Waiting as the VA drains away my soul

It's a beautiful December Saturday in southern California. We've had some funny weather lately (for instance...I've had to use my defrost to get the ice off of my car's windshield more than once this week). It's been raining, cold and nasty for the better part of the week, but somehow the sun managed to poke out from the clouds and life warmed up into the 60's today. It's actually the kind of day that makes you feel like going out and doing things -like errands-because an umbrella is not a necessity and dirty pant-hems are not a foregone conclusion. Which is, friends, EXACTLY why I am spending my entire day sitting in the VA hospital doing not much of anything at all except taking inane quizzes on the internet that tell me "What Breed of Cat" I am, or "What Kind of Wine" I should try. (By the way, quiz guru - I am most certainly NOT as nasty as most Siamese kitties, nor do I think that chardonnay is the way to go. Rethink your advice.) It's the last day of my ICU rotation, and had it not been for one unfortunate fact, I would have been skipping merrily out of the hospital doors at 11:00am this morning, ready to enjoy my two solid weeks of Christmas vacation. The unfortunate fact: my ICU team senior resident is the on-call resident today. This means that while he will be here all night...the rest of the team will be here all day to help him should he get barraged with admissions from the ER. I am hesitant to type these next few words, lest I jinx myself...but...my pager has not gone off. Not a peep, not a beep, not a chirp. Not that I really have much to look forward to if I went home: while my Christmas shopping is done, my house could be declared a national disaster area. {Come to think of it, maybe I SHOULD have it declared as such...then maybe FEMA would help me out, too.} There are dishes to do, floors that are crying out to be vaccuumed, a pile of laundry that smells rather badly, and a million other things to do before Chris and I set out for Phoenix on Tuesday. So the unfortunate reality is that even if I were not tied to a chair in the VA doing not much of anything, I'd probably just be glued to the sofa at home doing not much of anything there, either. *Sigh* But still, I wish, I wish, I wish...that I were skipping happily through the doors on the way to Christmas vacation, instead of rambling aimlessly on the inter web in a feeble attempt to bide my time.

An Open Letter

Dear Patient:

I think we need to set a few things straight. We probably should have set things to right when I admitted you; it was obviously an oversight on my part, but don't fret too much - it won't happen again.

I am very sorry that you are sick. Truly, I am. I am very sorry that you are stuck in the ICU when it is so near to Christmas. I understand that you are upset, probably for a variety of reasons. Undoubtedly, some of these reasons have to do with me.

I am sorry that you've been kept up by the nursing staff most of the night so that you could get the medications you need so that you can eventually go home again healthier than you are now. I am sorry that the IV machine that carefully keeps you hydrated ran out of steam and played the "I'm So Empty, Come and Fix Me" symphony last night. I am equally sorry that I had to be the one to wake you at 5:00am (after you'd finally fallen asleep) just to ask you inane questions about your pain/bowels/fever/vomiting/etc.

I know that you are tired of the vampire-ish phlebotomists that attack you with needles every few hours. I know that hospital food is about as far away from edible as it can get. I'm terribly sorry that I need to listen to your heart and lungs in the middle of your morning coffee-break. I realize that you are angry, depressed, scared, and feeling sorry for yourself.

But before you take all of your frustrations out on me:

I'll tell you a little secret here, one that I'll just bet you haven't considered. So chew on this, dear patient: I know that you don't want to be here, but I don't want to be here, either. At 5:00am, I'd MUCH rather be tucked up in my nice warm bed in my nice warm home. But alas, I rise out of bed and dress, stumbling into the hospital from the cold, dark December dawn just to make sure that you are alright. Make no mistakes...I do this for your health, not mine.

I don't particularly appreciate your abrupt dismissal in the middle of my questions. Maybe you're tired of talking to me...but trust me, I am very tired of asking you about your bowel/bladder/chest pain/breathing/vomiting ad nauseum every single day. And by the way, it's not just you I'm "annoying the hell out of" in the mornings; it's generally 4 other patients in addition to you. I don't really want to contemplate your bowel habits; I need to know about them before bigger problems arise to spoil your holidays.

