ID compared to House, MD

It is Medical Monday, yet again.  Actually, I feel like it has been a long time since the last Medical Monday.  Either way, it is time to hook up with some other medical related blogs for some medical and Monday-ish goodness.

As some of you who read this blog regularly know, I am currently on an Infectious Diseases rotation and I have likened it a bit to the TV show House, MD.

I have been giving it some thought (and noticing the continued strange popularity of my post General Surgery Is NOT Grey’s Anatomy) and decided that it is time I both prove and dispel some more TV related medical show perceptions, this time referring to House, MD.

First of all, why House?

For starters, it is one of the other medical shows I watch(ed).  Also, when I think of real medical specialties that are kind of like “diagnostician” I think Internal Medicine and, more specifically, ID or Rheumatology because they get to see some of the weird and wonderful.  And I am sure in some big places, someone really is a diagnostician specializing in the really complex cases.  That being said, it isn’t a residency or a common position.  At least, I don’t know any, so this is my reasonable facsimile.

The similarities:

  • There really is a gaggle of people who deal with the complicated cases.
  • People do sit in a group and bounce ideas off of one another complete with internet and journal searches and a white board, or more commonly, a sheet of paper.

    Image from teichdoesmedicine.blogspot.com.

  • Someone who is generally much smarter than everyone else does lead the pack (and sometimes bosses people around).
  • Often times, much of the staff are not fans of the person in charge of the hospital.
  • Patients do lie.  For reals.

    Okay, not everybody. Image from Iamilliontrees.net.

  • The days can be crazy long and chaotic, but also interspersed with mind numbing waiting and boredom (or time for other antics).
  • When you just think you have someone or something figured out, there is a twist (sometimes).

    Image from eatliver.com.

  • Sarcoidosis, lupus and obscure infections are often somewhere on the differential.

    Or is it? Image from http://www.quickmeme.com.

  • You do have to work in places you don’t always like to or want to in order to keep the hospital running and such.

The differences:

  • Patients do tell the truth.
  • One does not generally have a team of fellows who were staff in every other area of the hospital.  Those people often just stick to their own jobs.
  • You can’t just go around running your own lab tests, diagnostic scans and procedures all willy nilly.  There are people specially trained to do all of those things better than the doctors on the show.
  • You would lose your job for screwing around with a clinical trial, stealing drugs, blatantly endangering patients, etcetera.
  • A good start to making a correct diagnosis is a good history and physicial.  They tend to skip that step.
  • A next important step to a correct diagnosis is doing the correct diagnostic test.  Most of the scans they do aren’t appropriate and then the images are not actually of the scan they claimed to order.  In fact, they often put the patient in the incorrect machine.
  • You can’t order everything STAT.  That would make “STAT” routine.
  • There are more staff in the hospital than the “Diagnostician” and a lone oncologist who happens to treat EVERYONE (including children) with cancer.

    I do quite like their bromance, though. Image from tinyobsessions.wordpress.com.

  • As a consultant, you consult, not make all the decisions.
  • People don’t code that often.  At least they don’t code that often and survive.
  • Patients die.
  • Sometimes you just don’t figure out the answer and the person either dies or gets better and you don’t know why.  That isn’t a failure.  Just life.
  • Breaking into someone’s home, car, workplace and so forth is a felony, not medicine.
  • It takes much more time to figure out complicated and novel cases.
  • You can’t just throw drugs at people (or take them away) and expect them to get better.
  • If it walks like a duck and quacks like a duck, it is probably a duck, not a zebra.  House almost always gets the zebra.
  • Sometimes, it really is lupus or sarcoidosis.

    Image from housemdconfessions.tumblr.com.

  • Nobody would let you practice medicine on that many drugs.  No matter how good you are.
  • You can’t just go taking over in the OR, bursting into the OR or really, doing anything in the OR if you are not currently practicing as a surgeon.

    No. Just, no. Image from housemd-guide.com.

  • There is a financial and ethical limit to how much you can and should do.
  • Doctors aren’t immune to whatever the guy in the bed has.

1 in 4: Lessons in reality on the transplant unit.

I have spent the last almost month now on a bone marrow transplant elective.

I always throught I would like to be involved in transplantation.  I get that in my field, it is a small role, total body irradiation for certain indications, but nonetheless, it is a contribution, and I thought being a part of that team would be fascinating.

I have obviously been working more from the hematologist (and thus, the more involved) side of things.

I love it.  I might end up stuck at work late most nights and skip meals because it is too busy to eat properly (but really, how is it that much different from most rotations), but it is fascinating stuff.

The thing is, it is different from what I expected.

