Happy Holidays: Who Needs Barbados When You've Got the ICU?

I woke up the other morning and realized with a start: Oh-my-gosh-it's-already-December-how-did-that-happen? (This was after I did the whole mentally cursing at the 5 alarm clocks buzzing in succession at 4 am - see my earlier posts for more information/whining on that). This realization may not have occurred but for the fact that, for the past few weeks, my clock radio has been stubbornly, cheerfully featuring such saccharine ditties as the hot-chocolate-craving-inducing "Winter Wonderland", the never-fails-to-be-slightly-creepy "Santa Baby", or the theatrically diva-esque, classic Christmas earworm "All I Want For Christmas".

Even then, I'm a bit slow in the mornings. Luckily, I'm a dedicated Walgreens customer, and anyone who knows anything about Walgreens knows that this store is like America's weathervane. To wit:

• Pondering if a recession is looming? One glance at the teetering display of unsold nose-hair trimmers and As-Seen-On-TV Ab Rollers, and you have your answer.

• Trying to keep up with current city trends? Check out the ever-changing display in front of the checkout counter - here, a revolving display of San Francisco staples: canvas grocery/tote bags (the more in-your-face logos about recycling and environmental consciousness, the better), stainless steel water bottles (plastic and polycarbonate = decidedly c. 2005), petroleum-and-paraben free chapstick, mini-compost bins, umbrellas.

• Curious about the ethnic makeup of the neighborhood? Again, that friendly front counter, home to such clues as Yin-Yan sticks, dried seaweed snacks (endorsed by an evilly-grinning porcine cartoon man promising "Most crunchy Snack! Top quality!"), Thai Ginger Chews, Hot Tandoori Mix (which, in an embrace of the gaudiness-gets-dollars marketing philosophy, flashes a shiny lilac and tangerine wrapper showcasing a picture of tired-looking green peas, glistening oil-soaked peanuts and dangerously neon-yellow noodles).

• Wondering what contemporary songs the discerning music aficionado will soon blacklist from her MP3 player? Linger and listen in the aisles while listening to soulful crooners negotiate ten octaves in pleas for lost loves and one-more-chances - then give into your urge to buy earplugs STAT.

Anyhow, in line with my bustling social life as an intern in San Francisco, I end up taking several weekly jaunts to Walgreens - where I catch up on my "reading" by reviewing the packages of various OTC medications (one day, I will smoothly tackle those "Doctor, what dosage of Metamucil did you want to give now?" questions from pharmacy)...followed by a few more hours scrutinizing face creams in hope of finding the magic cure to hospital-inflicted Problem Skin....followed by a jaunt down the snack aisle to peruse the various metabolic-syndrome-inducing ethnic goodies...and invariably culminating with me buying some form of chocolate.

It was finally at Walgreens, after a few concerned mothers began steering their kids discreetly from my path, that I realized I was sashaying down the Foot Care aisle to the beat of Beyonce's R&B-ified "Rudolph the Red Nosed Reindeer". (If anyone can R&B-ify Rudolph, it's Beyonce.) This, coupled with the appearance of Limited Edition white-chocolate-and-peppermint Ghirardelli Squares - and the stuffed reindeer that started screeching "Meeeerrrry Christmas, Baby!" when I accidentally knocked it from its shelf - jolted my being into realizing that Christmas was around the corner.

Spending the holidays in the hospital, a seemingly depressing prospect, is actually....indeed quite depressing. For every intern across the nation, it is a time of reflection; a time to ponder exactly what mind-altering substance s/he had ingested when making the decision to enter medical school; a time to ponder the feasibility of partnering with a gleamingly-white-toothed infomercial "M.D." and launching a career sponsoring Botox parties. After all, the holidays are when normal people are supposed to sup, laugh and relax with families - or, as the case may be, engage in passive-aggressive standoffs with in-laws, gossip about blatantly tacky re-gifted presents and office-party hookups, argue with the airport security guard about to confiscate the $300 bottle of Napa wine in your carry-on.

But there is a wisp of silver lining - or, at the very least, a Claire's-Accessories-esque, contact-dermatitis-inducing yellow-dyed nickel lining - to this sad cloud of intern drudgery. Which is: working over the holidays allows the intern-victim to lay legitimate claim to the title of Generally Good Person/Humble Hardworking Servant/Martyr.

It's the sort of thing that gets you admiring, sympathetic glances from, say, grandmothers, friends vacationing in Barbados ("You're working full-time on Christmas, Thanksgiving, Boxing Day, New Years' Eve, Kwanzaa AND New Years' Day? What kind of messed-up job is that? Oh sorry - got to go, our mai tais just arrived") and cashiers at Walgreens. It might theoretically work as a facilitator of chemistry/booster of perceived attractiveness in the Potential Significant Other/Hot Date marketplace, except said intern would actually have to be physically present at said marketplace, which is of course impossible to do when you're on call and in the hospital that day. (Thus, single readers out there, if an intern you meet in September 2008 happens to let slip the sexy fact that they are working in the ICU on, say, Thanksgiving Day 2009 - yes, they are indeed interested.)

Even if an intern's spending 99% of it in the hospital, and thus is determined to wear the sullen mask of Intern Slave throughout, December is one of those months that burrows its pesky snowflakes-and-sleighbells, cinnamon-and-nutmeg-scented way into your soul. And, slowly but surely, it began to finagle its way into my grumpy mind. Maybe it was the green and red tinsel festooning the "The 7 South Team Works To Help You!" bulletin board collage, featuring action-shot cutouts of sprightly nurses bounding to gather medications, beaming unit assistants holding up remarkably expediently-processed order sheets, and startled-looking doctors trying to untangle their stethoscopes out of door hinges (why does that always happen to me??), all captured in the candid glare of flash photography. Maybe it was Gus, the perenially cheerful janitor, whistling a soulful version of "Christmastime" as he cleaned up the remains of a low-salt, pureed-diet tray a psychotic patient had decided belonged on the floor rather than in his stomach (who could blame him?). Or maybe it was the sudden, unexplained appearance of an yellow- slicker-sporting stuffed bear in the resident lounge, which dutifully belts out "Singin' in the Rain" at oddly random, unprovoked intervals. (I'm not sure what the last one has to do with Christmas - but the notion of anyone singing anything in the resident lounge has to be associated with a special season.)

In any case, it wasn't long before I was idly humming the theme from Charlie Brown's Christmas as I recorded patient vitals ("The patient's bed alarm is going off, but I can't figure out why - we'll need to call maintenance," one flummoxed nurse told another as I passed by), or found myself moved to shed a tear or three as a black-and-white Tony Bennett crooned "My Favorite Things" on a Christmas CD collection commercial in a patient's room (only $12.99 + S&H! If anyone wants to buy me a Christmas gift...). My bah-humbug, I'm-a-grumpy-intern exterior had officially waved the white flag of surrender to the subliminal effects of seasonal marketing. And so in my first move of acceptance, I logged onto sephora.com to take advantage of my newfound elite shopping status, partaking of the joy of holiday sales. (Damn subliminal marketing.)

But the other "great" part about working over the holidays is that you instantly have a bond with all the other lucky souls who are sharing the hospital space with you: fellow interns, cafeteria cashiers, pharmacists, nurses, social workers, CT techs (okay, maybe not so much the CT techs. Since they are never working when you need to order a STAT CT on a sick patient over the holidays.) It's why you can walk by a total stranger vacuuming the corridor on Christmas morning and exchange a high-five and warm hello like you were old college buddies, or why you finally get to mooch some extra coffee from the notoriously eagle-eyed cafeteria ladies.

