Code blue

The first code I ran, it was a nightmare. The patient was hypotensive because he was losing vast volumes of blood into his GI tract. I had three lines of a triple lumen running in wide open saline. I emptied the crash cart of atropine and epinephrine. 6 amps of bicarb. All in the first 10 minutes.

I turned to the unit supervisor, who looked back at me and told me, "Five more minutes, Dr IFinding." So I tried for 5 more minutes. And got nowhere. And that was that. And he was officially dead when I said he was dead. And I wrote in his chart "dead."

It's very surreal, calling a code. I say he's dead, and poof! He's dead. As if the words from my mouth have some sort of magic power. I go to talk with the family, and that's that. One time, I sat with the patient, watching each agonal breath, thinking to myself that I know that I called the code after 20 minutes. I know I gave a gallon of epi and vasopressin. I know that I couldn't get a pulse out of the patient using every trick and technique I had. But watching those agonal breaths...

It's a good reminder to me of the desperate primal urge to live. I remember a line in Crime and Punishment: "...if he had to live on some high rock, on such a narrow ledge that he'd only room to stand, and the ocean, everlasting darkness, everlasting solitude, everlasting tempest around him, if he had to remain standing on a square yard of space all his life, a thousand years, eternity, it were better to live so than to die at once! Only to live, to live and live! Life, whatever it may be!"

Sometimes, all we do is try to live. But sometimes all of nature and all our best intentions are not enough.

So, what are you going to do with the rest of your life?

It's about that time of year when the 4th year students are sending out their applications for residency. It's always interesting to find out what people are going to do with their lives, especially the students that I worked with, to see if my predictions were right.

I do alright. I usually bat about 0.400, which isn't too bad considering. The surgeons kind of stand out usually. The family practice folks stand out as well. The medicine nerds are pretty consistent. Anyway, around about now, advice comes as easily as toilet paper.

My advice to medical students is always the same: you have to love the pathology. People tell me all this shit about shift hours, good pay, no call, or radiology (nuff said), and all sorts of other things. Here's the thing though. 4 years of undergraduate education. 4 years of medical school. A minimum of 3 years of training. A potential career of 30+ years. We work too damn hard to do something we hate.

But if you love the pathology, you can do the job. You can make the hours work. You can make the time. But you can't learn to love a career you hate. So if you love treating hypertension, you'll be okay. If you love cutting out gallbladders, you'll be aces. If you love looking at CT scans of the abdomen, you'll do alright. If you love treating kids, then you'll be fine.

You are exceptionally fortunate that you can choose what you want to do, so why wouldn't you do something you love? Find what you love. Do it.

But if you're picking your career based on hours or shift work or pay, you'll never be happy, because you'll spend every moment you're at work wishing you were somewhere else. And that's fine if you're a high school dropout mopping floors or stripping at the titty bar. Then feel free to hate your job and life. But what a fantastic waste of your life if you put in 11 years of education and $100k+ of debt just to have the same satisfaction in your work as a high school dropout. Is it any wonder that the folks going into ER just for shift work end up burning out?

And here's more bad news: I know a lot of janitors and strippers who love their jobs.

Social calendar

So Sunday is The Simpsons. Monday is football, and sometimes pro wrestling. Tuesday is Veronica Mars, and Rescue Me when it's in season. Can't forget Dancing with the Stars. Wednesday? All about Lost. Thursday is relatively free. Friday, I have to admit that I have become attached to Avatar, the last Air bender. Saturday, more football. Sunday, repeat.

I talk to some of the other residents, and they tell me about their girlfriends, wives, children. They tell me about how wonderful it must be to be single. They have to take the kids to a doctor's appointment, or the wife wants a new car. They're shopping for a new place. Mothers-in-law.

The single life, right? What a dream. But for the most part, I watch a lot of bad television, cook, play around with my laptop and my digital cameras, and go to bed. It's a pretty boring life. I tried to get out and live a little. I was spending evenings in Starbucks, driving around to all sorts of local spots. I went to a lot of local sports events. A LOT. I was even going to some night spots and bars for a little while.

But when you're on your own, it's not exactly like there's a point. Sitting by yourself in Starbucks isn't really any different than sitting at home with a far cheaper cup of coffee. Going to see a baseball game has its own merits, but it's not like I'm meeting people. No matter where I go or what I'm doing, it's really not social. It's just being alone surrounded by a lot of people.

It's not that I'm so lonely. It's just that sometimes, I wish I had someone to talk to. Life feels a little empty without someone to share my life with in some way.