My perspective of bone marrow transplants is romanticized.  When I thought transplant, I (despite my previous criticisms of the realism of the books) pictured something from the pages of My Sister’s Keeper or one of Lurlene McDaniel’s books.  I saw them as tough and filled with complications, but also as a cure and this glorious saving grace.

Transplants are these things.  But, there is so much more to them than what the books suggest.  I feel like books and movies make them seem like a cure-all thing, but they aren’t all the time.  And although complications are addressed, I feel like they aren’t portrayed as the potentially fatal things they can be.

You don’t just go getting transplants all willy-nilly.  They are for people meeting specific criteria.  For people who are otherwise healthy and for people who have some baseline reserve.  They are generally for people who are at risk of dying from their disease sooner rather than later if they don’t go to transplant.  They are serious business.  And continue to be long after the transplant is done.

The bone marrow transplant hematologist I am working with this month is cautious to remind us regularly that there is a good chance any one of our patients could die.  Even if we do everything right.

He says it is one of the toughest parts about doing transplants  1 in every 4 or so people he develops a relationship with dies.  This is tempered with some lower risk transplant variants where it is only 1 in every 10.  But still, average that out and you still have 1 in every 5 or 6 dying.  And there is still the risk of relapse and such in the long term.

Kids do better than adults.  These odds are adult odds.  Kids tolerate everything better.  That is just how kids roll.  They can take so much more than adults can.  I am glad for that.

I know, this from the oncology resident who loves palliative medicine where 99.9% of people die.  But, you know that going in.  You know there is no cure.  This is a potentially curative treatment.  That is tough to go through and a good chunk of these people die.

I am okay with the odds.   I get that the odds of survival in transplant in the setting of malignancy are better than the odds of surviving their disease without treatment or with other treatments.  That is the only way you can really justify going through it.  People are referred for transplant only when survival post-transplant are higher with than without it.

Plus, flip the odds around… 3 in 4 survive, 9 in 10.  That sounds decent, I think.  Especially compared to what it would be without treatment.  Tough stuff, but realistic stuff.

I have watched people do well with transplants.  I have seen people come in with brutal side effects and consequences of transplant.  But, they are alive.  I have had people horrendously sick one week come out of it looking great and running into me on the street after they get out.  I have had others who came in looking great and have tanked.

Known risks.  Known benefits.

Everything in life is like that.  In the oncology world, these risks and benefits can be extreme.  Sometimes the odds and the risks blow my mind.  Seeing us making people so sick with toxic doses of chemotherapy and then saving them with stem cells.  Watching someone hover at risk of infection, of bleeding trying to keep them comfortable and safe and hoping that their body recovers their blood cells before things get out of control.  Watching someone recover their counts and their life day by day.

When it comes down to it, when you look at the data, some risks are worth it.  And there are always those who defy the odds in either direction.

The transplant patients I have worked with have been some of the toughest, bravest and nicest people I have worked with.  That is probably part of why I shudder when my staff doc reminds me again that there is a chance the person won’t survive, even if I do everything right.  At least, I am learning how to do things right.  And be realistic while being supportive and caring.

I am glad for this experience.  For the realistic perspective I have of bone marrow transplants I have gained.  And I still want to be involved with them because they save lives and buy time for so many.

Sometimes, I still wish it somewhere near as simple as it seems in fiction books.

You know you have done a lot of dictations when…

Today I did something super embarrassing.

I had been doing dictations.  For those of you who aren’t forced to articulate their correspondence in this archaic form, this requires you also stating your punctuation (because stuff like that isn’t obvious to the lovely folks who sit and listen and type it).   That means, you actually say “comma” or “period” and things like “new paragraph.”

If you have ever done a dictation, you know they are an acquired skill.  You feel so stupid at first saying these things and it takes twice the time to get all your thoughts out in a semi-organized form than it would to type. And then, you see the typed form and you realize how stupid you probably did sound.

It does get better, but I would love to do a randomized controlled trial regarding whether or not dictating is more efficient and accurate.  I am sure experience is a factor.  And tech savvy-ness.  But, it stuck for a reason, I suppose.

Anyway, I did a few dictations and then there was a small disaster on the floor that required me to make some frantic phone calls.  That is fine.  Then, I realized I wanted to cancel one of the procedures I had requested an hour before based on the turn of events.

I made a call, which went to after-hours voicemail that went something like this (with my verbal punctuation bolded):

Hi, this is Trisha _____, the resident on BMT calling regarding patient X.  I had spoken with someone earlier regarding getting a line replaced on John Doe tomorrow morning period.  As it turns out, we do have good access comma so we will just remove the old line and get in touch again should we need something else placed in the future peri… Agh.  Sorry.  Thanks, bye.

