Chapter 3: Outpatient Internal Medicine


Love, Sanity, or Medical School

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Chapter 3: Outpatient Internal Medicine

July 29: Monday

7:10 am: I will not cry today. I will not think about my breakup with Casey. I am sitting at the Starbucks at The General Hospital and I will not cry. So far so good but it’s only 7:15 am. Off to my first morning at the internal medicine outpatient clinic. Remember, no crying.

7:50 am: There are two other medical students present when I arrive at my first assigned clinic site. A nurse shows us our schedule for the day. Looks like our first patients will be arriving in ten minutes. Ok. Turns out this is the student clinic where we are expected to see our own patients, take a history (the patient’s recitation of their illness), and do a physical exam (aka the H&P), then develop an assessment and plan. Just like grown-up doctors. This is all well and good, I just had no idea I would be having my own patients right now this second.

9:15 am: I took my worst history ever. Probably a combination of being caught off guard with this situation of walking into a student-run clinic, having my own patients, it’s Monday morning, and I’m still distracted from everything that happened this weekend with Casey. Sad. No, no, no, not going to cry. Not here, not now. This patient’s history was made particularly difficult because the patient recently had a stroke and has memory impairment.

Me: “Sir, how long have you had diabetes?”

Patient: “I have no idea.”

Me: “Ok, what happened when you had your stroke?”

Patient: “I don’t remember.”

Me: “Do you take all of your medications every day?”

Patient: “Yes.”

Me: “You take every one of your medications every single day?”

Patient: “Well...”

Suffice it to say that the visit did not improve from there.

4:30 pm: I used to live in Chicago and I loved it there. I moved there on a whim after graduating from college. If not for Casey, I never would have left Chicago. I’m aching to go back there at the moment.

6:15 pm: I’m about to leave for dinner with The Boss, my trusted advisor and confidante. When I first moved to my little Midwest city, I desperately wanted a job at The General Hospital to increase my chances of being accepted to their affiliated medical school. Casey searched around the hospital and found out that The Boss, one of the senior attending physicians in the emergency department at The General Hospital, was thinking about taking on a premed student to help her with a new research project.

I emailed her out of the blue and basically wrote, “Hi, my name is Silvia, you don’t know me, but you want me to work for you.” She wrote back the next day with something like, “I have no idea who you are, but I’m intrigued.” Shortly thereafter I began working for her.

We quickly developed a productive and trusting working relationship. She became my premed advisor, helping me navigate the application process, prepping me for my interviews, and even writing one of my recommendation letters. Once accepted into medical school, she became my academic advisor. Years later, our working relationship has grown into a friendship as well. Upon hearing of the breakup with Casey, she immediately offered to take me out for dinner and drinks (aka get me drunk). So, off I go to dine and drink with The Boss.

Midnight: I’m a couple of beers and martinis deep right now. The Boss and I talked for hours and she informed me that when I am ready to date again I will have no problem meeting new men. Her explanation went something like, “It will be just like Zappos, you will have an array of options, and you will pick the one you want.” I told her that mostly I am unhappy but a part of me is a little angry, a little disappointed, and oddly, a little relieved. I offered that if she wanted to, she could be a little mean to Casey when she runs into him at the hospital. She immediately declined my suggestion, of course.

July 30: Tuesday

10:30 am: I have no clinical responsibilities today, just afternoon lectures, so I spent the morning moving my stuff into the guest bedroom. My outpatient medicine schedule is noticeably lighter compared to inpatient medicine. I work two half-days at the student clinic, three half-days at Far Away Clinic, and one half-day in a cardiology clinic.

3:02 pm: I’m ok until someone asks me if I’m ok. I feel like a life I had been planning for years just died.

July 31: Wednesday

7:30 am: Back at the student clinic, then this afternoon I’m working at Far Away Clinic, a fair distance away from my little Midwest city. I’m not sure what my responsibilities will be this afternoon.

9:43 am: It turns out that patients frequently do not show up to their appointments at the student clinic. I have yet to see any patients today.

10:15 am: When I’m upset, I lose my appetite. Everything tastes like cardboard. When I went through Hurricane Katrina during my senior year in college I lost almost 20 pounds in just a few weeks. Fortunately, it was right after my junior year studying art abroad, and most of those 20 pounds were souvenirs from my months spent in Rome and Paris. Stories from college are for another time, perhaps another book.

6:15 pm: I didn’t sit down the entire afternoon at the Far Away Clinic and I barely had time to write my notes. I really enjoyed the pace as well as the wise Dr. Pearl, the physician with whom I worked.

Dr. Pearl would send me into the patient’s room to do an H&P, after which I would present the patient to her and then offer my ideas for what we should do. She would then step into the room for a few moments to greet the patient and clarify anything that was unclear. I was immediately trusted to see patients and give my opinion on their care. This is a first on this rotation. Dr. Pearl apologized for all of the running around, but I loved it. She doesn’t know I spent a lot of my days on inpatient internal medicine sitting and studying. Between seeing patients, she offered pearls of wisdom about medicine and life as a female physician.

One of my patients this afternoon was a tall, dark, and handsome man, who arrived in his manly uniform. He was sprawled out on the exam table, nearly naked in just red and blue striped briefs, too tall for the table, his legs dangling off quite a way. He was lying on his side, head propped up on his hand as if posing for the annual Midwest uniformed man calendar. Do you have a nice visual yet?

Unfortunately, his whole body was colonized with the bacteria called MRSA, which left him covered in painful abscesses. Being so big and tough, he didn’t come in until the lesions were huge and he could barely get dressed. Some medical terms I used in my note on him include: indurated (hard/firm), fluctuant (squishy), erythematous (red), purulent (pus-filled), and malodorous (smelly). He was lying on his side because that was the only comfortable position for him. Why naked? So that we could drain the larger abscesses on his hips and thighs. Not so sexy. Sorry. At least I’m learning proper medical terminology.

August 1: Thursday

8:45 am: I’m waiting to see the human resources folks at the Cardiology Clinic to get my ID badge. Tonight will be my first time seeing Casey since our breakup last Saturday evening. We… wait, no… now it’s “I”, I need to take myself off the shared cell phone family plan we’re on. The car and renter’s insurance need to be separated. He’ll be moving out soon and I’m going to need to move on with my life. Not easy. Not fun. I thought he was going to be my husband and the father of my children. Time to delete the Pinterest wedding I had planned.

10:34 am: Finally done with obtaining a Cardiology Clinic badge.

12:45 pm: Back up in Far Away Clinic.

It’s noticeably different working for a physician who does not trust you. The doc I’m working with today is a young attending named Dr. Newbie. Just like yesterday, I would go into the room, report back to him, and then he would go in. However, unlike Dr. Pearl, Dr. Newbie would then proceed to re-ask every question I had already covered. Patients must get annoyed answering the same questions repeatedly. It certainly annoys me because it means he either wasn’t listening to me, didn’t care what I said, or didn’t trust the information I reported. Every single patient. Not every physician will operate in the way that I, the third-year med student, wants them to. Oh well.

Dr. Newbie lacks a bit in the interpersonal skills arena. For example, a new patient arrives at the office to establish care, she has ripped shoulders and arms, is dressed in workout gear and running shoes, and I’m guessing she will leave the office and head straight to the gym. While getting a history from her Dr. Newbie queries, “Do you ever work out?” Um… really? He couldn’t be like, “Oh, I’m guessing you’re a runner?” Or something equally appropriate?

The patient and I exchanged glances and then she politely responded, “Yes, I do work out.” There were several moments like that with other patients throughout the afternoon.

