Rapid response in a surgical suite. I get there, and people are frantic.

"Does anyone have a stethoscope?"

"Yes, I have a stethoscope."

"We have no idea what to do."

"Start chest compressions."

"We don't remember how to do that."

It's amazing how quickly knowledge and instinct can atrophy when they're not used. I mean, I did surgical rotations in med school, but don't remember anything useful, if I ever knew anything useful anyway. And the surgeons don't know anything about medicine anymore. And pretty soon, once everyone starts fellowship and is immersed in whatever specialty they're in, that's all they'll know and a patient comes in with a problem outside of their field and they won't have any idea where to even begin. This is why patients end up coming to clinic telling me they see nine different doctors, and why it's hard to find someone who can effectively coordinate care between them. We pretend we can divide problems into these individual silos, but not every problem is so easy to assign to one specialty. Things interact. The patient's diabetes affects multiple organ systems, etc.

At least we eventually got CPR going. Gosh.

Just tired. 27-hour shifts are torture. Don't even know what day it is anymore. Someone said something about the 28th, and it took me a few minutes to even know what month he was talking about, and whether he meant today. Yesterday becomes today. I go to sleep in the light, I wake up in the dark, I don't know what is going on. I eat two breakfasts and a half-dinner. This doesn't serve me or the patients very well.

Weird to be in charge. Don't feel in charge. Don't feel like I should be in charge, or like I'm ready to be in charge. I had to run a rapid response for a baby having a seizure. I don't know what to do with babies. We don't learn anything about babies. But in the middle of the night, we all do everything. Weekend overnight meant I was carrying six different pagers at once. I didn't know what was going on. I got paged four times while I was in the bathroom. I don't think I'm supposed to go to the bathroom. 27 hours and I don't think, technically, I'm supposed to go to the bathroom. This rotation cannot end soon enough.

It's so strange to be in the position of giving out admissions instead of receiving them. People see me coming down the hall, and instead of smiling (or, more typically, ignoring me completely), they try and run away. I'm the terrible person handing them more work that's going to keep them there for more hours. But it's not my fault! It's the job! Blame the patients for coming in! Blame the guy whose spleen ruptured!

The comment thread on my post from Nov. 14th got pretty interesting, by the way. And I think one commenter got unfairly criticized perhaps. The system is broken. Without a doubt, the system is broken. I think asking whether doctors should be treating people in emergency situations who can't pay is the wrong question for a civilized society to have to ask. I think, on the surface, a lot of countries seem to have figured this problem out better than we have. I think the insurance system is a mess. I don't have a solution, but I would be surprised if the current system was really the best one, in terms of cost, equity, and overall care. It would be one thing if we were lapping the field as far as life expectancy. And I know there are issues of demographics, and it's not fair to compare the U.S. to countries with a more homogenous population, but still, I have a hard time believing we've really figured it out.

I am thankful for...

--The turkey in the call room, or at least the idea of it, because in reality it sort of sucks.

--The fact that I'm not the only one stuck here working tonight.

--Respiratory masks, so I don't get pneumonia.

--Sleep, or the promise of it, eventually, someday.

--Not being an alcoholic or drug addict.

--The patients who say thank you, or seem like they're thinking it even if they don't actually say the words.

--Only having to carry three pagers instead of four, because it's a holiday.

--The excellent blind date I went on last week.

--My own health, and the health of family and friends.

--The confidence that I will almost definitely be able to pay off my student loans eventually, even if it's hard to think so many decades into the future.

--Blog readers, even if they're calling each other horrible people in the comments (and I'm intending to write some thoughts on that comment thread from Nov. 14th, but not today).

--Wounds that heal.

--The Bridesmaids DVD that someone left in the DVD player in the call room.

--Less than two dozen overnight shifts left in my residency.

--Wireless internet, as a general concept, even if it doesn't work in most of the building.

"I called you, doctor. I called your office three times and you didn't call me back."

