One of the "great" things about being a medicine intern is how certain choice four-letter words that you used to refrain from using insidiously make their way into your daily vocabulary so you start swearing like a sailor. Like when a patient's troponin level jumps from 0.99 to 25.8 (thus signifying an acute myocardial infarction, for those of you non-med readers), and your first reaction upon seeing the lab result is "Oh sh*t!" (and your second reaction is to run as fast as you can to the patient's bedside to make sure he/she's still alive). Or when you learn that the cause of your patient's profound anemia (with a hemoglobin of < 5.0 on admission) is due to colon cancer, and the first word out of your mouth is: "F*ck!" I think I've become especially fond of the latter expletive - it's just so much fun to say.

It's certainly a helluva lot easier to say than: "I'm sorry to have to tell you this, but..."

We got off to a very inauspicious start.

"Ms. Simon¹?" I inquired as I entered her room to take a history & physical.

"That's not how you say my name," she replied bluntly, without a hint of humor in her voice.

I quickly backpedaled. "Oh, I'm sorry. How do you pronounce your name?"

"It's not 'Ms.' Simon," she hissed, the coldness in her voice permeating the room. There was another gentleman in the room who I could only assume was her husband, so for a split second, I thought maybe she was one of those grammar nazis who was going to tell me her name was "Mrs. Simon." Still, I wasn't quite sure how to respond.

"Ummm...how would you like for me to address you as?" I asked, completely flabbergasted.

"How about Doctor Simon?" she responded, "If I'm going to call you that, I expect the same courtesy from you!"

Holy crap. This was a woman who clearly wasn't afraid to speak her mind. Sensing we had started off on the wrong foot, I apologized again and tried to continue with my interview, "How are you feeling today?" It was meant to be an innocuous question, one that I usually ask my patients to help break the ice. I don't think she saw it that way.

"How am I feeling?!?!" She shot me this look as if I was the village idiot. "Oh I'm just wonderful! How are you?!" she answered sarcastically, not even bothering to hide the disdain in her voice.

Ignoring her negativity, I took a deep breath and attempted to elicit the patient's chief complaint. "So what brought you to the hospital then?"

"The ambulance," she deadpanned. It wasn't quite the type of answer I was looking for when I posed the question, and I'm pretty sure she knew that too; she was intentionally giving me a hard time.

If I'd had a choice, I would have just walked out of the room right then & there and washed my hands of this troublesome patient. Unfortunately, I didn't have much of a choice. It was my job to get a history and exam on Dr. Simon, no matter how big of a pain in the ass she wanted to be. I ended up spending close to an hour with her, and it was pretty much the same old story. I would try to ask a question pertinent to her medical condition, and she would go off on some long-winded diatribe about the crappy hospital food, the stupid psych questions the nurses had been asking her, or the substandard care she was getting from her doctors. And for some reason, I just stood there and listened. Maybe it was a desperate subconscious attempt on my part to try to build some kind of rapport with her. Maybe there was a part of me that genuinely felt sorry for her (after all, she did have stage IV lung cancer with mets all over her body), no matter how mean she acted towards me. Most likely, I was just too terrified of her to do anything else. But once I got all the info that I needed, I got out of that God-forsaken room as quickly as I could.

The rest of her admission stay, I went out of my way to make sure I wouldn't have to interact with her any more than I absolutely had to. I would still see her every morning when I rounded on her, but then I would spend the rest of the day trying to avoid her at all costs. If I had to walk by her room, I'd speed-rush past the door, hoping she wouldn't see me. Heck, there were even a couple times when I decided it was worth taking the long way around (which involves going down a flight of stairs, walking across a hall, then going back up a flight of stairs) just so I could avoid having to walk past her door. It was that bad.

So when she finally went home, you can imagine how deliriously happy & excited I was. But her discharge home also unexpectedly triggered another emotion that continued to linger long after the immense sense of joy and relief had worn off: guilt.

In Scrubs episode 1.18 ("My Tuscaloosa Heart"), J.D. deals with a ridiculously mean-spirited patient by avoiding the patient when possible. The patient eventually dies (of terminal metastatic colon cancer), and J.D. is left unable to sleep at night, wondering if he did anything wrong. Technically, he didn't; the board of medicine concludes that J.D. provided adequate standard of care. But as Dr. Cox astutely points out, "If you're wondering whether or not you treated [the mean patient] differently because he's a complete jerk, well... I think you know the answer to that one already, don't you?"

