My First

Buckingham Fountain in Chicago

I don’t remember my first patient. Not from medical school or residency or even private practice. It struck me when Linda Bethea of Nutsrok asked the question, that I have no idea who those people were at those milestones in my life.

What do I remember, then?

I remember being terrified. 

Was I going to make a fool out of myself? Would I misdiagnose something? What if they didn’t like me? 

There are many patients that I do remember over the years. They all taught me something. Even if I made a mistake. Even if they didn’t like me. Even if I didn’t like them. Even if I don’t remember their names or their faces now. Who I am today, as a physician and a person, is largely due to an accumulation of experience from all of them. 

So maybe I don’t remember my first. Or even my second. But maybe that doesn’t matter so much. 

I bet I WILL remember my last…

(Go check out Linda’s new book!)

Am I Dreaming Yet?

dinosaur hanging from the ceiling of the Field Museum in Chicago

It was 4PM. I snapped awake at the desk, looking around quickly to see if anyone had noticed my moment of weakness. 

No one was watching.

Relieved, I continued to dictate the patient’s discharge summary. As words tumbled from my lips, I realized they were not making any kind of sense. I stopped the recording and replayed what I had just said.

A bunch of gibberish.

I tried again, rewinding back further. Still gibberish. 

Fully awake now, heart racing, I trashed the whole dictation and started over again, jotting down a quick outline so my brain would not get lost.

My whole body ached from the fatigue. All I wanted was a bed. Nice cool sheets. A fluffy pillow. Maybe a soft blanket or two. Darkness would be nice but was not critical.

Then my pen started to laugh at me.

Wait. 

Was that a dream or a hallucination? After 38 hours of awake, I was no longer sure…

It was the very first hospital shift of my intern year of residency. I had never been up that long at one stretch before.

When people talk about how hard residency was, this is what I remember… the bone aching fatigue. When I was moving, things were better, so when I was on the hospital service I got into the habit of dictating and writing orders while standing up instead of sitting down. I think I got used to the sleep deprivation, if you can imagine. 

Resident work hour restrictions went into effect my last year of residency. Rather than coasting to graduation, letting everyone else cover call, I found myself covering intern and second year primary calls overnight at the hospital, filling in their gaps. My class worked much harder than anyone before or after us. We were caught in the middle.

Interestingly, while everyone believes work hour restrictions save lives, what they don’t realize is that it has increased medical errors from more frequent hand offs. When you go off duty, you have to check out your patients to the next physician. It is not possible to discuss in detail every event of the preceding shift, so you give a short summary. It is thought that the more frequent hand offs, increasing those lost details, has caused an increase in medical errors that cancels out the fewer errors from sleep deprivation.

So in the end, it’s a wash. 

Seriously.

Personally, I think the longer hours made me tougher, taught me that I could do and survive much more than I ever thought possible. It reinforced my work ethic. It exposed me to a lot more medical knowledge than I would have gotten otherwise. It helped shape me into the person I am now.

Does that mean we should go back to insane work hours? 

Not necessarily. 

Sleep deprivation clearly does increase errors, but that isn’t the only source of medical errors. We need to drill down on those. We need to figure out better ways to do patient hand offs. We may need to add a year to family practice residency in order to get the proper exposure, to ensure we are graduating solid physicians. 

I love that people are looking at these things more closely now, identifying where errors are coming from, but dang if we don’t move painfully slow on this front. Work hour changes in the U.S. went into effect over a decade ago…. Seems like we should have a better handle on this by now.

Calling Names

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Porter Girl, aka “The Juice” asked about my nickname.

I will tell you. 

My nickname is…. wait for it….

Code Red.

*gasp*

I know. It was given to me in residency. Makes me sound a lot more bad-assed than I ever was.

Why this name, you may ask?

First thing you have to know is that I have red hair. Is it real? Is it fake? I have posted the answer to that elsewhere. Do you remember? For this story, though, that doesn’t matter. It only matters that it is red.

The next thing you need to know about is hospital “Code” talk.

