The Final Straw

I plugged along for one week at [] hospital. I came into the hospital early in the morning to round on my patients, but there was always something missing when I reported to my resident, a kind and patient third year named William. Actually, there was always a lot missing. I usually hadn't talked to the nurse about overnight events, I usually hadn't looked up the vital signs, I may have looked at the Electronic Medical Record, but I often hadn't looked in the Paper Chart.

As an aside, electronic medical records promise to solve the problems and confusion arising from scattered notes written in illegible handwriting. The hospital was trying to upgrade to a completely electronic system, but, while some of the electronically written notes were easy to read, the changes were creating even more chaos. There were two computer systems- one was older, and the hospital was trying to phase it out. Unfortunately, the new computer system wasn't as user friendly so those used to the old system shied away. And then some people didn't use either, preferring to leave scrawls in the old fashioned "paper chart."

So, when I came in each morning, I was supposed to look up the vitals, carefully recorded by the nurses overnight at 4 hour intervals, in the newer of the two computer systems. Then, I was supposed to check for notes. While in a hospital, a patient may be followed by a particular service, in this case Medicine. But, while there, any number of consults may be called. The patient suddenly develops numbness and tingling? Call Neurology. Questions about a new antibiotic regimen? Call Infectious Diseases. The patient has chest pain? Call Cardiology. Funny vaginal discharge? Call Obstetrics and Gynecology. Broken bones? Orthopedics. So, during the day, any number of clinicians may have visited each patient. And, each department tended to leave notes in different places. Neurology invariably left notes in the new computer system. Obstetrics and Gynecology used both computer systems, so any notes discussing the possible etiologies of vaginal discharge could be found in either. Of course, there were individuals from every consult service who preferred the Paper Chart, leaving an actual tangible note there.

The nurses basically serve as the eyes and ears of the service. Teams of medical students, attendings, and residents constantly switch. A particular resident, for instance, may be on one of the Internal Medicine services for a few weeks and then switch to another service, vacation, or outpatient clinic. Medical students only stayed five weeks in any particular place. And, the attending physicians seemed to rotate as well. A single patient staying in the hospital for any length of time would see a great number of medical students and doctors passing through. Teams of nurses, however, tend to remain on the same floor. Not only that, during their shifts, they actually stay on their assigned floors. Doctors and medical students might be running around to clinics, the operating room, rounds, teaching sessions, or any number of activities, but the nurses are actually present, on the floors, at all times. So every morning, nurses can provide information on how a patient has done overnight. Did the patient spike a fever? Sleep well?

It was generally the job of the medical student to gather and consolidate data in the morning. But with my sudden pathological forgetfullness, this became a nearly impossible task. William took me aside, saying, "Are you confused about what you're supposed to do in the mornings?" I nodded. "I already told you this, you go to the PAPER chart, you go to the COMPUTER, you talk to the NURSES, you talk to the PATIENT, you gather ALL THAT DATA, and then you report to me..." He stopped, looking at me, and then wondered aloud about whether there was something wrong with me. William generally had a look of kind understanding. He was the sort lauded on good bedside manner, the type patients could trust, and the type not to be annoyed without good reason.

"I think I could be a good doctor one day..." I tried to explain that I wasn't usually this forgetful, that this wasn't me, that I didn't know what was wrong, but that I was sure if it was fixed, that eventually, I could function as a doctor. But the mounting tears prevented me from speaking.

"Did you have trouble during first and second year?" asked the resident. The look of kind understanding reappeared on his face. I didn't answer- a tear rolled down my cheek and another threatened to join it. The fact that I had done well during the first two years, that my board scores were excellent, almost made things worse. The resident likely took my silence as agreement. Our conversation ended with him pausing and saying "I don't think you can function in a hospital." He spoke carefully, as though delivering bad news to a patient. He paused, looking at me with a mixture of sympathy, confusion, and annoyance.

The fact that William was mild mannered and didn't routinely abuse those around him made our conversation even worse. I couldn't complain to my classmates over drinks about yet another injustice incurred at the hospital. I couldn't dismiss this or laugh about it later.

I knew he was right. I left the hospital that night and didn't return for nearly a year.

(The above post describes past events, right now I'm in school and doing fine)

The Descent Continues

My medication change, my talk with the Site Director, my realization that if I just kept getting up in the morning, going to the hospital, coming home, taking Ambien, going to sleep, and getting up again, I could go on indefinitely. And that's what I did- I slogged back and forth between the student housing and the hospital. I ate, I slept, I did all the things and ordinary human being is supposed to do during his or her time on earth. And I fell into an equilibrium.

