STAGES of the PHYSICIAN
I want to help people.
I want to make it through this hell.
I want to make it through this hell without killing someone.
I may have killed someone.
I want someone to help me.
I want to make money.
I want to spend money.
I want to save money.
Where the hell is my money?
I need to make money.
I don't know anything.
There is too much to know.
I will never know all of this.
I don't need to know all of this.
I only need to know a little.
I don't care if I know anything.
I want to be needed.
I love my white jacket.
I love the power of the pager.
I hate this f*cking pager.
I don't want to wear a stupid jacket.
I want to be left alone.
This patient has some interesting problems.
This patient has some real disease.
This patient needs to be hugged and loved.
This patient has a lot of nothing.
This patient has Sh*tty Life Syndrome.
This patient needs to leave; I need to be
hugged and loved.
MEDICAL STUDENTS’ REVENGE
Our OB-GYN rotation at a busy inner-city hospital was one of the most grueling of medical school. The residents were miserable and as all miserable residents do, they torture medical students for relief. One particularly sadistic senior resident was on call with us on Friday night, one of the busiest of the service. He would extract as much scut from us as possible and he was merciless in his criticism. Any procedure we would attempt was quickly taken over by this impatient resident. Since it was the last day of the rotation, I was eager to finish a call and never touch a speculum again. My medical student colleague, however, had only revenge on his mind.
At around 3 a.m., we were called to the ER to work up a morbidly obese patient with “itching down there.” After our thorough history and cursory physical, we called the senior resident. In his usually abrupt manner, he dismissively listened to our presentation and proceeded into the room for the exam. The patient put her legs on the stirrups, but as with most morbidly obese patients, there was no hint of the vagina except the odor and converging folds of endless flesh. Even the sweat in between the rolls of cellulite gave an additional pungency to the aroma.
“I'm sorry I'm so fat, doctor,” she kept repeating half sleepily. With much reluctance, we each held back a thigh so our fearless leader could plunge into the depths with his speculum for his examination. As our resident diligently probed flesh with his speculum, my medical student colleague looked up at me with a gleam in his eye and a wink …
Thwack!!
He had let go of his thigh and I instinctively did the same …
Thwack!!
I will never forget the seemingly headless senior resident flailing his arms trying to free himself from the deluge of flesh and odor that was delivered onto his bare cheeks. He was now cheek to cheek with our sleepy patient who barely reacted to the fracas. We quickly regained our composure and insincerely apologized to our resident, who tried his best to proceed with his exam. The rest of the evening just seemed to pass by effortlessly and our senior resident was much nicer to us for the remainder of the shift.
ER STUFF
As a very green third-year medical student in Bellevue Hospital (NYC) emergency room, I spent much of the time wide-eyed and terrified. With its surreal mix of the heroic, overwhelming, and bizarre, Bellevue ER was a great place for memorable patients and events that have stayed fresh in my mind for years.
One shift I noticed a man on a stretcher having a grand mal seizure. This seemed to make absolutely no impression on the surrounding patients, or the staff for that matter. Just as I was really getting worried, a nurse strode past, said to the patient,
“Oh Jack, cut it out!” … and he did.
My story begins when I was a fourth-year medical student at a large inner-city emergency room. I was doing a required rotation taking twelve-hour shifts and working closely with an intern as well as an attending ER physician. I enjoyed the fast pace of the big city ER but did experience significant anxiety when a code was underway or an imminent or a major trauma was unfolding.
The attending wanted me to see patients, assess them, and formulate a plan. I went to see what seemed to be my 100th patient this shift. Ms. Greenjeans was a 76-year-old female who presented with nonspecific pelvic discomfort. She had the usual past medical history including diabetes, tobacco abuse, alcoholism and substance abuse, hypertension, renal insufficiency, etc. Her abdominal exam was unremarkable, but as we all know, “No abdominal exam is complete without a pelvic exam.”
The forty-bed ER was nothing more than a large room separated by pull curtains that do provide visual privacy but do not provide much privacy in regard to conversation. In other words, the whole ER including patients, staff, etc., can hear every word I say to the patient.
Ms. Greenjeans was morbidly obese and hard of hearing so this pelvic exam would likely be difficult but, considering I had done two pelvic exams in my entire medical career (counting this one), I thought I could handle it.
Ms. Greenjeans was placed in the lithotomy position with lifting help from nursing (#1: because nurses are much stronger than doctors; #2: because all doctors have “a bad back;” #3: because this patient's legs resembled large, soft, fleshy bags of cottage cheese). I reached for a speculum not realizing that they actually came in different sizes. By chance, I chose a medium-sized model and inserted it into the vagina. Unfortunately, due to the size of the patient, I could barely see the labia minora.
