On Rounds.

"Fourteen dollars, Costco," said the chief of transplant surgery, stretching out his arms to show off his blue pin-stripes, proudly even, as we sardined into the elevators to the S-ICU, white coats flapping, before the conversation turned, once more, into the use of chemo-embolization in hepatocarcinoma.

One of Them.

He does not look up when I enter the room. It does not faze me. I have had my share of obtunded and intubated 90 year old women. But this was a 31 year old guy, with his eyes unmoved from Judge Judy on the television screen, some unidentifiable hip-hop blaring through his headphones. Usually patients like this offer at least a grunt. Not so much luck here.

I am probably the 5th white coat he has seen today. Except I am not really in white. I am in blue. Contact precautions -- the signs announce in front of his door -- alongside other such ornaments in multi-colored papers that read NPO, Fluid Restrict to 1500cc, Wash your hands. All this means is that you must put on a blue smock backwards before you enter his room. And you cannot feed him pizza and coke with your grubby hands.

Good Morning. Are you having any belly pain? No words. A faint shake of the head no. Any difficult breathing. Eyes still on the good Judge. Mind if I take a look at your belly? I drew up his hospital gown. He lets his hand fall.

It is still distended from the ascites, despite having been drained yesterday. Brown-yellow fluid, said the Interventional Radiology operative note. Fluid sent for amylase and bilirubin levels; rule out bowel perforation. Fluid cultures positive for mixed flora, despite days of the strongest antibiotics out there.

I note how his head seems to small for his body. Eyes nonresponsive. Transfixed on the television, to which he is not even listening. I would later tell my supervising fellow that he was non-verbal at baseline, but likely from unwillingness rather than inability. Although at that moment I was not certain.

I covered him again, listen to his heart and lungs. He knew the routine. Breathed deeply when I pressed my stethescope along his sides, and back to normal breathing when I auscultated over the heart field. He's been through this. Yes, my heart's still there. And if it's not, you might just as well put RRR no m/r/g, anyway. In fact, it's probably there already, in your pre-written note, even before you laid one finger on me.

I peeled off my blue smock, and said goodbye. And thank you for letting me examine. He remained unchanged. The judge still on the screen. Hip hop still in his ears.

And then I realized. I did not even tell him my name.

SIG E CAPS

There was an article in the September issue of NEJM that talked about depression in medical students. It seems counterintuitive -- that the prevalence is higher in the clinical years than in the basic science years. One would think that the thrill and rapid change and novelty will excite and solidify one's love of medicine rather than bring on the blues.

Somehow this article made me feel better -- justified everything I've been feeling the last few months. It's difficult - because no matter how difficult the rotation, there is a sense of belonging once one finishes, that the thought of leaving and going into something completely foreign is unpleasant, at times terrifying. One month ago, on the subway to my sub-internship, I wished that the train would stop and I would never arrive. But now, two days into possibly the easiest elective I will do this year, I crave the hectic schedule that last month brought. I longed to wake up at 4 AM everyday to see my patients. Longed for the calls that told me my patient had a fever, and now needed cultures drawn. The admission papers. The daily progress notes. The disappearing temperature boards. The lack of clean utility. I miss everything. And now, bereft of my former setting, which I view both with contempt and fondness, it is hard to pull myself out of this depression.

But this is nothing new. Relationship are ephemeral in the time of rapid change, and there is the sense always of being lost, alone, never really belonging anywhere. You build your reputation one place, work so hard to impress yourself upon others, only to have to do it all over again. It becomes tiresome, and depressing.

I just wish there were some way I can pull myself out of this.

Needs vacation.

One tends to think that things have a way of tapering down; that the way this subinternship month for me would end would be much the way it began -- a slow to medium paced chain of events, all of which lead to a happy conclusion.

But Of course, no.

Over the last 48 hours, I spent 4 hours with a patient going into and out of a seizure, during which time I found myself in negotiation with the interventional radiologist, who informed me that another patient is now on the OR table, but cannot be done because her PMD is an idiot who has no idea how to reverse anticoagulation, preprocedure, followed by the next day, in which two patients were bounced back to me, who, conveniently, both developed fevers and thus required the full fever workup, one of which is so cachectic 3 IV nurses failed to insert a line in him, the other so demented that he jerked his arm each time I stuck him, causing me to pop three veins, leaving me to constantly run back to the poorly stocked utility room where a fucking syringe is NO where to be found. And of course, this order needs cosignature, that order was lost, that order needs to be renewed, you need to add these labs, these orders are written wrong, we don't carry that drug. And then the demented patient's wife yelling at me because he was not given lunch.

