In the call room, we have a list of all of the patients by room number and their diagnoses. I get in this morning and here's what I see:

1104 Fainted after macerating


"What?"

"What do you mean?"

"This guy fainted after doing what exactly?"

"Read the board."

"Yeah, I know. Macerating is when you put sugar on strawberries and they get soft. I assume that's not what he was doing."

"No, read the board. He was, I don't know, touching himself."

"Yeah, that's not the right word."

"Whatever, you know what I mean."

"Doctor, doctor, come quick," said the nurse. "The patient has a very hard lump under his skin, where they put the pacemaker. It is very alarming. I think there is something very wrong."

I go and take a look.

"Yes, that is the pacemaker."

"But the lump--"

"Yes, that's where the pacemaker is. That lump you are feeling is the pacemaker."

"So it is normal?"

"Yes."

"Oh, I did not know."

"Just let one of the girls do it."

We have a substitute attending today, and I think he's stuck in the 1940s. Out of the three interns on my team today, I'm the only guy-- the other two are women. And all throughout rounds, the attending is talking directly to me, as if I'm the only one who matters. I kept trying to avert eye contact, to look at my co-interns, anything to divert his attention. And then we get to one of my patients, who needed some gauze re-wrapped, and I lean over to do it and he stops me and says,

"Just let one of the girls do it,"

and he gestures to one of my co-interns. I was like, "no, it's my patient, it's fine," but he insisted, and made one of the other interns re-wrap the gauze. He also told one of the interns she looked pretty, and asked the other one if she had a husband yet. She said she doesn't, and he gave her a look.

It's weird, women have been doctors for a long time now-- and in fact there are more women than men in the residency program, and I think more than 50% of new medical graduates nationwide are women-- but there's still definitely second-class treatment.

Seems like every other day one of the female interns is complaining that a patient thought she was a nurse, or asked to speak to the doctor when she was standing right there. It's like they can't believe their doctor can be a woman.

Which is silly, and I feel bad for my colleagues who have to deal with it-- I've been asked a few times if I'm a nurse, mostly in moments when I've been completely incompetently trying to draw a patient's blood, or running around like a lunatic when a family members stops me in the hall-- but it's nothing like what the female interns and residents experience.

And it's one thing if it's patients who are ignorant, but for it to be the attendings, it's a little more unfortunate.

I just noticed someone asked in a comment on my blood transfusion post, "How much does the hospital charge for a blood transfusion? How much does it pay? (Is the blood donated? What's the processing fee?)"

The question makes me laugh. How much does the hospital charge? I have no idea. The processing fee of a blood transfusion? Beats me. We order things, they get done, we are completely insulated from whatever the billing process is. And I'm glad. Not just because the last thing I want is more paperwork-- we write tons of notes as it is, we spend a great fraction of our day sitting in front of computers and typing instead of actually doing patient-care-related things-- but the last thing the system should encourage is making decisions centered around things unrelated to patient health.

Yes, I think the system is broken-- I know hospitals charge what seem like insane amounts of money, and if you don't have insurance, any little medical issue can absolutely bankrupt you-- and I think that's bad, and troubling, and frightening. But I don't think the answer would be asking our patients if they'd rather have the $3,000 TEE or the $0 "lie in bed and wait for another heart attack." We do things because they're necessary-- the fact that they cost money is unfortunate but I don't think we want doctors deciding on the balance between cost and health, and I don't think patients are equipped to sensibly make those choices-- is the procedure worth it even if you need to default on the hospital bill and declare personal bankruptcy? Well, if it means the difference between life and death, I think it probably is, and I don't know who wants to argue that it isn't.

What I do know is that the billing doesn't always make sense. Insurance companies have deals with the hospital where they pay a fraction of the "retail" rate that self-pay customers are billed. Patient might get a bill for $500 when an insurance company would have been able to settle that claim for $50. That's clearly unfair to patients who, for whatever reason, aren't covered. And that doesn't just affect the uninsured-- it affects people who are seeing doctors outside of their plan-- which isn't always the patient's fault-- the hospital sends over a specialist for a consult, you have no idea if they take your plan and you're in no position to do anything about it even if they don't. There are tests that aren't covered, there are claims that get rejected. It's a mess.

