Steve Wants A Sandwich

A Two-Act Play

If you worked at a restaurant, instead of at a clinic, and your restaurant implemented an electronic medical record, this is what it would be like.

Act 1: Steve, Sally and Host

Steve arrives at a restaurant, and walks up to the host with his date. The host is looking at a screen.

Host (to screen): Welcome. Please tell me your name.

Steve: (After a few seconds, when the screen doesn’t respond) I’m Steve.

Host: Steve. OK. Steve.  (Punches some keys)

Steve: Party of two.

Host: (stressed) Steve. You’ll have to slow down a bit. This system is new.

Steve: OK.

Two minutes go by.

Host:  Alright. Steve. Can you spell Steve for me, please?

Steve: S-T-E-

Host: Oh, shit.

Steve: What?

Host: It froze. (grabs pencil, twists it in hands, it breaks. Twiddles thumbs. Grabs mouse and clicks repeatedly.)

Steve: I just, I mean, I just want a sandwich. I come here every week. Can I just go back and sit in my usual spot?

Host: (looks terrified) No, I don’t think so. This is really important.

-Ten minutes later-

Host: OK. It’s up. Now how to do you spell Steve?

Steve: S-T-E-V-E.

Host: Great. Steve. Now I will need you to stand there while I take your picture.

Steve: What? My picture? For the birthday wall?

Host: No, silly. For the computer. So your waiter will remember who you are.

Steve: I’ve been coming here for 10 years. I’m pretty sure he remembers…

Host: (looks stern.)

Steve: OK, fine.

- takes picture -

Host: And how will you be paying today?

Steve: Wait. I don’t get a sandwich first? Normally I pay after.

Host: I know, but this box here has an asterisk next to it. It won’t let me close this box unless I fill it. And if I can’t close this box then I can’t open the Sandwich Encounter. If I don’t fill in all the asterisked boxes then whole heads of lettuce might go to waste. Or something. I don’t really know the details.

Steve: (Groans) I’ll pay cash, like I always do.

Host: OK, Steve. This will just take a few minutes.

Steve: (feels faint) I’m really getting hungry.

Host: Steve, how do you spell Cash?

Steve: C-A-S-H

Host: Good. And will your partner be eating a sandwich today, too?

Steve: No, she usually gets a burger.

Host: (Worried) Are you sure? Because I need to close your account and open another for her. Excuse me, ma’am, what is your name?

Sally: Um, I’m Sally.

Host: OK. Sally, are you a migrant farmworker?

Steve: What? I mean, what the hell does that matter?

Sally: No, it’s okay. Yes, I am.

Host: Good. We get money when we track that shit. (clicks box) What is your ethnic background?

Sally: I am Iranian.

Host: What is that? Is that white Hispanic? Or white non-Hispanic?

Steve: It is white, non-Sandwich.

Host: Steve, please sit down.

Sally: I think I’m just not going to eat anything.

Host: that would probably be best.

-       types for 5 minutes –

Host: Good news! you can go sit in the waiting room now. It will be about an hour wait. Here is a blinking light buzzer thing. Also a magazine about retired people and colonoscopies.

(to line of 35 people): Next…

Act 2: Steve, Sally, and Ted

(Steve and Sally are sitting at a booth, reading a menu advertising colonoscopies)

Steve (looks up): Hey! Ted! How are you?

Ted (who is the waiter): (wheels over a computer station) Hello….

(Logs on for 2 minutes) Steve.

Steve: (suspicious) Ted. This has been a crazy day. But I’m so glad to see you. I’ll have the usual.

Ted: (Looking at screen) This will just take a minute. OK. Oh, wait. I’m in the other guy’s screen. (Clicks mouse for 30 seconds.) OK. Steve. Now what brings you here to see me today?

Steve: Uh, sandwich? Like usual?

Ted: OK. I need to open the box about Sandwiches. Huh. Probably under food, American. Steve, do you think your sandwich is more like a pastry, or a vegetable?

Steve: Wait, what? It is a sandwich. I want a grilled cheese sandwich. This is what I always get.

Ted: (confused) Are you sure? It’s not listed. I have to find it in these folders. I’m just going to start typing under “General.” OK. So. When did you first want a sandwich?