Realizing that things were better, but not great, I again called Dean Stewart to ask about taking time off. “Now that you’re psychiatrically stabilized, I don’t see that there’s any benefit to you taking time off…” I wanted her to understand that while I felt my feet were becoming more firmly planted beneath me, that things weren’t right. I was functioning in the hospital, puttering about, writing notes, presenting on topics; and while I wasn’t excelling, I was now certainly up to standards. She advocated self care, telling me that perhaps I should take a day off on the weekends as opposed to voluntarily going in to the hospital to see my patients.

I eventually finished my 5 weeks of internal medicine at Glendale and returned to my home hospital at [] medical school for the final five weeks of the rotation. When I arrived I’d been branded as a “student in trouble,” a distinction which awarded me “extra help” in the form of constant suggestions during my presentations. Were I not to have been branded, I believe, a lot of those little mistakes would have gone unnoticed, or would have appeared in my evaluation as qualifications to my otherwise stellar performance. But instead, my preceptor, desiring to “help” me decided to do so by bringing our preceptor sessions to a screeching halt when he sensed that I did not understand something. The other 3 people in the sessions politely waited as my presentations were drawn out and picked apart. Did I understand the difference between infection, and vasculitis? Yes, I stammered, turning red; the preceptor was doubtful that my response reflected true understanding and launched into a long explanation.

My descent into hell

Glendale had a community hospital where the nearby wealthy landed should they not have a medical problem urgent or obscure enough to land them in one of the “fancier” university hospitals in the area. It was a small hospital, contained in one building, and having only four floors. While [my med school's hospital] has a MICU, a PICU, a NICU and a SICU, the last three letters standing for intensive care unit, the first letter standing for medicine, prenatal, neonatal, and surgical, the Glendale hospital had only an ICU which occupied only one part of one floor. The other specialties, medicine, neurology, surgery, pediatrics, and obstetrics and gynecology were distributed throughout the four stories.
After arriving in Glendale, myself and the other two students from [] medical school met briefly with the Course Coordinator, a smiling woman named Joanne, who gave us the keys to our student housing, and ushered us into a conference room to meet the course director, a kindly gray haired internist named Dr. Foulton. Dr. Foulton had a halting way of speaking and often, while trying to recall a specific point, or think through a particular problem would close his eyes and hold his hand up as though shielding himself from sunlight. He had a gentle manner, and a gruff, albeit soft, voice. Dr. Foulton, unlike some attending physicians didn’t STRIDE through the hospital, he walked. He led with a quiet confidence that required no outward reminders of his rank or position. He did have the curious habit of introducing students as doctors and this was the first time I was to hear myself introduced as Dr. Forest. It was unnerving, and had a classmate or nurse introduced me as such, I would have qualified with “STUDENT doctor.”
The student housing at Glendale consisted of three houses- two of which were filled with [my med school] students, and one of which was for med students from [a nearby med school]. That house had only one resident, a medical student doing her family practice rotation. In my house, some students were lucky enough to have single rooms. I shared my room with another [my med school] student named Allisa Carter. Allisa was doing her Ob Gyn rotation and spent more time out of the room than in- an arrangement which suited me well. In fact, when I first moved into the room I didn’t see her for the first couple days and knew only that I was co-habiting with someone who had small feet, expensive shoes, and a penchant for tidiness.
I slowly slipped into a routine- I’d get up at 6 to be at the hospital at half past for pre-rounds where I’d stop by my patients for a brief assessment. Rounds were at 7 sharp, a relatively informal affair lead by Dr. Foulton. We generally stood in the hallway- anyone who had a new patient to present would give Dr. Foulton the run down, and then we, as a group, would visit certain patients. Usually we’d visit new patients, or those with interesting physical findings. One of my patients had aortic stenosis, for instance, and we went to her room where we lined up, one by one, to listen to a heart murmur that radiated from the right side of her upper chest to both sides of her neck. The aortic valve separates the heart from the rest of the circulation, and when the valve is stenotic, meaning it doesn’t open quite enough, the blood flow makes a distinctive noise as it tries to force itself past the too-small orifice. Instead of lub dub lub dub, I recall hearing Bwoosh, Bwoosh, Bwoosh. At the end, Dr. Foulton took the woman’s hand in one of his larger ones, and gently thanked her. When I returned later that day, the woman didn’t wish to see any more medical students.