And people, need I mention the most obvious highlight of working the holidays? Quite simply: Chocolate. Don't even get me started on the chocolate. It's everywhere - ensconced in workrooms, randomly making appearances at conference tables and floor kitchens, burgeoning from boxes in the resident lounge - and it seems everyone is always offering you some. One nurse actually accosted me in the hallway, grabbed my hand and marched me to a potpourri-scented break room where she poured me cups of hot apple cider and warm baked chocolate-banana bread. (That bread was so good, I think it makes up for every hour of working over the holidays.) And one particularly devious resident, whom I will not name, has taken it upon himself to plant mammoth boxes of chocolate covered macadamia nuts in vulnerable interns' paths (Hawaii's annual economic boost in December, I'm convinced, must be attributable to this resident's mass purchase of macadamia nuts for us common folk). Anyway, I firmly subscribe to the philosophy that no obstacle is too insurmountable, no barrier too impenetrable, no task too monumental, no patient too complicated as long as you have a decent bar of chocolate at hand. And with all the chocolate that marks Holidays in the Hospital, I think I'm pretty set (unlike my scrub size, which I think may be on its way upward after this month).

So on Christmas Day, while rested folk celebrate good tidings and cheer (or at least try to prevent die-hard Republican Uncle Leo from provoking die-hard Democrat Aunt Betty at the dinner table and causing another one of those notorious family cold wars that had the children crying for hours last year, poor things!), look up at that stale bottle of Pepcid you're about to grab to treat that nagging heartburn (Aunt Betty never really grasped the term "cooking light", did she?) and think of me. For my scrubs-clad self will be marching resolutely to work at 0600 on Christmas Day, past shuttered store windows and rows of sparkling Christmas lights, bearing the tell-tale battle scars of cavernous undereye circles and alcohol-gel-dehydrated hands. But to be honest, it's not going to be that bad. Fun people + Official Stamp of Good Person from the Universe + TV in resident lounge + Enough Chocolate to Happify an Army = content, overworked intern.


And with that, time to get back to work - I think Tony Bennett's playing in room 56. Long live the holidays!

Arugula and Intern Year Are Not Mutually Exclusive: Or, Yay, Barack!

Eep! How time flies in the world of a delinquent blogger. In the span of multiple weeks since I last posted, a run-down of what's been happening in the world of the medicine intern and beyond:

• 
  Someone absolutely awesome was elected president

• I finished 2 straight months of wards without passing out, quitting, hyperventilating, or regressing to a fugue state in which I am reduced to waddling aimlessly in the hospital clutching an abandoned hospital gown as a security blanket

The first event, arguably slightly more momentous than the second, has already garnered a fair share of coverage by such fringe publications and offbeat blogs as Newsweek, Slate, Time Magazine, etc. etc. In the spirit of the day when HIAD becomes a household name (laughter? is that laughter I hear? As Joe the Plumber ekes by on his $250,000 annual pittance, "K" the blogger battles callused, carpal-tunnel ridden fingers, an overheating laptop and frown wrinkles gratis....all for you, my Loyal Readership (Population: 4?). At least you can play along.), here's my personal, intelligent contribution to the fray:

WOW.

Okay. It doesn't take a rocket scientist (or a doctor?) to understand the impact of this watershed election, that it's a symbolic and cathartic achievement dedicated to the sacrifices of past activists, a moment to be treasured by citizens valuing equality, civil rights and justice, etc. But: how about understanding the unfolding of the campaign through the eyes of an overworked, underpaid, grouchy, TV-deficient resident carrying several risk factors for don't-care-about-elections-because-it's-not-like-they're-going-to-discharge-my-patients-or-give-me-weekends-off-or-a-pay-raise syndrome?

The average layperson, after all, knows the life of a resident is fairly "busy", with that pesky pager potentially interfering with such things as Eating, Sleeping, Going to the Bathroom, let alone those civic duties known as Voting and Being Politically Informed. And yet, across America, zombie-like interns buried in their tired HIPPA-compliant progress notes and fecal-occult-blood-testing cards unhooked the stethoscope-noose around their neck, looked up at the rousing voice of change - and Cared.

I know I speak for more than one intern when I say that even 12-hour days filled with scutty minutiae did not keep me from being an informed and politically (over)involved citizen. I promptly joined the ranks of approximately 99.99% of my fellow San Franciscans by buying my OBAMA-BIDEN 2008 sticker (and sporting my "Read My Lipstick: I'm Voting Democrat" bonus button), cheerfully canvassed voters by phone in swing states after work (luckily, as election results now show, I didn't hurt Barack's campaign too much), scrimped on lattes and shoes to direct my small-dollar, working-class, earned-by-the-sweat-of-my-brow, fished-out-from-the-change-return-slot-of-vending-machines contributions to his campaign, treasured and categorized every one of the 15,009 email correspondences and text messages sent by Barack and friends (Say what you will, but I know the campaign personalized mine. I just know. I mean, we're on a first-name basis! And they liked me so much that they're still emailing me. How many of you can say that???)

Don't get me wrong - it's not as though my life as an intern was on complete hold during this peskily nail-biting, convulsion-inducing, rapture-producing election season. The two arenas simply coalesced and congealed, much like those uneaten pancakes Barack ordered at a diner in Pennsylvania, or like Joe Lieberman's efficacy in the Senate. My key memories of the campaign unfolded in the sterile environs of the hospital. It was while palpating a patient's abdomen early one September morning, for example, that I saw on the TV the headline from CNN: "Breaking News: McCain Picks Gov. Sarah Palin as VP". (Seconds later, two nurses were in the room responding to the call button said patient had pushed, prying my hands off the patient's abdomen - upon which I had absent-mindedly begun compressing with unrestrained panic as I imagined the implications of a VP Palin.) And it was during one long night as cross-cover intern that I ran down 9 flights of stairs, bounded across corridors, leapt over such obstacles as runaway crash carts, lost medical students, beeping pagers and piles of inkless gel pens, breathlessly punched the code to the resident lounge just in the nick of time to tune into PBS and Gwen Ifill moderating the presidential debate. (To think. If I'd been running to a code, I probably could've saved a life or two.)


Like most of my fellow residents, I stayed glued to CNN, quoted stirring passages from debates to anyone who would listen, poured out my vision for the country and helpful suggestions for his campaign in eloquent messages sent to barackobama.com. Okay, so maybe I was the only one quoting passages and sending messages, since my wet-blanket fellow residents apparently felt it was more important to do "doctor" things like write orders, check patient vitals or reconcile medications. (Talk about misplaced priorities.)

And the result, as we all know, was sweet. That extra little tremor in the earth you felt at around 11 pm EST on Nov 4, 2008? No, wise-alecks, not me in high heels stepping down from the bus....no, not the stampede of patients fleeing from my Strep Throat RapidScreen Test swab...no, not the thud of my shopping bags after a very productive 5-hour shopping spree at H&M. (You all, I must say, are very poor guessers.) That jolt was the rumble of about 760,000-odd San Franciscans cheering and toasting the official Democratic victory in unison. After all, this is the city that placed on its official ballot Proposition R, calling for the renaming of the city's Oceanside Water Treatment Plant to the George W. Bush Sewage Plant. (Rumor has it the workers at the sewage plant revolted against this, not wanting to work for a company with "George W. Bush" in its name.)

On the political squawk-box, you heard a lot of talk about the crucial role of various key voting blocs: blue-collar America, white-collar america, green-collar america, hockey moms, diaper-changing dads, parsnip-sauteeing, arugula-wilting singles, bald white gun-toting racoon hunters, manicured black Prada-wearing metrosexuals, Porta-potty-frequenting ultramarathoners, etc. The truth? I humbly submit before you: It was us, the Supposed-to-be-White-but-More-like-A-Gray-Brown White Coats of America, the Interns, that brought it home for Barack.

And on that note, I think I hear some parsnips calling my name. Change.gov, here I come.

Killing my circadian rhythms softly: Night Float Adventures.

