Tuesday, April 08, 2008

Pages From The Dark Side

There are many reasons why I have disappeared (see below for a more serious account). Yes, there are many. I could go on and on (and on and on) listing all these reasons, a diatribe on intern year...but I feel like that's been done before (see House of God), and I'd hate to shamelessly rehash material that has already been discussed ad nauseum. After 9 months of some of the hardest work I have every done, often under utterly absurd circumstances one could only describe as Kafka-esque, I have emerged. In other words, the last nine months have been a total shit show, and I've been just too freaking tired to do anything other than work, eat, poop, and occassionaly sleep. So, umm, sorry?

But with clarifications in mind, I thought I'd touch on one of the biggest parts of my intern life: my pager. Back in medical school (about 86 years ago, or so it seems), I touched briefly on the fears I had about receiving my first pager, even then sensing that something rotten lurked underneath that plastic shell. Two years later, wrought with many a prank page from the likes of Dr. Jablomie (first name Haywood) and Dr. P. Tang, I actually developed a soft spot for my pager as a form of divisive medical student entertainment. After all, when you are a medical student with zero responsibilities and a lot of free time to screw around with an electronic toy that all your friends are also carrying, life is good.

But then this year happened.

Like the cigarettes and lighter rammed up one of my more memorable patient's rectum (I’ll let you decide if I mean that the patient himself was memorable or that it was the unique qualities of his rectum that emblazoned themselves in my brain - I already know you're going with the latter), I have been subject to what amounts to a pounding of putrid pages that would make the most sane of men crack. (Was the "rectum" and "crack" in the same sentence shtick too much? It's been so long, I have a lot of things to flush out of my system...OK OK, I'll stop. Woo!) So, naturally, I would like to celebrate the best pages of the year, and what better way to do so than to hand out all sorts of awards that make no sense.

(By the way, what follows in no way suggests that we interns don’t contribute our fair share of complete incompetence that royally pisses off our nursing and pharmacy colleagues, because we do all sorts of stupid things that make their lives hell, things that I am sure I will touch upon in the near future. So I hope I do not offend anyone, specifically health care personnel or people easily offended by poop jokes - of which I predict there will be many - as it has already been established that the intern is the lowest form of scum known to man.)

Outstanding achievement in complete horseshit goes to…the 3 AM poop special
Picture it: It’s 3:00 AM. You have been working since 7 AM the day before, tirelessly, sometimes helplessly. You have finally finished up all your work and are just about to crawl into the stinky, steaming call room for a glorious 2 hours of sleep before you have to run around like a madman seeing all your patients before morning rounds. You lie down, close your eyes, start to dream about – ah shit, your pager just when off. You call back and are greeted by a cheery night-shift nurse, who poses the following question regarding one of your long-term players:
“Umm doctor? Patient _____ has not had a bowel movement on my shift and needs more meds for constipation now.”
Seriously? I mean, seriously? You’ve got to be kidding me. After nine months gentle restraint, I’m letting it all out right here, right now: PEOPLE DO NOT CRAP AT 3 IN THE MORNING, SO STOP PAGING ME ABOUT THIS!
Wow. I feel much better. Actually no I don’t. But I just cannot fathom why any rational human being would be compelled to think the middle of the night is the time to evaluate whether someone needs to drop a deuce. If anything, you’d think it would be more page-worthy to inform me if someone was dropping the kids off at 3 AM, because I’d want to start eating whatever they are eating as I bet it’d make me feel a lot better.

Best unintelligible performance goes to…*239
This page beat out some of the other contenders (namely, 33011053 and 2) for reminding me that people generally aren’t just stupid, they are also stupidly persistent. Imagine you’re me (sorry!) for a moment and you get a page that reads “*239”. Knowing that your hospital functions on 5 digit extensions and that your pager functions on 4 digit extensions, you disregard this page as an error on the hands of the person that pages you. Except 2 minutes later you get another page that reads “*239”. And then another. And another. And then you start getting paranoid, wondering which one of your patients is coding without you knowing about it, all while getting another three pages that reads exactly the same as the first. It isn’t until two hours later that, while walking down the hall, you run into the cardiology fellow, who cusses you out in front if your peers for not returning the five pages she sent you. It is also about that time that you realize your life sucks. Ladies and gentlemen, intern year!

