Blow-by-blow: On Call

Here’s what’s going on right now.

I’m eating an apple. By all appearances it’s a Red Delicious. But it tastes too good. It’s not mealy, and it’s sweet plus tart.

I can measure my life, maybe, in Red Delicious apples. I remember when they were just like this, when I was a child. They were my favorite apple, the quintessential fruit. No wonder Eve and Adam fell into sin. But then, a result of grafting the same monoclonal stock onto millions of trees over decades, it was lost. They became mealy, bruised. No longer shiny. I lost interest.

And now this? A last-minute resurgence?

I’m taking a break from my upstairs life. I wandered down a few minutes ago to the doctor’s lounge and found this apple.

Clinic this morning was a mess. Several complex medical patients were either very vague historians to the point where I realized 20 minutes into the interview I still had no idea what we were talking about, or they had stopped taking their medications and but wouldn’t really tell me that until I asked three different ways. For reasons clear to no one I had 6 patients booked in the last hour before I went on call. I’m not sure I ate lunch.

Clinic work spilled into the afternoon because everything in the hospital could be managed by phone. Triage called and I logged into the remote monitor so I could watch a patient’s strip while dictating at the same time.

Then GB called.

“Hi, how are you?”

“I don’t know.”

“Oh, okay. Well, I’m about to put the kids down for a nap.”

“Cool?”

“So I just wanted to see how your day was.”

“Um, busy. I’m on call.”
“Okay. Well, T.P. was jumping out of a mulberry tree four hours ago and cut his hand.”

“Wait, what? Is it bad?”

“Well, yeah, it’s pretty deep. I mean, it’s not into the tendons or muscles I don’t think, and it didn’t bleed much, and I just put a bandage on. So should I just put him down for a nap?”

“Um, I should probably at least look at it. Can you bring him in?”

So they came in. And it was deep. Into the fat on the palm of his little right hand. And of course I decided to sew it up.

Why? I don’t know. The ER would be a long wait, and the wound had already been gaping for hours. But a teeny part of me thought I’d do just as good a job. And that if I didn’t, I’d only have myself to blame. And that if I had someone else do it, I’d have to go through the work of comforting him anyway, and then be powerless to fix the problem.

Yeah, I don’t know. I just did it.

He made a big fuss of it until finally we just held him still and gave him some lidocaine. Then he kind of got into watching the suturing.

The triage phone barrage thankfully held off until almost the end of that.

Next I had to go to the hospital. I checked in with a tachypneic baby and a laboring mom, and sent some other people home.

I was in the hallway trying to remember where I was going next when I got sent to assist on a stat c-section on a trauma patient in the main OR. I put on some scrubs and jogged downstairs to the doctors lounge. I passed some bored-looking orthopedic surgeons and confirmed I was heading the right direction.

At OR 2 the scrub nurse was getting ready. Then I saw that She, my nemesis, would be the primary surgeon. She chatted perkily with Swiss, my pediatrician friend, who looked a bit panic-stricken. The patient was nowhere to be seen.

She left, and Swiss looked at me. “Why do we have to do it in the main OR? They said she’s only 31 weeks, and we don’t even have a warmer down here. I can’t even find the elevator to get the kid to the peds floor if we need.”

So we talked with the nurses who brought down a warmer. We went through the masks and tubes and checked the suction and bag mask until everyone descended at once in the OR.

The patient writhed in pain, blood and stitches all over her face. Her left leg was in a splint. We moved her to the operating table and she screamed. I didn’t know yet that she had a femoral fracture.  Lines went in. They forced a bag onto her face, white milky propofol into her veins. She went limp.

Shenemesis and I hurried out to scrub, the quick kind where you use that gel from the wall instead of water. I gowned myself while She got her gloves. Then gloves for me too. Next the drape while the intubation was finished. Then skin, fascia, bovie, muscle. Bladder blade, uterus, bulging bag, child. Limp, little.

The sewing started. The uterus was floppy and I kneaded it constantly. The bleeding slowed.

In the baby’s corner it was still chaos. Swiss intubated, then I heard a scuffle as anesthesia was upset for some reason. Another pediatrician arrived. The baby needed to be ventilated, but no chest compressions yet, so that was good.

A second layer of suture closed over the first on the uterus. I followed the stitch, kept the uterus firm, dabbed blood off the places She needed to see. “You’re a pro under fire,” She said, not bothering to conceal her surprise.

“Yeah, that’s because I actually know what the hell I’m doing,” I didn’t say.

“Sure, well, we do what we can,” I mumbled.

We talked about where I work, about kids. She called herself jaded. I figured it was an honest admission.

