Finished!

Sorry for the lack of consistent blogging down the home stretch.  Was spending far too much of my free time hoarding medical supplies before they deactivate my ID.  Do you know what you can get for mini-bottles of hand sanitizer on the black market?  If anyone needs band-aids, e-mail me, I'll send you some.  It must have been amazing when they let pharmaceutical companies market to residents.  For a pen or two, I think I'd prescribe just about anything to anyone.

I imagine it takes a while to sink in.  Like an indentured servant getting his freedom.  What do you do when no one is making you work 28 hours in a row?  What are two-day weekends like?  What are one-day weekends like?  What is it like to be able to make someone else write notes on your patients?  What does it feel like to sleep every night in your own bed, instead of a stained, mildewed mattress on a rusty set of springs in a roach-infested call room, sharing a bathroom with a psych patient who is in the middle of his long-planned escape?  What does it mean to have underlings who listen to you?

Before we could leave, one final scavenger hunt as we were required to collect a dozen signatures from various administrators verifying that we'd returned our white coats, didn't have any overdue library books, given back our pagers, emptied our lockers, and not smuggled out any adorable elderly patients.  It was the first time I'd been in the library since orientation, with everything online.  I didn't even know we were allowed to check out books.  I had an end-of-year review where I was told one patient requested a different doctor because I seemed like I was in a rush.  I remember that patient.  He was three hours late to his appointment, he was tacked on to the end of my schedule, and, guess what-- I was in a rush!

24 hours of "vacation" until fellowship.  What should I do with all of this luxurious, responsibility-free time on my hands?  Maybe I'll nap.  Napping sounds good.  Showering, napping, taking a couple of alcohol wipes and rubbing down everything I've touched in the past three years.  Catching up on about three thousand unread e-mails-- I think I have a couple of Groupons to spend before they expire.

"So I guess I'll give you feedback... never."

"Hey, I know this is the last week of the rotation, but can I just give you feedback next week?"

"This is actually my last week."

"Oh, you're a third year?"

"Yeah."

"You don't seem like a third year."

"Is that my feedback?"

"No."

"You want to do feedback now, then?"

"No, I don't want to do feedback now.  What's even the point if you're not gonna be here?"

"I'm gonna be somewhere.  I'd still like the feedback."

"I'm not wasting my time if it's not going to matter to the hospital.  I'll call you with feedback when I have a chance."

"Do you need my number?"

"No."

"So you're not actually going to call me with feedback."

"Nope."

"Okay, that's fine.  Is there anything quick that I should work on?"

"That would be feedback.  Sorry."

What's that patient's name again? The one whose privacy I'm about to violate.

We're in a patient's room.  All of us-- attending, fellow, intern, nurse, social worker, about 8 of us, with the patient, his wife, his kids--

Attending: "Yeah, so, we have a whole treatment plan set up.  Your situation is actually very similar to the guy down the hall-- what's his name?"

[no response]

Attending: "[Intern], what's that guy's name?  The one with the same cancer-- 65, short, bald, what's his name?"

Intern: "Uh, I'm not sure...?"

Attending: "Oh, come on, you know.  He has the wife, with the neurological thing..."

Social Worker: "I'm not sure we should be talking about the other patients..."

Attending: "No, just tell me his name.  Now it's going to drive me nuts."

Nurse: "Wouldn't it be a violation of HIPAA?"

Attending: "Come on, HIPAA doesn't apply to things like this.  What's the patient's name?  With the chemotherapy that didn't work.  Who we're trying to give a few more months to.  He was a dentist, his son is a travel agent-- what is his name?"

Fellow: "I think maybe we should move on."

Attending: "Fine, well, anyway, my college roommate Bob Schlabotnick had what you have, and he's fine now-- under my care-- so I'm hopeful we'll get you there too.  He also has herpes, can you believe that?  Someone my age."

Fellow: "Okay, let's move along."

Attending: "Dave.  Dave Ramirez.  That's his name.  Originally from Detroit.  He's in room 2604, you can compare notes.  Feeling a lot of the same things you are, a lot of the same emotions."

Nurse: "I'm gonna go check on something else."

Attending: "See if you can find Ramirez's file on your way out.  I had it in my hand, but I don't know what I did with it.  Must have left it in another patient's room.  See if you can grab it.  Thanks."