Remember that principle of "see one, do one, teach one" I was talking about in my last entry? Well, nothing quite exemplifies my residency program's unshakable confidence in its neophyte interns quite like a rotation schedule that has said intern taking care of 80 medical inpatients - that's all the medicine interns' patients - by yourself. Overnight. In the second month of intern year. (Maybe the "see one" part was the one month of rotations and patient interactions during the day??)

Welcome to my life as night float intern, a bizarro universe where my day begins at 7 pm and ends as the sun rises. Judging from my past whining about not being a morning person, a logical reader might posit that this owl-like lifestyle would be a welcome schedule pour moi. However, in a cruel twist of illogical fate, it just so happened that after a month of 4:19 a.m. wake-up calls, I actually had been falling into a pseudo-rhythm of sorts...rolling the rock one inch further up the hill in my Sisyphean quest to become the sprightly morning person who "just can't sleep" past 6 am. Suffice it to say that that rock has now rolled back down the hill with renewed vigor, squelching me triumphantly in the process. My circadian rhythms have not only gone incognito; they're in desperate need of a GPS system (or one of those nifty iPhones that can find out where you are with the touch of a button. Sorry, I'm in San Francisco...got to have the iPhone plug.)


Contrary to what you might think, night float is not in fact the brainchild of cackling, sadistic anti-resident conspirator ghouls haunting the hospital basement. (What, you don't believe in ghosts? Just wait until you've stayed up 7 nights in a row. ) The system was actually designed with an altruistic, noble goal: Let's Help Our Interns Get Some Sleep.


Let's expound on this. See, in the world of yore, hapless Intern X arrived at the hospital at 0600 am, flitting around the hospital floors all day like one of those hyper, in-denial, confused flies that keep hitting the windowpane thinking they're escaping to the sky beyond. She would continue to stagger in a semi-awake fugue state for that night and half of following day and, if all went well, departed at 12:00 noon - capping off a grand total of 30 bed-less and home-deprived hours spent breathing hospital air.


That was then. Now, in today's modern world, we not only have microwaves and TiVo: with night float, we have Intern X going home at a reasonable hour on the - wait for it - same day she came in, thus enabling her to return to her own little converted-closet-aka-you-really-pay-$1500-a-month-for-that-room? and crashing in her own "bed" (using the term figuratively, of course, since said room isn't large enough to accomodate furniture and a human being.) Now, as haggard interns wrap up a 15 hour day, no sight is more gladly welcomed than that of the rested and showered night float as she strides in, valiantly squelching all circadian protestations against starting a workday as the sun is setting. For it is this unlikely superhero who will release the interns from their workday, taking over their patients.



Of course, as the economic principle TINSTAFL (There Is No Such Thing As A Free Lunch) suggests, such a tremendous boon doesn't exactly come without cost. "Cost" in this case refers to that scrappy soldier, that multi-pager-balancing, order-juggling, scrub-clad acrobat, that sensitive soul who, like Atlas balancing the world on his shoulders, takes on the Patients and Their Care when the clock strikes "shift change". This pantheon of intern freedom and sleep enablement is, of course, the Night Float. While the interns snooze soundly at home, she takes on the role of Confused, Bruised Fly for the night, tending to patients while the city sleeps and informercials for arthritis cream play endlessly on TV.

"Night float" is a deceptively ethereal, serene-sounding phrase, conjuring up meditative images of shimmery physician-wizards dispelling illness with a wave of a magic wand while riding on the odd airborne unicorn. (You thought of that image too, didn't you?). Reality goes probably more like this: Night float, balancing a phone on one shoulder, flipping through various stacks of "sign-out sheets" describing all the happy snoozing interns' 80 patients, trying to listen to the nurse on the other end of the line, fumbling in a dingy white coat to find the two pagers buried under the graham cracker packets that have simultaneously decided to begin insistently beeping (the pagers, not the graham crackers - although strange things happen at night), while nodding to another nurse that has just tapped you on the shoulder to talk. I think being a night float intern is kind of like how it feels to be a Walmart, if a Walmart could feel: stuffed with an assortment of random items, trying to be organized but somehow always chaotic, always struggling to produce exactly what a demanding customer wants when they need it. Not to mention, both of us could probably benefit from some disinfectant and a nice hot bath around 3 am.

But wait, say you, the astute reader. Being a doctor takes years of medical school and residency...and during the day you have three levels of care - intern, resident, and attending - triple checking work on a team of patients....and now, one lone intern is in charge of handling the workload of about 40 people. At night. How is this legal again?

Well. Lest all of you decide to start boycotting hospitals altogether, let me reassure you that the night float does have "backup" in the form of 1) a senior resident on call and 2) the night attending on call. These are the people to page if Things Are Getting Weird or Scary: i.e. a patient starts going into ventricular tachycardia every time they try to have a bowel movement, or is hurling their oxygen monitor at the window, or threatening to sue the hospital if they can't have a cigarette (true stories.) For all other items, however, the night float relies on such help as 1) Google 2) a dog-eared handbook termed the "Intern Survival Guide", 3) coffee and graham crackers. Trust me, somehow it's a system.

Importantly, this system hinges upon the vital piece(s) of paper known as the "sign-out". At first blush, the sign-out looks like any other normal piece of computer paper: 8 1/2 by 11 inches, white, 4 straight edges, that sort of thing. But don't let that fool you: the 0.5-size Arial font that it bears might as well be gilded gold ink. For the sign-out is the night float's passport, Frommer's guide, boarding pass and pocket translator all in one (if only the destination were, say, Brazil as opposed to ward 7 south. But still). Its humble pages contain such key highlights of each intern's patient as "Name", "Room number" and "Meds", along with assorted important pearls - "What to do if patient's heart starts beating at 240 bpm", "Patient's wife is very high maintenance - soy milk at bedside at all times", "Call senior if patient's blood pressure drops to 70/40 and he looks sick".

The sign-out is how an intern, paged at 0300 by a nurse on 6 Center that Patient X can't sleep and needs something now, knows that Patient X needs Ambien in lieu of Restoril (since the latter makes him sleepwalk to the kitchen and sleep-eat through all the coffee creamer packets.) Or how she knows, when paged by a nurse that Patient Y's blood pressure is 85/40, that this always happens during the night when the patient is sleeping and there's no reason to call a code.

To ensure that the night float does not spend the entire night watching the Olympics on the doctor's lounge flat screen TV (who, me?), there is also a "To Do" section, which usually entails such things as: "Make sure patient has a bowel movement tonight - very important" or, "Patient needs to finish all her colonoscopy prep solution!! Check at 8 pm and make sure she drank the entire 3 liters!!", "Follow up on chest xray and make sure patient is breathing okay and not sick", or "Check blood counts at 8 pm and transfuse blood if Hct less than 27."

As the night float learns, the hospital is a different place in the wee hours. Maybe it's the antibacterial hand gel fumes and incessantly beeping machines, or maybe it's the bad hospital food. Somehow, the conversant and lucid individuals of the day become pain-racked, fearful, sleep-deprived, blood-pressure-dropping or -raising, constipated or diarrhea-ridden, urine-retaining patients. Somehow, as the sun sets, the sweet 70-year old knitting-a-scarf-for-her-godchild-libarian-slash-grandma starts to pull out her IV and insist that the Russians are coming to kidnap her. Somehow, around 3 am, the pleasant 26-year old college student awaiting surgery for an infected gallbladder starts to break out in hives and have difficulty breathing.

And thus, night float life is filled with intimate knowledge of sleep medicines, pain pills, laxatives and stool softeners, blood transfusions, patients' nocturnal hallucinations, hearts beating too fast or too slow or funny rhythms...along with the odd adrenaline-searing experience of rushing to a code or running up the stairs to help a crashing patient.

I'll write more later - but right now, it's time to answer yet another page. Day time folks: just be glad you don't have to convince your night-time selves to drink an entire container of colonoscopy prep. It ain't pretty.

