To my late father, Samuel, who died before he could read this book, and to my mother, Shirley, whose heart is in this book though she’ll never read it.
Contents
1. The Bunker
2. Slangmeister
3. Code Brown and Other Bodily Fluids
4. Status Dramaticus
5. Failure to Die
6. Swallowers
7. Caesarean Section Consent Form
8. Incarceritis
9. Harpooning the Whale
10. Frequent Flyers
11. Blocking and Turfing
12. Cowboys and Fleas
13. Horrendomas
14. Circling the Drain
15. Slang Police
Acknowledgements
About the Author
Copyright
Dedication
About the Author
About the Publisher
1. The Bunker
6 p.m. Handover
In a small, secluded room behind the nursing station of Ward 6 West, residents gather for the daily ritual called handover, or patient sign-out. It’s the moment when the army of staff doing scheduled tests, interventions and operations shifts down to a skeleton crew of residents on call whose job is to monitor patients and attend to any sudden emergencies. It’s also when residents who aren’t on call finally get to go home. But first, they have to give their colleagues the heads-up on every patient under their charge.
The rectangular room where they meet is nicknamed the Bunker. The room contains four cubicles equipped with computers, a printer and a coffee machine. A small sofa bed is off to one side. The walls’ blue paint is scuffed with furniture marks. In the middle of the room is a small conference table ringed with chairs.
The Bunker is where residents meet with the ward chief—the attending or most senior physician in charge of the patients—to write up chart notes and to talk frankly about patients and fellow doctors who work on other floors and in other hospitals. The room, teeming with two sets of residents—the ones on call and the ones handing over—is hot and stuffy.
“Room 22, bed B, 82-year-old male,” says Rick, a first-year resident in internal medicine. “Admitted ten days ago with a fractured pelvis. He also has moderate Alzheimer’s dementia, GERD and type 2 diabetes. OT and PT say it’s not safe for him to go home. He’s awaiting placement.”
“What’s his code status?” asks Sandi, the senior resident on call.
“He’s Full Code,” answers Rick. “We tried to get the DNR but the family said they’re thinking about it.”
“Thinking about it?” repeats Sandi. “Can we do a Hollywood Code?”
“You’re on call, so it’s your show,” says Raza, the senior resident on Rick’s team. “But the family is there 24/7. I think they’d know it if you run a Slow Code.”
“You may hear about a consult we did on ortho,” says Raza. “Eighty-eight-year-old female five days post right total hip replacement. Post-op, she was overhydrated by the ortho resident and put into CHF. She had a bump in her troponin. We’ve given her Lasix and she’s feeling better. She’s stable now.”
“Saved another FOOBA,” says Sandi.
“That’s the third one this month,” says Raza.
“Next patient is Room 24, bed C, 58-year-old female,” says Rick. “Admitted over the weekend with type 1 diabetes and DKA triggered by a urinary tract infection. Unfortunately, she developed a pressure sore on her sacrum. Plastics is consulting on that.”
“Pressure ulcer?” asks Sandi. “How the hell does a 58-year-old diabetic get a pressure ulcer on her bum?”
“She’s a beemer,” says Raza.
“How big is she?” asks Sandi.
“Three clinic units,” answers Raza. “We tried using the Hoyer lift but it wasn’t rated for her.”
“Sounds like a horrendoma,” says Sandi.
“It gets worse,” says Rick. “We don’t have a bariatric commode or wheelchair to get her to the bathroom. She had a Code Brown in the bed.”
“Who got to clean that up?” asks Sandi.
“Thank god for LPNs,” says Raza. Everybody in the room laughs.
* * *
The dialogue you just read was created to illustrate just how much medical jargon can be packed into a brief discussion.
The 82-year-old man has GERD, which stands for gastroesophageal reflux disease, better known as heartburn. The residents referred him to OT and PT—occupational therapy and physiotherapy. That’s standard procedure for a patient with a cracked pelvis to determine whether the fracture will keep him from going home; an OT/PT assessment is also used to find out if a patient is likely to fall at home and what preventative safety measures might be necessary.
Raza’s 88-year-old patient on the orthopedic floor went into CHF—congestive heart failure—after the orthopedic resident gave her too much intravenous fluid. A “bump in her troponin” means the woman had a slight increase in the level of a protein called troponin, which indicates that she suffered a mild heart attack.
The 58-year-old woman was admitted to hospital with DKA, which stands for diabetic ketoacidosis, a life-threatening condition in which both the sugar and acid in the bloodstream rise to dangerous levels. A “plastics consult” means she was seen by a plastic surgeon, the specialist who usually manages skin ulcers.
But the residents also used a bunch of words and phrases that aren’t found in any medical textbook I know of, yet they were understood by everyone in the Bunker. If you sat in on that conversation, you might have thought you’d wandered into a very boring French film. Now, let’s provide the subtitles—starting with the 82-year-old man.
•“He’s awaiting placement” means there are no ongoing medical issues and if he could go home safely, we’d have sent him out by now.
•“What’s his code status?” means “Do we have to do CPR (cardiopulmonary resuscitation) if his heart stops?”
