Things I would like to get off my chest...

In honour of my last day of my internal medicine rotation, I would like to air some grievances. So here, in brief, are a few things that I've wanted to say at some point during the past two months.

To the nurse who paged me at 3:30 in the morning, 10 minutes after I had managed to drag myself to my call room for the first time that night-- you seriously called me to clarify a TYLENOL order from someone I'd just admitted from emerg? Are they in dire need of Tylenol RIGHT NOW? No? Then leave me alone.

To the woman who gives out the call room keys at the information desk of the hospital-- I am aware that it is 4:45pm. I am also aware that we aren't supposed to pick up call room keys until 5pm. But this might be the only chance I get to get down to the information desk before the keys become fair game to other services at 1am. So unclench and give me a freaking key.

To the patient who told me that the reason she was feeling better was because my attending was such a good doctor and that she really respected and valued his medical skill. My attending couldn't pick you out of a lineup. I am your doctor, for all intents and purposes. I am the one who has visited you daily, managed your care, fought on your behalf for tests and spent time looking up information on alternative treatment options. He visits you for about 10 seconds every second day or so. Not that I'm looking for a medal here, but seriously!

For the rookie nurse that just started on the floor-- I don't envy your position. You must feel overwhelmed. But if you call me in the middle of the night wanting something ordered, please at LEAST know what the person was admitted for, what other meds they're on and what allergies they have. When I have to sit there holding the phone while you say "um, I'm not sure" and look through the patient's chart, I am not amused.

To my senior, who knows a helluva lot of internal medicine and very little about people-- that's really something you need to work on. Yelling at a patient's family member because she doesn't understand the difference between "intubation" and "resuscitation" when clarifying code status will not win you Humanitarian of the Year awards.

To the infection control people, whomever you are-- my patient has been in the hospital for three days with a COPD exacerbation. I have no idea what posessed you to decide that he needed to be in isolation with droplet precautions AFTER we discharged him home (for the 15 minutes he was waiting for a cab) but that may win the prize for the most ridiculous hospital policy ever.

To my attending-- don't manage my patients behind my back. Particularly not if you're going to decide, with the help of the urology attending, what the right treatment is for my patient when you've never taken the time to actually meet her. If you'd spoken to me, you'd know that putting a percutaneous nephrostomy tube in a developmentally delayed woman who yanks out lines as fast as we can place them is a recipe for disaster.

To the entire Interventional Radiology department-- what the hell makes you so special? Why can you get away with not answering phones, not returning calls and not answering pages? Why do we need to actually go down to IVR and seek you out in person and beg you to perform procedures on our patients, like you're doing us a big, fat, favour? IT'S YOUR FREAKING JOB!

To the nurse on 4Z who paged me 4 times in an hour because I hadn't come to pronounce her patient yet-- as I've told you three times already, I am dealing with someone crashing on the floor. Your patient is unlikely to get any deader. The one I am treating right now is a very different story. So no, pronouncing your patient is not my priority right now.

To the chief medical resident who made up the call schedule for the month of June-- was scheduling me for 4 call in 8 days a punishment for taking vacation at the beginning of the month? Or are you just trying to kill me? And I know that someone has to be on call on the last day of the rotation... but why does it always seem to be me?

Sigh. I feel better now.

Stick a Fork in Me...

It's funny. I used to think that the worst month to get get sick would be July. All of the new residents start on July 1st. But now, nearing the end of my first year of residency (or the end of my internship, for all you Americans out there) I no longer think that July is the scariest month to be in hospital... it's June.

In July, we KNOW we're new. We're scared. We feel like we've suddenly been given a massive amount of responsibility that we may or may not deserve. And for the love of God-- we don't want to screw it up. So we're meticulous. And careful. And probably more than a little paranoid. So the first few times the nurse calls for an order in the middle of the night, we'll drag our asses out to the floor to review the patient's chart first. And we'll double-check the dosage. And triple-check the med list and the allergies. And THEN we'll write the order. If a nurse calls and wakes me up because a patient is hypotensive, I'm on my way to assess them before she's hung up the phone. And it's not just the R1's that are like this-- as the R1's in internal medicine take up the lofty title of Senior Medical Resident, literally overnight they are ultimately responsible for the CCU, two wards of inpatient medicine, all consults from emerg, all consults from other services and every code called in the hospital. It's a lot. And rightfully, they're petrified as July 1st draws nearer.

