Hospital-ed

Death, or Birth

 This week I've been in the hospital.  It's fine.  In many ways I've gotten a lot of other things done because it's not so busy as seeing clinic patients all the time.  A few couplets to round on here and there, someone to induce, someone else to rule-out preterm labor in.  There are some old ACOG green journals in the call room which I've been perusing, and reading "journal watch" online for the first time.  Mostly though I've tried to catch up on life things like responsible people do.  Like figuring out if I have car insurance anymore.  And oops, I don't.  Like getting my eyes checked.  And then realizing I've lost my sunglasses, and having to drive home in a near-total white-out of blazing sun.

The other night I delivered a baby without breaking the membranes.  It was a really nice, induced, but otherwise natural birth.  I didn't break the bed down.  The woman did beautifully.  The nurse working with me that night commented to the student nurse about what a nice "veiled" birth it was.  We got to talking afterward about how long she'd worked here (19 years), and I told her she'd have to help me find my way around.  She told me she initially was in pharmacy school, but everyone she talked to in that field felt like they were in some sort of assembly line/factory.  She got out because she wanted more patient interaction.  First she was a tech at the hospital, then she went to nursing school.  And she loved it.  Now she also has a farm near the hospital with 60 chickens, and she gave me some eggs for my kids.  I told her I was looking forward to working with her again.

This morning as I was sitting at the triage station I learned that she had died, unexpectedly, that morning.  The nurses were all in shock.  I know it's not my tragedy, and I barely knew her.  But it really reminded me of the frailty of life.  It could be any one of us.  We're no more protected because we're in the business of bringing new life into the world. Death, like life, is random.  And devastating.  It never gets less so. 

A few minutes after I heard the news, there was a "CODE BLUE, PEDIATRICS" page.  I grabbed the closest reference book I could find and ran toward the door, hoping against hope it wasn't my patient, the one we were rehydrating for gastroenteritis.  "Shit," I said, as I thought about gastroenteritis, and codes.  When I got to the ward, the nurses said "all clear."  It wasn't my patient, and everything was fine anyway.  I wobbled back to the call room and sat down.  I googled all the PALS courses in the area.  Really need to take one of those.  Probably also ATLS in case anyone falls down in the hallway.  Shit.  I forgot I wasn't actually prepared for every possible contingency.  Maybe if I just know enough algorithms, it'll all be okay.

(But can you ever really be prepared for death, whether it's yours or someone else's?  Or life? Or birth?)

Psittacosis

Getting Worked

Yesterday was one of those days.  I got worked.  I showed up to work, and I got worked.  This was big-kid medicine.  In an attempt to gain some control of the situation, I followed the advice of many sage and elder doctors before me, and wrote down my clinical questions.  The trouble is, I couldn't answer even the most pressing because THE INTERNET was BROKEN.  What?  I thought the end of the world was going to be in December 2012.  I was not ready for this.  And it's not like I have room in my doctor bag for Harrison's Textbook of Internal Medicine and Williams Obstetrics and that other Pediatric text what with all the diapers and Thai coins and ACLS cards and 57 different name tags in there.  Here is a small sample of the things I want to review from yesterday: How to safely taper patient off s***-load of diazepam patient has been taking for 10 years while avoiding seizures and panic attacks. How to convince patient this is a good idea. Does Mirena cause low libido?  I know "it doesn't." But does it? How to know if a headache in a hyperactive kid who's been exposed to NAT 9 months ago is ominous or not. It was a day of breast lumps, profuse diarrhea, hypoglycemia to 25.   It was a day of telling people all day long to drink water only, and no soda, and not to eat cookies.  And spending so much time on nutritional advice that for lunch I didn't have time to go to the natural foods store.  So instead found some cookies and soda.  Really. And I hid in the corner and ate them.  On the plus side I walked out of a room to find someone had brought their pet hawk along to their doctor's appointment.  He demonstrated how not to get the bird to bite you.  He had a cage, leather gloves, the whole bit.  If I had known it was show and tell I would have brought my.... rock collection? Who am I kidding, I can't top that. My last patient of the day came in concerned for breast lumps.  Turns out she'd also had some systemic symptoms lately, fever, and diarrhea.  Or not.  Sometimes people live with a vague idea of what is happening in their body, and sometimes you are meeting them for the first time.  The hardest thing in our job sometimes is to decipher what's really going on in someone's body (and in their mind).   I was sufficiently concerned.  I fell back on my triage basics.  Hospital or no?  Urgent work-up or non-urgent?  I decided what I needed to do and discussed with the patient.  She agreed, then I ordered the appropriate labs, imaging, and referrals.  Then I left the room and went to look for cookies. The lab folks found me soon after and told me the patient wasn't going to be able to do the labs because she couldn't afford them.  And if we could only do one or two, what would they be?  I hate these sorts of decisions.  I mean, are we in the developed world or not?  Why should how I treat people depend on their ability to pay?  I like to think it doesn't.  But if they can't afford something and so I cancel some of the labs, then it does.  It just does.  This sucks.