Green Tea and Beyond: The Wisdom of Medicine.

How do you really learn medicine?

As I complete lap #2 in the 12 month intern year cycle, this question often rears its niggling, bemused head (okay, maybe that's my bemused head. But the question is still niggling. And I still got to use both those words!). And it especially niggles every time I meet a patient who grips my hand gratefully when my white coat enters, in their eyes an implicit trust that I will not only Tell Them What's Wrong, but I will Help Them Feel Better. For those patients, I'm a magical computer that can instill diagnostic meaning and context to myterious symptoms and physical findings, such as "My pinky toe, Doc, it's been twitching southward at exactly 5:03 pm for the past month. What's that mean?" or "Why does the corner of my right eyelash itch when I'm trying to sleep?"

In essence, for many patients I'm regarded as an auror, or a tea-leaf reader, or maybe a slightly better-dressed $1.99/min telephone psychic, taking in the facts and symptoms calmly with just the right gravitas inflecting my "Mm-hmm", "Uh-huh" and "I see", cooking them in the white-coat-aura machine and emerging triumphantly with a Diagnosis and Treatment Plan. It's kind of like in high school, when you learned about the concept of a function in algebra, there was that annoying picture in your textbook showing a picture of a computer taking in x and spitting out f(x) . (That one's for all my fellow high school Mathletes and Math Club alumni! Long live the differential!) I don't think I ever really understood that function computer thing until now - when, presumably, after 4 years and a $150,000 education, I'm supposed to be that computer, able to spit out f(symptom) at a patient's whim. Where symptom could be anything: that vague scratch in their throat, that faint pink rash on their upper arm, the strange rumbling in their stomach after eating that street-corner hot dog (come on, patient - I think we both know what caused that one.)

Of course, not all patients adopt the pleasant world view that Doctor Knows Best. Some patients are a little more, shall we say, jaded. Or maybe skeptical is the right word. No, how about questioning? Challenging? Domineering? I-Googled-This-Yesterday-And-I'm-Not-Leaving-Until-I-Get-A-Biopsy? (Ooops, not an adjective).

The anti-climactic reality is that doctor-ing lies in between those two extremes. If you've followed my posts, you probably have already happened upon the rather non-concealed truth that I'm hardly an auror, or a tea-leaf reader, and hopefully I look at least a little more shapely than a computer spitting out parabolas (and those weird asymptote graphs - didn't you hate those?) when handed a patient's symptom questionnaire chart. But I would also, at this juncture, clear my throat rather pointedly and turn the reader to Exhibit A, which is Myself upon the eve of our medical school White Coat Ceremony, a day where my knowledge of medicine consisted of little more than how to wear a white coat. Compared to that happy-go-lucky rapscallion, my current self possesses some symptom-processing knowledge to match those impressive undereye circles, no? Even if, ironically, I seem to have lost the ability to wear a white coat without instantly attracting some sort of stain. (I need that irritating Cheer Detergent lady who always seems to be bleaching some unkempt bachelor's socks to accost me on the street and whiten my coat. That would be a miracle.)

As residents, we like to think we're more dynamic and critically appraising, more contemplative and (hopefully) more alive and alert than an isolated Google I'm Feeling Lucky search, But the uncomfortable part of the doctoring reality is that, even after all those tests and classes and presentations and memorizing, even though we Know Stuff and Treat Things, we residents are still doctors-in-training. The "in-training" part means that every patient encounter is still practice. And that a lot of times, we have to act a lot more confident and authoritative than we feel.

There's an infamous motto of medical training that runs like this: "See one, do one, teach one." This is not the learning style that medical schools stress in their glossy brochures, which feature the requisite multi-ethnic group of pleasantly dorky students gazing intently at a microscope or textbook (and yes, that does happen to be me looking at that slide of squamous tissue on page 2. The lone pair of 3-inch heels in the bunch!) These happy booklets are geared at convincing the pre-med student, whose often nearsighted obsession with getting into medical school can obscure thinking about what lies beyond, that Medical School X will give you the knowledge and tools to doctor away like a pro. What you find out, only after completing medical school, is that even if you memorize every fact and ace every test, there is still nothing that teaches you...like practicing on the real thing. Even if, for example, you were one of those annoying people who could recite the precursors to oxaloacetate and identify the exact defect of the hypoxanthine phosphoribosyltransferase pathway in Lesch-Nyhan syndrome...you still might not know that you never give Fleet Enemas to patients with renal disease. So there. Nyah.

As scary as the connecting between "practice" and "patients" sounds (and I'm not even thinking about the patient yet!), the system of medical education rests on this implicit nudging forward of residents beyond their comfort zones, of learning by apprenticeship. Of course, you always have backup - your senior resident, the attending, etc. But funadmentally, our education is based on the notion that the only way for residents to be comfortable inserting catheters and arterial lines, of performing lumbar punctures and placing chest tubes, of using a defibrillator to convert a dangerous cardiac arrythmia....is to practice. On, incidentally, real live people.

For mortals like me, who incidentally really, really warmed to that "doing no harm" theme mentioned in the Hippocratic Oath, the notion of Just You, Some Book Knowledge, and the Patient can be terrifying. Which might explain why my heart was racing as, standing in a patient's room at 2 am, with a nurse, heart monitor and crash cart to keep me company, I slowly injected a potent anti-arrythmic medication in the IV line of an 86-year old patient whose heart stubbornly beat away at 190 beats/min. Or why, despite my sustaining a chronic sleep debt rivaling the U.S.-China trade deficit, I suddenly felt every cell in my body poised on hyper-alert as I prepared to insert a 10-cm needle into the spinal column of a patient with possible meningitis.

You learn in biology about the "fight or flight" response - the biochemical changes of the body's "sympathetic response" that happen when you face the odd grizzly bear, hungry man-eating monster, someone rushing ahead of you to grab the last pair of 75%-off cognac Frye boots. Nothing, I submit, nothing captures "fight or flight" - well, the "flight" part, anyhow - quite like Intern Year. 2008 may be the Chinese Year of the Rat, but to interns it is the Year of Eternal Adrenalin.

The funny thing is that you start glimpsing a logic to the system, the veracity to the "see one, do one, teach one" principle. A procedure, done even once, takes on the aura of charted territory: despite - or perhaps because of - that initial terror gripping you before the first attempt, the imprint of the experience and its lessons are indelibly marked in your brain. And thus, another piece of the impenetrable, mysterious black box of medicine becomes visible. Terror and adrenaline is ultimately replaced by calmness, confidence, that serene feeling of This is familiar, and I know what needs to be done here.

It's this demeanor of calmness, I have found, that instantly identifies the knowledgeable, good doctor. (And I'm not talking about that strained "I'm calm! I'm really calm! I'm so calm! Where's my inhaler?" expression that we interns tend to wear on our face.) Case in point: A month ago, I remember being called on a patient complaining of chest pain; arriving at bedside I found a patient who looked pale, clutching her chest and wheezing for air. I was handed an EKG that showed an abnormal, very fast heart rhythm and tell-tale signs of cardiac ischemia. The nurse then informed me, "Her blood pressure's dropping - and she's going down on her oxygen." Despite having attended three cardiology luncheon talks that week, at that moment the only thought that ran through my head was Help! I need a doctor!

Much like a mirage, only except real, my senior resident appeared in my peripheral vision, walking to the nurse's station to file a chart. I pounced, breathless, shoving the EKG in his face: "Mrs.-Bates-chest-pain-she's-tachycardic-EKG-bad-she-looks-terrible-blood-pressure-dropping-think-she's-having-an-MI-help!" And he calmly surveyed the EKG, calmly reviewed the vitals, calmly entered the room,calmly examined the patient and patted her on the shoulder as he calmly, effectively reassured her, "Mrs. Bates, we're here - we're going to help you,", calmly instructed the nurse to bring the crash cart inside along with 2 1-Liter bags of normal saline, camly drew up a syringe of metoprolol, while calmly instructing me on the key clinical pearls of the differential diagnosis and treatment of tachyarrythmias. This was the James Bond of doctoring: so calm, cool and in control he made Buddha look tense.


