Let's Play Jeopardy!

We play two types of Jeopardy at Wilford Hall. One fairly entertaining and always educational. The other, well it kills a little bit of me every turn of the game.

The first version involves Morning Report. We break up into teams and do Jeopardy in the regular TV fashion complete with little hand buzzers. It's pretty great. 'Nuff said.

The second version involves the few pleasant rotations we have each year. In order to complicate them and instill a pervasive sense of fear we are periodically put on "jeopardy." For a number of days were are required to carry our pagers with us wherever we go in the rare case that someone cannot come in for work and a substitute must take his or her place. For some it is an uneventful moment in time that passes before it is even realized to have begun. For others the rare moments seem to rarely be rare. And for some, namely the married men amongst us, it is a chance to strike it rich at the Impregnate Your Wife Lotto. With enough planning, and enough of some other things as well, a beautiful new baby child can be brought into the world right in the middle of one's ward month or ICU block ensuring a garunteed week of paternity leave to, you know, assist the wife with child care and stuff. It is the scourge of childbirth that has created such a terrible taste in my mouth for jeopardy, and I blame paternity leave for all of it.

At this point I would go on about how when we cannot come in due to illness we either still come in or come in once the rigors have stopped while paternity leavers seem to always return 7 days later fully rested, I may then segue into how I rose from bed one morning vomiting and yet still reported for duty, and I could then follow that with even more raving about how every jeopardy I have been on this year, save the one I covered for a friend, has resulted in me being jeopardized, but I will instead end my rant here. Let me just say that Jeopardy sucks, I hate it, and come on people! Enough with the baby making already!

(or let me in on some of the baby making action.)

Let's Get Intensive

Back on call again. Still sucks.

I've realized, though, that for those whose only impression of "call" comes from Gray's Anatomy and Scrubs, being on call is a hazy, ill-defined concept, and reality's blurred. My repeat assertions that "it sucks" have surprisingly done little to clarify the matter. The truth is, aside from the casual sexual encounters with coworkers, there is not much in common between the real world and the world of make believe. As an example, an average call in the Medical Intensive Care Unit (MICU):

• 0530, Wake up, realize it's a call day, grimace.
• 0600 - 0630, Drive to the hospital in silence. This is likely the happiest I'll be all day today.
  
• 0630 - 0635, Arrive at the hospital and change into scrubs that I have found and scavenged throughout the hospital on previous non call days. Sometimes they fit, sometimes they're stained, sometimes there're huge unexplainable holes in 'em.
• 0635 - 0830, Begin pre-rounding on my old patients. Pre-rounding consists of recording a slew of vital signs, lab values, consult information, nursing reports, radiographic data, drip rates, machine settings, and then, finally, talking to the patient for 5 minutes. Thankfully many ICU patients are on ventilators and do not have much to say.
  
• 0830 - 1200, Round with staff and fellows. Staff rounding consists of telling the staff physicians about everything I have just collected and then politely nodding while my co-interns do the same.
  
• 1200 - 1215, Run the board with the resident. Basically we find a big marker board and cover it with little check boxes of the things we have to do today.
  
• 1215 - 1230, Get lunch at the cafeteria to go. As the food choices are often some sort of fish, often pollock -- whatever the hell that is, and some odd mix of sides that do not go together I frequently find myself eating a lot of grilled cheese sandwiches. It turns out BAMC has the best grilled cheese sandwiches.
• 1230 - 1600, Work. Write notes, write orders, record more information, and repeat. Sometimes I accidently find myself talking to my patients which only puts off all the work I have to do.
  
• 1600 - 1700, Take sign outs. Around this time, while I am still going about my regular business, various other interns page me to come check out their patients for the night's cross cover. This is when I get to add more little boxes to all the previous boxes I had already checked off for the day.
  
• 1700 - 1730, T-cons and emails. If there's a lull in the work and we have not already had to admit any new patients, I just may get to take care of the other, non-ICU, work that builds up 24/7 year round. T-cons are things I need to call my outpatients back about and emails are typically incomprehensible military things I need to delete or poorly characterized tasks I have to take care of somehow, somewhere.
  
• 1730 - 1745, More sign outs.
• 1745 - 1130, Admit patients. Nightly we receive anywhere from 0 - 5 new patients from the ED. Typically it's around 1 - 3. Each individual patient seems to take me about 2 hours to fully work up, admit, and write a History and Physical (H&P) on. I would say I am slow but I honestly do not know how to go about it much faster without cutting corners. Or at least more corners than I am already comfortable cutting.
  
• 1745 - 2330, Cross cover. At the same time I'm admitting patients I also gotta take care of all those pesky check boxes!
  
• 2330 - 2350, Dinner. Hunger pains and hypoglycemia force me to momentarily stop or slow what I am doing to eat. Thankfully there're usually other things that can also simultaneously be done while eating. Like checking boxes for example.
  
• 2350 - 0200, More admits and cross cover.
  