Outstanding effort in existentialism goes to…the insulin form pages.
What follows is a roughly verbatim transcription of a telephone conversation I had with a nurse at around 3 A.M. regarding a two page insulin form (one page for when a patient is eating, another for when not eating) at my hospital:
Me (sleepy): “Hello?”
Nurse: “Umm doctor? Can you please come up and clarify insulin form?”
Me: “Now? Seriously? What’s wrong with it?”
Nurse: “The two pages have different times at the bottom.”
Me: “Well ya, because you made me fill out the second page 3 hours after I filled out the first even though the patient never actually needed the second page in the first place.”
Nurse: “Yes well they have to be timed at the same time.”
Me: “Why?”
Nurse: “Because otherwise they do not match up.”
Me: “What does that mean?”
Nurse: “They do not exist unless they match up.”
[I should remind you that we had this conversation on hour 22 of my 30 hour shift]
Me: “What does that mean?”
Nurse: “What do you mean?”
Me: “How can it not exist, I filled it out with my pen!”
Nurse: “It cannot exist if it is not filled at the same time.”
Me: “So nothing exists unless it occurs at the same time?”
Nurse: "What?"
Me: "You're telling me that these forms don't exist, that my writing doesn't count, unless they exist at the same time right?"
Nurse: "Right, they don't exist because they are timed differently."
Me: "So if they don't exist, I never filled them out in the first place. How could you be calling me about something that I never did?"
Nurse: “I don’t understand – you come fill out form now OK? Bye!”
Click.

Best attempt at unintentional comedy goes to this text page:
”Doctor, patient _____ reports that he fell out of bed last night because of the ghosts and goblins in his room. Pls call to confirm. Thx, RN”
OK maybe it’s not so funny now, but I got this page at the tail end of a 30 hour shift and it seemed like the funniest thing at the time. But I’m not sure what’s more ridiculous, what the patient told the nurse, the fact that the nurse felt like text-paging me about it, the fact that the nurse thought the information was so important he wanted me to call back just to make sure I got it, or the fact that the only thing the goblin in my room keeps telling me is that I'm paler than he is. Just making sure you are paying attention.


Outstanding achievement in clarification goes to…the All-Caps Pharmacist:
“ATTN: RE PT _____, PLEASE CLARIFY ROUTE FOR COMPAZINE SUPPOSITORY, CANNOT GIVE MED UNTIL CLARIFIED.”
(I should remind you that these are all real pages I have received.) Yes, I would love to clarify the route for that suppository. In fact, why don’t I walk over to the inpatient pharmacy and just show you where that suppository is supposed to go, but instead of a suppository how about I use my pager instead? Hey, I’ll even set it to vibrate for you. And while I’m at it, this pharmacist must be the last person on Earth to know about that whole caps = screaming rule that everyone else learned in some shady Internet chat room with their dial-up modem 10 years ago. What's next, is this guy going to tell me to start buying my pet food on the Internet? (By the way, does anyone miss the crazy buzzing sound those things used to make when logging on? No one? OK I guess it was just me.)

Best performance in shorthand goes to…the Night-time Telemetry Tech.
At the beginning of my cardiology rotation, I started receiving all sorts of pages from one of the nighttime telemetry technicians (the folks who took at patients heart tracings and inform us if anything bad is going on) that would generally read something like “GMD, VTx3 BTS for ACS PT”. It took me weeks to figure out that “GMD” was “Good morning, Doctor”, “VT” was “ventricular tachycardia” (OK that one was kind of obvious) and “BTS” was “beats.” Well, here’s my reply: “WTF? It DM, SPMWTC”. (Loosely translates to “What the fuck? It doesn’t matter. Stop paging me with this crap.”) And by the way, it’s not a good morning if you’re paging me about something that doesn’t matter at 4 AM.

Outstanding effort in night float angst goes to…bed 14.
Night float refers to the gloriously appreciated (cough) job of the intern who has to cover all of the patients over night (except for the admitting team’s patients), which usually consists of anywhere from 50 to 70 patients on any given night. Your job is to make sure that everyone’s patients remain alive through the night, fielding pages from nurses at all corners of the hospital in rapid succession about everything from the scary (“Hi Doc, patient hasn’t been breathing for about 2 hours”) to the mundane (“Doctor, patient's blood sugar is 120, what do we do?!?!?!”). However, nothing is more maddening than this page, which I have received in various forms about 800 times this year: “Umm…doctor? Patient in bed 14 sick. Please come.”
Bed 14 eh? No name? No team? Not even a floor? Let’s think about this for a second. There are roughly 7 patient floors at my hospital, each with two wings. Each wing has a room 14, and each room has two beds. Multiply that by the stack of papers with each patient’s information, and you get 458. Why 458? Because that is the amount of hairs that fell off my head trying to figure out who the nurse was referring to.