From Resident to Attending

I don't quite understand how people go directly from resident to attending in the same hospital.

You've spent three years being tortured, on the bottom of the totem pole.  And now all of a sudden you're supposed to be able to turn around and be the boss?  And enjoy it?  You've spent three years asking questions and now you're supposed to be the one giving answers... which is hard enough as a transition generally, but in the same place, surrounded by the same residents, nurses, other attendings?  The people you've spent three years being afraid of are now your peers?  You call a consult and someone who you've taken orders from for the past three years comes down-- and now you're supposed to be able to stand your ground and act like you're his equivalent?  You're in charge of people who you may have worked with a day earlier as co-residents, as peers, as friends?  And now you're the one making them stay late and write notes?  You were the one trying to leave early... and now you're the one making them stay late.  And they're supposed to be able to respect you?  I don't quite see it.

I'm glad I'm not staying here and becoming an attending, but what I find interesting is that the people who are staying here are the ones who complain the most, who seem to hate it.  And, sure, you can hate life as a resident and still want to be here as an attending... but to come back every day to work in the place that tortured you... why?  Why do you want to do that, except perhaps because you want to pay it back and torture future residents so they suffer as much as you did?  I don't want to be the first residents that a new attending has, especially if the new attending hated being a resident, hates the hospital, and has an agenda to make sure I don't have it any better off than he did.  Maybe that's no one's conscious agenda, but subconsciously, under the surface, can it be avoided?

Two more weeks... two more weeks...

Two Lists

Another resident said something last night that got me thinking.

Something to the effect of, "I was just saying to this other resident, I wish I could be more like you [meaning me].  You know, not so crazed all the time, staying super-late, agonizing over every decision..."

He meant it as an insult.  He means everything as an insult.  I don't necessarily dispute the characterization, but I definitely dispute the intent behind it.

I think there's an unfortunate tendency to assume that difficult people are better residents.  That someone might be a jerk, but they're a jerk on behalf of their patients, they're a jerk because they don't want to risk mistakes, they can't deal with anything less that perfection, they have high standards that they're simply demanding that everyone else live up to.

I don't want to say that no one falls into that category, but sometimes people are jerks because they're jerks, and it has nothing to do with how much medicine they know, or how much they do or don't care about their patients.  It's an entirely independent characteristic.

Of course the list of residents I like is to some extent different from the list of residents I'd send a family member to see.  There's a difference between being a good colleague and a good doctor.  Everyone wants to work with pleasant, efficient, friendly people.  But pleasant, efficient, and friendly don't necessarily have anything to do with diagnostic skills.  Sure, they has to do with bedside manner and patient relationships, and those are important.  But medical knowledge is entirely independent of tolerable personality.

The problem is that it doesn't make any more sense for me to say that all the jerks are good doctors than it does for me to say that all the people I'd want to play softball with are good doctors.  The truth is, I don't know how good most people are, unless I've worked with them-- and even if I've worked with them, people are good at some things, and not so good at others.  Some patients get better-- and some don't, no matter what you do.

Looking busy-- looking stressed, staying late, taking hours to write a note that should take minutes, double-checking orders you know you put in, waking patients up just to make sure they wake up, running tests just to run tests and give you a reason to still be there at midnight-- does not necessarily make someone a better doctor.  At the same time, writing notes as fast as you can, double-checking nothing, and failing to notice patients who haven't woken up in quite some time-- not so good either.  

The point?  I don't know...

"Nope, still me..."

I'm at the nurse's station, finishing up a patient note, and getting ready to leave.
So I take off my white coat, shove it into my backpack, start to click out of the computer.
A nurse walks over, turns to me.

"Who are you?  You can't be back here."

"Uh, it's me.  [My name.]  You've been dealing with me all night...?  I just took off my white coat...."

"I don't know who you are.  You can't be back here.  You don't even have an ID."

"The ID is in my coat.  We literally just had a conversation about Patient Jones ten minutes ago."

"What do you know about Patient Jones?  Who'd you say you are?"

"[My name.]  The resident.  The resident you've been dealing with for the past twelve hours."

"I need to see your ID."

So I open my backpack, pull out my white coat, put it back on...

"Oh!!  You!!  Of course I know you.  I didn't recognize you without the coat on.  I'm sorry."

