What Have I Done?

I had my supercharged latte in one hand, papers/graphs/lab results/ekg's crumpled in the other. It was 6 a.m., and I was making my morning pre-rounds in the ICU before the attending arrived, so that when he did come to work, I could tell him what had happened overnight to everyone and how they were doing. For the most part, everyone was stable. Sick, but stable.

I walked into room 3. "Good morning Mr. Smith," I said. "How do you feel this morning?" I had already reviewed the night's events: his night nurse said he slept through the night peacefully, his foley catheter had put out lots of urine (I myself should try that before going to bed so that I don't wake up to walk to the bathroom 12 times a night), and he didn't spike a fever. All good news. His laboratory work showed normal blood counts, electrolytes, liver function, coagulation profile and cardiac enzymes. He was a 70-year old man who had been through a lot: open heart surgery not too long ago, vascular surgery, severe pulmonary hypertension (he has to sleep sitting up), and two heart attacks. Diabetes and chronic obstructive pulmonary disease had ravaged his microvasculature over the years, and the surgeons were doing their best do alleviate that damage by creating new vessel routes throughout his body.

"I feel alright," he said. "So-so."

"Yesterday you said you were feeling great. Why only so-so this morning? Are you having any pain or problems breathing?"

"No, not that."

"Then what's the matter?"

"It sounds weird, but I, um.....I....." It looked like he was fishing for the right words to say. "I feel like I'm doing a bit worse, and well, I feel like I'm going to....well....I feel like I'm going to, um, die today or something. Does that sound weird to you?"

Every doctor knows -- from intern to resident to attending -- that if a very sick patient verbalizes that they're going to die, you'd damn well better listen. It is inexplicable -- not everyone says that or knows that, but some do. And whether it's through evolution or intelligent design, nature is full of examples of sentient and non-sentient beings who have an innate proximate sense that their time on this Earth is up: fish go their place of birth and die, dolphins will do the same, and most of us have probably had a pet dog or cat who just kind of knew that they needed to lie down next to you one last time.

I thought about Mr. Smith's comment only very briefly and shrugged it off. Every objective marker said he was doing better. "Oh Mr. Smith," I sighed, "you'll be fine. You're doing very well and we're all proud of you."

"Okay," he replied. He seemed reassured, as if I was giving him the answer to a question he didn't necessarily ask.

I finished my pre-rounding in time to get some "real" food from the cafeteria -- mass-produced eggs with sausage made from grade D beef, one step up from bovine cannibalistic bone-meal that's been linked to mad-cow disease. I wondered if those cows from which the sausage I was eating knew that they were going to die on their slaughter date.

A brief while later, I made rounds with the attending. "How's Mr. Smith?" he queried.

"He did well overnight. He was afebrile, urine output was roughly 60 to 100 cc's an hour with only 20mg of lasix q 12 hours; he has no elevated white blood cell count and no bandemia, his hematocrit is low-normal but stable, his cardiac enzymes are negative, and his creatinine is normal. His vital signs were within a normal range all night, and his systolic blood pressure ranged from 110 to 140."

"Good. His exam?"

"Same. Alert and oriented, communicative. Pupils reactive, breath sounds a little coarse, be we know he has bilateral, small effusions on chest x-ray. His heart has a regular rate and rhythm to it, and I don't hear any murmurs. His abdomen is soft, non-tender, and bowel sounds are present, and he has 2+ pulses in all extremities."

"Fine. So what would you like to do for him today?"

"Well, he's now seven days out from surgery. For the past two or three days, all we've been doing is monitoring him and watching him get better. He still has some small pleural effusions that are diuresing nicely with lasix, but he doesn't need to be in the ICU for that. I think we can send him to the regular floor now."

"I agree. Tell you what -- take out his arterial line, change his central line over a wire and send him to the regular post-op unit."

"No problem."

We finished making rounds, then we chatted for awhile. The attending does bedside teaching, but he also is great about having at least one topic a day for teaching and discussion over a cup of coffee -- today it was about ventilatory settings. But my attending is also a very interesting man with a lot of opinions on many subjects. We've had spirited debates about Supreme Court nominees, iPods as examples of unfair market practices of monopoly, and whether Israel should engage in pre-emptive air strikes of Iran's fledgling nuclear facilities. Today's brief non-medical foray was whether ABBA was true musical genius or simply transient pop phenomenon of the 1970s. (Transient? Are you kidding? Their influence is still felt the world over, and if you listen, really listen to the music, the interplay of instruments and their talent is non-debatable. Obviously, I took the pro-ABBA-is-genius side of the debate.)

So we wrapped up our morning session (I promised to email him some mp3's that he promised to really listen to), and I went to work. I put in some orders, ran some lab work, dispensed some medications, and checked over some x-rays. When it came time for Mr. Smith, my list was easy: remove the arterial line, change his triple-lumen central line over a wire, and send him to the regular post-op unit. I had already told the ICU nurses to give report to the post-op unit that Mr. Smith was coming in an hour or so.

I removed his arterial line and gathered up the materials for a new central line. For those of you unfamiliar, a central line is a giant IV that goes directly to the heart for rapid infusion of medications or more invasive hemodynamic monitoring. These aren't your garden-variety IV's that nurses put in: these are large devices that MD's have to put in because there is a not-too-insignificant amount of morbidity and mortality associated with these things. And think about it -- why wouldn't there be? You're puncturing one of six large vessels (two in either side of the neck -- the internal jugulars; two in either shoulder -- the subclavians; or two in either side of the groin -- the femorals), and you're feeding a large tube that actually sometimes touches the heart. The list of complications is legion: you can introduce an infection if you don't do it under sterile conditions; you can puncture a large artery instead of a vein; you can dissect the vein itself and cause internal hemorrhage; you can puncture a lung and cause an iatrogenic pneumothorax; you can slice an important nerve running parallel to the vein you're trying to hit; you can accidentally introduce air into the vessesl and cause an air embolism; you can even accidentally puncture the heart itself with the wire over which you thread this giant IV and cause a heart attack or even worse -- a pericardial tamponade where there's bleeding in the sac in which the heart sits -- so much so that the pressure on the heart from the blood surrounding it is too great for it to pump anymore. Thus, this procedure should not be taken lightly.

I got all the central line materials together and explained to Mr. Smith what I was going to do. "Mr. Smith," I told him, "you're coming along so well, we're going to move you to a regular floor. I'm going to change that big IV sitting in your neck first though, okay? To do that, I'm going to lay you flat for about five minutes and cover your face and the rest of the bed with a sterile drape. It's important for you to stay very still during this and not move around after I clean off the area and set it up. Understood?"

"Yep. Do whatcha gotta do, doc."

"Great, thanks." I laid the bed flat, cleaned off the area with antiseptic, and put a large sterile drape over the bed. His monitor was in sight so I could see his vital signs while doing this, and I changed into a sterile gown with sterile gloves, mask and cap. This will be easy, five minutes tops. I've done this a hundred times now.

It was going smoothly. I put a wire into the old central line at the proper mark (not too deep, not too shallow), pulled out the IV, held onto the wire, there was very little blood leaking out, flushed the new one with fluid, and inserted it over the wire to the 16-cm mark. I tested each of the three separate ports that coalesced into the large-bore IV going straight to his heart, and each one returned blood when I aspirated with a syringe, and each one flushed nicely with normal saline.

"How are you doing, Mr. Smith?" I asked as I was doing the procedure. I could see his heart rate, blood pressure and oxygen saturation were all fine. I just couldn't see his face under that sterile drape.

"I'm fine," he said, voice slightly muffled. In fact, I kept asking him so much how he was doing during the procedure that he told me to shutup and stop asking.

I noticed the whole time that he was slightly shifting his legs during the line change. I had asked him to be perfectly still, and he was doing a pretty good job of it. The legs weren't really interfering with what I had to do, so I didn't mind that he was trying to get more comfortable. But I was sewing the line onto the skin, and I asked again:

"How's it going, Mr. Smith?"

Muffled noise. And he was no longer shifting his legs.

I looked at the monitor. Everything was still normal. I finished sewing one of the two locks down onto the skin.

"Mr. Smith, how are you doing?"

No answer.

"Mr. Smith? Mr. Smith?"

He didn't answer me, but the monitor did: beeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeep. I looked up at the monitor with gooseflesh:

Flatline. No heart rate.

HO.

LY.

SHIT.

I whipped back the drape. His eyes were open, staring, non-focused.

"MR. SMITH! MR. SMITH!" I smacked his face. "MR. SMITH, ANSWER ME! CAN YOU BREATHE???"

