The Forty-Nine(rs)

In the last three days of my ED rotation, I’ve seen 50 patients. One of whom had an actual emergency (new onset seizure). The other 49 were just chillin’.

The worst part of the medical bureaucracy is the feeling that it’s never going to change. Example: three of those 49 patients called their PCP or clinic and were told to come to the ED just in case, because everyone is afraid of being sued. One of the 49 was at a local health center, actually being seen for her non-emergent problem, the health center nurse called some ENT to try to get her an appointment, the ENT told her to come to the ED. Was my only order on that patient “ED Consult to Otolaryngology”? You betcha. Did I feel bad about calling that consult? Well…. maybe just a smidge.

I try to be very clear in my discharge instructions what constitutes an emergent condition. A good rule of thumb is, if you think you might need to come into the hospital overnight, the ED is a good place to be.

I would love to see more Urgent Care Centers, but I’m told over and over that they won’t solve the problem because you can’t ask people to triage themselves. To which I say “Why not?” We ask people to vote for president and contribute to the infrastructure of their country through taxes. We allow them to drive 2 ton vehicles, consume mind-altering substances, and purchase assault rifles. If they can behave like responsible adults with all of the above, why do we infantilize them medically by insisting that they can’t possibly know if they are sick or not sick. And if someone triages themselves to Urgent Care when they should have gone to the ED, the physician or nurse practitioner there should send them over straight away. 

Internship is making me cynical, and kind of a horrible person. Battle-weary. I am not tired or fatigued per se, but I do need a vacation, a change of scene. Really I just want to go hiking, which I can easily do here, but I suspect there is still snow on the mountains. So in two weeks, I’m turning off my pager and going to Sedona, AZ. I may not come back.

 

What do you do when?

I seem to have the worst luck on call. Not that it’s oh so busy, but I seem to attract all the totally devastating cases. Of course, I also seem to only write when I am post-call and the tragedies are fresh.

I just wrote a long and literary description of a stroke code the other night, but then I realized the things that make it interesting also make it a HIPAA violation, try as I might to change the details. Damn you, HIPAA!

I suppose that, like most people, I hate it when crap things happen to young people. I mean, crap things happening to anyone is bad, but permanent disability as a result of sheer bad luck frustrates me. I’ve had a fair number of near misses myself over the years (including recently falling asleep while driving home from work) and sometimes it fucking terrifies me when I see myself or my family in my patients. It angers me, like Lear on the heath anger, to see how random death and disability can be. And it saddens me to realize how very little we can do in most of these cases. On balance we are probably better off than a hundred years ago, but it still feels like despite all the trappings of civilization and pharmaceuticals and Modern Medicine, there’s a hell of a lot of random violence in the world. Inflicted violence, of course, but also the arbitrary-ordinary violence of stroke and infection and cancer.

I’m reading A History of the World in 10 1/2 Chapters, by Julian Barnes, who is a pointy nosed genius. It’s a short story cycle, which I love best from a craft point of view — each tale stands alone, but reading in sequence you see threads and throwaway references that make you feel like the author is winking at you with a series of inside jokes. Anyway, one of the themes here is the caprice of selection. It starts on Noah’s Ark and continues all the way down the ages. That’s what I’m driving at, really, and Mr. Barnes puts it far better than I. 

 

Anti-depressant

Intern year? I’m over it.

I seriously wonder, if someone told me back when I was in college what being a doctor was really like, would I have believed them?

The success stories are awesome. That guy who got PEGged that I was so nervous about? The next morning, he’s sitting up in bed with his glasses on reading the paper. “Who are you, and what have you done with Mr H??”

But most people aren’t successes. I’ve written about the Angel of Death phenomenon already. But I’ve since discovered something even worse: pending placement (or its equally alliterative alternative: dispo disaster). It’s hospital jargon for a patient who is medically ready for discharge, but has nowhere to go. Home situation is unsafe. No money for a nursing home. No insurance for a rehab facility. No resources in the community for home services. (This last one is a really big deal, because my hospital’s catchment area spans about 4 hours’ drive. There’s only so much our visiting nurses can do.)

Seriously, high schoolers and college kids who have stumbled on this blog: being a doctor is fucking depressing. I feel totally beaten down by the system — no one goes anywhere; it’s like the Vestibule of Hell — that part where everyone is flying around in a circle. (Apologies, it’s been a long time since I read the Inferno.) There are only two ways out: having money (and thus being able to afford necessary services) or dying.

When I was in medical school, I used to get really frustrated when patients tried to game the system. Now, I admire them. Like the lady who showed up from the ED with 4 bags of personal belongings, including a portable DVD player and a slew of DVDs. She’s getting what she wants: she’s become another dispo disaster.

