For the naive, happy, carefree outsider, the world of medicine often carries an oddly "glamorous" mystique. For proof, we look at Popular Media, where the glory of doctordom is handily presented in broad strokes: 5-second miracle brain transplants, routine chest-cracking/bare-hand heart massage and placenta-less, assembly-line pregnancies. In this world, general anesthesia is essentially a formality, replaced by the swoon-inducing, sheer hotness wattage of budding Patrick Dempseys and Katherine Heigls.
The media mystique is pervasive:
- You've got doctor soap operas featuring chiseled, Botoxed doctors barking "Nurse, scalpel, STAT!" as they powerfully steer gleaming gurneys through endless hallways, while scandals fester in deceptively innocent supply closets.
- You've got cheesy doctor documentaries with the token James-Earl-Jones-esque baritone gravely narrating things like, "The young boy's heart had stopped beating and all hope seemed lost - when finally, Dr. Smith decided to take a chance on a miracle", accompanied by some kind of backwards-ticking digital clock and a beeping red heart rhythm pulsing ominously on the screen.
- You've got doctor beach-lit featuring a tortured young doctor-protagonist questing after a tainted stethoscope which has been implanted with a timed-release, deadly diarrhea-inducing virus and is now spreading the runs among patients with each auscultation. (This, sadly, could actually be real life. Reader, meet C difficile.
- You've got beanie babies inspired by loveable, charismatic interns such as yours truly. (Come on! The Obama girls are too glamorous to be anything but doctors when they grow up.)
In 2008, 31,000 people applied to jump on the medicine glamour bandwagon in 2008 - and that's 31,000 people who are clearly not reading this blog. (Perhaps, by listing this statistic, I could be part of the search results for "number of applicants to medical school", which Google reports has been searched for 5,833,000 times. Talk about instant increase in blog readership!) At least some of them (or their parents) must have been motivated by the seeming panacea of glamour offered by the M-bomb. After all, what better way to quickly sum up the biodata of "steady-income-earning potential with requisite intelligence, strong likelihood of compassion, PLUS a lifetime of free medical consultation bypassing hours of flipping idly through backdated issues of Golf Digest in a cramped doctor's office" than simply attaching the "M.D." after your name?
Ah, glamour. In former, naive, pre-internship times, I thought the term referred to things like strappy patent leather high heels, Paris, Fred Leighton drop earrings, spelling glamour with a "u". Back then, I also used an eyelash curler, sometimes read Dostoevsky and Sedaris by a crackling fire, served as an upstanding member of the DSW Frequent Shopper Rewards club, lovingly tended to a clothing collection which conspicuously lacked drawstrings, reversibility, and the color group "sickly pale green".
Then, I entered the world of medicine.
Some people think the hardest part of medicine is getting used to the "blood and guts". Tales abound of the 6'2, broad-shouldered football player who faints at the sight of an IV line or the neophyte intern who trembles with nausea after smelling the yeast growing under her patient's pannus. Sure, there's weeping ulcers, bile-stained dressings, toenail fungus, prolapsed hemorrhoids, inflamed follicles, oozing pustules, frothy sputum, ecchymoses, furuncles, liver spots, blood-streaked stool, tarry stool, fatty stool (sorry, there's a lot of stool). But forget all that. The hardest part of medicine in a nutshell? Quite simply: the sacrifice of the wardrobe.
At first, my natural instincts protested against the scrubification of my soul. You see, in those pre-medicine days, I was an ardent follower of the venerable art of wardrobe sciences, the reigning neighborhood shopping marathon endurance champion. I was the kind of shopper who obsesses over the subtleties of onyx vs jet black, who tries on two (seemingly!) identical pairs of the SAME SIZE trouser jean to evaluate subtle, sub-size/style variations in fit or wash, who navigates to fitting rooms using only smell, memory and touch due to the tower of clothes in her arms obscuring her vision. I curated my closet with the same fervency and dedication of a Smithsonian expert, organizing clothes by color, texture, season, temperament/mood, number of compliments (or odd stares) received.
And then, one fine day while journeying along the path to medicine, I suddenly found myself facing the prospect of obtaining my outfit from a vending machine.