No answer. Oxygen saturation on the monitor was dropping.

What the fuck just happened?

"NURSE!!!" I screamed, "CALL A CODE RIGHT NOW IN BED 3!!!!"

I know I have a 31-year old heart, but what was going on right now whipped it into an 80-year old heart that kept skipping beats. In a test of quantum mechanics, one millisecond had morphed into ten minutes. The room was spinning, I had no idea what the fuck was going on, everything had been going so well, and I had done this same procedure for the umpteenth time. My heart sank well below my stomach and I myself was lightheaded. But it's my job to function at a time like this, so there's little to think about during a code.

But my first thought was this: Primum non nocere -- first do no harm. I just gave this guy an air embolism.

Thus, the first thing you do is drop the head of the bead and turn the patient to their right to trap an air bubble -- if there is one there -- from going to the lungs or brain. After that, it's all ABC's: airway, breathing, circulation.

Within one minute, a horde of whitecoats rushed into the room and the nurse had already wheeled a crash cart in. I whipped out an airway kit and intubated him to secure his airway and started bagging him. I also noticed this right-sided neck IV only halfway stitched in. My attending ran in there and provided focus to the throng of doctors and nurses that flooded the room: he ran to the head of the bed, kept bagging, and ran the code.

"Is there pulse?" he called out.

"NO," shouted someone trying to feel his femoral pulse.

"Start chest compressions!" he yelled.

Someone stepped up and started rhythmically compressing this man's chest. During these compressions, one has to compress very hard and very deep in order to externally approximate the heart's intrinsic contractility. And with the compressions, we all heard crack, crack, crack. Those were his ribs -- this man is 70 years old and has osteoporosis. But that's the least of your concerns during a code, and everyone who's been involved in one knows that rib fractures happen if you're doing the compressions correctly.

Mr. Smith vomited. He shit his pants. I think I did too.

On the monitor, there WAS electrical activity of the heart -- there was just no pulse. Called a P.E.A. arrest (pulseless electrical activity), there is, as in all medical codes, a certain algorithm to follow.

"Push one amp of epinephrine!" my attending shouted.

I was also at the head of the bed, holding this IV in place with my finger so it didn't slip out while his body was violently shaking during chest compressions. This is also the only IV access he has, so it CANNOT be lost. In a contortionist feat, I held onto the IV and unlocked one of the ports with one hand, and injected epi with the other.

Nothing.

"Resume compressions!"

POUND POUND POUND.

"Push one amp of atropine!"

Again, I injected and held onto that IV for dear life -- his AND mine.

Nothing.

"One amp of bicarb!"

Still nothing.

POUND POUND POUND

Thank God I wasn't trying to run the code, because I could only think one thing:

He's gonna die
He's gonna die
He's gonna die
He's gonna die
He's gonna die

-- and it's all your fault.

"Another epi!"

In it went. Still electrical activity on the monitor, but still no pulse.

"Another atropine!"

After each round of a drug, everyone -- the world, it seems -- stops to look at the monitor. There's an eery two-second pause where no one speaks, no one shouts, no one moves, no one does chest compressions, no one even breathes while we wait to either see something on the monitor or to feel a pulse.

Please, Mr. Smith, please please please please please please please please please please please.

Nothing.

"Another bicarb!"

In it went.

POUND POUND POUND.

"STOP COMPRESSIONS!" shouted someone. "I think I feel a pulse."

Huh?

Someone did feel a pulse. And someone else felt it. Someone on another limb said, "I feel it here too." And another person did too. As if we all had one mind, we all simultaneously looked at the monitor: indeed, there was a heartbeat. There was also a low, but present, blood pressure. Everyone slowly put their hands up and backed away from Mr. Smith, as if disturbing the air around him would cause him to re-code. Me? I whip-stitched the rest of that central line so fast that I'm not sure anyone saw me do it.

I know that there were at least two angels in that room: one sitting on Mr. Smith's shoulder, and one sitting on mine.

----------------------------

We all slowly filed out of the room.

"WHAT THE FUCK DID YOU DO???" screamed the senior resident at me.

My scrubs were already see-through, soaked with sweat.

What could I say? I told him what I did: changed his original central line.

"YOU KILLED HIM YOU FUCKING MORON!!! I CAN'T BELIEVE HE MADE IT THROUGH THAT CODE! HE WILL STILL PROBABLY DIE IN THE NEXT TWENTY-FOUR HOURS AND YOU WILL HAVE DONE IT!"

A group of about twenty people were watching this interchange.

How do you respond to that? I just let myself be his whipping boy because I thought he was right.

"YOU PROBABLY GAVE HIM AN AIR EMBOLUS AND KILLED HIM! WHAT THE FUCK ELSE COULD IT BE??? IT'S NOT JUST CONVENIENT COINCIDENCE THAT HE DIED WHILE YOU WERE CHANGING HIS LINE!" He was gesticulating wildly.

A stat bedside echocardiogram was being done as he was yelling at me. If there's an air embolism, on this cardiac ultrasound, one would see an air bubble in the heart.

Thus a jury of twenty doctors and nurses once again flooded the room to look at the echo as the cardiologist was sliding the probe over Mr. Smith's chest. His heart was still beating, his blood pressure was still there, and his oxygenation was still good. The cardiologist kept running this probe over different areas of the heart, taking snapshots, making printouts, and using Doppler color-flow technology to see red and blue perfusion areas. It took less than five minutes, but to me, standing there by the echo machine (in the witness stand), and the twenty people behind me boring into my soul with their accusatory eyes, it seemed like forever. We were all looking at that echo, but to almost all of us, since we're not cardiologists, it just looks like a loud, snowy screen, similar to those UHF channels you had on your TV as a kid in the 1980s. We were waiting with baited breath for the expert witness and judge -- the cardiologist -- to render his verdict. He finished up his echo and turned around to face all of us. I kept my back turned to everyone. I couldn't bear to hear it.

"There's no air embolism," he factually stated.

I slowly turned around and saw everyone looking at him, then at me, in disbelief.

As if the cardiologist could sense that disbelief, he repeated it: "There is no air embolism." And then as if he were my personal savior, he also followed that up by saying, "In fact, his heart is functioning as well as it was on his previous echo from days ago. The valves are fine, there's no effusion, and his ejection fraction is unchanged."

Like I said, Mr. Smith AND myself each had an angel on our shoulders.

Everyone filed out of the room and shrugged their shoulders. The air embolism theory was the only explanation for his initial code that anyone could think of. If not that, then what?

And though I was exonerated from one crime, I was still guilty of something in the senior resident's eyes.

"YOU STILL FUCKED IT UP. I DON'T KNOW WHAT THE FUCK HAPPENED, BUT LIKE I SAID, IT'S NO FUCKING COINCIDENCE HE DIED WHILE YOU WERE CHANGING HIS FUCKING LINE. YOU BETTER THE FUCK FIGURE OUT WHAT THE FUCK IT WAS, YOU FUCK. AND HE'D BETTER NOT FUCKING DIE AGAIN, OR YOU'RE REALLY FUCKED."

And then he stormed off.

Alright, I get it. You kiss your mother with that mouth?

Now, this is true: I never drink to relieve stress after a stressful day; it's a personal rule I have. But all rules have exceptions, so after I left that day, I called my ER compatriot Jay, and we went straight to the bar over which my apartment sits.

"Sean," I said, "I'll have a ketel one martini straight up, extra dry."

"Rough day today?" he asked.

"I killed someone," I replied.

"In that case," he said, "this one's on the house."

So Jay, God bless him, listened to me vent, was a great friend and really dissected down the day's events. I actually didn't kill Mr. Smith, and my technique in doing the procedure was fine. No one knows what exactly happened, and no one may ever know, but Mr. Smith, if you'll recall, knew that something was going to happen to him that day.

A little while later, I stumbled upstairs to my apartment and prayed and prayed and prayed. And despite three martinis and an ambien, I slept about 90 minutes that night total. I was not even buzzed or woozy or sleepy in the least. I kept waking up and calling the ICU to check on Mr. Smith. The nurse finally told me to quit calling or to come in in the middle of the night and check for myself.

So that's what I did.

-------------------------

THEN the rumors and politics started, and boy, does the story twist from person to person. The next day, I kept overhearing people talk about "that amazing code where the guy actually lived through it."

"Did you hear???" some resident said to another. "There was this total fuck-up intern, some foreign medical graduate from Guatemala or something, and he totally killed this guy, but he lived through the code."