OK, I’m not actually that depressed. My life outside the hospital is not at all bad, actually. Last night’s surprise snowfall made the world lovely this morning, and the basil on my windowsill is growing, and I feel settled and a part of my community. I just hate looking at my list of patients and thinking “Placement, placement, placement, actual medical needs, placement, placement.”

 

How to be a good doctor

Now that I’m halfway through internship, I’m thoroughly aware that being a good doctor and being a good intern/resident are not the same thing a bit.

Being a good doctor means listening to your patients and their families, advocating for them, thinking about their problems. You know, all Marcus Welby. Or even, twistedly, House.

Being a good intern means writing a crapton of notes, and fielding pages about critical lab values, microbiology results, and blood glucoses. And normal vital signs. (Please, RNs stop paging me about normal vitals. I DON’T FREAKING CARE.)

I really worry that I’m slowly turning into the kind of doctor I don’t want to be. I baaaarely see my patients — five minutes? if that — on prerounds, and spend the rest of the day trying to hide somewhere and document things. I try to prioritize as much as possible, but honestly, I find myself resorting to a series of knee jerk responses to the vast majority of these pages.

I ran a family meeting today (not my first, but undoubtedly my most disastrous), where the patient’s son commented that this was the first time, in his father’s 25 day hospital course, that people had kept their promise about the timing of things. And then, like an idiot, I let them talk me into promising a PEG tube for this gentleman tomorrow. The last thing he needs is a PEG tube. I don’t even know if it will happen tomorrow.

One of my resolutions is to try and be a better doctor. Even with the unbelievably frustrating patients, the ones that make me want to run out of the room, but I stay in the mistaken belief that maybe I can build a therapeutic relationship with this completely steroid-psychotic person. And I worry that because I’m trying to field pages on 14 patients at once, I’m missing things. (I know I’m missing things because my resident will be like “did you realize that Mrs. R. had 15 BM today?” and I’m like “whaaaat?”) I’m definitely not able to think about people very medically — I’m barely staying afloat of their day-to-day crap.

And yes, I know, part of being a good intern is knowing when to ask for help. My resident and attending have both been great in terms of backing me up. Today was simply a crappy day with several family meetings going down simultaneously, so we decided to divide and conquer. At least mine was better than the psych/ethics meeting on another guy, where they decided to take away his capacity to refuse medical treatment, but then said that if he protests the medical treatment we have to honor the protestation. WHAT?

Um. I’m going to watch Downton Abbey now. And drink some cider. And wake up at 5:30 tomorrow and try to be a good doctor.

 

I’m an old lady

I just read this article about donating Kindles to poor schools in Ghana, and, well, I have mixed emotions.

First off, it’s wonderful that these kids have access to books, especially to read in their native language. The way English glomps local languages is a serious problem for diversity and beauty in literature. And it’s very true that book drives often turn into book purges: ship the unreadable or extraneous to Africa and everyone wins — except the children who were meant to benefit. (This happens with medical drives too; expired drugs: no good! If you wouldn’t use it here, don’t send it there.)

But there’s something deeply disturbing to me about distributing Kindles instead of real books. The economics are simply unsound. A donated Kindle costs $69 just for the device itself with intrusive ads; for that you could buy over one hundred books from the 48 cent carts outside the Strand. These people want to get 1 million Kindles out to Africa; for that you could buy up the whole goddamn Strand, even the basement that no one ever bothers with. Kindle e-books cost less than new editions, but far far more than used paperbacks. So from the sheer standpoint of providing quality literature, used books win.

Then there is the problem of battery charge. Apparently these Kindles can be recharged with solar and wind power? If so good for Amazon, because if rural Ghana is anything like rural India, electricity is a precious commodity and power cuts a near-daily occurrence. (This is the irony of the modern age: that peasants will have cell phones and no way to recharge them.) On a side note, I find it really amusing that Kindle’s big selling point is that you can read it in the sunlight. Like … a book?

And last, the deep and real pleasure of a book itself. The cover design. The typography. Reading on a Kindle is just plain boring. (I know. I’ve tried.) The pleasure of fiction is in the imagination, sure, but there is also the sensory pleasure — the smell of old books, the weight of them in your hand, the crinkle of the page. And you learn a lot from the physicality of a book: when it was made, how it was read, the assumptions in the cover design (have you seen those lurid 1930s dime novels?) Yes, sentimental, but real nonetheless. Books, hardbacks and paperbacks and little homemade chapbooks, insist on their own reality in a way that an e-reader or tablet or electronic delivery system of choice cannot. Electronic media are ephemera, and presenting something as enduring as literature in electronic form just doesn’t make sense!

