Sitting in front of me, alert, oriented, and chatting away on her cell phone was a patient I treated the Friday before.  I saw her last week when I was working triage on the Labor and Delivery floor.  She was high as shit and annoying the piss out of me.  She was complaining of leg pain but wouldn’t answer any of my questions.  It was an imposition that I needed to know about her leg pain, that I needed to know her medical history, and that I not only did I need to know her daily dose of methadone I needed to know what other drugs she took today. I lightly touched her leg and she started wailing uncontrollably and making a scene.  While everyone else on the floor was freaked out about this, I actually felt like I was at home, in my element back in the ED. She is status post c-section, post-op day 8, and is boarding at the hospital because her baby is withdrawing from methadone.  At this point I am tired, annoyed, and have about a million other things that needed to be done 20 minutes ago.  The trouble with this though, as an emergency medicine physician, is that as much as people piss you off, and as much as you think they are full of shit, people can still be sick.  This woman was recently hospitalized, had recent surgery, is an IV drug user, smokes cigarettes (all risk factors for a deep vein thrombosis), and is now having unilateral lower extremity pain and tenderness (which may or may not be real). Those of you who read this blog who are in the medical field (none of the three of you), will understand this: I recommended a lower extremity doppler to my attending.  He, who had the benefit of knowing this patient well (perhaps there’s something to be said for continuity, or maybe just experience), nodded politely at my “emergency medicine” work-up, and discharged her with some Tylenol.  A week later on that bus she was still annoying me but I was relieved to see she was not tachypneic, DVT and pulmonary embolus free.

On that same bus ride, sitting directly next to me was another lovely gentleman I ran into two weekends earlier.  Two weeks prior he was asking for money on the subway.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.”  There was no response from the passengers and next thing I know he’s making a scene, screaming, swearing, punching the walls, and scaring the crap out of those from whom he was just begging for money. Before my experiences working as an intern at the hospital where I work I think I probably would have been frightened, or maybe felt bad for not giving him money. I think it’s also important to note, however, that I know this guy.  During my first month as a doctor I saw him come into our trauma bay two times over the course of one twelve hour shift.  The first time he left angry and AMA (against medical advice) as soon as he was able, the second time he was admitted for a heroin withdrawal. During his outburst on the subway I was neither frightened nor felt compassion for his plight. Mostly because he turned into a jerk and started scaring people. Needless to say, yesterday the same dude, in the same red sweatshirt, hopped onto my bus.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.” And as luck will have it, there was a seat open right next to me.  I was about to get a bit nervous, I didn’t want to be between him and the window when no one offered him money.  Luckily, there was a nice gentleman with one of those classic heroin toothless smiles (who also looked vaguely familiar) in the front of the bus who gave him five bucks.  My buddy in the red sweatshirt got off at the next stop.

And then, no joke, toward the front of the bus on the right there was another familiar face.  It was an overweight 28 yo male who I have treated on numerous overnight shifts.  He lives in a shelter and has a multitude of mental problems and likely a very low IQ.  He abuses the system, but has no idea what that even means.  He likes coming to the ED.  We give him sandwiches and we’re nice to him.  Last time I saw him it was at 3am because he had a cut on his foot.  It wasn’t infected, though with his lifestyle and medical history, it easily could have been.  It was just a little cut.  I cleaned it and gave him a band-aid and wrote him a doctor’s note so the shelter would let him back in at such a late hour. Twenty minutes after he left I called the shelter to make sure he arrived, it was a slow night.  I walked by him on my way off the bus and we made eye contact, there was no recognition on his part.  And I’ll probably see him again next week.

Oh how I love taking the bus.

Thus far I’ve spent 2 months in the ED, a month in the MICU, and am now finishing up my month on OB.  All four months have been utterly exhausting. But I can’t believe how much I’ve changed in such a short amount of time.  You really only realize it when you compare yourself to the med-students.  Once every few days, for survival purposes, it’s necessary to listen to them present on rounds and realize that you are not the total asshole that everyone else makes you feel like. You’ve actually come a long way. God I love med students, especially the third years.