But the fortunate thing for residents is that we deal with none of it. And, frankly, I can go on and on about how in an ideal world I don't want to be a hospital-based physician, I want to see patients in private practice, I want to see them when they're well and not when they're dying-- but there are huge advantages to being based at a hospital and spending part of your week dealing with inpatients-- the hospital deals with all of that back-end stuff, you don't need to deal with the billing and the insurance, you don't need to deal with finding and maintaining office space, and having a staff and the infrastructure you need to effectively run an office. You get to spend your time seeing patients instead of being an accountant. So there's certainly benefits there.

But, gosh, the last thing I want to do is think about how my patients are paying for their medical care. I just want to worry about getting them healthy enough to leave.

"When was the last time you saw a doctor?"

"Oh, just recently, when I got some Tylenol."

"Why did the doctor tell you to take Tylenol?"

"No, he didn't tell me to take it. I asked him where it was, and he showed me."

"You went to a doctor's office, and a doctor examined you?"

"No, you asked me when I saw a doctor, and I'm telling you."

"What kind of a doctor did you see?"

"The doctor who worked at the drug store."

"Do you mean the pharmacist?"

"I don't know."

"The doctor examined you?"

"No! I keep telling you. The doctor told me where the Tylenol was."

"I think you're talking about a pharmacist. That's not a doctor."

"Well how am I supposed to know?"

"Doctors don't work in the drug store."

"Then he shouldn't be wearing a white coat and pretending he's a doctor."

"Sir, we're going to need to get your consent for a blood transfusion."

"No."

"Your blood count is really low. We need to do a transfusion-- it's important."

"No, this is the kind of thing I want a second opinion about."

"Sure. Would you like me to get the other doctor [my resident] in here to talk to you?"

"No, I mean, look: I know this isn't the only hospital in the world."

"This is a standard procedure, lots of patients get transfusions-- I know it sounds alarming, but it really does happen all the time, it's safe, and it's important to get you on the road to recovery."

"I know what you guys try to do. You try to get us to say we'll let you do all sorts of stuff we don't need. That's how you work. Well, I'm onto you."

"I promise you, we wouldn't want to do this transfusion unless we really needed to. I'm happy to get the other doctor to come in and explain it. I'm happy to get [the attending] to explain it next time he comes by."

"You just want to do it because you'll make more money."

"I earn a salary for working here-- I'm not paid based on how many things I do to the patients. I'm paid the same thing whether we let you lie here and don't do anything, or we do a million different things to you. It doesn't matter to me. I just want to do what's best to get you healthy enough to leave."

"Well, someone's making money off it."

"I assure you, this has nothing to do with anyone making any money off a blood transfusion. It's important that we do this. Do you want me to come back after lunch and we'll talk about it some more?"

"I'd rather talk to the lady doctor about it."

"Okay then."

I just watched the season finale of Grey's Anatomy.

[Stop reading if you don't want to be spoiled.]

A shooting in the hospital? A guy roaming the halls and executing doctors? This is going to give me nightmares. Anyone can get into the hospital-- the security guards in the lobby don't actually stop anyone, to come up as a visitor requires nothing. You walk in. No one questions where visitors go, I see patient families in the pantry, in the nurse's station, in the staff restrooms. If someone wants to come into a hospital and start shooting doctors, there's nothing to stop them.

That part of it, the show got right.

The rest of it-- well, not so much. I don't know why I watch these things. I spend most of the episode trying to catch as many mistakes as I can, as many things that wouldn't happen, can't happen, make no sense at all.

First of all, the guy who's shooting people-- he blames the doctors for killing his wife, for removing life support. Yes, there are cases when the hospital withdraws life support, but it's never quite that easy. We have a patient now who's being kept alive by machines, no brain activity, never going to recover-- but the daughter wants everything done. The guy is DNR, if it were up to the hospital, care would have already been withdrawn-- but no one ever wants to override a family member, the system works to keep people alive, not to remove support. In the case on the show, there'd be ethics consults, there'd be family meetings, there'd be days and days and days of hand-holding and convincing and discussion. A doctor isn't going to walk into a patient's room, look at the chart, and order someone's death. Doesn't happen. Can't happen.

Next, Dr. Bailey's patient-- the resident she tries to save and then drags him to the elevator, elevator's shut off, and so he's stuck in the hall, and she tells him he's going to die. This one I didn't understand. He's conscious, he's talking, she thought she was going to save him right up until the moment the elevators aren't working. Well, why couldn't she run down the stairs and look for help? If she was going to drag him into an elevator, why couldn't she go herself, to a staircase, and look for someone to help? But the bigger issues:

(1) She has him on an oxygen mask that's connected to nothing. Mask alone doesn't do anything. Nonsense.

