The CCU

I had it easy. I keep thinking that.

When I was an intern in the Coronary Care Unit last year, I had some fun. I really did. My resident was great; she looked out for me and didn't give me too much work. She let me sleep after midnight. She read EKG's with me. She showed me how a balloon pump worked.

Now, I've taken on her role. I have an intern. My intern is sad. He is overworked, overwhelmed, miserable. I took him out for a drink the other night, at which point, after two amaretto sours, he confessed all this and said, in addition, "And I haven't learned anything!" I was crushed. I resolved to help ease the stress on him in the CCU. I took on all the admissions after 8PM and made him go sleep or read or watch the newest episode of Lost.

But what happens when I feel overwhelmed? I'm still trying to juggle my roles of resident and teacher, runner-of-unit and friend. Challenging, soul-pulling. I feel as though I don't know enough to be able to handle the additional responsibility and help my intern not be so sad.

The CCU at my hospital is notorious for being demanding at times. Especially in the winter/holiday months. We have seven CCU beds and about 25 step-down beds. Often, I am moving people out of the CCU soI can at least keep one bed open. If I have to fill the unit, if people are just that sick, then I close the unit. But even if I close the unit, even if ALL MY BEDS ARE FULL, the ER can still hurt me. At first, I thought they were simply in denial.

"OK, I have a lady down here..."

"Wait, you know the CCU is full, right, and that all the step-downs are full, right?"

"That's not my problem."

"I'm sorry?"

"I have a lady down here with chest pain!"

"But I'm telling you, I have no more beds."

"OK, you and I have to work together, for the benefit of the patients."

Again, I'm not sure what part of "WE HAVE NO MORE BEDS" that particular resident didn't understand. People often will hear what they choose.

The best part of this medicine hell called CCU q3 overnight call is that every six days, I get a much deserved day off. The sad thing is that I spend it sleeping. A lot. I make like my cat and turn into a bowl of sleepy jelly. I will occasionally wake, maybe eat something, and watch saved episodes of Grey's Anatomy on my roommate's TIVO. Sometimes, I will fall asleep during these episodes, I'm that exhausted. I try not to interact with my mother during months like this, because she often thinks I'm running myself into the ground. On purpose. I don't think she remembers her own medicine residency, what it was like to be pushed to human limits.

Not to worry, my friends. This will soon be over. I have one more week. One more week to keep saving lives, preserving lives, teach my intern something remotely cardiac-related, and to improve on my interactions with the ER staff.

My Moonlit Night

I experienced my first moonlighting shift as a somewhat "real physician" this weekend.

It will probably be my last for a long time. This is how it went: I did not have the opportunity to eat or pee for 12 straight hours. How is this different from resident wards, you ask? House staff, ER attendings, nurses, and other staff members called me "the night attending" and asked me what I thought they should do in certain patient cases. Me! I had ten admissions, turfed an additional three to the resident teams, and answered endless cross coverage pages on private patients. I came out alive and pondering whether or not I should purchase a green or pink iPod with my check.

I also got to make the call on which patients went to the resident teams and which stayed non-teaching. Well, it wasn't much of a call. My good friend happened to be the resident taking admissions that evening, and she quickly blocked all my potential teaching patients with phrases such as "But it just doesn't sound interesting. Mental status changes in an elderly nursing home resident with normal pressure hydrocephalus just doesn't do it for me." She took me out for breakfast after our shift.

Am I starting to feel the onset of power, perhaps? Likely not. My self-esteem may be much improved over the tiny quark it was in high school, but I still laugh at myself several times daily. Me. A doctor? Patients and staff say it all the time. My mother still can't get herself to call me doctor. I suspect medicine will always humble me.

Another humbling thing that happened during my moonlit weekend was this: the guy I was seeing "broke up" with me on email. Yes, email. We had only gone out on two dates and they were friendly dates, no bedrooms involved, yet he decided to compose a Dear John letter to me. On email. In the middle of a long moonlighting shift. On email. I sat there staring blankly at the computer when--

"Hey. I have two more patients you need to see," the ER attending tapped me on the shoulder and spoke with some urgency.

I looked back at her, unable to shake my blank stare.

"What?"

I explained to her what happened.

"That bastard. I'm so sorry. You want a yogurt?"

Nothing soothes a broken heart more than food. Or alcohol.

"Does it have scotch in it?"

"Uhh, no. But I have tangerines! Do you want a tangerine?"

I smiled and accepted a tangerine. She patted me on the back and put two charts in my lap. "Don't worry, hon. He'll come crawling back. They always do."