•“He’s Full Code. We tried to get the DNR but the family said they’re thinking about it” means the family wants him to be resuscitated if his heart stops. They can’t see the handwriting on the wall—that there’s no point in doing CPR if his heart stops—and they aren’t ready to sign a Do Not Resuscitate order.
•“Can we do a Hollywood Code?” means that if his heart stops we’ll do a pretend resuscitation in which it looks as if we’re trying to save him but we aren’t.
Now, we’ll take look at the acronym Sandi the resident used to talk about the patient on the orthopedic floor who was put into congestive heart failure. “Saved another FOOBA” means the internal medicine team saved another patient who was “found on orthopedics barely alive.” It’s a dig at orthopedic surgeons, who have a reputation for being so focused on what needs to be fixed surgically that they ignore signs of other diseases. FOOBA is a play on FUBAR, a military slang term that has entered common vernacular and stands for “fucked up beyond all repair.”
Finally, let’s unpack the slang that was used by the residents to talk about the 58-year-old woman in Room 24, bed C:
•“How the hell does a 58-year-old diabetic get a pressure ulcer on her bum?—She’s a beemer” means the woman got a pressure ulcer on her buttocks because she has a high body mass index, or BMI, a polite way of saying that she is morbidly obese. In other words, she’s so large that she developed a pressure ulcer from lying on her backside too long because she was too weak to move and she weighed too much for nurses to shift her position in bed.
•“Three clinic units” is a sneaky way of saying the
patient weighs 600 pounds. One clinic unit refers to a weight of 200 pounds.
•“Sounds like a horrendoma” refers to a horrible or awful condition.
•“We don’t have a bariatric commode or wheelchair to get her to the bathroom. She had a Code Brown in the bed” means that she is so large that when she had to defecate, several nurses—who didn’t have special lifting equipment—could not manage to move her to the bathroom or commode or even to place a bedpan underneath her, so she defecated in her bed.
•“Thank god for LPNs” refers to licensed practical nurses. Poop runs downhill. Residents can laugh about a Code Brown because they aren’t the ones who have to clean it up.
That is a crash course in the Secret Language of Doctors and what the language reveals about how these doctors view patients and their families in the culture of modern medicine.
* * *
Doctors share a culture that many hardly realize exists, much less talk about. In a 2008 paper published in the journal Academic Medicine, Dr. Carla Boutin-Foster and colleagues defined medical culture as “the language, thought processes, styles of communication, customs, and beliefs that often characterize the profession of medicine.”
Much of what is written about the culture of medicine focuses on the qualities of the ideal physician—what Boutin-Foster listed as “honesty, empathy, altruism, honor, and respect.” These attributes are considered the core values of medical professionalism. The doctor’s white coat is a powerful symbol of medical culture. Many medical schools hold a White Coat Ceremony during which first year students receive a white coat along with a lecture that teaches positive cultural values to young doctors to be.
But, there’s another side to medical culture—one that reflects how doctors cope with the not-so-nice aspects of medicine—everything from exhaustion and sleep deprivation to frustrations with Obamacare, not to mention frustration with certain kinds of patients and families, fellow doctors and allied health professionals.
They share these feelings only with trusted colleagues. To know what they really think about you, a loved one, or the heart surgeon about to remove a cancer inside your belly, you’d have to eavesdrop on conversations that take place away from the bedside.
* * *
To understand what you’re hearing, it helps to learn a little bit of “medical slang.” A more accurate term is argot (pronounced “ar-go”), which is defined by the Merriam-Webster Dictionary as “an often more or less secret vocabulary and idiom peculiar to a particular group.” The purpose of argot is to prevent eavesdropping outsiders from understanding what you’re talking about and to create a bond among colleagues, teammates or friends.
Argot is a French word. According to linguist Pierre Guiraud, the first known record of the word is in a document written in 1628; Guiraud wrote that argot was derived from les argotiers, a name then given to a group of thieves. In his 1862 novel Les Misérables, Victor Hugo described argot as “the language of misery.” As you will discover in this book, that description fits with the experience of residents and sometimes of other medical staff working in hospitals.
Argot is also sometimes referred to as a cant or cryptolect. The Thieves’ Cant—a secret language used by robbers and other criminals—was popularized in theatre and pamphlets during the late sixteenth and early seventeenth centuries. Today argot is used to describe the informal and highly specialized nomenclature and vocabulary used by people in a particular occupation, hobby, sport or field of study.
An argot comes not just with a unique vocabulary but also with its own grammar and syntax. If you were to overhear two physicians speaking medical argot in an elevator, you might have trouble understanding what they were saying. But you’d probably be able to recognize that they were speaking English. Medical argot is simply English augmented with code words that are incomprehensible to all but initiates.
* * *
My introduction to the secret language of doctors came when I was fresh out of medical school in 1980 and doing a year of residency in pediatrics at the Hospital for Sick Children in Toronto. Residents are new graduates of medical schools taking postgraduate training in everything from family medicine to neurosurgery. At one point, I had chosen a career treating children with disorders of the brain and had to do at least three years of training in general pediatrics before embarking on the “final” stage of my career development. However, within six months I abandoned that career choice entirely, in no small part because of the suffering I experienced as a young resident.