Yesterday, at approximately 3 PM, I decided in favor of law school.

What frustrates me is the constant paperwork, which is not a big deal except that they need to be written in such a way, be cosigned; you need to call or tell who ever it is the paper's going to to actually do what it says, or they play the "i didn't get it" game, expecially when faxing is involved, and when it doesn't happen you have to run down and personally send it yourself, all of which involves running up and down the stairs, because the elevators have a mind of their own, and because the hospital is in the cro-magnon stage of computers in which, unlike any hospital I have worked in so far, orders need to be hand delivered and signed, rather than being inputted into the computer.

All this leads up to the fact that there is really no way to keep on top of things. You start to accomplish one task and can't even think straight because you're so anxious to get it done quickly before the next page comes, so that when the next page does come, you would have accomplished nothing.

And this is when you start being murderous. Those stupid family members that flag you and demand answers, even though the decisions weren't even made by you. The nurses who demand things be done now, because they, too are busy and do not personally care if you are running ragged (welcome to their world, darling). The stuid, slow-walking service people who hog up the elevaters to go from floor 3 to 1 (because their fatness precludes the possibility that they sustained any excercise in the past 3 decades.) The people that put you on hold AFTER you answer their page 5 seconds later, because for some reason they can't wait that long by the phone, that they are now wasting your time. All the while you have to smile smile smile, like none of this is bothering you, and your world is just peachy.

But this teaches me one thing this month. That to begin this profession is harder than I ever thought imaginable. That I still have mountains to learn. That there will be more nervous breakdowns and doubts and fears and anger like I've never known.

But moreover, that I can do this. And maybe one day I'll actually like it.

Delirious

Today my bitter flamboyant friend allowed me to draw his blood. I suppose I ought to construe this as sort of an honor -- after all, he did refuse the third-year resident on the day he was admitted. When I penetrated the first vein, and nothing but fizzles seeped up into the tube, he told me, not entirely mean-spiritedly, that I really out to practice on my boyfriend. I smiled at him, trying to hold back saying what I really wanted, that I had no boyfriend in the picture, and moreover that I had been up for nearly 30 hours, with about a 1 hour nap between 5 and 6, in the cold intern's lounge, without blanket, with my body pressed up against my pager, barely able to close my eyes for fear that it would alarm as soon as I become unconscious, and that I was beyond tired -- that what I felt was this trippy light-headedness, a sort of delerium, where I wandered, sleep-walked, almost ghost-like to my next destination, at times wondering how I ended up in a certain spot I had no intention of being in. I did not want to heighten his anxiety anymore, the way he was heightening mine. He had amazing veins. Bulging from his lean, white arm -- ideal for even the most amateur of phlebotomists. But, even in my altered state, I felt this overwhelming need to impress him -- this person that greets me with a dismissive "hello, little girl" each day that I come to examine him. And as expected, nerves got the best of me.

So this was my ending to possibly the longest day I have ever spent. When two minutes before I was about to leave to rest in my warm bed at home, the nurses call me to tell me that he who was minutes away from being discharged, had, now a fever of 101. And my attending, with all the habitus, and none of the charm, of Archie Bunker, gruffly told me that of course I needed to culture. Kiss my bed goodbye. I forsaw that before I were to attempt to sign off again, I would receive another page. They never fail, these nurses, at predicting when the least convienient time would be for you, and page right at that moment. Ahh, medicine. How beautiful that sound of the beep.

And to think; in less than 12 hours I will be right back where I started.

Crash and Burn.

There is no way to prepare for this moment. When the patient is lying there, oxygen mask on, an aspirin, a nitroglycerin, and 20 milligrams of morphine later, eyes wide with fear and in irretractable pain, when all the cardiac workup has been negative, when all eyes are on you and you don't know what the hell is wrong with her, and what the hell can raise her pulse from 70 to 140, her systolic pressures rise from 110 to 150 in a matter of minutes -- it is like a train about to crash, with you driving, and you suddenly realizing you didn't know how to drive, all this time.