(2) There's no monitors. How does she know he's going to die? How does she know how much blood he's lost? She's giving him fluids-- I don't know why he suddenly went from save-able to dead. Didn't make sense.

Next, Dr. Karev. The amount of blood he lost, and the amount of time he was lying in the elevator after he dragged himself inside. First of all, how did the elevator go unused for so long? In my hospital-- in any hospital-- there's people on every floor waiting for elevators, you put a bleeding patient in the elevator and not only will he be discovered in ten seconds, he'll probably be trampled to death by the people who are waiting for the elevator and desperate to get out. I've seen visitors elbow doctors out of the way so they can get on the elevator before it fills up. I've seen visitors cut off patients in wheelchairs with IV poles dragging behind just so they can get on the elevator. But, second-- all that blood and all that time, he's not surviving. Sorry. Guy who's talking and getting fluids dies and guy bleeding out in the elevator lives? Nope.

Dr. Yang. Why is the idea of performing surgery without an attending so scary to her? She's been at this hospital for, what, five seasons? She's supposed to be this amazing surgical resident. By now, she's performing surgeries alone with attendings barely involved-- they're observing, they're the safety net. But she can totally perform this surgery by herself. Yes, she'd be nervous because it's her friend-- but she can do this procedure.

And, finally, what dedication these doctors have... to their personal lives, and discussing them even in the face of terror and tragedy. It takes quite a level of focus to put aside the fact that there's a gunman on the loose in the hospital to still be able to be angry at your girlfriend or obsessing about your romantic prospects. I guess it was partly just to pad the episode to two hours, but, really, let's give these doctors a little perspective.

And now, because it's my day off and the only reason I woke up at 6:30 is because my body doesn't know any better, I'm going to take a nap. Hopefully, no nightmares from this. I really don't want to be shot, even if just in a dream.

Thanks so much for all the comments on the previous post -- certainly gives me reason to keep doing this, and the feedback's much appreciated.

You know, sometimes this job feels less like being a doctor and more like being a detective. In the past few months, I've tracked down missing test results, missing blood samples, and, of course, missing patients.

And missing family members.

One of my patients has been in and out of jail for the past thirty years, completely estranged from his family, and we had to tell him yesterday that his cancer has spread and there's really nothing we can do to help. He wants his sister to know what's going on-- only problem is, he has no idea how to reach her, and hasn't been in touch in years. We asked where she lives, and he wasn't sure. We asked if he knows anything about her-- and all he knew was her name... sort of. "Her last name is something like [Johnson], but not exactly, and I don't know how it's spelled."

And he had an old address from years ago.

So I Googled. I found a reverse address lookup site, plugged in the address, and after a few clicks, found a name that was close. Then I plugged that back in and tried to find current information. Seems like it's an unlisted phone number, and nothing on Facebook or anything like that. But I found a current address in the white pages online.

So he asked me if I could write her a letter-- he dictated what he wanted to say, I typed it up, and sent it off. Will she come to visit, like he's asking? I have no idea. I don't know what caused the rift between them, although I'd assume it's related to the reasons he's been in and out of jail for all of these years. Will she forgive him? I don't know. Did any of this relate in any way to anything we learned in medical school? Nope.

I feel like residency has taught me that being a doctor, especially in a hospital setting-- and really especially in a public hospital, where you're dealing with patients who don't have all the advantages in life, don't necessarily have a support structure or a family or a stable life outside of the hospital-- is about a lot more than the medical piece of it. For some of these patients, we're their only allies, and part of the job is to be therapist / advocate / counselor. And, sure, sometimes they'll reveal something that does help us make a better medical diagnosis. But sometimes it feels just as important to listen to our patients merely because it's the human thing to do and they have no one else to talk to.

The hard part is that the human interaction is always bumping up against everything we have to do that is judged to be more critical-- writing notes, following up on lab results, doing admissions. There's always more to do, always more time we can spend with a patient, or a patient's family. And knowing what's enough-- when it's okay to leave-- is also a big part of the job, and something I think most of us are still working on.