And another: "This stupid second-year MED STUDENT did a CENTRAL LINE without telling anyone and the guy died."

I kept hearing it all day:

"This bonehead actually pierced his heart and they did emergency heart surgery and saved him."

"Some foreign anesthesia visiting student gave him a pericardial tamponade."

"This idiot intern dissected his AORTA."

Intern? Foreign student? Aorta? I chose to ignore it. If they were talking about me in my presence, then they didn't know it was me, and I preferred to lay low and keep it that way.

I just kept my eye on Mr. Smith -- and he's doing fine.

Life imitates TV for once: drama-rama

I never watch the show "ER" anymore. I can't. It's like working all day and then going home and watching your job on TV. I need more distance than that. Plus, the show tends to be rather dramatic (a burning helicopter falling on the ER? Please. Although, a helicopter did crash in the East River a few months ago and everyone was brought to Manhattan County hospital). But anyway, it's considered malpractice to do some of the things they do on that series: Burr holes, craniotomies, emergent hemicolectomies right there in the E.R. But the fights and the affairs that happen on the show are, for the most part, real.

Anyways, in an odd cosmic twist, life imitated art tonight for once. This literally just happened about thirty minutes ago. Really.

I was just in the hospital library pulling articles to read and present for journal club. On my way out of the hospital, in the lobby of the main entrance, I saw a young man stumble in right off of First Avenue.

"I NEED A DOCTOR!!!" he screamed.

Usually I ignore those dramatic pleas if I hear them on NYC sidewalks for two reasons: 1) they're usually not sick at all; and 2) according to New York state law, if you're an M.D. and you initiate care, you cannot then transfer care to a non-M.D. Meaning, if you stop to help and then an ambulance pulls up, you cannot just let the patient get into the ambulance with the EMTs and go to the hospital -- you must go with them. And I don't think Good Samaritan laws apply to M.D.'s. Now, if someone REALLY needs a doctor on the street, I'll be the first to help. But one has to be judicious about stopping and helping in certain instances. I consider that to be more of a sad state of affairs of the current legal maelstrom surrounding healthcare rather than personal indictments of physicians who choose to avoid potentially legally disastrous situations.

At any rate, this guy screaming really did need help: he was clutching his chest, blood pouring through his fingers and streaming down his white t-shirt in a scarlet fervor.

"I NEED A DOCTOR!" he reiterated. "I CAN'T BREATHE!"

Drama was calling.

I ran over to him, bundled up in my coat/scarf/gloves and said, "Come with me right now sir." I grabbed his elbow and started running him towards the trauma slot.

"What is your name?" -- an important question to see if one has enough blood pressure to perfuse their brain.

"JOE," he said.

"What happened just now?!" I asked, all the while running him towards a stretcher.

"I GOT FUCKING STABBED ON 29TH!"

Drug deal gone bad. Right along my path home.

"How old are you?!" I'm speaking very loudly to make sure his attention is focused.

"19!"

"What medical problems do you have?" -- very important to know one's past medical history.

"A FUCKING STAB WOUND!" he retorted. Fair enough.

"What medications are you on?" Another important piece of information.

"COCAINE!" he shouted.

Hrmph. The ENT docs actually do use that to stop severe nosebleeds (and pharmaceutical-grade cocaine is actually pink), but I suspected that that was not his primary problem.

"Have you ever had surgery before?"

"YEAH I GOT STABBED A FEW YEARS AGO."

What a piece of work.

By that time, I had done a primary assessment on him, thrown him into the trauma slot on a stretcher and activated the trauma system. A slew of whitecoats rushed into the room, I told them his story, and we examined his abdominal stab wound that was spilling out feculent material. We cut his clothes off, threw some large IV's in him, put him to sleep, intubated him and off to the O.R. he went. I'll check on him tomorrow, and in a few months, I'll probably see him in the ER again for the same thing.

And hey, I still made it to dinner on time.

Who goes to the ER?

I see many patients with myriad complaints who come in and out of the ER. I know I'm only a second-year resident, but I think all patients who come to the ER can be grouped into five major categories:

1) Those that are sick.

2) Those that are not sick.

3) Those that are sick but appear/pretend not to be sick.

4) Those that are not sick but appear/pretend to be sick.

5) Those that are dead.

Keep in mind that I work in a famous Manhattan county hospital. People from all walks of life come in throught the gateway that is the ER: foreign dignitaries, tourists, bums, drunks, everything. Since it is a public county hospital, we also provide medical clearance and care to NYPD prisoners, a source of many stories. It's overcrowded, understaffed, and understocked with necessary medications. People wander in off the street, are picked up by 911, are brought in by the police yelling and screaming, and some are even hurled at the front entrance in a drive-by dumping by drugged-out "friends" who don't want to get caught. So my classification system is, I think, pretty okay considering I have an N of over 1000 in this study so far.

The aforementioned categories:

1) Those that are sick

These people still scare me. They arrive with the grim reaper as their escort; they're minutes or hours away from death. They're infected, bleeding out, end-stage cancer, or maybe running in the front entrance holding their severed hand.

Being as this is a famous hospital (they're actually filming a movie in it right now, starring Jessica Alba), people from all over the world will seek care here. Case in point of a very sick man: he arrived from a remote region of Pakistan to JFK airport, then took a cab straight to the hospital. He spoke no English. He carried with him only one piece of paper that someone else had written in broken English: "My father with cancer. Please to help in New York America." That's it.

"Well," I thought, "at least we have a diagnosis." I have no idea who wrote the note (I guess his son did), what kind of cancer he had, or was it even cancer?, how far along was he in his illness? What I did know was that his heart rate was very fast, his temperature was high, and his blood pressure was low. At that point, few words need to be exchanged, so it was no big deal that we couldn't speak to each other. I hooked him up to a monitor, drew some blood, ran some tests, got an EKG, ordered a CT scan for him, did a lumbar puncture, started broad-spectrum antibiotics (in short, he got the ER special; one of many ER rules: "If you don't know what you're dealing with, do everything.")

Here's the part that mattered: white blood cell count of 88,000 (typical is 8-12K), hematocrit of 12 (normal in an adult male is about 45), 21,000 platelets (normal is between 150K to 450K). Of those white cellls, a large percentage of them morphologically were myeloblasts -- this man had acute myelogenous leukemia.


2) Those that are not sick

Many, MANY people come to the ER because they have no primary care doctor. They also don't have insurance. So they might say, "hmmmm....that back pain I've had for the last five years? I'm in the neighborhood, I might as well get it checked out now." So they pop into the ER like they were buying a soda, except they have no intention of paying for anything. These are the same patients that will thusly wait for hours (since the sicker ones need to be seen first) and then loudly complain about their wait time. This category includes those with nausea, those with one episode of diarrhea, drug-seekers, fakers, those who need attention, those with a seasonal cold. Before I got into medicine, I probably fit into one or more of those categories anyway, so I'm never really mad at these patients; they usually just need a little attention and assuaging and telling them they'll be fine.


3) Those that are sick but appear/pretend not to be

Probably the smallest of the categories, these people have a regular doctor, don't like going to the ER (too noisy, wait too long, they get discombobulated) and have no interest in seeing a physician. They're usually there at the insistence of their families. To wit:

"Doc," one concerned daughter of a patient said to me. "My father said he was having severe chest pain after he climbed upstairs to our apartment."

"How long ago was this?" I asked.

"Two days. He didn't want to come here, I had to drag him here."

I re-directed. "Sir," I said, "how are you feeling right now? Are you having any chest pain?" His arms were folded tightly and he had little beads of sweat on his forehead.

"NO," he grunted. "I'd really just like to go home and get some rest."

These are the patients you really need to keep a keen eye on -- don't rely only on what they say. Look at how they act, listen to their families, ask very probing questions, run more tests than you think is necessary, and even pay attention to their ethnic background. Not to racially profile, but I will (in a good way): certain cultures and ethnic groups tend to be very stoic and see illness as weakness; thus, they deny they are sick.

In this instance, after speaking more with the daughter, the nurse handed me his EKG. How about that -- an acute heart attack in evolution. Call the catheterization lab stat!


4) Those that are not sick but appear/pretend to be sick.

By far and away this is the largest proportion of patients in the ER. These are the ones you want to strangle -- they whine and moan (but only when you're watching) in inverse proportion to their underlying pathology; they demand things, they threaten you legally, they need -- no, desperately crave -- attention, they pull your mental and physical resources away from other patients who need your care. I believe their thinking is that if they act very dramatic, you'll take them more seriously. These patients also tend to feel very entitled; they act as VIPs or visiting royalty who need incessant one-on-one care. Their most-asked question is, however, "when are you bringing me food?"

