PGY-1

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I came back from a wonderful vacation to a pediatric neurology service that included a previously healthy, normal little boy who was found floating face down in a pool.

I’ve done a bunch of brain death exams before, but that one was, hands down, the worst one I’ve had to do.

As my attending said this morning on rounds, the kids with congenital defects, or perinatal injuries, are do-able. It’s the ones that were previously normal that make you nearly cry in the room.

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PGY-1 · PGY-2

I’m alive!!

Yes, my friends, I do exist. Somewhere deep in the depths of the hospital…

No but really. PGY-2, my first “real” year of neurology, has been unbelievable. In a good way. The hours are longer (hence the lack of keeping up with this blog) but so so very much better. Try as I might, by the end of intern year I really just did not care about cirrhosis.

I’m working an overnight in the neuro intensive care unit at the moment. I was admittedly terrified of the ICU — after my horrible month in the medical ICU as an intern, when I felt like the Angel of Death more days than not. I am not sure that I like it, exactly, but it’s much more manageable than the MICU. My tiny brain can only handle one organ system at a time, yo!

Currently reading: 1493 (Charles C. Mann) as well as The Grass is Singing (Doris Lessing). Oh, and also Wolf Hall (Hilary Mantel). Only one organ system, but oh-so-many books!

PGY-1

Hello again!

Yeah, ok, I’ve been delinquent. Intern year, especially during the dark days of winter, slowly saps your ability to be a Real Person. (Newly minted MDs, are you excited?) It’s odd, because even though there is nothing specifically bad about internship/residency, the constant grind really wears you out. I can’t even imagine how the surgeons manage it.

But now, that summer’s coming, and it’s light out when I go to work and even when I leave, my spirits climb. A long-overdue haircut, a wedding, the summer series of outdoor concerts, and a new pair of hiking boots help. Plus, there was an unexpected success story last week at the hospital — I don’t want to go into details because they are too specific — but it made me think that maybe, just maybe, we can save some of the people, some of the time. Also, that Haldol is a wonder drug.

(On a side note, the history of medical advertising, as a reflection of medical sociology, is pretty wild. Psych stuff, in particular, seems to have undergone a sea change in the 60s and 70s, from the “quiet, docile white woman with schizophrenia” to the “angry black man with schizophrenia.” Jonathan Metzl writes about this, and other things, in Protest Psychosis; here is a pretty good review. Contextualizing illness is key, and I would say this holds for medical illness as well as psychiatric. Just look at the social history of cancer, treated wonderfully in Dr. Mukherjee’s Emperor of All Maladies.)

Alright, friends, time to do some Step 3 questions! (I’m trying not to treat this exam like a joke, if only because how embarrassing would it be do be in the 2% of people who fail?)

PGY-1

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.

PGY-1

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. 

PGY-1

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.”

PGY-1

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.