BRBPR... & hipsters

Today I realized two things:

1) BRBPR does not stand for "be right back, personal relations". It stands for bright red blood per rectum.

2) You can't spell PBR without BRBPR!

Hierarchies in Medicine

Despite my feminist background, I really do enjoy the hierarchy in medicine. Not because I think it’s helpful for anybody in the medical field, but because it makes sure there are checks and balances in patient care.

For example:

As a medical student, I have no idea what’s going on. Ever. In any given patient interaction, I will likely be the most confused person in the room. Even patient’s seem to know more about what’s going on then I do. But there’s a ton of reasons for this: my medical training is incomplete and, most likely, I’ve only worked at this hospital for a couple of weeks and I couldn’t find the nearest restroom or wherever they store tourniquets if I was offered enough money to cover my student loans.

But I’m not an idiot. I can catch errors. Very rarely I get to catch huge, major errors simply because I am the least busy person on the team. Like forgetting to order furosemide for the acute exacerbation of congestive heart failure patient. Really, it’s just an oversight. But I caught it and it changed management.

Doctors and residents are sometimes upset with me for not doing something or being “incompetent”, but it doesn’t matter, because I have an excuse: I’m an incompetent student. Whenever people give me criticism, it’s always in the form of, “One day, when you’re a resident/physician, you’ll be expected to…” which means that I’m not really expected to do much more than what I’m currently doing.

A Slave to One's Emotions

On a recent episode of The Daily Show with Jon Stewart, the guest was Michael Fassbender and he talked about his experience on the set of "12 Years a Slave." It's apparently an intensely emotional and raw movie adaptation to an actual book written by an actual person in the 1800s. Fassbender, who is hella white, plays a supporting role as the incredibly cruel plantation and slave owner. Of this experience, and how he dealt with having to pretend to be a terrible person for most of his days, he said this:

"I mean especially when you're dealing with such heavy material it's nice and necessary sometimes to have light moments in between so it doesn't become all the time heavy and you get [blinded]....
so the moments you can find relief and respite you do, and other times that require it, you stay in the moment as it were."

I think this quote describes how I deal with working in hospitals. You're surrounded by so much of what is disgusting with humanity: pain, deception, corruption, death; so much unabated suffering. On the one hand, I'd like to live in the moment and experience the pain my patients suffer with them. But on the other hand, if I did that with everyone in the hospital, I'd be so drained every day that I don't know if I could function. Both of my parents are hilarious--albeit in different ways (one's abstract, surreal humor; the other's just dark and sarcastic)--maybe that's the only way they survived medicine for the decades they sacrificed to it. 

But on the other hand, I'd like to feel with my patients so that I never stop working for them. When I turn patient's into little anecdotes, I stop caring for them. When I just stare at their assessment statement and their labs, I forget that they are people who may lighten if I go talk to them, who may benefit when I hold their hand. 

CURIOSITY//NO PRETENSE OF LINEAR THOUGHT//WHAT MAKES A GOOD STUDENT DOCTOR?

This is an interesting article suggesting that the best doctors are not the smartest or even the most "humane"... simply the most curious. It makes a lot of sense. One of my favorite things about medicine is that you are constantly learning. You have to keep taking CME courses to keep passing boards; you have to stay up to date with how disease management is changing so you can give your patients the best care; etcetera. Rosalind Franklin University's motto is specifically: "A Life in Discovery." You rarely make discoveries if you're not curious.

This was my favorite quote:

"Watching talks given by Nobel Prize winning scientists for inspiration, she noticed similarities in their ways of thinking. They all seemed to toss around ideas with no pretense of linear thought, no semblance of structure, and, perhaps most importantly – no pretense of competence."

http://blogs.scientificamerican.com/unofficial-prognosis/2012/03/08/what-single-quality-predicts-a-good-doctor/

This also reminds me of a conversation I had with my dad about how we had both learned a lot more from our medicine rotations than our surgery ones (my dad even told the head of the surgery department at the Feinberg School of Medicine (Northwestern University) that he didn't want to go into surgery because "surgeons don't know as much as internists.") In surgery you were either right or wrong, you studied on your own time. In medicine you can still be right or wrong, but you can also be close to right but not quite there yet, we're not standing over an anesthetized body and we've got the time so we're going to teach you right here right now. I love that. I love that I can think out loud and not be told that I am wrong but rather be told that I am going to learn something today. 

Besides that one day I showed up on 4 hours of sleep and severely hungover from a friend's Oktoberfest, I have learned at least one fascinating thing every single day of my rotation. 

Ode to my Intern

My intern is a terrible person*, but all in all, I think he's taught me a lot about how to deal with your intern year without completely losing your mind.

1) TAKE A LOT OF NAPS
You have a call day on the weekend and you're waiting to round with your attending in like five hours? Take a nap! Any surface you can lay down on is a surface where you can fall asleep. Direct quote from my intern: "Remember in preschool when you had those roll out sleeping pads and you had a twenty minute nap? They should make all the residents do that after morning report.

2) FIND HUMOR IN EVERY SITUATION... as long as you're standing far enough away from the patient's room.
Not going to lie, a lot of the cases we get in internal medicine are incredibly depressing. Any humor--even if it's dark--can be beneficial to one's (read: my) psyche. I am most impressed by the fact that my intern can make fun of any patient or any patient's situation, and then be incredibly, and sincerely nice to them when he goes to see them.