The ER nurse who was chaperoning my exam recommended a change in equipment. I looked up at the nurse with total confusion on my face as she handed me a jumbo-sized speculum resembling a small fishing vessel or salad tongs. I again inserted the instrument to get a better look into the vaginal vault. Words cannot describe the horror, surprise, and disgust as I watched several hundred maggots squirming to exit to the outside world. I jumped back suddenly, nearly falling on my butt. “This could not be happening? Why me?” I quickly ran over to my attending to tell him the news; he casually walked over to the business end of the exam table and confirmed my diagnosis.
“Yeah, those are MAGGOTS.” He then informed me that I should tell the patient her diagnosis and then proceed with cleaning them out of there. Sounded like a plan, but, why me, why here, and why now? I stood up at the head of the exam table and in my best doctor voice I said, “Ms. Greenjeans, you've got maggots in your vagina.” Suddenly the busy ER seemed so still, so quiet. I was sure everyone in the department could hear my every word. Ms. Greenjeans looked at me with a confused look on her face. She then yelled at the top of her lungs …
Talk About Blowing It
He was a passive guy and very laid back. When I saw him on the gurney I was surprised how calm he was. The ER physician had called earlier in the afternoon and stated that Frank was back because of his nausea and vomiting. He had a history of multiple admissions for gastroparesis from his diabetes. He truly had the latter disease and was insulin dependent. The gastroparesis was in question and previous testing never proved it. He was in his forties and had an obvious history of polysubstance abuse as well. He loved to smoke and drink and failed detox on many occasions. He also had chronic back problems, as well as the abdominal pain he claimed to have from his gastro-paresis. His primary physician was tortured by him because she couldn't shed him from her practice. She had him on 60 mg of OxyContin three times a day and held him to a narcotic agreement/contract. He never overtly broke the contract, but when he would run out of his narcotic medication early he would coinciden-tally have severe nausea and vomiting and abdominal pain. Subsequently he would go to the ER for admission to cover those days he didn't have the medication he needed at
home. Since dehydration can make diabetes lethal, it would be inappropriate to just ignore his demands and send him on his merry way. Even though no one ever saw him vomit in the ER, there was no one who would question Frank and chance the possibility of malpractice.
I knew Frank was a fraud and told him right away that I wouldn't give him any more medication to go home with when I discharged him. He didn't bite. I was expecting a fight but he just nodded quietly. He then rattled off the combination of anti-emetics and narcotics he needed intravenously while he was an inpatient. It made the admission pretty easy and I put him in the hospital in about 10 minutes. By the second day of his admission, I had taken him off all his IV drugs and put him back on regular oral pain medication. Once again, no complaints. In fact, he was as nice as pie. Since I had never met Frank before, I was amazed at how easy admission was going and started to second guess the accusations about him. I told him that he should be able to go home the next day and he agreed wholeheartedly.
The next morning I was seeing a patient on the floor below Frank when I received a page by the nurses taking care of him. Since I was coming up in about five minutes, I didn't answer, figuring I would see the nurses personally. When I opened the stairwell door to enter Frank's floor I saw a huge commotion. About four nurses were buzzing around his room and two were frantic by the phone waiting for my call. Then I noticed that security personnel were mingling around as well. This is not good, I thought.
It seemed poor old Frank wasn't enjoying himself as much as he would have liked to. He was getting his normal dose of OxyContin as he would at home, but I guess there was more fun to be had. The morning nurse had walked into the (room to find our friend in the corner snorting some “home” OxyContin that he snuck in with him. Initially he dumped it on the floor and spread it around as much as he could. Too late. The nurse confronted him and he confessed. They are tough birds who don't take no for an answer easily.
Never underestimate the stupidity of some people. Frank was being discharged that morning and he knew it. All he had to do was wait an hour and he could have gone home and had a party with his medication. No one would have known, and his charade would have continued indefinitely. Instead, Frank showed his impatience and blew it (literally). When I confronted Frank myself, I found a different man. He wasn't so nice anymore. He yelled at me. He cursed me out. He was ready to fight. As if in some way I was the bad guy, Frank put on a borderline personality show.
I finally ended our conversation by giving him two choices: discharge to home or detox. He chose to go to detox but left soon thereafter. Frank was discharged by his primary physician for lying about his drug use. I have a funny feeling that I will see Frank again on our “unassigned” service. My heart tells me that he won't stop his narcotic habit either.
My recommendation to readers of this encounter is to be a little leery of gastroparesis that sounds suspicious. It is a perfect alibi to get some pain meds for a joy ride.