One very busy day, I picked up the next chart in the rack. Low back pain. I sighed.

Look, I know lower back pain hurts, I've had it before, it SUCKS, it takes a long time to go away, regular strength over-the-counter drugs barely help, and you hobble around. But unless the proximate cause was a true traumatic event and you're having worsening neurological function due to, say, a fractured vertebrae with sequelae like fecal incontinence, then it's not a TRUE emergency in the strictest interpretation of the word. Yes, they need to be seen by a doctor, they need prescription-strength analgesia, and they need reassurance and instruction in proper exercise and lifting.

"I might as well make this quick," I thought. Yeah, right.

I pulled back the curtain and saw the same middle-age obese woman I had just seen in the cafeteria walking around, buying a doughnut. Make that three doughnuts. Somehow, I knew it was going to be her that I would be treating. I hadn't heard a peep coming from that curtain until I opened it. Then it was caterwauling.

"DOCTOR," she cried, "it's my back, it REALLY hurts, I can't walk or do nothing at all!"

I always try the calm, sympathetic approach first. "Hi ma'am, I understand you're feeling a lot of back pain.

"Ju don't even know, o-KAY?" Her hand is up in Jerry-Springer-like fashion with one finger pointing up, neck cocked.

Uh-uh bitch! I'm trying to help!

"How did it happen, ma'am?"

"I was lifting a box, and -- " ring ring, her cell phone is crying for attention. (Actually it was a Beyoncee ringtone: "Baby boy, make me lose my breaf.")

"Ma'am, please don't answer that right now, and besides, you can't have it on in here, it can interfere with the equip--"

"Hey gurl, nah, I'm at the doctor now, they said I might have to be admitted for pain control. I think I might have a spine tumor or something. Call you later!"

Who said anything about admitting?

"Anyways," she continued, "I lifted a box and it was heavy and then I was having pain. But I've been having this back pain for years now. I can't even walk or anything."

"Actually I saw you walk into the ER and to your bed."

Whoops! Wrong thing to say. But it was a reflex reaction on my part! Even as that sentence was escaping my lips, I still couldn't -- wouldn't -- take it back. It's provocation just hung in the air.

"What??" she yelled, "Ju don't believe me??? Are ju calling me a liar?"

"No ma'am." Play defense just a bit. "I just meant to say that if it's a longstanding thing and it's not crippling, we can get you some great pain control and put you on bedrest for a little while."

"I dunno doc," she starts. "I think I need to be admitted, or least get an MRI right now."

"You can't get an MRI from the ER in this hospital."

"Well you can for me. I'm having BACK PAIN."

Healthcare in this country is going bankrupt, but we'd head there exponentially time-wise if we got an MRI for everyone who came to the ER with low-grade back pain.

"No we cannot. And I don't think you need it, you're not having symptoms consistent with spinal cord injury."

"Like what?" she was fishing for something she could use. I wasn't about to give it to her.

"Anal incontinence. I'll have to do a complete rectal exam on you to determine your rectal tone." Ace in the hole (so to speak), heh heh.

"No, I can shit just fine." (I didn't doubt it, she seemed to be full of it.) "You need to admit me to the hospital then."

I was certain her tenement apartment was getting fumigated and she needed a place to stay. "No ma'am, you also do not need to be admitted. Now what you DO need is a prescription for --"

"You'll just have to speak to my lawyer then."

I hear that a lot. The personal injury lawyers have a stranglehold on many people's minds and make them believe it's a type of lottery. You sue, they settle, you get money, there's no messy trial. But believe it or not, most of the cases that actually go to trial are won by the defendant/hospital. To my knowledge, in this particular instance, I had done everything according to the standard of care, and she refused a rectal exam anyway. And for every 100 people who say they have a lawyer, maybe only one of them actually does. So I called her bluff.

"Put him on the phone." Our eyes locked, my pupils became pinpoint, and she attempted a face-saving maneuver.

"I don't have his number with me. But give me my pain prescription so I can leave."

Do you see what kind of mental and time resources a patient like that drains out of the ER? I'm really a nice guy, but I can be a bitch on command, and it never makes me feel good or better to do that. But I also believe in treating others how you wish to be treated. And I also believe that even if you are ill (really ill), it does not give you license to be rude to anyone, especially your treating physician. I understand when patients are short-tempered or loud because they are in pain, and it's my job to alleviate that discomfort. But there is a difference in being rude and being appropriately demanding of a certain level of warranted care. Not everyone in category 4 is as egregious as this woman, but it certainly highlights the type.


Finally, there is category 5: those that are dead.

Believe it or not, there is a fair number of people who are dead on arrival to the ER. Whether they are brought in by ambulance or family, a certain percentage are unsalvageable: massive heart attack with no pulse in the last hour; someone whose brains were squished into a colloidal mess by a subway train; someone who jumped 10 stories; and even those who died peacefully in their sleep after a brave struggle with a long, protracted illness.

The next time you're headed to the ER, think about which category you fit into.

Why Emergency Medicine?

As you might have read in the previous post, certain personality types gravitate to certain fields in medicine. A colleague of mine composed a diagram that was published in the esteemed British Medical Journal -- it's essentially a hilarious but true algorithm to determine what type of physician you should be. Take a look at it: specialty algorithm -- page 2, it's a .pdf file. If you're in medicine, follow the algorithm and see if you ended up where you belong. I did. If you're not in medicine, you can see what kind of personality your medicine friends have.

So before I get back to more stories from the ER, I should briefly explain how I got into the field in the first place. In summation, it's because I have no attention span.

Generalizations are made about every field of medicine. In a previous post, I described how surgeons were jerks, hardworking, but still jerks; internal medicine people are smart and pontificate for hours on end, etc. Similarly, there are some generalizations about the type of person who decides on a career in emergency medicine. In no specific order, they are:

1) No attention span. On some level, ER docs have a component of ADD. We don't have the patience to spend hours with one person and concentrate on the nuances of little (but important) details like, for example, the level of sodium in someone's urine, calculating that with their cardiac output, etc. We like quick assessments and quick fixes to problems. If we can't fix it, we turf it out to someone who can, and this is a big source of problems during residency (a topic to which I'll return shortly).

2) We like having an outside life. ER docs do shift work. We know when we're coming, and we know when we're leaving. If something is not done by the time your shift is up, you pass it along to the next ER doctor taking your place. After residency (let me stress after), you work much fewer shifts, an average of 3 or 4 days a week. You don't carry a pager with you because when you're off shift, you're off shift.

3) We're adrenaline junkies. Most of went through third year of medical school bored to tears with endless rounding in the general inpatient wards, and similarly exquisitely impatient standing in the O.R. acting as a human retractor of fat while the attending surgeon tried to find what he or she was looking for. Things get interesting, however, when someone is crashing in front of you and you have to figure out something very quickly.

4) We like patients, but not that much. Of the people I see, I like the vast majority of them, really I do. They tend to be nice, understanding, and in need of something quick (stitches, a cast, removal of that bowling trophy from their rectum). However, I don't want to be lifelong friends with them. I even like the challenge of having to establish trust quickly. However, there are a few patients that make me wish I DID run a clinic and could see them repeatedly.

Point number 4, however, creates an ominous, obvious flipside: you can't refuse anybody (by law). EVERY ER doc can regale you with stories of incredibly difficult patients that you wish would either a) leave AMA or b) arrive DOA. The drunks, the belligerent, the MEAN, the "I'm gonna sue you" patients, the demanding ones, the self-entitled ones, the emotionally disturbed patients. However, they provide fodder for good party stories -- that's why we're a hit at Holiday gatherings.

5) We like a little bit of everything. Every ER doc I know went through third year of medical school on each rotation saying, "I could probably do this field." While the thought of doing a vaginal exam horrifies internal medicine docs, I don't mind them so much. While a surgeon would hate to acutely manage malignant hypertension, I don't mind that either. But I like managing the emergent aspects of all those differing fields of medicine.

6) We enjoy solving diagnostic dilemmas. There are very few areas in medicine these days in which the treating physician does not know the patient's diagnosis. The ER is one place left where undifferentiated patients arrive and you have no idea what is causing their symptomatology. The patient fainted? Could be anything: cardiac arrhythmia, stroke, low blood sugar, etc. We get to figure it out, then pass that person along to the next most appropriate service with a working diagnosis (which may or may not ultimately be correct).