So embarrassing throwing random punctuation into a voice mail, then kind of apologizing.  I wish they wouldn’t laugh at me.  But if they do, I hope I at least brightened their day with my stupidity.

And… Switch.

It is switch it up day again.

I still hate changeover days.  I don’t like the unknown of going to a new rotation.  I dislike finding new offices, sorting out times to go to new clinics and all that stuff.  The unknown kind of sucks.

I was really sad to leave Peds Onc.  Minus my episode of semi-depression after the first week and a half, it has been a fabulous rotation.  Kids and Oncology… Not much else more to love!  At least to me as an Oncology resident who not-so-secretly sometimes wonders if Peds is the place for her.

Seriously, it was a great rotation.  I learned how to do cool things like lumbar punctures (poking needles in spines… and administering chemo) and bone marrow biopsies.  And I don’t even like procedures, but those are similar to taking blood and I do get strange kicks out of taking blood.  I learned a ton about kids cancer and chemo drugs and such.  But the bigger piece is that I got to know some super awesome families and play with some fabulous kids.  I actually followed some kids almost weekly in clinic, and a few of them I followed from diagnosis as an inpatient.  In the world of a resident where you are forever darting in and out of services, that kind of consistency is pretty exciting.

Now, I am off to Family Medicine.

My Dad that I should get a by and not have to do it given the med school I went to.  Not so much.  But it is true, I have already done over 12 weeks of Family Med and another 4 of general community Internal Medicine (which in some contexts is still a lot of primary care).  That makes me feel prepared for the rotation, at least.

Family as a med student was one of my best and one of my more liked rotations, but part of that was the doc I worked with was a person I got along with famously.  It helps.

My orientation was good.  The clinic is nice.  I am fascinated by the electronic medical record.  It will be my first time using one in a non-hospital setting.  I am intrigued because I am very pro-EMR (seriously, I wrote a whole health systems paper on them during undergrad).

I start with my first patients tomorrow in clinic.  Whoo.  I find the hardest part is figuring out what people want and what things I need to review and what things I need supervision for.  It seems everyone is different, so it is always a process.

The thing I am most angsty about is that the service also covers their own obstetrics.  Although this isn’t the main thing I am supposed to be doing, I may have to go to a few deliveries (so not my thing), although I will be thrilled to do some prenatal visits (my favourite thing after seniors and babies).

Such is the adventure of new rotation.  You take the good with the bad and figure the rest out as it goes.

This is rotation number 12 of residency.  Our physics exam is at the end of the month, then we are done that for the “year.”  I will no longer be a PGY 1 in just two months (eep).  It is crazy how this stuff flies by.

“Special” Days

It is Pi Day!  Happy Pi Day to all the nerds like me out there.  Pi is my second favourite irrational number with my first favourite being Euler’s number.  I wrote about this whole number thing in this post.

Today was also first day on yet another new service day, as well as first Gyne-Onc call shift day.  I like Pi Day better.  Although, at least this service has oncology in the name.  That makes it seem a bit more relevant.

Patrick likes to inform me at random about days that are entitled ___ Day.  He just out of the blue will say, “Hey, did you know it is Women’s Day (or Talk Like a Pirate Day, etc.).”  When we were dating, he would occasionally send me festive e-cards for a particular “day.”  Once, thanks to a very big ecard error in dates, I received an ecard he had sent me on a completely different date over a year earlier on a completely unrelated day.  It was for something not quite so obscure like St. Patrick’s Day, so I just thought he was being weird.  Turned out, the internet was being weird.

I am not a festive person, but having random days for things can be kind of fun.  At least sometimes.  At other times, it is just plain annoying.

For instance, my birthday is apparently “Hug Holiday.”  What the heck?  I hate hugs (for the most part).

Today is not only Pi day, but also National Potato Chip day and Learn About Butterflies day.  Fascinating.  I feel we need to go out and pick up a bag of chips after work… I like chips better than pie and it will make call better.

The other night was my last Internal Medicine call (big win!).  I had a suspicious feeling it would be eventful for a number of reasons, including that my parents were visiting and I wanted to go out with them the next day, but also that, well, it was my last call.  Apparently, it was not a full moon, but people were all squirrely and doing things like leaping out of bed and breaking hips and all sorts of colorfulness.  I deemed it the night of delirium, though I could have also called it more interesting names like the night of the walking (er… falling) confused or last call, but really delirium was the biggest trend.  Such is medicine call.