But what a difference a year makes.

Want an order? Are they allergic? Any obvious contraindications? No? Sure, give them Ativan 0.5 mg po qhs prn. I barely even have to wake up anymore. Your patient is hypotensive-- are they stable? Any congestive heart failure? Give them a bolus of fluid and take the pressure again once it's run in. If it's still low, call me back. If a patient is stable I probably won't get out of bed for a systolic less than 85. Apathy? Maybe a little. But I can now do the bread and butter of my job with my eyes closed-- and sometimes, at 4:30am, I do.

The Things My Patients Teach Me

Today I was back in my family medicine clinic seeing patients for the afternoon. After the past few weeks of internal medicine it's hard not to think that their complaints are petty and insignificant sometimes. When I'm still thinking of the woman on the floor with end-stage COPD gasping for breath, it's hard to muster up sympathy for someone's itchy elbow.

But this nearly killed me. I have a patient whom I'll call Mr. E. Mr. E is an elderly guy whose first language is something eastern European that I most definitely do not speak. Mr. E is full of complex medical problems ranging from lichen planus (a skin condition-- see lovely picture to the left) to atrial fibrillation and everything in between. Currently we are battling Mr. E's high blood sugars (he is a poorly controlled diabetic) and his high cholesterol. This is complicated by communication problems-- the last time I asked him to check his sugars four times a day so that we could identify more specifically when they were high, he dutifully did so. When he brought me in his record book it was hard not to laugh when I saw that he had checked them at 7am, 8am, 9am and 10am. I had explained at the time that I actually meant to test upon waking and then before each meal, but he apparently hadn't entirely understood (in spite of assuring me many times that he did).

Today, Mr. E forgot his record book but was eager to tell me that his sugars were finally under good control. They had been steady all day, usually around 5 or 6. Lovely. I told him how glad I was that things were finally getting better-- his chronically high sugars had previously left him feeling nauseous and fatigued. He decided to share his secret with me. Salt and vinegar potato chips.

Um... pardon you?

Yup. Ladies and gentleman, the secret to diabetic control. Mr. E noticed one day that his sugars were good when he ate salt and vinegar chips after every meal. I asked him if such a high fat food was a good idea to be eating three times a day. Oh no, he informed me. No fat. Just salt and vinegar. Apparently, in the mind of Mr. E, they only put fat in the 'fat flavoured' chips. So he had decided to continue to eat the chips after every meal in order to keep his sugars down. I'm choosing to attribute the 'miracle' of normal blood sugars to the fact that we started him on Gluconorm at his next appointment.

I can't wait until his next cholesterol test. We may have to filter the fat globules out of his blood to test it. Sigh.

The Streak is Dead... Literally

Considering the amount of time I've spent in the Emergency Room, people are often amazed when I tell them I've never had a patient die. Honest. Actually, my life has been pretty much untouched by death entirely (touch wood, quick!). All of my family members who have passed away did so when I was too young to really get it, and no one has died in the past 15 years or so. Colour me lucky. And my patients... well, I guess they've been lucky too. I've had a patient or two die, but it was never while they were actually under my care. And only one of them was a patient that I'd actually had time to get to know beyond last name and chief complaint.

Even when people are supposed to die on my watch, they manage to hang in there until a new team comes on in the morning. A patient can be actively trying to die throughout the day but will miraculously stabilize at the exact moment I accept the code pager. And speaking of codes-- four code blues, four ICU transfers, three have improved well enough to come back to the floor. One is still in ICU, but doing better. No deaths. Un-freaking-believeable.

Basically, if you have a parent in the hospital... you want me on call. Not for my skills, but for my crazy good karma.

Now in all fairness, this might also be due to the fact that since becoming a resident I have actually spent very little time in the company of sick patients. Anaesthesia, Emergency Psych and Obstetrics don't often lose patients. And my time in family medicine was much the same. So the only time I was ever really in danger of losing a patient was during my hellish two months of general surgery and now, in my second month of internal medicine.

Which is why I was a little unprepared when I got called in the middle of the night to pronounce a patient on the hematology/oncology ward. We don't usually cover that ward on internal medicine-- those patients have specialized problems, and are usually handled by the specialists themselves. This was a young-ish guy (in his late 40's) who had developed a particularly unfortunate case of Graft-Versus-Host-Disease after a bone marrow transplant for a rare lymphoma. He had been doing poorly in hospital for over a month, and had acutely decompensated over the past few days. His death was expected to the extent that the attending hematologist had already gotten verbal consent from the man's wife for an autopsy to try to explain his recent rapid decline. All I had to do was pronounce the man dead and fill out the death certificate.