Thus, we can do a little bit of everything, but few things to complete depth. The most famous descriptive axiom is that we're a "jack of all trades, master of none." The blue-collar MDs, if you will. There aren't very many things we can do that someone else in another specialty can't do better. The anesthesiologist may be able to intubate better (sometimes) than we can, but they cannot cast a broken leg; the cardiologist can read an EKG better than we can, but they cannot intubate or treat acute salicylate poisoning.

I don't mind that at all, except it sets us up for what is usually a big problem during residency: the rest of the hospital hates you. I was unprepared for this fact (yes, fact) when I started residency. It makes sense, however -- you only give other residents more work to do. NO ONE likes to get a page from the ER. We are frequently second-guessed and blamed for "incomplete" work-ups. This is mostly a byproduct of particular residents' personalities -- assholes are assholes no matter what field they're in. However, all residents are overworked, and I do understand that sinking, angering feeling when your pager goes off and it's coming from the ER. But in terms of general patient care, it works. You're really sick (and by that I mean REALLY sick), you go to the ER. The ER doc works you up, triages appropriately, makes initial interventions, then passes them along. We stabilize. Patients need it and like it. Other residents don't appreciate it until THEY'RE done with their own residencies and then make a buck off of the work we give them.

The biggest fights occur between residents when the ER thinks a patient should be admitted to the hospital and the resident from x service thinks they can be discharged. Admitting someone is a large amount of work for a resident, and they certainly don't get paid extra for it. At this hospital, however, the ER has unlimited admitting privileges, so the resident from whatever service can say what they want, but if the attending wishes that person to be admitted, it's done. More often than not, the ER was correct, but you rarely hear the admitting resident who was previously spewing venom do a mea culpa to the ER. There was, however, an intra-hospital study done about "inappropriately" admitted patients. And guess what? Over 90% of the time, those patients that other serviced wished to discharge decompensated rapidly in the hospital -- they died, required emergent surgery, etc. Most of the time, however, even though the workload is increased, both the ER and the admitting team agree when a patient needs to be admitted. I have the privilege of being part of a reputationally-strong ER program -- some programs are mediocre (true of any field). The attendings here are VERY smart, and it's considered an "intellectual" ER program, so generally there's a high level of agreement.

Having said that, however, we as a department also quite physically isolated from the rest of the hospital -- what goes on above the first floor is largely a mystery, though you'll find most ER doctors follow-up on their interesting patients that have been admitted.

However, as an emergency medicine resident, we are required to rotate through different services that are considered germane to the study of emergency medicine: trauma surgery, ob/gyn, critical care units, orthopedics, etc. We don't spend all 4 years totally isolated in our ER bubble downstairs. So we get to know other residents on other services, we make friends, it helps politically. Orthopedics and ER tend to get along the most well together, and that's probably because we're the most fun and know how to relax. Work is work, play is play, work hard, play hard, do each other every now and again (it happens all the time).

But when I rotate on other services, I hear criticism all the time of the ER, and nearly 100% of the time it's unwarranted. "Well, the ER did THIS," "They totally mismanaged this person," "Can you believe they *didn't* do this?" We work with limited information. We do the best we can. The other residents are largely just expressing displaced anger at having more work to do.

Because the ER is downstairs and largely isolated, however, I have seen many, MANY residents simply LIE to their attending to save their own ass and because they know it's almost impossible to get caught. The party line is, "It was the ER that did that, I'm not sure why."

True example:

Trauma situation -- car accident victim comes in, both lungs require chest tubes to drain bilateral hemothoraces. The ER resident put one in on the right side, the surgery resident put one in on the left side; I was there, I was a witness. The patient is stabilized and brought upstairs.

The trauma surgery attending sees the patient an hour later in the critical care unit upstairs, and he pulls up the x-rays. The right-sided chest tube is in perfect position and drained the blood in that side of the thoracic cavity and the lung is re-expanding nicely. The left-sided chest tube is kinked, not in far enough, essentially useless and needs to be re-done. Without even being queried, the surgery resident said, "The ER resident put in that screwed-up tube. I put in the other one."

A complete and total lie, and he knew it. But he knows no one is going to take the time to verify the truth or non-truth of that statement.

And so it goes, on every unit, at some point, some resident will cover their own tracks and say, "That was done in the ER," knowing it's a lie.

Sure, we make mistakes like everyone else. But by and large, all residents from all services try to get along and work together. It's the right thing to do. And it most certainly helps that all residents in surgery, medicine, orthopedics, urology, and ob/gyn are required to rotate through the ER too so that they can see reciprocally see what life is like on OUR side of the fence. They usually leave the rotation with a very good understanding of what we go through, but they also typically lose that perspective about 30 days after finishing the rotation. I suppose, however, the same is true of us after we leave THEIR rotations.

And so the cycle continues.

Med School in Two Postings: Part 2

Let's see if I can successfully encapsulate med school in a few paragraphs. (If it's entertaining enough, I promise I'll write an entire other blog about it.)

First off, I can't say enough about the medical school at The University of Chicago. Yes, they'll get some donations when I'm done with residency. They have a lot of private money, and they gave me a lot so that I could attend.

The med school at U of C (called "Pritzker" after the just-slightly-less-richer-than-the-Hilton family) is an anomaly among the rest of the University: people there are happy. The U of C itself is an old gothic set of buildings in the war zone that is the southside of Chicago, always overcast. The undergrads are sullied and no fun, and they have this incredibly apparent inferiority complex to Northwestern, up the road about a dozen miles. The law school kids are overworked and exhausted, the B-school students are too quantitative to have a personality, and everyone else in the grad school is partaking their communion from their own triumvirate of Paxil, Prozac, and Zoloft.

But the med school was a happy place. Really. The anatomy lab had windows (not at ground level of course, but could you imagine how fun that would be?) and it was well-ventilated. IT WAS PASS/FAIL ALL FOUR YEARS. Class size was small, and they had an abundance of people who had taken time off before med school like myself. Everyone was interesting, and I loved my classmates. Educating each med student costs the university a lot of money, so they had zero interest in weeding anyone out. In fact, though it was a pass/fail system, we called it "pass/pass" or "pass now/pass later," since you can remediate anything at anytime.

So let me boil down four years:

Year 1: Learn how the body is supposed to work.

Anatomy, physiology, biochemistry, ethics, history-taking, you get the idea. Anatomy was a hoot. Pritzker is a private school, so we could afford to buy more dead bodies (what a weird statement to make, eh?); thus, there were 3 or 4 people assigned per cadaver as opposed to 8 as in some places.

I'll admit, it was freaky. The only dead body I had heretofore seen was my grandmother in her casket when I was 12. And even then there was a mildly humorous component to it because her best friend showed up to the viewing wearing the exact same dress as my dead grandmother. She didn't stay long.

So we as a class walked in together to the anatomy lab. There were 30 dead bodies there to greet us, but all in bodybags. We had to unwrap them like they were Christmas presents. ("Did you get a male or female?" "Can you tell how yours died? Mine has the back of his head missing, I think he blew his brains out.") It was actually a fairly horrific sight -- they all have their heads shaved, and their hands and feet are bound together like they were kidnapped homicide victims. They've been stored vertically in giant preservative tanks, so they have that wrinkly, waterlogged appearance of a drowning victim, and they all have that tale-tale giant roped knot sticking out of the side of the neck where their internal jugulars were punctured and drained.

What they say about murder and sex is also true of human cadaver dissection: the first time you do it is the hardest (but funnest?) and it gets easier and more boring afterwards. The first day, my hand was trembling when I pierced the sternal skin with a scalpel. By the end, my lab partner and I were skinning legs and talking about our respective weekends.

The most grotesque part about it, however, is the tri-section. The pelvis is a very difficult area to learn -- it's where the upper part of the body collapses into a small space and the lower part of the body takes off. Everything becomes a microscopic, coalescing mess, and then you add in the reproductive organs to take up more space. So how do you get around this three-dimensional quandary to see what's in there? You do this: take a regular old saw, put it at the navel, then saw back and forth, back and forth, until the top half of the body is separate from the bottom half. Then you take said saw, place it where the labia meet each other at the clitoral frenulum, then saw the legs away from each other. Now pull like a wishbone. Tah-dah! You now have a body in three parts. By this time, most schools will have been done with the entire top half of the body and you chuck it into a large bin on the side of your table.

Now, lest you think this is disrespectful, it actually kind of isn't. We had a solemn "thank you" ceremony at the end of the semester to dispose of the bodies and give the ashes to the families. As gross as it is, there doesn't seem to be any alternative to educate future doctors. It's also a rite of passage into med school in my humble opinion.