Steve: 10 years ago. Then again, today, about (sadly) 2 hours ago.

Ted: How big is the sandwich?

Steve: I’ll let you know when I see it.

Ted: On a scale of 1 to 10, how bad is the sandwich?

Steve: It’s pretty good. Or I would have left about an hour ago.

Ted: So, a 3? 4?

Steve: Is that how the scale works?

Ted: I have no idea. But I need to fill in this box. It’s got an asterisk.

Steve: Wait a minute. How many boxes are there?

Ted: It’s like they never end. They just keep flying at me. I’m not even sure what we’re talking about anymore.

Steve: (tries to make eye contact with Ted.) This is a restaurant. I am Steve. I come here every week. I have a grilled cheese sandwich every week.

Sally: I am Sally. I am Steve’s girlfriend. He really, really just needs a sandwich.

Ted: I think I have to go get some help. Can you wait for a few minutes?

Steve: Let me have a look at it.

Ted: No.  Believe me, you don’t want to. Well, maybe it wouldn’t hurt. Are you sure?

Steve: (turns computer console to himself, begins checking off various boxes. Finally order is complete) Looks like we’re ready for the grilled cheese!

Ted: Yes. Now I just have to electronically transmit it to those guys in the kitchen.

(Steve and Sally stare in horror toward the kitchen where several cooks are hovering over computers, no one is cooking, and smoke arises from the grill where several sandwiches are burning alongside a keyboard)

Sally: I need to use the restroom.

Steve: (resigned) Go ahead. It will be awhile.

Sally walks away from the table, past Ted who is still staring at the screen, into the kitchen, past the cooks, grabs some bread and cheese and makes a sandwich.

- THE END -

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.

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.

House of Scorpio

My last few calls had been cake. Not bad. Maybe I even thought I was just a super awesome doctor/efficiency master. And then I’d return to clinic, where reality would set in. But no matter: call was not so bad.

Then it was my Hospital Week.

At no time during Hospital Week did I have fewer than 9 patients to round on in 5 hours, and often more like 15. Most of them had pyelonephritis and were vomiting. Rounding on those patients was totally do-able. I am totally awesome at treating uncomplicated pyelonephritis and vomiting.

Except that I was also in charge of all 30ish-week twin pregnancies who may or may not have been in labor and needed to be evaluated and possibly transferred to the University for seeing spots and having their right hand spontaneously weaken vs. having their bag of waters rupture prematurely. Of which there were 3. During which I was also in charge of all placental abruptions at 35 weeks bleeding half of their blood volume into the bed. Of which there was thankfully only 1.  And of all of the babies who seemed to be doing very well but then immediately prior to discharge developed extremely high bilirubin levels. Of which there were also 3. Or 27. I lost track.

And also of teaching residents. And of taking the amniotic fluid samples to the lab downstairs 55 times because the bulb is out on the microscope on Labor and Delivery.

And of locking my keys in the car in the middle of the night with the car running and not noticing until I came back out after a delivery.

“It’s crazy around here,” I mused as I sat next to a nurse. She was scanning through the computer. “Yeah. It’s the Supermoon, which is in the house of Scorpio. Or something like that.”

Obviously. That explains everything.

Love and Blood

I went in early to work today. I needed to look at as many diseased cervices as I could find in a textbook before 8am. At 8 procedure clinic would start and I’d be supervising the Superstar. On the docket were 2 lipoma removals, 2 colposcopies, and a punch biopsy.

I wasn’t sure if I remembered how to do any of these things, let alone supervise them.

See, a colposcopy, for example, is about two things. Thing 1 is sheer awkwardness: setting up cameras and screens in front of a nervous, half-naked woman. Then you spend another grueling 20 minutes finding a speculum and adjusting the camera and adding a filter and zooming in and clumsily knocking the camera over and contaminating the biopsy tray and asking for another and adjusting the light and the camera again, between the mortified woman’s legs.

“Oh, sure, just like at home,” our nurse JHot said when I explained this to her (she lamented never having watched one. For reals.)

