ain't life grand

my last day on this cursed rotation. for at least 11 months anyway.

all this talk about patient autonomy is BS. once you start working on the wards, it’s all about ativan and restraints. getting nervous? ativan. talking back? ativan. complaining too often about pain? ativan. want to pull out your NG tube? ativan. trying to pull the foley? ativan. it got to the point when even i was saying to people, “i don’t like how we treat patients here. we control them medically. i want to do things the old fashioned way and talk to them.” explain things so that they aren’t as nervous, instead of masking their nervousness with drugs.

i’m also finding that i resent patients who don’t do exactly what i tell them to do. i want to yell at them to stop using so much morphine because that’s preventing them from taking a dump and getting off my patient census. get out of bed, walk, and work with PT/OT because if you don’t, it’s me who gets yelled at during signout at 6pm. why is the patient still here? because he’s a typical lazy ass leech enjoying his stay at our $1000/night hotel with free food, cable, and phone service. somehow, i doubt that these guys who live in their pickup trucks have much motivation to leave their bed and free cable just to go back to sleeping in their car.

i’m finding i need to fight the tendency to become punitive with my idiotic patients. i know it’s not pleasant to have tubes in every orifice, but if it’s what we need to help you get better, stop being dumb and keep that shit in there! i have this dumbass who aspirates every time he eats anything, so i put in a dobhoff tube for tube feeding. this moron pulled the DHT probably more than 5 times during the time i was there. he’s constantly begging to eat something by mouth. hey listen dude, we already explained to you that if you eat anything through your mouth you WILL choke and die. if you keep pulling the DHT, we can’t feed you, and you will starve. it’s funny, when the choices are starve/choke/die vs keep a thin tube coming out of your nose, this jerk off chooses the former every chance he gets. i was pretty damn tempted to say screw it and let him starve for a day.

dumbass patients create exponentially more work for me. just think… if this asshole didn’t pull his tube 3 times, i wouldn’t have had to write 3 orders to put in a tube, 3 orders for a stat KUB, look at the xray 3 times to check the placement, or tell the nurses to pull back on the tube just a little bit… and get another KUB, look at more xrays, etc. all this fucking work to feed some loser. if i ruled the world, noncompliant patients like this would be kicked out of the hospital, and if they choked and died, that would be their damn fault, and it wouldn’t be my responsibility to baby this asshole like a little child. whatever happened to personal responsibility? he’s not crazy, he’s just stupid. he’s free to make foolish decisions. why should i prevent that? let’s face it, the vast majority of the world makes dumb decisions and we let them do it. he’s an adult. a dumb one, but i think that still counts.

and let me just say, that i think it’s bullshit that some idiot who shoots himself with a shotgun (i’m not entirely sure how he managed to do that), has to be coddled back to health while watching cable tv and sitting on his ass while nurses and doctors have to change his wound dressings several times everyday, wipe his ass, and record the amount of urine he makes every 8 hours. you think america doesn’t take care of the uninsured in this country? then how do you explain why this redneck asshole with no insurance is getting world class healthcare after trying to kill himself? how do you explain how someone with no insurance has been staying at my hospital for 90 days getting huge operations, skin grafts, tube feeds, TPN, cable tv, and all that shit? if we didn’t treat uninsured people, i wouldn’t have spent all those nights smelling all the rank ass shit coming out of someone’s bowel fistula, obsessing over how much potassium she has in her blood, how many calories she’s getting in her TPN, how much urine she’s made, how well she is working with physical therapy, what types of stepdown places will take her without insurance, or write a note on her (non)progress for 30 god damn days. hell, i wouldn’t have had to deal with over half of these uninsured dipshits who drink like 20 shots and play chicken with a tree on the side of the road. i would have had time to eat at least once a day, actually take a piss more frequently than every 12 hours, and had time to read and actually learn something other than the doses of morphine, dilaudid, and fentanyl.

oh the pain

i don’t know if it’s karma or irony, but the last night was terrible. everyone and their grandma complaining about their pain. it’s like it was half strength morphine day and no one let me know. got to the point where i was trying to figure out the half life of morphine and compare it to the point where respiratory depression starts to kick in.

consider the patient who got a lysis of adhesions, post op day 1, on dilaudid PCA, toradol, and fentanyl. i get notified she’s in severe pain. i go see her and she’s there just bawling her eyes out. i’m like wtf, does she have bowel leak? then i remember she only got LOA. ok, does she have another small bowel obstruction? well, she’s been NPO and getting NG decompression for 24 hrs before her LOA, so that’s doubtful. puzzled, i ask my chief resident for advice. she’s like, i dunno, bump her pain meds up.

seems easy on first aid for step1 or step up to medicine. increase meds, sure, ok. so i give her a one time bolus of dilauded on top of her PCA, toradol, and fentanyl. i come back an hour later… “did it do anything?” her: “i sort of felt it but now it’s worn out”. at this point i want to put this chick on a vent, max out dilaudid and transfer her to the ICU. but one last try. i double the dose on her PCA and cross my fingers. i didn’t hear from her again that night, which is good because i pretty much stopped caring.

at the same time this was going on, some other chick from a car crash was complaining about muscle spasms and pain. which was reasonable because she cracked her hip. muscle spasms huh… how about some vencuronium, vent, and transfer to ICU? well, even though retiring from medicine at 27 seems appealing, i wasn’t self destructive enough to get myself fired that night, so i did what i’ve been doing all night. increase her morphine. of course there was only one problem. i didn’t know that she took dilaudid and loratab everyday at home. no wonder i kept getting paged about her still complaining of pain. yikes. how much dilaudid can you give again? i don’t remember how much i gave but it was an assload. stopped getting paged about her too, eventually.