Part of me would like to believe that in spite of her difficult attitude, I still gave Dr. Simon the same level of care and respect that I give to each and every one of my patients. And maybe I did; several nurses and doctors told me that she privately raved about what a "nice guy" I am. Still, there's another part of me that knows better, a part that's reluctant to take a deeper, more introspective self-exam of myself because if I do...I might not like what I see.

"The worst part of being a doctor is that you fall short a lot. The best part is that if you wait around for a few seconds, you'll get a chance to redeem yourself. I guess there's good and bad in all of us. And once you've accepted all sides of yourself, it's a lot easier to sleep at night."
~J.D., Scrubs episode 1.18 ("My Tuscaloosa Heart")

¹ Not the patient's actual name. (Duh!) Oh, and in case you were wondering what kind of doctor she was, she's a dentist.

Getting Nailed

I swear the tires to my car must be magnetic because there's no other rational explanation as to why metallic objects (i.e. nails) keep finding ways to imbed themselves into my tires time and time again. By my count, I've taken my car in to the repair shop to get my tires patched at least four different times over the past couple years (not counting one incident where a nail was discovered lodged in a tire, but hadn't punctured it completely). Heck, just a month ago, I took my car in for a routine oil change, and they found a nail stuck in one of my tires. Not even two weeks later, I realized that my left front tire looked noticeably flatter than the others. I finally got a chance to take my car in to the shop to get the problem fixed today, and lo & behold, what was the cause of the air leak? That's right, boys & girls...yet another nail! I think I've run over enough nails to build a house with (just don't let the big bad wolf come near it, cuz it'd be a pretty shoddy house.)

Frickin' Rhode Island roads.

Walking from the parking lot to the hospital early yesterday morning, I felt a sudden wave of apprehension overcome me as I approached the entrance to the hospital. After my mini-meltdown as documented in the previous blog post, I wasn't entirely sure if I wanted to endure whatever horrors might have been waiting for me inside. I had four patients on my census, all of whom were stable enough when I signed out the previous night, but in this profession, you never know. Plus, it was our "short call" day, meaning our team would be accepting a few admissions from overnight. If I wasn't careful or efficient, my census could easily increase by 33% at the end of the day. It potentially could have been a very bad day for me, the start of yet another rough cycle where I start accumulating patients and fall behind on my work, leading to delays in running important tests so I can diagnose, treat, & discharge my patients, thus causing my census to continue to balloon with each and every passing call day until it spirals completely out of control and I'm entirely capped out. So standing before the sliding glass doors of the hospital, I experienced what could only be described as a sense of dread. I could just picture an imaginary sign posted right above the doors, reading: "Abandon all hope, ye who enter here!" Taking a deep breath (or was it more a sigh of resignation?), I slowly entered the hospital.

Surprisingly, it wasn't that bad of a day. In fact, it turned out to be a pretty damn good day. I ended up sending four of my patients home, meaning I ended my day with fewer patients than when I came in, despite being on short call. That always qualifies as a successful day in any intern's book. And today, I managed to discharge another patient home, leaving me with a grand total of...(drumroll please) ONE patient on my census, going into my on-call day tomorrow. I think I can live with that. More importantly, I think I'm gonna be okay. 

In spite of what I wrote previously, I doubt I'll end up like Nick, the intern who quit on Scrubs; I've worked too damn hard to get to where I am, and truth be told, I do love this job, even if it deprives me of sleep and sucks my soul dry (kidding...well, not really). Of course, I'm probably not going to be the star intern that J.D. was either. My guess is that I'll end up somewhere in the Elliot mold - someone who gets totally overwhelmed by the stress of intern year but still somehow manages to hang on & survive. (Just please, please, please don't let me turn into Doug - a woefully inept resident who is so bad, Dr. Cox once commented: "That young man has killed so many patients, I'm starting to think that he just might be a government operative.")

Deep breath in. Deep breath out. Let's do this.

