinate during the day."

"On purpose?"

"I don't know. But do you think it has to do with my mother's leg infection?"

Drunk guy I'm admitting from the ER. Checking his mental status.

"Who's the president?"

He gives me a look, mumbles something under his breath.

"I'm sorry, I didn't hear you. Who?"

"That n*****"

Seriously?

"Sir, please don't talk that way in this hospital."

"Yeah, f*** you."

Just another day.

"I'm looking at your records and it doesn't look like you've ever had a pap smear. You're of the age we really ought to make sure everything's okay. Would you like to schedule that for next time?"

"That is a test of the anus?"

"No. The other side."

"The breast?"

"No. The vagina."

"Oh. And you do what there?"

"We take a sample of cells from the area around the cervix and make sure everything looks okay."

"No thank you."

"No, I didn't mean now. I meant we'll do it next time."

"No. We won't. I'm going to leave now."

Somehow I had a three day weekend. I don't know how. I sometimes have nightmares that I misread the schedule and I've missed work and a patient dies because of it. It's more likely a patient will die because I'm there than because I'm not there. But I guess those thoughts are too dark even for my nightmares.

I had a 94-year-old patient in clinic. He used to be an alcoholic. (Not too many alcoholics seem to make it to 94, but this one just got lucky, I guess.) He was unable to stop drinking for decades. Until. Until he began to experience the early signs of dementia. His family sent him to a facility for 30 days where he wouldn't be able to drink. When he got out, he had forgotten he liked to drink. He had a new routine. He forgot he would go to the liquor store every day. He forgot the allure. He hasn't had a drink since.

Amazing. If I believe the story at least. Here we have a benefit of dementia. Astonishing.

I had another patient, end-stage lung cancer, still smoking and insisting that there's no proven connection between smoking and cancer. "Have you read the original study?" he asked me. "No, I haven't." Well, if you do, you'll realize there is no link. "Sir, you have lung cancer." "Yes, I know. It's not related to the smoking, I'm sure of that." I don't care, dying patients can believe whatever they want to believe. I guess.

Working at clinic is starting to get interesting.

The goal, as we progress through residency, is that we'll end up with a bunch of patients we follow for the three years, as their primary doctor. The appointments don't always work out-- if they have urgent needs, it's likely I won't be the one who sees them, because I only do an afternoon or two per week in each clinic I'm assigned to. But for ongoing checkups and maintenance appointments, they try to schedule the patients to see me if they can. So now there are about a dozen people I've seen two or three times, and they think of me as their real doctor.

And I'm starting to realize why being someone's doctor can be completely frustrating.

"You said last time you wanted to quit smoking, we put together a plan, and-- you haven't even taken the first step."

"Have you been watching what you eat? Because we came up with some ways to modify your diet, and it doesn't seem like you've taken any action--"

"Did you ever even fill the prescription I gave you last month?"

"You've canceled four appointments in a row. Why has it been so difficult for you to come see me?"

and so on.

I understand the practical difficulties-- people have to miss work to come see the doctor, transportation can be an issue, etc-- but it's hard to feel like you're making a difference if nothing gets acted upon, nothing gets followed up. You spend an hour counseling a patient on how to reduce her cholesterol, she writes down a plan... and then comes back two months later and acts as if the conversation never happened. We're not hall monitors. There's a limit to what we can make someone do.

There's a patient who I usually use the translator phone with, but the Wolof translator (have you ever heard of this language? I hadn't.) seemed to be out to lunch, because the phone just kept ringing and ringing. So we tried to muddle through in English. All I know is that there's something wrong with something in the general area of his stomach. Maybe.

Someone asked in a comment on the previous post:

"Why are you drawing blood and not a phlebotomist?"

Middle of the night, no phlebotomists. And, hey, sometimes middle of the day, no phlebotomists either. In a perfect world, we wouldn't have to draw blood, sure. And I think I expected coming into residency that I wouldn't be drawing blood. Or, I don't know, putting in central lines. Or doing lumbar punctures. Or doing anything to a patient that someone else is a lot better trained to do, and a lot more comfortable doing.

But there isn't always anybody else to do these things, and certainly not if you need them done quickly. And so we do them. I'd say 90% of the time one of my patients needs blood drawn, I'm not the one doing it... but that still leaves 10% of the time when I am. Like when the nurse is supposed to do it but "can't find the vein" and so it's my job, as if I'm going to be any better at it. Or when the phlebotomist won't have time for six hours, and it's a little more urgent than that.