Year 2: Learn how the body can get fucked up.

Year two is devoted to what can go wrong -- you learn microbiology, immunology, and pathology among other things. This might have been my most interesting year in med school because you learn about all the diseases by way of organ systems. I had no idea that there were so many ways to screw up your liver and how that will screw the rest of you over. (Yet I still get holiday cards from the folks that produce Ketel One.)

However, we were required to attend a gross pathology conference. All 104 of us filed into a small Roman-esque auditorium as though we were about to witness the Christians vs. the Lions. And though that's not exactly what happened, it was still a slaughter.

On the slab in front of us was a man who died about six hours prior to us walking in the room. With fervor and aplomb, the pathologist took his scalpel and just started cutting away, trying to lecture all the while. This was a much different experience than gross anatomy in the first year -- the cadavers then hardly looked like people. This current guy looked like he was asleep! The bone saw came out, sternal cage removed, organs hacked away and weighed, the only thing missing to make it look like a feast was being prepared was a set of Ginsu knives. I turned white, then green. The pathologist yanked out the slippery liver, and all I could think was "that liver would go well with some fava beans and a nice chianti. Fifififififififififfffff."

But the worst part was the face. The pathologist made a large incision at the base of the skull and just pulled the face right off the skull. He sawed open the head, yanked out the brain with the spinal cord still attached (it whipped right out like it was trying to get away) and then he put the man's face back on!

So of all the medical specialties from which to choose, I crossed pathology off my list first.


Year 3: Taste the six major poisons

In year 3, you rotate in various numbers of weeks in the six major specialties of medicine: surgery, internal medicine, ob/gyn, pediatrics, family practice, and psychiatry. Rather than detail specific happenings during each rotation (another blog, another time), I'll describe the gist of the personality types to be found in each major specialty; and remember, these are very gross generalizations.

Surgery: assholes with God-complexes for the most part. They only get good at what they do through repitition, so it becomes almost reflexive vocational work. (If you're my surgeon reading this, just kidding!) The field is militaristic, residents are treated very VERY poorly and not only does shit flow downhill, it also begets more shit. It's a very stressful life because you're opening up someone's body and mucking around in there, but it's gratifying in that within hours, you've fixed a major problem that was really screwing that patient up. And patients seem to LOVE their surgeons. The exception to this rule is the orthopedic surgeons: they're always nice, funny and they know that they only know bones and that's it and that's all they want to know.

Medicine: this is where the smart people go. They have to know everything about every organ system, and it's the stepping stone to where even smarter people go, like cardiology, oncology, etc. They pontificate way too much and let the surgeons walk all over them. And they hate kids.

Pediatrics: it takes an extra special person to be a pediatrician -- you have to be patient beyond belief and act like a veterinarian because the kids hate you for what you do to them. And pediatricians have to suppress the murderous rage they have for the parents. You do get to wear funny ties and play with toys though.

Ob/Gyn: I don't even want to talk about it. PTSD.

Psychiatry: crazy themselves. They're just very patient people who are sometimes entertained by psychotics who remind them that they're still (barely) sane.

Family Medicine: I'm still not totally sure what this is. You do a little of everything: kids, adults, gynecology, obstetrics, even psychiatry, but nothing emergently. I think they just write a lot of referrals to specialists who may give them kickbacks.


Year 4: Pick your poison

Now you have to decide what you're going to be when you grow up. Some fields are so competitive, that if you didn't already know you were going to specialize in that field (and how could you without rotating through it?), you're behind the curve and need to take a year off to do research and more electives in that field. Such is the case with orthopedics, neurosurgery, urology, dermatology, ophthalmology, and radiology to some extent.

You spend most of the year preparing your applications and guess what? You're paying again -- just like when you were applying to med school to begin with -- to go on interviews all over the country. Most students (including myself) took out extra loans just to afford flights and hotels on both coasts.

And then you have The Match. Nothing strikes more fear into the hearts of upper-level med students than The Match. It goes like this: you interview at x number of hospitals, these hospitals will interview y number of candidates. You put a list together in rank order of where you want to go, and the hospitals rank their interviewees. It all goes into a central computer in Washington, D.C. and one day in March, every med student in the country at the exact same time (it's timed across all time zones, how sick is that?) receives an envelope with one and only one name of the hospital where they will spend the next few years of their lives.

That just sounds stressful, doesn't it? And it brings out the worst in people. Everyone's OCD acts up and you catch them doing weird rituals to make sure they get one of their top 3 choices. In one day, you find out if you're living on the east coast, west coast, no coast, or -- eek -- that you didn't match anywhere at ALL, every student's nightmare. And it happens, especially in the competitive fields. These students have the option of taking a year off and trying again, or switching into another specialty that hasn't filled its training spots.

This is making law and business school look a lot better, no?

Fortunately, the large majority of students will end up in a program within their top five choices, and then the REAL fun of residency begins. Regular life comes to an abrupt end overnight -- your time is not your own, you lose friends, you lose money, you can do about 5% of the social things you want to do, and that includes holidays and special occasions like weddings and birthing a child. You might gain weight, you might lose weight, but you'll certainly get more grey hair if you have any hair left. Your friends from undergrad who went to law or business school will call you up and say, "hey, we're going to Aspen this weekend, want to join us?" And you'll say, "I have less than 10 bucks in my bank account and I'm on call anyway, so no thanks." Yet somehow, the vast majority of residents say they would do it all over again and still pick that same residency.

So how did I end up choosing emergency medicine for my residency and career? That'll be the next post.

Med School In Two Postings: Part 1

Medical school is an entire other blog/book.

I want to get you up to speed, so I'll make this quick, though there are a few funny and interesting forays along the way.

First, it's an expensive venture to try and get into med school. You fill out a general application, send it to all the schools you're interested in (and many of those you are not), pay them money to read it, and hope they think it's good enough to send you their own school-specific secondary applications. You fill those out and send them another check. (Many, many essays ensue; one school I applied to required fifteen essays.) Then, if they like what they see and you make the next cut, you have to interview at their school on your dime. YOU pay for travel, YOU pay for a hotel, YOU pay for a rental car if you need one. (You repeat this again when you're applying for residency, by the way. Oh yeah, and then for advanced fellowship training too.)

All the interviews are pretty boring. You hear horror stories that are urban legends about how the interviewer will pretend to drop dead and see how you handle it. Completely untrue -- regardless of whether I wished they'd drop dead or not. Most are quite boring -- all black or blue suits, everyone on their best behavior, and everyone pretending that THAT'S their first-choice school. And you see the same people over and over again on the interview circuit, especially within a region of the country. And you notice that everyone has one and only one interview suit. Usually it's poorly tailored. Mine was.

One interview story merits attention, however. I flew to D.C. to interview at Georgetown, and there's a very famous (in med school circles) prim and proper Catholic/Jesuit woman who gives all the applicants in the morning a speech with three key components:

1) We don't care what religion you are, but every classroom has a crucifix in it. This is a Jesuit institution.

2) We don't care if you're pro-life or pro-choice, but you will not learn any component of D&C's here during your ob/gyn rotation. This is a Jesuit institution.

3) We don't care if you're gay or not, but you will not be allowed to form a gay student union or club. This is a Jesuit institution.

At that point, even though I AM religious, I thought it was a bit much and I couldn't wait to get onto to the tour so I could see where Father Karras hurled himself out of Reagan's window in a bloody, demonic mess as seen in The Exorcist.

In fact, when The Jesuit Introduction Woman asked if we had any questions, I wanted to spin my head around and say with a drunken, Cockneyed accent: "Do you know what she did? Your cunting daughter??" I just didn't think I could do Linda Blair justice.

So anyway, my interviewer was this crotchety old bat of a woman (I usually love those types) who used the interview more as a soapbox to lament managed care intrusion into her beloved field and how the state of medical education has really changed today. She even had a lit cigarette in one hand, and I'm sure a half-empty martini was sitting in one of her desk drawers.

"Med school is nothing like when *I* went," she said.

How do I respond to that? I just didn't. And apparently she didn't want me to.

"THESE days, you have so many Indians and Asians in med school with names you can't even pronounce."

Yep, she really said that. In 1996, and those were the Clinton years.

Oh no she di'ent!

I finally spoke up: "Ma'am, I should probably tell you at this point that I'm half Asian."

"Really?" she seemed genuinely surprised. I halfway expected her to say, "but your eyes are so big and round!" But it was even worse! She said, "Well, then they should change their names to something more pronounceable like YOU did." With lips pursed and eyes glancing out the window, she took a big puff off that Virginia Slim like she was Miss Scarlet on her Clue chaise lounge and blew smoke rings.