In the end, the good news about learning to be a doctor is that If You Seek, It Shall Come. As you go through the experiences...watch your super-human senior residents achieve the impossible (ie. convince the patients to eat the low-salt renal diet tray? That's pretty much the litmus test of "impossible". I bow down.)...and, yes, practice...you begin to find out that more of the mysterious black box is becoming your readable tea leaf.

Which is maybe why, when I got called a couple of days ago on a patient with chest pain and a heart rate of 180, and another wheezing patient with oxygen saturations of 82%, I found myself actually striding directly to their rooms, my feet avoiding their usual detour to the resident-on-call. Instead of the usual stream-of-consciousness panicked chorus of "oh no oh no what do i do oh no oh no where's the resident help!", rational and logical thoughts of differential diagnoses and treatment plans were carefully building like Lego block towers in my head. (Okay, maybe more like a Lego hut, or a hill. But still. Progress.) "Let's get an EKG now - we'll draw a Chem 7, and please also have crash cart in the room," I found myself saying. In what, I suddenly realized, was an oddly calm voice.

Who knew?

Better than Broadway: The Hospital's Opening Act

Odd as it sounds, sometimes in the flurry of signing orders, collecting vitals, making sure you can forget that most of medicine is "people-based".

In theory, medicine is a great job for the extroverted chatterbox - you know, the person who solemnly insists , "But really, I'm really shy, deep inside...I was the high school nerd...I still look at myself in the mirror and see an awkward teen with a big nose...," and then goes on to regale the crowd, entertain like a seasoned pro, and leave the party with a napkin practically dripping ink from all the phone numbers scrawled hopefully by infatuated admirers. (Seriously, folks. Let those of us who still surf the web for pocket-protector close-outs on Friday night or really have a big nose stake our claim to Nerd membership in peace. Get your own support group.)

Extrovert or otherwise, it is mostly true that medicine, you are going to be dealing with people all day. (Those of my classmates in medical school who balked at this reality - ahemfutureradiologistpathologistahem - decided that, even if unable to handle the Person in the living, breathing, demanding forme entiere, they could become desensitized by focusing on one digestible piece at a time: a thin-trichome-stained slice of biopsied lung here, perhaps, or an amorphous looking abdominal CT there.)

But just who makes up this cast of characters, you ask? (I'm flattered. You care!) We all know about the patients. But that's only the beginning. A brief sampling:

• Fellow interns, whom you now get to call "colleagues" for that extra elite-sounding punch (even if that "colleague" happens to be a fellow hapless intern who's standing behind you at the Pharmacy Reference Desk to look up the dose for Mylanta). NB: In the outside world, the casual toss of "Yeah, I'm a medical intern" might inspire a layperson's awe or even admiration. There is no such "casual toss" in the hospital. Rather, "I'm an intern" is usually a meek confession of sorts (i.e. "I'm wearing this white coat like I'm supposed to, but, um, I'm actually an intern,") , or alternatively used as an excuse (i.e. "Oops, I didn't mean to fax that X-ray requisition to the gift shop. Must have the wrong number. Sorry...I'm an intern.") Nicer hospital staff who learn that you are an intern usually offer their sympathies. (One nurse gave me a hug and said, "Bless your heart, honey, I'll keep you in my prayers.") An intern is commonly seen 1) trying to figure out where her pager is and how to turn it off as a cacophony of beeping erupts around her person 2) furtively sneaking graham crackers and bitter coffee from the nutrition kitchen 3) looking puzzled, scared, apologetic or confused.

• Residents, who are released from the shackles of the "intern" status, serving as official proof to the humane world that the hospital does not actually digest, process and recycle interns to become part of that suspiciously mosaic-speckled-tile hospital flooring. Yes, there may be battle scars - a few fine wrinkles, perhaps a double-chin or two, maybe an extra love handle or three (three love handles? I call that a hospital experiment gone wrong) - but on the whole, the resident is still intact, the triumphant victor in the battle of Intern vs. Hospital. The gloating period is short-lived, however, for the resident soon realizes that now, in her new role, her first task is to supervise and handle....not one, but two (or even three)...you got it, interns. (And all of their patients.) It's like Groundhog Day.

• Attendings and consultant/specialists - Fellow nerds: You know how in computer games there were those various little secrets and codes you could enter to "beat the game" and vanquish the evil monster "boss" who was holding the princess hostage? Well, attendings and consultants are like the Wise Elders of the hospital, having successfully learned all the codes and "beat the game" to vanquish the evil "boss" of residency. It's easy to identify them: the white coats of these realized souls swing crisply with the natural fit and pristine authority of a custom-made Armani ensemble, carrying nary a pen stain or overstuffed reference book. They don't need "books", for they have they have superpower ability to reference such details as the etiology of hypotonic euvolemic hyponatremia and the NEJM journal article last month that identified its optimal management....by just...thinking. (Really! No stealth googling, no panicked flipping through size-2-font pocketbook print, no running down to the librarian and begging for a lit-search. Isn't it amazing?)

• Nurses, who usually are united by the following qualities: 1) Access to all types of amazing food at all hours of the day, usually involving some type of baked good, and 2) Extremely cognizant of the unique superpower they wield- that is, the Power to Page Intern At Will. No matter how early they have to come into work, nurses usually sport neatly styled hair and pleasantly colored attire, have photos of their children/dog/cat within easy reach, and are always up for whipping together an aromatic casserole for the weekly floor potluck. From the intern's perspective, nurses usually fall into one of two categories: They Like You or They Hate You. Thus, the wise intern, when not working at her primary job of keeping patients safe from herself, focuses equally upon making sure that the nurses fall into the former category. After all, this is one excellent way to ensure endless free food (and access to the latest issues of Us Weekly.)



• Discharge planners and case managers, who quickly become your best friends in the hospital. They help you with that word that causes interns nationwide to break out into a cold sweat and run for cover: "Placement". "Placement" is why a patient who's been on your service for a month, who's so healthy he now routinely trumps 6'5" nurse "Rocky" in daily challenges of 1-on-1 pickup basketball, still wears a backless hospital gown and sleeps in bed 6789A. "Placement" is why 92-year old Mrs. X can't have that teflon-coated walker she needs to go home unless you fill out 2 sets of blue and green forms and stamp them on the lower-right-hand corner and then initial and date the top-left-corner of the third page before triple-hole-punching-and-faxing-and-filing. (And then being paged to come back and re-initial, date and time a stray pen-mark on page 4 that looks dangerously close to being forged.) But with a good discharge planner, suddenly you only have to fill out one form that takes care of everything, and your pseudo-pro basketball-player-grandma is going home tomorrow!



• The unit assistant: usually a commanding, authoritative female matriarch-figure who mans the front desk of each hospital floor and its environs, and is in charge of making sure charts are in order, patients are in the right rooms, and the orders scribbled by harried interns are scanned and processed. Rule #1: Never enroach on the sacrosanct territory of the Unit Assistant or Crowd Her Space. (As an ignorant newbie, I once made the mistake of meekly resting my water bottle on the side of the Unit Assitant's desk while pausing for a rare moment to breathe. Within seconds, the heat I felt coming from her menacing gaze nearly singed my split-ends. Never, never again.)