I don't particularly enjoy being cursed at or smacked as I attempt to listen to your heart through my stethescope. That goes for the groping, too. Just because I have breasts doesn't mean that it's open season while I'm bending down, otherwise occupied. Perhaps my timing is not the best, but please put down your cup of coffee and take a couple of deep breaths for me so that I can make sure that you don't have a developing pneumonia. When I "bother you," I actually do have my reasons...it's not for kicks and grins.

Even though this shouldn't be news to you - YOU ARE IN A HOSPITAL, NOT A HOTEL. I'M YOUR DOCTOR, NOT YOUR SECRETARY. I'm not here to care about your schedule or the fact that you think your breakfast eggs are too soggy and undersalted. It's tough luck that the accommodations aren't quite what you're used to getting when you stay at the Ritz. I'm here to help get you well enough to enjoy your Christmas holidays at home. I don't do any of these things for personal pleasure, trust me. I do them because my job is to take care of you.

You came to me for help, so let me help you. I don't ask for much from you; as Aretha says, "All I'm asking for is a little respect!"

Respect me. Respect my time.

Listen to Your Heart

let me listen to your heart;
bare your chest to me,
bare your soul to me.
tell me about this scar on your chest but
hide that scar you carry deep inside,
hide it away from me if you must.

take a deep breath for me;
in and out, nice and steady.
i know it's hard.
i can hear the work, you know-
but go ahead and pretend.
there is little you can hide from me.

i'm going to press here;
here on your stomach but please
tell me if i cause you pain.
my hands are cold but my heart is warm
and i know it hurts but you would
feel so much better if you would tell me the truth.

but instead, you lie and
let me listen to your heart,
let me hear you as you breathe,
let my cold hands wander along your stomach
even as i question your scars and hurts
and you quietly return to places you never wanted to revisit.

so share with me your worries and fears;
that's why you are here, after all.
your heart is heavy, not dead-
i know because
that's what i heard when you
let me listen to your heart.

Musings after Interview #1

I have just finished my first residency interview. I guess the season has officially started.

Cons:

1. Being stuck in the middle of Queens in the dark near some sketchy Wal-Greens store on my first night in the city; the cab I called apparently didn't feel like picking me up and my hotel had NO idea where I was. I don't recommend spending 60 minutes like this. Hilarity did NOT ensue. On the "bright side," I'll never again forget to bring pantyhose with me to interviews.

2. Wandering around Queens in the dark because I am directionally challenged and got lost upon exiting the subway station. Somehow, I turned a 5 minute walk into a 90 minute walk. [Note to Queens borough: you have an abnormally large population of weird men that hang out together in clumps after nightfall. You should fix that.] Hilarity did not ensue here, either - however, I did have an anxiety attack in the middle of the Flushing Meadows Park. Another first for me.

3. Spending 3 hours with the good (and, on occasion, scarily interesting) people on the NYC subway. It was supposed to take me 40 minutes but I kept getting on the wrong trains.

4. Having to settle for a visit to the Natural History Museum instead of the Met because I was just so tired of getting on the wrong train and the NHM happened to be right in front of me. Even I can't get lost when it's right in front of me....generally....

The program was good, for sure. But I just don't know about living in New York City, when it comes right down to it. Manhattan is nice, but too expensive...and from what I saw of both Queens and the Bronx, I can't live in either place. I guess we'll see how this all turns out.

Rip Van Winklette

Rip Van Winklette
Current mood: angsty

When I sat through the first lecture of my medical school career a few years (?!) ago I thought to myself, "Man. This is seriously awesome. I can't believe I'm actually in medical school!"

When I came close to failing my first biochem exam as a freshman I thought to myself, "Man. This is seriously bad. What have I gotten myself into?"

When I was struggling, trying my best to understand pathophysiology during sophomore year I thought to myself, "Man. Dr. Werner just seriously schooled me. This blows."

When I finished taking the USMLE Step 1 after my sophomore year I thought to myself, "Man, that was heavy. I am seriously ready to be a third year student now."