3) INDIANS PRONOUNCE THE WORD POTASSIUM WEIRD
Seriously weird. PO-TA-SHE-UM. Similarly they mispronounce Calcium and Magnesium. He was raised in America but still pronounces important elements like he was speaking... not Amuuurican.

4) BE A HUMAN BEING... and be humble
One of the things I was most worried about was how I would deal with being an intern. You don't know how to do everything yet, so sometimes you may feel incompetent, and you just finished your M4 year, so you may not remember everything that was on Step 1 or Step 2. But my intern just kind of rolls with the punches. I know he's learning a lot because he doesn't look anxious when he gets a question wrong, he just checks uptodate.com for an answer and proceeds to help out a patient. Also, my intern (and actually a lot of residents) goes out and/or spends time with friends. Not a lot of time, but he spends his off time having fun or sleeping (the two most important free time activities).

I am incredibly sad that I will have to leave this rotation. It's been great: learned a lot, laughed a lot, slept enough, I could not have asked for a better rotation.

Figure 1: Intern and I passing out during our post-prandial states

*His ideal patient is between the ages of 15 and 35, who is educated, and who has insurance. Good luck finding them!

star trek is actually the greatest teacher

When I was an M1, an M4 was trying to do a research project on how Star Trek could be used to teach medical students about bioethics. At that time, I had barely finished watching all of Star Trek The Original Series and Star Trek The Next Generation. Within the last month, however, I finished watching all four of the widely accepted spin-offs (I know Enterprise is cannon but everyone keeps getting so angry when I bring it up!), and as I walk around the hospital I find myself wondering what life would be like if I was instead on a starship or asking myself how one of the four doctors would have chosen to deal with my current dilemmas. 

So in honor of them, I made this art:

What's Death Got to Do With It?

I realized something today while I was hypoglycemic at 63 mg/dL and more susceptible to fear: I am absolutely terrified of death. Not that that is something new. When I was nine I watched a movie about time travel while vacationing around Mesa Verde, and I realized, at nine, that one day I would die and all my accomplishments would account for naught. More than that, I realized that an eternity of total, unyielding unconsciousness was something I never wanted to experience but something I one day would. I, personally, do not want to die. Besides the fact that I engage in a lot of moderate risk behaviors, I do not want to die. I have been suicidal twice in my life, and those events were partially fueled by untreated depression, but they were mostly fueled by my previous realization that one day I will die and everything about me will mean nothing. 

Besides the soul-crushing nihilism surrounding my personal future death, I am also reaching the age where the people I know and love are starting to die. Yet still these deaths are mostly accidental… I feel a great amount of guilt for the deaths of people close to me… those that have stolen people who are related to me by blood in particular… but I cannot change what I did, and ultimately, even though I failed to do things that may have prevented their deaths, their lives were not my responsibility*. 

Now that I am in medicine, lives are very much my responsibility. I have a feeling that this is the source of my fear. I have always been a very good liar. I sometimes attribute this to the fact that I am a natural fiction writer, and therefore I am more readily capable of producing fictional realities in my mind. But the reason why I lied when I was little, and the reason why I occasionally lie now at the age of 24 is because I do not want to let someone down… I do not want to fail.

As a result, when I encounter a patient-doctor situation where the patient might be dead, I run back to my resident and make up reasons for not seeing the patient. I have two examples of this behavior:

The first example occurred when I was asked by my team to inform a suicidal patient that he wouldn't be able to leave the hospital until he was admitted by psych and evaluated for several days. I went to the patient's room and found it empty… But all suicidal ideationists have to have a 1 to 1 sitter, someone with them at all times…. yet here was a hospital room completely devoid of people…. although the bathroom light was on… and it occurred to me that this patient of ours may have hung himself on the water line that connects to the shower head… or cut open his veins, letting the blood pool out from around his wrists, only to let is fall on the brown tiles that constitute our hospitals bathroom floors. WHAT I WISH I COULD HAVE DONE would have involved knocking on the door, and upon not hearing a response from its occupant, opening the bathroom door to see if any dead bodies were mucking around. If a dead person had been found, I surmise I would have run out into the hallway and yelled "HELP", forgetting how to present patients to healthcare professionals.

The second occasion involved a patient with chronic hypotension. My intern instructed that I run to check the patient out--ask about dizziness, measure blood pressure, assess any changes in mental status--but when I got to the room the patient was fairly unarousable… he was asleep. I knocked several times on the door to this room and on the walls containing him. I even yelled out his name. Yet he did not even twitch underneath his sheets. The next step in arousing a patient would be to apply a sternal rub--basically pounding on somebody's chest with your fingertips. But I couldn't bring myself to touch this patient… what if he was really dead? He wouldn't respond to my tapping. He wouldn't be saved no matter what medical interventions were applied to him.

In both of these situations, the patient was found to be very much alive. I was acting inefficiently when I decided to enter the patient's room only to promptly leave it when I didn't get the response I wanted. 

The death of a patient seems like the greatest insult to a physician, even scoring above having your medical license removed. It tells you that you missed something. Hell, we have M&M's specifically designed to analyzed where you as a physician failed the patient.

I don't want to tell someone a patient died because we didn't check their blood pressures often enough. I would rather lie than experience that shame and guilt.