Thing 2 is pure pattern recognition. Mosaicism, leukoplakia, bridging. Immature metaplasia. Punctation, nabothian cysts, papilloma. Decreased uptake. Ulcerations. Algorithms.

I’m better at thing 1.

Thing 1 is all about finesse. Thing 2 takes frequent, repeated exposure. Hard work, at that one thing. Studying with your eyes, as much as with your mind. But I’m willing to put in the work.

The good news is, it went well. In an hour I brushed up just enough to know what to biopsy.

Also, I’m good at surgery. Relatively, I mean. I had forgotten this about myself. I’m not a surgeon because instead I trained to be a family doctor. I just mean I have the aptitude. I know how to handle the tissues. My fingers know what to do.

If I’d done surgery maybe I’d be a better surgeon than the family doctor I am today. Maybe I’ll try not to think about that too much.

I watched the Superstar cut through the epidermis overlying the lipoma. I told her to hold the knife a little different. She obliged. Dermis. Connective tissue. Fat. She dissected. I dissected. We got out fancy instruments. We uncovered the fatty tumor, used a clamp to lift it and found the tissue plane between it and the fascia below. 

Then it was out in a satisfying glump. We closed the wound with two layers of stitches. I showed her ways to hold the skin, to produce better tissue eversion.

Blood and tissue equals gore, but surgery is heady. How many nights did assisting on a c-section awaken me from half-sleep? Blood means business. It narrows the focus to the present, life and death, meanings therein. It’s messy and euphoric. Once I even got cut in surgery with a scalpel, and I didn’t notice. Only when the Dragon asked “did you just punch me in the scalpel?” did I realize I was bleeding into my glove.

I like it, and I have something to offer in teaching it. Relatively speaking, of course.

That felt good.

I finished clinic early (for me) and stopped by the hospital on my way home. My  patient had delivered the day before.

She’s the one I worried about, with possible cholestasis, then liver issues, then renal insufficiency vs atypical preeclampsia. I wanted her delivered sooner, but couldn’t pin a diagnosis on her. Plus she was going to try a VBAC.

She didn’t make it. When her bag of waters broke, there was meconium and the baby’s heart rate went down for a while.

The love of her life had left her when she became pregnant. “I guess he wasn’t ready for the responsibility,” she told me. When she was about to have her baby, though, her mother drug him to her bedside as she writhed in pain without an epidural and people ran in and out of the room. He went into the c-section that ensued, watching the blood that poured onto the floor. “Mom thought he deserved a front-row seat,” she told me.

Her baby rests now, on her chest. He doesn’t want to leave her, not for a moment.

Last year in the worst of times G.B. told me I didn’t know how to love anymore. I spouted off something angry and doubted myself for days. He was wrong. I do know how. But love is not what we’d believed it to be, maybe. Love is blood. Love is war. Love is backbreaking, work in the trenches, elbows deep in carnage, debt, dirty diapers. Love is a clear blue sky torn through with screaming missiles, fire sweeping the fields, children cowering in tents. Why else does cupid shoot you in the heart, but that you may bleed?

Blood is love. It is not all of love. But what else but love and blood, rushing through our veins, keeps us alive?

Fatty tumors. Blood-stained babies resting over Mother’s heart. I’m going home now, to all those I’ve bled for.

The Big One

???

Lately I can’t even finish a thought. That is because everyone who walks in the door has splenomegaly or a giant pelvic mass or a blood pressure of 194/105 or a hematocrit of 20%.

Sometimes I try to redirect them into familiar territory.

“Yes I know you have a giant spleen, but do you also have diabetes?”

“Your blood pressure is quite high. When was your last pap?”

But, really, those things don’t matter when you’re staring the Big Question Mark in the face.

My job is full of little question marks. “Should I check labs now or in 3 months?” “What’s the best antidepressant for this patient?” “Does this patient need a follow-up DEXA scan?”

But time stands still when I have to ask “What the hell is happening here?”

And it’s not such a great week when the Big Question Mark happens 5 times.

Put aside for a moment the technical difficulties in actually obtaining diagnostic tests in such very sick patients without insurance or any money for food. It’s hard enough to even know where to begin the work-up.