I got right up and said, "I think this interview is over."

The only reason I said that and didn't lose my spine and agree with 100% of what she said was only because I had already gotten into three med schools by that interview.

I went back to the main office were Father Dean Something-or-other said, "That was fast."

I re-told the entire story to him without embellishment and he scuttled around, sweating bullets before saying, "I'm sure that interview won't be an issue in our decision and I'm sure she won't be giving anymore interviews. She's new, you know."

"That's alright," I said. "I'm not the p.c. police."

"So you're going back to Chicago, then, I take it?" His awkward attempt at conversation was apparent.

"Yeah, I've got to get back to work."

"What do you do?"

"I work for a law firm."

Silence.

"See you later, had a nice time, g'bye!" I said as I exited the door.

I hung out that night and for two more days with my friends in D.C., caught a plane back to Chicago, came back to my apartment and a Next-Day FedEx letter was waiting there for me. I opened it up. "Congratulations!" it started, "The Admissions Committee of Georgetown Medical School would like to congratulate you on your acceptance."

As promised, more background

So if you've read my first two posts, you know that a) I'm an ER resident and b) I wasn't supposed to be a doctor in the first place.

As promised, here's more of the story of how I got here.

I quit grad school four weeks into it (a true Gemini, fickle to the end) and moved back to Chicago. After working with asshole litigators who were turning me into an asshole but telling me not to be an asshole, I decided to try and figure out a career that would keep me from being an asshole (medicine is certainly not that career path, but that's a whole other story). Really, it's just not in my nature to be a jerk (most of the time).

The truth is, I'd probably love law school; I'd just hate life afterwards.

Anyways, three things happened as the planets aligned that made me think very seriously about medicine as a career:

1) I kind of dicked over a dead kid. And his family.

Before you level your judgment, let me explain. I'm not going straight to hell, I'm at least going to spend some time in limbo probably for this. I was just a cog in the legal machine at the time (that's my defense and I'm sticking to it). You see, I was spending countless days and hours helping to work defense on a case in which unnamed plaintiffs were suing an unnamed corporate pharmaceutical monolith for knowingly allowing tainted blood products to be used for transfusions on hemophiliac children. A class action suit ensued, and I worked with lawyers well into the evenings to explore ways to get out of this one. And we did -- on a technicality. I won't bore you with the details (read: I can't divulge, I still fear retribution), but the court tossed it out. Completely. Scot-free. OJ-Simpsonesque, if you will. "If you didn't file your complaint in time, it ain't a crime." (I never really said anything stupidly brazen that appealed to the least common denominator like that; and I haven't forgotten that Johnny Cochrane died of a brain tumor.) Dozens of families and parents were emotionally stunned. So was I -- I really was not expecting that outcome.

About two weeks later, I received a handwritten letter. It wasn't addressed to me specifically at this firm, but on some level it was. One of the fathers of one of the children who died from AIDS-related complications from tainted blood said this:

"You bastards. I got nothing. Nothing but a dead 12-year old kid. Me and my wife don't even have enough money now to give him a proper burial. He's in a goddamn wooden box without a tombstone."

Ouch. Re-read that letter and really let it sink in.

Call me a wuss (I am), call me gay (I am), call me soft (I am), but what can I say? I cried. I am the crying type. I cry from watching Little House on the Prarie re-runs (except when Nellie Olsen gets her due). I can't watch Animal Cops because I cry when I see abused dogs. This really was a watershed moment for me. I'm not a terribly good person, but I don't think I'm all that bad either. One of my close lawyer friends with whom I was working on that case wrote one of my reccommendation letters for med school. And partially based on this case, she said, "I think Brian would be a great lawyer, but I can tell you without hesitation that it requires a certain ability to be at times distant and cold, to remove all emotions from a situation for a long time and potentially psychically damage others. And I just don't think Brian has that in him."


2) My attempt at karmic re-adjustment.

This is the second of three sequential events that led me to medicine.

A few months after closing up that case (I asked not to be involved in the appeal), I found myself with an inordinate amount of free time. I worked till 6pm and had most weekends free. After having wasted enough of those evenings and weekends in bars, I decided to give back a little and volunteer.

It will probably come as no surprise to you that I ended up volunteering at an AIDS hospice.

There is a place in Chicago I learned about that gives housing and food to people with end-stage AIDS. Most of the residents there had long been disavowed and disowned by their families and most friends. Through bad luck or bad attemps at maintaining proper medication schedules, they had developed resistance to the current life-saving regimens of anti-HIV drugs that make HIV almost a manageable chronic condition. So they went to this agency to live and die with dignity.

My role as volunteer there was to assist in preparing meals and generally keeping them company. I could play Texas Hold 'Em with the best of 'em, but as far as the cooking, well, let's just say the volunteer coordinator decided to place less of an emphasis on that role for me. (I was restricted to bringing bowls of cereal with milk on the side.).

And I loved it. I liked working with the patients, I liked listening to their stories, and in turn, they enjoyed my presence. And yes, I did like the way it made me feel.

One thing bothered me very much, however; it was that I did not understand their disease. The concepts of T-cells and protease inhibitors, immunosuppression, and even the basics of cell-regulated immunity and compromise were completely lost on me. I was fascinated by the science behind the disease and wanted to learn as much as I could about it. I was, after all, a total science nerd in high school (and I mean real nerd: braces, headgear, thick glasses, slacks-not-denim) before I became a humanities nut in college.

Then the third thing happened:


3) I ran into my old friend Jane.

Jane was a senior in college when I was a freshman. She was an English major who was going into publishing, and we met -- actually I don't exactly remember where or when -- some random function in college. Jane was a quirky gal with a deadpan sense of humor and a funky fashion flair -- in short, your typical faghag. Like two brown dwarfs (the stars, that is), we gravitated towards one another and began orbiting. Actually, we weren't able to spend THAT much time together since it was the end of the school year, and soon she graduated and we lost touch.

Several years later, I ran into Jane on the streets of Chicago (actually knowing her, I think it was a gay bar), and we caught up.

"What are you doing these days, Jane?" I queried. "Editing Vogue yet?"

"Not really," she said. "I'd still do that, yes, but I'm in the people business right now."

"Doing what?"

"Medical school."

"Huh?" I truly had lost touch with her. "I thought you were an English major. I never had you pegged as one of those hypercompetitive premeds."

"I wasn't," she said. "I did a post-baccalaureate premed program."

I had no idea such a thing existed. After a long conversation, I found out one only needed four classes to get into med school: biology, chemistry, physics and organic chemistry. I thought long and hard about this one, believe me. Here were my options at the time (actually these aren't so unique, you'll discover most of you have similar options):

a) continue working in a dead-end job and live paycheck to paycheck;
b) go to law school (three years and you make a pretty good buck)
c) go to business school (TWO years and you make a pretty good buck)
d) do a post-bacc pre-med program in two years at night, use your weekends to do required laboratory work for those classes, then four years of med school, then several more years in residency, then begin to make a pretty good buck that tends to decrease in linear fashion with more federal, state and private regulations.

Guess which one I chose?

Even though we're all taught to pick "C" when faced with an unknown, I decided after a lot of thinking (really, a lot of it) to try the med school thing. When I told my parents about this plan, I think they finally forgave me for dropping out of Yale. "Can you do THIS for more than four weeks?" they asked. An understandable question on their part.

So in two backbreaking years that required me to give up nights and weekends (most of them) previously devoted to alcohol, I immersed myself in those Big Four Classes. I endured the wandering eyes and competitive spirit (actually it was a crushing spirit) of competitive pre-meds, only this time it was during night classes when claws could be more easily bared under the cover of darkness. And who was I kidding? The only science class I took in undergrad was Highlights of Astronomy, and that was my worst grade in all four years.

I know -- this is exactly what you want to hear from your doctor, right?

Once a nerd, however, always a nerd. Science came back quite easily to me (maybe because I'm half-Asian?) and all was fine. The premed coursework is just something you have to get through -- I didn't like chemistry, I didn't like biology even, and I certainly didn't like physics. In fact, the only physics I currently have to know is the principle of gravity -- when someone ingests poison, you force charcoal in them, flip them over, back again and stand out of the way when they hurl black goo in projectile fashion. Organic chemistry, however, was something I totally got into -- weird, I know. But it was like a beautiful symphony -- you just figure out where the electrons go and everything else in the reaction falls into place. That's the only premed class that made sense to me.