That's part of what scares me as intern year comes to an end soon and I become a second-year, in charge of the interns. I don't want to have to wait around for the slowest intern, but I also don't want to neglect the patients. I want the interns to have a chance to learn, but I feel like I'm going to be compelled to do their work for them just so it gets done and we're not here until midnight every night and back again at 6. I'm less worried about the medicine, honestly-- I do feel so much more confident about the medicine as I did a year ago-- not quite competent yet, but I've seen so much more than I'd seen, I've made decisions, I have more confidence in my instincts. But it's the people management part of that's a little frightening. I'm not a patient person, all things considered. I don't like waiting around, I like sleep, I don't have the work ethic that some of my colleagues have. Work ethic is the wrong phrase-- I'm not insane like some of my colleagues are. I don't feel compelled to be here 24 hours a day. I don't feel responsible when it's not my shift. Is that a good thing? I hope so, but from a patient's point of view, probably not. In any case, time for rounds.

I told a nurse about this blog. That may have been a dumb thing to do. I'm not sure she's going to remember the address or anything like that, so I probably have nothing to worry about. And even if she read it, what's she really going to do? I don't know, it's tough sometimes to worry about keeping it going when I don't know who I'm writing for. Do me a favor, if you read the blog and like it, send it to a couple of friends or link it or something. Just want to get a sense if anyone's out there who this is resonating with.

I have a 90-year-old patient who used to be a doctor, except he hasn't been a doctor in 35 years so he thinks he knows what we ought to be doing but doesn't actually know. I told him we're giving him a certain drug and he starts yelling that he wants a different one-- but the one he said he wants hasn't been on the market since 1982. So he's not getting that one. I tried to explain that this is a better class of drugs, fewer side effects, matches his problem, it's the standard treatment-- but he thinks he knows better. He named the type of catheter he wanted, I had to Google it-- it exists, and he's probably right that it would be fine for him-- except we don't have it, and we're not going to get it just because he wants it. He's rightly frustrated that we don't seem to be listening to his expertise as a doctor-- but we're the ones responsible for his care, and when he starts telling us things that would have made sense in 1953 but not now, I don't think we should be expected to change what we're doing.

He also seems to think that the doctors have some control over the patient food, which I don't even think was true in 1953. He's on a low-salt diet, which is predictably tasteless, and I can't do anything about that no matter how much he complains. I can't get him white meat instead of dark meat, I can't have them cook the vegetables more, and I can't get him a different dessert. It's not a restaurant, it's a hospital. And even though I feel bad that he's 90 and has no family, I still don't get to make special requests in the hospital kitchen.

But I did sneak him a doughnut.

Why they serve doughnuts to doctors twice a week-- instead of, oh, I don't know, something that isn't nutritionally bankrupt and fried in fat-- I don't know. Nutrition ranks just above, I don't know, dental health on a list of things the medical profession ought to care more about but chooses to ignore. I've gotten into the habit of noticing doctors who neglect their dental hygiene. You'd think doctors would take care of themselves but somehow dentists are seen as beneath us, I guess. I told someone I had a dental appointment for my day off and she told me she hasn't seen a dentist in seven years. Sexy.

New patient. I bring her ID number up on the system. Am scrolling through past notes.

October 2002 -- fractured hip, here a week, discharged.
March 2004 -- bronchitis, discharged
December 2004 -- pneumonia, here for nine days, patient expired, sent to morgue.
May 2010 -- admitted with a persistent cough.

Hold on a moment. What??

I call medical records. "The computer says my patient died in 2004." "Oh, we'll check on that." "You'll check on what?" "Whether she expired." "She's here now, alive." "Are you sure?" "Yeah, I'm pretty sure." "Okay, we'll check on it."

A few hours pass, I input my orders, check her record -- still listed as deceased. I call the records department back.

"Still says my patient is deceased." "Yeah, we're still looking into it." "Well, she's definitely not deceased." "Well, what's her condition -- we don't want to go through the trouble of changing everything if three days from now she's deceased again anyway." "Uh, hopefully she'll get better -- but I don't know if leaving her in the computer as deceased just in case is really a solution." "Oh, you don't want to jinx her?" "No. I don't want the records to say I'm administering medication to a body that's been dead for 6 years." "Yeah, we need to check what the insurance status is anyway."