I stared into the bowels of the behemoth, Darth-Vader-like automaton ScrubVendor TM, where rows of puke-green 70% polyester cylindrical bundles appeared to mock me, daring me to select them. The prospect of donning a pair of drawstring pants in my early 20s - not just any drawstring pants, but a pair of bunchy, tapered, thigh-enhancing, leg-shortening, crotch-disfiguring pants - flooded over me; feeling suddenly faint, I grabbed onto a chair for support. I briefly contemplated quitting medical school, then decided to furtively drive 30 miles to a specialty store to pick up a tailored pair of boot-cut, low-rise scrubs.
For a while, I continued to stubbornly resist enculturation into the world of medical fashion, determined not to be taken in by the temptations of tackiness marauding as socially acceptable norms. I boycotted clogs, refused to pair scrub tops with jeans/ khakis/mismatched scrub bottoms, never wore a scrub top without at least one "safety shirt" underneath, and of course, never, EVER did things like wear scrubs to the grocery store or the gym. Even as the anemic green rags snickered with a tempting, mindless, just-choose-me-I'm-so-convenient appeal at the fashion-challenged hours of 4am, I resolutely marched to my closet, determined to exercise my brain cells in choosing a real outfit that reflected my mood (needless to say, there were several outfits consisting of black, metal chains and spiked cuffs). While every other (sane) individual soft-shoed around the tiled hospital floors in ergonomic harmony, I was the one clack-clacking away in 3-inch heels, inciting intrigued/annoyed glances from nurses and unit assistants shopping for Louboutins on eBay/trying to reconcile medications.
But of course, like so much else, things change. Maybe it was the time I was sitting on a swivel chair, clad in a flowy A-line skirt and cognac pointy-toed heels, grasping a pair of heavy-duty pliers with one hand and the callused, toenail-fungus-ridden diabetic foot of a schizophrenic patient in the other, trying to complete the assigned task of removing said toenails with said pliers. Or perhaps it was the time the intoxicated college student in whose arm I was trying to place an IV decided to wake up and retch all over my camel-wool trousers and tie-neck blouse (at least the boots were spared!) Or maybe, it was waking up at an ungodly hour one morning and realizing that by wearing scrubs I could snag an extra fifteen minutes of beautiful sleep!!. That was it. The shapeless, tapered duds went on. A thunderclap was heard, and somewhere the evil denizens of de-fashionization cackled and rubbed their hands in glee.
Clearly, the glamour of medicine does not emanate from its wardrobe. It's also not likely to stem from the routine tasks of internship (see: Bowels, Idiosyncracies of; Missing Studies/Tests/Labs, follow-up of and endless waiting for; Google/Wikipedia, worship of; Agitated Patient, calming of; Mysterious Dizziness in 32-kg, 125-year old gentleman, lengthy workup of; Chicken With Head Cut Off, constantly running around like.) To be honest, it's probably more glamorous to be a resident of Albert, Texas - just think: if you had twins, you could almost double the population!
But even if it's not glamour in, say, the we-are-all-devastatingly-attractive-and-scandalous Grey's Anatomy sense, there is still something extraordinary about being part of the fold - about being one of the scrub-clad army of neophyte physicians. It's funny, the way it works. When the thin catheter you're inserting in a patient's chest suddenly slides in perfectly and the cloudy fluid drowning his lungs finally starts to drain; when you suddenly connect textbook facts in the context of your patient to arrive at a diagnosis; when you update a patient's family member and realize that they actually seem to trust and respect your opinion - that heady rush of "specialness" sort of hits, as close as I've gotten to sensing the M.D. glamour. But invariably, it's at these very moments that my undereye circles are their most cavernous, my stomach is likely staging a vocal, Graham-Crackers-Are-Not-Enough-themed protest, my scrubs seem especially ill-fitting, or my stethoscope is once again yoking me unceremoniously and un-glamorously to the doorjamb. Go figure.
So pshaw, TLC. You don't want no scrub? Pass 'em to me. They may get no love from you, but I know how to work it.
Thursday, February 12, 2009
Monday, December 22, 2008
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:
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!
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!
Saturday, November 8, 2008
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:
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.
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.
Wednesday, August 27, 2008
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.
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.
Friday, August 8, 2008
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 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 h
appen 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 m
entioned 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.
I
t'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 E
KG, 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 g
ood 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?
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 h
appen 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 m
entioned 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.
I
t'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 E
KG, 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 g
ood 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?
Saturday, July 19, 2008
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:
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.
Thursday, July 10, 2008
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.
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.
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