Intern year sucks and there is no way around it.  Sometimes I wonder how anyone makes it through, and then I realize that everyone makes it through.  It’s a year of being perpetually tired, shit-on, abused, uncomfortable, and anxious.  That being said, I’m at an amazing program, working with awesome people, and I see  fascinating/hilarious/upsetting stuff on a daily basis.  As much as it sucks, and as much as I complain, I really do love what I do. I love what I’m learning, I love my crazy-ass patient population, I appreciate the strange group of people that are drawn to emergency medicine in one form or another, and I most of the time love the raw emotion that I get to be a part of every single day.

Well, not really, but I was one year into medical school and decided that medical school was an incredible, wonderful, soul-crushing and terrifying experience and that I needed an outlet.  That day, on that first post, I wrote about three promises I made to myself: 1)stay normal, 2) do not become a crazy bitch, and 3) do not turn into a goblin.

Three years have passed, Dr. French Fry is all grownz up.

Tomorrow I start my residency. Tomorrow I  become an intern.  FuckShitFuckCrap.

On the eve of this horrifying day I am going to amend these promises:

1) Stay normal.  Sometimes I think of medical school as a dark brown smelly slop of quick sand.  If you are not watching where you walk you will take one big giant step into a pile of shit that will straight up swallow you.  You will either never emerge, or if you do you will return to the world entirely unrecognizable.  Since complete avoidance is impossible, I spent four years of my life trying to make sure I didn’t blindly fall in. I tried to keep my ties to the real world and when I got about waist deep I was usually able to tug on them to bring me back.  The verdict is still out on whether or not this was a wise decision, but I managed to get the residency I wanted while continuing to lead a somewhat “normal” life.  I fear this will be harder to do in residency, but I’m gonna give it a shot.

2) Do not become a crazy bitch.  Well, I am going to do us all a favor and combine this with #3, do not turn into a goblin.  I will not turn into a goblin if I am able to sleep.  Likewise, I will not become a crazy bitch if I am able to sleep.  I am going to, against all odds, get some goddamn sleep this year*.

3) Write.  I am going to need an outlet. I am going to have some good stories.  I am going to make an effort to document my experience.

* I should probably apologize in advance for turning into a giant crazy goblin bitch.

Deep breath.

It all started with the innocent little ding of the seatbelt noise on the airplane.  “Any medical personnel on board, please ring the call bell, your help is needed at the back of the plane.”  Before I had time to decide whether or not I was actually the medical personnel of whom they spoke, my friend in the seat next to me had already rang our call bell, forcefully, four or five times.  Well, I am sure there’s a doctor on the plane, I’ll just go back and see if I can help.

I trail a woman who says she is a nurse to the back of the plane.  When we reach the galley at the back I notice three things: 1) there is a sweaty man lying on the floor; 2) the only two people who have responded to the request for help are me and this nurse; and 3) I am sweating and after that long walk to the back of the plane my face is certainly bright red.

The flight attendant looked at me, are you a physician?  No, I am a fourth year medical student (yes, I emphasized those words), can you tell me what’s going on?

I crouch down on the ground next to the man, ask him his name, and introduce myself as a fourth year medical student.  “Bruce,” he responded.  Okay good, I thought, airway intact.  I did a quick survey, breathing is fast but unlabored, radial pulse is 110 and strong.  Determining what appears to be immediate stability I continue with questions.

And so this, organized as a medical HPI (history of present illness) as I might present to an attending, is what we were able to gather:

50 year old man with a past medical history of asthma and high blood pressure is presenting with shortness of breath. The shortness of breath started about five minutes prior to presentation while sitting in his seat on an airplane, shortly after the initial symptom he felt as if there was mucous stuck in his throat.  This made him aware of his breathing, which subsequently made him extremely anxious with associated feelings of imminent death.  He was diaphoretic, lightheaded, and noted a tingling in his fingers.  He denies chest pain, back pain, nausea, vomiting, loss of consciousness, or numbness anywhere in his body.  He has no history of diabetes, his last meal was breakfast, he had only water on the flight, and took his daily hypertensive medication this morning as scheduled.  His asthma is well controlled, he uses his rescue inhaler one every 3-4 months.  He had one panic attack, one year prior, that felt similar but not identical.