A few more hours pass, I get a call back from medical records. "We had her mixed up with another patient with the same last name." "Yeah, I thought so." "Yeah, I think we fixed it. But if she ends up dying-- you should know we wasted a ton of time on this for nothing."

This afternoon, I'm the intern who cried chest pain. I have a patient who complained to me about chest pain for twenty minutes, and I grabbed the attending to take a look and see if we should run any tests. I bring the attending in, and ask the patient to repeat what he was telling me.

"Chest pain? I didn't have any chest pain."

"You just spent twenty minutes telling me about your chest pain."

"I don't remember any chest pain. I feel fine."

And this is not a patient with dementia. At least we didn't think so. I decided I'd press my luck and do a quick mini-mental exam.

"What year is it?"

"2006."

"Who's the President?"

"Clinton."

"You sure you didn't have chest pain?"

"Why would I have chest pain?"

Okay, at least the attending realized I wasn't crazy. I wish patients would come in with signs around their neck-- "Good Historian" or "Don't Trust What I Say." It would make things easier.

I walk past one of my patient's rooms and see him lying face down on the floor. I rush in and yell for the nurse. She comes running.

I check the patient, he's moaning-- fell out of bed, had been lying there for hours. I ask the nurse--

"When was the last time you checked on him?"

"We rounded half an hour ago."

"And--?"

"I thought he was sleeping."

"ON THE FLOOR?"

"He's been there for hours. The nurse on the last shift told me he was sleeping. She didn't say where. I figured he was fine."

"Who's sleeping on the floor?"

"I don't know-- I just assumed."

No comment.

Someone e-mailed asking what happened to my personal life. That is, where it went, since it hasn't been on the blog in a while.

I can't have a personal life. 6 days a week, 14 hours a day, I can't have a personal life.

When I was on outpatient, I could complain that I didn't have a personal life, because I had time to have one if I was able to craft one for myself. But now, when can I have a personal life? I get home, I eat dinner, I go to sleep, repeat. I went to see a comedy show the other night with a couple of other interns and I feel asleep. In a chair. In a comedy club. For an hour. Without waking up. And when I did wake up-- the other interns I went with were also asleep.

Part of the blame surely goes to the comedians-- they were terrible. But most of it is, hey, we're tired. Not only are the days long, but they're draining. There's no down time. There's no surfing the web. Okay, there's a little bit of blogging, and the occasional e-mail. But it's mostly not about us, it's about the patients. And that gets tiring. So when I get home, and I try to get the energy to make a bowl of pasta or heat up some chicken-- that's about all I have the energy to do.

I don't have a two-day weekend again until September. September! All summer, I don't have a two-day weekend. Let alone a vacation. Personal life? I barely have time to read about who gets kicked off American Idol.

There's a woman in my program who's been the subject of rumors all year-- she messed up this, she messed up that, three of her patients died, she missed two days of work without calling in, she tried to write herself a prescription under her resident's name, etc. Every bad thing you can do as a resident, people have said she's done. I've assumed it's all just rumors, and I haven't worked with her directly so I barely even know her.

Today they sent out the e-mail with next year's schedules, and she is on a "research sabbatical" for the fall. So now the rumors are that "research sabbatical" = forced time off, to punish her for any one of a million things she might have done.

And then this afternoon my attending mentioned this intern in passing-- he worked with her a few months ago, and recommended she be removed from the program. So maybe it's not all rumor, maybe some of it is actually true.

But here's the thing-- if there's an intern who really is a danger to patients-- who's harming people, because of incompetence or laziness or whatever-- what good is a "research sabbatical" and then she just comes back in the spring and does it all over again? No hospital wants to fire its interns-- it would be crazy if we went around all day worried we would be fired if we accidentally screwed up. We're supposed to be learning, we're not supposed to know everything, mistakes inevitably happen. But on the other hand, these are real patients we're learning on, and surely there should be consequences for being worse at this than any well-meaning intern ought to be.

And yet I'm not sure there are. I've never heard of an intern getting fired, anywhere-- and I've heard some crazy stories about mistakes people have made over the years. These interns are your doctors, my doctors, everyone's doctors. There are interns in my program I wouldn't want as my own doctor, and there are some who I'd be thrilled to have. I don't know what the line should be for learning vs. incompetent, and when someone should get fired-- but surely there should be some line, right? Not everyone who can get through medical school and pass a bunch of multiple choice tests is cut out to treat actual human beings, are they? Maybe they are. Maybe med school is the hurdle and if you can make it through med school, you're good enough-- but I don't think that's quite right.