When I became a 3rd year medical student I thought to myself, "Man, what was I thinking? I seriously want this misery to be OVER with. When will it end?"

And now, as a bonafide senior medical student I am thinking to myself, "Man, where has the time gone? There are some serious choices to be made in the next few months."

It's funny to me how the events that you never think will happen eventually come to pass. Sometimes I feel like Rip Van Winkle, that poor gentleman who took a nap under a tree one day and woke up only to find that somehow, he had inexplicably slept through nearly 100 years of his life. To me, it seems like just yesterday that I was a freshman in college struggling to adjust to life 2,000 miles away from the only home I'd ever known. Then, in the blink of an eye, today has dawned and with it, I realize that I am just a mere 7 months away from having two letters after my name that will actually mean something to a lot of people. It leaves me scratching my head and wondering just where the time went...and how I've magically gone from being plain old Chelsea Tooke to (very nearly) Chelsea Tooke, M.D.

If I think about it really hard, it gives me minor panic attacks. You never realize just how much responsibility will be thrust upon you after you walk across that graduation stage. Today, I sit in the pathology department and read slides with attendings. I don't always have a clue exactly what it is that I'm looking at (especially when we're talking dermatopathology) but that's ok, because I'm a student and I'm learning. I don't have to deal with calls from the blood bank about possible transfusion reactions, and I don't have to stress about immunohistochemical stains and whether they are nuclear or cytoplasmic and what the relative staining patterns actually mean. But tomorrow is a different day. Tomorrow, I will be an attending. I will look at a slide and help decide someone's fate. I will help the ENT surgeons decide whether or not they need to remove the entire voicebox or dissect through half of a patient's face. I will help decide whether the general surgeon needs to remove most of someone's colon. I will help the dermatologist decide whether a skin lesion is a small basal cell carcinoma or a malignant melanoma. I will help the Internal Medicine service diagnose metastatic cancers. I will help clincians decide exactly how much time a person has left on this planet when I give them my diagnosis. I will oversee the labtoratory functions that every clinician takes for granted: blood banking, microbiology/immunology, drug testing, CBCs/CMPs/LFTs...I will have a hand in it all. I will be expected to have answers. For today, I am safe...but I am scared for tomorrow. And tomorrow is coming quickly.

In the next few months, I will be exhausted as I criss-cross this country. I will spend thousands of dollars on plane flights, hotels, and rental cars. I will answer the same interview questions over and over again until I think I will vomit if I hear "So tell me about yourself" ever again. I will most likely spend more time sleeping on hotel beds in unfamiliar cities than I will at home. I will pay monthly rent to live in a place that, for a few months, will seem more of a myth than a reality to me. I will lose sleep over my Rank Order List and will probably need to start taking anti-depressants in February, a full month before Match results post. I will pack my belongings and move to a new city to start a new chapter in my life. Tomorrow is indeed a frightening prospect.

So I sit here and reflect on yesterday instead, and remark to myself just how quickly these four years have flown by. I've dreamed of this moment...residency interviewing and graduating for years, and if it didn't hurt and wouldn't leave a mark, I'd pinch myself very hard to ensure that this is not just some dream. Soon, there will be no more patient care. There will be no more 5:00am alarm bells sounding me to my pre-rounding duties in the hospital. My stethescope will lay forgotten in my car, hearing the sounds of wheels on pavement much more than beating hearts in human chests. I'll never again pick up an ophthalmoscope and try to discern cup-to-disc ratios (not a big loss, frankly). I'll probably never ask another person about their bowel habits or whether they have had any "funny discharge" (again, this is really not a crushing loss). I won't be delivering babies at 3:00 am, admitting patients when my shift is technically over, or performing Ortolani-Barlow maneuvers on infants.  However, I won't receive Christmas cards from long-time patients and I will probably never hear a "Thank you, Doctor" fall from a thankful patient's lips. I will work behind the scenes with the knowledge I've acquired these past years, heard although largely unseen. It is by turns a bittersweet symphony, this life, these choices.

