Have you ever been tested for HIV?

"Have you ever been tested for HIV?"

"Oh, sure, I had that once."

"An HIV test?"

"No, HIV. I got it from some bad seafood or something. A lot of vomiting. Went away after a few days."

"I don't think you mean HIV. I'm talking about HIV, the virus that causes AIDS."

"Yeah, I know. I had that too."

"What, AIDS?"

"Yeah. It was terrible, just like they say. Felt really itchy. Took about a week to go away."

"I think we'd like to test you, just in case."

"I'm telling you, I don't have it. I haven't slept with a hooker in, like, at least a month."

A sandwich

They catered in lunch for a staff holiday party this afternoon. Sandwiches, soda, some cookies. I'm rounding on a couple of patients an hour later, and I get to the room with my two cirrhotic diabetics-- low salt diets, etc--

And they each have a sandwich in their hands and a can of Coke on their bedside tables.

"Uh... where'd you get that food?"

"Seemed like there was a party."

"The party wasn't for the patients. You shouldn't be eating that."

"Come on, doc. What's it gonna do, kill us?"

"Uh... what if I said yes?"

"I'd eat it anyway."

* * *

An hour later, their nurse pages me.

"BP is 90/50, what should I do?"

"Um... I'll come by again. What did it drop from?"

"Drop from? No, it was 61/41 half an hour ago."

"Excuse me-- I think I misheard you. Did you say 61? Six-one?"

"Yes, doctor."

"Why didn't you call a rapid response?"

"There were no symptoms?"

"You mean he wasn't dead?"

"I don't know."

"So 60/40 you ignored, but 90/50 and you call me?"

"Yes, doctor."

"I'll be right there."

* * *

"So you think it was the sandwich that caused the blood pressure to drop?"

"No."

"So I can eat another sandwich? I put one in my closet."

"No."

"Come on, why not?"

Merry Christmas

"...so, I don't really know that I needed to come in, but I've been having a little bit of chest pain and my wife wanted me to get it checked out, and it's been going on most of the day, and I guess the past few minutes it's been getting worse, and AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA---"

It's not every day the patient literally has a heart attack while talking to you.

Yikes.

Merry Christmas.

I can't walk as fast as I used to

72-year-old man. His complaint?

"I can't walk as fast as I used to."

Are you having trouble breathing? No.
Any pain? No.
Any limitations on how far you can walk? No.
So it's just the speed that you're walking? Yes.

"And what would you like us to do?"

"I don't know. You're the doctor. Make me fast again."

"This is part of the aging process, unfortunately."

"There's no surgery?"

"Surgery on what?"

"I don't know, my legs?"

"No."

"Well, you're going to admit me, right?"

"No. Unless there's something you're not telling me, there's no reason you need to be in the hospital. There's nothing wrong with you."

"Tell that to my wife."

"Where is she?"

"She's right here."

"Sir, there's no one else here."

"Did I mention I've been seeing things that aren't really there?"

"No.........."

Too old for med school?

A friend of mine, almost ten years out of college, just told me she wants to go to med school and asked me what I think. And so much of me wants to tell her she's crazy, and tell her to look at this ridiculous life I've had for the past 7 years, either studying 80 hours a week or working 80 hours a week, for far less than no money-- as a resident, I'm pretty sure I haven't yet earned back my tuition money, even if I didn't have living expenses to take into account, and of course I have living expenses to take into account-- having far less than no fun doing it. I mean, whatever rewards I thought there were to a career in medicine-- and I don't mean just financial, at all-- do not make themselves clear as a student or in residency. No one should want to spend this much time in a hospital. Anyone who enjoys most of residency-- really, truly enjoys the moment-to-moment work of a resident, most of the time, not just the very occasional non-torturous moments-- has something seriously wrong with them.