I don't know that I have a conclusion-- or a point, at all-- after all, I'm sleepy, and I have three patients screaming that they want to go home even though they're still sick. So what do I know.

Middle of the afternoon yesterday, a nurse pages me. Patient's hematocrit is 5, down from 9-- that's low. "He lost half of his blood since the last test" low. "He has a major internal bleed" low.

I run to his room to see what's going on. He wasn't my patient-- on the weekend, you cover for the people who have the day off, so this was a patient on someone else's list, I'd never seen him before, I'd never examined him, I didn't know his usual condition. I asked the nurse to take a look, the nurse said he looked like he's looked all week. I looked at his chart-- quickly, though-- if there was something acute happening, I didn't have time to read every note and carefully study the chart. He's not a getting-better patient, he has very little brain activity, it's not like we're dealing with someone in a state where he can tell us what's wrong. But still, patient having a massive bleed, you need to figure this out, you need to do something.

Examined the patient, very quickly. One eye not opening right. Left side of his face not completely normal, I didn't think. Issue on one side of the body, massive bleed-- I thought stroke, and thought it was pretty obvious.

Called my resident, my resident said to get him to cat scan, stat. We did another blood draw on the way, just to re-check everything. Scan comes back normal -- no evidence of stroke. Condition hasn't changed, we have no idea what's going on.

Blood comes back. Hematocrit back up to 9.

That's not actually possible-- his hematocrit couldn't have dropped to 5 and then come back up to 9, that didn't happen. I call the lab-- "one of these tests could not have been his blood."

The lab insists they did not make a mistake, and definitely not with this latest one.

But then how to explain the eye muscle weakness?

I couldn't. And I didn't know what to do.

Nursing shift changed. New nurse comes on, happens to pass the patient's room, comes in to check. I ask her-- did he look like this yesterday?

"Sure."

"What do you mean, sure? Look at his eye."

"Uh, he has a glass eye."

WHAT?

"He has a glass eye."

Maybe that should be in the chart! In big letters!

So, okay, he's stable. But if that wasn't his blood that came back with a hematocrit of 5 -- whose was it, and do we have a patient with a massive internal bleed that we haven't identified yet.

We have no idea. I still have no idea. The lab has no idea.

Excuse me while I check to make sure all of my patients have their own lab results and not their neighbor's. Gosh.

Happy Mother's Day.

Of course, I'm in the hospital, working.

I mean, I'm not really complaining. If I were off today instead of yesterday, I would have probably volunteered to switch shifts with someone who really wanted Mother's Day off. My mother lives far enough away that I wasn't going to go home to visit, and I can just as easily call to wish her a happy mother's day from the call room as from my apartment.

But for people who actually ARE mothers, it seems pretty lousy to have to work today. Unless they hate their kids, in which case perhaps it's a welcome relief.

There are a couple of extra visitors in the hall today, compared to a usual Sunday morning. People visiting their mothers.

Of course, one patient was in for a pretty ridiculous surprise.

Her mother's not here.

She should be, but she's not.

I showed up this morning and one of my patients was missing -- seems to be the week for that. But this one hadn't just been moved to another room. This one was really, really missing.

"Oh. The nursing home came and took her," said the nurse.

"Really? Are you sure?"

"Yep, I have all the paperwork right here."

"Yeah, the nursing home took the wrong patient. She's not going to a nursing home. At least not today. They're going to need to return her."

So I called the nursing home and explained they took the wrong patient. And after arguing with me for ten minutes, they realized that in fact they did come and take the wrong patient.

"But this one is coming here when she's discharged, right?"

"Yeah, she's going to need nursing care-- but we haven't talked to the family yet, and we certainly haven't discharged her."

"Can you talk to the family today?"

"Why?"

"Can you convince them to send her here when she's released, and then just discharge her to us after the fact and we can keep her?"

"Um, we haven't discharged her yet. She needs to come back to the hospital."

"She seems stable."

"That's great. BUT WE HAVEN'T DISCHARGED HER YET. I don't think it's supposed to work this way. You can't take patients before we tell you to come get them."

"But it's such a waste to bring her back if we're going to have to turn around and come get her again tomorrow."

"I'm sorry, you're the ones who made the mistake."