August 2: Friday

7 am: I miss my family. I need a hug from my momma. My sister Olivia – pregnant with twins – is due to go into labor at any minute. I’ve been secretly painting a Winnie the Pooh themed piece for the twins’ future bedroom. I wish I could be in NY right now.

11:15 am: Interesting patients today at Far Away Clinic.

Noon: I have a new appreciation of the word hypochondriac. Into clinic this morning walked a healthy-appearing young woman with a multitude of concerns. Her vital signs (meaning her heart rate, blood pressure, respiratory rate, and temperature) were normal, and even though she frequently visited the office, she did not have any actual medical conditions listed in her chart. She ended up getting four referrals to various specialists, all at her insistence, and we addressed several other concerns unrelated to the referrals as well. Several of the docs informed me that with some patients, it’s easier to give in and let them have whatever referrals they want. Not sure how I feel about that.

2:13 pm: I’m getting antsy, I can’t take it anymore; I have to get out of this city.

5:10 pm: I’m trying my best to not sit around wishing that I had never left Chicago. I loved it there so much. Professionally, I’m in a great place. I love my school and my friends, I’m going to be a doctor, and I know that I can leave this shitty little city in less than two years. That’s gonna have to be enough for right now.

August 3: Saturday

4:24 pm: Almost finished the Winnie the Pooh painting for my sister.

August 4: Sunday

10:43 am: I really need to be studying, but I’m still so distracted. It is weird to think of myself as single after all these years. One of my friends asked me if I would be willing to date a guy who has kids. Huh? I don’t know, I hadn’t really thought about it. Yes? No? I have no idea.

Noon: I will be an auntie exactly 24 hours from right now! Olivia’s soon-to-arrive twins have no idea how much they have already helped brighten my life this past week. Every time I have felt sad this week, I imagine her and my little nephews. I can’t help but smile and think that one day, with the right guy, I will know that happiness too. Is it possible to have tears of pure joy and abject sorrow at the same exact moment? Let’s not find out right this moment, though, as I’m sitting at my neighborhood Starbucks, and it would be really awkward if I started crying right now. I have to stop writing for a moment.

5:44 pm: Interesting article for those so inclined: there’s a NY Times opinion piece from August 3, 2013 entitled “The Trauma of Being Alive” by Dr. Mark Epstein, in which he mentions the Kubler-Ross stages of grief. The stages include denial, anger, bargaining, depression, and acceptance. In thinking about my breakup, I can see how the stages apply. I think I spent the last year in denial about my relationship being over. I am starting to feel a little angry, but mostly I am still just sad. I don’t know how bargaining will play into this, and I certainly am not at acceptance yet.

I have a lot of experience with grief and trauma, but I am already emotionally wrecked about Casey, so I won’t torture myself or depress my audience any further right now with thoughts of those other haunting experiences… Stop! Redirect. Babies. Think about my sister’s babies and how I will have a photo of them tomorrow. Focus on the happy stuff. See, I’m already smiling.

August 5: Monday

12:30 pm: I’m struggling with how much to include here because I set out to record my experiences as a third-year medical student, not to share the details of my love life. Well, here goes nothing. Casey and I had sex last night. Our evening started off innocently enough but, as tends to happen whenever we are left alone, we can’t stay away from each other. He hasn’t moved out yet, so I knew I was in a high-risk situation. I couldn’t remember the last time he had seemed so interested or passionate. It was incredible. I cried afterwards.

I keep trying to blame myself for our relationship falling apart. I think if I weren’t so stressed with school the past two years and so focused on us getting engaged, then maybe we would’ve kept the fun lightheartedness in our relationship that had always been present. But I remind myself, if he had proposed a year and a half ago then maybe I wouldn’t have gotten so down and serious in the first place.

I don’t understand what went wrong, or what wasn’t right enough for him. We had a fun and happy relationship. He treated me so wonderfully; he was affectionate, cooked for me almost nightly, and routinely helped me study in med school. The sex was always incredible. But, after seven years he still wasn’t 100% certain that I was “the one.” I couldn’t give him any more years of my life. I had to end it. I need to stop. Dwelling on this will only make me mopey and weepy again. I just wish I knew what it was about me that wasn’t good enough for him.

1:00 pm: As I sit here, depressed, eating my Greek salad, I am also obsessively checking my phone every two minutes, awaiting updates from New York on the progress of Olivia’s delivery. At this precise moment she is in a hospital in Manhattan getting an epidural. Babies will appear soon. Within an hour, perhaps?

2:34 pm: I am creating tracks in my carpet from all my pacing. Olivia went down to pre-op about 20 minutes ago, and her hubby Alejandro was called down to meet her in the OR a minute ago. Here we go!

3:04 pm: Olivia’s cesarean should be almost done, right? The babies should be out by now and her ob-gyn should be stitching her up. I want to see their bitty faces and give them kisses and thank them for helping me through the week.

3:08 pm: Two healthy, beautiful baby boys have arrived! Welcome to the world my little nephews Jackson and Henry. They are, in a word, perfect. My momma, now known as grandma, sent me adorable photos. Olivia, now known as mommy, and her babies are doing well.

PS: Yes, I saw patients today at the student clinic. No, I don’t really remember what happened.

August 6: Tuesday

8:00 am: Another day with no patient care. Outpatient internal medicine is not what I expected. At least we have a clinical skills lab today.

My friends and family seemed surprised and impressed when I tell them that I broke up with Casey and that I told him to move out. Everyone guessed that I would be the one to move out. As I explained to Casey, I was the one who already did everything. I left my beloved Chicago for him, I worked my ass off to get into the only medical school in this little Midwest City, and I spent every day of the past year and a half trying to figure out how to make our relationship work. I’m done being the one to do things.

So, Casey is the one moving out. He didn’t argue; he agreed. His move out date is about three weeks from now. Maybe once he moves out we’ll stop having sex? Oh, and for the first time in seven years, he left a hickey on my neck. I feel like such a teenager.

11:18 am: The cow eyeballs squished a bit when cutting into them. Slimy little buggers are slippery. A few almost went shooting off the exam table at our clinical skills lab. While learning about performing eye exams, we were treated to some pretty horrific images of human eyeballs in various stages of injury and infection. I like procedures. As I now have a break until afternoon lectures, I should probably go study.

1 hour later: I did not go study. I talked to my sister and to my mom. Somehow Casey and I are going out tonight for dinner. A non-date, if you will. I guess it’s better than ending our relationship with fighting? We’re just really bad at not being together. I wonder who will pay the check.

After Casey and I broke up, I tried reaching out to my girls first but everyone was out of town because we all had the weekend off. I then called Magnus, who picked me up within 15 minutes of me telling him that Casey and I had split. He brought me to his apartment, invited over a bunch of friends, and we spent the day drinking beer and watching classic dumb comedies such as Dogma.

At some point he apologized for not being good with “girl stuff,” but he added that he has plenty of beer for me, and beer is almost as good as girlfriends in these situations. I agreed. The following day I spent with Piper, Sophia, Jane, Maggie and Daria, who were also incredible. My friends showered me with love, hugs, and support. It’s not that I’m surprised by how supportive and kind my friends are, but they have gone above and beyond to take care of me. Truly incredible.

I love my friends.

August 7: Wednesday

6:53 am: My heart is still pounding from the nightmare that just woke me. There were blasts and bombs going off all over. I was with my cousin Violet. It was the day of her October 19 wedding and her hair was already done. We needed to get out of the area because we were in danger. Firefighters directed us towards safety. There were blocks and blocks of debris piled high for as far as you could see. We had to climb over the piles because there were no longer any clear roads to walk on.