Baby was stable enough to take upstairs, to get ready for transport to the city. We finished up and closed the various layers, finishing with a haphazard subcuticular, honestly the sloppiest layer She did.

Then, my work was done. There’s that satisfying “pop” when you grab your scrub gown by the sides and break the string that ties it, rolling it away from yourself until the bloody parts are inside a nice blue ball. I retraced my steps upstairs as the ortho team set up. “We’re going to put a big rod in the middle of the femur,” the jovial one told me when I asked. “Should be quick.”

Upstairs my tachypneic baby still needed oxygen, so it was time to investigate a bit further. I ordered some tests and visited him again. He wasn’t working hard to breathe. He was eating fine. All the other vital signs were stable. He was a chunky 8 pounds next to his 18-year-old mom.

I started to order the tests when the overhead pager went off “Neo-code, room 3914.”

“Fuck,” I said, at the nurses’ station. I’ve never been clear on whether or not this is appropriate to say at the nurses’ station.

I ran to the other ward. Swiss and the team were already there, but the baby had lost his airway. The other pediatrician was bagging, but it wasn’t going well. A very pregnant nurse tried to get IV access. RT was arranging supplies for another intubation attempt. Another nurse dug through the crash cart for meds, and another kept shouting about the vitals. “O2 sat in the 40’s!” 17 other people stood all around.

“I need another mask!” Swiss said. I crowded past a few folks and dug through the cabinet. No one knows where the hell anything is in a code. We needed a smaller mask. We found one. Then no one could find the right tube. Then the tube was in. Then we weren’t sure. O2 sats still low, kid bradycardic. Bring out the epinephrine. Hard to ventilate. Get some surfactant. Xray. Xray again. Look at the xray.

It wasn’t my code to run, thank God. But it’s hard to watch, not able to do much. Mostly what I did was listen for what folks were saying and try to bring them what they needed, or pass on a message. Because no one else was doing that, maybe. It’s always hard to say.

Finally, there was an airway, a heart rate over 100, and saturations in the 90’s. The transport team was on their way.  There were still too many people around, so I left.

I checked on a woman who was in the throes of labor. She really wanted an epidural. The anesthesiologist, of course, was occupied with the neo-code. “There’s been an emergency. We’ll try to get it as soon as we can.”

Then I was in the hallway again, unsure of how I got there. Some men were installing some kind of screen into the hallway. I had to find something to eat.

I went downstairs to find bars over the cafeteria entrance. I missed it. It must be late? I decided to visit the bathroom next to it.

I walked in and wasn’t alone. A woman, rail-thin, wild hair down her back and a soul-less crazed look in her eye stared at me through the mirror she faced. She furiously mopped up what may have been water from the sink. Her pants fell halfway down her ass, and she had on no underwear. I avoided eye contact, thought about leaving. Somehow, I figured she might be less likely to kill me if I used the bathroom as planned and acted as though I routinely find half-naked women shooting up in the bathroom. Or whatever she was doing, totally normal, you know? I washed my hands next to her and she turned back to the other stall and began vigorously cleaning the walls.

And then I walked past a couple of folks in biker leather fighting with security. And then I hid in the doctor’s lounge, where Fox News was playing, and I was the only one there.

And then I found this apple. And here I am.

I look at the clock. It’s 8. All this, in only 12 hours.

There have been many times, many calls in which I’ve felt the world turns over in 24 hours. Not just one rotation of the planet, but a lifetime goes by. I can measure my life, maybe, by a call or two I remember.

Will this be one of those?

Another bite, and nothing is left but a thin core. My phone rings. A new life is about to begin. It’s time.

Pile of Boxes

Since I’m on call every other day lately I sent the family to the in-laws. While they were away I did something remarkable:

I cleaned out my Pile of Boxes.

It’s worth capitalizing because it took up half the room.

I promise I’m not a hoarder. That the boxes were sitting there for 8 months was about not having time to go through them what with being a busy doctor and mom. Promise. Probably.

What was in them? Oh, you know. Stuff. Pieces of myself. Who the hell knows? Most were packed more than 8 months ago. Try 4 years. Obviously, if Former Self thought the Stuff was important enough to place in boxes, it was important enough to keep for long enough to forget what was in the boxes. That makes sense, right?

I’ve been putting it off. It’s painful. It reminds me of my own pathology. Also actual pathology, because I found that textbook.

A sampling of what else I found:

Flannel shirt I bought in 1994 and was hoping would come back into fashion. Which it totally has.