"But you guys let her go."

"That wasn't me."

"Well, someone did. So I don't see why we need to return her."

"Do you really not see why you need to return her? I'm just an intern, but I'm pretty sure you stole a patient and so that's why you need to return her."

"I'm just trying to save both of us the hassle. You don't have to get so dramatic about it. She needs nursing home care, we're a nursing home, we're offering to take her."

"I think I have to get the social work supervisor involved."

"You can't just sign the paperwork and send it over?"

"The patient hasn't been discharged."

"You keep saying that, I know. But I'm just asking whether it's really necessary that she still be in the hospital."

"I'm going to have to get someone else to call you back. In the meantime, you really ought to bring back the patient."

"We'll wait until we hear that from your supervisor."

I walked into one of my patient's rooms this afternoon -- empty.

I mean, completely empty. Even the bed.

So I ask the nurse -- where's my patient?

"He's not in his room?"

"Nope."

"Maybe he's talking a walk around the hall."

"With his bed?"

"Oh, his bed's not there?"

"Nope."

"And he wasn't discharged?"

"Nope."

"I guess I'll check."

"Yeah, let me know."

Turns out they moved him. But maybe they ought to keep better track. Or tell the doctor when they move a patient. (Or at least leave a note.)

Is it okay if I have homicidal thoughts about my patient who's having suicidal thoughts?

Because that would kind of solve both of our problems, right? If I kill him? He won't stop telling the nurses to page me. All day, every five minutes. I can't do anything for him. He's not physically ill, he's a psych patient. But there's no room on the psych floor, so he's my patient. And I don't want to be his doctor anymore.

Because I'm not a slave. Or a nurse's aide. I shouldn't be the one who has to stop examining someone with a real illness so I can go over to him and find out he only paged me because he needs more water. Or ice. Or he has an itch, and since they've used restraints to fasten him to the bed -- not my call -- he can't scratch it.

He wanted a fork, to eat his dinner, but I was told by the psych resident that he can't have a fork, because they're worried he's going to use it to hurt himself. Or others. Perhaps me. Maybe that would be a good thing. Maybe that would get him off my service.

Every five minutes. Fluff my pillows. Call my parents. Take away my meal tray. Give me back my meal tray. Do you have any magazines? Can you tell me what's on TV? My tooth hurts. I want to hang myself.

This is not a hotel, and I am neither a babysitter nor a psychiatrist. Yes, he needs help, I get it. It's not his fault. Still doesn't stop me from wanting to push him out the window.

And, somehow, he's able to convince the nurses that every time he needs something, they need to page me. He scares them much more than I do, apparently. Because they're fine ignoring me. Completely fine ignoring that I've told them twenty times that they should only page me regarding this patient if there is an actual medical emergency. I think he tells them he has actual medical emergencies. Can't breathe. Guess what? Can't breathe somehow turns into "feed me my Jello." One nurse said she thinks the patient has a crush on me. Great. That's just what I need.

Maybe I'll just give him that fork.

"Have you moved your bowels"

"What?"

"Sat on the toilet."

"What?"

"Have you made any poop?"

"Poop?"

"Do you know what I mean if I say feces?"

"No."

"Bathroom? Sitting down? Not the liquid."

"I don't understand."

"Doody?"

"What you asking me?"

"Have you made ca-ca."

"Oh, yes, ca-ca. Yes, this morning I do ca-ca."

"Terrific. That's all I needed to know."

I see a nurse's aide in a scrub top feeding one of my patients, as I'm doing my pre-rounds, so I go over to check on her.

"How's she doing today? We want to take her for a scan later if she's up to it."

"Oh, she's not doing well at all. Seems like she's completely out of it."

"But she's eating?"

"A little."

"When you get a chance, if you could also check on the guy in 314?"

"Sure, absolutely."

"He needs to be drinking more water-- if he's not, I want to start him on IV fluids, so let me know how he's doing?"

"Yes, sure."

Ten minutes later, I see her come out of the room and head toward the other patient.

And I happen to notice this "nurse's aide" is wearing a visitor badge.

I *run* from the call room and catch up to her.

"Wait-- you're a nurse's aide, right?"

"No, no, I was just visiting my mother, down the hall."

"Wait, wait-- what? But you were feeding someone else--"

"Yes, I noticed when I walked by that she didn't have anyone to feed her, so I just thought I would help."