Week 4 - more

On Smart-ness

Something was funny yesterday with the universe.  Charts were missing, and I had a substitute MA in clinic.  The fetal fibronectin test I did on Labor and Delivery was whisked off into the unknown depths of the hospital by the tube system before the nurse could enter the destination "lab."  We didn't know where it went.  Anyway I'm not even sure I got it into the posterior fornix, because I was trying to do it without a speculum for the first time.  It was repeated and both (when the first was found), were negative.  I feel better now. 

Was given an additional patient in clinic because the scheduled provider was sick.  This was an elderly Mexican former caballero c/o hip pain for a hip that was supposed to be replaced 2 years ago.  I bantered with him and made the referral, then he tried to take me home at the end.  Cute-ish?  Maybe creepy?  His teenage son thought so.

Another thing I learned:  I don't know anything about tongue problems.  I remember lots of exciting graphics from medical school.  That's it.  I remember that there were graphics.  If you have an acute tongue problem you should see someone else this week.  But the good news is, I'm reading up on it.

My buddy Niner sent me an article that talks about intelligence.  Apparently folks who believe intelligence is a fixed entity don't learn as much and often are less successful.  What's more, they're more likely to view their failures as devastation.  People who think intelligence is fluid, and can be improved by studying or experience are more likely to learn from their failures and to take them in stride.  They're more successful and adaptable.  This is like when you tell the kids who take a test they're smart, then they don't try as hard later because they're afraid to fail and look less intelligent.  If you praise a child, instead, for working hard on a problem, they'll do better in the long run because the effort is valued instead of the innate talent.

I could have done better, it seems.  I was always told I was smart, and I remember "learning" from some "expert" at one point that intelligence or aptitude was basically fixed genetically.  But now I'm going to be actually smart, and stop believing that.  This year is going to be a learning year.  Every time I make a mistake or doubt my knowledge; every time I kick myself for not knowing something or compare myself to another doctor, I'm going to say the following to myself:  "I am going to learn a lot this year."  And maybe, just maybe, someday I'll be a smart, good, competent doctor.
 

Weekend notes (week 3)

Bed catches baby. I'm still falling.

Had my first call all on my own over the weekend.  Well, actually wasn't all on my own because I was supervising a resident.  It went as follows: couplets discharged home: 1. Term NSVD: 1.  Breech PPROM transferred out for higher level of care: 1.  Babies delivered by bed: 1.  In some ways it felt very natural.  Babies have been being born for the history of humankind despite our attempts to manage the process.  It's a little weird being the attending.  Now I was the one responsible for ensuring a patient was stable for transfer.  I was the one reading the strip (all were good this time).  I had to choose how much to interfere with the resident's delivery and thought process.  She was very gracious. 