"I don't have an office. I don't know who you called."

"The main desk. They connected me, but the phone just kept ringing. That's no way to treat your patients."

"I don't know where they connected you. I'm a resident. I have a pager, but I don't have an office, I don't have a desk, and I don't have an assistant. I'm sorry. I can't be reached on the phone by patients. That's just how the system works."

"But I called three times!"

"It doesn't matter if you called a hundred times. I can't be reached that way. You need to ask the nurse to page me. I told you that yesterday."

"I expect to be able to speak to my doctor at my convenience."

"And that's just not possible in a hospital setting. I'm sorry."

"You're sorry? Well, I'm leaving."

"You're not in a condition to be released."

"I'm leaving anyway."

"Can I at least get you to sign some paperwork that you're leaving against medical advice?"

"Medical advice? Medical advice is exactly what I wanted, but you didn't answer your phone. Goodbye, and I hope I never see you again."

and all I can think is... YAY, ONE LESS PATIENT ON MY SERVICE!

I'm sorry that a week has passed without a new post. I took the second half of my vacation seriously. Vacation ended yesterday and now I'm back in this mess, with the worst rotation of the year, so posts will be fast and furious. I'm the senior admitting resident for the entire medical department-- or at least I'm one of them, in a rotation with 3 others. So anything crazy that happens, I will be part of it.

I'm nervous-- I'm in charge of who goes to what department, of doing medical consults on patients from other services, I'm the one making decisions-- but, hey, if I screw up, the worst that can happen is that patients die.

So it's no big deal.

Posts 6x/week for the next month or I won't be mad if you stop reading the blog. If I renege on this promise, I will sacrifice a patient to compensate for my lack of blogging discipline.

I have an attending friend who wants to write a guest post sometime. So look out for that too.

Helped someone on the street yesterday. Can't escape the job even on vacation. Saw someone on the ground, struggling to get up, first instinct to walk past without stopping but saw that he was really struggling. Went over to him, someone else stopped too, we tried to help him up, asked what had happened. He said he was weak, couldn't get up. He was outside a medical office, so I asked if he had just come from the doctor. He said he hadn't. Someone went into the medical office and called for help. The guy said no, no, he didn't want help from the medical office.

"Why not?"

"I don't have insurance."

"But you can't even stand up by yourself."

"But I don't have insurance."

"You need help."

"But I don't have insurance. Just leave me here."

We got him to a bench, asked where he lived. He said he only lived a few blocks away, and said he just needed to catch his breath and call his wife.

"Are you sure you don't want us to call an ambulance, or get a doctor?"

"No, no doctors. I don't have insurance."

"You sure you're going to be okay?"

"I'll be fine. I don't have insurance."

Clearly, there is something wrong with our health care system.
(I don't have any answers.)

My two weeks of vacation started on Monday. Actually thinking about taking some moonlighting shifts, so I can make some extra payments on my student loans. First year, it felt like I had to go somewhere, had to take advantage of the time off. Second year, kind of felt that way too. Third year, the light at the end of the tunnel is visible. Sort of. I'm using one of my weeks to go somewhere, but this week is more of a decompress, catch up on the DVR kind of week.

Any book recommendations?

I have a new clinic patient who has high cholesterol, is overweight, high blood pressure, diabetes. I asked him what his job is. He runs an ice cream cart. This is not my first patient who deals with ice cream for a living. I didn't realize there are so many people in the ice cream business, and how it (predictably) affects their health.

"And do you eat the ice cream?"

"No, not really."

"You sure? You can tell me if you do."

"No, no, I know it's not healthy for me. I try not to eat it."

"What do you eat, most days?"

"Oh, not the ice cream. It's not healthy."

"I know. You said that. So what do you eat instead?"

"I get food."

"Yes, sure. What kind of food?"

"Me and the other food carts, we trade."

"Okay..."