• The pharmacist, who is also your best friend, but also your Protector and Secret-Keeper. You see, within the first week of internship, as they read the prescriptions and orders you grandly authored with what you hoped was the flourish, experienced manner and carefully strategized unintelligible scrawl of a Doctor, they quickly realized just how little you knew. Yet, this realization remains unspoken as they continue to address you as "Doctor" (without the slightest trace of irony!), while valiantly protecting the patients from your advances. Thus, the phone call from Jorge at 4pm: "Doctor, I see an order for Vitamin K. There's no dose specified - was that 5 mg you wanted to start with?" I reply calmly, "Why, of course, Jorge - thanks for catching my oversight. We'll do 5 milligrams," as though it was a simple, universally known fact that 5 mg was the perfect pro-coagulation dose of Vitamin K for my septic, somnolent, febrile, super-complicated patient who gripped me in mortal fear with his comorbidities. As though I hadn't, uh, deliberately written a vague, open-ended "Vitamin K x 1 now" on the order sheet in the hope that an all-knowing pharmacist would call to fill me in on the right dose. All in a day's work.

So. There you have it: the cast and characters of hopsital times, in a nutshell. I did have a larger purpose with this entry, but as my mental juices have officially evaporated by way of the alcohol-hand-sanitizer-gel on my dehydrated hands, I'll have to attempt to retrieve it in a future entry...stay tuned.

And so with that dubious hook, time to go back to rehearsing my lines for Intern: Day #21.

The Non-Morning Person's Rant

It's only been two weeks since I officially signed my life over to the innocent-looking hospital down the street, and yet it's amazing how much two weeks on the wards can seem like a veritable era. Gone is the scared, flustered newbie who spent most of the first week running in circles and trying not to set off the emergency fire alarm while scurrying up stairwell 3a. Now, my extreme directionally-challenged self having mastered where the cafeteria is and identified access points from all hidden stairwells, I only run in circles when trying to find such incidental, archaic locations as the pharmacy, X-ray, the patient's room, okay, maybe the hospital lobby. But all is well, because at least I know where to find caffeine at any hour of the day. Like a moth to a flame...like an ant to honey...like me at a DSW shoe clearance sale...it's true love.

Two weeks is even enough time for me to reminisce fondly about the time when I Never Felt Sleepy, or when My Alarm And I Were Friends. Now, the mornings go typically like this: I typically jolt awake in the morning at 4:19 a.m., rustled from such fiftul dreams as the one where the hospital suddenly grows menacing, toothy jaws and evilly grins at me as I cower in a corner whimpering, clutching my stained white coat over my head as the stormy air begins to rain ugly Dansko clogs and unsigned progress notes. (And you wonder why they spend so much time at orientation devoted to "When A Physician Needs Help.") I growl at my cell phone alarm as it cheerfully sings "Hello World" every 5 minutes. As a pleasant reminder that it is indeed time to wake up, my pager begins to beep at 4:24 a.m. (my backup alarm) followed at 4:28 a.m. by the static of my clock-radio alarm (my backup-backup alarm) that for some reason I can never get to actually play anything remotely musical. I slowly wake up in the process of turning off the various alarms - enough, at least, to pick a matching pair of unappetizing sickly green scrubs (and by "matching", we mean: I pick a top and a bottom. Success!) and remember how to exit my apartment and find my way down the street to the hospital.

"Maybe being an intern will help you to become a morning person," my mom suggested one sunny, carefree morning in late May as I padded down the stairs in my cow-print pajamas, at the decidedly undisciplined hour of 11:30 a.m. I nodded vaguely, notions of "setting an alarm", "sleepy" and "the sky before sunrise" appearing as abstract concepts belonging to a bizarro world - where, for example, your father might shower you with praise after you buy that extra pair of tan knee-high boots, where all Muggles could Disapparate at whim, or where chartreuse spandex could be cute. (No. Don't even think about it.) The thought of waking up early flicked across my mind then like a thin wisp of cumulus cloud traveling over the cheery sun of vacation, but it quickly evaporated against the aroma of Mom's Brunch, a meal so complete it could be featured on the back of a cereal box.

In many ways, my journey to medicine chronicles the battle waging between my circadian rhythms and Regular Business Hours. I'm telling you, it's a conspiracy against poor moi. Evidence: who had the bright idea of shifting the clock artificially forward for 8 months of the year? (Ben Franklin: I blame you.) Did someone think, "Hmm, I'm not sleepy enough when I wake up at 5 am. So why don't we actually turn 4 am into 5 am, so that we all feel sleepy when we wake up at the new 5 am, which is actually 4 am in real time?" I ask you, are we all masochists? Am I the only one who signed the Official Petition to End Daylight Saving Time? (Am I the only one who is basing my choice of presidential candidate based on who has a most pro-abolishing-daylight-saving-time record?)

Anyway. Digression aside - blame the wandering mind on lack of sleep - if Regular Business Hours is a challenge, the world of medicine takes the concept to a whole new level. Think of RBH as the little "0.5-Kilometer FunWalk for Kids" with lots of lemonade and refreshments and bounding puppies in the park. Then the world of medicine is like running an ultramarathon in Death Valley. You'll crawl out of bed at 4am, pull 30-hour shifts, spend the day running around corridors frantically trying to remember what you were running around the corridor to do...and then, at hour 29 of staying awake you might be expected to respond to a code, intubate a patient, do a spinal tap or place a chest tube, analyze an abnormal lab result, admit a new patient. All this, even when the next morning you might be scheduled to give a lecture on the health evils of sleep deprivation. We physicians are a logical bunch.

But even as my battle wages on, and my debt of sleep begins its slow and steady accumulation, there is one funny thing I've noticed. It's that even at hour 29 of an exhausting day, when you're beginning to see mirages of floating pillows and warm bubble baths, something happens when you are in front of a patient that needs help...and they're looking at you. It's like a jolt more powerful than the most potent Red Bull-green-tea-spirulina concoction (ew), that sharpens and heightens every sense and instantly obliterates the fog in your mind. You suddenly realize that this is what you've worked for: this is why you sat through the endless tests in medical school and studied away while your friends slept in on the weekends...this is why you scurry around the hospital daily for hours paid less per hour than minimum wage....this is why you finally get out of bed at that ungodly hour of 4:23 a.m. There is something that instantly snaps your mind to attention, that instantly makes you wake up when you see the life in front of you that you are about to touch.

And yes, sometimes that life you are about to touch is just a question of telling a patient, for the 139th time that evening, that there is no more morphine in the hospital and no, you are not authorized to prescribe marijuana even though, yes, you are in California. Or spending 10 minutes trying to nod with what you hope is empathy and interest as a patient eagerly describes the diurnal variation in the character of his bowel movements and engages in a discussion on the esoteric difference between "mucoid" and "loose". (Sorry.) But sometimes, it's rushing to a code on a crashing patient and saying things like "Give him 1 amp of D50 stat" and knowing that that's the right thing to do. Sometimes it's sitting down in front of a terrified patient who asks you, "What should I do, Doctor?" and letting the beauty of medical knowledge guide you and enable you to coherently explain, to soothe, to help ease the pain and worry. Sometimes, it's looking at a set of lab data or imaging studies or physical exam findings and realizing with a flash that you know what's going on, and you know how to fix it.

Sometimes, it really is about saving a patient's life, about - warning: corny alert - making a difference. And I guess that's what, in the end, is really my wake up call.

A Recycler's Dream

One of the things that interns almost everywhere grapple with is paper. Mounds and mounds of paper. Salmon colored paper with stripes to fill out progress notes, bright green paper with neat rows of checkboxes for ordering scans, tired-looking, off-white paper for discharge instructions that you can only write on with a ballpoint pen (to make sure the imprint comes through on the eight sheets of carbon paper underneath.) Forms for home health care, forms for skilled nursing, forms for prescriptions, forms for antibiotics, forms for X-rays. Templates, sign-out sheets, post-it notes ("DON'T FORGET to check Mrs. Smith's creatinine at 3 pm." or "Chinese food in the 6 Mezz conference room! Be there!").