The piles were made of blasted building bits and body parts. Bleeding and horrifically injured people cried out for us to help them, but we couldn’t help anyone because it wasn’t safe to stop. The smell of burning flesh and smoke hung in the air.

Four missiles zoomed overhead so we ran into a building for cover. We could feel the heat of the blast. I thought the building was on fire and that we would burn to death. The fear choked me. Back outside, we again began climbing over the piles of bodies. A woman reached out her hand for us to help her, but the firefighters yelled at us to keep moving. I tried to apologize to her for not helping but I was rushed along too quickly. We reached a staircase and started climbing. Violet yells to me “No, I can’t do it anymore.” I support her back and push her forward as we climb. She faints backwards onto me. I woke up screaming.

Noon: There was only one patient for me to see in the student clinic. I was hoping for a busy day to pull me out of my post-nightmare haze.

I spent my afternoon at Far Away Clinic with Dr. Pearl. Her patients absolutely love her. It’s inspiring to see a physician happy and relaxed yet working efficiently.

As much as I love my two-bedroom, two-bathroom apartment, I cannot afford to live here by myself. I’m starting my roommate search by posting my apartment on a website called Rotating Room. It’s designed for students in healthcare fields who travel to work at different hospitals and need a place to stay for only a month or two at a time. This seems like the easiest and fastest way to get a new roommate.

August 8: Thursday

I shipped the Winnie the Pooh painting I made for my nephews Jackson and Henry. A relaxing morning so far, then off to Far Away Clinic for an afternoon with Dr. Newbie.

Some days every patient seems to have the same complaint; everyone will have a cold, or back pain, or asthma, or whatever. Not today. I saw a spider bite that resulted in a full body rash, a rare bleeding condition complicated by a blood clot in the patient’s leg, and a post-op visit.

In response to the patient with the spider bite, one of the nurses spent a solid hour googling various spiders on her giant flat screen computer monitor. I have horrific arachnophobia and fear paralyzes me whenever I see a spider, no matter how miniscule. Unfortunately, her computer screen faces my workstation so I had to crouch down behind my own screen to avoid seeing the myriad of tarantulas, wolf spiders, brown recluses, and other little horrors. Occasionally she would exclaim, “Oh that’s so gross! Look how hairy! It’s so big! All those eyes!” My heart is racing and my skin is crawling. I keep telling myself to take deep breaths and not look so visibly freaked out. It’s unprofessional.

I walk into the room of another patient and notice that his face and ears are speckled with large blood vessels called telangiectasias. He has a rare bleeding disorder called HHT. I forgot what it stands for... Hereditary hema... Something. Basically, it’s a disease of the blood vessels which causes both bleeding and clotting issues. He came in with leg pain that is highly suspicious for a blood clot. We sent him for an emergency ultrasound and several hours later got bad news: blood clots filled his leg from his ankle to his mid-thigh. Blood clots in the thigh are dangerous; some can break off and go to the lungs, causing blood clots in the lungs, called pulmonary emboli. Typically, you can give blood thinners to people with clots. But, giving blood thinners to someone like him would likely cause potentially fatal bleeding. Definitely a catch-22; treat the blood clots and risk him bleeding to death or don’t treat the blood clot and he will likely get a fatal pulmonary embolism. What to do?

HHT is hereditary. One side of his entire family is affected. While HHT is not fatal in and of itself, it puts you at major risk for bleeding to death from minor trauma. The disease is variable, so some family members will have worse symptoms than others, and there is no way to guess how bad it will be for a particular person. The first sign tends to be recurrent epistaxis... aka lots of nosebleeds. His children have recently begun having nosebleeds. His story makes me wonder if he, someone with a potentially deadly genetic disease, ever thought about not having children. If it were me, I don’t know if I’d willingly have children. I say that as someone who may be a carrier of a 100% fatal hereditary disease.

August 9: Friday

Countdown to the weekend.

8:40 am: Two nurses are working today. Let’s call them GN and BN for Good Nurse and Bad Nurse. BN sat at her desk picking her nose. GN called patients with test results, while BN made a personal call. Not that I’m against personal calls, I couldn’t care less, but BN came across as lazy while GN was working.

8:55 am: GN asks, “BN, why haven’t you gone through your pile of papers yet?” GN points to a stack of papers next to BN, a pile of lab results and other things that need follow up.

“Wait, what? Why didn’t you tell me earlier that I had work to do?” BN rolls her eyes and sighs dramatically before she stops picking her nose and starts to go through her paperwork.

Another morning with the young Dr. Newbie. He still repeats every question I ask. Today one patient replied to a question with, “I already told your med student…”

To which he countered, “Yes I know, she told me.” Awkward.

11:30 am: BN is sitting at her station assaulting my ears with her singing. I can’t.

12:38 pm: Off to the Cardiology Clinic.

Today started off with Dr. Heart, a world-renowned cardiologist, offering the opportunity to work with her for the afternoon. Simultaneously thrilling and intimidating.

One of her patients today was a spry 100-year-old man, named 100, who had come in for a checkup. Although he had no complaints, Dr. Heart completed a thorough physical exam. This is going to sound so nerdy, but her exam skills are mad impressive. Using the tips of her fingers and her palm, she felt a subtle murmur, determined not only that the heart was enlarged but specifically which chamber of the heart was enlarged, and she figured out that 100 was in the early stages of heart failure.

Dr. Heart explained her exam findings to me as she went. She tried to have me copy her maneuvers so that I, too, could reach the same conclusions. I don’t think I have ever felt more inadequate as a medical student. To confirm her suspicions, she decided that 100 needed a few lab tests and an electrocardiogram (EKG). Of course, all of her suspicions were spot on. Damn, she’s good.

August 10: Saturday

I spent the day “cabrewing” with a bunch of classmates and other random people. For those unacquainted with cabrewing, it is basically canoeing while drinking a lot of beer. I am mostly sober now and need to get some sleep. It was great to get out of the little Midwest City and do something different. I also met a lot of people. A super cute blue-eyed guy named K Canoe got my number. I’m not interested in him, or anyone at the moment, but I thoroughly enjoyed that a tall and handsome stranger flirted with me. Flirting and all that is still novel to me at this point in my breakup recovery. Too bad I didn’t meet him a month or two from now when I’ll hopefully be ready to start dating.

August 11: Sunday

10:30 am: The Winnie the Pooh painting arrived while I Skype’d with Olivia and the twins. She loved it and is going to hang it in their room.

1:24 pm: Blehh… studying. If I studied as much as I painted and journaled, I think I would be a phenomenal student. Every move I make hurts as I am sore and covered in bruises from all the times my canoe flipped over onto me yesterday.

Casey and I ended up going to a super fancy dinner together last night. At least we didn’t sleep together afterwards. Progress?

Off to get my hair done. I need a new look. It’s time to go from being a bland brunette to a fiery redhead!

August 12: Monday

11:15 am: We had eight patients scheduled for the student clinic today, three showed up. Each student got to see one of them. At least I was done by 11 am. My one patient had stitches on the back of her head, left behind by the trauma team. No, I did not call a trauma consult to ask their permission before I removed them.

It’s weird to give nurses orders. Even weirder when they do what I request without question. I’ve read that some women tend to have a harder time commanding others to do things. Turns out I’m one of those women. Maybe it’s because I don’t feel like I know enough yet, coupled with the fact that I’m giving orders to people much older and more experienced than me. I guess I’ll just have to get comfortable doing it.

Off to go study. For real this time as I am running out of time to procrastinate. At the end of each rotation we must take a final exam. These exams are nationwide, and the scores end up in our residency application, so they are high stakes. The exam is in less than two weeks!

August 13: Tuesday

Studied all morning. Go me. Off to Super Tuesday afternoon lectures.

