Thoughts and Thoughts

I’m going to try to title my entries from now on. It makes it feels like they are television episodes, like Scrubs.

I used to make a snide remark regarding Korean soap operas. For those of you who don’t know, the Korean dramas run in short mini-series format (usually 16-24 episodes), and have a marked tendency to be melodramatic. A few years back, it seemed that at some point in every one, a major figure would come down with brain cancer, thereby leading to some tear-jerking tragic ending. I used to always note that there must be an “epidemic of brain cancer in Korea.”

I think that I always took solace in the fact that brain cancer was so rare, and it happened to so few people that I can safely not think about it. When I started my internship, however, I was signed-over a list on which one-half the patients had brain cancer of one form or another.

I think God is teaching me how insensitive I was.

It is interesting working with these patients on a daily basis. It is particularly tough because in Internal Medicine we usually take a big role in the discharge planning for the patient. By playing this role, the impact that health has on the patient really hits home. A patient that was walking, talking, and independent before entering the hospital now requires nursing home care or 24 hour help.

Whatever assurance I had in the small number of people that are affected by this condition, I find gone now. It really hits home just how much a medical condition changes people’s lives. Everytime I write up a discharge summary and patient instructions, I realize that their lives are just no longer normal.

Whew, a couple long hour days in the hospital recently. Because of a blip in the call schedule I ended up working long-call for two days in a row. It’s fun for the most part though. It’s really the most fun when something actually happens. Most of my call nights involved correcting mistakes that nurse has caught that another doctor has made during the day. I suppose they need an official doctor’s approval for the change of action. It’s very clear that the nurses know how to protect themselves from legal liability. A lesson that doctors could probably learn.

Today, one of my patients had an episode of testicular torsion. It was pretty impressive, and it looked exactly like the textbook. “High riding testis with a transverse lie.” Acute-onset “excruciating” pain. So, I tried to manually untorse at first, then called surgery (who covered urology), and then went back and successfully untorsed it.

(FLEX MUSCLES)

The scary thing is, I was the only person around that knew what to do. I guess in my ER electives, testicular torsion is talked about a fair amount (because it is a true surgical emergency). My resident (for whom today was her last day of Internal Medicine), did not know that it was possible to manually untorse. Even more amusing, I had the opportunity to speak to a scared 2nd and 1st year surgical resident who kept trying to claim that they weren’t covering urology. They might have just been misinformed, but they were also clearly scared. I thought surgeons are supposed to feel comfortable manually fixing something. Oh well. (I was told to go to the chiefs if such an occurance happens again).

So I fixed him.

It feels good. It is a little scary though, because it was so obvious that nobody else knew what to do. Since testicular torsion is so time-sensitive, I have to wonder a little what might have happened if I wasn’t the person actually there.

It’s worth saying, the other prelim-intern from Columbia knew exactly what to do. I guess that means we should give props to my medical school rotation in urology….

Well, I somehow survived my official first day as an intern. Up until now I carried a partial list, but today I carried the full load of patients. I even managed to get all my work done, albeit 4 hours after most of the other interns left. I try to justify it by saying to myself that I had an unusually tough work load, but I just can’t be sure.

The encouraging thing is that I know that I learn things quickly. The flip side to that is that I almost always seem to flounder in the beginning. I’m not sure if some people are more prepared or somehow manage but I don’t think most people bomb as badly as I do in the beginning.

Today, I did something I really didn’t like doing. There was a patient under my care who was in a severe alcohol abuser, and who actually seemed reasonably motivated to fix himself. He wanted to get into rehab, and I wasted most of the day stalling so that he would have a chance to get in.

It turned out that he couldn’t get into a rehab program directly because there was no space available, so I ended up sending him home. I fully expect that he will relapse once he gets home to his usual environment. I just didn’t feel like I had much choice. I knew that my attending had basically demanded that he be discharged today, and my resident didn’t like him because he apparently made some sexually inappropriate comment to her, so she wasn’t exactly sympathetic to him. Still, I have a nagging feeling that if I kept him in the hospital for another day or to until he could be directly transfered to rehab, he would have a better chance of actually making a recovery. I think he really wanted to recover, and he was clearly disappointed when at the end of the day I had to tell him that there was no space in either of the two places we were looking to try to get him into.