Cards from former boyfriends

1,056 ballpoint pens (estimate)

3 leg warmers

50 pounds of rocks

Framed pictures of people I do not know, some frames broken

Letters from my dad

Articles I never read but was supposed to for Internal Medicine Rotation in school

Scarves I wore on my head for years until Kimberly Clark told me I looked like a babushka in 2003

A burr hole drill

A Masai hunting knife

A trilobite fossil (gift from GB)

My lifeguard swimsuit

17 spiral bound notebook “journals” circa 7^th grade

Notes from several college classes

3 irons

6 umbrellas

It’s never easy for me to go through these things. I get nostalgic and sit down to read portions of essays I wrote for Freshman English. Then I move on to journals from 7^th grade. Then I become depressed and concerned for the youth of America. Then I read a card my Grandmother sent me for my 18^th birthday, mostly to do with weather and some people named Ethel and Howard who I’ve never heard of. Then I find a rock and try to figure out why I hauled that around for 10 years. Then I read a poem from an old boyfriend, and vomit a little bit.

I kept a few of these things because I meant to do something I didn’t do when I was supposed to.

I kept most of these things because they were a piece of me that I wanted to remember, to hold on to. Like I’d lose my roots if I tossed them, lose touch with who I was. So I kept them, and dragged them through several states, 15 years of school, various relationships and jobs.

And this time, I tossed them. Almost everything. It wasn’t even hard.

Something is different now. Maybe I’m ready to move on and leave it all behind. Maybe what I have now is brighter and better than everything before. Maybe that’s part of it.

But I hope what it means is, for the first time, I’m not afraid of losing myself. I’m here, and I’m not going anywhere else but this moment in time.

Here’s what I kept:

Flannel shirt from 1994 (dude, I’m totally wearing it all the time now)

50 ballpoint pens

Birth announcements, pictures and papers from my kids

Cards from GB

Letters from my dad

Trilobite fossil

2 journals from 7^th grade (so I can try to empathize when my kids are there.)

Burr hole drill

Remind me never to buy pens, socks, irons, thumbtacks ever again.

Lurking Gaps

So, the kid has syphilis.  And when the highlight of your week is diagnosing syphilis in an 8-week-old child, you don’t know whether to pat yourself on the back or run as fast as you can into the desert.

It’s all fine and dandy and heroic to diagnose venereal disease in babies and extract other babies in distress from their mother’s vaginas using vacuums but when it comes down to it I’d just like to do some well child checks. Or counsel people on contraception. Heck, constipation.

I’ve been learning. A lot. It’s having to look things up on the fly, or teach a resident something I’m rusty on, or following a patient’s course and working things up.

But I know that learning always means forgetting. You hope your forget the outdated stuff from medical school in order to assimilate more up-to-date information that you read off, uh, UpToDate. But you feel like what’s really happening is things are getting stuffed in one ear and falling out the other.

In the words of the great Dr. Nirvana, “I’m not afraid of what I don’t know, I’m afraid of what I don’t know I don’t know.” And then he made a smoothie.

And I’m afraid of getting cocky with a few correct diagnoses or timely decisions and forgetting that I don’t know what I don’t know that I forgot or never knew in the first place but should really be aware of in this very moment. Which doesn’t sound as catchy, now that I put it all down.

What gaps in my knowledge are just lurking around the corner, hiding in an exam room, haunting me at 3am on call?

I think I’ll run into the desert. But first I will have a smoothie.

I wish I had a dermatologist in my pocket. Instead I have syphilis.

Wednesday was Rashes No One Has Ever Seen Before Day.

A lovely pregnant patient came to see me complaining of an insect bite. It was not an insect bite. Unless insects bite you only on your groin and instead of creating a small pink welt they cause grouped clusters of yellow or blood-filled vesicles crossing several dermatomes and only mildly itchy or painful. I got out the atlas. Then I pulled in the Dinosaur. “I don’t know what that is,” he said.

 Awesome.

In the hospital on call a VBAC awaited. Her bag of waters broke early in the morning and there was thick meconium. She had no contractions yet. This is called PROM, only no one wears fancy dresses, least of all me. The nurses needed me to talk to her also about why we weren’t starting her on Pitocin to induce her. The reason is because it increases your chances of uterine rupture from 4 in 1000 to 11 in 1000. And uterine rupture is a bad thing, since it has at least a 10% mortality rate for baby. But the longer we wait the longer we risk infection, which is more likely, just less dangerous. And she could always opt for a c-section, which is less dangerous for baby on all accounts, but riskier for mom. So, a complex discussion to be sure. Try doing it in your second language.

Arguably more fun than regular prom, though.