I'm not a real doctor

An actual conversation:

me: We've done a bunch of tests, and several of them are inconclusive. I'm very concerned that this might be a heart attack. I'm going to order some blood tests, and we will observe you overnight, and I will ask a cardiologist to see you in the morning.
patient: Well, you're wrong. I know it's not my heart.
me: Umm... okay. Can I ask how you know this?
patient: Don't be smart with me. I know my own body. This is not my heart.
me: Ma'am, you have diabetes, you have high blood pressure and high cholesterol. These are all risk factors for having a heart attack. Some of the tests have come back worrisome for a heart attack. It may not be a heart attack, but there is a very real possibility.
patient: Well, you don't know what you're talking about. This is not a heart attack, and I'm going home. You're just a resident. You don't know anything. You're not even a real doctor.
me: Ma'am, I admit a lot of patients to the hospital, but your case is concerning enough that I've already spoken with the cardiologist. I must urge you to reconsider.
patient: Screw you. You residents don't know what you're talking about. I want to talk to a real doctor.
me: Ma'am, I am a doctor, but I have already discussed this with two attending physicians, the attending internist and attending cardiologist.
patient: You probably lied to them and told them a bunch of lies so they'd agree with you. Or you didn't even speak to them. You're probably lying to me right now.
me: I'm not going to argue with you about this. This is a hospital, not a jail. If you want to leave, then please sign this form that states you understand that there is a very real risk of death if you leave against medical advice.
patient: I'm not signing anything! You're just doing this to cover your ass!
me: Fine, don't sign it. But you should understand that I think you're having a heart attack, and you may very well die from it, and if you leave, it is against medical advice.
patient: Whatever. I'm done with you.

The line "You're not a real doctor" is a common one that I get from irate patients, and this lady got to me, believe it or not. I am usually very cool in my patient interactions. My interns have seen patients and families scream at me. But this lady, I was pissed. Afterwards, I felt pretty bad. After all, she was frightened that she may be having a heart attack, and we all react very differently to terrible news.

People think empathy is being with a terminal patient or comforting a sorrowful family, but I think that the real challenge of empathy is understanding the belligerent patient. Because anyone can feel sorry for someone with terminal cancer. Not everyone can see from the perspective of someone yelling at you and cursing your name.

I am not a pediatrician

I was trying to get out of the hospital on time, when I was cornered by an irate family member of one of my patients. The family member was very angry that I'd ordered so many tests, and wanted me to cancel them. Specifically, the problematic test was an ultrasound of the lower extremity for DVT. One had been done only a few days ago at another facility.

I tried to reason with the family member. We didn't have the report. Ultrasonography is very technician dependent. The swelling in the leg had worsened, and was unilateral. There was significant concern of DVT. Still, the family member would have none of it, and accused me of wasting the patient's money ordering useless tests. It was like being a pediatrician, trying to reason with parents.

I am not one to get into an argument with patients' family. I canceled the test and walked away. No point in getting angry or raising my voice. And undoubtedly, some of you are saying, "Well, it WAS a useless test! You had an ultrasound done only a few days ago!" I don't order useless tests. I don't even order daily labs. I am a minimalist. But I felt very uncomfortable with a worsening extremity, and a strong clinical suspicion of DVT. But now we won't know.

I'm about to go to bed, but I can guarantee you that I'll be sleeping like a baby, because if my patient has a DVT, it ain't on me.

Reminiscence

I saw some people that I haven't seen since high school, and it was a little bizarre, and very uncomfortable. All that growth and personal discovery and becoming a man stuff, that all seemed to go in the shitter, and I felt like a pimply teenager again, with all the same uncertainties, fears...

And it's hard not to think about how it seems like everyone I know from back then has had so much personal growth. They're married, they have kids, they own homes and have jobs and all that stuff, and it seems like I've sacrificed so much going the route that I did.

And yes, I've got a BS. Yes, I've got an MD. Yes, I'm in residency and looking at a future in internal medicine. There's no way that I can deny that I am an adult, through and through.

A few years back, I met up with a girl whom I had not seen in nearly a decade. It was like old times, and we reminisced. We felt young again for a few hours, but all those feelings that I had for her back then, a silly, little crush that smoldered for ten years, those feelings hurt, and I felt miserable rather than happy.

Seeing all these people from my past, it ends up being a little painful, seeing all the things in my life that I've passed up.

The admitting resident

I was admitting patients the other day, and it was another great day in the history of emergency medicine.

Case 1: 54 year old female with diabetes and hypertension who complains of chest pain and difficulty breathing with diaphoresis. Exam has reproducible pain. Cardiac enzymes are normal. EKG shows... it shows... wait. There is no EKG. The emergency department hadn't done the most basic assessment of a cardiac patient.

me: So, you want me to admit this patient for...
ER doc: For chest pain. She's here for chest pain rule out.
me: And her cardiac enzymes are...
ER doc: they're all normal. Why are you-
me: The EKG?
ER doc: It's fine.
me: Are you psychic?
ER doc: huh?
me: because you didn't do an EKG.