2:34 pm: My first lecture covered a ton of interesting material in an engaging way. Now, we’re halfway through the second lecture and the new lecturer is monotonously reading her slides of black text on a plain white background. My mind is starting to wander, not to anywhere specific though.

I’m thinking about my upcoming test, my gorgeous new auburn hair color, dinner with Casey, my classmates, starting my surgery rotation, and wondering how badly I’ll be suffering from lack of sleep. Basically, I’m thinking about everything except my current lecture. I wonder if and how I’ll manage to write during my surgery rotation. I guess I’ll try to at least jot down a few thoughts each day and go back and expand on them as I have time.

Glancing around the room, everyone seems pretty spacey. A lot of students are typing on their iPads and laptops. I’m guessing they’re ‘taking notes’ just like I am right now. Magnus is sitting next to me, on his iPad, alternating between Facebook and researching players for his fantasy football team. Ok, her lecture should be ending soon. My classmates are squirming in their seats.

Our lecture has already run a couple minutes over. Oblivious to our lack of interest, the professor announced, “You guys seem to get it, I could probably leave right now, but I’ll go ahead and go through the next two cases anyway.” The crew is getting restless. There may be a mutiny soon. I am trying to keep a neutral, pleasant looking face. Magnus is sitting next to me practically jumping out of his seat. I appreciate informative and engaging lectures. I don’t like lectures without any new information, without pictures, and that run long. Oh, the next lecturer just poked his head into the classroom and gave the current lecturer ‘a look.’ Message received, she just wrapped up. Finally.

3:11 pm: Now this is a lecture: clinical decision making tailored for new third year medical students, using a common disease as an example but easily applicable to other medical conditions. Words of wisdom from this lecture: use evidence-based medicine but never betray your gut.

I have no cell phone service in the lecture hall. As soon as I walked out of the classroom my phone beeped with a text from K Canoe, the guy I met cabrewing on Saturday. I was kind of hoping he wouldn’t contact me because I feel bad ignoring him, but I’m definitely not ready to date yet as I’ve only been single for two weeks.

August 14: Wednesday

At the student clinic once again. My patient is a soft spoken and kind young man who has a genetic condition causing high blood pressure, diabetes, and severe heart failure. Clearly embarrassed, he revealed to me that he couldn’t afford all of his prescriptions. We sat with the attending and went through every single prescription, picking out the most important ones. The whole time, I felt incredulous that there was not more we could do for him. The attending noted that this is not an uncommon situation for many of society’s poorest.

Another patient I saw today also has multiple medical problems. This patient cannot afford his medications either, but it’s because he keeps spending his money on cigarettes, alcohol, and cocaine. Sometimes I wonder how to impress upon people that they must take care of their bodies.

6:30 pm: Casey told me he found an apartment. I guess that’s a good thing. Back to studying.

August 15: Thursday

1:56 pm: Studied all morning and now I’m back up at Far Away Clinic. I examined a soldier in army fatigues with a mysterious rash. We have no idea what it is or where it came from. Seriously. I have yet to figure out which rashes and skin conditions can be examined without wearing gloves. Dr. Newbie ran his hands over the little bumps covering the soldier’s body. I guess he figured it wasn’t contagious. I’m going to stick with gloves for now… always. Just to be safe. Apparently, dermatology is not for me.

2:05 pm: I’m between patients, waiting for my 2:15 to arrive. When I look at the patient census for the day, all I see is a chief complaint. For my 2:15, the chief complaint is “butt pain.” I have all sorts of ideas as to what could be causing that particular chief complaint. Of course, my mind immediately imagines a guy limping in, looking incredibly embarrassed and refusing to sit down while a faint buzzing sound hums in the distance. I don’t really imagine that being a Thursday afternoon kind of chief complaint though. That is probably something more likely to show up in the emergency department on a weekend. I’m guessing it will be something way less entertaining.

2:16 pm: He’s still not here so I began thinking about the rise in emergency department visits related to women getting Ben Wa balls stuck in them and needing removal. This problem really skyrocketed after 50 Shades of Grey was released.

The 2:15 walked in limping but it is most likely sciatica, not a true “butt pain.” Oh well. I think Dr. Newbie is also secretly a little disappointed at the anticlimactic visit. Our patient, however, found the situation entertaining as he kept repeating, “I have a pain in my butt, haha.” No sir, you have hip pain that shoots down your leg. Let’s not exaggerate and get the medical staff really interested for nothing.

6:01 pm: My brain is a bit fried from studying. I’m in a bad mood about Casey finding an apartment. I’m not doing well today.

August 16: Friday

An email popped up a moment ago that someone from New Orleans is interested in my apartment. I’m about to call her. Hopefully it works out.

An hour later: After a phone call, some emails, and a price negotiation, it looks like Zooey will be my new roomie. She is a speech therapy student doing a three-month rotation at The General Hospital, from September 13 to December 10. The timing will be interesting. She will basically be moving into my guest bedroom as Casey is moving out of the master bedroom and while I’m moving my stuff from the guest room back into the master bedroom. I’ll be on surgery until November, so I don’t even know if I’ll see her that much. Who knows? This year is already quite different than I thought it would be.

August 17: Saturday

This time next week I’ll be in NY visiting my baby nephews. I am so beyond excited.

August 18: Sunday

10:00 am: Woke up in Casey’s bed. Oops, how’d that happen?

7:18 pm: Another one of Casey’s married friends is pregnant. I am happy for them but so jealous. My life has been pushed so far away from being at that point. I don’t want to be married and having children with someone just for the sake of doing so, but I thought I had found the person with whom I would share my life. Starting over sucks so bad.

August 19: Monday

Every morning at the student clinic I have to walk past the pediatric exam rooms to reach the medical student office. In the pediatrics hallway is a Winnie the Pooh height chart, and every time I see it I smile and think of my baby nephews.

One of my patients gave my attending a completely different history than the one she had given me. Now I look like an ass. Thanks.

3:15 pm: Zooey and I have a Skype appointment at 4:00 pm. She sounds fun and bubbly and I’m excited to meet her. Maybe she’ll be my new BFF.

5:01 pm: I don’t think Casey realizes that he still calls me ‘honey’ when he’s trying to get my attention.

August 20: Tuesday

Studied outside on my deck all morning. Sunshine felt wonderful and brightened my mood.

Not sure how prepared I am for this final exam. Best go back to studying.

12:24 am: After I finished studying around 10 pm, I sat down with a suture kit and practiced tying knots for two hours. I am getting really psyched for surgery.

August 21: Wednesday

6:44 am: Last day of outpatient medicine. Last day of my internal medicine rotation. Finally.

8:05 am: The heat is suffocating in the student clinic today. Neither myself nor the two other med students are interested in internal medicine and we’re all thrilled that the rotation is nearly over. Before the fellow arrived, we started the morning wishing that none of the patients would show up.

11:36 am: Done with the student clinic. I can leave here forever once I get my final feedback. Then off to Far Away Clinic for my last afternoon with Dr. Pearl.

Fun afternoon at Far Away Clinic:

My first patient was a big, badass, heavily tattooed biker here for his annual physical exam. He sat in an itty-bitty paper gown, with a black skull-patterned bandana atop his shaved head. Even the toughest among us need medical care. My favorite part of the encounter was when Dr. Pearl and I informed him that he was due for a vaccine. He gaped at her wide-eyed and whined, “But Dr. Pearl, you know I hate needles!” It was adorable to see this big beast of a man showing trepidation about getting an injection. Especially as I’m pretty sure that tattooing involves needles…

A healthy and fit lady in her early seventies came in for an annual physical. She had been traveling for the past two weeks with her hubby and some friends. During their adventures, she informed us how they all went hiking, biking, and did other outdoorsy activities. In the next week or so she will be off to Europe for a couple of weeks.