Fortunately for me, I have already been dumped earlier this year. Twice. By different men. With the right therapist, anti-depressant, and a great set of friends, one can get dumped several times over the course of a year and still preserve the ability to love oneself. I was able to pick myself up and move on, even though for a while there I was lying on the floor like Izzy in "Grey's Anatomy." I think being dumped fosters a sense of rejection in the dumpee. Even if it is a friendly parting of ways with the other and meant with the best intentions, I still feel like I wasn't good enough, pretty enough, smart enough, funny enough, sexy enough.

I looked away from my email inbox and looked at the charts waiting in my lap.

I put on my white coat and peeked behind the first curtain.

"Oh, doctor. I'm so glad you're here."

I had never been so grateful for feeling needed. Even though my dating life teeters on the edge of non-existence, at least I love my job.

She looked too healthy.

I spotted her in the waiting room. Her hair sat neatly made in a French twist, smooth bangs parted on her right. She wore blue cargo pants and a green sweater, and she was reading a book on Baruch Spinoza. What was she doing in my medical clinic?

Most of my patients arrive to clinic in a state of chronic or acute illness. Many of them are appropriately dressed, but they look sick. Many of them are in constant pain. Some of them want their fix, their benzodiazepines or their narcotics. Others just want their blood pressure medications refilled. This is not to say that the average decent human being who is a patient in Resident Medical Clinic and who happens to be homeless, uninsured, or disabled can't also look fabulous.

However, I have yet to catch any of them reading a book on one of the most compelling and complicated philosophers in history.

"Hi."

"Hi."

"I'm Chloe. I'll be your physician today."

"Lindsey. Nice to meet you."

"So."

"So."

"What can I help you with?"

She explained her problem with occasionally seeing blood in her sometimes liquid, sometimes formed stool. I quickly settled into my comfortable medical place where there is one complaint and I can beat it to no end with specific, detailed questions, until--

"I don't really remember my 20's." [Laughs.]

"Really? Why not?"

"I was smacked out on heroin."

[Silence. Not many jokes I can make about heroin. She smoothes the front of her sweater.]

"I guess that's why I'm so jittery now," she continued.

"Right. Are you still doing..."

"Oh, NO. Nonono. I was on Methadone and Suboxone, now I'm completely clean." [Smiles]

I knew that was coming. The interview was too easy up to that point.

The rest of the history-taking went well. She seemed pleasant and sincere. She brought all her medications. She knew her allergies. She's been trying to get her masters in Philosophy at a local college, but she had to quit her job the week prior due to unending and embarrassing diarrhea. I worked up malabsorption and wrote a referral to the GI folks down the hall. Her mother has a history of ulcerative colitis. She might need a colonoscopy.

The plan was set. I felt like I knew what I was doing. I even had a full fifteen minutes before my next patient, then--

"So the GI Clinic will call you with an appointment. Is this your correct phone number?"

"Yes."

"I noticed it's in another state. How long did it take you to drive here?"

"Umm, about and hour and a half. Not that long."

"An hour and a half?"

"Yeah, I just didn't want my boyfriend to know I was coming here. "

"Oh, why not?"

"Well, he's kind of controlling."

"How so?"

"He yells sometimes. And he restricts my allowance. Since I can't work, I get an allowance from him."

"I have to ask you--"

"Does he hit me?"

"Yeah."

"Sometimes."

I remembered seeing bruises of various ages on her hip, arms and legs. She told me just minutes ago they just appeared out of nowhere, that she must have bumped into things at work or at home. How did I miss the possibility that their etiology could have been something other than what she was telling me?

After a long sob, the patient smoothes the part in her hair and buttons the top button of her sweater. She shakes my hand and promises to get those lab tests I ordered and make those appointments I recommended and to see me again in a month.

I haven't seen her since.

Early Satiety

Welcome, old and new readers and friends! Thank you so much to my loyal readers for your encouragement and kind words. I'm glad to be writing again, and I'm so touched you've continued to read my work.

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Early Satiety

"I’m getting fat! How do I stop gaining all this weight?"

My patient throws her thin arms into the air and looks at me. Her abdomen sits rotund, larger than a 42 wk pregnancy, and her sleeves are loose and parachute-like. She tells me she used to be able to eat four hamburgers; now, she can only finish half of one before she feels full. At night, she can no longer lie flat without becoming short of breath from the weight of her insides pressing on her. She is 66 and has not had a period since the 1970’s. She has a history of breast cancer, status post radiation and mastectomy. She also had a vaginal hysterectomy for fibroids, and she opted to keep her ovaries.