When I was in Nuc Med, this one time, we had a bunch of renal scans, which are a bit more labour intensive than your usual bone scans and cardiac scans (at least in that it involves a different radiopharmaceutical) and we deemed it renal day.  We also once had a technologist appreciation day during which all of the students baked stuff and shared it with the techs that helped teach us… It could also have been called find an excuse to eat excessive baked goods day.

This weekend, this small theatre locally is playing old-school To Kill a Mockingbird for a discounted rate.  I really want to go see it and keep reminding Patrick about it.  I am calling it To Kill a Bird weekend… Because that is what I called the book in high school.  And I need to pretend the weekend is special somehow, even though that will really only be a two hour block of time and it kind of sounds morbid.

If I had to pick a day that is “official,” I think, at this point I would choose either July 13, “Embrace Your Geekness Day,” or July 15 “Cow Appreciation Day.”  Although, close runners up would be November 6, “Saxophone Day,” May 14, “National Dance Like a Chicken Day,” or September 29, “National Coffee Day.”  The good thing is that they all fall on separate days, so I can theoretically legitimately celebrate all of them!

Pre-Vacation Hurdle

All that is standing between me and a week of vacation is a single Saturday Internal Medicine Medical Teaching Unit (MTU) call.  And I am already in the midst of that.

I have one of those giant smiles on my face like one of those ridiculous animal memes just thinking about it.

Image from catpicsomg.com.

This is my last weekend MTU call.  Cue giant smile again.

I must say, I do love internal medicine.  That or peds (aka children’s internal medicine) are my two second loves after the whole oncology/palliative medicine thing.  I love the puzzles.

I do not love medicine call.  It is busy.  I don’t know almost any of the patients (although month two of covering this call has enabled me to know some about some of them).

The worst part is for some odd reason, I always get scheduled for Saturday call on the weekend.  Now, you may be thinking, “Gee Trisha, it is one day of 2 kind of 3 weekend days to be on call, why so glum?”  Well, Saturday call is the worst weekend call of all.  Actually, Friday and then Sunday in-house is the absolute worst, but that is less scheduled because if you do that, then you get your two “weekend” days a month in.  What winds up happening to me is that I get two Saturdays.  Doing Saturday call means you work from 8 or 9 Saturday morning until 8 or 9 Sunday morning.  Thus, you lose your whole Saturday minus a slight sleep-in and then basically lose your Sunday too due to overall sleepiness.  Oh, and if you are an old lady like me, you also lose a piece of your Friday night because you have to go to bed at your regularly scheduled time in order to not want to die on Saturday.

There are some bright sides to medicine call, particularly medicine weekend call.

I am going to list them for you, even if you really don’t want to know.

  • I am not on one of the teams, so I don’t have to round in the morning.  That means that although I am required to be in hospital and ready for pages, the team is there rounding until at least 11 or 12, so I really don’t have anything to do except sit in the library and do things like work on my research, or write blog posts or stare longingly at the sunshine outside the window.
  • People go for fewer tests on the weekend and have fewer interventions.  That means fewer complications or problems that arise.
  • Based on the first two points, I get more studying, emailing and other work done on weekend call days than entire weekends when I am off.
  • I basically roll out of the bed in the morning and don my sexy scrubs.  And stay in them for 24 hours.  It is basically kind of like wearing awkward pajamas for a whole day AT WORK.
  • Call stipend… Well, it is something.  Even if you work it out and realize that you are getting paid under $5 an hour to work on a weekend.
  • And this weekend, there is an added bonus that I get to hide out away from my sick husband in hopes of avoiding (unlikely) his influenza-like illness he likely contracted from the kiddos (my chances are already better than his at surviving, as I got my flu shot).  I know, I am hiding in a hospital, but nonetheless, the patients don’t generally kiss me.  I also know that the incubation period is such that I probably already have it.  And I was with him all last night when he felt worse.  Still, let me have my positive.

So, just a day and night from vacation, I am.  And I am excited.  Which is sad, given my only definite plans for the week include a dentist appointment, an attempt at making a doctor appointment and cleaning/redecorating the apartment.  Oh, and possibly helping the Child decorate their new apartment.

Adulthood-type vacation does not look so becoming right now.  We will have to fit something childish in… Possibly skating at the outdoor rink up the road.  Or staying up late.  Weeknight movie, perhaps?

Next weekend heralds the start of March break at home-home, so we are becoming a hotel for the week with visits from L&C and then V&D.  I am not wishing my vacation away just to get to those fun bits, though.   Although I am pumped for the visits from the besties and their spouses!

One of THOSE days

Have you ever had one of THOSE days?

One of the days where doing your job… The job that you love and feel called to do feel feels like a chore.  Where duties that you like are enough to make you want to gouge your eyes out and you drag your feel at every step?

