A Few Random Things

Sick as Stink

We eye each other warily, Mr. Kelso and I. His remaining leg dangles over the side of the bed as we face each other.

“So, Mr. Kelso, what brings you to see us today?”

From top to bottom Mr. Kelso is a walking pathology textbook. An impossible combination of signs, symptoms, and disease who is probably only alive because his many comorbidities haven’t decided which will have the honor of finally dispatching him. He balances precariously on the edge of the bed, the exertion of which makes his oxygen saturation dip to alarming levels. Life itself is exertion to Mr. Kelso who has not been off of oxygen for ten years.

He dangles his scaly, pulsless foot and contemplates my question as his dessicated, lifeless toes with the crumbling nails and open ulcerating sores brush gently against the floor. I wish, not for the first time, that the nurse had left his socks on. Medicine is for the living. There’s nothing below Mr. Kelso’s knee that could possibly interest me and the smell of a foot going to meet it’s maker is incredibly bad, like a combination of sweat and a dead dog on the side of the road.

“My doctor told me to come in,” gasps Mr. Kelso as he adjusts his gown stretched tightly against the impressive pannus which flows over his thighs like fleshy lava. He pauses to suck deeply from the oxygen mask. “I’m having a little trouble breathing.”

“When did it start?” I ask philosophically as I study the the totality of Mr. Kelso, already trying to think how I’m going to fit him into the inadequate confines of a note. I’d hardly know where to begin. From a review of his old charts I know he has most of the usual abbreviations including one or two I had to look up. It’s an exacerbation of something that’s for sure but in a guy like Mr. Kelso we need to consider the possibility of congestive heart failure, asthma, emphysema, all of them, two of them, or none of them. It could certainly be a pulmonary embolism. Maybe not fluid overload from kidney failure because he was dialyzed yesterday but who know?

Maybe he’s had another heart attack. The long scar over his sternum signals that Mr. Kelso is no stranger to a little coronary artery disease now and then. He has more bypasses than the New Jersy Turnpike, not to mention (an almost offhand comment on most of his notes) “Multiple Stents. ” (Because, you know, after four or five the exact number is just trivia.)

Mr. Kelso gapes and his eyes focus on eternity somewhere behind my head. Good Lord. He’s a going to arrest and he’s a “full code.” I briefly contemplate the logistics of getting him back on the bed and how we’re going to do chest compressions through at least a foot of padding.

But then he removes his mask, sneezes on me, grunts, wipes his nose on his sleeve, and gasps, “Yesterday.”

“What’s wrong with me, Doc?”

“Everything, Mr. Kelso, Everything.”

And yet, a guy like Mr. Kelso barely raises an eyebrow around here. He’s a little fatter, a little sicker, and a little more decayed than most but it’s merely a question of degree. I can walk through any floor of the hospital and see dozens of people in almost as bad shape.

My point? Nothing really. Just that I don’t think a lot of people are prepared for exactly what they will find in medicine once they finish first and second year of medical school. Even shadowing or volunteering as a premed probably will only give you a brief taste of what to expect. You will see sick people, of course, but the enormity of their bad health can sometimes only be totally appreciated by admitting or following the patient for a long time.

My second non-point is that one of these days we will be forced to change the paradigm of modern American medicine. Currently, we operate from a sense that all life is priceless and that no effort should be spared to preserve life regardless of the cost, duration, or the quality of what we preserve. This outlook is certainly understandable but as health care, like any resource, is scarce and becomes more scarce and costly the more it is needed we can’t on one hand bemoan rising health care expenditures and on the other blithely spend hundreds of thousands of dollars on largely futile care which extend the lives of completely non-functional people by a span of a few months to a few years.

People have got to die sometimes. Seems obvious but have we become so sheltered from death that the families of my many 90-year-old demented patients (who should be allowed to die in peace) have forgotten this?