Just ask yourself, would the opening scene of Fahrenheit 451 retain its power if the old woman were clutching an e-reader? Would Catherine Morland get so hung up over a virtual Udolpho? Would you choose to read Curious George on a pictureless device instead of with its vibrant illustrations?

Don’t get me wrong, I think the Kindle does provide portability, which is great for long bus rides or plane flights. (But I still do prefer the ritual of looking through my books and choosing just the one — or ok, maybe two or five — that will be my companions for a week.) I just got a tablet for the primary purpose of reading journal articles, and it’s working out great — but journal articles are, essentially, ephemera, to be digested and used until the next clinical trial comes out. They aren’t Anna Karenina.

So back to the kids in Ghana. I’m glad they are reading and I hope they continue reading, but I also fear greatly that the delivery system, being electronic, will fail to compete with the other electronic demands on their attention: computers, cell phones, television. And so no one wins, except Amazon, which gets to look good in the media while continuing to fill their coffers.

 

Oh brave new world

Tonight I volunteered at the local Free Clinic, an independent organization that is staffed mostly by physicians from my hospital. Double fun because: (1) seeing patients on my own and presenting them to the senior neurology resident and (2) free dinner!

The weirdest thing for me is that the free clinic is not electronic just yet. Setting up an EMR takes an unbelievable amount of capital, so obviously they would prefer their donations go to things like medications and direct patient services. But for me, who came of age in the post-computer world, it was so very weird to be handed a thick paper chart and be launched into things.

I only had two patients scheduled all night. Took my time with the first one and planned to write the note afterwards (as I usually do on the computer), but given the way the patient flow is set up, I need to finish the note before the patient can leave. Which, oops! So with the second patient, I tried to write as I went along, which made me feel like I wasn’t paying any attention to the patient because I was writing my full note in front of her.

I also had a LOT of trouble writing a script on a prescription pad because … I’ve actually never done that before. Ever. I usually just write electronic prescriptions which get e-sent to the pharmacy; it’s all just a bunch of check boxes and hit send. What do you mean I have to know the tablet strength??

The patients were actually really good, seemed quite grateful for the care they received (from me, still wet behind the ears). One complicated patient who really needs proper follow-up with continuity, and another much more straightforward case of vertigo. I do wish I had felt less rushed — but that, perhaps, will come with time.

So: educational for me on ambulatory care; helpful for the patients; and generally all around an awesome experience.

 

Words, words, WORDS

Isaiah Sheffer, Founding Artistic Director of Selected Shorts died the other day. “Storytime for Grownups,” as I like to call Selected Shorts, is one of my favorite weekly podcasts. His reading of “The Dead” is probably the only story that can make me laugh and cry all at once. Partly because James Joyce is so. Unbelievably. Amazing, but also because Isaiah captures it. (I really wish I had burned it to CD, because now it’s no longer available on the site.) I like the New Yorker Fiction Podcast too, but Isaiah brought a down-to-earth, joyous zing to his selections and his readings and his discussions that Deborah Treisman just can’t quite get to because she is too high-minded. Equally awesome, of course, but Treisman reminds me of the perfect hostess, trying to make sure everyone is satisfied and has enough to nibble, whereas Isaiah is the storytelling uncle regaling the kids in the corner, or the librarian you always dreamed of, picking out the stories you will surely like, and ones that perhaps you won’t at first but will knit themselves into you nonetheless.

That’s why stories matter, of course, because they are a set of lies told by one person to another that, in the hands of the right teller and the right reader, become true. I was reading The Gentleman from Cracow, by Isaac Bashevis Singer (a writer I discovered through Isaiah!), which is in a consciously fairy-tale style, and when the mysterious gentleman descends from his carriage in his beaver-lined caftan, he was there, visibly, conjured out of nothing. I had a similar feeling toward the end of Vanity Fair — cheering for Dobbin and utterly horrified at Becky, as though they were real people with choice instead of characters whose fate was scribbled down irrevocably more than a hundred years ago. 

It’s almost frightening, sometimes, how much power the storyteller can have. Of course, even the dumbest politician realizes that, which is why we have censorship in dictatorships and Banned Books Weeks here. I realize that fiction is inherently political — that’s what drives the majority of literary criticism these days — but fiction is also inherently intimate. That’s where it glistens, when you’re curled up on a sofa with a blanket across your knees and a pot of tea and a story. That’s what fiction has in common with medicine, you see, because medicine is also inherently intimate. Fewer sofas and pots of tea, but one person telling — often with lies and elisions — and the other retelling.