If a baby is stolen, it is called a Code Pink. Don’t worry. That didn’t happen very often…

If someone poops where they should not have, it is called a Code Brown. Interestingly when someone pees where they aren’t supposed to, we never called it a Code Yellow. I wonder why…

When someone was crashing in the hospital, though, it was called a Code Blue and was announced over the intercom. Everyone would run to the patient room announced with the code. The first doctor to get there got to run the code. CPR, intubation, and everything. I was a fast runner but those codes terrified me. I thought if I could get more experience it wouldn’t scare me as much. Didn’t work. It still scares the ever livin’ bahjeses out of me.

I had a reputation for being tough. No nonsense. Mainly that was because I could somehow find a common ground with some of the most difficult patients. Someone was making problems? They sent in Code Red. At times that meant cussing someone out. I was pretty good at that. I could do it in a nonthreatening way with a smile on my face that eased tension and made patients laugh. It was like magic. 

Sometimes it meant hugging or crying with someone. I was pretty good at that, too. 

More so it meant listening. I was extra good at that. Listen long enough and everyone will tell you what is going on.

Soon, the difficult patient was not difficult anymore. I am not sure anyone cared how I was doing it. They all assumed it was simply extra swagger and bravado. It wasn’t. I didn’t share my secret. It is good to have a reputation. But the truth was, I just really love prickly people. 

So there you have it. My bad-ass nickname.

It’s All An Act

colorful canal in Burano, Italy

“It is better to know some of the questions, than all of the answers.” – James Thurber

In medical school the first thing you want to do is look smart. Hell, that all any of us want no matter what our walk in life, right?

How to accomplish this while surrounded by 100-150 other brilliant academic and social high acheivers? This is the dilemma. 

My strategy was this:

Only ask second or third order questions and ask them only if you already know the answer. Even more importantly, know when to keep your mouth shut.

Here is the scenario:

You are a third year medical student assisting the most bad-ass vascular surgeon in the hospital during an abdominal aortic dissection repair. This guy is scary. He has kicked other students out of the OR for simply looking at him the wrong way through their face shields. You have to be on the top of your game.

The Prep:

You knew this was coming because you checked the surgery list before you left the night before, read all of the scheduled patients’ charts, and stayed up half the night reading up on everything in text books.

Over coffee on your hour long drive in the next morning before the butt crack of dawn (enough caffeine to stay awake but not so much that your hands shake… it is a fine line) you plan out and memorize your questions.

Act One:

As you are holding retractors, trying to keep the small intestine from sneaking over toward the clamps and bovies, you ask, “So this fellow had a 7.5cm aneurysm. That puts his annual risk of rupture at about 20-40%, right?” You don’t look the surgeon in the eye, though. Never move your eyes from the operating field….

“Yes…” Is his gruff, muffled response. He knows the game you are playing and can appreciate it for what it is.

He then starts to pimp you on the anatomy and you ace it. Thank you, Netter’s Atlas of Human Anatomy…

Act Two:

“Oh, shit!” 

You can see the aorta is dissintegrating in his hands. 

The scrub nurse stands up a bit straighter while the resident surgeon standing next to you kicks your ankle hard, shooting you a warning look as beads of sweat form on his brow. Your own heart is pounding.

Act Three:

The next several hours are tense. You don’t say a word. Your arms are killing you from hold the retractors so hard for so long but you don’t dare let go or even intimate by body language that you are in pain or tired. 

All of those extra questions you carefully planned out? You don’t use them. Instead, you keep your mouth shut because you know that at a time of crisis the last thing anyone needs is a showboating med student trying to make a good impression.

The Grande Finale:

The graft requires two re-sews. You are dangerously close to the renal arteries….

Somehow, though, it holds. No leaks. Everyone stands back and watches for a few minutes just to be sure.

Instruments and sponges are counted.

As a reward, you get to practice sutures. 

“Nice knots,” Dr. Bad-ass says as he looks over your shoulder after scrubbing out. The resident will handle it from here. “I am doing a bypass tomorrow. You are welcome to come hold a retractor.”

Yes!