On average, I worked seventy to eighty hours a week, from 8 a.m. until 6 p.m. on weekdays, plus one night in three on call. If I was on call for the weekend, it was more like 110 hours for the week. Being on call meant that I stayed overnight in the hospital while my fellow residents went home. That meant I was responsible overnight for my patients and for theirs. In addition, anywhere from four to ten times a night I had to go down to the emergency department to admit patients assigned to my ward.
The nights on call were gruelling and relentless. I can remember running from one sick baby or child to the next, with little time even for a pee break. In addition to the volume of work, when you’re treating very ill babies and children there’s often a greater sense of anxiety than there is when you are treating adults. In large part, that’s because sick children come with anxious parents. Then there were the weekends. For one entire weekend every month, I was on call. That meant I went to work dark and early on Saturday morning and didn’t step out into the fresh air until six the following Monday evening.
In 1980, the pediatric cardiology service at the Hospital for Sick Children moved into the newly built wards 4A and 4B. Coincidentally, I began my first year of residency at the hospital in July 1980 and, for my first rotation, was assigned to 4B. My senior resident was Dr. George Rutherford III, who has had a long and distinguished career as a specialist in pediatrics and public health. Currently, he is director of the Institute for Global Health and head of the Division of Preventive Medicine and Public Health at the University of California, San Francisco.
Educated at Stanford University and the Duke University School of Medicine, Rutherford had come to Sick Kids, known then as one of the top five pediatric hospitals in the world, to round out his American training with “international” experience. Rutherford was not only brilliant, he was also wise in the ways of the world and of residents. The fact that he had been a collegiate teammate of famed tennis player and eight Grand Slam titles winner Jimmy Connors gave me a man-crush on the guy.
Rutherford was adept at sizing up an infant or child who was sick. More than that, he took it upon himself to teach me how to survive as a resident at Sick Kids. Following my first night on call, Rutherford arrived on the ward, saw my haggard appearance, not to mention the deer-in-the-headlights look in my eyes, and made a beeline for me.
“So, Brian,” he said, putting a reassuring hand on my shoulder, “how many babies did you box last night?” Box, as in coffin. He wanted to know how many patients I’d killed! For a half-second, he kept a perfectly deadpan look on his face, and then broke into a wide grin.
By the time I finished medical school, I’d learned about 20,000 technical terms that laypeople don’t know—everything from aphasia (the inability to understand language or speak it, a key symptom of stroke) to zygoma (the cheekbone). Boxing a patient wasn’t among them. Once I got over my initial shock, I was delighted. I have to admit that I found Rutherford’s jibe witty and darkly funny. I was quite nervous that first night on call, and Rutherford’s slang use of box told me that I wasn’t alone in that feeling. Moreover, by using it he was letting me into a secret fraternity. It made me want to learn more, as did most of my contemporaries and tens of thousands of young doctors and other health professionals who have followed in our footsteps.
One man who carried his passion for medical slang to another level is Dr. Peter Kussin, respirologist and critica
l-care physician at Duke University Hospital in Durham, North Carolina. Kussin, a teacher who majored in linguistics and comparative literature before becoming a doctor, is Duke University’s resident expert in medical slang. Kussin must love slang, because he picked an awfully strange place to use it. Duke University is well south of the Mason-Dixon Line. It has a buttoned-down, genteel vibe in which slang is considered déclassé and part of gutter culture. That makes Kussin, who was born and raised in New York City and went to medical school there before coming to Duke to do his residency training in the 1980s, an uncomfortable presence.
“The fact that you may have heard that I use and am an aficionado of slang is probably a 70–30 proposition,” Kussin said when I visited him in the doctors’ lounge at Duke University Hospital—a cavernous, mall-sized room with tall windows and dotted with tables, booths and a cappuccino bar that make it look more like a restaurant than a lounge. Kussin, ever the outsider, eschews the shirts and ties worn by his Deep South colleagues. Bald, rumpled and dressed in comfortable slacks and a blue scrub-suit shirt, the middle-aged internist has a voice that sounds warm, worldly wise and lived-in.
“Seventy percent a compliment and 30 percent wild man,” Kussin said, taking note of his reputation as a purveyor of medical argot. “New Yorkers are like that; that’s how we roll. We’re direct people. That is how you live in a city of 12 million people, right?”
The question was rhetorical. Kussin was the one schooling me in how he came to be a modern-day master of slang. His interest began in the early 1980s, when Kussin was a resident in internal medicine at what was then called Mount Sinai School of Medicine in New York City. The hospital had an Upstairs, Downstairs feel to it. One entrance, used by religious Jews, was on Fifth Avenue; the other—used by residents of East Harlem—was on Madison Avenue. The medical students and the residents who trained there were as heterogeneous as the patients. Kussin recalled how medical argot was shared among fellow trainees.
“Medical students weren’t allowed to speak it on rounds,” he said. “We were not initiated, but amongst ourselves there was a great prize in learning the lingo and then in listening to it and then, in private, using it amongst ourselves.”
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