"So usually a hot dog, pretzel, some, uh, funnel cake."

"Those are also not so healthy, unfortunately."

"I like the corn dog on a stick."

"Yes, not healthy."

"But better than the ice cream."

"I'm not really sure about that."

"I sometimes eat the cotton candy. Is that healthy?"

"No."

"The, uh, hot dog without bun?"

"Not so much."

"What cart should I eat from?"

"Maybe you could bring lunch?"

"I thought of that. But I have nowhere to keep lunch cold."

"What about in the ice cream freezer?"

"Oh. Oh, wow. I never thought of that."

"I'm all prepped for my colonoscopy, Doc."

"Yeah?"

"Yep, I drank all of that stuff. I was on the toilet all night!"

"That's great."

"I'm all cleaned out. It was pretty terrible, but I know how much you wanted me to get the colonoscopy."

"Yep, it's important."

"So where do I go for the test?"

"What?"

"Where do I go?"

"You go to the endoscopy suite-- what time is your appointment?"

"I don't remember. Can you check in the computer?"

"Sure, but you're sure it's today? I don't know if they're usually able to schedule the tests on the same day as you have a regular appointment."

"I sure hope it's today. Hey, Doc, can I use the bathroom while you check the computer? There must be some stuff still left inside me."

[I go to the computer and check. I come back.]

"I'm so sorry to have to tell you this. Your colonoscopy appointment is in January."

"But I don't have to drink that stuff again, right?"

"Uh, not unless you don't eat anything until January."

"You're saying I shouldn't eat until January?"

"No. I was kidding. You have to drink the stuff again."

"Oh, man."

"I wish we could squeeze you in today, but I have no control over the scheduling. I'm really sorry you got the appointment time confused."

"You're sorry? I'm the one who went to the bathroom all over my bedroom floor."

"I'm really sorry."

"See you in January."

Was doing a shift in the ICU and was assigned to write a note on a patient being transferred back to the regular floors. She'd been in the ICU for two days.

I look at the previous note. "Patient is in ICU. Doesn't appear to be in too much discomfort. Stable."

Well. That's not very much information.

I go over to talk to the patient. Doesn't speak English. I ask for the translator phone. Oh, it's in the closet. I go to the closet. There is a phone there. It has no cord.

"Has anyone actually spoken to this patient in the past two days?"

"I'm not sure, no. I think we just went off the transfer note."

"So no one has any idea what the patient is actually feeling, her mental status, nothing?"

"Not sure we do. Nope. You should just write the note and let them deal with her on the floor."

"I don't know what to write if I can't talk to the patient."

"Just copy the last note-- and hurry up, we need the bed."

"My stomach hasn't been feeling well since this afternoon."

"Did you eat anything funny?"

"Well, now that you mention it, I had some chicken that didn't look exactly right."

"What didn't look right about it?"

"It was sort of pink in the middle."

"Okay. Your symptoms are starting to make a little bit of sense."

"Really? You think it was the chicken?"

"Could be."

"I also had a pretzel wrapped in a hot dog."

"What?"

"Oh, sorry. I mean a hot dog wrapped in a pretzel. It was pink too. Is that okay?"

"Hot dogs are pink, yeah."

"I thought maybe because you said the chicken shouldn't be--"

"No, chicken shouldn't be pink. But hot dogs are pink."

"I also had a funnel cake."

"Were you at an amusement park, or a state fair?"

"No, I was at home."

"You make funnel cake at home?"

"Sure."

"Did you eat anything else?"

"Just a couple of candy apples."

"I'm going to set you up with the nutritionist after this food poisoning subsides, if that's okay."

"Oh, I already have a boyfriend."

"No, not for a date. For an appointment."

"I know what to eat."

"I'm not sure you do."

"One of my friends said you can give me cookies if I ask."

"We're going to skip the cookies until you stop vomiting, if that's okay."

"I guess."

"Thanks."