So I was kind of harsh, but really, what if the patient had ST elevation MI, and she was sitting in the ER for a couple hours while I was getting to her, and she should've been in the cath lab? The ER doc and I both knew that he'd dropped the ball big time, and was lucky that she had a negative EKG, because if it was positive, he'd be presenting at the next M & M conference.

And this was how I began my night of admissions. I wish I could say that it got better from here, but there's a reason I numbered that first case.

Case 2: 30 y/o with HTN presenting with chest pain with difficulty breathing, diaphoresis, nausea. ER doc wants to admit him for rule out MI. SIGH! Okay, well, at least tell me about it. I'm assuming the cardiac enzymes are normal and the EKG was okay. But the ER doc didn't do them. After all, he's a 30 y/o with chest pain and low risk. Why bother?

Case 3: ER doc calls and doesn't know the patient's name, age, room, what the vitals are, what labs were done, or if they were done. The reason for admission is difficulty in breathing. That's all I got.

Case 4: Called to admit patient that by the time I come down, he's intubated. So I ask, "So, this is going to the unit?" Dead silence. He still thought I was going to admit!

Y'know, to any ER docs or people involved in emergency medicine, this right here is why the medicine resident is always pissed when you call for admission. Because this is not okay. This ain't kosher. And it's sad when patient safety relies exclusively on me doing the ER doc's work.

The ER was pretty busy, so I decided against ramming a pole up ER doc's ass, because that waiting room full of people is more punishment than I could ever mete out.

The idiot box

ER ruined it all. When I went to medical school, ER was in its prime. I remember in college, people would get together on Thursday nights to watch it. It was a social event, more so than Desperate Housewives could ever hope to be. It was big.

And as any doctor my age can tell you, it ruined the field of emergency medicine. There was a glut of ER applicants, and it quickly became highly competitive, a field that became a separate specialty relatively recently.

And as you might imagine, for every one emergency medicine applicant for residency, there were 10 bitter pre-meds that didn't get in, and missed on their chance to be Dr. Ross or Dr. Greene or Carter. It was a rough time getting into med school when I was applying, with the average rate being somewhere around 1 spot for every 8 or 9 applicants throughout the Midwest.

The problem is, as anyone that's worked in an ER can tell you, the show is nothing like a real ER. There is none of that drama and tension and romance and horror. ER is not real. The #1 question I was always asked was, "What's it like to work in the hospital. Is it like ER?" It was such an absurd question.

Now I see it again with Grey's Anatomy. It's so ridiculous. People watch it and think that life is really like that, as if being a doctor is somehow so automatically dramatic. And I'm always asked now if I watch Grey's Anatomy, and is it really like that to be a resident.

I think if you took a poll among doctors, we as a group tend towards Scrubs. When I saw this show, I felt a real connection. I didn't start watching until my clinicals, and after watching episodes on breaking bad news and patients dying and bad outcomes, I was instantly enthralled, because that was me. I was the person telling Mrs B that her cancer had returned. I was the one holding Mr H's hand when he found out that he needed a bypass surgery. I was the one offering tissues to the family of Ms S as they found out she'd died.

Through all the humor and flashbacks and weird characters, far more surreal than any of the other medical dramas, it actually ended up far more realistic. It didn't shy away from laughing at disease. It didn't hide from medicine destroying our personal lives. It was honest.

I would watch a show like ER and it would pick up on all the bad things in medicine. It was all codes and crash surgeries and everything horrible. But I could come home and watch Scrubs, and it was healing. It was like sitting in the resident lounge, talking about my patient that died and how she never got to finish her needlepoint of her favorite NASCAR driver's car, and getting a cheap laugh. JD would realize something, and I knew it too.

Nowadays, even Scrubs has departed from this coveted status. The only medical show I watch now is House, because I enjoy the diagnostic challenge. Honestly, Erdheim-Chester? C'mon. That's awesome. But if you were to ask me what TV shows a young and budding pre-med should watch, I'd say the early seasons of Scrubs, and maybe St. Elsewhere. That's what feels right to me.

ut aliquid fieri videatur

It's been a long time since I've done Latin, but the best I could come up with was "How something is seen being done." This phrase means doing something for the sake of appearing that action is being taken. Action for the sake of appearances. An example would be like after Columbine, there were all sorts of gun laws regarding youths, but truth be told, the laws did next to nothing. It was done just to show that the government was doing something.

One of the attendings I've worked with was real old skool, East Coast internal medicine, and occasionally pulled out obscure Latin, peppered with stories of Osler. That's East Coast medicine for you.

All the time in medicine, we do things not because they're necessary for care, but so that we can give the impression that we are doing something for the patient. Many patients don't feel like we're doing anything unless we're ordering tests or getting daily labwork. In fact, I often make it my job to tell patients that we are indeed taking care of them and not sitting around drinking coffee.

And I wonder sometimes if the show isn't for patients, but is for ourselves, so that we can go home at night, look at our handiwork, and say, "Look what I did today!"