But if life, as Shakespeare so poetically stated, is a play with everyone having their own parts, I can think of no better role for me than the one I have been chosen to play. I have acquired this knowledge and made my choices. As I reflect on these past four years and their relative brevity I feel a multitude of emotions. I am happy at times that this experience, this new chapter is upon me. I am sad, I am worried, I am terrified, I am ecstatic. I am learned with much still to learn. I am older and occasionally wiser. I am more than I was four years ago and yet not who I will become. This time has moved so slowly, yet is gone in the blink of an eye. These four years have been such a long road for this weary traveler. I feel as though I am standing on a precipice with arms outstretched over a grand mystery, scared to fall into the abyss yet afraid to remain rooted where I stand. I suppose that I must simply take it on faith that all the knots in my mind will right themselves and that this modern day Rip Van Winklette will manage to happen upon a small, silent eddy in this racing, tumbling river of time

Reflections on Medical Specialties

Reflections on third-year clerkships
Current mood: content

OB-GYN: OB was routinely 14 hours of waiting in pregnant-lady hell for something to happen. Attendings and residents in OB tend to have the most malignant personalities I've ever encountered, and let me tell you what - women in the throes of labor are no bowl of ice-cream either. It was cool for about two days, but there is only so long that you can spend 5 hours at a time staring at dirty floor tiles only to have the monotony broken by the thrill of a sterile vaginal exam. And when something actually happens, it WILL adversely affect your pearly-gray tympanic membranes. What got me were the grand-multiparous women who were screaming like they were extras in some D-list horror flick. Half of the time, I wanted to look at the woman and say, "B%*!@, puh-lease. Can ya knock off the screaming? This is baby 9- like you didn't know this experience was not exactly a full-day spa treatment." And overnight call? At 2 am, I'd rather be eating lima beans in a prison camp than watching a yelling, sweaty lady push a watermelon out of unmentionable areas of the body. Oh yeah -the "miracle" of birth? It's just plain gross, folks.

PSYCHIATRY: Aside from the fact that the patients really ARE stark raving lunatics, it wasn't so bad. It's also really hard to apply the idealistic garbage they force-fed you through the basic science years. You know? The stuff in Understanding Your Patient and Psychpathology about how mental illness strikes at the very heart of a person?...it's sad and worth remembering, true, but also very hard to remember when your patient has informed you that they'd like to eat your face for breakfast because the tap-dancing aliens in their fingernails told them you'd be tasty.

SURGERY: Could have been better,could have been worse. Unfortunately, because of overnight call on surgery, I still have nights where I wake up and scramble blindly for my pager,only to find that the phantom-pager demon has struck again and there is, in fact, no sadistic resident that wishes to wake me up at 3 am so that I can attempt to drive the laproscopic camera. Upon having that experience on one overnight call, the attending asked me if I even knew what the appendix is and if I knew up from down - words cannot describe how much I yearned to tell him "It's 3 am and I've had 1 hour of sleep because you just HAD to fix an inguinal hernia that could have waited until tomorrow. Drive your own damn camera, amigo."

FAMILY MEDICINE: I was placed with a 9-ft tall, orange-haired Amazonian who received her medical degree from a university deep in the heart of Mexico. That statement right there just about sums up my experience on family medicine perfectly. I'm not sure exactly how Amazon-woman contributed to my medical education - she prescribed Robitussin for a teenage girl with severe right lower-quadrant abdominal pain that turned out to be appendicitis. Who knew? Not her, apparently.

PEDIATRICS: Peds was the most miserable time of my medical career. The residents are incredibly strange people who are worthy of being subjects in some sort of clinical trial on how mentally screwed up residency can make you. Or mayhap they've dealt with small, screaming germ-bags for so long that they forget how to be normal and speak in sentences that don't include insipid words such as "tum-tum" and "poopy". In addition, during the course of my rotation, I mananged to get a bacterial pink eye in BOTH eyes, two viral colds, and one particularly nasty case of pneumonia - all inspite of having meticulous hand-hygiene and submersing my stethoscope in Chlorox after every patient encounter. Syonara, peds. See you again never.