I know that my attending and my resident are speaking from more experience when they basically wrote him off as an alcoholic that will probably die as an alcoholic. Still, I don’t think either of them spent as much time with him as much as I had, and maybe there is a bit of idealism in me that keeps insisting that this patient will be different from the usual crop.

But today, the workload got really high, and I had already spent too much time trying to do the extra thing for this patient. I also know that this discharge was one measuring stick that my attending placed before me, and it was one thing that I didn’t want to fail reaching. So I let him go, and said a quick prayer as I did so. I had to trust that if he really was as motivated as he seemed, he will somehow have to find a way to keep himself sober enough for a few days so that he can get into rehab.

It might have not changed anything in the long run, but I still had to carry the burden of the possibility that it might have.

My friends have recently started calling me “Dr. Dave.” It feels rather odd. I always considered people who insist on being called “Dr.” in public to be really obnoxious. I know they’re just being endearing, so this is definitely different, and with such common names they need some identifier to distinguish me, but it is still weird to feel defined by your work in a social setting.

It changes the social dynamic. It won’t change anything for people who have known me for a while, but it can certainly affect the interaction with every new person I meet. Could you imagine? How would you start a conversation with someone that everyone calls “Dr. Dave?” Medicine is one of those fields that threatens to completely take over your life as it is, so it would be nice if I could be incognito every once in a while. At the very least I can pretend to be like someone else.

That is not to say that it isn’t nice finally being called a doctor professionally. Inside the hospital, finally being called doctor (and not by mistake), and actually introducing myself as doctor to every patient, at the beginning of every phone call, and to everyone while I’m working creates it’s own high. It immediately says, “I have something important to say.” I usually don’t feel like people are blowing me off or anything, but being a medical student all these years certainly had their effect. The change feels magical. I didn’t feel like anything changed right when I graduated, but after working as a “doctor” for just a few days, I now feel like everything has changed. Even me.

The truth is, when my friends called me “Dr. Dave,” what bothered me the most is the fact that it didn’t bother me all that much. Someone asked me today what I did, and I surprised myself when I simply answered, “I’m a doctor.” Why didn’t I say I was a resident? Why did my impulse answer that way?

It was a reminder that I’m changing.

Some Pictures:

I’ve just finished a long day, but I’m really loving it so far… it’s fun! I feel like I’m some crazy though. We’ll see how things beat me down over the course of the year, but I decided to take some pictures so that we can compare.

Enjoy!

Well, as most of you know, I’m just starting my medicine internship. It’s been an interesting week so far, and everything does change when you can introduce yourself as “Doctor” so-and-so. You actually feel like you have business being there, unlike the “sorry-do-you-mind-if-bother-you” feeling you get as a medical student.

The weight of responsibility is very different. For example today, a patient had just finished a procedure, and was under instructions to not eat prior to getting the procedure. I had neglected to enter the order to “resume diet,” and therefore the patient could not eat. I eventually got paged to get this problem fixed, but it certainly changes your own sense of significance in the whole hospital process.

I’ve also found it amazing how quickly the patients grow attached to you in the hospital. I have one patient who is very anxious and depressed, and tends to refuse treatment. However, if I show up 5 minutes before the procedure and spend 30 seconds to let her know I agree with the procedure and think that she should go, there’s no problem.

The other night I watched a patient die. It was one from the other team, so I didn’t know her, but it was odd, regardless. She was a cancer patient, with metastasis to her brain. Her condition was incurable, and so she had the order “Do Not Resuscitate.” She was awake, alert, and speaking to people less than 30 minutes before she suddenly got seizures, her pupils became fixed and dilated, and she went into agonal breathing. Her private doctor was right there (he just finished speaking to her), and he told us to let her go.

What followed was rather strange. She still had a pulse, even as she wasn’t breathing anymore. We couldn’t pronounce her dead until her heart stopped, so we stood around waiting for a while. Eventually we slipped away and went back to work, and a resident popped in and out of the room to track her progress. I think a while for her heart to stop.

It was a good thing she was DNR. I’m assuming that she crashed so quickly because one of the metastasis in her brain starting bleeding. Even if we did CPR and somehow saved her, there is little chance we would have been able to save her brain as well.

I’ll try to write more later.