Wednesday, January 4, 2012

Back in the Saddle Again

January 3, 2012

It’s my first day back in the hospital since August.  After orientation, the Internal Medicine Department secretary looks at me over the rims of her glasses and says, “I’m going to put you on team D.  You don’t mind being on call today, do you?”

I’m always on call on the first day, this is the kind of luck I have.

The rest of the students go off to check into the dorms.  I go down to the consultants’ office in the Emergency Department – three clunky computers, gray carpet, no windows.  I introduce myself to the third year resident, Dr. Borris. 

Sidebar: the internal medicine teams typically involve one third year resident, two interns (first year residents), a smattering of medical students, and the attending (the big boss).  The team admits patients every four days; this is called a q4 call schedule.

Dr. Borris sends me to ED bay 30 to get a history and physical on Mr. Kleevy, 61 years old, altered mental status.  I check that I have my stethoscope and my pen.  I try to remember the parts of the history and chant them to myself: chief complaint, history of present illness, current medical issues, home medications, past medical history, past surgical history, social history, family history.  I feel like I’m forgetting something. 

I wander out into the chaos of the emergency department, the pockets of my short white coat stuffed full of security objects.  My reflex hammer and pregnancy wheel, a book of normal lab values.  At least they will help me look the part.

I find bay 30 and say, “knock knock,” as I push aside the curtain.  Mr. Kleevy is a small man, curled on his side in the gurney, wrapped in blankets.  His wispy gray hair is the only thing sticking out. 

He is alone, no wife to fish a med list out of her purse or explain how he is not his usual self.  No kids to tell me how much he drinks.  I go to the side of the gurney.  His face is thin, his cheeks sunken.  I’ve been watching a lot of Bones recently, and Mr. Kleevy’s face is the shape of his skull, there isn’t a lot of extra flesh.  He looks much older than his 61 years. 

“Mr. Kleevy?  How are you feeling today?”

He looks at me, his eyes are glassy.  “Oh God,” he says.

“Are you in pain?” I ask him.  He nods.  “What hurts?” I ask.

“Oh God,” he says.

“Does your stomach hurt?” I ask, because he seems to be clutching it.  He nods.  “Does your head hurt?” He nods.  “Does your chest hurt?” He nods.  “Does your big toe hurt?”  He nods.  “Are you the president of the United States?”  He nods. 


I frown.  Mr. Kleevy is obviously not well, he is in pain and I can’t begin to tell why and I really can’t begin to tell how to fix it.  Also, if I can’t get a history out of him, I am going to look like an idiot. 

After the third year of medical school, I was very burnt out.  I questioned if medicine was right for me.  I wanted to quit.  I took a year off and went to grad school, and had lots of time to think about the kind of doctor I wanted to be. 

For so many doctors, the practice of medicine is more about them than it is about the patients.  The surgeon who cares more about his ego than about his patient’s pain, the internist who complains about his patient being non-compliant rather than understanding where she is coming from.  I was surrounded by these doctors, I was trained by these doctors, and I was becoming these doctors.  My first reaction to a patient coming to see me had started to be resentment rather than empathy or curiosity. 

I realized is that I could only follow this path if I made a conscious effort to be a different kind of doctor.  I would return to medicine, but I would make the practice about the patients and about healing, not about me or my comfort or my ego.  I would endeavor to understand what was important to my patients and make that thing my priority in treating them.  I call it my New Mission. 

And here I am, my very first day back, and already the ego is creeping back in.  I do not want to go to Dr. Borris empty handed.

Then a nurse comes in and saves both of our lives.  “I’m going to cath him, the resident said he might self-cath at home, so he could have some retention.”

A “cath” or urinary catheter, is a small rubber tube inserted through the urethra and into the bladder to drain the urine.  People with certain types of neurological dysfunction are unable to relax the sphincters necessary to urinate on their own, and so are trained to insert a catheter at home. In the hospital, we tend to use Foley, or in-dwelling catheters, which stay in place and drain urine into a bag.  People who home cath tend to use an “in and out” cath, which is a more rigid tube that is inserted to empty the bladder and then removed.

I step to the side and let the nurse do her thing.  If I were more of a gunner, maybe I would have asked if I could do it.  But I am feeling totally defeated by my patient’s inability to speak coherently and I don’t feel up to the challenge. 

She works quickly. Mr. Kleevy does not seem to notice, and most people would certainly notice a rubber tube being shoved into their urethra.  As soon as the tube is in place, the bag starts filling. The nurse and I stand there, transfixed, as more urine than we thought possible drains from this tiny man.  In the end it is almost two liters.  What I had taken for Mr. Kleevy’s pot belly disappears.  This could very well be the cause of his discomfort, if not his confusion.

The nurse leaves, and I move on to my physical exam.  The language of medicine is coming back to me as I scribble notes on my paper: “Gen: 61 yo m, mild-moderate distress, appears older than stated age, oriented x0, CV: irregularly irregular rhythm, no murmur, 1+ pulses  throughout, Lungs: CTAB, Ab: +BS, no masses, suprapubic tenderness, CVA tenderness bilaterally.  Neuro: limited exam, PERRL, DTRs nl, extremities: no edema, no deformity or tenderness, skin: no lesions, no jaundice.”

This is the part I like, gathering the clues, writing in this silly doctor code.  Next I should find his EKG, not that I will remember how to read it.  Before I leave him, I hold Mr. Kleevy’s cold hands and look into his glassy eyes.  “We’re going to get you feeling better, sir.  We’re going to admit you and move you to a room upstairs.  I’m going to go look at your tests, I will be back to check on you later.”  He nods. 

I’m glad to be back here.  Remembering all the things I have forgotten is not going to be easy.  Implementing the New Mission isn’t going to be easy.  But I think I am on the right track, because I can already tell that I have a soft spot for Mr. Kleevy and I am actually excited about heading to the library to look up urinary retention and change in mental status.