• 0200 - 0205, Think about sleeping, but then do more admits and cross cover.
  
• 0205 - 0245, Take care of a crazy patient. Inevitably someone will completely lose their mind over the course of an evening and I get to try and persuade them not to. It seems restraints and tranquilizers are not in fashion these days.*
  
• 0245 - 0250, Think about sleep again, but then do more admits and cross cover. Maybe watch part of a show in an unconscious patient's room.
  
• 0250 - 0345, Code Blue. Someone is dying and it's my job to stop it! Or at least delay it for another few days or weeks till it inevitably comes about.
  
• 0345 - 0545, Admit again.
• 0545 - 0700, Finish whatever needs finishing, and pre-round on my old patients if there's time. Sometimes I eat a yogurt cup.
  
• 0700 - 0830, Check out with the CCU (Cardiac Care Unit) team. This is when I learn that despite working continuously for > 24 hours straight it just isn't good enough.
  
• 0830 - 1100, Check out with the MICU team and staff. This is when I learn that because I worked continuously for > 24 hours straight it's clear I did my best. Good game everybody, good game.
  
• 1100 - 1230, Finish whatever needs finishing again. Complete notes, complete H&Ps, and sometimes fall asleep at or on my keyboard.
• 1230 - 1231, Leave the hospital. My reward? The sensation that someone has thrown sand into my eyeballs. Whether cloudy or sunny, wet or dry, walking to my car is always a mildly stinging experience.
  
• 1231 - 1300, Drive home with music blaring and singing along. This is likely the happiest I'll be all day today.
  
• 1300 - 1530, Eat, shower, and go to bed.
  

Total time awake: 33 hours

Friggin' miserable.

In international news, President Bush. Guy can dodge bullets. Or at the very least well thrown shoes from close range. And Prime Minister al-Maliki? Way to step in where the Secret Service was not. Batting away gun shots -- err shoes -- with greatest of ease. I know I don't have moves as smooth as that. Would have taken both shoes square on the nose, back to back. No country would take us seriously afterward. Really, though, it seems global politics is going more and more the way of Austin Powers these days.

"Who throws a shoe? Honestly! You fight like a woman!"

In domestic news, we've got Christmas lights!



Almost looks respectable from this angle!



This angle not so much. It turns out I did not quite measure the required length of lighting very well. But, uh, it's the thought that counts?

*Not to suggest that they should be. Restraints and tranquilizers should only be used when absolutely necessary. Like when the patient has made you angry.

A Labor of Love

I have been working 80 hour weeks for the past five weeks. I have three left to go. I do not enjoy it much. I leave to work with it dark outside and return to work with it dark outside. In these harsh and trying times I like to think of a block back at BAMC when my co-intern stepped in to visit a patient of his.

The woman, elderly, foreign born, and a bit demented, had just had a nasogastric tube inserted through her nose to relieve the pressure building up in her gastrointestinal track. Being so demented she did not terribly appreciate this.

Upon entering the room to see how the procedure had faired she, from her curled up position in bed, waved her grizzled hand and said in her thick East European accent, "Traitor."

"You'll pay for this."

The joys of patient care.

Today a family in clinic gave me a pack of gum. It was pretty good.

Ahh... for the good ol' days....

He Eats Mostly Milkshakes

There are few joys in the life of an intern. One's days consist mostly of recording an endless sum of data, transcribing an endless number of notes, returning an endless stream of pages, and laboring endlessly in the hospital's endless bituminous coal mines. It is infrequent when one can smile and if you smile too long they call it mania and start you on depressants. One consistent joy, however, has always been stumbling upon the curiously written statements of other physicians. (Yes this is what goes for joy these days.)

For medical and legal reasons everything must be documented meticulously. Sometimes, however, well, there just ain't time to do it well. As a result well crafted statements succinctly conveying information are often replaced with whatever thought first enters the physician's mind which, to him at least, conveys what it is he's trying to convey. The vast majority of times this is sufficient. Some of the time, however, it just doesn't quite come out right.

In one recent event concerning an elderly, fatigued patient of ours, the consulted hematologist-oncologist wrote a quick one paragraph statement discussing the nature of the man's pancytopenia. After briefly describing the patient's signs and symptoms in the standard medical jargon he writes in a new sentence, plainly, "The patient states he eats mostly milkshakes." He was trying to convey that the patient was malnourished and so lacking in the vitamins necessary for adequate blood production, but all I could think was, "that is awesome. He really does enjoy his milkshakes." This was, incidentally, a miscommunication -- the patient had informed us earlier that though he did indeed love himself some milkshakes he actually ate microwave dinners from time to time as well -- but nevertheless that's what was recorded and that's what everyone will be forever reading when they go through his medical records. I can only imagine what will be recorded by future physician robots of me. Probably something like, "The patient states he eats mostly sandwiches. Patient perseverates on the idea that he makes quite possibly the best sandwiches in the world discussing the matter at length. Consider psych consult."