And yet-- she's not crazy. Because-- unlike so much of what so many people I know do-- there is an endgame here. Not even 4 years of med school and 3 years of residency have convinced me (yet!) that being a doctor can't be a rewarding way to spend a career. There is human interaction. There is job security. There is financial stability. There are opportunities to think, and to read, and to be engaged in something important. Not in every setting, of course. And not right away, certainly. But there is an endgame, and I'm not yet convinced that the endgame has to be terrible. And I'm not yet convinced the endgame is incompatible with having a life you can enjoy and feel fulfilled by. And, as I look around at people I know and what they're doing, I'm not sure that medicine isn't unique that way. Because I don't know what else has stability, intellectual reward, and the chance to have some control over your time and your life. Tenured professor, probably. But getting a PhD and then tenure somewhere you want to live seems like as much of a slog as residency.

My friend, if I'm doing the math right, will be 34 when she can apply, after taking the appropriate post-bac classes. 35 when she starts med school, 39 when she finishes, likely 42 or 43 or 44 when she finishes residency, depending on what residency she chooses. Older if there's a fellowship too. I don't know what the job market looks like for 45-year-old brand-new doctors, and if that job market is different from the market for 35-year-old brand new doctors. Realistically, the debt is going to be around for a while after that. Realistically, my friend can't be doing it for the money, because the money isn't going to be visible until she's 50. Realistically, while being a doctor is hopefully compatible with having a life, I know that being a resident isn't.

I couldn't do this again. Having done it once, I couldn't do it again, at all. If someone wiped the slate clean, somehow my 4 years of medical school and 3 years of residency vanished and I had to experience it all again or I couldn't be a doctor, I could not do it again. But if I'd never done it, if I put myself in my friend's shoes, then maybe. I see the allure. I don't want to see the allure. I want to shake her and tell her she's crazy and it is not a smart plan to go to medical school when you're 35.

But I didn't shake her. Partly because the conversation was over the phone. But even if it were in person. I understand the impulse. I understand the allure. If I didn't, I guess I wouldn't still be a resident. There are people who've dropped out of the program. I don't know what they went through medical school for, and how they're able to justify the years and the work and the expense, but, I don't know. And then I look at most of the attendings, and they all seem kind of miserable, so I don't even know how I can still delude myself into thinking there's a light at the end of the tunnel, but I guess all the hope hasn't been wrung out of me yet.

Four patients today have asked me what I'm doing for the holidays. Four patients feel bad that I'm working. They shouldn't. They have it worse, because-- and I'm not sure they realize this yet-- they'll still be here too. And come Friday, I really don't think anyone's getting discharged over the short-staffed holiday weekend-- or, really, most of the week-- so, if you're here tomorrow, you may very well be here until 2012. Hope your beginning-of-the-year deductible isn't too high...

Me: "This patient's asthma attack is like nothing I've ever seen before. She's breathing really strangely."

Not me: "That's because she's faking it."

"But why would she want to fake an asthma attack? We're going to end up intubating her. Who wants to be intubated?"

"She's a psych patient. Why should what she's doing make sense?"

"Because even a psych patient shouldn't want to be intubated."

"She wants the attention."

"And you're 100% sure she's faking it?"

"99%. But you should still treat her like she's faking it."

"And what if she's not?"

"Boy who cried wolf. Serves her right."

"Really?"

"Yes. I have other patients. Page me if she dies."

I'm not really sure how the American Board of Internal Medicine can be a non-profit organization when they charge so much for their tests. My internal medicine boards registration just cost me almost as much as one of my paychecks. This is what I end up doing on a "slow night" as medical consult-- almost remarkably slow, practically no admissions, no consults, but instead of trying to take a nap (which, realistically, I guess I know won't happen because the pagers are still going off every twenty minutes), I end up sitting front of the computer spending hours falling down a rabbit hole of reading about study guides and review materials. MKSAP vs. MedStudy, how much do they update each version or can I get by with an older edition, and if so, how old, and is anyone selling this stuff on Craigslist, do I really need to spend hundreds of dollars on study materials after spending hundreds and hundreds and hundreds of dollars just to sign up for the test...

And then I come across a 5-year-old thread on KevinMD filled with comments about doctors who fail recertification and get kicked out of their practice. As if 4 years of medical school and 3 years of residency isn't enough.