Curtain Call:

It is well after 8PM when you finally get to your car only to find that you have a flat tire. You blink the tears from your weary eyes and swallow down the lump in your throat as you get out the car jack and tire iron and set to work. 

The universe has a perverse sense of humor.

As you are screwing on the final lug nut the OR scrub nurse drives past, rolls down his window, and offers to help. You decline, smiling to yourself as he drives off. You now have a witness that you, a girl, sat in the dark parking lot and changed your own flat tire.

Tomorrow you will be legend.

My Request:

Questions. Ask me a question. What do your inquiring minds want to know?!?!??? Silly questions? Thought provoking ones? I don’t care… Bring them on! 

Just please don’t ask for medical advice. And NO, you cannot send me a picture of that rash you have “down there.”

*If you have been with me for a while, you may have recognized this post from last year. I thought I would recycle it, hoping to get some blog posting ideas from your creative minds!

Their Fantasy

yellow flowers against a blue sky reflected in rhe water

When I was in residency, I worked hard to be more like the guys.

I played fantasy football. 

I cussed. A lot.

I learned to like scotch and cigars and golf.

Despite my best efforts, though, I was still always a woman. You simply cannot run away from the vagina. 

Fortunately, though, you can run away from fantasy football and cigars….

Over The Line

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A few posts ago I asked if male physicians ever had the same uncomfortable moments with their patients as I experience with mine

Here are a few stories I received from the male side of things but not all of them involve patients… 

“Once I did surgery on a local high school football coach. The procedure went well and I was writing the note outside the room. As the patient was leaving, he smacked me on the rear like I had scored the winning touchdown. I believe it was the highest compliment he could have given but I would rather he had not done it.”

“Some older female patients say things about me being handsome and dating their daughters or something like that but nothing too bad. Also some female patients say things like, ‘After having three kids I am not shy.’ Then they toss their gown off and parade around naked which I really would prefer they not do.”

“Occasionally some female drug reps will say some very, very suggestive things…”

“As a second year resident I did a study with our program director and we were going to present at a meeting in Chicago. The secretary was making the travel plans and she called and asked if I wanted separate rooms or to share. I said separate and that was the last I heard of it.”

“I have a couple of patients who refer to me as ‘good looking’ or ‘handsome’ in a way that makes me a bit uncomfortable.”

“When I was a resident, a nurse at the clinic took a liking to me. I went into the supply closet to gather supplies for a procedure. She followed me in and aggressively made a pass at me. I had to ‘escape’. Later that day she walked past me and pinched my rear. The attending saw it and gave me a lecture about staying away from the nurses despite my protestations that I was innocent.”

This last story reminded me of my own residency program. The list of new residents, complete with head shots, would get published and posted all over the hospital each July. No one cared about the lady residents but the men… The staff would cross out the photos of the ones that were married and drew hearts around the photos of the ones that were “available”. They became targets and were persued mercilessly and relentlessly while the administration did nothing to stop it except to lecture the male residents about how they interacted with staff, as if it was their fault. I know the male residents did not appreciate the attention and I felt uncomfortable as a woman just watching it. That was over a decade ago. I wonder if it still occurs….

Doctor Love

Chicago 115

The phone rang. I was off duty as of five minutes ago. Suck it, people! I looked at the caller ID. It was NOT the ER this time. 

I answered it.

“Hey! I got you something special….”

“Really?” I tried to hide the surprise in my voice.

“Yep! You’re gonna love it,” he promised.

I hopped into the car, heart swelling, and fantasized about that gift all of the way over from the hospital. What could it be? Jewelry? An antique of some sort? A rare book? 

He never got me real presents. But it was Valentine’s Day after all and he had been out of town at a specialty conference all week. 

Please let it be something nice!

When I arrived he proudly handed over the gift bag. It was navy blue and it felt heavy.

Not jewelry, then.

I tossed the white tissue paper aside and looked eagerly inside. A breath caught in my chest.