The minute the intern gets a page that a patient is about to be admitted, there is a mad dash to get the paper in order. The big blue binder is brought out, the tabs ("Medications", "Physician Orders", "EKGs", "Demographics") neatly laid in place, a rainbow of papers hole-punched, stapled and stamped with the patient's name. This is the patient's Life in The Hospital, the famous site of unintelligble physician scribblings, tentative orders by interns (with the trademark scratch-outs and revisions), medications and progress notes.

And then the patient becomes an official part of the intern's personal roster. This is the intern's Life in the Hospital, her most dearly protected possession (second only to a non-leaky black ballpoint pen), containing such vital facts as each patients' hemoglobin count, latest echocardiogram results, past medical history, name and age, the all-important "TO DO" list, that kind of thing. Each intern's system varies, but have the following requirements:

• MUST fit in a pocket that is already crammed with various sundries (pocketbooks, gum and pens). Big clipboards and other such fussy items may look organized, but like any short-lived fashion trend, they will soon lay abandoned in a forlorn corner, languishing near a stale donut and the June 2006 issue of US Weekly magazine.

• MUST allow for fast retrivement of basic data. You do not want to enter room 6442, turning to face the patient with what you hope is the air of a confident, knowledgeable physician exuding empathy and compassion, only to realize you have completely forgotten which patient is in 6442 and have to scramble frantically through your size 2-font printed sheets to find this basic information. Big printed name = Good.

• MUST have plenty of space for scribbling. This is important. Interns run around hallways all morning and afternoon, with the vague, disturbing sensation that they have forgotten something Important. The only way around this is to checklist, checklist, checklist; write down; write down; write down. Thus, "Hey - can you make sure to call Mr. X's daughter to update him today?" or "You know, Doc, I really need a bedpan, and I've asked the nurses ten times to get me one but they haven't" or "Doc, Can you find out if the cafeteria serves grilled cheese on Tuesday evenings after 5?" each take on the anointed status on the intern's roster of Written Down/Box To Be Checked Off. It makes the intern's life supremely easier if all of those boxes and tasks are written in the same organized place as opposed to, say, the back of one's hand, a random grocery receipt, a crumpled dollar bill, the hem of a white coat. (And can I tell you: at the end of the day, looking at all those checked-off boxes feels like an accomplishment in itself...)

You can get fancy: pocket-protector types may be seen carrying around those brightly colored index cards, neatly alphabetized, segregated by patient condition and date of admission, finished off with a smug little binder clip or binder ring to - can you believe this? - hold everything together. More, um, creative, stream-of-consciousness types like, um, me (I'm still trying to get myself to stop writing my to-do's on the back of my hand) rely on the ever-classy Sheet of White Paper Folded in Half (it is classy - doesn't that sound like the title of a still-life portrait?) complemented with Supplemental Scribblings on Other Sheets of Random Papers in Coat Pocket.

Of course, such a roster adds yet another exciting element of paper to the intern's life.

The hospital at which I'm doing my residency proudly proclaimed, on our first day of orientation, their mission to go "paperless". The speaker talked of a utopia where everything would be clickable, cut-and-paste-able, retrievable remotely, wirelessly and infra-red-lessly. Physicians would carry their all-important roster on a PDA or TabletPC, charts would show up on computer screens. "I have a dream," he intoned into the sterile hospital air, "that one day, the single push of a button will bring a physician all the important data on the patient...where paper" - he spit out the word like it was a piece of over-chewed gum - "where paper will no longer exist inside the walls of this building."

After he left, the technical support staff came to do their presentation on the new electronic recordkeeping system to which our hospital is beginning to transition. "We've prepared a comprehensive handout for you so that you physicians have the info at the tips of your fingers," the staffmember beamed, as he passed out thick, single-sided handouts to each of us. We added the Learning to Use the Electronic Database handout to our orientation folders, which would, by the end of the week, bulge with the company of various other stapled paper counterparts: Cultural Diversity in the Physician Workplace; What To Do When A Physician Needs Help; Nurses and Physicians - Working Together for Better Health; Information Security Cares About You.

Maybe a paperless hospital is possible. But as I print out my patient roster every morning, order Mr. X's CT scan using the white form (not the yellow form, which is for EKGs, and not the green form, which is for consults only), write my hopefully legible progress note in the pink section of the patient's chart, silently curse the computer that inexplicably prints out three copies of Mrs. Y's history and physical when - I swear - I just asked for one copy...I sometimes wonder whether hospitals and recycling companies have a secret contract that has to expire first.

Time for me to go plant a tree.

The Steep Learning Curve

It's only been 6 days, but it feels like an era has passed since my naive self stepped onto the salmon-and-gray-speckled tiles of 6 South last week. (Why do all hospitals choose that same 70's-esque color scheme of tan, gray and pastel pink accents?) Just as I've grown accustomed to the new feeling of my long white coat flapping around my knees (it even has a curious pseudo "belt" at the back, which, rumor has it, is supposed to create a "waist" for us females. Or, perhaps it will help hide our waist that we'll gain from eating hospital food over the years...), it's already no longer white - but instead taking on that familiar shade of coffee-and-stray-ink-mark mosaic. The pockets are already overstuffed with pocketbooks and other medical goodies, so that as I bend down to palpate an abdomen or reach to retrieve my stethoscope, I end up inadvertently showering the patient with M&M's, a stray pager or The Sanford Guide to Antimicrobials 2007. And after stuffing the front pocket with approximately 10 pens, I've already managed to lose 9 of them...and I've even earned the wrath of the clerk when I absent-mindedly walked off with the coveted front desk gel pen (despite its sporting a hot-pink tape flag sternly rebuking the thief: "This Pen is not Yours.")

You start hearing the phrase before your clinical years in medical school: "It's a steep learning curve." And then you hear the familiar phrase describing intern year, echoing through the halls of the hospital as kindly upper-year residents comfort bemused interns gingerly rifling through patient charts, searching in vain for the Truth.

Steep, perhaps. But no-one mentions how slippery it is. And how much is at stake if you fall off. The first day, walking into the residents' lounge at the decidedly non-cheery early morning hour of 5:45 am, I suddenly became the primary intern for 8 patients, who would all look at me wearing my white coat that morning, call me "doctor" and trust that I knew everything about them and would do all the right things to make them feel better. It's a good thing that the real world isn't like that bad movie with Mel Gibson where everyone could hear what he was secretly thinking about women. Otherwise, my patients would have heard something that goes like this:

Me (walking into room and waking up patient): "Hello there. It's nice to meet you. I'm - ah - Dr. - Dr. K, and I'll be taking care of you today."

Me: (inner voice, screaming): Oh My God. Did you just call yourself Doctor? Does she even believe you? Why is she reaching for the nurse alarm button? Wait, this patient is supposed to be male...did I get the wrong bed number?

Me (softly): Um. Sorry ma'am, I'll, uh, be right back. Just, uh, forgot something.

(Exits room, trying to retain remaining scraps of dignity)

At our program, 8 is the "cap" for the maximum number of patients an intern can carry at any one time. As a medical student rotating on the wards, I'd carried a maximum of 4 or 5 patients, and that was with an experienced senior resident monitoring me to ensure I didn't accidentally write for three enemas on the same patient. And all these were patients that I actually helped admit to the floor, thereby seeing them from the first day of their hospitalization and following them throughout their stay. They were patients I knew through and through.