When all was said and done, I got into a few med schools and decided to attend The University of Chicago.

Winning the battle, losing the war

Okay.

So I just returned from patient Z's room after I got paged that he yanked out his own breathing tube. Normally, this is a good sign -- the person wants to breathe on their own. In this instance, however, the guy doesn't have the ability to protect his airway since he had a stroke, seizure, aspirated his own food and gave himself a chemical pneumonia (damn that spicy stroganoff the hospital serves). So back in goes the tube. The only thing is, you gotta sedate and paralyze someone to intubate them. Not a problem: push drug x, push drug y, the guy is out cold and generally flaccid as a 12-beer penis at 4 a.m. I'm at the head of his bed, bend his neck backwards and outwards a bit, intubation blade in hand, it slides in easily and moves the tongue out of the way and --

oops -- there's a problem: the dude's moustache was so fucking thick, I couldn't see shit.

"Do you see the vocal cords?" -- the first and only question my nervous attending is belting with levity that will soon morphe into impatience.

"Kind of." (What the fuck kind of response is that? I wonder.)

"What the fuck kind of response is that?" he blurts back.

"Dr. B, all I see is hair."

"Hair??!! Is he a cat? Did he lick a furball into his throat?"

The oxygen monitor is making that ominous beep that becomes deeper in pitch and slower in frequency as the oxygen saturation of the blood lessens.

"Dr. B, it's his moustache. It's in the way." (What the fuck? The nurses keep him clean-shaven but they leave this big bushy-ass 70s disco gay leather club handlebar obfuscating mess of hair on his upper lip??)

"What?"

"Um....."

"DO YOU SEE THE CORDS OR NOT? IF YOU DO NOT SEE THE CORDS STEP AWAY FROM THE HEAD OF THE BED OR I WILL BOX YOU OUT."

(Box me out? The attending is 5'4" on a good day, I'm sure he wasn't star center of Podunk High Basketball team.)

Yeah, that's helpful. Yell in one ear, have me listen to dropping oxygen monitors in the other ear, all the while trying to establish an airway.

ER residents can do a lot of things, and similarly, there a lot of things we cannot do. But we're quite well trained at tuning out extraneous bullshit and listening with a third ear to what's important. So while I hear "blah blah blah," I'm listening to "beep, beeeep......beeeeeeeeep," and suddenly through the thicket I see the patient's vocal cords and POP goes in the tube.

"Did you see the tube pass through the cords??" says the attending.

Goddamit I saw the fucking cords and I passed the fucking tube and the guy is breathing and he's fine, it didn't help with you shouting in one ear and it certainly doesn't the fuck help right now to keep yelling.

"Yessir," I meekly said, "I saw it go right through the cords. His O2 sat is up to 100% and I hear breath sounds bilaterally and equally. I'll order a chest xray now to check tube placement, and I'll send off a blood gas."

No response from the attending.

I grabbed a suture removal kit, took out the scissors, and cut that moustache off until it looked pre-pubescent.

--------------------------

I paused for a minute.

What exactly were we doing for this man?

I've been seeing him everyday for over two weeks now, and he has had zero mental status improvement. His organs are slowly but surely shutting down one by one. Each day when I check his laboratory work, the proximate markers of his individual organ function continue to belie what we attempt to do on a semi-shortsighted basis. Get his oxygen better. Make him breathe more. Bring that fever down. Give him another antibiotic. His kidneys shut down? Put a dialysis catheter in him and give him mechanical kidneys.

At what point do we stop?

His wife already had signed a DNR order. What exactly constitutes rescuscitation on this man? He is septic from an unknown source, he's on every "big gun" antibiotic known to modern medicine, his blood pressure continues to drop, and then we start pressors on him to bring the pressure up.

I think there's an indefinable moment when everyone knows that further work is futile; the only question is, what is that point? As docs, we sit back and say such self-soothing things as, "his BP was dropping, I started levophed on him, now look! His pressure is back to normal." Or, "his creatinine shows he's in acute renal failure, we dialyzed him, now look -- his electrolytes are back to normal."

So it's these little battles we win, but it becomes an ethical gray zone to say when to give up the war. Not to drudge up political battles, but I will: Terry Schiavo. Her post-mortem showed her brain had the consistency of oatmeal. That war was over long ago.

I'm just wondering when we will decide for Mr. Z that his war is over. I actually pray that he is not conscious for any of these painful interventions we do.

First entry, December 26, 2005: The day after Christmas in the ICU

I decided to start a blog the day after Christmas to keep from falling into the abyss of insanity around which I've been orbiting since day one of my residency.

I just returned to the surgical intensive care unit after 48 hours off (in and of itself an anomaly for residents) to find that two patients had died ("Could you please check the 'expired' button on their computer registry?" asked the nurse when I came in); another patient had bilateral pneumothoraces (his lungs literally blew up, he'll probably die within another 48 hours of writing this), and another one who was recovering quite well from major heart surgery had a massive stroke and is neurologically devestated. His wife is now left to care for their mentally-challenged child alone.

Merry Christmas, everyone!

Let me just pull you all up to speed.

The background: I'm 31 years old (yipes) and a second-year resident in Emergency Medicine at New York University Hospitals, deep in the heart of the epicenter of the Western Hemisphere. I never planned this, believe it or not. In fact, from about age six, when I talked and argued incessantly with my parents (I still do, I'm staunchly left-leaning, the rest of my family are card-carrying members of the NRA in rural Georgia -- a subject I'll return to many times over; and yes, I'm gay, let's just get that out of the way), it was decided that I should just go to law school and make a living out of smart-assing.

Turns out, helping one large corporation screw another one out of millions of dollars via jurisprudence nuances wasn't my thing. Neither was sitting in an office with no human contact for 18 hours a day except to fight with opposing counsel over the phone.

During my adolesence, after a number of failed hunting trips with my dad (I sat in the deer booth reading US Weekly, scaring away the deer on purpose because I saw Bambi one too many times), I decided that when it came time to apply to college, I would only look North of the Mason-Dixon line. Forget Athens or Atlanta -- despite everyone's protestations that they're liberal bastions ("really, it's like a northern city with so many expatriates,") I've been to both places enough to know that that's what Democrats tell themselves to make themselves feel better about living just outside the Zone of Mullets. (Though one of my brothers has a mullet -- and I actually convinced him it was originally pronounced "Mull-ay," as the style had obviously descended from 18th-century French aristocracy. When he clipped it down to the "rat tail," I gave up.)

So my dream undergrad school was The Lavender Ivy, despite it being in New Haven. I had the test scores, the grades, the essays. The only thing I didn't have was the courage to put a stamp on the application package for fear of rejection. So when fall of 1992 came, I packed my bags and headed to Northwestern just outside of Chicago. Loved it. Fucking phenomenal four years (from the parts I remember; that's another topic.)

So here's the thing -- I studied humanities and social sciences, I was the nerd who always went to discussion section (PREPARED for it, no less) and talked the most. I *liked* researching for my papers, and I always wrote them ahead of time and way over the page limit (can you tell?). I was on the debate team and travelled twice a month across the country for policy debate on a range of topics. And, like over 95% of college policy debate geeks, I thought I was going to go to law school.

I took a quick detour first and ended up in a PhD program in political sociology at -- you guessed it -- The Lavendar Ivy. My grand plan was to be the ultimate nerd -- PhD/JD, read, write, research, teach, end up as a federal judge somewhere.

I hated it.

And I hated New Haven. I was reading the same books I read in undergrad, only this time with more response papers and public flogging in smaller groups. In retrospect, I think I simply burned out. So four weeks into grad school, I had a conversation with my advisor that went something like this:

Me: "I need to take a break. I can't do this right now."

Him: "Would you like to take a leave of absence?"

Me: "Yes please."

Him: "Would you like to show up next fall?"

Me: "Yes please."

And that was the last time I have ever been to Connecticut.

I moved back to Chicago and went to work for a litigation firm doing a bunch of legal research. I was working and researching like a first-year lawyer (I was 2nd place for billable Lexis/Nexis hours in the entire firm) but with 5% of their pay.

And then one night, x number of martinis with the associates later, one of them said, "Fletch, don't go to law school for this. I would not let my children do this." (Children? I slept with him weeks ago. I didn't even know he was married.) When 100% of the other associates agreed with the aforementioned wisdom (only 25% of whom I also slept with), I thought, "I have to sleep with the rest of them now." Just kidding. I thought, "there has to be something better than this."

That something will be post #2. I just got paged; apparently, patient Z just pulled out his own breathing tube.