After I finished the nurses asked me to stay for 2 minutes and translate for their assessment. They have no translators today. They are woefully understaffed.

I needed them to watch my strip for me because I just got called to the ER.

Dr. ER Green Zone had a baby for me to opine on. “He won’t move his arms. He’s 8 weeks old. His xray looks weird. I’m not sure what it is.” Cool. I’m sure I’ll figure it out right away since I know so much about orthopedics in 8 week old children.  We look at the xray right away. The distinguished radiologist has created a differential diagnosis for the diffuse periosteal inflammation that includes several vitamin deficiencies and a disease I have never heard of, Caffey’s. I go in to see the patient. He’s cute, but he hates it when I touch him. His arms seem weak. And there’s a weird rash on his arms.

I should have put on gloves, but the rash is unexpected. I touch the soles of his feet, where the skin is peeling. A scalloped red border extends to the sides. There are plenty of raised pink and red bumps, but in circumscribed areas. There are some ring-shaped lesions. It looks for all the world like nummular eczema, except the two spots that look like ringworm, and the spot on his chin I can’t convince myself isn’t an early herpetic lesion.

Shit.

I ordered some labs and started reading. I asked Swiss to come look at the rash, too. I called the patient’s PMD, who took care of his mother in pregnancy. She came late to care and never did her labs. The hospital drew a paltry few when she was in labor.

I decide it’s syphilis. Swiss, the resident, the medical student and I go back to the ER to take another look. We keep refreshing the computer screen waiting for the RPR to come back. I call the lab. “Oh it is send-out. 3 to 5 day.”

I ship him to the University hospital. He deserves specialist consultation, which we don’t so much have here. Not for derm, not for ortho, not for 8-week-olds, anyway.

The VBAC PROM is still hanging out. I go home and take a nap.

At 1 am a woman arrives at labor and delivery and goes from 5 cm dilated to delivering a baby on the floor in 10 minutes. The resident was sort of in the room at the time.

And then… nothing. My hands may have syphilis. It is not confirmed. That is all.

Good thing I don't smoke.

Had a delivery last night that I think shaved 2 years off my life. 8 minutes of terminal bradycardia, probably more but the nurse was lackadaisical about the FHT and wouldn't get me an FSE. And I had to ask another nurse who got me an IUPC instead. And the woman was so Mg-ed out we couldn't move her side to side. And then the first nurse told her she just needed to relax and I said "no, she needs to push this kid out" and finally she was barely +2 so I vacuumed the kid out and then he was gray and the nurse said "he's just stunned." and then we resuscitated him.

And then I forgot the name of the 4x4s for the repair and all I could do was ask for "more of those white things. The little ones."

Oh, and there was a resident.

Grown-up

Today I wanted to cry at work. There was no one moment that made me feel that way. No time where it was close to happening. It just felt that way. Maybe it was my upper lip, next to the left side of my nose. It kept twitching, and made me feel awkward talking to people.

It’s the lip quiver I also get just before I do cry, when I suddenly can’t control the words coming out of my mouth. It’s the tremble I saw in my own dad’s face last weekend as we left my hometown.  We were eating burritos at Taco Time. “I just realized this morning how much I miss you guys,” he said. There were tears in his eyes. And I don’t know but this might have been the first time I’ve really seen him cry. I think he has before and I always looked away, trying to be polite. But I looked at him and I didn’t fall apart. I miss him, too. But I have my own little pieces of my heart running around and filling every waking moment. When I think about them one day having their own lives and leaving my home to visit only a few times a year, well, then I can understand.

Work sucked today. Let’s be honest, it’s not been as much of a picnic the whole last month. We started with our Electronic Medical Adventure about 5 weeks ago. Since then I’ve been overbooking my schedule to see everyone, at the same time helping everyone else learn to use it and building templates into the system so that one day we may stand a chance in hell of getting back up to previous productivity levels.

I hate it. I don’t use that word very often. I hate this.

I don’t even like computers. I want to be outside, playing in the creek. Other providers have complaints and concerns and I feel like I need to be supportive of the system and the administration, but I don’t know why. This medical record system sucks. I told them it did before we even chose this one.  All transitions are painful, but the pain might never leave us with this system.  And now I’m a Super User. Somehow it’s made me feel like I need to act like a grown-up, not gripe, stay late, be a team player, be patient, be energetic.

Patient A complains no one called her back when she was suicidal.  So I say “Boy, I’m sure sorry about that. I never got no darned message about you wanting to kill yourself. I’ll put in a word with the triage nurses.”

Patient B’s blood pressure is 160/80, previously well-controlled. “My pharmacy said you denied the prescription refill, so I never got the med.”  So I say “Oh, durr. Silly computers. Of course I want you to take that medication!”