I spent a few hours at home, and actually got a good nap in the afternoon with the kids.  But every time there was something going on I felt I needed to be there.  Get this: I spent 10pm to 1am waiting for a lady to deliver, which I was certain was going to happen at any moment.  And then she delivered in the bed while we were across the hall.  So, I guess I was right.  About the imminence, anyway.

Today is Tuesday, 2 weeks from when I saw my first patient here.  Went out with the other newbies to one of those restaurants with a funny Asian play-on-words name.  We talked about where we were from, what our partners did, how we feel supervising residents.  It was a great start.  I need that.  I feel so lost sometimes in such a new place without any anchor.  I used to think I was a solid person in myself.  No more.  I feel like a flighty rabbit, or chicken.  Or piece of paper blown around in the wind.  Or hamster.  Something anyway.  I know I need to cut back on coffee.  I know.  But there's an emptiness I'm trying to fill with constant moving about. Searching facebook. Email. Overanalyzing emails. Texting. Running in and out of clinic rooms. Calling the internet company incessantly.

I feel best when I'm running or hiking.  I need to do that, and not drink coffee anymore.  Right.  Will get right on that.

The Hokey, or Evidence-Based Medicine

Evidence-Based Medicine

Once, during surgery at 2am, the Dragon asked me what religion I was.  I had an unexpectedly visceral reaction to the question, not the blood and uterus in my left hand, and said "That's a pretty personal question."  "Is it?" he apologized.  "I didn't think so."  Then I backpedaled and said "That's okay," and jumbled together some approximation of words suggesting, that, what with all the medicine I'd been immersed in for the past 7 years, I hadn't had time to reflect on the world in that way.  You know, and come to conclusions in an empiric fashion.  Maybe using a spreadsheet.  "Well, for some people medicine is their religion, and that's okay," he offered.  "Yeah,"  I said vaguely.

But here's the thing.  And it's a Sting song, so be prepared.  You could say I've lost my faith in science and progress.  Medicine is most definitely not my religion.  I think I believe in what we do about as much as I believe in anything, which is, not to put a definite number on it, approximately 97.5%.  So there's 2.5% of me that says you know what?  Maybe planetary alignment is what it's all about.  Or perhaps meridians.  Need to look more into meridians.  Maybe Western medicine is just a teeny tiny part of the whole of health.  (I actually am pretty sure that statement is true).  And how about that homeopathy?  Vs. rock crystal energy?

Yesterday at work a new colleague expressed her excitement about us newbies arriving.  Maybe now that we're here we can lend a more academic atmosphere than she's experienced previously.  I smiled and nodded.  Because, sure I can digest and regurgitate research with the best of them.  I can look up my statistics and decide whether a paper is accurately reporting the data or fudging a bit.  And, oh, hellfire and brimstone if they're faking it.  I can teach.  I can work with what I "know."  Every day, in fact, I assume that what I've been taught is true, even though I know a fair amount of it isn't.

Because every medical student finds out in the first few weeks of school that "about 50% of what you're learning here will be found to be untrue in the next 5 years."  And how in the hell are we supposed to work with those kind of numbers?  When a patient comes to see me, we enter into what my dad describes as a "sacred trust."  I'm agreeing to be their healer, to use the best of my knowledge to bring them to health.  Do they know that only 50% of the best of my knowledge is actually true?  And which half?  Of what the board believes is necessary to practice family medicine, I know a fair amount.  I score above average on most tests.  Still, I don't get all the questions right.  My dear, trusted patient, let me get out a pie chart and see how you feel.

And don't even get me started on the pure capitalistic fraud that flies routinely under the radar disguised as "research."  Designed to stuff our heads with "knowledge" that was never known to be true in the first place.  That is another issue entirely.

Even if all the research in the world was done by well-intentioned, non-profits and if every single study was randomized, controlled, double-blinded, do you know what?  There'd still be the unknown.  We'll accept something as fact even if there's a 5% chance the results could have happened by chance alone.  Are you okay with that?