Call Still Sucks

And it is pointless and inhumane. The fact that my attendings and every other resident for the last hundred years have done call is irrelevant and even if it was, I don’t care. I think the “old school” attendings with their stories of how hard they had it are full of crap anyways.

Times have changed.

Hospitals today are high throughput patient mills compared to the boarding hotels they were forty years ago. A point I want to reinforce to you guys is that “call,” something you will be doing for from three to seven years depending on the choices you make, is not “call” at all but “work” and just an extension of the work day. In fact, on many rotations you will work harder on call than during the day because not only will you admit patients for the other teams but you will have to cross-cover their patients.

And yet, you will run across even some of your fellow residents who think there is nothing wrong with staying up all night every fourth day and, even though they are being cheated out of most of the money given to the hospital for their training (approximately $110,000 per resident per year from Medicare), not to mention working in conditions that would cause the lowliest hamburger-jockey to laugh contemptuously, will spout the same stale propaganda that has been used to justify this sort of abuse or the last fifty years.

I am sick, for example, of hearing “Patient Care” being used as if it were the atom bomb protecting us against improved pay and work conditions. Ask for more time off? Sorry. “Patient Care Comes First.” More money? “Your Medicare Direct Reimbursement is used for Patient Care.” A few hours sleep on call? “Sorry, We Need to Think about the Patients and their Care.”

If Patient Care is so important than why not have the attendings sleep in the hospital, the nurses work for free, and never let anybody go home for any reason at all except for the sleep required to ward off psychosis. Obviously Patient Care Comes First only if you are a resident and only because the hospital has our gonads in its firm but benevolent grip. Whenever you hear “Patient Care Comes First,” check your wallet and put your back to the wall because someone is getting ready to sodomize you after picking your pocket.

So Does Residency Training

I shower, brush my teeth, and shave every day. This takes about five or six minutes (ten tops) because I have a short haircut, a good razor (Gillette Mach 3) and am not a metrosexual. I was on call a few weeks back and my senior resident became somewhat irate because I had “vanished” for fifteen minutes in the early morning hours and she couldn’t get a hold of me.When I said I was showering, she looked at me with contempt and said, sarcastically, “Must be nice.”To which the only response is something to the effect of, “I shower and shave every day because I am not a shit bag.”

It’s a little thing but the resentment towards me for taking a few minutes to attend to the basic business of life was far out of proportion to the offense. Can you imagine working at any other job where someone would resent something like this?

Another quick story: I was on call last week. I had been working solid since 0630 that morning. My pagers were going off almost non-stop. For the last several days I had been in the grip of a weird gastrointestinal bug. I could go about an hour or two between bouts and I was even thinking of asking for an IV and a liter of fluid.

Going home was out of the question. You can’t just say, “Hey, I’m not feeling well, I’m taking the rest of the day (er, night) off.”

It got so bad that I had to set up a little communications command post in the crapper with my cell phone because the pagers don’t stop and I had to answer them. Plus I was admitting patients from the ED to all of the medicine services which is a full time job that doesn’t let up until five of six AM. (I was off service from EM which means I am a receiver, not a giver…and it is indeed better to give than receive.)

Can you think of any other job where you would be expected to stay on the job, much less show up, if a physician (me in this case) determined you were so sick you needed IV fluids?

Housekeeping and a Plea for Help

I broke down and bought a domain and as soon as I figure out the intricacies of WordPress or Typepad (I haven’t decided which) I’m going to transport the archives and start posting on www.pandabearmd.com. I confess that I am intimidated by the thought of using HTML, loading WordPress, and screwing around with that kind of thing.

If anybody knows where I can get a free or reasonably priced WordPress or Typepad template for a blog of this kind please email me. The ready-made templates provided by Typepad (which seems to work better than WordPress) are pretty crappy. Hell, if anybody knows how to add a sidebar item which will let me add links to my current template which you will see if you click on my new domain, please email me. I will give you my password and maybe you would do it for me in repayment for the many articles I have written and which I hope you have enjoyed.