INTERNAL MEDICINE: Riverside County Regional Medical Center sucks. Really, really sucks. I'm still trying to figure out who I pissed off in a former life to deserve going to RCRMC. Don't get me started on the anal-retentive, micro-managing, tree-wasting Attendance Nazi of the clerkship. By the way, _____, the world will NOT, contrary to your opinion, end if my weekly patient log is missing the useless purple cover sheets you incessantly jam down the throats of clerkship students. Also, I would like to inform everyone who reads this that the Attendance Wizard is full of beans - the Simulated H&P is not at all useful unless you delight in having a new anal orificine unkindly manifested on your backside in a short, 30 minute time span. I'd also like to ask the powers that be why the VA insists on those annoying, computerized health reminders for DM, HTN, high cholesterol, coronary artery disease, etc - when they also insist on feeding their veterans fried chicken and deep fried hamburgers for lunch. Anyone else see the weird dichotomy there?

Can we say harrassment?

Inpatient medicine at the VA hospital is SO much better. I get my own office with a sign outside the door. I get to put in orders. I don't have to see 20 patients a day. In fact, you know how many patients I saw yesterday? 3...all day. 2 in the morning and 1 in the afternoon. It's glorious. I'd go into internal medicine if I could work within the VA system. However, I think pathology is still the place for me.

Anyway, my rant of the day is about the simulated patient H & P that I went through on Thursday. It wasn't pass or fail, so I wasn't worried about it. I went in, talked to the patient, examined her, told her she likely had GERD (acid reflux), and told her to try some OTC Zantac. No problemo. The following is a truncated version of the 40 minutes of hell I went through afterwards

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Dr.Meanie: Do you even know what H2 blockers and PPI's do to a patient with GERD?!

Me: Umm..they lower the lower esophageal sphincter tone, but secondarily help diminish acid production in the stomach. *Look at how much I know!*

Dr. Meanie: Do you have any idea that it is malpractice to prescribe those drugs to someone with GERD?! What if she got an aspiration pneumonia and DIED!? What would you tell the judge? Huh? And don't even get me started on the way you embarrassed yourself with the gown!

Me: Huh? *I guess he'd better tell this to the millions of doctors out there using Prevacid, Nexium, Zantac, etc. Embarrassment? About the gown? What??*

Dr.Meanie: Let's move on and talk about breast exams now. (proceeds to talk a lot about the clinical breast exam and about how I should be feeling up a lot of women)

Me: ......... *Confused at the turn of this conversation, because a breast exam was not warranted in this patient who was complaining of reflux.)

Dr.Meanie: Did you know that young men are unnecessarily using Viagra because they think they'll make their partners orgasm if they last longer?

Me: ........................... *Now, I'm really confused, because this patient was not even a man*

Dr.Meanie: Most women can't orgasm from sex. They need TOYS!! Mechanical stimulation!! (He launches into a really weird conversation about sexual intercourse)

Me: .........*Someone HELP ME! I just want to be anywhere but trapped in this little room with this obviously whacked-out and very creepy old man. What in the hell does this have to do with GERD??!*

Dr. Meanie: "I hope that this session has been of value to you and you will use this in your clinical practice"

Me: Sure. Thank you very much. *Or not, you jackass. I'm going into pathology*

On a side note: How is this uncomfortable talk about women's sexuality (unwarranted, because the patient was complaining of acid reflux) and men's sexuality (irrelevant because the patient was a WOMAN) going to help me? You also insulted me 95% of the time. How is that useful?

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I'll admit it. I'm a little bitter. How was that supposed to be helpful to me? I went through 40 minutes of an old, crabby man holding a one-sided conversation about sex and throwing insult after insult at me. It was ludicrous. Ridiculous. Friggin' insane.

I have never, ever been so insulted this entire year. I admit that there was one 30 minute stretch of pediatrics in which I broke down and cried after an attending's well-meant criticism...but in my defense, I had been up all night on call and was battling a recently acquired pneumonia.

I think I'm going to report him. There was absolutely no excuse for how I was treated.

On a side note, there is supposed to be a Sex & the City marathon on today...but I can find it nowhere on the tube. I'm even more aggravated.