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.