The nurse mentions that she has a prescription for clonazepam, an anti-anxiety medication.  She asks me if she should get it.  Umm, why are you asking me?  I’m a med student.  And why is everyone is looking at me?  Oh. Okay I get it. I am making this decision. I racked my brain for any contraindications.  If this is cardiac clonazepam won’t hurt.  If this is neurologic clonazepam won’t hurt.  If it is a panic attack it will help, shit, even if it’s not a panic attack it will help.  There are no contraindications with asthma, and in this situation with such a low dose I’m really not worried about respiratory depression.  Is there anything else I should worry about?  Fuck Shit Fuck. “Okay, go get it,” I respond. She returns and shows me the bottle.  I nod.

Twenty or thirty minutes have gone by and I crouch back down by the man lying on the floor.  “How’re you feeling, Bruce? Any changes?” “No, feeling a bit better,” he responds. But he looks terrified and his legs are trembling. I tell him that it doesn’t appear that anything acutely dangerous is going on and that I think he is going to be okay.  Most likely this is a panic attack, but with the resources we have there is no way to know for sure and that I want him to go to the doctor when he gets home.  “I am so embarrassed.” Don’t be, I tell him.  I had a panic attack before and I felt like I was going to die, it’s a real and seriously scary feeling. I explain to him that if anything changes, if he starts having chest pain, if he starts having more difficulty breathing, if he feels numb anywhere, I want him to tell me or the flight attendant immediately.

We all stand around for another while, watching Bruce, checking his vitals, trying to think of things to talk to each other about. His pulse is down, his BP is down, he is looking much better. The nurse heads back to her seat. Slowly I start feeling like my old self again. I am left with Bruce and the flight attendant who asks me for help with the paperwork.  I help her fill out the presenting symptoms and vital signs and I see there is a spot to write down the name of the medical personnel.  I remind her, “You know, I’m just a medical student. I am not sure that counts as medical personnel?”

Agraphia: a modest proposal

One of my favorite bloggers covering an issue I am forced to confront in one way or another every single day I spend in the hospital.

35 yo  F 10 weeks pregnancy had seizure, similar to szs in past.

68 yo M with cardiac history here with chest pain, started this morning.

25 yo M sore throat.

Yes, boring. But today things took a turn toward crazy:

48 yo M felt the need to direct traffic today to keep the city safe, given orders by the dept of justice to direct traffic on a different corner.

24 yo F needs to get pregnant.

33 yo F has a painful rectum and can’t stop eating.

Really.  How can you not love this job? In other news, today instead of asking my patient if she has diabetes or hypertension in her past medical history I instead asked her if she has diapertension.  Yes, diapertension.

A while later he’s been moved into a room and I arrive back with the suture kit.  Now there is a dirt covered, young, white man in the room with him.  My patient’s employer introduces himself to me.  This man, no older than me, immediately (and with a lack of social graces) wants to know how long this will take.  I told him that realistically we have two more hours.  But for him, that just wouldn’t do.  Well, sir, your friend was in a car accident.  We’ve determined he doesn’t have any serious injuries but he has a pretty bad cut in a pretty bad place.  We need to do a slit lamp exam to rule out any corneal abrasions and then will need to sew him up.  By the looks of that cut the suturing alone could take over an hour.

Yeah but he still doesn’t understand why it will take two hours.  Two hours at minimun, I reminded him.  ”Okay, but see,” (and he lowers his voice) “I’ve got a van outside full of five guys  outside,” (he glances over to my patient), “and there’s no AC.  Can you ask whoever is in charge if he can speed the process along?”

Um, really? You have a van outside with five men in it with no AC? Are they locked in? Aren’t they adults? Might they step outside for some fresh air? Must be a completely legal and humane operation you’ve got going on. And b.t.w., I am in charge of how long this process will take.