Let's take a math break!  What I know = 85%ish boards material x 50% of that is true x 95% probability that results aren't explained by chance alone = 40.3% under ideal circumstances.  Not great.  60% chance I'm missing something here, something maybe astrology could explain.  Or energy vortexes.

And patients don't follow the rules.  Here's what I think.  People are fantastic, infinitely complex.  And that's personality, physiology, psychology, pathology, all of it.  Inherently unknowable in their entirety.  Just like God.

So there you have it.  I'm an agnostic, medical or otherwise.

I used to see this bumper sticker sometimes on the way to work that said "What if the Hokey Pokey IS what it's all about???"  That, my friends, is the true absurdist extreme of what I believe about the world.  What keeps me up at night.  When the kids and the pager aren't.

But that doesn't mean I can't be a doctor.  I believe in a lot of things.  I just believe I might, just maybe, be wrong.  I believe there's a road in front of me.  There might not be, but I'm going to walk anyway.

And here's the other thing.  I love it.  Every day.  I love experiencing what I cannot ever truly know.  And that includes God, and people, and nature.  And actually maybe those are all the same thing?  I guess I'll never know for sure.

Week 2

This morning I’m in the hospital.  I will be here occasionally in this job.  It is large and daunting but I have found the cafeteria.  It’s not busy this morning apparently and the guy I’m supposed to follow around isn’t here yet.  In fact I may have awoken him with my 6:56am call.  There’s free wireless though so I can do facebook and pretend I’m somewhere familiar. 

Last week was remarkable for the presence of a Day Off.  This is a marvelous phenomenon which apparently exists in the real world of real doctors.  In it, you do not work on that day.  Except probably you spend the whole day unpacking boxes and go for a 4-mile run while the kids are sleeping.  But that turns out to be lovely.  And then when you go back to work the next day it is Friday and so it is only One Day Before the Weekend and you can do anything for one day.  Even if one of the patients requests you get a second opinion from a doctor who "looks older than you do."

Even if you discover in clinic that there are no ortho supplies.  Or crutches.  And you had to send a poor little girl hopping to the ER holding on to her mother’s arm.  That is unfortunate.  You can think about that on your day off.  Actually, maybe you shouldn't.  But you probably will anyway.  Hmmm.

**********

Here are some things I thought about, 10 minutes too late, today.  First impressions matter.  As you meet people while touring a hospital, probably don’t comment on people’s impressively western outfits, or tell them about your previous experiences with mentally ill nephrologists, or let them know about your fringe activities in the medical field.  Probably don’t  try to pronounce their name unless it’s John Smith.

But then I had my first delivery of the likely many to come.  One nice thing about babies is that they all come out in the same one of two ways no matter where you work.   And almost all mothers think at the last minute that they can’t do it.  And then they do.  Lovely little boy.  The thing is that in every hospital all the forms are different and the protocols are different and the delivery tables are set up differently and you’re never supposed to put the laps in the same place.  But whatever.  Babies.

Bless the babies.

Names

There’s a bird

that’s between mourning

dove and whippoorwill, that lives in

those dusty streets I ran.  And

those streets are the other side of Earth

from here.

But here’s the thing:

I don’t know names. To name it

fails to capture what is.  Running down streets bare

feet with fields, firewood burning dust and ashes

falling sunlight filtered red and rosy cheeked.

The haunting calls.

Despite it all I named love.  I named it

to know it and to call it

capture forgets who chose the ring

around

my heart

to keep

the pieces as one

But then what is your name? 

And I don’t want to call it.  Words dance

in a circle of games and eyes and

never speaking the pockets full of

things we know.  Looks to filter

light and laughter and other ways

we are.  If.

And I left that haunt of the bird and I

left the sun and ashes in the dust

and I know it was so long ago but

when we parted the dust

never settled. 

I heard it again today,

here.  The call.

That bird.

Day 4

Well.  I survived the first day of patients.  And the second.  Here is what I learned.  There are many rashes in this world that exist, and which I cannot identify.  Getting an atlas out does help me to generate an impressive differential diagnosis, but not necessarily the correct diagnosis.  When in doubt, I tend to dictate an impressively long note.