"So we're just all the same to you, yeah?  Anyone wearing a white coat, that's all it takes?"

"Don't pretend you'd recognize me in street clothes, Doctor."

"Maybe not tomorrow, but a minute from now I'm sure I would."

"Don't be so sure."

Oops, wrong door!

Room 1308 is the attending call room.  There is no sign on the door.  There is a code to unlock the door.  The attending who is on overnight uses the room to sleep.  You don't wake the attending unless something terrible is happening.  That's just the way it is.

Room 1310 is the staff bathroom.  There is a sign on the door that says STAFF BATHROOM.  There is a code to unlock the door.  It is the same code as the attending call room.

This usually wouldn't be a problem, because one door clearly says BATHROOM and the other door does not.

You would have to be very, very sleepy to accidentally open the attending call room door when you intend to go to the BATHROOM.

You would have to be very, very sleepy to not even realize the mistake until you walked into the attending call room, turned on the light, and saw the attending, sleeping, on a cot.

You would have to be very, very sleepy to not even realize you had entered the wrong room when you saw the attending, startled, waking up, and seeing you there, hand on the light switch.

You would have to be very, very sleepy to ask, "Dr. Attending?  Why are you sleeping in the bathroom?" before looking around and realizing this wasn't the bathroom and quickly exiting, hoping he would fall back asleep and in the morning think this had all been a dream.

You would have to be very, very sleepy to then return to your call room and tell your intern, "I don't think the bathroom is there anymore.  They seem to have turned it into a second attending call room."

I am very, very sleepy.

So close, yet so far

How can three weeks seem so close and yet so far away?

You would think that knowing there are only three weeks left would make it easy to handle anything and everything.  Long night?  So what, it's only three more weeks!  Six admissions at the same time?  Who cares, I'm done soon!  Nurse who won't do anything, intern who spends four hours writing one note, attending who yells at us for sport?  What's the difference, I never have to come back here again!

And yet... and yet the power of sleep deprivation is strong enough to destroy rational perspective and make it seem just as terrible as it would seem if I were just starting.  Working overnight is awful.  It's lonely, it's draining, and it's terrible for the patients because at 4AM, I don't know what I'm doing.  I stand there, in the patient's room, staring at the monitor and forgetting what the numbers mean.  I look at medication dosages and find myself utterly unable to do simple math when I haven't slept in a day-- and haven't slept well in two weeks, because the body is not meant to keep switching between days, nights, and 27-hour overnights.  Does he get 10 mg, or 100 mg?  The difference is meaningful-- at one dose, he gets better; at the other, he doesn't, or even worse.  But I find myself double, triple, quadruple checking, because I just don't trust myself.  And there's no one to ask for help.  I can't wake up a fellow at home at 4AM to ask if I'm dividing right.  Or to help me draw blood, because my hands are shaking because I'm running on some combination of desperate adrenaline, three sips of Coke that I forced myself to drink, and the fear that someone's not going to make it through the night because they're stuck with a resident who isn't designed for sleeplessness.

They justify long hours because they want to minimize handoffs.  But a handoff is pretty useless when the person handing off the patient can't think straight.  My signouts are pretty terrible in the morning after an overnight shift.  "Jones is still alive, yeah.  Check his labs, I guess.  I think I checked his labs a few hours ago.  Might have been a few days ago.  Might not have been Jones.  Wait, Jones was discharged yesterday.  I mean Johnson.  His labs, yeah.  I think I ordered them every two hours.  I meant to.  Maybe I dreamed it.  Anyway, he should have labs, and you should check them.  Unless I'm dreaming his entire existence.  We transferred Jackson to the ICU.  I meant to call his family, but all the numbers on the phone looked funny, so I didn't.  He woke me up to change the channel on his television, so I guess he's probably okay."

I promise, day shift signouts are much better.  Try not to be in a hospital overnight.  Try to stay out of hospitals generally.  Or bring your own doctor.  Yeah, that's it-- hire a doctor-- an awake doctor-- to watch over you all night, so that residents like me don't come in and try to give you 10x your medication dose, or take you for a test that they imagined you needed but were actually having a nightmare about during the 45 minutes they were able to curl up on a roach-infested couch and close their eyes.