Monday started with a patient with itchy hands and feet, worse at night. No rash. Oh, and she’s also 37 weeks pregnant. I ordered some bile acids and LFT’s, and started her on ursodiol for presumed cholestasis. Then I called the Dragon, who happens to be an expert in the field. I interrupted him during tai chi. Yes, he is 85. And Chinese.

“So if this turns up positive, should I induce? She’s a VBAC.”

Then on to the next several patients. Soon I met a man with a rash all over his body for 8 years with a large, firm spleen. To be honest, I’ve never felt anything like it before. I’ve tried and failed in Africa, and confirmed its absence in kids with mono. This one was hard to miss. I percussed it too. I texted a photo of the rash to Dr. DDX. Then I got out my Washington Manual and read the section on splenomegaly. HIV. TB, mycobacterium avium. EBV. Portal hypertension. Tumor. Hemolysis. Awesome.

Then I put in 2 IUD’s.

Tuesday a lovely lady came to see me after a several year absence in which she developed worsening pelvic pain. She is 49. She has a gigantic pelvic mass.

Forgot to mention the 47 y/o cocktail waitress who presented with restless legs and turned out to have a hemoglobin of 5.7. I ended up sending her to the ER to get transfused so we can potentially get her a colonoscopy.

None of these people have insurance.

I soon found myself between patients texting my dad about splenomegaly, emailing Dr. DDX, and browsing through 3 derm atlases and a stack of charts, with 5 AAFP articles open on my desktop.

It was a bad week. I read a lot and didn’t come up with many answers. I was just busy enough not to dwell on the ridiculous inadequacy of our medical care delivery system. Not too busy to feel completely inadequate, myself, though.

But the good news is there’s time. All except for the pregnant lady, who’s been in and out of labor and delivery three times this week at my behest.  Everyone else has time. Time for me to think, and study. Time for studies to be done. Time to work on funding.

Everything seems urgent, because these are major medical unknowns. But the truth is these people have been living with these problems for a lot longer than I have. All of them for months, at least. And if all I can offer them is questions, at least I’m asking them. At least they’re here. It’s not my fault they couldn’t see a medical provider sooner. It’s not my fault they don’t have any money. It’s not really theirs either. It is what it is.

I can’t fix very much about this system. And I'm not going to know all the answers tonight. So probably I should go home before it’s time to come back again.

I added 5 stickers to my S.L.

If I Couldn't Be

Sometimes I think about what I might do if I couldn’t be a doctor.  You know, were I to become incapacitated for medical work, or lose my license due to a lawsuit or clerical error by the Medical Board (not inconceivable), or were the apocalypse to be nigh, for example on Dec. 21, 2012.

Here are some ideas I’ve thought of.

·      Physics instructor

·      Actor

·      At-home parent (GB laughs at this idea, but maybe I could do it, right?)

·      Faxer of Things (see The Other Shoe Dropping 12/15/11)

·      Forest ranger

This morning as I pulled in to the hospital parking lot I realized ALL OF THESE THINGS ARE INSANELY BORING.

Obviously I would be a helicopter pilot for Life Flight (or similar.)

Probably I have never thought of this before because I have never parked directly next to a helicopter before.  It is a lovely beast.

It would be fantastic.  Not only would I be rescuing folks from remote hospitals with mediocre specialty access and possibly SAVING LIVES but more importantly I would be FLYING A HELICOPTER.

Probably I’ve never been in a helicopter before but I don’t think that matters too much.  How hard could it be?  Ask me a troubleshooting question.

What happens when there is a storm approaching?

·      Fly away from the storm.

What happens when the helicopter turns upside down?

·      Obviously you reverse the direction of the blades.

See?  Easy.

What if all the power goes out on the helicopter?

·      You should have brought your battery.  I would always bring a back-up battery.

What if there was a mutiny on board the helicopter mid-flight?

·      Obviously I would start singing Kum-Bay-Ah or a made-up song about helicopters.  Works for my kids.

What if a velociraptor appears from the sky and tackles you?

·      Consult Up-To-Date for Helicopter Pilots.  (They have that, right?)

