"Yes, of course I know him!"

"Did you know there's a cockroach in the bathroom?" asks the intern on with me tonight.

"Of course I know him!  We're pals."

"Pals?"

"Yeah, he's been here since I started, at least.  He won't bother you, don't worry."

"He's pretty scary looking."

"Not as scary looking as some of the patients."

"That's true.  Still, I don't like him."

"Come on, he's harmless.  And the bathroom on 12 is cleaner anyway, so I just use that one and let him have this one."

"That kinda sucks, having to go downstairs to use the bathroom."

"It's nothing-- I also sleep in a chair because I don't want to kick the spiders out of the cot."

"There are spiders in the cot?"

"Lots of 'em.  Also a patient told me he saw a mouse."

"A mouse?"

"He also told me it's 1874, so I'm not sure whether to trust him or not."

"At least if he thinks it's 1874, it's probably not so awful for there to be a mouse crawling around.  I assume they didn't have exterminators back then."

"We don't have exterminators now."

"Not here, but I mean in normal places."

"I should ask him what life is like in 1874."

"You should ask him quickly.  I was coming to tell you his BP is 80s over 50s."

"You should have probably led with that."

"I got distracted by the cockroach."

"Yeah, he likes to distract people.  It's all a game to him."

"Are you getting enough sleep?"

"Decidedly not."

"You want me to lead any codes we have to run tonight?"

"I can't think of anything that would make me happier."

"You're really looking forward to being a fellow, aren't you?"

"I am."

"Any advice for making it through two more years of this?"

"Blame things on your interns."

"Gotcha."

"No, I'm serious.  I screw anything up tonight, it's your fault."

"Um, 80s over 50s... what should we do?"

"I already forgot you just said that.  Wow, I really should try and get some sleep."

"No, seriously, I don't know what to do for the guy."

"Call the ICU attending and have him take a look, let's try and get him transferred.  He shouldn't be on the regular floors.  How about we try and get everyone transferred and then we go home?  I think that should be our plan."

"So, call the ICU attending...?"

"Yeah.  Or ask our cockroach friend.  He clearly has the secret to staying alive in this hospital.  He's outlasted just about all of my patients."

You're 90??

"I'm sorry, my chart says you're 90 years old?"

"Yep."

"You don't look 90."

"Thank you."

"And you said you still work...?"

"Yep, I run my own business.  Cook for my wife, walk the dog, exercise five times a week."

"And your wife is how old?"

"34.  And in terrible health."

"Sir, compared to you, everyone's in terrible health."

On the plus side, you let me sleep...

I read the comments even if I don't always respond.  I'm not going to answer who made the brownie last night, but as far as post-residency plans-- it's a fellowship, starting July 1, although I'm going to be vague for now about what field specifically.  In a different hospital than the current one-- probably better in some ways, worse in others, hopefully home to fewer members of the insect family.

"So how's [Smith] doing," I ask my intern.

"Smith?  There's no Smith."

"Sure, Smith.  I asked you to check on him a few times through the night, no?"

"Yeah, but I didn't see his name on the patient list."

"He was a late admission..."

"Oh!  That explains it!"

"So you didn't check on him?"

"No, but I checked on [Jones].  Figured maybe you said Smith but meant Jones."

"No, Jones is stable."

"Yeah, all night, Jones was totally stable."

"Yeah, I know-- I wasn't worried about Jones, I was worried about Smith."

"Sorry."

"If you didn't know who Smith was, you should have asked me."

"I didn't want to bother you."

"You're allowed to bother me."

"Well, at least Jones got great care overnight."

"Uh, yeah, sure.  Thanks."

"You're welcome."

Ugh, I Touched My Snack

I've been bringing food to eat-- for dinner, and then snacks for later-- during my night shifts.  Nothing too exciting, but if I know I have a little treat to look forward to, I'm less likely to stab a patient in the chest with a piece of medical equipment.

I spend a little time before I leave for work packing everything in its own ziploc bag, wrapped in a napkin.  Best are things I can eat without touching at all -- granola bars, bananas, little snack bags I can pour directly into my mouth.  Second best are things I can keep wrapped in the napkin and carefully eat that way -- cookies, a sandwich.   There is no third best.  I will not eat anything I have touched.  I know what lives here.  Aside from my cockroach friend (still here! yay!), of course.  I try not to touch anything, but I can't be 100% vigilant. Door handles, faucets, paper towel dispensers, patient charts.  I am contaminated the moment I walk in.  So if I touch anything, it's over.  It does not go in my mouth.  I've had a couple of unpleasant viruses over the three years, and have learned my lesson.