Patients with real illnesses are sent home without being seen by a provider. Others are sent to the hospital for not feeling their baby move before 20 weeks. Which is normal in humans. No one can find any paper charts, but nothing is populated into my electronic chart.

I’m fucking sick of it and I’m terrified that at any moment something catastrophic could happen.  Everything is entirely out of control.

But instead of saying so, I act like a grown-up.

Here’s the thing, though. I’ve been acting like a grown-up for the last 5 weeks. And feeling more or less like a functional adult, instead of a 12-year-old on Career Day. And it’s entirely overrated.

The more grown-up I am, the less human I am, I think.

I want to cry, for the pain of my patients, for how out of control this raging machine is. Instead, my lip just quivers as I smile and offer empty apologies.

I want to cry, for every night I stay away from my children because of internet connection delays, or making calls to return to disgruntled patients, after everyone else has left the building.

Instead I’m a grown-up now, watching my dad cry for all these reasons in a career only 24 years longer than mine.

Back

Years ago I worked in the woods every summer, next to a lake. The days were endless in North Idaho, and it was light from 4am until after 10.  The water, chilled in early June as though the ice just barely cleared, was 75 degrees by August as it rolled over our golden skin. At the end of the day, we’d clear the swimming area of kids, and send them to shower. Then we’d backflip off the lifeguard tower, or jump into the boat for a quick ski around the lake.

In those days there was so much to believe in. My legs were strong and there was God and night would always fall slowly like the way my Midwest relatives say goodbye. Most of all there were all of us, working 18 hour days together under the sun, to make people, kids, happy. There was this common goal, so there was community. I was never alone.

A world later, I found it again, in the place you’d least expect it, residency. In the hardest months of my life I found them. Earnest folks who know who I am and what I am capable of, and somehow still believe. In me, in medicine, in the joy that is working together.

It was hard, sure. The work took everything I had and more. And I’ve said before the toll it took on my family nearly broke us. But in those days, there was so much to believe in, even when I didn’t believe in myself.

Where I live now it’s different. There’s less cohesion, less inspiration. Belief in anything is optional.

I’d been gone a year. I feared I’d been forgotten, that I’d forgotten everything I learned.

And then I went back to the place where I became the doctor I am today. I visited all the familiar haunts: the hospital, the sacred sign-out place that is the Falcon’s office, the call room, the clinic.

I must have looked weary to the Dragon when I met him for lunch. “What’s wrong?”

“I’m just tired,” I said, and ordered a pizza. Later I mumbled that I might be less than excited about my job.

“Tell me a story about a patient,” he said. An attempt, I think, to inspire me, remind me of what I do love.

I told him about Potter.

Which of course is the worst patient story from the last 8 months, but it was the only one I could think of.

It’s unfair to blame this dysthymia on external forces. There’s something I need to learn here, some way I need to grow.  But I miss these people, like I miss the Idaho summers of my youth. Not for the work itself, but that it was made bearable by a community. These people give me something to believe in.

It’s a crutch. I need to believe in things myself. I need to inspire, not just to be inspired. Maybe I need to be without my people right now so I have something to offer when I move back and establish the commune.

See, I want to work with these people again, share practices and overseas projects with them. We should all buy a piece of land with yurts around the periphery, a garden ringed with daisies, and Shaman will create a series of baths. The Visionary will inspire me and Haiyan will stretch open my mind to the world, and my kids will be raised by a village. We’ll call it Yurt Village. We’ll have matching tattoos.

It’s sort of a joke. Except I mean it. It would be neat.

A half hour later I somehow found myself in Vasectomy clinic, a syringe and a Li clamp in my gloved hands. Ceci, a year behind me in training, invited me to do her surgeries for her; she doesn’t want to learn them. My clinic needs me to. She handed us instruments. The Dragon stood across from me.

I operated successfully on two men. It had been a year, but I remembered the techniques, and learned the updates. Plus, I was a visitor, but I was home.

And something had changed. I don’t think Ceci saw it, I don’t even think the Dragon noticed. But I was no longer a resident, across from my mentor. I was an attending. I was thinking each step out for myself. I didn’t wait for the instrument to be selected for me, I asked for it or took it off the table. When there was bleeding I moved to control it.

It was an unexpected boost to my faltering ego. I got to see, for a moment, how far I’ve come.

Huh. And most of that came out of being mostly alone.

And then I went to the woods, which was the real reason I was in town. The Visionary was getting married, after all, next to a lake. We swam and canoed, and slept late under the trees.