The Beginning

The patient had been in China. And- she had respiratory failure. This basically meant that she required a tube to help with breathing. The intensivist wanted to send for COVID 19 testing but- his efforts were blocked by the county health department. Only certain patients could be tested- there were specific symptoms listed (the patient checked that box) but- also- the patient needed to be exposed to a patient with a known, proven case of COVID. Commercial testing was not available- so- we were all at the mercy of the county health department. Three doctors- 2 intensivists and an infectious disease specialist- had all tried to get the patient tested. But- this was to no avail. The patient did not have documented exposure to a documented case. 

Furthermore- the county health department was dictating that we remove the patient from isolation. (She was in an isolation room.)   In order to get to the patient I had to pass through one door- close it- then- pass through a second door. Negative pressure. There was a closet sized room in between the first and second door. Inside there was a sink and boxes of masks. N95 masks, specifically. The family came to visit frequently. And- each family member dutifully donned one of the masks prior to seeing the patient. One family member's mask was tilted slightly- providing no real protection. Open at the top, open at the bottom. The nurse was wearing a CAPR (Controlled Air Purifying Respirator)- one of very few in the hospital.  This looked like a helmet with a facemask attached.  

"I think I'm going to cry," the nurse said, emerging from the room. She was trying to get the family to stop poking at the patient. The trash can in the small in-between room was overflowing with used N95 masks.  

I'd read a post on my Facebook group November 2019.  Someone's husband was an epidemiologist and he had issued dire warnings. "He said it's going to be like the movie Outbreak."  I could see that this was happening in China- far away.  I recalled Severe Acute Respiratory 

I'd been sick that January- I medicated my 102.1 degree fever, I'd put on a mask, and I'd dutifully gone to work. My eyes were red- like I'd been crying. "A bad cold," I thought. Nurses gave me a wide berth. Nobody sat near me when I stopped to pound out my notes at one computer terminal or another. This was par for the course- doctors didn't take sick days. My "bad cold" had resolved when I saw the aforementioned patient. My husband had proudly shown me the dining room table- in early February of 2020. There were paper towel rolls, toilet paper rolls, hand sanitizer, bottles of sanitizing spray. A giant, shapeless mound of cleaning products. I'd walked past- thinking that we were set for the next decade. 

My "bad cold," the mystery patient, the pile of cleaning products, the Facebook post- looking back- this was The Beginning 

Not sure where to start

I'm not sure whether anyone reads this- I'd forgotten that I had a blog. It's years later- I finished medical school, internship, fellowship. I was never the *best* resident. I was hard working, reliable, knowledgeable. I lacked the Perfect Resident Gleam- the intangible qualities that lead to awards a chief position. I lacked the Bad Resident Tarnish as well. I wasn't somebody on the Program Director Radar. Late for morning report? Nobody noticed. We did have a Bad Resident- when she was late- this further bolstered the PD's characterization of her.  When she did a good job- attendings never seemed to notice.

I spent several years self employed before switching to the safety, security, and predictability of a w-2 position. I'm married- in a nice house in a nice town. My student debt went from a high of around 250 k to under 60 k. I'm doing well

Splitting

I was pretty sure my resident didn't like me. On my team at the hospital, the main players were my attending, the resident, and a medical student. The attending has the highest rank- she was the one on the team who'd graduated from medical school and who'd finished residency. Dr. Mia, the resident, was lower on the totem pole. She'd graduated from medical school two years prior to my stay, and was working her way through a Psychiatry residency. The medical student was what I was supposed to be. She was doing her third year clinical rotations.

Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.

I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."

Patients who split are considered more difficult so I tried valiantly to hide my feelings.

"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependent personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.

When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.