When all you want is to curl up and cry, this same sick panic you've been feeling everyday for the last week, when you're feeling like you really don't belong here, and that you're no good for this. This feeling of incompetance. Wanting people to know that you're only (for God's sake) a student who can spew out the molecular mechanism of coumadin without knowing why the hell someone with an INR of 3.96 could still extend her pulmonary embolism and suddenly be in respiratory distress. And even if you did, not knowing what the hell you can do about it, short of holding her cold, shaking hands, looking into her tearful eyes, and apologizing for her pain, her suffering, her terror, and your helplessness.

This feeling. Of not being ready. I don't think I have ever questioned my career choice as much as I am now.

Cry me a river.

I am allowed to dislike a patient. Although so much of my medical training has ingrained in me the fact that countertranference is a reality that must be overcome in order to achieve empathetically rapport, I think that's bullshit written up by some hippie freak who never had an asshole as a patient, or was too oblivious to diagnose the assholism.

Now, what is ironic to me, is that most of the cheeriest, most affable patients that I have met are oncology patients. This is perhaps due to the fact that I have met so many later on in the disease, either when they have already achieved remission, or when they are so far advanced that they seemed to be at peace with their future. For the most part, I have noticed them to be stoic, strong, with a complacency that I, myself, even envy.

But there is the other extreme. Luckily, he is the first one of this prototype I have ever encountered, but by no means the last.I liken him to a cross between Jack McFarland and Simon of American Idol. With a Frasier-like snobbery, a biting sarcasm, all atop a cloud of blazeed flamboyancy. So that you can imagine him mauling away at your self-worth, flinging your insecurities in your face, all while sipping tea with a raised small finger.

"Oh look, new residents. How tedious," says he, as my resident and I enter the room. And when I introduce myself as the sub-intern, he retorted, dismissively, "oh I figured as much." Not to be outdone, I replied that I only looked young. "Don't worry, I won't last," this he replied.

I imagine that he fancies himself more intelligent, more respectable, and above all this -- the hospital, the nurses, the house-staff. Moreover, I imagine that he feels, because of his illness, that sense of entitlement. That all the world should pity him and that he is justified in accepting this pity with scorn, sarcasm, and blatant rudeness.

I could understand this mentality. When you, being terminally ill, become so inured to condolences, so many of which are forced, dealt out of necessity, pursuant to social decorum, rather than from sincerity, when you become so weary of the helplessness of those most capable of help, when you are so depressed, anxious, even terrified of your fate, and all anyone has to offer are drugs that ravage your immune system, make you sicker than you already were, render you bald, cachectic, and weak, at the end of which you hear no happy news, but rather more "sorries" and "how terrible" accompanied by stupid mylar balloons and kitschy cards filled with inane Hallmark-sentimentality. I cannot imagine how that must be like.

But at the end of it all, you are the one that decides how to respond. Whether or not you choose to spread your embitteredness to others, because you suppose their pity to be a byproduct of social conformation. I will not say that it is wrong, because that is a personal value judgment. Rather, I will say it is unjust; it is exploitating your condition, knowing that no one dare challenge your cruelty because their own conscience cannot allow it.

I hate that he chooses to be cruel, and that I feel reservation at resenting him, because I feel this need to understand his point of view, without his being obligated to consider mine. Because he is with condition, and I am without. And that he feels, in some sordid way, that fairness can only exist between us if he is allowed to be vicious.

Perhaps in the course of his stay, we will reach an understanding. That my goal is simple -- to help and not to impose. But somehow I think his years of hard-experience have already numbed his sensibilities, and that he has already transcended the reaches of human compassion. And here left is this hard shell of a being, devoid of human emotion, cold, practically dead.

Doctor's orders

Yesterday I wrote an order for Percoset 5 times. And spent 20 minutes figuring out how to order Colchicine without the nurse being on your case about overmedicating. I am beginning to hate the page that begins with "Hi, are you covering for [insert name]? I have an order for...". It's never good news. Once you start writing the order, the cascade begins. Change the IV infusion rate. We don't carry this formulary/dossage/form. We don't give it at this frequency. Change your dosage. You can't crush the pills. Patient is NPO; order the IV form. You will kill the patient with this dose. This does isn't strong enough.

Writing orders is an art, one which I will not master any time soon, most likely.

Documentation nazis.

I have a new favorite beep. These people call themselves documentation experts; gestapo is more apropos. They have a sense of what possibly is the worst time to call, and then attack. Like in the middle of director's rounds, when I am crammed in a tiny room with 20 other people, listening to a case presentation, and I have to squeeze through 2 chairs and 5 people to get to the door, B-line it to the nearest nurses station, find a free phone, and call.