And in the middle of the night... look, you're lucky if anyone shows up to a code, let alone someone wandering around looking to draw your patient's blood. I've been at codes where I'm the only one there, and if the patient was still alive, well, he wouldn't have been for long.

And sometimes you're just lucky.

Last night of night float. Last admission in the morning. I got assigned the pleasant elderly man with pneumonia. My co-resident got the HIV-positive homeless guy.

And while taking his blood,

She accidentally stuck herself with the needle.

This is a known hazard of the job. She should be fine-- the odds (and I've been googling this) seem to be about 0.3% that she'll actually get infected, and this was a superficial injury from an asymptomatic patient, so the numbers are probably even lower than that-- but she has to take six weeks of post-exposure prophylactic meds just in case. And they have side effects, and she'll feel pretty terrible for the next six weeks -- headaches, diarrhea, fatigue. It's pretty awful, and stressful, and concerning.

And scares me more than reading the story about the surgeon who got shot at Johns Hopkins, to be honest. I don't expect I'm at risk of getting shot by too many patient family members. But an accidental needle stick from an HIV-positive patient is not unusual, and is seriously frightening. And it's really only the luck of the draw that it wasn't me. I could have just as easily been assigned that patient, and after 13 hours of being awake through the night, I could have just as easily stuck myself. It took me what seemed like twenty tries to get my elderly patient's blood -- I couldn't keep my hand steady, I was ready to fall asleep, to pass out, whatever. So I totally could have stuck myself with the needle by accident. And if I'd had the other patient, I'd be the one taking the antivirals and feeling awful for the next six weeks.

Ugh.

Six admits, including a guy I argued for twenty minutes needed to get admitted to the ICU. Arrived in terrible shape, couldn't really be stabilized, we should not be admitting him onto the regular floors, we just shouldn't, he needs more care than that.

No, no, the night attending insists. He'll be fine, they'll deal with him in the morning. The ICU can't handle another bed, whatever.

So we admit him to the floor, I send him up there and then he's not my responsibility anymore. The night attending goes home at midnight. I do five more admissions and try not to fall asleep.

The day team shows up. And I get paged. And screamed at.

"How could you admit him to the floor? We came to visit him on rounds and ... wait for it ... HE'S IN A COMA"

"I didn't want to admit him to the floor, I wanted--"

"Yeah, well, this is your fault."

"How is it my fault?"

"You should have insisted."

"I did."

"Not enough."

So now we have a guy in a coma and apparently I did something wrong yet I still have no idea how I could have done anything differently when there's an attending telling me that I have to admit him to the floor and the ICU won't take him.

And they kept me there for an extra hour to get blood gases and do a whole battery of scut work on this guy, pretty much undisguised punishment as if I deserved to be punished and shouldn't be allowed to go home and go to sleep.

The guy should have gone to a different hospital, and I should have gone to business school.

Patient comes in last night. Homeless guy, alcoholic, had a seizure. Looks like just another homeless guy. We start talking.

"So how long have you been homeless?"

"A couple of years."

"Where were you living before that?"

And he names one of the nicest neighborhoods in the area.

"Really?"

"Yeah, I was a Senior Vice President at [ ]" and he names a company I'd heard of.

Whether he got laid off and then became an alcoholic, or became an alcoholic and then got laid off, I'm not sure -- but both of those things happened, his wife kicked him out of the house, and now he lives in a park. He gives business advice to other homeless people in exchange for money he can use to buy alcohol. He drinks the equivalent of a bottle of vodka a day, his wife hasn't let him see his kids in months... and just a couple of years ago, he was living the kind of life people aspire to. Crazy.

***

Two hours later, I get another patient, brought in by ambulance, passed out drunk, two of his friends along for the ride. They were clearly not used to being in the hospital.

"What hospital is this?" one of them asked.

I tell him. He pulls out his phone, starts looking it up... on Yelp. Is Yelp rating hospitals now?

"Is our friend going to get arrested?"

"No."

"Even if he's under 21. We're not saying he's under 21. But if he was."

"No. This is a hospital. We're going to treat him."

