Agraphia Medical Tragicomedy

9Aug/12Off

Lunch Break

"Ah, shit," I mumbled to myself, "I forgot my damn lunch."

This is a bigger deal than you would think.  I get pretty nervous if I leave the ER for even a few minutes to grab food from the cafeteria.  Who's dying while I'm gone?  Sit down for a nice half-hour and enjoy the scenery? Forget it.  I haven't had a lunch break since medical school ended.

In fact, nowadays I eat like a wolf, which I'm pretty sure is not flattering.  As long as the calories can get me through the shift, I go for it as fast as possible.  This originally contributed to a 20 pound weight gain during residency... which I have finally shaved back off by cooking my own, healthy food.

And so, I come back to the saddening realization that my delicious salmon stir-fry is sitting at home in my fridge, and my stomach is all alone for the next 11 hours.

And then, "Hey man, I've got some food in the doctor's lounge upstairs if you want it.  I already ate.  If you're hungry, it's yours for the taking."  I swivel around to see one of the hospitalists at my new job.

Let us be clear - other physicians do not share food with ER doctors.  We're pariahs.  Persona non grata.  Veritable untouchables within the hospital hierarchy.  Every time we call, we add more work to the pile.  Every train-wreck nursing home admission, teetering on the border of life and death, comes from us.  Every medical mystery that I can't figure out - once "fun" and "interesting" is now just more work.    Shoot the messenger applies in full force.

But here was a wholly unexpected olive branch!  Not only was it great food, he didn't even poison it!  And his reward?

An unresponsive nursing home patient who was drooling all over herself.

Sorry, dude.  I really am.  But seriously, thanks so much for lunch, I was getting hungry.  I'll give you some of my stir-fry tomorrow if you're still talking to me.

Filed under: Medicine 1 Comment
13Jul/12Off

Alone

I'm not really sure what to do with myself right now.

My class of residents had our final dinner party last week.  There were some tears, lots of laughter, and some very earnest plans made for when we'll all see each other next.  The next morning, everyone left the city, leaving only a couple of us stragglers behind.

Over the past week, it has sunk in that for the first time in perhaps my entire life, I'm really alone.  I went straight from college to medical school and through residency, so I have never had a period of time where I needed to figure out how to be alone.  Sure, there were summers in college and (rare) vacations during my medical training, but for the most part those were spent with family or friends.

Residency is fairly isolating.  The hours are brutal, and especially in emergency medicine, unpredictable.  I have been fairly unsuccessful in keeping up a lot of friendships outside of the hospital, and for better or worse, my relationships have suffered as well.  My girlfriend - well, ex-girlfriend now - moved all of her furniture out of my house today, leaving indents on the carpet where memories once stood.

So, since residency ended, I have been not Dr. Zac, or a Resident, or a Medical Student, or a College Student, or any of the other identities I've assumed over the past 25-some years of school and training.

Right now, I'm just Zac, and that's kind of neat.  I guess I need to figure out who that is.

I start the next chapter of my life in a week.  I hope it's as interesting to read as it will be to write.

Filed under: Medicine 6 Comments
24Jun/12Off

End Of Another Era

And like that, it's done.

I walk out of the ER after my last shift, finished with residency.  It's an incredibly bittersweet feeling.

I've been in school for 23 years.  Elementary, middle, high, college, medical, and then residency.  I've been in training all of my life. For the first time I'm on my own.

I'll always have someone to ask advice from, of course.  My fellow physicians, nurses, patients, families.  But someone finally gave me the top degree, the final award.  I'm an attending physician.

It is liberating - and terrifying.  I no longer need to ask if I should bring someone into the hospital because of their mild chest pain.  Then again, I no longer can ask if I should bring someone into the hospital because of their mild chest pain.

I'm ready, I suppose.  A patient the other day had a serious blood clot in his lungs, and another physician asked me - colleague to colleague - whether or not she should give the patient clot busters.  It's a weighty decision. Given to the wrong patient, they die immediately from massive internal bleeding.  Given appropriately, a healthy patient goes from death's door to alive and well.  We discussed the benefits and drawbacks, and in the end I recommended the drug.  Right now, the patient is back with his family, sharing memories he might not have shared.

One of these days, I'll be wrong.  Perhaps it will be my failure to recognize the problem.  Maybe I will advise the wrong treatment.  One day, it will just be bad luck.  But from this point forward, it's me and no one else who will be responsible.

I look back now on 4 years of college, 4 years of medical school, and 3 years of residency, and ask myself if it was worth it.  I've sacrificed the best years of my life to this profession and to my patients.  The other day, one of our nurses saw my ID badge and remarked how much I had aged in only 3 years.  My girlfriend pokes fun of my grey hairs at the young age of 29.

Was it worth it?  I'll never forget the hard times.  To this day I remember almost crying tears of joy when I thought I was stuck in an elevator.  I've had so many good people die. I've had so many mean people live.  I've been so tired I want to cry, and I've been so hungry I've stolen food off of meal trays.

It's a wonderful, vicious, honest, angry, happy, unfair, and real life that I've lived.  I have seen the very best and the very worst side of people.  I have been spit at, cursed at, and punched while trying to help the very people that assault me.  I've been blessed by, prayed at, and thanked by more people than I can even count.