There were dozens of drug rep pens. A viagra tie. One of those squeezy heart shaped stress ball thingies emblazoned with the name of a heart medication. An out of state hospital system sports bottle. AND a flimsy looking vegetable peeler with a tag that made it clear it was some sort of lame marketing gimmick: “Peel back the fog, try our Alzheimer’s medication…”

I looked up to examine his face, searching for a clue as to whether or not this was a joke.

“Do you like it?” he asked, his eyes sparkling hopefully.

Not a joke. Dang.

“Um. How many girlfriends have you had before?”

“Why do you ask?”

“No reason…”

I grabbed the sports bottle and filled it with ice water, took a sip, then told him that I loved it all. 

He beamed. It was then that I understood. Sometimes the smartest men are the most clueless.

But that’s OK. You just have to love them anyway.

“Do you have some carrots? We can try out that veggie peeler…” 

The White Room

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“You have protein in your urine and your blood pressure is up very high. We need to go ahead and take the baby.”

I thought it would be a simple routine check up. I was going to go get some groceries afterwards with the food stamp allowance that just came yesterday. We ate canned beans last night, the kids and I. It was all I had left in the apartment.

My doctor sat next to me on the hospital bed beforehand, had me sign all of the consents for the C-section while they waited on my lab work. He said he would be there, assisting during the surgery.

He is too young. He still thinks he can save me, save the world. He asked me if he could pray for us… Pray? For me?

“Do you have a name picked out for him yet?” he asked, smiling.

I laughed. I actually laughed just a few hours ago. I laughed and said, “I will name him for you, doc, just make sure he gets here OK.”

Now, I want to tell them all to get the fuck away from me. Just bring me my baby so I can see him. Hold him. Touch him. 

I haven’t even seen him yet.

There is something in my throat. I try to pull it out only to have two nurses cry out and hold down my arms, tying them to the bed by the wrists.

Don’t DO that! I can’t hold my baby if you do that.

There is another doctor suddenly standing over me, a lady wearing blue scrubs. She has red hair. I don’t know her. The room is too bright, too white. It hurts my eyes.

“Your heart stopped and you stopped breathing. We had to put the tube down to help you.” She is so young. Too young. Where are the real doctors? “Everything is going to be alright but you are bleeding and we are having trouble stopping it. I need for you to stay as calm as possible. Ok?” 

I nod.

Having a machine breath for you is a terrible feeling. It reinforces the fact that you have lost all control.

Your liver is showing inflammation and your platelets are down….

The little doctor, the prick who did my C-section, is prancing around the room, fighting like a cock in a ring, trying to peck everyone’s eyes out.

Where is MY doctor?

I ask the lady doctor in scrubs if I am dying. My words are only ghosts formed around the plastic tube, no sounds. I can see how scared she is. She seems to understand. She tells me, “Yes, but we are going to help you.” 

I don’t believe her.

I can feel the blood gushing out from between my legs. I can see my belly getting large again, like having a second baby growing on video played in fast forward.

There is a somber gray haired man in the corner, standing with his arms crossed. I don’t know him but he looks like he knows something. “How many units now?” A pause while someone I cannot see calculates. “Fourteen.” He looks up heavenward and closes his eyes. “She needs more FFP.”

Do you think God loves drug addicts with Hepatitis C? Does he love their babies?

The red headed doctor is holding my hand. “It is going to be OK,” she lies. “Do you hurt anywhere?” 

I try to tell her around the tube that I want to see my baby but she cannot understand. Frustration turns to tears and I cannot stop them.

“She is bleeding it out as fast as we put it in.”

The rooster doctor is yelling threats from outside the room. Why is he so angry?

I want to go to sleep but I am afraid I won’t wake up.

“I won’t leave you. I’m going to stay right here. You keep fighting.”

Another lady doctor with long, black curly hair whispers something into the red headed doctor’s ear. I can’t hear what they are saying. She shakes her head solemnly and says quietly, “See if they can bring her baby. Tell them if he is stable to bring him right now.” 

Yes. Please! Please bring him.

I am so tired. The alarms are going off. A hand reaches up to turn off the monitor. Everyone stops rushing around. Silence. 

Everything must be OK, finally.

I close my eyes and open them. The room is still white. 