I am so excited about my alternate career I might even see if they will allow me to ride in a helicopter one day so I can subtly talk them into letting me fly it, such that they will not even realize my pretext until it is too late.

I will grasp the steering wheel (Console? Handlebars?) with my pasty-white, overly-dry hands and conjure up reflexes and dexterity long-held dormant to guide the lovely beast safely through the air.  I will push buttons (lights?) and talk on the radio with a headset (is it called CB or CV?)  “Roger, 40, what’s your 20?  I’ll have a number 17 with Ranch Vinaigrette.  Will be landing shortly if that’s ok.  Do I land on the X or next to it?”

After we land I’ll take a moment to relax and drink some lemonade while reading a little bit about Helicopter Piloting Terminology.  Probably I’ll be considered a prodigy and earn a medal.

But first I guess I will round on a few patients.

Monster Hospital

Yesterday I woke up and I didn’t like my job anymore.  I had a bad feeling in my stomach as I backed out of the driveway.   Then I made an attempt to identify the factors which led to this feeling.  I outlined the following:

1)   It is 6:30am

2)   I was hanging out with the kids all weekend, leading to:

a.     Utter exhaustion

b.     Wanting to hang out with those guys even more

3)   I’m afraid of the hospital

Then I had the following self-dialogue.

“Um, you are 30 years old.  You are a doctor.  Why are you afraid of the hospital?”

“I’m a crappy doctor.”

“Why do you think you’re a crappy doctor?”

“Because that one lady was mean to me.”

“Because a lady was mean to you.  What lady?”

“Let me fill my self in.  Last time I was on call there was a lac I thought was a third degree and I’ve never repaired one and I didn’t want the patient to be incontinent for the rest of her life, so I called Her.”

“You called the patient?”

“Uh, no.  I called Her.  The OB on call.”

“Ah.  The one who told you you couldn’t do a pelvic exam.”

“Yes Her.  And She told me if I can’t repair my lacs maybe I shouldn’t deliver babies.”

“And you believed Her?”

“Yes.”

Yes, yes I did.  This is the thing about me.  I believe what other people say.  I take it seriously.  And so probably I shouldn’t be delivering babies.

That makes me sad.  Also it makes me not want to go to the hospital.  Because what else should I be able to do that I can’t?  What else should I know that I don’t? 

I’ve said I believe in family medicine, more than I believe in myself.  I believe that competence can be something other than knowing everything, being able to do it all.   Competence is listening, understanding, explaining.  Taking care of most things, and perhaps most of all, knowing when to ask for help.  Yeah, that’s what I believe.

Except on the days I don’t.

All I really want is what’s best for the patient.  Almost always I believe that they should all have family doctors who care and have a relationship with them and only very rarely need to ask for help.  Almost always I believe this will provide excellent care with better outcomes at a lower cost.

Except when I don’t. 

And when I figure, maybe I should just stay home with the kids.

I feel defeated.  And now I’m already halfway to the hospital.  I’m lame.  I don’t want to go but I’m in too deep to get out of this, so I sheepishly keep showing up to work.

But I also feel a little bit angry.

Who is She, to take away my fire?  Who is She to turn someone like me into a defeated apathetic heap?  I mean, at least I’m nice.  Also, I speak Spanish.  Also, I’m conscientious.  I’m reasonably intelligent. 

And I care, damn it.  I care about these people. 

Hundreds of folks have invested in my training.  I’ve invested years of my life.  I’ve shown up at 4am for Surgery rotation, stayed ‘til 9pm after clinic.  I’ve spent countless hours away from my kids, so many nights away from my bed.  I’ve studied about and rounded on and written notes on and talked with and sat with and broken bad news to and operated on and bargained with and delivered babies to thousands of patients all day and all night and all day again for seven years.  All because I believe.  I believe I might one day make a difference for my patients.  Who is She to stand between me and my patients?  Because that’s what She’s doing.

Because I’m letting Her.

The hospital looms like an ungainly monster.  It’s snowing hard.  I park next to the helipad and sit in the drivers seat.  The temperature plummets as I turn off the car, step outside the car. 

There’s still a little fire in my belly.  I hardly notice the chill as I run for the Emergency Room door.