That was my today.

Well, at least that is how my today turned out.

It started out like any other day doing routine morning rounds on the inpatients when I got a call about one of my sicker and more complicated patients.  They weren’t well and were asking for the attending to come see them.  Instead, they got me.

Needless to say, although we like eachother (I think) they weren’t thrilled to see me.  And I really couldn’t do very much at all to help, except hold hands (until I got yelled at because I was limited in what I could give or do until I spoke with someone else).

And thus began a roller coaster of a day.  I somehow managed to speak to every consultant involved during the course of the day, some of which have starkly different opinions and approaches, all of whom want me to in speaking with my staff have a million changes happen.  And some of them are discongruent.  And I seem to be one of the only common points of discussion except the patient.

As the day went on, I found myself caught up in a he-said she-said drama and somehow managed to get paged at least once an hour about some sort of issue with orders, a need to reassess a new symptom, talk to a new family member/team member and yet still needing to do the rest of my work.  And I still needed to complete my other regular duties (not that they are particularly heavy at the moment, but nonetheless they do exist and I missed rounding with staff on our other patients and teaching and part of clinic due to this important, but relatively non-life threatening conglomerate of events…)

Normally, I would take all of this in stride.  But, by noon, I was frustrated with being pulled in different directions, tired of having to go back to that floor every time I tried to leave and annoyed… Not with the patient or their family or the team, none of this is within their control (one might argue the team could do better, but it is really complicated), but with the whole package and with myself for being annoyed.  I began to feel resentment at whomever was the source of my pages.  A little voice inside my head wanted to yell “No, I don’t want to go up and reassess the patient!”

But, I didn’t do that.   I took a deep breath and prayed for the patient and for myself.  Then, I smiled and ploughed on.  There was a lot of fake it until you make it happening on my end today.

I feel awful when I don’t want to see patients or when I get annoyed with people calling me.  It is my job and it is their job.  I try not to show it ever and it doesn’t happen often, but sometimes, it really can be a struggle. Sometimes calls or duties that are not necessary happen.  Sometimes you work with people who you don’t always enjoy spending time with.  Neither of these sometimes were in this situation, this was more of a sheer volume and confusion thing.   And often, it snowballs and the feelings get more intense if I don’t do something to calm down and regain perspective.

Was I the picture of perfect?

Nope.  I sighed and occasionally rolled my eyes while writing notes.  At one point I contemplated throwing my pager out the window.

By the time the afternoon was starting to come to a close, I thought I was in the clear.  But, then I had to go do a procedure.  Which, of course, like the trend of my day was not without complication and then a page from my staff wanting to see the patient immediately after (which turned out to be longer than they would have liked).

This all made me think of this song by (one of Patrick’s favourites) Mark Schultz… Including the getting the name wrong piece… One of the staff I work with is convinced my name is Krista, no matter what I tell him.

I would like to say I was never so happy to go home, but as it turns out, I was on call.  I missed the last shuttle to the other hospital, so I had to power walk with all of my stuff.  Where it has been busy since my arrival up to right now.

But again, there is something to be said about keeping my cool.

I know the nurses appreciate it.  And as irritated the patient and family are with the circumstance, they probably prefer me to be calm and pleasant (I hope anyway…).  And I always appreciate people who are nice, especially if I expect them to start getting annoyed.

The day is far from over.  And, to be completely honest, I want nothing more right now but to go home and curl up in the fetal position next to my husband. However, I look at it like this… I am usually happy.  I love what I do.  It was a bad day and things like that happen.  I remind myself I did my best.

I am far from perfect.  I know I wear my emotions on my face.  I have been told that before.  So, I am sure someone along the way picked up on my frustration or angst or fatigue.  And sometimes I overcompensate.  But, I like to think I was still helpful and open and wiling to try at a times (and they were multiple today) where I could have thrown in the towel or avoided the situation.

Tonight, I still feel on edge.  I still feel bitter about a ton of things that happened.  I also feel good about some of the things that happened.  About what I learned.  About the progress we made, even if it felt small.

But, the cool part of it all is that this is just one day in a million. There will be other bad days, but there will be many more okay days and some awesome days too.

The other cool part is how great God is at getting me through the suckyness without gouging out someone’s eyes.

Without Him, I would never have the patience or the perseverance to deal with stuff.  As strange as it may sound to some of you “Trisha is all crazy and Jesus-freaky sometimes” folks, the brief pause to say a prayer is time to gather myself.  And my premorbid personality is such that I get annoyed with inefficiency, disorganization and complaining, three things that today was full of.  So, without big changes that have taken place in my life, this would have been much worse.

