grrr... boys... grrr. You think by 30 years they would have learned a thing or two. Just thought I'd throw it out there.

Saturday calls have the feel of putting out small bush fires. Although most of the sixty plus patients you are covering will not bother you, the good twenty or so that will are enough to make you contemplate a career change. I remember those idyllic medical student days, when I would never write an order for pain without checking and examining the patient. At the end of your first 24 hour float call, you are pushing narcotics like any street criminal. ( IV Morphine .... ahh ... my panacea for pain/agitation/putulance/insomnia. How I love thee. Let me count the ways.) The trouble is explaining it to the team the next morning.

You begin to hate the words "What is your name?" when a nurse asks you at the end of a page. Because then they can put "MD Wang made aware" from which point any calamity can be pinpointed to you. And at times, MD Wang was not made aware. Figures. With 60 patients to cover, they definitely figure they can slip a fast one by you.

This is when you realize that so much of intern year is not about learning. It's about keeping your head out of the water, gasping for air when you can. When you realize there is no sympathy, that everyone wants something right then and now, and all responsibility falls on you, as soon as you are "made aware". And that MD is not as glamorous as you thought it was on graduation day.

Expired

Our favorite euphemism for patient death is "expire" - suggesting people become no longer suitable for use after the printed date, after which they mold, curdle, become rancid, dessicated. I always think of a person exhaling out that one last breath of air, after which they lie motionless. Without commontion, emotion, serene - "expire", unlike "death" which is fettered with morbid connotations, of treachery, violence, grief, is more like the natural course of things. I have never seen anyone die, but this is how I imagine them to do so in the hospital, so many of the time - expectedly, quietly, into the night, on this - their expiration date.

On Tuesday I ran into my old patient from the CCU Mr. M down in Medical Records. Or rather, I ran into his back. He was hunched over a form, slowing scrutinizing its contents, and, happily for me, incognizant of my presence. I slipped in and out of the room, thankful that my reappearance in his life remained anonymous.

I first met him with a nonrebreather on his face - the first sign that this patient may be a keeper. A coronary cath, a ream of EKG's, a few grams of lasix, two pneumonia antibiotic courses, and a mone marrow transplant later, he was little better. True, he no longer needed the face mask, but his face, arms and feet becaume elephantine from the water rentention and corticosteroids, his arm mottled with a patchwork of bruises after we stuck him day after day for labs, and his cough worsening from the URI symptoms that plagued him from the start. Every morning he would be up at 5 in the morning, wearing his blue pajamas and forest-green robe, headphones on, listening to the walkman that sits on his bedside table, nestled amidst the stacks of used tissue, plastic cups, and apple juice boxes. And when I would sit down to listen to his heart and lungs, to examine how bad his edema was getting, I wanted to tell him his symptoms are improving, and that he was ready for home. But I know this is not true; every day in the hospital makes his cough worse, his legs more elephantine, and his mood more forlorn. The best I could offer, could ever offer - after four years of intense study- is apologies.

No one teaches you about this guilt that pervades the beginning of your intern year. This is because I suspect not everyone has it. What they do teach you is that sometimes you'll have a rough day, and patients give you a hard time, and you're supposed to go home, shake it off, and leave work at work. This is easier said than done.

All this is independent of your clinical acumen; I have seen both the callous and the caring amongst the most brilliant minds. But the truth of the matter is that what the senior residents tell you at the beginning of residency is true - if you stop to do right for everyone you will wear yourself out. At the end of call, it takes all my energy not to snap at that patient with irretractable nausea, who is interrupting my getting information together for rounds. Those stone-cold doctors I vowed never to be like became that way out of adaptation. Not unlike boot camp.

I know at this point, the best thing I can do for my sanity is to not take so much to heart; one only has a limited capacity for heroism before driving oneself to lunacy. But I guess in the grand view of things, this guilt may be my savior from being that callousness that I hate. A sign that, at that particular point in residency, I still have to potential to be a good doctor.