* * Anonymous Doc: December 2010

Friday, December 31, 2010

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.

Wednesday, December 29, 2010

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.

Monday, December 27, 2010

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.

Sunday, December 26, 2010

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. :)

Friday, December 24, 2010

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.

Thursday, December 23, 2010

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."


"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."

Wednesday, December 22, 2010

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.

Tuesday, December 21, 2010

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.

Sunday, December 19, 2010


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.

Friday, December 17, 2010

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

Thursday, December 16, 2010

"Have you been taking your pills?"




"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.

Tuesday, December 14, 2010

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."


"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."


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

"Starting tomorrow?"

"No, starting now."


Monday, December 13, 2010

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.

Sunday, December 12, 2010

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"


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


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


"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.

Thursday, December 9, 2010

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.

Wednesday, December 8, 2010

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.

Tuesday, December 7, 2010

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?"


"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.

Saturday, December 4, 2010

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.

Thursday, December 2, 2010

"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."


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

Wednesday, December 1, 2010

"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?"



"Did you win the debate?"