Is it worth it?

Yes.

Filed under: Best Of 15 Comments
10Oct/11Off

Water Poisoning

I had the most endearing interaction I think I've ever had today with a patient.  He was an extremely polite schizophrenic man who came in because he was convinced his water supply was being poisoned.

Me: What makes you think your water is being poisoned?

Him: Well, my girlfriend, she told me to drink less water.  She thinks I have too much every day,  so she told me to drink less.  I'm pretty sure she poisoned it.

Me: Why would she want to do that?

Him: To get me to drink less, of course.

The logical explanation lies with his past medical history; he suffers from a condition known as potomania - overactive thirst - which can cause significant electrolyte imbalances in the body with too much water ingestion.  The treatment is to drink less water; his girlfriend was actually looking out for him.

For a moment, I entertained the fallacy of his reasoning.  "Why on earth,"  I thought to myself, "would your girlfriend poison your entire water supply? This is the schizo talking."

Then, I thought back a couple of weeks.  In the middle of a particularly hectic shift I took care of an autistic kid who kept coming up to the physician's desk asking the same question over and over again.  "Can I get my medication refill now?  Please, I want my medication refill now.  Now? Now."  I finally lost my temper and snapped, "Listen, kid.  I'll get to it when I have the time.  Right now I have more important things to do than refill your meds."

I saw the hurt in his eyes and immediately regretted my words.  One of our child life specialists who I deeply respect pulled me aside and admonished me.  "Zac.  He's scared, it's loud in the ER and he needs help.  He's autistic and he's already out of his comfort zone.  I know you're busy, but don't lose your compassion."

Fast forward to today.  "Tell you what, boss," I said, "why don't I do a good physical exam and we'll make sure you didn't get water poisoning?"

"That would be great," he said, "I've been so worried."

I've been reading Cutting For Stone by Abraham Verghese, a physician at Stanford well known for his veneration of the physical exam.  Dr. Verghese gave an incredible TED talk about the powerful bond a careful exam creates between physician and patient.

So, finding myself with a few extra minutes in my day, I examined my schizophrenic patient in minute detail.  I tested for nystagmus, checked Romberg and Babinskis, carefully listened for the slightest of cardiac murmurs, and checked his ears for wax.  And, after a normal exam:

"Good news, I don't think your water was poisoned!"

His response was wonderful. "Doctor, thank you so much.  You've put my mind at rest.  It was going round and round like a carousel and I couldn't seem to get off the ride."

I suppose a physician's touch - even in a busy ER - is still a valuable tool.

Filed under: Medicine 14 Comments
1Oct/11Off

A Book, You Say?

I've written a novel!

Well, sort of.  It's been a longtime dream of mine to write an actual novel, so I did a bit of investigation.

On a whim, I exported my entire blog to Word. It comes out to exactly 197,748 words in length, excluding comments.  Wikipedia (as you know, this is my favorite source for 100% factually correct links) states that most novels are somewhere between 50,000-175,000 words in length. I figure that makes my blog a novel equivalent!

Incidentally, my last post was post #400.  Thank you, dear readers, for bearing with me for all these years.

Filed under: Book 5 Comments
26Sep/11Off

Book Reviews

You know your blog is sort of popular when publishers start sending you books to review.  Sadly, a lot of the books I've been sent have been... well, poorly written.

Sometimes they lack a distinct narrative.  Sometimes the author just doesn't know how to write.  Sometimes I find myself actively hating the narrator. Worse, I realize they are shitty doctors.  There is a huge gulf between most of the books I get sent and captivating novels like House of God or Complications.

Rather than selling out my physician writer friends (hey, it's not easy to both write and see patients) by writing scathing diatribes on every book I'm sent, I've just chosen not to review crappy books.  Perhaps one of these days something will come along that will so captivate my attention I recommend that you all read it.  For now, I suppose you'll have to put up with my blog.

In the meantime, publishers, keep 'em coming my way. I've got a veritable bookshelf of mediocre medical books.  More fuel for for my eventual masterpiece.  Yes, dear readers, eventually there will be a book by yours truly.  And none of this ghostwritten shit, either.

Filed under: Book 4 Comments
7Sep/11Off

Changing Roles

I'm really enjoying being a senior resident.  This month I'm mentoring our medical students, and it's been loads of fun so far.

Today we had a "simple" laceration that needed closing.  Typically this is the medical student's job, since the residents have traumas and coding patients to take care of.  I sent Medical Student to sew up the lac, but two minutes later he came out of the room, pale-faced and nervous.

"Dr. Zac... I took off this guy's pressure dressing and he's kind of... bleeding out from his wound.  Like, sort of spurting blood. Kind of everywhere. I think I need help."

I'm a pretty laid-back guy, but years of emergency training have instilled a GO switch in me.  I immediately popped in the room.  Sure enough, this guy was hemorrhaging blood from multiple severed arteries in his leg.  I grabbed Med Student's gloved hand and shoved it in the wound.

"You feel where that's pulsing?  I want you to keep your fingers right there and hold pressure.  I'll be right back."