I also firmly believe that God acts in some of the tough situations to help work things out.  Can I prove it?  Not especially, but I still believe it (maybe I am crazy, or maybe I have seen some pretty weird things work out the right way).

And God keeps my perspective right.  Again, this is something people can do without God, but I like having Him in the equation, I think it makes it easier.  But, I try to see people how God might.  With love, with respect and I try to treat them as such, even when I don’t want to.  It is hard.

I guess you could say I tried to Golden Rule-it-up today by treating others how I wanted to be treated.  And some of them treated me nicely back… Even though their days were clearly going poorly too.  Funny how that works?!

Sometimes, I think people need a V-8 (remember those V-8 commercials where people would smash others on the forehead?  No… Well, I do.).  It isn’t always my place to give it.  And some days, I do too.   And sometimes there doesn’t seem to be anyone to crack me on the head.  So, you get through it and carry on.

When you love what you do, when it is a calling, not just a career, having one of THOSE days is not enough to make you want to quit, but it is enough to require you to take a step back and breathe (and possibly consider taking up some bad for you habit as a vice), but then carry on happily (maybe not quite that same day, but a few days later).

Musical Call Interlude

I am on call.

It is busy.

And yet here I am writing… Suspicious.

In my defence, there is a lull, but I can’t sleep because I need to check one more piece of blood work pending or I will be rudely awakened before I even settle.

I have selected two songs and lyrics that have been running through my head as appropriate call theme songs.  I will share them with you now while I await late night blood work before hopefully getting a bit of a power nap in.

Song number one… “Some Nights” by Fun.

Some nights I stay up cashing in my bad luck
Some nights I call it a draw
Some nights I wish that my lips could build a castle
Some nights I wish they’d just fall off
But I still wake up, I still see your ghost
Oh, Lord, I’m still not sure what I stand for oh
What do I stand for? What do I stand for?
Most nights I don’t know anymore…
Oh, whoa, oh, whoa, oh, whoa, oh, oh,
Oh, whoa, oh, whoa, oh, whoa, oh, oh
This is it, boys, this is war – what are we waiting for?
Why don’t we break the rules already?
I was never one to believe the hype
Save that for the black and white
I try twice as hard and I’m half as liked,
But here they come again to jack my style
That’s alright;
I found a martyr in my bed tonight
She stops my bones from wondering just who I am, who I am, who I am
Oh, who am I? Mmm… Mmm…
Well, some nights I wish that this all would end
‘Cause I could use some friends for a change.
And some nights I’m scared you’ll forget me again
Some nights I always win, I always win…
But I still wake up, I still see your ghost
Oh, Lord, I’m still not sure what I stand for, oh
What do I stand for? What do I stand for?
Most nights I don’t know… (oh, come on)
So this is it. I sold my soul for this?
Washed my hands of that for this?
I miss my mom and dad for this?
(Come on)
No. When I see stars, when I see, when I see stars, that’s all they are
When I hear songs, they sound like this one, so come on.
Oh, come on. Oh, come on. Oh, come on!
Well, that is it guys, that is all – five minutes in and I’m bored again
Ten years of this, I’m not sure if anybody understands
This one is not for the folks at home;
Sorry to leave, mom, I had to go
Who the f*** wants to die alone all dried up in the desert sun?
My heart is breaking for my sister and the con that she call “love”
When I look into my nephew’s eyes…
Man, you wouldn’t believe the most amazing things that can come from…
Some terrible nights… ah…
Oh, whoa, oh, whoa, oh, whoa, oh, oh,
Oh, whoa, oh, whoa, oh, whoa, oh, oh
The other night you wouldn’t believe the dream I just had about you and me
I called you up but we’d both agree
It’s for the best you didn’t listen
It’s for the best we get our distance… Oh…
It’s for the best you didn’t listen
It’s for the best we get our distance… Oh…

I just love this song for a variety of reasons.  A bit because it is great and catchy (I have referenced it previously in my posts), but it is call appropriate just by title “Some Nights.”  Plus, it talks about staying up cashing in bad luck and then others you always win and such.  If you have ever been on call with me, you would learn that I either have great or terrible call karma.  Plus, the whole concept of people not understanding and the whole thing being a bit of a cause for loss at times.

The second song is Paramore’s “Fences.”