i think half the patients on the service were actively complaining about their pain that night.

playing nice

i don’t think i’m too much of an asshole. i’ve been nice to every single one of my chronic pain patients. i didn’t always give them all the pain control they wanted, but i figure if you get into a car accident, you shouldn’t expect to be pain free. that’s just not realistic. and i sure as hell don’t want their sorry ass getting pneumonia, because that would require me to fill out tons of useless paperwork for every day that they’re sitting on their ass getting antibiotics.

it’s weird being called doctor. i haven’t decided yet if this is a sign of respect or sarcastic patronizing, especially since i make no pretense about not knowing what the hell i’m doing. it’s either “let me look up the dosing” or “let me ask my senior”. it’s weird because during med school, i always heard the residents called by their first names. but here they all call me doctor. maybe that’s the way it’s done in these parts.

you're going to feel some cold gel on your bottom

my job as an intern (a “real” doctor, mind you) is awesome. i have the pleasure of sticking my finger up a stranger’s butthole and sticking a plastic tube into someone’s peehole. it’s funny comparing adults and pediatric trauma patients. pediatric trauma patients will do everything in their power to prevent someone doing a rectal or foley. i remember this one 14 year old guy started to cry, as if getting a rectal was like getting raped, and this would turn him gay for the rest of his life. he clenched his buttcheeks so hard he could have broken walnut shells.

that got me thinking… isn’t that what a normal person would do? it’s amazing to me how adults allow doctors to do all these things to them. they barely even protest. i wonder what their experience in the hospital has been like; they’re trauma victims, so they don’t necessarily have an extensive medical history. what is it about adulthood that makes them so resigned to let the doctors do things that a teenager would do anything to avoid? i’m pretty sure it’s not better understanding of what needs to be done, because, frankly, i don’t give my trauma patients that much credit. i think it has something to do with being constantly beat down by society. subclinical learned helplessness i think is ingrained in virtually every american citizen.

the learning curve and the incessant agony of working in a dysfunctional hospital

a lot of people say there is a steep learning curve during internship, and you know what? they’re absolutely right. there is a huge learning curve… about narcotics. after about a half a week of working, it seems like i’m on a narcotics internship instead of a surgical one. seems like i write for narcotics more than morning labs. oxycodone, percocet, morphine, dilaudid, roxicet, fentanyl… is there any narcotic i haven’t prescribed yet? i understand people are in pain, and that sucks. but at the same time, i hate them and i wish i could just load them up on pain killers so they would go to sleep and just shut the fuck up. and having had night call, i had a pleasure of taking phone calls from drug seekers about their “lost prescriptions”.

internship just sucks ass. in an ideal world, i would write an order for a chest xray. it would actually be done, and i would be notified when it was available to see, and the attending radiologist would go over it with me when i wanted. but i work in the real world, and working in the real world is infinitely more painful.

1. make box to order chest xray
2. order chest xray
3. shade half a box to signify having ordered the chest xray
4. wait 2 hrs
5. go to chart to see if order was faxed to radiology
6. wait 1 hr
7. call radiology to see if they got the order
8. wait 30 minutes
9. call radiology to ask when they will take the xray
10. get tired of waiting, write chest xray STAT (costing hundreds of extra dollars for shit people should be doing quickly anyway)
11. xray done
12. wait 1-2 hrs for xray to show up on stentor
13. look at cxr
14. let senior resident know about cxr reading
15. wait 2-4 hrs for final read from attending
16. let senior resident know about final cxr interpretation
17. check off rest of the box indicating cxr was ordered and read
18. write note about xray findings on sign-out sheet
19. write note about xray findings on tomorrow’s progress note
20. write note about xray findings on tomorrow’s rounding list
21. write note about xray findings on the trauma tertiary survey form

the best thing about internship is spending the whole day obsessing over other people doing the work they’re supposed to do, 1) because you don’t trust them 2) because if they don’t do their mcwork it’s your ass on the line 3) patients suffer if people who don’t give a shit don’t do their mcjobs.

the second best thing about internship is documenting the hell out of everything onto four, five, sometimes even more pieces of paper, because hospital computer systems are total shit.

the third best thing about internship is getting paged about someone’s pain, seeing that they are on fentanyl and morphine, and it isn’t “touching them”, and writing for dilaudid. and then having to increase the dilaudid. and then finally giving up and giving them dilaudid PCA even though we’re supposed to “normalize” patients to get them the hell out. and hoping they push the PCA enough times to go to sleep and stop bothering me for the rest of the night. then getting paged about a phone call from someone who was recently discharged and lost their narcotics. then having them ask to talk to the attending because i won’t give them more narcs for them to sell to their friends. then writing for narcs anyway.

there’s some irony in how painful internship already is, and that i’m prescribing all these narcs all the time. but i didn’t major in english and i’m lazy.

thankfully 4th of july was unexpectedly quiet. and there’s free chocolate milk in the resident’s fridge. i do love chocolate milk.

the surreal life

the other day we rounded on this patient who had her own clothes on in bed. “i feel like a human being again”. i was like, yeah that’s great. what about me? i’m still in my scrubs and been working the night shift for a week.