I actually don't mind taking tests. This isn't a post complaining about the existence of the tests. They shouldn't make us pay for the tests. And the tests should actually measure something useful. I have no idea if the boards up to this point have measured anything useful. Step 1, Step 2, Step 3, you study, you take the test, you have no idea when you finish the test if you passed or not. I think there's something wrong with the test if you can't tell whether you've passed or not after you take it. Step 2 CS-- the clinical skills test, with fake patients-- almost made sense. At least it was trying to test us on stuff we actually need to have in our heads, we actually do need to remember what questions to ask patients and how to do a physical exam. We actually do need to develop hypotheses and some working ideas of what's going on with our patients. But what dose you give of what drug in what context, we look that stuff up anyway. I shouldn't need to memorize the eight steps of whatever, because when I'm faced with needing to know it, I pull out the card and I use it. I check drug interactions on an iPhone app. And, yes, over time you memorize some of them, and it's a good thing to know as much as possible without having to check, but you check anyway, to make sure, and there are too many possible interactions to memorize every single one.

In principle, I think it's good that we have to take tests to get certified and then re-certified every x number of years, because doctors who aren't up to speed on the latest knowledge are almost certainly hurting their patients at least to some extent. But they make it such a burden, not just the cost but the time you end up spending reviewing things for a test instead of reviewing things for the patients you're actually treating. And who knows if there's any correlation between test score and doctor quality. I'm guessing there is a small and barely-significant correlation. Which is also the correct answer to any epidemiology question on the boards. There is a small and barely-significant correlation. Answer choice C, usually. So, MedStudy 12? 13? 14? Is there a difference? MKSAP? Mayo?

Through the translator phone:

"Doctor, I don't know why I am here."

"You had an appointment. You made this appointment because...?"

"My kidneys."

"You have a problem with your kidneys?"

"Yes. I had a pain in my chest area."

"Okay, that's not your kidneys."

"I went to Mr. Wong. He gave me a kidney medicine."

"Is Mr. Wong a doctor? What medicine did he give you? How did he determine it was a problem with your kidneys?"

"I don't know. All of those questions, I don't know."

"Did Mr. Wong have a business card?"

"No. He is not a business. He is just Mr. Wong."

"And you don't know what he gave you?"

"No."

"Was it a pill?"

"I don't remember."

"Was it something you swallowed, something you drank, something you rubbed on your body?"

"I don't remember."

"Where was Mr. Wong's office?"

"Not an office. On the street."

"Great. Do you remember where?"

"Not really."

"And he told you the pain in your chest was your kidneys?"

"Yes."

"Did he do any kind of test to make that guess?"

"He looked at my front area."

"Your front area?"

"He looked at my body."

"On the street?"

"Yes."

"And the pain, you still have it?"

"Usually no."

"But sometimes?"

"Sometimes."

"Okay, I'm going to do a physical exam and then run a few tests to see if we can figure out what's going on. But I don't see any reason to believe it's your kidneys, and I think you should avoid listening to people on the street and taking whatever kind of medication they might give you or recommend you take, okay?"

"He said it was my kidneys."

"I'm going to run some tests and we'll see what's going on."

[Postscript: Kidney cancer. Amazing. Who is this Mr. Wong and is he covered by my insurance?]

3:46 AM

Me: "Hey, I was just here about that consult ten minutes ago. I left the patient's chart at the nurse's station. Have you seen it?"

Nurse: "No, sorry. Which patient?"

Me: "I don't remember the name. But I was just here, 10 minutes ago. It was, uh, chest pain. Older man, alcoholic."

Nurse: "That's, like, everyone. I wasn't here, I don't know. Let me ask the other nurse."

Me: "Okay, thanks."

Other Nurse: "No, doc, I don't know, you haven't been here for hours."

Me: "No, I was here 10 minutes ago."

Other Nurse: "I was here 10 minutes ago. I didn't see you."

Me: "I went right to the room. Then I entered an order in the computer, but left the folder."

Other Nurse: "We don't have the folder. You don't remember the patient's name?"

Me: "Robert something, I think."

Other Nurse: "Roger Jones?"

Me: "Sure. Maybe."

Other Nurse: "He died."

Me: "What?"

Other Nurse: "Three hours ago."

Me: "I know the guy who died three hours ago. I ran that code. This is a different guy. This guy wasn't dead, ten minutes ago."

Other Nurse: "Then I don't know who you mean. What room was it?"