Immediately following her was another lady of the same age. However, this patient could barely walk after years of metabolic disease and various other illnesses. It was so striking to see them back-to-back. It made me realize that I need to start working out again. I know I usually eat healthy, but I’m really scrawny right now. I could use some muscle. These women really have me thinking about health maintenance.

A young woman came into the office for an annual physical and I am really jealous of her. She recently returned from a several week around-the-world trip. Next week she is moving to an awesome city to start a new job, and she looks like a Barbie doll. Seriously. Not fair. I hope she realizes how lucky she is. I know absolutely nothing else about her, but I am judging her entire life on those three things because I am jealous of all of them at this moment.

My last patient is a chatty and jovial woman who is a couple of years older than me. Her blood pressure normalized after being high for some time, and she no longer needs any blood pressure medication. Turns out her blood pressure dropped once she finally divorced her husband and stopped dealing with the stress and anxiety of being in a bad relationship. She told me about the years of angst that came with trying to make a relationship work that wasn’t right. Now she is finally relaxed.

She talked about starting over in her early thirties with a hopefulness and positivity that I have yet to find. I wanted to thank her, to tell her that she gave me hope for happiness in my own future, but I just listened and congratulated her on her improving health. I find it entertaining when patients share their stories with me, but I have yet to figure out when or even if it’s ever ok to share any snippets of my life with them.

I’ve really enjoyed the wide variety of patients I’ve gotten to see at the Far Away Clinic. Young, old, black, white, healthy, sick, rich, poor, and from all walks of life. I’ll have to keep that in mind when choosing where I want to do residency.

August 22: Thursday

7:30 am: Study, study, study.

The library is blissfully quiet right now but freezing. I’m completely incapable of studying at coffee shops or anywhere there are people walking by or when there is any noise. I have major difficulty sitting still and studying for extended periods of time. On the opposite end of the spectrum, I could paint for hours without realizing any time has passed. And of course, I can sit and journal pretty much anywhere without noticing any chaos going on around me.

7:30 pm: Back in the privacy of my apartment. In the past, my home was more of a clothing-optional type of place. Being proactive, I instituted a clothing-mandatory rule about a week ago to decrease the likelihood that Casey and I have sex again. It seemed logical to me that the more clothes we are wearing the less likely they are to come off. However, Casey is ignoring my rule. Right now, he is strolling around the kitchen without a shirt on and with scrub pants barely covering anything. How can I be expected to concentrate on studying with him strolling around all tanned and half naked? It’s asking too much from me. Oh well. I tried.

9:39 pm: Final push. I have one more section to review and then I quit. If I haven’t learned it by now it’s not happening.

August 23: Friday

6:30 am: Walking out of my apartment this morning the sky was dusky blue and a few stars were still twinkling. It had been raining all night and the humidity in the air was drenching, creating a foggy aura. The crickets and bugs sounded like a large chorus. It was like being in the blue lagoon at the Pirates of the Caribbean ride in Disneyland. I headed off to my exam this morning humming, “Yo ho, yo ho, a pirate’s life for me.”

Post exam: That exam was terrible. Everyone walking out looks completely shell shocked. Three weeks until I get my score. One of my hardworking and studious friends just came up to me and told me she thinks she failed. At least I’m not alone?

2:34 pm: At the moment I am sitting at the new wine bar at the airport. My flight to NY leaves in about an hour. I’m sipping on a glass of Pinot Grigio hoping it will lessen the pounding stress headache I got from thinking about this morning. I would have been at the airport earlier, but I got stuck behind some slow-moving farm equipment on the highway. Welcome to the Midwest.

My feedback from Far Away Clinic was uniformly positive and I earned excellent clinical grades. The doctors collectively thought I did a solid job presenting my patients and creating differential diagnoses for them. Dr. Pearl told me I should consider internal medicine as a career, which I take as an incredible compliment coming from her.

My feedback from the student clinic was not so great. The fellow informed me that I started out a little scattered, didn’t seem enthusiastic, and did not go above and beyond, though I improved a lot over the course of the month. It might be more accurate to say that I was barely functioning during my first day at the student clinic, which was not even 48 hours after Casey and I broke up.

Overall, she gave me average marks and I could not disagree. At the same time, she cut me zero slack for not being on top of my game in my post-seven-year-relationship breakup state because medical students are expected to perform at our highest potential all the time, no matter what. I’m still learning how to turn my emotions off when I walk through the doors of the hospital. I’m not sure if I’ll ever be able to do it.

Two months of third year down, ten months to go. Off to surgery.


Chapter 2: Inpatient Internal Medicine


Love, Sanity, or Medical School

Chapter 2: Inpatient Internal Medicine

July 1: Monday

1:00 pm: They just handed me a pager. Now what?

I’m sitting in a barren, windowless classroom tucked away on a top floor within The General Hospital, surrounded by a small group of newly-minted third-year medical students. It’s our first day on the wards. We are waiting for the senior residents to collect us and distribute us to the various medicine teams.

2:15 pm: Still waiting…

3:30 pm: Turns out that the senior residents didn’t know that we, every medical student in the entire College of Medicine, were starting today so we sat there until three pm. We tried calling them. We tried paging them. Finally, an attending physician randomly passing by came to our rescue and located the seniors. They seemed pleasantly surprised to see that we’d been patiently sitting there for hours.

3:55 pm: I met my team, comprised of a fourth-year medical student, an intern, and a senior resident, and then was dismissed. Everyone seemed welcoming.

July 2: Tuesday

7:01 am: I have no idea what I’m supposed to be doing.

8:15 am: My attending, the young Dr. Osler, immediately comes across as friendly and enthusiastic. We discussed my goals for the rotation. His focus is on improving my patient presentation skills and teaching me to come up with broad differential diagnoses (aka medical explanations) for my patients’ problems. Sounds good. My ‘personal’ goals: 1. Avoid personal embarrassment. 2. No crying if I get yelled at. My first impression is that Osler doesn’t seem like the type of attending who torments third years, though I guess I’ll find out soon enough.

The crux of “having a patient” is rounding. Each medical student and resident takes turns presenting their patients to the rest of the team during rounds. We hop around the hospital, traveling room-to-room, until we have checked in on every patient on our list. Rounds are nerve wracking because it is imperative to know every single detail about your patient’s work up. The ‘work up’ is a generic term referring to all the data collected on a patient, including physical exam findings, daily blood tests (aka lab values, or, labs), and imaging results (such as x-rays and MRI scans). Knowing how a patient is responding to their treatments is essential, too. All of your decisions regarding their care are debated and nitpicked. If the attending finds your management of a patient to be unsatisfactory, the consequences may range from an eye roll, to an audible sigh, to a verbal berating, to being locked in a dungeon without food or water until such a time when your attending believes you can once again be let loose on the wards.

I officially have my own patient! He is in the hospital for a ginormous (proper medical terminology right there) foot ulcer. I could call him Mr. FU for foot ulcer, but let’s go with Mr. UFO instead. Having my own patient means I now have someone to present on rounds. Each morning, before the team arrives, I’ll get to The General Hospital super early to read up on any new lab studies or overnight developments in his care. This is called pre-rounding. After presenting him on rounds, I’ll write a note on his progress and goals for the day, while helping plan for his discharge. Waaaay better than being in the classroom.