There are varying degrees of emergency; this is one that can be fatal if left unchecked.  I ran out of the room, grabbing the necessary equipment and sutures.  Med Student seemed quite relieved when I returned.  Quickly I tied off the bleeding arteries while explaining what I was doing (throw your stitch under the artery, loop back around again, and tie it off.  This is called a figure-of-eight suture and it will save your ass in a pinch).  Within a minute I had the bleeding stopped.  Med Student appeared impressed.

Suddenly, it was a simple laceration repair again.  I supervised him closing the wound with little teaching points along the way, and to his credit, he did a fantastic job.  It will look great when it heals.

The patient's wife pulled me aside later.  "Doc, you really seem like a fantastic teacher.  We were both so reassured that you were there. Thank you so much for taking such great care of us!"

It was a great day, and it's been a wonderful month so far.  If the rest of my life is like this, I'll be a very happy physician.

26Aug/11Off

Command Center… ONLINE!

Our emergency department just switched over to a new EMR.   The transition has gone quite well - my charting has gotten faster and better overnight, orders are infinitely easier to put in the system, and I have more time to spend with patients.  All in all, I could not be happier.

One thing in particular stands out with sheer awesomeness.  We can make macros. For the less-technically inclined, macros are simply a way of automating something you do often.  For a computer nerd/engineering type like myself... well, I've made some improvements.

All I need to do is pick up the dictaphone and say "Computer, activate command center."  I then walk away and see my first patient.

Within seconds it boots up all of my patient records, EKG-reading software, radiology images, drug databases, and email.  Then it opens up another window and prints out:

"Command center online, Dr. Zac.  Have a wonderful day!"

It's really the greatest thing that's happened to me since... well, ever.

I have my very own HAL-9000!

Filed under: Medicine 8 Comments
26Jul/11Off

The Grind

Being an ER doctor isn't all fun and games.  Well, it's usually fun, and mostly games, but really we're at the mercy of the city and its drunk and dying denizens.  When two trauma 1's roll through the door at the same time, a scattering of chest pains and GI bleeders are still waiting to be seen in the back rooms, and the hallways are filled to the brim with gurneys... well, my heart rate starts to rise.

I enter autopilot, and start doing what I loathe the most - overtesting. It's what emergency physicians refer to as "moving the meat."  It's a term I hate, but when there are multiple patients needing to be seen - any of whom could be dying - and the department is bedlam, it starts to make sense.

Chest pain?  Check.  How long?  Describe it for me.  Risk factors for cardiac disease.  Labs, chest x-ray, pain control, next room.  In and out the door in a couple minutes.  Scribble on the chart, "typical chest pain story, patient appears well and in no acute distress, check labs.  EKG nondiagnostic, will evaluate xray for pathology and admit for observation."

It becomes formulaic at this point.  Patients with abdominal pain get "belly labs" and a CT.  Headaches get compazine/benadryl/decadron and probably a CT & spinal tap.  Traumas get "trauma labs" and a $15,000 full body CT scan to search for any hint of bleeding - it exposes them to approximately half the radiation experienced by survivors of Hiroshima.

My normally friendly bedside manner goes out the window.  I'll usually introduce myself, "Hi, I'm Doctor Zac and I apologize for being brief.  Unfortunately an SUV just overturned on the highway and they'll be arriving in 5 minutes, so I just wanted to pop in and see how you were doing."

I never yell, but I can be brusque.  Before residency, I would have never imagined myself to be the type to say "I'm sorry, I don't have time for you right now,"  but it happens.  At least I always say "I'm sorry" first.

I suppose it's part of being a feast-or-famine specialty.  We don't have the luxury of scheduling our patients.  It still leaves an unpleasant taste in my mouth when I don't feel like I can care for people the way they need to be cared for.  Especially when it means spending thousands of dollars of their money that I know they don't have, and delivering enough radiation to possibly cause cancer down the road.

24Jul/11Off

A Tax For Cigarettes

I saw a cardiac patient today; 3 stents, COPD, peripheral vascular disease... the whole 9 yards. While asking him my standard social history questions (smoke, drink, do any street drugs?) he hung his head low.

"Yeah, my doc tells me I gotta quit, but I can't get down to less than a pack a day."

It's something I hear all the time. I've talked to smokers who are crack and heroin addicts - they say that the nicotine urge is worse than any other addiction they've fought.

For better or for worse, patients seem to focus on the lung cancer aspect of smoking. I suspect it's due to a particularly effective ad campaign in the past few decades, but the truth is, smoking is far worse with regards to other diseases. Tobacco, whether chewed, smoked, or snu'ed causes a huge variety of vascular diseases.

I figure it should be easy enough to calculate the cost of a pack of cigarettes. Ask a random sampling of ER patients how much they smoke per day (we measure tobacco use in pack-years, i.e. the number of packs per day they've smoked times the number of years). Get permission to access their healthcare records, and calculate the differential in healthcare costs between smokers and non-smokers.

Take that differential, divide it by pack, and add it as a healthcare tax.  I support people's right to make bad choices; I also support their right to pay for those choices.

Your thoughts?