"And now you were going to go check on the guy in 314 -- why didn't you tell me you didn't work here?"

"I just thought you needed help."

"I do, but-- this isn't your job. You shouldn't be doing this. We have staff to do this. Go visit your mother."

"Are you sure?"

"Yes, absolutely."

Lesson: not everyone wearing a scrub top works in the hospital.
Lesson: our visitors are more helpful than some of our nurses.
Lesson: I should make sure people work here before giving them assignments.
Lesson: before I start talking to someone about a patient, I should make sure they work here.

I spent half of the day seeing clinic patients. One guy, an immigrant from Russia, I used the translator phone to understand what he was saying. As the visit finished, I let the translator go-- as soon as she's off the line, the patient says to me, in his broken English:

"I also have a, how you say, sexual problem."

"Um... okay, what kind of problem?"

"My wife, uh, she does not want to have sex."

"Has this always been the case, or has something changed?"

"Always problem, but more now."

"Perhaps she should see a doctor-- she could have a medical problem."

"Uh, I hear in this country, some women have boyfriends?"

"You think your wife is seeing someone else?"

"No, no, no." He laughed. "No, I just wonder if maybe it would help if she see someone else. I am, you know, not as handsome as I was before."

"You're saying you want your wife to have a boyfriend?"

"I think that could help, yes. You do not?"

"I don't really know if I'm the right person to be talking to about this."

"Do you know anyone who could be my wife boyfriend?"

"I'm really sure I'm not the right person to be talking to about this."

"Do you have a wife?"

"I'm going to have to talk to my supervisor and see if there's somewhere we can refer you--"

Just getting home after my very last 27-hour shift (until the summer, when I'm on this rotation again as a second-year). For the next month, my long call nights are going to seem pretty terrific when I get to leave at 10PM instead of having to stay overnight until the morning.

I told one patient it was my last day, and he smiled and thanked me for helping to take care of him.

I told the attending it was my last day, and he grunted and walked away.

Why are the patients nicer than the doctors? The patients are the sick ones.

The final night was not without some drama. One of the patients, a tiny 86-year-old man, actually in relatively good shape for the ICU, but suffering from some pretty obvious dementia. Not entirely sure he knows where he is, he certainly doesn't know what year it is or the name of the President-- the standard questions we use to see how oriented the patients are.

But he's a lovely man, just wants us to be nice to him-- he gets scared when there's a commotion or someone raises their voice, but he responds so well when we talk calmly to him, make him feel like he's safe and being taken care of.

Two specialists come into the call room at 9:00 last night looking for me. "We have a big problem. Your patient won't consent to the [painful but fairly necessary procedure]."

"He's not able to give consent. He's demented."

"Well, he won't let us touch him."

"Just calmly reassure him. He's not denying consent. He doesn't know what's going on."

"He should consider himself lucky that Dr. [Jones] is the one doing this procedure," the young specialist said, referencing the older specialist next to him. He's a world-class expert in this."

"I'm sure he is. But the patient doesn't even know where he is."

"Well we have a problem."

"I'll calm him down."

"You sure you don't want to get your attending to explain the procedure to the patient?"

"It doesn't need to be explained. He can't withhold consent. He's not mentally competent."

"Well, if he doesn't consent, we're going to have a big problem."

So I go into the patient's room, and I calmly explain to him that he needs to let these nice doctors do this procedure, and everything's going to be okay.

"Oh, this isn't the place for that," the patient says.

"No, it is," I calmly tell him. "You're in the hospital."

"No, this isn't the hospital. I don't think I want to go to the hospital. I'll just stay here."

"Okay, you can stay here, but it's important that you let these people do what they need to do."

And then the younger specialist interrupts, screaming--

"You are very lucky Dr. Jones is willing to do this for you. He is a world-renowned expert. Very lucky!"

The patient turns to me-- "Is he talking to me?"

"No. Just relax. Is it okay if they do what they need to do to make you better?"

"If it's okay with you, it's okay with me."

"Yes, we should let them do this."

"Okay then."

"Okay, great."

The specialist turns to me-- "Oh, that was great. Thank you so much for getting him to consent."

"He didn't consent! He's demented!"

"Well, he's very lucky to have Dr. Jones doing this for him. I hope he realizes that."

"He doesn't realize that!"

The procedure went fine. Jeez.