Excuse me, it looks like this patient is just here for a foot infection; can't they just put him on something at home? You need to document the real reason for admission.

Believe me, lady Nazi, I would be more than happy to send these people home. But truth is, I probably have less say than you. Barking up the wrong tree, you are. Why don't you page the admitting doctor at work, and see what nice words he has for you.

And why don't you document that, bitch.

That infernal beeping

I am scared of my pager. That devlish flashing. Those insidious digits. That piercing, obnoxious, persistent, caustic beeping. The feeling of urgency, of panic that it brings. Like the sound of your mother calling your full name after your baseball flew into the window, the jerk forward after you have been rear-ended, the gutteral sensation a millisecond before a free-fall, the sight of a nurse holding a needle. Panic. Pure and simple. It is like a phantom, following me everywhere. WIth each passing beep I hear, on the streets, in the stores, I clutch my left chest, where my white-coat pocket normally is, and feel for that wretched plastic box, realizing that it is safely tucked away in my locker. I live in constant fear of the beep. Scarfing down my food, racing for the nearest elevator, lest it summons me at my most inconvinient moment. It has made a nervous mess of me, always in a state of impending panic, alert, vigilant, petrified.

Here is a list of some pages I have received in the past 1.5 weeks. From least to most malignant. Beep beep...

1. Hey, It's Liz; let's get lunch.
2. Hi pharmacy here, we can't carry out this order ... can you run up 5 flights of stairs and write it again?
3. Hi, 16 E here, are you taking care of Ms. _________? Oh she vomited/had diarrhea/ got constipated/ leaked her colostomy bag/ developed a fistula again.
4. Hi 16 E. Are you taking care of Ms. __________? She received Lasix at 10 AM but still has not urinated. what do you want ME to do? Well [nasty voice], I think she needs to be ASSESSED, don't you?
5. Hi, Vickie, Case manager here, about Ms. ____________ - so why is she still in the hospital?
6. Hi, this is 16E. Ms. ________ just had a temp of 100.8. You need to poke her impossible veins and get blood cultures. And did I mention two sets?
7. Hi, this is 16E. Ms. _________'s daughters and son are here to bitch you out.
8. Hi 16E. Ms. _________ is in respiratory distress; she's desating to the mid 80s. What should we do?
9. Hellloooo, this is Adam (my resident). I know it's 15 minutes before you get to sign out, but boy do I have a great admission for you.

It is like the Clockwork Orange; the beep is my Beethoven 9th. I have the rest of my life to become insane, as well.

I just need a fucking PRN.

Excuse the poor writing. For I am frustrated.

Just when I thought I figured out how to beat the system that seems to thrive on bringing me down, it strikes. There's no avoiding it. This inefficiency. The bureaucracy. It's like a den of wolves. No matter how you try to arm yourself, you will get mauled.

And it'll just get worse.

I mean, it was just a skin infection case right? Easy. But of course he had to have the resistant strand. Of course, we needed Vanco. And when I saw him taken out of the Xray room, the Vanco infusing, and he is scratching his head desperately, turning red from the medication, of course I knew how impossible it would be to get a nurse to give me a stupid PRN Benadryl.

Don't you know how to treat this? Do you know anything? The resident's face read this. Of course I know. I know a lot of things. I know to store butterfly needles, bandaids, gauze, tape, IV needles, down to fucking alcohol pads in my pockets. I know to store every possible form in my personal folder so I do not have to run 10 flights of stairs to get a lab slip. I know to write the orders early, as soon as the nurse asks for them to cajole them. Even if it's for something tomorrow. I know to smile, smile, smile, even when I feel like I have to be on floors 7 and 11 at the same time, when I can't think straight, when there is 100 things to do and I don't know where to start, and I find myself on floor 11 wandering around when I realize my patient is actually on 16. I know. I know.

But I don't know how to find help when I really need it. When I am stranded, in the middle of the ER, with everyone flying around me, intubated patients rushed in and out, and random patients yelling at me for their pain. Because I have this white coat. It feels like a disguise sometimes. For someone who can do something. Clearly, all I'm capable of doing is packing order forms and supply room equipment. There are only rocks and hard places. And I don't know who to go to. And I just want to cry.