I’m sitting in a room,
Made up of only big white walls and in the hall
There are people looking through
The window in the door
they know exactly what we’re here for.
Don’t look up
Just let them think
There’s no place else
You’d rather be.
You’re always on display
For everyone to watch and learn from,
Don’t you know by now,
You can’t turn back
Because this road is all you’ll ever have.
And it’s obvious that you’re dying, dying.
Just living proof that the camera’s lying.
And oh oh open wide, ’cause this is your night.
So smile, ’cause you’ll go out in style.
You’ll go out in style.
If you let me I could,
I’d show you how to build your fences,
Set restrictions, separate from the world.
The constant battle that you hate to fight,
Just blame the limelight.
Don’t look up
Just let them think
There’s no place else
You’d rather be.
And now you can’t turn back
Because this road is all you’ll ever have.
And it’s obvious that you’re dying, dying.
Just living proof that the camera’s lying.
And oh oh open wide, ’cause this is your night.
So smile.
Yeah, yeah you’re asking for it
With every breath that you breathe in
Just breathe it in.
Yeah, yeah well you’re just a mess
You do all this big talking
So now let’s see you walk it.
I said let’s see you walk it.
Yeah, yeah well you’re just a mess
You do all this big talking
So now let’s see you walk it.
I said let’s see you walk it.
And it’s obvious that you’re dying, dying.
Just living proof that the camera’s lying.
And oh oh open wide, yeah oh oh open wide.
Yeah, oh oh open wide,
‘Cause you’ll go out in style.
You’ll go out in style.

I think of this one almost every time I am on call.  Clearly that makes me emo or something.  But, beyond that, it fits.  Sometimes, you just have to let people think you would not rather be anywhere but where you are, and you feel on display.  Even if you aren’t really anything but a mess like everyone else.  And I feel as if I am at the point where I can’t go back… This is what I will do for my life.  I am happy with it, but nonetheless the line resonates with me.  Then there is the whole dying thing… Sometimes that is more me in my head to people.  Plus, the whole big white rooms and endless halls… Seems pretty hospital like for me.

And thus concludes my musical call interlude.

Not JUST an R1 and other difference making moments.

Today, I was answering my attending’s pager and a GP calling from outside the hospital said the nicest thing to me.

It is my first day doing GI consults, which can be rather interesting.  I find consultation services fascinating because you get to see people with all sorts of problems for all sorts of other problems.  The bigger the puzzle, the better in my books and I saw a couple doozies today.

In fact, in one of them, someone with some liver test abnormalities, I solved the puzzle without prompting thanks to my time spent on the liver service!

Anyway, back to my story… So, I answered the third outside call of the day.  The people calling expect to get the specialist, not the junior resident.  And normally this person is excellent at answering.  But, because they were mid-scope or mid conversation, I was sent to answer, so at least the person would get a response and some interim advice before the attending could call them back.

I heard the whole story from the GP and agreed that the person needed to be seen and that things weren’t right (but I had no clue what else needed to be done or in what timeline exactly), so I told the GP that, “I am just the R1, so I can’t really make any suggestions,  but I will get my staff to call you back when they get a moment.”

The GP responded, “You are never JUST an R1… You are a part of the team.  Had you not answered, I would have been stuck waiting by my phone.  At least now I can say I talked to someone and they need to check into things.  This is how you learn.”

Such a nice thing to say.  A simple and obvious statement, but one of those things that you need to be reminded of.

I know that deep down inside.  But, sometimes, especially on a consult service… And new to that service, you feel as if you are just a middle man.

But, that is what I am there for.  To help people.  And to learn.  And part of that learning and helping is answering calls and consults that I really can’t do much about besides take a good history and physical and do some reading around it.  And once I review it with staff, I learn.  And next time, maybe I will know what to do for real.  Or at least have a better educated guess.

I am so thankful for people who understand that situation.  Who take time to teach or understand that I am learning.  It makes a world of difference in my day.

Other world of difference to my day moments were less profound.

I woke up and Patrick informed me that I slept through yet another Habs win.  On the bright side, I stayed awake to the end of the second period (I sure felt it this morning, though).

I finally pulled that darn grey hair out of my bangs.

I realized that the cold Patrick gave me last week has now had me talking like a man for a week.  I think there are people I have met on several occasions now who may think I just have a husky voice.  And for some reason, that strikes me a little funny.

It was unseasonably warm today, so I walked home without wearing a hat and mittens for the first time in ages. Also, I left work at 5 and it was still somewhat light out when I got home.

Clearly, my life is exciting.  Thank goodness that doctor was nice.

Morphine and Hand-Holding… When the word “fix” changes meaning.

Sometimes, we, as humans, are helpless.  Subject to the needs of our biological bodies and in a position where we are doing well simply to breathe.

Babies, despite being tough little cookies are helpless.

And sometimes, when we are critically ill or dying, the same phenomenon can take place.

Life comes and life goes.  That is how we were made.  Our Earthly bodies are finite.