I was so excited about tonight's treat.  A homemade brownie.  I didn't make it, but someone did!  And as I carefully opened the ziploc bag and started to push the edge out to take a bite... somehow I pushed too far and it tipped out, fell into my hand... and, uh, nope.  Into the trash.  I'm probably crazy.  And what a waste of a brownie.  But I don't want norovirus.

New Friend

There's a huge cockroach in the bathroom, working the night shift with me.  Every night, he's there.  Like me, all alone.  Like me, looking pretty sleepy.  The day resident says he hasn't noticed him.  I think he only comes out when I'm there.  Maybe he likes me.  I've started checking in to see how he's doing.  I'll open the door, see if he's still there.  He is.  I don't know what he's eating.  I kind of want to bring him food.  Or maybe just IV fluids, if he's here for a procedure or something.  I should probably check his chart before I give him anything to eat.  I don't know if he has any restrictions or allergies.  He doesn't seem to have any family visiting, at least none that I've seen.  He seems lonely.  I wonder what he's thinking about.  I wonder if he realizes there are places that are a lot nicer to live.  Or at least with better food, and more of it.  Maybe he has thousands of family members, under the floorboards somewhere.  Maybe I just haven't seen them.  Maybe they've sent him away for some reason.  Maybe he's the lookout.  Maybe he got lost.  Maybe he needs my help to reunite him with the rest of his tribe.  I just checked on him again.  He's still there.  I gave him a nod.  Not sure how friendly he is.  I've been going down the stairs to use a different bathroom, because I don't want to disturb him.  It wouldn't be polite for me to intrude.  For all I know, he likes the peace and quiet.

Yep, busy night over here.

...So, you'll give him pain medication?

The night shift is lonely and overwhelming.  There's pretty much no one else here, and I don't know the patients.  I get paged about people I've never met, and have to make decisions about treatment based on hastily-written notes, while half-asleep and barely functioning, without anyone to check my decisions against except an intern, who's just as half-asleep as I am, and doesn't know the patients any better.

I get a page from a nurse that wakes me up at 3AM.  I call back--

"Doc, I have a patient here.  I'm not sure who he is, but he's in a lot of pain."

"Um... okay....  What kind of pain?"

"Seems like it's his shoulder.  There's a bandage on his shoulder.  So I'm thinking it's from that."

"Did he have surgery on his shoulder?  Is he even a medical patient, or is he a surgical patient."

"I don't know.  I'm covering for another nurse.  I don't even know who he is."

"Can you check the computer?"

"I'm not near a computer."

"Can you ask the patient his name?"

"He's sort of out of it.  I was just hoping you'd put in an order for some pain medication."

"No... and I can't put in an order without knowing his name anyway.  And I'm not going to put in an order without knowing if he's even on my service, or examining him."

"I just thought you could put the order in under whatever name of another patient and I'd know it was for this guy and just give it to him."

"No..."

"Come on, he's really screaming in pain, his roommate is complaining, and it's hard for me to even concentrate on doing anything else if I have to listen to him.  Maybe just one pill?"

"No..."

"I'll find out his name."

"Why don't you find out his name and what his medical problem is, and then we can talk about medication.  But I'm not ordering meds for someone I haven't examined."

"Come on, I just want to get some sleep."

Hot Dog

I get paged down to the ER for my new admission.  An obese, middle-aged woman, complaining of chest pain, who they've decided to cath.  I get down there... and they can't find her.  "Oh, maybe she went to the bathroom."  Okay....  Let me know when you find her.  I head back upstairs.  Five minutes later they page me. "And we're thinking there might be a problem, she doesn't look good."

I run back down and meet her, and she's sweating profusely, just dripping.  So we're obviously alarmed, although she isn't.  We ask her what happened, is she in pain, was she in the bathroom...?

"You weren't feeding me anything."

"Yeah-- so?"

"So I went outside and got myself a couple of hot dogs from the street vendor."

"You did what?"

"I was hungry.  I got some hot dogs.  Shoved them down.  Raced back here.  That's why I'm out of breath."

"You're getting cath'ed tomorrow.  You can't eat hot dogs!"

"I was hungry!"

"And you can't leave the hospital."

"You're supposed to feed me."

"We don't feed people in the waiting room."

"Well, you should."

I'm feeling really good about the prognosis here.

No admit

Working nights, I'm given patients as they're admitted from the ER.  So it's in my best interest for patients to not be admitted.  Patient gets sent home and I get to get some sleep, at least until the pager starts beeping again. The ER resident gets me on the phone:

"I've got one for you."