There he is, just beyond the door way. A nurse is holding him, wrapped in a blue blanket. My beautiful boy. I walk to him and brush his little sleeping cheek with my finger. My little boy.

The Power of Love

brightly colored zinnias 
When I was in training there was a woman who for many years taught every single resident to come through that program how to treat congestive heart failure.

She was the classic definition of a frequent flyer. She lived alone in a ramshackle motel on the outskirts of town. She had kids but they didn’t like her and never came around. I can’t say that we blamed them. She was mean as hell.

Each time, she would stop taking her meds and her body would swell …legs like giant sausages, lungs frothing, drowning in the excess fluids. You could see on her face that she was suffering and it was hard to understand why she did this to herself time and again.

Just take your frickin’ meds already!

We would admit her, give her IV Lasix, make her pee liters and liters over 3-4 days, and then send her on her way knowing full well that she would be back again in two or three weeks.

One late night, it was my turn. She had a reputation for being an ugly, hateful woman and I did my best to walk in with a Code Red swagger, guns blazing. This tactic worked for a lot of difficult patients… but not for her. Before I had completed my interview for her history and physical she was spitting and cussing and screaming at me to get the f**k out of her ER room. 

(In all fairness, that room had probably had been purchased for her by all of those previous visits so she was well within her rights…)

I decided to let her cool off and try again in a few hours before morning rounds. 

When I went back I decided I would try the sweet, perky lady doctor routine. When I bounced into the room she cracked one eye open at my cheerful greeting and grunted.

“I remember you,” she growled, told me to go to hell, then rolled over in bed with a few more loud grunts so that her back was to me.

“Look, you know the routine. This isn’t your first rodeo. I have to do this, so let’s just get it over with shall we?” 

I did a cursory exam as she riddled off expletives at me. She was a professional abuser and before it was over with, I was fuming.

I had let her get to me.

As we did rounds with the attending, she was sitting up with her bloated legs hanging over the edge of the hospital bed. She lit into me again, telling anyone who would listen that I had cussed at her (I might have) and had manhandled her (that part probably wasn’t true).

Finally, I had had enough. I let everyone go on ahead of me and I sat on the edge of the bed next to her.

“What do you want?” I asked her, struggling to keep the frustration out of my voice.

“Something you can’t give me.”

Was that a tear? My stony heart softened ever so slightly.

“Try my?”

She stared warily at me for a minute, sizing me up. Finally, she spoke. “I want someone to love me.”

I swallowed my pride. I put my arm around that woman and I told her that I loved her. Then, I told her that she needed a shower in a bad, bad way. 

She laughed. I laughed.

And that was the last we saw of her in the hospital. 

No joke. 

I saw her in the clinic every few months. She took her meds faithfully. She was not hospitalized again until 18 months later when she died of something completely unrelated to the heart failure.

She became one of my favorite patients and I miss her even now. She taught me that love, not swagger, gets things done. 

Memory Lane

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Traveling back to the city where I did residency is a surreal pilgrimage that sets my teeth on edge.

Is there anyone who really enjoyed residency, I wonder? There were things about it that I did not detest but mainly it was a thing to be endured.

Three years of hell to survive.

Just passing through…

Yesterday I drove past the house I lived in back then. I have vague recollections of it, like I do of the house I lived in until I was in fifth grade, but that vagueness is disconcerting. It was not that long ago was it? Seems those memories should be much more vivid. After all, I remember things at the hospital in great technicolor detail.

I’ll just drive around a bit, call it therapy.

They changed the color of the house and put up a new fence. I got lost in the neighborhood, the stores and buildings are not the same. The hospital is brand new, all shiny and sparkly. The old call rooms and ICUs no longer exist. It is disorienting. A feeling like those memories are no longer grounded.

Perhaps that is a mercy. 

I don’t want to run into any of those old attendings, my fellow residents, any hospital staff. I don’t want to travel back to that nightmare. When I am back in that place, it opens old wounds, brings back old terrors. I have left some of it here in this blog. Some of it I cannot let go of quite yet.

Are there places like this for you? Where? Why?