"Lame?"

(Disclaimer- while this blog is a real account of some of the things I went through- any patient descriptions have been changed out of respect for privacy - i e the patient described here does NOT resemble any patient I have come across- there was, however "a" patient deemed "lame" by an intern)

At the start of my new rotation, my resident sat down with me to explain expectations, how I could succeed, how he could help me. He told me I would be on "call" with him and that during each call, it was my job to "work up" one patient. I would then "present" the patient to him.

"When I was a medical student, I thought my presentations were pretty good... but when I got my evaluations, they weren't as good as I thought..." he explained that he would save me from a similar fate by working with me. The thought of "presenting a patient" had always made me a little bit nervous. Practice, practice, practice... I was told. Practice in front of your friends, in front of a mirror... A great presentation was key to honoring a rotation. The way presentations were described they sounded like they required something on the level of power point. Patient presentations always used to make me nervous, but they shouldn't have.

A patient presenation is basically a way of telling people how the patient came to be at the hospital, relevent symptoms, medical history, physical exam findings, and any x-rays or lab results. If a patient comes to the hospital with a heart attack, your presentation should convince those listening that this is why your patient came to the hospital. Presentations are really not something to be feared, they're just a way of communicating, a way of weaving together a story.

So, if you have a brown haired, brown eyed patient with three pet golden retrievers, and a recent history of coughing, and you know he came to the hospital with pneumonia, you're going to want to highlight things in his presentation and history that are relevant to this diagnosis. Telling the attending that this is a brown haired brown eyed patient with three golden retrievers who ate clam chowder last week might not be relevant, whereas a history of smoking, a cough productive of green sputum, and chest pain worsened by deep inspiration might be.

But, as my resident told me it should take me hours to work up my patient, and that he had spent all night on his patient presentations during medical school, I actually started to wonder. What did "working up" a patient really mean? Was there something I was missing? It didn't generally take me hours to interview and examine a patient, and it had certainly never taken me all night to work on a presentation. The resident was wasting his time with me, he didn't know that I was a Student In Trouble, a student pegged by the deans office, a student in danger of failing out of school. I wasn't an honors candidate, I was barely hanging on.

My first patient, on the infectious disease service, had multiple medical problems and she had been admitted with chest pain. She'd already been admitted to the service, and the resident presumably knew the reason why, but it was now my job to interview the patient, perform a physical, and decide why she had come, what her diagnosis was, and how to treat her. The first thing that struck me was how thin the patient was, beyond thin, emaciated. She was there for chest pain, but it was obvious he had something much worse going on, something greater than just her chest. Her head looked too big for her body, like a distorted lollipop. Her skin hung like an outfit that was two sizes too big.

The patient was from the Ukraine and didn't speak English so I got a translator. "So what brought you to the hospital today?" I asked. The translator, who sat next to me, looking toward the patient, repeated what I'd said in Russian. The patient replied and the translator spoke to me in English.

"Can't you see? It's obvious." I wasn't sure what to say. The patient spoke in Russian, throwing up her hands as she did. The translator explained that he had been interviewed by several people and didn't understand why I now was asking the same questions. I smiled, explaining again that I was the medical student, but that if she did not wish to speak to me, it was her choice. She threw up her hands again, and the translator relayed the fact that she didn't care, what did it matter.

I wasn't sure what to do, I knew the patient did not want to see me, even if she would not admit this outright. And, although she refused to answer most of my questions, it appeared that she did not have very much time left on this earth. I knew it couldn't be pleasant answering the same questions from person after person, and I didn't want to subject her to any unnecessary trouble. I wanted to drop her, and ask for a new patient, but I knew from the student handbook that students were not allowed to refuse to see a patient for any reason.

I asked my intern for advice, and he assured me that I could use some of the data he had gathered during his history taking. "She's sort of a lame patient, sorry you have to work her up." I wasn't sure what to say to this. There were apparently "lame" patients and "not lame" patients. What made this patient lame? The fact that she was difficult? Were her medical problems not interesting? Was it that she was Russian speaking? I wasn't sure how to respond, so I smiled and said, "It's ok, she seems nice."

"Nice." The intern looked at me. Now I really wasn't sure what to say. While she hadn't been "nice" by any stretch, but I thought that feeling really horrible physically might excuse one from societal expectations of politeness. I did a search for the patient's medical record and started to read about her history.

The patient had terminal cancer, and now, according the intern's assessment, she had pneumonia on top of this. It did seem that he had created some problems during past visits- she'd refused to speak to residents and attendings, she'd refused treatment, she'd been belligerent I worked hard to see how his more recent history and physical exam findings had lead to this diagnosis. She'd had a cough productive of green sputum, chest pain worse on inspiration, and her chest x ray showed an area of "focal consolidation" meaning that part of one of the lung fields was completely whited out. The patient would need to stay in the hospital while she got antibiotics. Then, she would be released back to her nursing home.

I wasn't sure what was worse- the fact that my time in the hospital was to be spent badgering a patient I felt should be left in peace as much as possible, or that my time in the hospital was spent in the company of someone who deemed this patient "lame." The resident didn't seem to share the intern's sentiment, and seemed to have a genuine feeling of empathy for the patient, but most of my time, I learned, would be spent with the intern. And if the intern had the world divided into "lame" and "not lame" I was pretty sure I fit into the "lame" category. But, I tried, I smiled, I was nice, I offered to help out.

So, I sunk into another sort of routine. I woke up, plodded to Starbucks for some caffeine, and then plodded to the hospital where I would briefly examine my patient and then present my findings to the intern and resident before meeting for attending rounds. Then we would all go to noon conference where I would swallow pizza and diet soda. When my day ended, I plodded back home to where I would watch television while waiting to fall asleep.

Internship

I'm now a nearly two months into internship and what a ride it's been so far. My program is better than most when it comes to hours, but my longest shift thus far was 33 hours. We have a night float system, but we still do 24 hour calls occasionally. The ACGME rules allow for the extra 6 hours for transfer of patient care, bringing the total to 24 + 6 (or 30) but my program supposedly abides by a 24 + 3 rule. In other words- 27. It's like they think we won't realize we're working more than 24 hours if instead of saying that the shifts are 27 or 30 hours, they say "24+3" or "24 + 6." Managing my medication on long calls is tough, and I have to make sure I don't flip into hypomania so I HAVE to take my evening dose of Seroquel, even if I'm going to be staying up all night. I take less of a dose, and make sure I get sleep when I return home. So far, so good. No hypomania. Just exhaustion- like all the other interns.

I keep my illness a secret from other people- sneaking pills from inside my Coach wristlet- and I don't think anyone I work with now would ever guess in a million years that I'm hiding something. If you met me now, you'd have no idea. It's nice to be out of medical school because my hospitalization is now a nearly three years in the past. I just tell my peers that I did a research year if it comes up that I was in medical school for 5 years. Of course when I was interviewing, I didn't lie- when asked I said I was on medical leave and then did research. But now, there's no reason to discuss this with my new friends. I just say research year, leave it at that, and I don't have to answer uncomfortable questions anymore.

It's great- sure I do struggle- but I'm so happy to have made it. Sure, there are sucky parts of internship. I had a 24 hour call last night and a nurse called me at 2:30 am to say the BP was 180/80 when it had been that way all day. But, despite these annoyances, I don't regret going to medical school.

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.