"You sure?"

"What do you mean?"

"You sure you need to admit him?"

"Yeah, we want to do IV antibiotics."

"Can't do oral, treat as an outpatient?"

"You don't even know what he has."

"I'm just making sure you really want to admit him."

"Yeah, we're going to admit."

"You know, there's a lot of sick people up here.  He could catch something else, might get worse.  You sure you want to take that risk?  Wouldn't it be easier to send him home, maybe have him come back in the morning if he hasn't gotten any better.  Not too early in the morning.  After 7.  Definitely after 7."

"No, we're going to admit him."

"And if I told you we were full?"

"You're not full."

"But, hypothetically, what if we were?"

"Then we'd probably park him here overnight and move him in the morning."

"Ooh, I like that plan."

"But you're not full."

"We might be full."

"You're not full.  Just come down here and take the patient."

"...Fine..."

"I've been charting my diarrhea"

If a patient ever starts a conversation with, "I've been charting my diarrhea," I've learned that it's very unlikely that the rest of the conversation will be pleasant.

"I think it's caused by drinking water.  Every time I drink water, I get diarrhea.  So I should stop drinking water, right?"

"No."

"But if I don't drink water, then the water can't come out the other end."

"No."

"Why doesn't that make sense?  It seems like it makes sense."

"You need water to replace what you're losing."

"But the water is causing the whole problem."

"Unlikely."

"I heard about water causing terrible illnesses back in England in the 1600s."

"I don't think you have cholera."

"Can you check?"

"Yes.  Look at me.  Great.  You don't have cholera."

"You don't know that."

"Is the water you're drinking water from your toilet?"

"No, it's bottled."

"Bottled from a toilet?"

"No."

"Great.  It's not the water's fault.  Did you eat anything strange?"

"No.  Just the usual."

"And what's the usual?"

"Every sample at Costco, and some leftovers I had on the counter overnight."

"Could be food poisoning."

"Nope, it's the water.  I'm never going to drink anything again."

"That's not a good solution."

"Well, if I don't drink water, eventually the diarrhea has to stop."

"That may be true, yes."

"See?  I was right."

"Nope.  Not right."

Back!

I am back.  And I apologize for the absence.  Started on nights last night.  Being back at work is not so much fun, but this is the home stretch.  Posts every day for a while, for sure, to make up for the absence (so tell your friends!).  I would have a day off (from work, I mean, not the blog) on Wednesday, except I am being forced to make up a shift in advance because I have to miss the last day of work for my fellowship orientation.  Somehow, fellowship programs don't realize that residents don't actually get days off, and so scheduling orientation while the incoming fellows are still working as residents could potentially be a problem.  Fortunately, all it means is that I have to give up the only day off I have for thirteen consecutive days.

Vacation

I think I've been sleeping for about 96 hours now.  Hence the lack of new posts.  I have been on vacation since Saturday.  I return to two weeks of the night shift.  Am trying to bank some extra sleep hours, not to mention catch up on everything on the DVR.  Who won the Super Bowl, anyway?  I should find out by the end of the week if my TV-watching pace continues.  Apologies for the lack of new thoughts since Thursday.  I will come up with some, and return to the usual pace of things.  Suppose I'd be happy to take post ideas in the comments, if anyone has anything they'd want me to write about, in between naps and reruns.  Also, Hulu recommendations.

The Unologist

"So what brings you here?"

"I want to see this kind of doctor."

The patient hands me a sheet of paper.  It says, in large capital letters, U N O L O G I S T.

"You mean a urologist?"

"No.  A unologist."

"Okay.  What is the problem related to?"

"I feel a tingling sensation."

"Where do you feel this sensation?"

"In my penis."

"All the time?"

"No.  Once or twice a month."

"Okay.  For how long?"

"Fifteen years."

"Are you sexually active?"

"I don't know."

"Is there any particular thing you are doing when you feel the tingling sensation?"

"Yes.  It happens when I wear a certain pair of pants."

"Maybe you shouldn't wear those pants."

"I like those pants."

"Maybe those pants are causing the problem."

"They are very tight pants."

"Yes, perhaps that is the problem."

"I would rather hear that from a unologist."

"You don't need to see a urologist."

"No, I need to see a unologist."

"There is no such person."

"Can you give me a referral?"

[Long silence]

"Yes.  I can give you a referral."

"No, that's not a good enough reason."

I've been filling out a lot of death certificates lately.

Not my fault.