This interesting diddy begins when I was a second-year resident at a large metropolitan teaching hospital. I was on-call one weekend during my Medicine Service rotation and hating life. A typical night on-call would involve somewhere in the neighborhood of four to eight admissions, a couple of ER blocks, and a whole lotta phone calls. My intern (I love how attendings and senior residents refer to their students and interns or residents as “mine.” It reminds me of slaves and indentured servants - which they are) and I were called down to the ER for a patient with a deep venous thrombosis. We figured that this patient would take us about 8.5 minutes (if we took our time) to admit into the hospital as he had no other major medical problems. More importantly, my intern was “seasoned.” This means that it was close to the end of the intern/ resident cycle and he had seen this particular problem several times in the past year. He could therefore manage this almost completely on his own. This also meant that I could go get a cup of coffee while he did the whole damn thing and just about the time when he was done (maybe 8 minutes and 20 seconds along), I would appear and give a sound bite such as “Looks like we need to get you in the big house and get this straightened out,” or “This looks like it's bad and needs fixin’.” Then I would review the intern's orders and drink more coffee. The teaching pearls for the case would come later while we reviewed the humorous or disgusting parts of the case.
I knew my intern was just about done with the admission when from across the ER I saw him move away from the patient and wave (I was a trained medical observer you know). I quickly walked over to the patient's bedside and looked at his grossly swollen red leg and proclaimed in my best authoritarian tone “This looks like the one! Let's get you upstairs and get to work.”
I then went to place the bed sheet back over his leg and something caught my eye.
Something was not right.
I had this strange feeling of a presence.
Something moved!
It turns out that this patient was the proprietor of a gay men's bar on the south side of town. He admitted to multiple sex partners in the recent past. As I focused on his groin, I could see what appeared to be a dirt smudge. A dirt smudge was not uncommon to see but a dirt smudge that was mobile was not an everyday occurrence. I moved in a little closer (or was it farther away) and saw a large gray and brown mass of small critters doing a line dance on his groin. I quickly turned to John (my intern) and asked him to take a closer look. I asked him to do it because there was no way in hell that I was going to. We both began to itch and feel the heebie-jeebies as the millions of critters switched from the line dance to the conga (dah, dah, dah, dah, dah, DAH!). What we had here was a good old-fashioned case of pubis pediculosis. That's crabs to you and me and it ain't the kind you eat.
I did what all experienced senior residents do. I got the hell out of there, but not before torturing the intern by making him get a painfully detailed sexual history including all STDs, previous partners, insect infestations, and the like. Sure he balked. Sure he was not motivated. It didn't matter because I was the boss and told him in no uncertain terms, “Get right to it so I can get to sleep - and no nitpicking.”
Sometimes it's good to be the boss.
The lessons here were simple. Call always sucks. Always make sure your intern does a proper and full exam (less you have to do).
And lastly … a smudge that moves is pretty
damn gross, even if you are a physician.
A SALUTE TO
THE BARN
My first med school rotation was in surgery. I was assigned to a large teaching hospital in inner-city Philadelphia, the city of brotherly love. Like all new third-year students I was terrified. Upper classmen were always quick to tell their horror stories about particular rotations and this rotation was not one for the weak hearted. I did not have a whole lot of interest in surgery, I just got stuck with a tough rotation. Rounds began the first Monday of the rotation at 5 a.m. Patients were rounded on, with notes on the chart by 6 a.m. so that you could round again with the attending. After rounds (which lasted until about 9 a.m.)
it was off to the OR
to become a human
clamp/drain/suture holder
while being pimped about
anatomical triangles, triads,
and trivia.
After lunch you would round again and await the ER and consult pages that steadily streamed in. Good Times! The house staff on the general surgery service consisted of the chief resident (slave driving, pimping, coffee drinking machine), several second-, third-, and fourth-year surgery residents, several interns, and a tribe of third- and fourth-year students.
We got a call from a general medical ward from the charge nurse telling us to get up to the floor stat to see this elderly lady with a large red mass protruding from her anus. My mind started to race, what the hell could it be?
I knew I had to think fast because the pimping would begin on the elevator up to the floor.
Cancer? Foreign body? Gerbil?
We reached the floor in a matter
of moments. The patient's room was a large common room with six beds in it. The room was affectionately known as “The Barn,” I guess due to the arrangement of the beds in stall-like fashion.
All of the patients in
“The Barn” were demented,
chronically ill, and smelled of
urine and feces (just like the
medical students).
There was music softly playing from a clock radio on the windowsill. I found out later in my career that this is standard operating procedure. The patients all were talking to themselves and seemed quite content. Mrs. Jones was our new patient. She was a 90-year-old demented black female. The chief resident gathered the house staff around her bed, and with great authority pulled back the sheets to reveal a large red mass protruding from the patient's anus! Holy shit! I thought.
What the hell is it?
(to my self of course … so I wouldn't be pimped). The chief resident and all of the surgical residents looked at one another and smiled. The interns looked at one another and grinned (like they knew what it was - but they didn't) and the students all looked at one another nervously.
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 2