"Do we have to sign anything to claim him, so he doesn't get turned over to the state?"

"No. This is a hospital. No one's going to arrest him for being stupid, or lock him up."

The one who looked up the hospital puts away his phone, turns to me --

"Uh, I don't mean to be rude, but-- are there any other hospitals we can go to instead?"

Sometimes I prefer the patients with dementia. Most of the patients, for obvious reasons they're often not in a very good mood. They can be angry, hard to deal with, complain a lot. But most of the demented patients are actually pretty cheerful, happy to let me examine them, forget they're in pain when they're not reminded of it, and generally don't make the job harder than it needs to be. Five admissions overnight. Four of them nursing home patients with dementia. One of them talked to me for twenty minutes non-stop while I did his history.

"Do you know where we are?"

"Slovakia."

"Are you from Slovakia."

"No."

"Have you ever been to Slovakia?"

"No."

"Why do you think we're in Slovakia?"

"I don't know."

"And what year is it?"

"1978."

"You know, in 1978, Slovakia didn't exist."

"Of course not."

"Do you know what day it is?"

"Only if it's Tuesday."

"Interesting."

7 AM, I'm signing out my 6 overnight admissions to the day resident.

"Where are the prescription lists?" she asks.

"Oh, [the overnight attending] said I didn't need to fill those out, they're in the computer."

The day resident gives me a look.

"He wouldn't have said that."

"Uh, that's what he told me."

"Yeah, right. You're just lazy."

"The forms will take five minutes."

"So do them."

We're on the same level, me and the day resident. She's not my boss. She's not my supervisor. I was just following orders. I don't know why she was yelling at me. I'd been awake all night, I could barely keep my eyes open.

"It's seven in the morning, I'm on my way out."

"Do the prescription lists."

"[The attending] said we didn't need to."

"No he didn't."

So I rolled my eyes, and I did them. Took five minutes per patient. Half an hour in all. I gave them to her as I was walking out.

"Here."

She gives me a look.

"Yeah, I don't need them."

"That's what I said."

"Yeah, whatever."

I did eight admissions overnight. This probably sounds terrible, but there's something relaxing about knowing that on this rotation I just have to admit the patients and don't need to follow them at all-- I never see them again once I do their initial workups and write their notes. If I make a mistake-- and I'm not saying I'm making any mistakes-- I'm not the one who has to deal with it.

What I don't think most people realize is that mistakes happen all the time. When I was on the regular floors, on the day team, it was not unusual to come in and find a new patient who had been completely mismanaged overnight. Wrong tests, wrong medications, wrong treatment plan. Hopefully not with any adverse consequences-- usually it just meant we had to start from scratch-- but there aren't really any checks and balances overnight. I'm given a patient, I do the workup, if I don't ask for help, it's assumed that I know what I'm doing and everything's fine. No mistake would be discovered until the morning. Unless it's some severe mistake that leads to a rapid response, in which case it's probably too late anyway.

A commenter on the last post said I was whining too much. And he (or she) is probably right. Compared to almost anything else I could be doing with myself, this isn't so bad. Even among things that fortunate people get to do, this is still pretty good. I'll make a good living, I'll be pretty well insulated from anything going on with the economy, I'll sound like a legitimate person at cocktail parties. But that doesn't mean it's not exhausting at times, and overwhelming, and frustrating, and sad. It can be all of those things in the moment-- and I can feel that while still knowing in the macro sense that I'm quite lucky.

There's more humor on the outpatient side, sure. And having not had regular clinic hours in a while, perhaps I've gotten a little dark over here. Clinic starting again soon. For now, all I've got is my patient last night who's doing a tour of the local emergency rooms.

"I was at County last week, then State over the weekend, and University on Tuesday-- they all said I didn't need to be admitted, and should follow up with my primary care physician, but I still wasn't feeling right, so I thought I'd come back and try you guys."

"Yeah, you still just have a cold."

"But I feel like I'd be more comfortable in the hospital than at home."

"Yeah, but we're not a hotel."

"I can't just stay for a couple of days, ride this one out?"

"No."

"You know of any hospital that might be more willing to let me stay over?"

"No."

I would have called social work for a consult... but it's the middle of the night. I gave him the number for social services-- I don't know, he doesn't really have a medical problem, but I sense he'll be back.

And now... sleep.