Me: "I don't know. 613, maybe? 615? 617?"

Other Nurse: "You mean 913, 915, 917?"

Me: "No, I mean 6--"

Other Nurse: "You're on 9."

Me: "What??"

Other Nurse: "You're on 9, not 6."

Me: "Oh, stupid, ugh. It's 4 in the morning and I'm half asleep. I'm sorry about that. I'm on the wrong floor."

Other Nurse: "Don't worry about it."

Me: "They shouldn't make all the floors look the same. It's confusing."

Other Nurse: "Get some sleep, doc."

Met a very pregnant 14-year-old today. It's weird, we see all sorts of people in the hospital who, I don't know, I started to write "who have made poor choices in their lives," but that's not entirely fair, and I know some situations are out of people's control, at least in part, or thrust upon them through no fault of their own-- but there are drug addicts, criminals in and out of prison, alcoholics, people mistreating their bodies in all sorts of ways, morbidly obese patients who won't change their diets, people who won't take necessary medication, people who can't seem to follow up and get the tests they need, etc. It's hard to keep from judging, but, in most cases, I don't think most judgments are necessarily obvious to the patients. I don't see people outwardly rude to their patients, for the most part. The goal is to help. But a pregnant 14-year-old, somehow-- and I wouldn't have guessed this-- seems to be far harder for a lot of people to deal professionally with than, say, a drug dealer, or an unreformable alcoholic. The tone, the looks, the attitude. Maybe it's because in medicine we don't generally see OB patients, this was an unusual circumstance, and so we're not sensitized to it. But I don't think that's it. I don't know quite how to put my finger on it. Yes, birth control is pretty accessible in today's society, but is getting pregnant at 14 objectively worse than a lot of other unfortunate situations seen in the hospital? I don't know. Maybe it would be different if I were female. Maybe it would feel like something more terrible, not that it makes any sense to be ranking terriblenesses. And, frankly, for me it tends to be the people-- especially the parents-- who won't quit smoking who I sympathize with the least. If I were a sociologist, this feels like an interesting research project-- what do people feel deserves the most stigma, off a list of unfortunate circumstances that are on at least some level within someone's control to prevent. By the end of the consult, I felt really bad for the patient and the attitudes she was surely dealing with to a much greater extent than just the 20 minutes I was with her. Yes, maybe she made some bad choices, and maybe it's going to seriously impact her chances of what the people who work in a hospital would call a successful life. But it is better than being a crack addict, no?

Ever see someone bleeding from the tip of his penis? Neither had I.

I don't know if it was better or worse that he was conscious and fully aware. But this was no trickle. It was pouring out. Soaking through his underwear, through his gown. And then spraying across the room.

"Why's this happening, doc?"

"I don't know."

"You don't know?"

"I don't know. Your blood is very thin, from your blood thinner. Too thin."

"And so this is what happens when it's too thin?"

"I don't know. I've never seen it before."

"And how long have you been a doctor?"

"Not that long."

"So I'll be okay?"

"We're going to try our best."

"That's not encouraging."

"Well, hopefully they'll be more encouraging once we get you to the ICU."

"I'm going to the ICU?"

"Indeed you are."

"In the morning, you mean?"

"Nope. Right now."

"So it's an emergency?"

"It is."

"And it's happening because..."

"Still don't know."

"So should I be panicking?"

"Panicking isn't going to help."

"But you'd be panicking?"

"To be perfectly honest, yes, I would."

About as close to losing it as I've been since starting residency. This rotation is awful. I'm the enemy. No one wants to hear they have a new patient on their team, especially not at 2AM, and I'm spending most of the night listening to arguments from the other residents about why this patient is too critical / not critical enough to be on their service. "He should be in the ICU." "She should be discharged." Fine, I get it, I was in their shoes three months ago, and I'll be back in their shoes next month, and I'll be fighting my hardest not to get slammed with more patients too. But we're all low on sleep, we're all here to serve the patient, why do you have to make me feel like I'm personally doing something to you? It's just the job, and we all rotate through it. I hate feeling like the bad guy. I'm just doing the job.