Wow. Well, it was a really exciting year for all the winners and the nominees. I hope the winners realize how lucky they are and, more importantly, how many months they have taken off my life. I look forward to yet another year fielding next year’s candidates for the most asinine pages of the year! Now if you'll excuse me, I have about fifteen pages to return.

Tired.

The easy, quick explanation for why I have waited so long is, quite simply, this one: I'm tired. Yes, the 80 (and sometimes more than 80 – shh, don't tell anyone) hour work weeks, the 30 hour shifts, the two week stretches without a day off…they’ve been piling up fast. So fast, in fact, that I only notice anymore by monitoring how soon I go to sleep. Let’s just assume for now that your average ridiculously handsome but still charmingly shy 26 (or even 27) year old heads to bed anywhere between 10:30 and midnight on any given night. In August, I was usually in bed 11 PM at the latest. By December, the occasional "in bed just before 10" was not that surprising. But now? I've caught myself crawling into bed at 8:30 PM, which basically makes the only non-work but still awake time of my life that glorious dinner hour and the four minutes I spend on the toilet in the morning (and just because I have no shame whatsoever, that four minutes used to be fourteen when I had more free time and could sit triumphantly on my throne, but now are only fourteen if I accidentally fall asleep while on the pooper).

However, there is more to this notion of being tired than what I have just described. Because, in all seriousness, this job has weighed on me so heavily that I have found myself beaten down, succumbing on a daily basis to many thing. Just tired...

Tired of the perpetual stress – of course every job has it’s stress, but I can only now grasp why the life or death aspect of medicine sprinkles in that extra pinch of chaos when compared to other jobs to make sure that, as the lowly intern, you are always one slip of just about anything (whether that be a needle or your pen) from killing someone.

Tired of the system – one of many systems where hyper-educated individuals are routinely thrust into a system that, at a local, state, and national level, is so beyond fucked up there is really no way to grasp the magnitude of it. But while inefficiencies in other fields may hamper your taxes, your business, or your local schools, it seems especially upsetting that inefficiencies in this system have killed, are killing, and will continue to kill on an alarmingly regular basis your grandmother, your friend, or even you. At least, as a once and future consumer of health care, it is upsetting to me. But to also know that some of the solutions are so simple (umm, national computerized health record please?) but so impossible to achieve in today’s reality for reasons beyond my control makes things all the more maddening.

Tired of the position – here’s where the intern-specific whining comes in, and yes I know that all of my superiors had it worse and blah blah blah I don’t care: being an intern has to rank up there with cleaning up the elephant poo at the zoo as one of the worst jobs on Earth. There is nothing quite like being caught in a tug of war between demanding attendings who require a long list of things to happen for a patient, nurses who actually have to do those things (take a deep breath…ok), and patients who half the time seem hell bent on refusing what we want to do but refusing to leave. Multiply that by 10-20 patients, 5-10 nurses, 2-3 attendings and 30 hour shifts…and then do all that while this thing attached to your hip keeps vibrating over and over again with new and different requests from any of the aforementioned parties and you’ll have a small idea of how painful intern year is for the schmuck intern caught in the middle of these forces. Something tells me I’ll have more to say about all that before this is through.

But mostly I’m just tired of the reality. Being confronted with society’s ills, in every sense of the word (because it turns out this job encompasses the literal medical ills, the economic ills, the social ills, etc., which is a lot more than what they advertise in medical school), on a daily and nightly basis is like (warning: over-used cliché alarm) being forced to push an immeasurably heavy stone up an unbelievably steep hill…only that the stone keeps getting heavier and the hill keeps getting steeper on a daily (or even hourly) basis. There is absolutely nothing more tragic to me than telling a sweet seemingly healthy middle-aged women that she has inoperable metastatic lung cancer to her brain, and then walking to the next room over and get cussed out by an otherwise healthy crack addict trying to abuse the system for pain medications, knowing that the former will probably never walk out of the hospital but the latter will keep leaving and coming back over and over again to abuse every last resource she can get.

It is this daily tragedy, unfolding before my eyes, that has been building up inside of me for the last 9 months, sinking me in and out of a mild depression each and every day, making it harder and harder to get any sleep at night, but forcing me to try to go to sleep earlier and earlier.

It is also why I have decided to start writing again…because for whatever reason, I feel better after writing about this, even if I’m usually not writing about why it is so catastrophically depressing all the time. If that means forgoing a bit of sleep to whine endlessly to myself, then so be it. Better than becoming so tired I cannot even function at all, I suppose.