That first morning, I started with 8 patients who had been admitted by the outgoing intern (who was now bidding farewell to the unenviable status of "intern" and climbing up to the more esteemed status of "resident"), and who were now being "handed over" to me. In the process of "handing over", the outgoing intern had talked to me about each one of the patients the evening before, making sure to cover main outstanding issues, letting me know that Patient Johnson was anxious about her upcoming liver CT or that Patient Smith firmly believed that he was Elvis and not to be alarmed if he might request me, as a new face, to be one of his backup singers. I had nodded and carefully taken notes, but everything blurred together as I now looked over the list of the eight unfamiliar names and the brief descriptions of their medications and history. I concentrated on trying not to break into a cold sweat (seeing beads of sweat on a physician's forehead, I figured, wouldn't exactly be conducive in inspiring patient trust and confidence)

A hospital isn't a hospital unless it is designed with bizarre staircases leading to nowhere, odd hallways that lead to exitless alcoves and hidden floors sandwiched between patient wards. As I would find, getting to the patients would prove to be one of the more daunting challenges of the day. Having reviewed the patients' vitals and information on the floor, I decided to take the stairs to the 6th floor, hoping the little burst of cardiovascular activity would prove invigorating.

Inexplicably, the particular set of stairs I took ended on the fourth floor, which opened out into a long, unfamiliar hallway. I wandered tentatively around with the trademark air of the Lost Intern on Her First Day, until the trademark sharp voices of Random Mean Scrub Nurse and Equally Mean Surgery Person both snapped, "This is a sterile area and you need to leave now." I was in SurgeryLand, not a good place for a hapless internal medicine intern to be. White coat billowing humorously around my knees, I quickly turned and scurried out another door, which led me into another equally unfamiliar hallway, with no exit or stairs or elevator in sight. I was trapped.

Looking around desperately, I saw a nurse standing in a corner flipping through what looked like a magazine. I summoned up courage and approached her with the decidedly intelligent query: "Um. How do I exit from here?" She looked at me coldly from the rims of her glasses and said, "I am administering medications right now and am not allowed to talk to anyone."

After taking the emergency measure of interrupting a group of nurses eating breakfast in a side room (usually verboten, but desperate times call for desperate measures), I finally found my way to the 6th floor. It then took me about 3.5 hours to go through my "rounds": getting vitals, examining my patients, familiarizing myself with their conditions and trying to convince them I was, in fact, a doctor. As I grappled with orders, notes and medications, all the while running through my head was the refrain: Please, please don't let me accidentally kill anyone. I found myself double and triple-checking every move I made, looking up the dose for Tylenol and Tums, paging my supremely patient and kind senior resident every five minutes to update him on bowel sounds and rashes.

Thankfully, most residency programs understand that incoming interns were hiking in Peru or skiing in Lake Tahoe only weeks earlier and have studiously avoided setting foot into a hospital after their graduation, so there is always plenty of backup. There's the senior resident, attending physician, nurses, and the ever-patient 6-South pharmacist, Jorge, who would send thoughtful "clarification pages" to interns writing medication orders. "Doctor, I'm sure you meant to write omeprazole 20 mg tablets, not IV, correct? Because, uh, it doesn't actually come in an IV form..." or "Doctor, you do know that 4 mg of morphine is an, um, pretty tiny dose? Did you mean to give that IV?" Thank you, thank you, my dear friend Jorge.

Looking back now on that first day, I am so glad it's over. The first day is really always the scariest, and I made it through without hurting anyone. It's only day 6, but I'm slowly ice-picking my way up the curve: I remember all my passwords - an incredible accomplishment! - I can calmly write for Dulcolax without a compulsive need to check my pharmacy book just in case. I know where the secret cappucino machine is on the 5th floor, how to bypass the scrub machine to snag an extra pair of free scrubs. And lately, some of my patients even call me "Doctor". And I didn't even have to bribe them to do it.

Help! I'm a doctor...

So as I start writing this, I'm hoping that in a few years I'll be able to change the title of this blog. Meaning, I won't jump quite so forcefully or feel the hairs at the back of my neck prickle when someone turns and addresses me as "doctor". But right now, on my fourth day as a first-year internal medicine resident, hearing the word oddly attached to my last name still elicits a knee-jerk reflex to scurry away in fright, or contemplate snitching my patient's pm dose of Valium.

The first time I heard "Dr. K", I was standing on a stage in front of about 1,000 people in Michigan, in a beautiful auditorium decked with flags and ornate paneling. Around me were beaming physicians, wearing beret hats and colored sashes. I remember thinking I had arrived because finally, I got to wear one of these awesome, huge black pouffy robes with velvet detailing on the side (see picture) - the robe that just screams "I'm damn smart and I got Education with a capital E". As if that wasn't enough, after hearing the deliberate, microphoned intonation of my name - version 2.0, M.D. - I then got to walk acoss the stage to applause and flashing cameras, accept a scroll of parchment (okay, it was paper, but still) tied in gold ribbon, and then bend my head as a silk, multicolored sash ceremoniously was placed over my head.

It was sneaky, really. Who could possibly get scared when our medical school had put into place so many tricky little details designed to make sure you felt absolutely Awesome and Special? With all the fanfare and unsubtle theme of the day that Our Students are Fantastic, you could have called me the Pope's physician and I would have thrown my head back, laughed in utter confidence, and coolly uttered, "Why, of course. All in a day's work."

It didn't hurt, either, that this moment of glory was framed against the end of the bumpy journey that is medical school. People often ask me, "What was it like, being in medical school?" Taking the journey analogy a step further: Medical school is sort of like driving from New York to California in a 12-year old Saturn sedan with 5 people; a radio that plays only a mix of Easy Listening and static; an arthritic, sometimes incontinent labrador retriever; 2 overripe bananas and a tub full of wasabi-salt-and-hot-chili-pepper cashews with 1 shared, lukewarm 8-ounce bottle of water to wash it down - and making the trip twice a week. On this journey, then, fourth year is like the Year of the Rest Stop....or like someone taking pity on you and saying, "Hey, I don't need my Porsche anymore. Here are the keys. Have fun."

Sure, I had a few weeks of vacation after the day I officially became a doctor to let it sink in, to practice writing out "Dr.K, M.D." (and ponder if that was too redundant), to come up with my own unique style of undecipherable handwriting and sloppy signature, to rehearse my professional sounding introduction with just the right gravitas and ego, to buy my "Trust me, I'm a Doctor" baby-doll t-shirt at Charlotte Russe. Instead, I decided upon a circumpsect, carefully-thought-out strategy of denial and embarked on a shopping spree that included assorted purchases of cognac stilletoes, flowy skirts and a really cute cropped jacket with bell sleeves. (This, by the way, is one of my most tried and tested strategies/therapies: there is always a reason to shop. Why else would the astute soul have called it "retail therapy"?)

Which brings me to here, acrossthe country in a little studio in San Francisco, about 0.8 miles north of a pink building that is the hospital I now call home. (The hospital, not the studio.) I'm four days into the year that is notorious - courtesy of such shows as Grey's Anatomy, House, and Scrubs - for gobbling up a well-rested, bright-eyed, cheery and optimistic young'un and spitting out a chewed-up, crabby, caffeinated, dehydrated, sleepwalking grouch with undereye circles big enough to serve as basketball hoops and a skin tone that screams "I Only Eat Refined Sugar Because I'm Too Tired To Care." (Except, of course, the Grey's Anatomy writers work in a magical hospital wherein all scrubs magically fit, sleep deprivation and surgical masks make you instantly attractive, and undereye circles are extinct.) I speak of, of course, Intern Year: the first year of residency.

So that's where this little project is born...a little peek into the life and times of that person wearing the white coat (not so white, if you look closely...I blame it on gel pens and leaky coffee cups), who still secretly gets a little visceral chill when she looks at her name followed by the letters "M.D." Hopefully, you won't get quite such a chill when you think of yourself as a potential patient of mine (ack! why am I getting the chill?) or realize just how human the person behind that pompous-looking white coat really is. Unless, of course, after intern year I can no longer accurately be classified as "human" and more aptly fit a category like "overworked breathing corpse".

So with that, here's to Intern Year.