I had to call someone in at 3AM off the emergency backup team-- I had no choice, we couldn't handle the number of patients coming in, and that's what the emergency backup team is there for. I got called in in the middle of the night when I did emergency backup, and I was absolutely annoyed to be paged in the middle of the night-- and then realize when I got there that in the 30 minutes since they called, they took care of their backlog and didn't really need me after all. So I tried really hard not to call someone in. I waited until we were absolutely maxed out, no question. I probably waited too long. I probably should have called at midnight, but I hoped things would slow down. And then we had a rapid response and two codes and it was 3AM and I had 4 patients on beds in the hall waiting for someone to do their admissions... so I had no choice.

I call, I get an argument (of course) from the resident on emergency-- a friend, or at least a friend until I woke her up-- and then she comes through the doors right as her assigned patient's heart stops. She joins us mid-code, I'm leading a team of 9 people trying to do CPR and push drugs and get this patient's heart beating again. The family is in the hall, pissed that their mother/daughter/sister has been laying on a cot in the hallway for hours, untreated-- she was stable when I got her, she was stable throughout-- and we couldn't get her back. 45 minutes we're trying, finally I have to call it. I don't think there was anything we could have done-- the attending told me there was nothing we could have done, this was going to happen whether she was in the hall or in a room, whether someone had taken her full history or not, whether I'd called in backup at midnight or at 3AM. These things just happen. People come to the hospital and die. Unfortunately.

And the first thing my friend says to me as I'm calling to get a death certificate to fill out--

"You woke me up for a f[***]ing dead woman? Go to hell." And she storms out of the call room.

As if I planned this. As if I thought, hey, I know, I'll play a great trick on the poor resident on backup by calling her in just before the patient I need her to write a note on suddenly dies. That'll be a great plan! Really mess her night up. Awesome.

I'm supposed to let the backup person go at whatever point the backlog is handled and we can do without her. Of course the backlog wasn't handled-- we'd just spent 45 minutes trying to bring someone back to life, and the other patients didn't disappear during it. So she still had 2 or 3 admissions I needed her to do. But she didn't. She sulked through one admission in 5 hours before I freed her at a quarter to 9. Now this case with the woman in the hall is our big M&M (morbidity and mortality) case for the week. So I have to come up with a presentation to explain what happened and what we could have done better. With slides. Can't wait.

And then today a nurse blamed me for using all the paper towels. Excuse me. To clean up a patient's blood. I'm sorry I grabbed a ton of towels and threw them down. I figured it was better than having people slip and fall. Guess not.

I am not the enemy. I don't think I'm the enemy. Ugh.

Night of the living dead. Or, more accurately, night of the dead. Sorry this rotation is such a downer. Rapid response after rapid response. It's not until you run five codes in an eighteen-hour span that you realize, hey, these don't work all that often. If you're dead, unfortunately, you're probably going to stay that way. Realize that sounds glib. Don't mean it to. These were fortunately all end-stage patients, no brain activity, not people who anyone was expecting to be leaving the hospital. Doesn't make it better, but it does make it a little less tragic. 32 people in the room at one point, with me leading the code. I don't know what to tell 32 people to do. I barely know what to do myself. More than anything in residency, this was actually how it looks on TV. This was an episode of ER. A terrible episode of ER where no one lives and there really aren't any good guest star roles to cast at all. I'm screaming out orders, just trying to be heard over the commotion, people are grabbing drugs, people are doing chest compressions, it is chaos, it is intense, it is overwhelming. And it was dinner time-- three in a row, right at 6:00, we were running codes solid from 6 until after 9, so everyone was cranky, tired, had to go to the bathroom, hungry, everything. Unsustainable. If this rotation were longer than a month, unsustainable. I don't know how someone can be an overnight attending, a hospitalist, these jobs must be unfillable, I just don't know who could ever choose to do this. I want 15-minute blocks to my day, I don't want to carry five pagers, I don't want rapid responses. I want medication refill conversations. I know, I say that now, and then once I'm doing it, it'll be dull and horrible. But at least I won't be pronouncing people dead. Couldn't even read the clock by the end, just tired. Staring at it. Like, 7... 8... I don't even know. Why don't we have digital clocks in the hospital? We have all of this complicated equipment, and we can't have digital clocks?