At this point another med student walks into the room, he’s checking to see if I need any more materials.  The boss looks at him.  Oh hey doc,  how long you think it’s going to take you to do this?

As I secure knot number two Mr. Bossman decides to confide in me about how he once sewed up his knee with no anasthetic.  Good work, buddy, you must be really tough.

Suture number three I ask my patient if he’s feeling anything.  ”Feeling any pain? Need some more pain meds?” Mr. Bossman feels the need to translate for me, “Hey buddy, hurt-o?”

Listening to the conversation next door I advanced another suture through my patient’s lower eye-lid.  Mr. Bossman, who was hovering over my every move, was apparently eaves-dropping on the same conversation.

… and do you take any medications at home?

AT HOME? YES! OF COURSE I TAKE MEDS AT HOME.  AND I LIVE WITH MY STINKIN HUSBAND. TWO OF MY FIVE WORTHLESS KIDS, FIVE GRANDCHILDREN, TWO DOGS, AND ONE CAT.  AND A SON-IN-LAW, EFFING JERK.

… okay, I understand.  But can you tell me what medications you are on?

YOU THINK THAT’S YOUR BUSINESS? I CAN’T BREATH. WHO ARE YOU? YOU ARE A DOCTOR? YOU ARE FIVE YEARS OLD. I WANT TO GO TO A REAL HOSPITAL AND I WANT TO SEE A REAL DOCTOR.

I have a smile on my face because seriously, how can you not get a kick out of this stuff?  By the pattern of her speech I can tell this woman is having no real difficulty breathing and I know the resident in the room next to me is having the same thought process. I am curious to see how this conversation will play out and to see how he will manage to gracefully worm his way out of her room.  I sense my patient’s employer looking at me.  Apparently he thinks we’re good friends now.  ”Wow, you must see all kinds of assholes in this place.”

I secure the last knot and  don’t bother to make eye contact. “You have no idea.”

My attending said to the resident, “you’ve done enough of these, right?  Right.  Okay, then let the med student take a turn.”

My pulse rate doubled.  Shit. And so I reluctantly turned to the scrub nurse, “Scalpel, please.”

Scalpel in hand I sliced through the skin and into the fascia, trying to hold my hand steady and maneuver a straight line.  At first I was too shy, “Come on, med student, CUT.”  But as I neared midline I had the hang of it.  Not bad, I thought, and found myself secretly hoping the procedure called for another incision.  A number of steps later we’re through the rectus sheath, pulling in either direction on the rectus muscle, and there it was, the uterus.  Inside that ball of a compartment is a tiny little human being.  The resident made the cut through the uterus, fluid gushed and spurted, and we saw the head.  Well, I guess they saw the head.  I saw fluid and smooth surfaces, shiny surfaces, dark surfaces and blood.

Extracting the head out of the uterus took some muscle.  I applied fundal pressure on the upper abdomen while the resident pulled.  And finally, a baby. I was so wrapped up in things I forgot to notice whether it was a boy or a girl.

I was sweaty and tired and ready to de-gown but looked up and realized the abdomen was still wide open.  Oh right, not finished.  We pulled out the uterus and plopped it on her abdomen.  Oh hello, uterus.  Wait, what? Really? This is how we do this? Through the blood we stitched it back together and shoved it back inside so we could could start putting her back together, layer by layer.  When we got to the rectus sheath, the only part of the procedure in which the sutures are proven to make a difference, the attending handed me the needle and pick-ups.  Shit.  Okay, I guess I’m gonna sew this up.

Once again, my hands were shaking, my mask was foggy, and by this time I was wondering if they would make fun of me for sweating through my gown.  I was taking my sweet old time (because that’s all I’m capable of at this point) and everyone in the room (scrub nurse, circulating nurse, anesthesiologist, attending, resident) was willing me to hurry-the-f-up with their pissed-off glares.  Sorry guys, I know it’s 2am, did I mention I have never done this before?

But I did it.  I cut her up and sewed her up.  And she got a little baby girl.

To the scrub nurse: “Suture scissors, please.” The resident cut suture 1cm above the knot. “Needle down.”