An eighty-something year old male with a past medical history of left-sided hemorrhagic stroke presented to us about a week ago with altered mental status. The patient was minimally responsive to verbal stimuli and entirely unresponsive to commands. Initially, the patient's symptoms were attributed to a seizure (someone from his nursing home had allegedly witness the patient twitching his arms), but the EEG showed no signs of seizure activity. Work-up for any other causes of acute mental status change also came back negative. We later checked an MRI which revealed a new ischemic stroke in the bilateral frontal lobes. This new insult to the brain, combined with the stroke he'd suffered previously, led to a very poor prognosis. Realistically, there was nothing more we could do for the patient. Barring some crazy miracle that would be on par with the David Tyree "helmet catch" in this year's Super Bowl, the poor guy was never going to return to his normal baseline.

So my resident and I called a family meeting a few days ago. We explained everything to the patient's family, outlining what had happened to him and why we believed he had a poor overall prognosis. We felt that the best option was to make the patient CMO - Comfort Measures Only. This meant withdrawing all supportive care for the patient that would prolong his life; the only meds we would administer would be morphine and Ativan to help keep him comfortable. The family agreed with us, but before they officially made the patient CMO, they wanted us to check one more EEG just to make sure there was absolutely no sign of seizure activity (they just wanted to know for sure that there was no reversible cause of the patient's altered mental status). My resident and I decided that seemed like a reasonable approach and obliged.

The EEG report was waiting for me when I got to the hospital yesterday. As we suspected, there was no evidence of seizure activity at all, just slow waves suggestive of encephalopathy (i.e. brain damage). Later that afternoon, when I had a free minute, I called up the patient's family with the unfortunate news. The patient's son agreed to make his father CMO at that point. It was a very emotional conversation for the son. I could tell he was getting choked up towards the end as the reality of what was happening began to fully sink in. I told the son that I was very sorry about his father, and that if he wanted to talk to someone when he came to visit the hospital later in the day, I would be around. And then I hung up the phone and went back to work without even giving the discussion a second thought.

What struck me the most was how nonchalant I felt about the whole conversation afterwards. We could have been talking about the weather, needlepoint, or NASCAR, and I'm not sure I could have felt any more emotionally detached. That's the part I find a bit unnerving; I mean, as a medical student, I used to always get this visceral, emotional reaction whenever I experienced the loss of a patient. That didn't happen this time. And it's not that the patient was some unpleasant person with a nasty demeanor; he wasn't. Or that I didn't feel bad for the family; I did. Maybe I've just learned how to deal with these tough situations better; maybe I have thicker skin; maybe I'm more "mature" now that I possess the title of "doctor." But I doubt it. I think I'm just too busy and too tired to really care about whether my patients live or die anymore. Okay, maybe that's a little too harsh. But there is an element of truth to that statement. And that's the scariest part.

Look, I spend more than half my day at the hospital just about every damn day of the week, I barely have any time to sleep, even less time to eat, and somehow I've been brainwashed into believing that waking up at 5:00 AM on the Sunday morning of the 4th of July weekend counts as "sleeping in." I'm dead tired. Fried. Exhausted. And even though (by some miraculous grace of God) I still haven't killed anyone yet, I have to question just how many of my patients I've really, truly helped. It seems like with at least half my patients, I'm not even entirely sure what's going on, and I'm just blindly throwing spaghetti against the wall and hoping, begging, praying that something sticks. (I'll bet that little confession helps inspire a lot of confidence in our teaching hospitals, huh?) Truth is, I find myself being perfectly content to just stabilize a patient and turf him out of the hospital & off my census. Just stabilize and turf. Stabilize and turf. 

There's this one episode early on in Season 1 of Scrubs in which a "superstar" intern named Nick realizes at the end of the episode that he can't do it anymore and quits. It used to boggle my mind how someone could invest so much time & money into realizing his dream of becoming a doctor, only to walk away after just two weeks on the job. But two weeks into my own intern year, I'm beginning to understand.

"The scariest thing was that I thought he was stronger than all of us. But maybe it's not about being the best. Maybe it's about finding the little things that get you through the day. Whether it's the support of someone close to you. Or letting yourself feel overwhelmed...if only for a moment. Or being selfless every once in a while. I don't know. I guess, in the end, it's about surviving...any way you can."
~J.D. - Scrubs Episode 1.07 ("My Super-Ego")