Sent a lady for induction for pre-eclampsia.  It was the correct decision.  It felt very, very weird to make that decision.  I felt the absence of an attending like a phantom limb.

Suddenly, I can understand why folks would want to be a PA or NP.  I could be content to fill that role the rest of my life.  I kind of wanted to be a senior resident forever, only be paid enough to support my family.  And maybe have a little autonomy from time to time, whenever I wanted it.  And then have an attending whenever I needed that. 

Once, on our eighth-grade class trip, my friend Bug sent several postcards in the mail without an address or stamp.  We gave her crap about it for years.  Yesterday I gave 2 people prescriptions without a name.  Or phone number.  Or birth date.  Just the medicines, and my signature.  Like, here's a blank check for metformin.

Precepted the resident OB patients in the afternoon yesterday.  That was cool.  Signed a note above the resident's signature, out of habit.  As if they were in fact co-signing my note.  Additionally used perhaps the oldest OB ultrasound still in regular use in the developed world to do an AFI with the resident.  Took my brain several minutes to distinguish amniotic fluid from uterine wall and/or intestines.  Machine is size of mini-cooper, color of emesis.

Today was more of same but less rashes.  Long long notes and diagnostic waffling.  Why is it so difficult for me to make decisions?  I know I'm always like this, actually, but it hasn't been much of a problem before.  Now it's a problem.

I'll tell you what's not a problem:  babies.  Babies can come see me any time of day.  I like them folks.  And I think that 3-month old I saw today liked me, too, a little bit.  She'll never know I was the one ordering the shots.

Day 3

A Brand-New Doctor

First day as a real doctor seeing real patients.  F***.  Why does this scare me so much?  Sort of mini-flipping out.  Had to read Up-to-date summaries in advance of every problem on the list.  Which meant I got up an hour earlier than I needed to.  This is not normal, certainly. All I see in my mind is a graph of y = 1/x.  This is an approximation of how much you remember of what you learned in medical school, where y = stuff you know and x  = time.  I know I don't remember anything about being a doctor.  How do people even do this job?  Also, I'm doing it with a new system of insurances, charts, computers and people.  It's like moving to another country. 

Should I drink coffee?  Would that just make matters worse?  I would either be a. more enthusiastic and forget about my panic or b. have a panic attack.

Tough to decide.  I'll give it another 90 seconds.

Today feels like a day of reckoninng.  What if I went to the wrong residency and I didn't really learn what medicine was all about?  What if my brain has developed an abnormal lesion or metabolic syndrome in the 3 months since I last worked as a doctor, which has caused me to be incapable of this job?  It feels like it, anyway.

Ok.  Calm.  Down.  When I walk in the room, it will still just be me and the patient.  I can still smile at them and do my best to take care of what they need.  Even if I need to look everything up.

OK.  Going to look for coffee.

Day 1

First Day of Work

First day of work.  Headed in.  Once again, didn’t have time to unload the car completely.  More specifically, the roof of the car.  At least this time it’s bikes and not a lawn mower. 

In a way I feel like it’s my first day as an adult.  Sure, I’ve been getting a paycheck for over 17 years.  Sure, I have 2 kids and I’ve been married for 7 years.  Sure, I’ve owned a house, traveled independently, finished a graduate degree and post-graduate education.  Sure, I’m 30 in 2 months.

But for the first time I’m starting the job I trained for.  Literally fought for.  Stayed up all night on multiple occasions for.  Almost lost my marriage for.  And I feel…unsettled.  

Not like when you wonder if you've made the right decision.  I purposely no longer wonder that.  It's a moot point, anymore.

Nervous, like when you get up to give a speech you should have spent another hour preparing.  Like when you're in England and you're not sure which way to hold your fork.  Like taking your drivers license test for the first time, and you almost hit the car next to you while backing out, and he passed you anyway.  And now you're on your own.