I can't even remember the code to the call room sometimes.  It's 4:30 in the morning and I'm standing outside a call room, punching in numbers until I hit the right ones, because I don't know if it's 1666 or 6111 or 1116 or 6661 or 6161 or 1616 or there aren't even any ones or sixes in it at all.  Why do numbers get so hard in the night?

"But I just started working here!"

Me, to a nurse, 3AM: "Hi, I just need you to put a Foley catheter into Patient Smith, when you get a chance."

Nurse: "I'm sorry, I just started working here."

Me: "Okay....  I'm [name].  Nice to meet you."

Nurse: "No, I meant I don't feel comfortable putting in a Foley.  Sorry."

Me: "I don't feel comfortable putting in a Foley either, on zero hours of sleep, and having put in, uh, two Foleys myself in the past three years, since nurses are supposed to be able to do it.  And I have six other patients to see.  Is there another nurse you can ask?"

Nurse: "I don't feel comfortable asking anyone else, since I just started working here."

Me: "Okay, well, I need someone to do this.  And you should learn how to do it, since you're going to have to do it."

Nurse: "I'm not sure what I'm supposed to know how to do.  I just started working here."

Me: "Please stop saying that!"

Nurse: "Can't you call the GI fellow?"

Me: "You mean the GU fellow?"

Nurse: "I don't know.  Where does a catheter go?"

Me: "Oh, wow.  No, I don't feel comfortable calling the GU fellow at home at 3AM about a Foley catheter. Is there another nurse on with you?"

Nurse: "She told me not to bother her."

Me: "Okay, how about you bother her, and one of you puts in the Foley catheter, okay?"

Nurse: "I don't think I can do that.  I just started working here."

Me: "Okay, I'm going to call my intern and the two of us are going to put in the Foley catheter, and then I'm going to tell your supervisor that you need to be trained on how to put in Foley catheters, and then I'm going to try and get some sleep and forget this conversation."

Nurse: "That sounds good, except for the part about talking to my supervisor.  Do you have to?  Since I just started working here and everything."

Me: "Please go somewhere else."

Nurse: "I'm supposed to stay at the nurse's station."

Me: "Can you at least get me a Foley catheter so I can put it in Patient Smith?"

Nurse: "I don't know where anything is.  I just started working here."

"Are you sure you want to be admitted?"

Because you can still leave.

If you leave now, there won't be any risk we'll keep you in here until you die.

If you leave now, no one will start poking around in your insides, looking for problems.

If you leave now, no one will ask you about whether you're an organ donor, and whether you'd like us to do everything possible if you stop breathing, or just do a little bit.

If you leave now, you can keep all of your limbs.

If you leave now, you don't have to worry about catching an infection-- and there are lots of infections here.

If you leave now, you won't get a bill.

If you leave now, I bet you can get a good spot at the walk-in clinic for tomorrow, where you can take care of your problem as an outpatient and don't have to deal with being trapped in a tiny room with limited channels on the TV.

If you leave now, I'll give you a $5 gift card to the cafeteria that's been sitting in my wallet for the past eighteen months.

If you leave now, you will almost definitely not get hepatitis from tainted blood products, at least not today.

If you leave now, no one will mix you up with another patient and take you in for a surgical procedure you don't need.

If you leave now, you won't be exposed to any excess radiation.

If you leave now, the government won't confiscate everything you own in order to pay your medical bills.

If you leave now, you can have a lollipop.  Or a sticker.  Or a box of latex gloves.  Or as many little bottles of hand sanitizer as you want.

If you leave now, your orifices will stay completely unprobed.

If you leave now, I don't have to do your admission-- which means I can go to sleep!

So please leave.

Thanks.

How Do Residents Spend Their Day?

I'm moving from flowcharts to pie charts.  Perhaps you might enjoy...

How To Triage a Patient

Second attempt at a flowchart.  These are kind of fun.

Click to make bigger.

How To Survive Overnight Call

In the spirit of this being the start of the last month of residency, I thought I might try and make a few flow charts to help future residents deal with some key situations that come up.

This is my first time trying to make a flow chart, so I apologize for the lack of graphical excitement.  I'll work on it in the future.  Happy to take suggestions for other topics (though I have a few ideas).  I used Diagramly for this, and am pretty happy with it, but if anyone knows of any better tools, I'm all ears.

Click to make it bigger.