In addition, she is a wonderful person. The nurses and CNA's love her. A regular in the Resident Clinic, she and her husband collect Social Security and Medicare, and the Clinic is situated conveniently on their bus line. I might be the fifth resident to have her in my three-year long Continuity Clinic.

"Good Lord, look at me! What is the deal?" she says, wiping the sweat from her brow. She's been easily tired. The weight started to pile on quickly in the last six months.

When I present the patient's case to my clinic attending in a nearby lounge, he shakes his head. "The nice-person, negative-prognosis sign," he says. I nod. I know what he's talking about--mean patients tend to be less likely than the pleasant ones to pass away.

I filled out a lab form that included a CA-125 and a CT scan of her abdomen and pelvis, in addition to an array of other serum levels. I walk quickly back to the room and tell her we are looking for something that may cause all this fluid.

"Like what?"

"I don’t want to alarm you."

"Like another cancer?"

"We’re not sure. We want to be sure."

"Isn't it all just fat?"

"I don't know. It could be."

"I mean, look at it!" At this point, she grabs her belly and tries to lift it off the chair. I try not to laugh while she shakes her head and lets out her own laugh, then a sigh.

"OK. Do what you need to do, Doctor. Just make sure Medicare covers all this."

I wondered to myself, if I hadn’t been an intern in OB/GYN for a year, if I hadn’t seen all those women with ovarian cancer, their abdomens sometimes so filled with malignant ascites they couldn’t breathe at night, would I have come to the same conclusion about the patient in front of me, in a general medicine clinic?

I hoped, Maybe it IS all a pannus. But the fluid wave. I couldn’t ignore a fluid wave. Her abdomen seemed to grow exponentially. It had to be ascites, but why? Her lungs were clear. A recent ECHO showed no evidence of heart failure. A set of liver function tests from last year was normal.

The last patient I took care of with ovarian cancer lived and died during my first internship, on my rotation in Gynecology-Oncology. I can still remember what her cries sounded like, and what her smile looked like. Her case infused my thoughts even when I was at home, though I tried not to let it. I knew it wasn't wrong to feel things while at work, but I didn't want to feel too much. I didn't want my emotions to hamper my job.

Seeing this new patient in front of me, this funny, pleasant, kind woman who brings her health to me and asks me to help take care of it, I know it is useless to hold back. If what happened to me with the previous patient repeats itself, then let it. If it hampers my job, it might also make me a better doctor.

Formerly on ResidentDiary.com

I used to have a regular stint on ResidentDiary.com, but after eight months of random readers writing harsh, unprovoked comments and some writers' block on my part, I pulled the plug and set out on my own. So here I am. I can write about medicine or not. I can write in verse or not. The choices are endless! I continue to be a resident in Internal Medicine, but I am finally done with internship. I don't recommend two internships to anyone. And I wonder daily why I'm so tired and whether or not it's my thyroid. [It's not.]

I will be sure to post some poetry, even some plays, in the future, but for now, let's start with a short story. A vignette, if you will.

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I went to Catholic mass and heard my pastor preach about sin. He had his right hand in the air, I presume, pointing to God, and a large hardcover Bible cradled in the crook of his left arm. He looked quite holy and kind of scary, but strong. This is my pastor, I thought to myself. My pastor, whom I have seen naked twice.

He was in the military before he became a priest. I took care of him when he came in for chest pain at the local Veterans’ Affairs Medical Center. His voice sounded calm and deep, a quality in it deserving of reverence. I didn’t know whether to call him Father or Sir or Mr. He was half-dressed in a hospital gown and reading a novel by the window. He was a tall, thin man who thought he had a heart attack.

I perused his medical records. I asked him if he was taking his anti-retroviral medications daily. He said, Yes. My viral load has always been undetectable and my CD4 count above 350.

I nodded, penned his answers in my notes. I would schedule him for a stress test. His cardiac enzymes were negative, normal. He likely did not have a heart attack, but we wanted to be sure. I never asked him the one question everyone wanted to ask him but could and did not have a medically relevant reason to do so: How did you contract HIV?

Instead, I asked, How many sexual partners have you had in the last year?

I asked, Do you use protection? Every time?

I asked every question around the actual question. Perhaps I myself did not want to know. When I saw him again, months later, in church, he seemed to look through me. I don’t think he knew who I was. When I receive the holy host from his fingers each Sunday, I avert my eyes, and I have a feeling he knows who I am, but he chooses not to know.