12:59 pm: Every Tuesday afternoon all students on the internal medicine rotation have class together from 1-5 pm. In an effort to make these four hours of lecture more exciting the internal medicine people have coined these afternoons “Super Tuesdays.” Sure. Whatever. There are a lot of stereotypes in medicine. Internal medicine folks are known to be super nerdy. So far, so true. And unfortunately, I can’t go home afterwards because I’m on call tonight. Being “on call” on the medicine service basically means an extra-long day, so instead of leaving at 5:00 pm I’ll be here until about 10:00 pm.

July 3: Wednesday

8:43 am: People take bad news quite differently. A patient on our service was told his fiancé gave him Hepatitis C and he nonchalantly commented, “Oh well, I’m marrying her anyway so I guess that’s that.” When the fiancé found out that she may have contracted Hepatitis B from him in return, she was NOT happy. I thought she was going to punch him or break the engagement right then and there.

10:15 am: While on morning rounds we met an elderly new patient named Mr. BH, who was admitted by the overnight team. He is suffering and in excruciating pain from multiple medical problems and a broken hip. As the overnight intern started presenting Mr. BH to our team, Mr. BH began reaching out past the intern and signaling for me to come closer. I was at the end of the bed and Mr. BH persistently motioned for me to move nearer to him. The whole time he was moaning in agonizing pain and it was confusing because we couldn’t figure out what he wanted. When I finally got close enough, he grabbed my hand and held it tightly. Turns out he needed some comfort and just wanted to hold my hand. He gripped my hand tightly the entire time we were in his room. It was very sweet and very sad. Pulling my hand away so I could grab my stethoscope and perform a physical exam felt more than a little heartless.

Happy Fourth of July: Thursday

8:20 am: It’s hard to watch people in pain. A professor taught us last year that patients should never be in pain, should never be short of breath, and should not die alone. These are deceptively difficult goals. Give too many meds and they stop breathing, give too few and their pain is intolerable. My team is trying to balance controlling Mr. BH’s pain without causing a deadly respiratory depression.

Noon: My day was brightened when I ran into my Sig O, Casey. We met nearly seven years ago on a random Tuesday at a dive bar in Chicago. It wasn’t exactly love at first sight but there was definitely some spark, some attraction, so we began dating. Dating casually grew into a relationship, falling in love, and moving in together.

1:12 pm: My team is constantly busy, and I feel like I’m in the way or at least just not on their radar this afternoon. Patients are sick as shit, and I don’t know my role yet. I’m keeping myself busy by reading and studying.

2:29 pm: I tried to learn to draw blood but was informed by the intern, “Don’t waste your time, you’ll never do that, nurses will do that for you.” Only thing is, I want to learn and I’m bored because I don’t know what else I could be doing right now aside from studying.

July 5: Friday

3:32 pm: I updated Mr. UFO and his family. I answered his questions and then discussed his progress and discharge plans. It feels better than simply being out of the classroom, it feels like I am finally learning to be a doctor. Wonderful!

10:18 pm: I managed to sneak in a dinner with Casey tonight. It’s been forever since I’ve seen his red hair and blue eyes, which is impressive considering we live together and work at the same hospital. As he is a general surgery resident, his schedule is even worse than mine. His muscular former-football-player frame is still tan from our recent trip to Central America. Even with the unseasonable amount of rain we still managed to sneak in some scuba diving and visit the breathtaking Tikal Mayan ruins. Most importantly, I was able to check another box off my bucket list - I swam with sharks. It was a phenomenal experience. My love of the ocean and my most recent bucket list is not relevant at the moment though; I need to get some sleep because I’m on call again tomorrow.

July 6: Saturday

11:00 am: Four and a half hours down, ten hours to go. The problem with Saturday call is that you have to come in post-call on Sunday. This means that my first day off since starting third year will be next Saturday.

Turns out, drawing blood is a clinical skill requirement for this rotation.

Mr. UFO is doing well and is going home tonight so hopefully I’ll get another patient, maybe even two. It’s hard knowing that I am the weakest link and that I slow the team down, but there’s really nothing I can do other than keep learning and try to improve as quickly as possible. In these couple of days my presentation skills, with the help of my attending Dr. Osler, have improved a lot. However, I still suck at describing wounds using proper medical terminology.

Dr. Osler: “Silvia, how would you describe this man’s ulcer?”

Me: “Um...” And I’m thinking to myself, well it smells really foul and looks super gnarly, as if someone took an ice cream scoop and scooped out a portion of the man’s heel, leaving behind a bloody, smelly, pus-filled hole. Hmm… need to learn how to translate that into words a grown-up doctor would utilize.

I was right about Dr. Osler though; he is not one to torture medical students. He gives detailed feedback and frequently checks in with me. Even better, he has not once threatened to throw me in the brig! So far, so good.

Noon: The family of Mr. BH, the one who held my hand, updated his advanced directives to solely comfort care. Everything will be done to manage his pain but nothing else - no other medical interventions, no CPR, no life support, nothing. His family believes that his quality of life will never again be at a point that he will find acceptable or enjoyable. In order to effectively manage his pain, we need to increase his meds. Any time we did that in the past few days he would get drowsy and hard to awaken so we’d back off on the dosage. However, alleviating pain is the only goal now. We increased his pain meds once again, which means he’ll likely go into respiratory depression again, which means he will die.

3:30 pm: I was assigned my second patient. She’s admitted for an intentional drug overdose that caused her liver to fail. I know quite little about liver physiology, but I’ll be able to put my master’s degree in psychology to use so she’ll be a good patient for me.

July 7: Sunday

8:58 am: Nope, no I take that back, she is no longer my patient. Turns out her psychoses and medical management are too far beyond my meager third year skills. It sucks to realize that my master’s degree in psych is not useful at all; I had envisioned being successful with psych patients but no, just like everything else, I have to learn from scratch. Instead, now under my care is a sweet young girl named Barbie with a nasty eye problem.

It’s weird waiting for someone to die. A resident from another team casually inquired, “So, has your guy Mr. BH died yet?” It wasn’t asked in a disrespectful way either, merely run-of-the-mill resident lounge conversation.

For the first time, and this may not happen again for a while, the senior resident on my team conceded, “You were right about your patient.” I’d asked if Barbie could have some anti-anxiety medication. He’d firmly replied “no”, that she doesn’t need any. She is young and healthy and shouldn’t be given anxiety medications because they’re addictive and potentially dangerous and blah, blah, blah. He then went and saw her in person and decided yep, Barbie is indeed super anxious and would benefit from a little Ativan. A small victory for the med student!

Barbie has a horrific eye infection and must have eye drops placed every 30 minutes for 48 hours. A nurse will go in her room and literally pry open her sleeping eyes every 30 minutes for two full days. Wow. The alternative is she risks vision loss from not treating her infection properly. OMG she is going to be a zombie from lack of sleep!

Speaking of zombies, there is another patient on my team with a leg infection that reminds me of a zombie wound every time I see it. You know those decaying zombies where it looks like strips of skin got peeled off and it’s all beefy red underneath? That is exactly what this woman’s leg looks like. Creepy.

July 8: Monday

11:48 am: There are three, nationwide standardized exams that have to be passed throughout medical school in order to get one’s medical license. They are referred to as the boards, and are composed of Step 1, Step 2, and Step 3. Step 1 is taken just prior to starting the third year of medical school. It’s a beast of a test and our scores are coming out soon. If you fail Step 1, you are immediately pulled off rotations and are not allowed to continue with third year until you have a passing score. Yikes! While I don’t think I failed, I know I will be incredibly relieved to see a passing score…

I picked up another patient today, a young woman named Ms. AI, with a difficult to control autoimmune disease. I didn’t actually offer to pick her up; she was assigned to me. No one on the team wanted her because she is known to be super bitchy and argumentative. Amazing how quickly patients develop reputations. Ms. AI is emaciated from a string of recent illnesses. My goals are to help her gain weight, get her strength back, and get her labs under control. I wonder if she sensed my distraction while we spoke. No offense to her but my brain is entirely consumed with thoughts of my Step 1 score posting soon.