We celebrate birth, but fear death.

Birth and death are not two different states, but they are different aspects of the same state. There is as little reason to deplore the one as there is to be pleased over the other. –Mahatma Gandhi

I have been covering call for the internal medicine floors.

I love internal medicine.  You can help a ton of really sick people with complicated disease get better.  The thing is, lots of sick, complicated people don’t get better.  At least not in the sense that most doctors or other people, for that matter, want to see.

I got called a couple times overnight to see someone.  A new admission.  Who had recently been admitted, but got better and went home.  And was now sick again.  Sicker.  This person had decided after past experiences to refuse intubation or other breathing assistance aside from oxygen.  So, we were treating the underlying disease and hoping for the best.  Otherwise this person would be in ICU on a ventilator.

I went to see this person, curled up and looking tiny in the big hospital bed.  Just breathing.  Breathing with every muscle in their body despite the high percentage of oxygen mask on their face.

I politely ask how the person is doing.  I knew the answer.  It was written all over their tired face.  They couldn’t breathe.  And as the med student behind me said later, we really weren’t doing much about it.  Some oxygen, some steroids, puffers and antibiotics and crossing our fingers.

I don’t know if you have ever not been able to breathe.

I have.

It is a terrible feeling.

So, I can only imagine how terrifying it would be knowing that you may very likely die from this distress.

We listened to her lungs.  Held her hand.  Asked if there was anyone we could call.  The answer was no.

I went back and looked at the orders.

Nothing for anxiety.  Nothing for pain or to ease the struggle with the breathing.  The plan was ICU until very recently.  And other issues until the situation became more grave made the use of anxiolytics and narcotics not the best idea.  But now, as the nurses said, they basically sent her to the floor to die or get better, whichever came first.

On-call residents are not supposed to change the management too much.

But really, sending me a possibly dying patient without palliative orders is unfair.

Not using invasive measures to sustain life does not equate giving up.  It just means that we don’t violate the pulp out of a person for what may be a non-existent benefit.  However, people who do not have CPR or ventilation often still receive other treatments to help their underlying problem by treating infections, diseases or symptoms.

Sometimes we withdraw everything except for comfort measures. But this decision comes with even further discussion with the patient and family and looking at other things in the picture like the stage of the disease and the goals.

At this point, this person was having their disease treated.  They still had a small but reasonable probability of recovery with treatment of the underlying problem, although their chances of coming off of a ventilator were slim.  We were also managing some symptoms, but they were still having significant difficulty.

I wrote an order for Ativan and for Morphine.   I had a good chat with the student about providing comfort care regardless of the prognosis, but especially when people are end-stage.  I showed her how the blood gases showed the patient was tiring out and medically needs intubation.

I looked in on the patient before heading to bed.  Still curled up and puffing away, but asleep.  I whispered a prayer and went to bed.

I was called to that floor a few more times over night.  Never for that person.  But, a few others with more “fixable” problems.  Things that feel miserable like shortness of breath and nausea, but that are often managed easily with some reassurance that the medications we ordered with soon kick in and they will likely feel better.

There is something satisfying about the easy fix problems.  Knowing that they likely will get better.  Knowing the next step if they don’t.  Or that someone else probably does.

Plus, easy fix problems are ones that can be resolved quickly or at least easily and thus we all get more sleep.

Even in people who are at a point where their problem cannot fix, there are easy fixes.  Sometimes, a simple change can resolve the unpleasant symptom, like the feelings of smothering.  Or holding IV fluid overnight in someone who is beginning to go into heart failure because their kidneys have now stopped working.

There is also something satisfying about seeing someone sleep after a night of feeling like they were dying, even if you likely didn’t change anything big.  At least you gave them some peace while you wait to see if the other solutions will work.

But, there are things that aren’t easy fixes.

There are the obvious difficult situations like complex critical illness, people who are so sick you can’t leave their side, those that need monitoring and multiple medications.

Even once people are beyond those things, there are still tough fixes.  Like fear.  Or loneliness.  Or the knowledge that death is imminent and you are scared.

Sometimes staying awake after a simple call and holding someone’s hand while they breathe and sleep is more satisfying than reviewing the second chest pain (that almost always is nothing) of the night.

The patient was still alive when I went home.  Still looking terrible, but less anxious and ever so slightly better on paper.

Things are complicated.  People surprise you.  People you expect to die live and vice versa.

We are all human.  We all deserve good care.  Even if it is the end of life.  We put tons of money and time into babies (and we should).  But, why not our elderly too?

I love internal medicine.

We get to fix people.  Even if it isn’t always in the way we conventionally use the word “fix.”