"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.