The computer system will only accept certain reasons for death.  I don't know who set it up this way, but it seems as if anything that could lead to a potential lawsuit, whether it's the real reason for death or not, needs risk management to sign off in order for the system to accept the entry.  And they never sign off on it.  Leading to maddening conversations over the phone.

"The patient died of a bleed, after he fell."

"Yeah, I'm not going to let you put that in."

"But that's what happened."

"Was there a secondary reason that doesn't sound so... incriminating?"

"We didn't do anything wrong.  We can't prevent every patient from ever falling."

"Yeah, I don't think that makes us sound good.  What else did he have?"

"He had heart disease."

"I like that one.  Put that."

"It isn't what killed him."

"But it would have."

"Yes."

"Soon?"

"Pretty soon, unfortunately."

"Perfect."

And while you may think this doesn't harm anyone...  (You shouldn't think that, but maybe you do.) ...it makes me wonder about all of the retrospective studies that look at patient outcomes in various circumstances.  Now this guy, who did have heart disease, but it didn't directly kill him, will be coded in the system as someone who died of heart disease, and anyone who runs a study... well, that's not quite accurate information going in.

"And this one, with the medication error.  Can we just call that pneumonia?"

"No."

"Are you sure he didn't have pneumonia?"

"Well, no, I'm not sure..."

"There you go."

Why They Weren't Discharged By 11AM

"I'm getting a lot of flak because our patients are being discharged too late.  They really want them out by eleven," said my attending.

"I know, but I'm trying to prioritize the patients who have things actively going on.  I want to make sure they're taken care of before I deal with the discharges."

"Well, they gave me a list of the patients who were discharged late in the day.  They want us to go through and justify each of these late discharges.  You think you can write up a couple of lines on each?"

[I sigh.  He hands me the list.  I look at it.]

"Um, there's a really good reason for pretty much everybody on this list."

"Yeah?"

"Yeah.  These are all patients who died.  After eleven."

"Oh."

"So I guess I'll just try and get our patients to die earlier in the day from now on."

"That would be good.  Thanks."

I think we found him.

Patient eloped yesterday.  Late-stage liver disease.  Didn't want to be here.

I get paged today by the nurse's station.  I walk over there and one of the nurses hands me her cell phone.

"Huh?  Who is this?"

"Just say hello."

It was another one of the nurses on our unit.  On her lunch break.

"I found that guy who eloped yesterday."

"You found him?  What do you mean you found him?"

"He's passed out, in the alley behind [the liquor store three blocks from the hospital].  I saw him, recognized him.  The owner was about to call the cops."

"So he's coming back."

"Yeah, he's coming back."

I hung up the phone.

Did not cross my mind until later to wonder why the nurse was hanging out in the alley behind the liquor store during her lunch break, but, hey, I'm sure she had a good reason.

So are we rooting for him to die?

There's a patient on my service who has been nearing the end for a couple of weeks now.  His family has been very involved, last week it seemed like things might have been getting slightly better, but in the past day or two they've taken a turn for the worse.

Last week, the patient's daughter mentioned to me that she had an important business trip coming up, and wanted to know if I thought she needed to make plans to reschedule.  I said it's hard to predict these things, but at that moment he seemed stable, so there was reason to think that things might not be happening immediately, and there was a decent chance the trip would be OK.

Of course, she left on Monday and almost immediately, things became much less stable.  She had said I should call if anything changes.

So I called.  And I said, again, it's hard to predict these things, but it's possible that he only has another day or so at this point, and if she wanted to make sure to see him before he dies, she may need to cut her trip short.

"You really think I have to?"

"I don't want to pretend I know more than I do.  It's possible he will rally again and make it through the week, but it's also quite possible he won't."

"You're not telling me enough to make this decision."

"If it were me, I'd come back as soon as I could."

"But he might not die."

"That's right."

"Okay, I'm coming back.  But my boss is going to throw a fit if my father's still alive on Friday."

"Sounds like a great boss."

"You think you could write me a note saying he died even if he doesn't?"

I'm seriously contemplating writing the note.

"You look like hell today."

"Morning, [Anonymous Doc]," said the attending.  "You look like hell today."

What is the right response?  I mean, I know some wrong responses:

"You don't look so hot yourself, old man."

or

"It's the fault of these terrible patients. I wish they all would just die already."

or maybe

"You'd look like hell too, if you actually took the time to round on these people and cared about whatever's wrong with them."

but instead, all I could manage to say was

"Does that mean I can leave early?"

"No."

"I didn't think so."