3:12 pm: I keep offering to my team to let me do things but they keep saying, “It’s ok, we’ve got this,” or, “Thanks but no thanks.”

July 9: Tuesday

6:30 am: Uh-oh. Apparently, Ms. AI has been moved to Step-down, a more acute care wing of the hospital. That’s bad. She became unresponsive overnight and a “rapid response” was called (not quite a code blue like when your heart stops and you’re actively dying but still really bad, and people are concerned that you might die). Scary. She seemed fine when I left last night…

11:00 am: Surprisingly, Mr. BH is doing well. Sure, we amped up his pain meds and risked killing him (at his family’s request, of course) but he pulled through. He has even been moved from Step-down to the floor. I’m too new to know whether or not this is an unusual occurrence. All I know is my team felt fairly certain that this guy was going to die a couple of nights ago.

11:55 am: Barbie’s eyes are doing well; it looks like she may be able to go home tomorrow. It’s too soon to know for sure, but it doesn’t seem that there will be any long-term vision problems.

3:50 pm: Very interesting Super Tuesday lecture today. Really, not sarcastic. Our discussion today is on death and dying. Upon walking into the classroom, we were promptly asked, “How do you want to die?” We all responded with ideas such as: at home, without pain, quickly, surrounded by family. Then we discussed the brutality and futility of CPR. We were told that only about 10%-20% of patients who get CPR will live to be discharged from the hospital. Additionally, we were informed that about 75% of people on TV shows survive such ordeals. Yes, I am typing while sitting in lecture. Shh… don’t tell; it looks like I’m taking notes. Anyway, talk about false hope and unrealistic expectations!

People with terminal diagnoses, who have time to plan their deaths, have a higher likelihood of dying at home, surrounded by family, compared to those who die suddenly. I wonder whether or not physicians also have a higher likelihood of dying at home because they know the poor outcomes that result from aggressive life-prolonging treatment. Hand is going up…

My professor really liked the question and suggested that I do a research project on the topic. I nodded noncommittally. I do find it interesting, so maybe I’ll get to it one day, like when I’m done with my book and my bucket list and my current painting and the ten other things I always have going on at once. First month of third year is not the time to start tacking additional tasks onto my to-do list.

July 10: Wednesday

I experienced my first two rapid responses today. When you’re the “on call” team you carry the code pager. When the shrill rapid beeping starts blaring, you immediately stop what you’re doing and race toward whichever room is listed. Both turned out to be nothing but it was thrilling to head toward an unknown emergency. When people see you running, with your white coat flapping behind you and your stethoscope bouncing on your neck, they jump out of the way, flattening their backs up against the wall to let you pass while craning their necks to see what medical crisis you’re off to fix.

To clarify, neither time did my own pager go off, I just obediently followed behind my team when they started running. There is a fundamental difference between people who get excited when they hear a code pager and those who cringe. Turns out I fall in the camp of people who get super excited. The rapid responses were great distractions from worrying about my Step 1 score and also broke up the monotony of rounding. Turns out that rounding lasts for hours and is pretty darn boring.

10:45 am: Passed my boards! Barely.

While of course I wish I had scored higher, I can’t help but be so, so, so relieved that it’s over and I am moving on with my classmates. My insightful mentor, The Boss, firmly stated in her email to me earlier today: “Do not be worried. You will excel in the clinical environment.” I trust her advice and input implicitly, so I will not worry. We’ve previously agreed that my strength is working with people and has never been, nor likely ever will be, taking multiple-choice tests.

2:30 pm aka 1430: I removed an internal jugular central line from a patient, which is a large IV that is placed in a patient’s neck. This marks the first time this rotation I have touched a patient other than during a physical exam on morning rounds. While the internal med folks are all really friendly (bordering on non-confrontational), I don’t see myself being in a specialty with so few procedures. I like getting my hands dirty.

Ms. AI was moved out of Step-down back to the floor. Good.

Turns out many end-of-life studies have been done and a greater percentage of terminally ill physicians die at home with no aggressive interventions compared to the average layperson. I direct interested parties to the article, “How doctors choose to die,” published in The Guardian by Dr. Ken Murray. Intriguing. I think I will fill out a living will someday soon.

My intern and senior resident both let me draw blood from them. Bloody good fun. We were doing this in the break room and received many odd looks from people passing by in the hallway.

En route to see a new patient, my senior resident shares advice that was given to him upon receiving his own Step 1 score: “Do not let your score influence your level of confidence.” I really appreciate hearing that, thanks. It was like he could read my mind and knew I needed a boost.

A patient disappeared today. Kind of impressive considering he is paraplegic and has minimal upper body strength. The patient is well known for screaming, weakly flailing his arms, and spitting at any staff member who enters his room. Additionally, he also refuses to put on a hospital gown, so he has been lying in his hospital bed covered in strategically placed washcloths. To sum up, not just a paraplegic but a naked paraplegic managed to escape off of the floor this morning. Strong work floor staff.

July 11: Thursday

10:11 am: I have so much to learn.

11:42 am: I often ask patients what they understand about their medical conditions. Many of them have never had anything explained to them in terms they can understand and they have no idea what is going on.

4:05 pm: The naked paraplegic was found and returned safely to the floor. Apparently, he wheeled himself to the hospital courtyard where he was eventually found and brought back up to his room. I’m not entirely sure if the goal was leaving permanently or just temporarily so that he could have a cigarette.

My poppa (my dad’s dad), the singing NY cab driver extraordinaire, escaped from a hospital once. After one of his many heart attacks, he left the hospital without telling anyone, got into a cab dressed solely in his hospital gown with his ass hanging out, and then had his girlfriend pay for the cab when he arrived at home.

I just realized I never described the patient on whom I removed the central line. Through a series of unfortunate events the patient had both hands amputated, and in their place they now have intricate hooks. The dexterity and speed with which the patient maneuvers their hooks is pretty incredible. You try tearing open a sugar packet, pouring out just half into your coffee, deftly using a stirrer, then picking up the cup and drinking without spilling! I don’t know if it’s inappropriate to be so impressed. Maybe that is the typical level of functioning for someone with those types of prosthetics?

July 12: Friday

11:43 am: Tried going on rounds today without a stethoscope. Such a rookie.

Mr. BH has been discharged. Alive. Not a celestial discharge. Still in pain, still with a broken hip, but alive nonetheless.

3:12 pm: Ms. AI started throwing up blood. She is in constant pain. I don’t know how to help her.

July 13: Saturday

Fifteen days in and my first day off since starting third year.

July 14: Sunday

6:43 am: Back at work. On call again. The internal medicine residents always seem nervous and hesitant to do things. We talk and talk and talk about patients and when we’re done talking, we call a consult or two and then talk some more. A consult is when you ask another medical specialty for their opinion about your patient. For example: if a patient has a seizure, you might call for a neurology consult; if a patient develops chest pain, you might call for a cardiology consult; or if a patient feels depressed, you may call for a psychiatry consult. I know these patients are complicated but commit to a choice and do something! I’m guessing their hesitancy is compounded by the fact that it is July, and they are all probably scared to do something that could kill someone. I guess that’s understandable.

It’s hard to give patients awful news. Every time we do I think I see a dark look cross the patient’s face. It’s as though they’re rethinking all the poor decisions they have made throughout their life that led them to this point in time.

