Sometimes when I look at my older patients, lying lethargically in their fetal position, sheets rumpled about them, IV lines abound, and bruises covering their bodies from all the recent blood draws, failed IV sites, heparin, insulin shots, I imagine myself in 70 years, in the same position, and the thought scares me to no end. I cannot fathom wanting to be kept alive in such pain, sadness, in such chaotic surrounds devoid to diurnal cycles, of life and health. I think so much of medical technology in the latter years serve to prolong suffering rather than to deliver relief. When I look at my intact skin, lean limbs, bruiseless, scarless chest and abdomen I cannot help but feel dread for the inevitable process by which all this will be marred, maimed, slowly, until I am but a wrinkled, purple lump in a hospital bed.

Always in my preceptor's office I feel the stares of the 40-50 year old daughters of the patients on my legs and skirt. While I, equally as surreptitiously, observe their varicose veins, protuberent abdomen, non-existent waistline, and feel that same dread. That I need not 70 years to lose what I have. The inevitable will be reality in mere 20 years.

I think being young in this profession, while having the luxury of being pristine, has the added disadvantage of seeing the future at its worst. When the accumulation of toxic habits result in the illness of being old and helpless. And it is far from an encouraging sight.

(Me and my favorite resident on his last day)

Tomorrow marks the end of my first floor month in the most scutty unit in the hospital. If only I had a nickel for every patient that was admitted and discharged on the same day. And those like Mr. L who still cannot leave because of unresolvable social issues.

But still, not all was a loss. I learned to speed through paperwork like never before, learned how to speed-round before the 9AM hour, how to bargain with patients over dosing of pain meds, how to beg for consults with no clinical indication what-so-ever, and how to drop NG tubes like it's nobody's business.

Last week was hell, and at this point I am so burnt out that one more day will make me seriously contemplate changing careers. But still, I know that the next month of repose will make me yearning for more of this madness. Because in the end, I can still feel justified being called doctor.

Yesterday Urology came by and placed a foley catheter in Mr. L. I could not watch; I left. It was too much. As he yelled out "Oh God Kill me now," I began to feel like a partaker in some vicious crime, a bystander who watches passively as a man is getting mugged, stabbed, kicked around. And I can only watch.

I should backtrack. Mr. L came to us last week after he fell on the wet ground outside his apartment complex. No heart problems causing syncope, no seizures, no tight carotids, no stroke, no blood loss. Just tripped and fell. His good neighbors brought him to the hospital to fix any broken bones (there were none) and make sure there were no internal bleeding (again, none). And from the ER he came to my unit; this is what we call a "social admit" - bringing in someone who we think cannot care for him/herself and trying to involve social services to bring home care.

All this was seven days ago. This past week has been filled with consults with hematology/GI services to help fix his anemia, failed attempts to install him into a subacute rehabilitation facility (thank you, Medicare), frustrating meetings with the case manager about what we CAN do for him (nothing), and trying to explain to him why we think it's necessary for him to be here (he does not) and that we are doing the best for him (which I do not believe). Every day I hear him pleading to God behind his curtains to take him out of this prison, his voice getting more and more desperate by the day, and recently, his asking God to end all this. And I just feel so guilty I cannot even look at him. I could tell he is not trying to be difficult. He is trying to maintain his dignity, and moreover his sanity. But in a place like the hospital, as many will tell you, this is a futile task.

I would like to think this is a system that is altruistic and generous, a system that accurately identifies those in danger to themselves and helps them get back on their feet. But more and more I see this as imposing our will on others, even if they do not want it. Somehow our sense of obligation deafens us from hearing what the patient really wants, because somehow we think all others are devoid of judgment.

How many times have I taken blood from an unwilling patient, subjected them to countless radiological tests, downed gallons of putrid radiocontrast dye, told them they cannot go home because WE do not think they are ready to take care of themselves. Meanwhile, longer stays inevitably lead to illness, until finally they cannot leave, and the only direction is down.

I want to send him home. I would drive him, if I could. Not because I believe he is capable of caring for himself ( I do not), nor that he is not a danger to himself (he is). But because I feel that everyone with the mental capacity to make decisions, irrespective of our approval for these decisions, should not have others' wills imposed on them, no matter how well-intentioned these wills are. I hate that our hands are bound by medical-legal obligations that we become automatons that systematically ignore what we feel to be the best thing to do. I hate that despite all this, not everyone is on the same page; while we are pulling all the strings, Medicare still insists they will have no part in it, and will not foot the thousands of dollars in bills that this hospital stay will cost.

Some days I feel more like a guard in some prison that makes a regular practice of torturing its inmates, working under the pretenses of beneficence. Three months ago I made a vow to do no harm. I am having a hard time fitting that into this system in which I work.