Speaking of eating nothing but milkshakes, my diet is actually not too entirely different right now. With no established lunch time and about 14 hours of work for an 11 hour day lunch is often cast aside and you eat what's nearby. Hopefully it's edible. For this last week it's been:

• Sunday: Half day, I made a sandwich. Possibly the best sandwich in the world.

• Monday: On call. 1100 ate some beef jerky. 1300 ate some dried strawberries. 1600 ate grilled cheese, fritos, and a Cherry Coke.

• Tuesday: Post call. 1400 made a sandwich. Possibly the best sandwich in the world.

• Wednesday: Off, I made a sandwich. Very likely the best sandwich in the world.

• Thursday: Normal work day. 1400 ate two bags of fritos and a 7Up.

• Friday: Normal work day. 1400 ate grilled cheese, chili mac, Ruffles, and a Barqs Root Beer.

And that's a good week. The pinnacle so far, however, has been the Tuesday prior when my lunch consisted entirely of a strawberry cupcake. At first I was worried I'd lose weight and become questionably anorexic, but it turns out the caloric intake of cupcakes is about the same as a regular meal. I'll just end up pancytopenic someday.

On a separate note. My long call last Friday resulted not in sixty new patients -- I cap at five new ones in most circumstances and so was done admitting new patients around 11:00 pm -- but it did have about sixty cross cover pages to take care of. I have been jinxed; I have been humbled.

Fair Weather Ahead

There are certain truths concerning medicine that are kept from the general lay public for the public health benefit. Mostly their peace of mind -- not so much their actual morbidity and mortality. One of these truths is that July is the best time to be killed by your doctor. Ninety-nine percent of residencies begin in July and all the fresh new interns -- most of whom know less than they did than as even fresher third year medical students -- combined with fresh new senior residents -- who were themselves only a year ago fresh new interns -- mean that the chances of you getting worse from your hospital stay are almost as good as you getting better. The same hand extended with an awkward smile to greet you on the gurney may be the same hand making the sign of the cross while pronouncing your time of death.* I imagine these statements won't actually hold up to statistical analysis thanks to excellent supervision, but it's a medical truth! It is so.

Another medical truth is that there are some physicians that bring with them them the storm clouds of disease close in tow, and then there are some physicians who are bathed in a gentle light of health bringing peace, refuge, and pockets full of medicine wherever they go. Black clouds and white clouds. So far, after two calls, it seems I am a white cloud. Not through any effort on my own part mind you; no one knows how the Gods decide the status of each physician. It is theorized that they either draw lots or simply look down from their collective ivory towers and name off the first few people they see, but whatever the means, once ordained it is unshakable. In my one and a half weeks of residency I have admitted three patients on two call nights and taken care of perhaps another three. This is less than what many teams see in a single call night. Sometimes I lay hands on patients and they get better, blow kisses at children so they'll stop crying, and wink at the elderly so as to resolve their dementia. None of this ever works of course as that's not how the black cloud/white cloud system operates, but I like to do it nevertheless.

And the last medical truth I will share with you all is that most medical truths are contradictory. Some may like to use the term "paradoxical," but, no, they're usually just contradictory. And as we residents are a superstitious lot it is likely that by mentioning my white cloud status just now I have successfully jinxed it. I am on call this Friday. I am expecting sixty patients.

*Actually I don't think most residents make the sign of the cross when pronouncing people dead. Except for maybe the Catholic ones.**

**Is this Catholic racist?

And Remember Kids

I have not officially begun my residency career, but I would like to lodge my first official complaint. With today's newer, softer physician training programs work hours have been slashed, antisocial personalities heavily medicated, and positive things said all around, but with such unbridled kindness and cheer has, as is so often the case, come also a little bit of insanity. Specifically, all the heartfelt behooving to "live a balanced, satisfying life" is ridiculous. I do not have any children, significant others, financial responsibilities, social commitments, or even a pet of any significant size, but even still I can confidently say that I certainly do not have much free time with my 80 hour work week to lead a life in harmony with my family, friends, and nature. The rest of the world seems to have enough trouble getting by on a 40 - 50 hour work week, and, given, though the average American may be in need of a few hour handicap to deal with some of the problems he gets himself in if the average American cannot live such a life with a 30 to 40 hour advantage are we to assume he is just lazy? I do not wish to create the impression that I think residency should be regulated to a 40 hour work week, and indeed in many ways sacrifice can at times in some ways make life stronger, but let's not play this silly mind game that living the good life as a resident is simply a decision that we make. We can make the best of what we got, but let's not pretend that what we got is anything fantastic. Residency is meant to be tough and our family, friends, spouses, and pets will feel neglected because they will be neglected. All the double think and smiling faces in the world ain't going to change that. So the next lecturer who tells me to take a quick nap after 30 hours of continuous work on call so that I don't somnolently drive my car off a bridge embankment and then in the same sentence tells me to take time out for the small things in life is getting a alphanumeric pager to the back of the head. You know, the big kind. With AA batteries. Grrr.