I knew the drill. I had seen it once as a medical student, and I knew the steps in theory. I entered the patient's darkened room and offered my condolences to the family. I then asked them to step out of the room for a moment while I examined their loved one. I turned my attention to the recently deceased. His mouth was fixed open in a silent scream, his head tilted towards the ceiling. Thankfully, his eyes were closed. His hands were cold and doughy. I was hesitant to touch them, feeling as though I were intruding on him at his most vulnerable. I felt for a pulse. Carefully, I peeled back his hospital gown to place my stethescope on his chest. I listened to the silence for a full two minutes, spurred by the irrational fear that if I rushed the process the poor man would sit bolt upright on the pathologist's steel table and I'd be interviewed on the evening news. I heard nothing. No breath sounds, no heart sounds. I tapped on the diaphragm of the stethescope to make sure it was working. It was. He wasn't. I pressed into his nailbed to assess response to pain. I reached over to rub his sternum but stopped-- his skin looked so fragile and delicate that I worried it would tear under my knuckles. Instead, I skipped to the last step. Prying open his dry eyes, I carefully touched a cotton swab to his cornea. No reaction. I gently drew his eyelid shut again.

I left the room. After a few more (likely contrived and artifical) words to the family, I retreated to the paperwork that accompanies death. I pondered over the offical cause of death for what was probably longer than I needed to. The autopsy would provide that information anyway... whatever I wrote would just be a guess. All I could think of was the coroner's talk we had received at the start of residency.

"Cardiorespiratory arrest is NOT the cause of death. Cardiorespiratory arrest IS death."

But I couldn't think of anything else to write.

By the time my shift ended at noon, I had been called to pronounce a second patient. An elderly man on the internal medicine ward with metastatic cancer, who had been bouncing in and out of the emergency room with severe nausea, vomiting and dehydration but determined to live out as much of his remaining days in the comfort of his home. Finally, he gave in and came into hospital to stay. He died with his family at his bedside, a jaundiced figure with a belly bloated with ascites and extremities that had wasted away to skeletal proportions. Although he wasn't 'my' patient at the time of his death, he had been under my care the week before during one of his shorter admissions. I knew him.

I don't know how many people I will have to pronounce during my medical career. I'd rather not speculate. But in the middle of the night in the darkened ward I laid to rest my first patient. And although I've already forgotten his name, his face will stay with me much longer.

You HAVE to be kidding me.

Yet another reason to hate call.

I don't have allergies. At least, I've never had any allergies that I am aware of. But I am seemingly allergic to call. Back at medical school, when a night of call was quiet enough that I slept for a period of time in my call room I would often wake up frequently during the night completely congested. I'd wake up in the morning rubbing my sticky eyes, trying to breathe out of my stuffed nose and prone to sneezing fits. Fun stuff.

Then I change cities. And hospitals. But the allergies remain. Now I've never had this reaction to another room away from home-- I've stayed in countless hotels and hostels and I've never had the same reaction to them as I do to call rooms. Dust? Could be, but my home can get pretty dusty too. Bleach? Don't think so. The call rooms are so sterile that I can't think of much that they all have in common-- plastic coated pillows that crinkle every time you move, rough white sheets, institutional blankets that need to be layered in factors of ten before they actually provide any warmth... what else is there?

Eventually, I just accepted that I am allergic to call and sucked it up.

Recently, though, it got worse. I started waking up from call ("waking up" is a bit of an exaggeration since I rarely get more than 20 consecutive minutes of sleep) with a rash. Again, I wasn't too concerned. I have insanely sensitive skin that is still recovering from a bout of poison ivy passed to me from the puppy from hell after a morning walk in the woods, and I seem to get random hives on a regular basis.

But these weren't hives. They looked like little pimples. And they itched like the dickens. I had a batch of them on my right ankle, and another batch on my left forearm. Then I looked closer-- the ones on my forearm formed a perfect line.



Ugh. I have bedbugs. Or rather, the call rooms have bedbugs. I am so grossed out right now I can't even think. The idea of bugs crawling over me as I sleep... UGH! If I can get bed bug bites when I sleep fully clothed, I don't want to think of what I'm taking home from the hospital attached to me in some way.