It was at Glendale that I first noticed things were really wrong. Normally chipper and awake in the mornings, I found myself with eyes closing during rounds. Coffee did little to lift my early morning spirits and I found that this tiredness followed me through the day. While I normally have an excess of energy requiring me to volunteer for duties on other floors, merely for the opportunity to gallop up or down the stairs, at Glendale my feet simply didn’t want to walk, just as my face simply didn’t want to smile. A friendly greeting was as difficult as trying to mold frozen butter. I could muster a smile, but it was more of a grimace. My eyes did not squinch shut and the rest of my face remained frozen. Every morning, I awoke and went to the hospital, but with each step I could barely muster the energy to continue with another. And another. And another. I wanted to melt into the floor and disappear.
My roommate from school called me, but I didn’t return her call. It didn’t seem worth it. Picking up the phone. Talking. Dr. Foulton asked me questions on rounds and I was unable to respond, unable to think. Thoughts slipped from my grasp like melting ice cubes. My psychiatrist quizzed me about my medications. Did any of the medications look different? Had I switched from genetic to brand name or vice versa? Was I taking the medications? She increased my Wellbutrin and Ritalin doses and I emerged from underwater, if only enough to look around and reaffirm what I knew was true. I needed to die. My doctor had prescribed me Ambien, and each night I took enough pills to render me unconscious- I didn’t want to worry about getting to sleep, I didn’t want to remember getting to sleep. Sleep waited for me at the end of each day like the period at the end of a sentence. With 40 mg ambient, sleep was sure. It would happen. And I awaited the end of each day so that I could resume my unconscious state.
I had a favorite computer in a corner where I would sit with my head down, long hair loose around my face, crying as I pretended I was mesmerized wit the computer screen, the keyboard. “You’re the most devoted medical student I’ve ever seen,” said a resident, noting I was always in the hospital. “What else is there?" I wanted to ask. The evenings found me released from the hospital but I was unable to fill my time. I studied, nothing stuck. I watched television, still not comprehending. The medication change helped a little bit, but it was powerless against the immense tide of my depression.
I asked the dean if I could have some time off. That way, I figured, I’d be able to address whatever it was that was dragging me to the bottom of the ocean. And I’d be able to study for my ob-gyn shelf. I just needed a little time and then everything would be OK. I also needed a haircut, but it cost money, and more than that, it cost energy. Because getting to the hair dresser or first finding a hair dresser, then getting to one, would take energy. And for what? My hair hung like a dress that’d been in the back of the closet for 3 years too long.

“Are you safe?” asked Dean Stewart during one conversation. I’d sneaked to one of the hospital bathrooms for this conversation, and told her that yes; I was safe, explaining that there were a number of other students in my house. I wanted to tell her that I wasn’t safe, that even as I spoke to her I was thinking that the bathroom, on the second floor, wasn’t nearly high enough. Were I to jump, I would likely survive. Each day I imagined slicing into my skin with a scalpel, watching a thin line of blood appear as the upper epidermal layer separated, and then seeing the yellow, lumpy fascia as the knife cut deeper. At this point, the edges of the cut would pull apart. My cuts often assumed the shape of a fish- narrow at each end with a wider belly at the center. They never healed as they should have. Instead of sewing the opposite sides together, I let them stay to heal as they would. The scar tissue would fill in and I’d be left with a dark rose reminder. My upper left thigh was filled with such reminders. A doctor once asked what the significance of this part of my body was- and there was none. I’m right handed and when I sit, my right hand is next to my right thigh. I cut on my left thigh once when I ran out of room. I cut on my stomach a few times for the satisfaction of slicing skin that had never been sliced, and I cut on my wrist on three angry occasions.
I wanted to cut but I had no privacy- I shared a bedroom with Allisa, an arrangement that left me unable to cut, unable to dose myself into a 24 our sleep, and unable to binge, hiding the contents in our shared closet. So, every day, I went to work imagining that a car would hit me as I crossed the road. I imagined slipping on the hospital floor and disappearing into a puddle that would evaporate.

One day, Dr. Foulton asked me to speak with him after rounds. I followed him into the conference room and he asked me how I was. I told him I’d had a rough time during Ob-Gyn, but that I’d be fine. “We do not rule through fear and intimidation here,” he said gently. I couldn’t answer; if I opened my mouth I’d start crying. I sat silently, finger in my emotional dyke. He told me that he did have his doubts, that I seemed like a bright young lady. He suggested I seek counseling. He said there was a minimum standard, and that I was not meeting it. I finally offered that I have a mood disorder and said that I was trying to get time off.
“This is the real world,” he said, explaining that if I was having difficulties coping, that taking time off would solve nothing- I would have a brief reprieve and return to the same problems. I wanted him to understand that I wasn’t normally like this, that taking time off would enable me to solve what was wrong so that I could return as an improved individual. He seemed to believe that I needed to handle things and not run away from whatever problems I was experiencing. “I’m not running away! I’m sick! I have an illness! I’ll take time off, recover, and then return,” I wanted to say. But I was silent, finger back in the dyke.