The sick role

I've been remiss in posting. I know. I'm sure all 5 of my readers are seriously bummed by this. I've been on the lower GI service this month. Which is pretty much colorectal surgery . . . but for us at my hospital we are the IBD (irritable bowel disease) specialists. The vast, vast majority of our service is made up of patients with ulcerative colitis or chron's disease. For those of you that didn't go to med school these are disease that affect the bowel causing cyclic waves of diarrhea and constipation. They can be painful, uncomfortable and life altering. But, they don't kill you. Well, they might be a contributing factor to your death. But your life expectancy isn't much altered as long as you have close medical/surgical care.

A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.

I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.

So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.

These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.

So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.

It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.

One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.

And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.

Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.

Specialization cut short by drinks.

So, a lot has happened since I last wrote to you. I've finished with Vascular surgery and I'm one week into lower GI surgery. I think I've written to you enough about all things vascular. It was not an easy month for me. Not because the hours were hard, and I even saw the humor in most of the patients. But, the medicine just wasn't for me. Right now, though, in the abdomen, I feel like I've returned to my happy place.

This has got me pondering on how young doctors pick their specialties. It's often said in med school that the professors can tell what specialty you are destined before just by meeting you. The nerdy ones with poor people skills often end up in specialties like radiology or pathology. It's always the geeky guys that are forever quoting journal articles that lean towards medicine. The kids that just quite pick what they are interested in lean toward family medicine. And the rough and ready guys that are always looking for their next adrenaline rush end up in the ED. The surgeons are the ones that are too cool for school. I could keep going on with the stereotypes. Tell you about the ladies the pick OB/GYN and the sometimes super creepy, too nice guys that go for it as well. But, you know all these things. Most of these stereotypes are quite intuitive. My question is about how one picks their subspecialty.

In this day and age being a generalized doctor is a death sentence to your practice. Everyone wants a specialist. We used to joke in med school that we would specialize in something obscure like the pinky and make a mint because people the world over would come to use for their pinky troubles. And we could charge double, even triple because we were the only one in the world. While that is a bit extreme it does have a nugget of truth. Specialization is the only way to survive.

So, now that I've picked surgery how do I pick a specialty?? We spend our first year rotating through a different specialty each month. We meet with an assigned mentor and we really should know what we want to do by our second year. But, it's a hard decision.

Ummmm, I'll finish later. I only just got home at 6 and I have tomorrow so I'd decided to just sit in and veg, write to you guys. But then a couple of my co-interns called and we've decided to grab some drinks since none of us have to work tomorrow. I'm going to wear make up. And fancy jewelry that dangles. Oh My God. It's been so long.

GTFO . . . Getting The Fuck Out

Most people look forward to vacations and breaks. But not like interns. Man, we literally live for them. They are the ONLY thing that keeps you going. As interns we work 80+ hours a week. Get only 4 days of a month and only 3 weeks off in the year. So when we go on vacation it's a big damn deal. I got all my vacation at the beginning of the year. And that is not ideal because it means no more than 2 days off in a row for the rest of the year. (Our year starts with June 24th and ends with the 23rd on the following June.)

So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.

Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.

No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.

I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.

Not another one

I was on call last night. I spent the day dealing with a patient who had either a ruptured abdominal aortic aneurysm or a small bowel obstruction. Clinically this man looked great. I really wasn't worried about him. My main concern was the nursing staff that just would not be helpful. I was sabotaged every step of the way. I wanted abdominal xrays they wanted me to order them at bedside (not useful). I ordered labs, they cancelled them.

I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.

I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.

I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.

It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.

These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.

But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.

I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.

I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.

List management

Census, rounding sheet, list, rounds report, these are all names we have for the list that we print out every morning with all of our patients on it. Each hospital and each service within a hospital has a different way of managing that list. Some hospitals list nothing but room number, patient name and diagnosis. Others are much more extensive. My hospital prides itself on our list. We like to think of ourselves as pioneers in this one bit of data recording. Our list contains not just the basics, but what meds they are on, their vitals, ins and outs and diet for the last 24 hours auto populates every time you print a new list. Additionally you can add in any procedures they have had or that are planned for. You can type up a plan, put in notes for the cross-cover intern. You can stick in random details about the patient that you don't want forgotten.

Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.

1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?

That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?

I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.

For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.

And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.

Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!

Dr. Give-A-Crap

I'm on vascular surgery this month which brings with it a whole new patient set. These patients aren't adorable kids like in the world of peds surg and they aren't misfortunate like the burn patients. Well, sometimes the burn patients are a little stupid. I mean, really what kind of person burns trash with gasoline? Gasoline doesn't burn, it explodes. But, I digress. The vascular patients are a whole new breed.

For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.

Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.

And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.

I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.

Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.

So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.

There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.

And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?

It takes a toll on you.

As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.

I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.

It's not a pager, it's a leash.

My last few posts have been kind off depressing. I don't want all of you out there (you know, the 2 people that read this thing) to think that my job is just one depressing event to the next. And, I don't want to dwell on just the sad stuff either. I see older residents who are angry and bitter because they can't get past the sad. When something good happens they can't enjoy it because they are so jaded. I don't want to become that kind of doctor and I don't want you all thinking that that's the way it is either.

Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.

1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."

Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.

Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?

Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.

Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?