4:30 pm: The intern is too trusting. A patient came in with a pus-filled infection on the dorsum (top) of her hand, which ostensibly developed after she fell off a bike one week ago. She has no other injuries, not a scratch on her. She swore up and down to the intern, and myself, that she does not do drugs. After leaving her room I commented to the intern that I thought she was probably lying about her drug use. Her injury looks suspiciously as if she was injecting heroin into her hand. He replied, “No, there is no reason not to trust her.” Sure. We’ll see about this one. The intern and I present the patient to our senior resident and our senior agrees with me that yes, she is probably an IV drug user. The intern sticks to his guns. Again, since one else wants her, she has been assigned to me. Let’s call this new patient of mine Ms. BA for bike accident.

5:45 pm: The urine drug screen on Ms. BA came back positive for all sorts of good stuff including opioids, cocaine, and marijuana, and that’s not even the fancy drug screen that picks up designer drugs. Called it. Another win for the medical student.

July 15: Monday

It’s shocking how many people have nasty foot problems from diabetes. The prevalence of diabetes makes me concerned for my dad - the disease is nearly ubiquitous among overweight Americans. My dad is out of shape, a former smoker, and has already had one heart attack. He is the poster child for a future diabetic, and I worry about him constantly.

I just found out Ms. AI is being presented at M&M today. Why? M&M, or, Morbidity and Mortality, is a conference where a patient who had a complication or who died, allegedly due to a preventable medical error, gets presented to all of the medicine teams. The teams then pick apart the case. The goal is to identify the cause of the problem so that it won’t be repeated by anyone else.

In theory it’s a non-accusatory forum to address life and death errors, but I’ve heard it can get pretty heated. Not quite like the TV show coming out called Monday Mornings, but something to that effect.

Noon: Morbidity and mortality conference. Here we go.

12:55 pm: Sitting in M&M while your patient is being presented is the worst thing ever, and I’m not even responsible for making decisions regarding her care. (I mean, I like to think I am, but really the residents make all the decisions and I just write her daily progress notes). The roomful of docs was provided with a barebones overview of her case, missing many of the details regarding the complexity of her condition. Then they start talking condescendingly about how they would’ve handled her case differently and perfectly. I wanted to yell out, “No, you don’t get it, she is crazy unstable!” but I sat there quietly and watched my team face the firing squad while I hid in a corner.

July 16: Tuesday

7:53 am: Feet smell powerfully bad. Especially right after morning coffee.

9:14 am: Ms. BA is still swearing up and down that she does not use drugs. We keep going along with her story about the bike. No one will confront her. I don’t think she should get more narcotic pain meds because she is drug seeking. Her abscess isn’t even that big, and it’s healing really well. Hopefully she doesn’t go home and inject more heroin into it.

2:20 pm: Super Tuesday lectures are made infinitely more bearable by the presence of my closest guy friend, Magnus. We share a dry sarcastic humor and hold similar views on many issues ranging from patient care to football to the importance of bacon.

Magnus and I became close because he dated my bestie Piper all throughout first year. The three of us would sit next to each other every day during lectures and hang out whenever not in class. Piper broke up with him right after first year ended and fortunately, they never once tried to put me in the middle of any of their drama. It was a messy breakup and they did not speak to each other for the entirety of second year. Piper and Magnus are still two of my closest friends; I just have to hang out with them individually now. They’ve had shared custody of my friendship since their separation.

July 17: Wednesday

This morning I walked into Ms. BA’s room to find her lounging in bed, quietly watching TV. She waits until a commercial starts, then looks at me and deadpans that her hand is killing her and she is in 10/10 pain. Not to be insensitive, but if you can calmly and clearly tell me about your pain while watching soaps then it’s probably not 10/10. Actually, it’s definitely not 10/10; 10/10 is more like childbirth to an extra-large baby without an epidural, or having a broken bone sticking out of your body at some weird angle, or having your leg bitten off by a shark with dull teeth. Those are examples of 10/10 pain in my book. I’m sure it hurts but really, I think she’s drug seeking again and I have no interest in giving her more meds.

Ms. BA is getting under my skin because lying is a pet peeve of mine. While growing up, my parents told my sister Olivia and me that they would never lie to us because once you catch someone in a lie, their word can never be trusted again. To this day, I still trust my parents; they’re awesome. Ms. BA sucks.

1:00 pm: We have a patient on our service with a three-week-old wound in the back of his head. There were stitches and staples put in initially, staples all down the middle with one stitch at the top and two stitches at the bottom. His staples were removed a week ago, but the stitches were forgotten about for reasons unknown. I offered to remove the stitches because they had been in too long (scalp stitches are usually kept in for 10 to 14 days). My team agreed this was a good idea, but my intern wanted me to consult the trauma surgery team first. Umm, no. Bad idea.

Calling the trauma team for their permission to remove THREE stitches on a well-healed wound would result in me either getting laughed at or yelled at by the trauma team. I explained that I wouldn’t call. The intern retorted, “Yes, you have to.” The intern then left to go do something else. I normally do not defy my superiors but this was ridiculous. To appease my intern, I called Sophia (my dear friend and fellow medical student), who is currently rotating with the trauma surgery team. That way I could aver that, yes, technically I did call the trauma team. She didn’t answer (because the trauma team is always busy, which is why I didn’t want to call in the first place) and then I went and removed the stitches anyway.

3:00 pm: My intern is not happy with me. Fortunately, the senior resident jumped in and defended me by explaining, “No, no, no, we do not consult trauma surgery for little things like that.” Phew. Yet another example of internal medicine people being terrified to do anything without the explicit permission of as many people as possible. Or another example of July interns being terrified to kill someone. Either way. But really, if you have three three-week-old stitches holding the back of your head together then you have way bigger problems in your life than a rogue med student.

July 18: Thursday

One of the patients got me sick. It hurts to swallow. My throat is on fire. My tonsils are disgustingly swollen. It feels like strep, but it’s likely something viral floating around. Ugh.

Night team gave Ms. BA more narcotics. Will people please stop increasing the pain meds on my drug-seeking patient? The senior resident reluctantly admitted to me that he had increased her dose. He explained that it was to make the night nurses lives easier. Fine, I get that, but isn’t there any other option?

I would like to have an honest conversation with Ms. BA about her behavior before she leaves. I want to tell her that she really needs to stop using needles, especially dirty ones, because she will get more abscesses. My team informed me that the nature of medicine is to treat and not bother addressing problems for which there can’t be follow-up. Ok, but what I don’t understand is this: I have the time, I have the training, and I’m still naively optimistic enough to think that I can make a difference in her life. What is the harm if I go over options for treatment programs? Either way she is going home today.

This whole time she thinks she’s pulled one over on us. She thinks she is so clever and has successfully tricked the medical team into believing that her abscess is from a bike accident. In addition to paralyzing hesitation to do things, there is also a large amount of confrontation avoidance among the internal medicine people. Beyond frustrating. I’m too action-oriented and straightforward for this specialty.

A couple of weeks prior to coming to The General Hospital, my other patient, Ms. AI, had a nasty infection that almost killed her. She had to be intubated. This involved placing a breathing tube in her throat and connecting it (and her) to a ventilator, a machine that breathed for her. This is akin to being placed on life support. She has extreme anxiety and nightmares about that hospital visit and she is terrified about the prospect of going to sleep, decompensating, and waking up intubated again. Her solution to this is to not sleep. She looks painfully tired and is fighting falling asleep.

Her previous hospital experiences have been pretty traumatic. Another horrific experience was during one of her pregnancies, which resulted in her requiring an emergent cesarean delivery. She shared with me about being whisked away into a bright room, being surrounding by people in yellow gowns and having a mask put over her face. When she awoke, she learned her baby had not survived the delivery. Poor Ms. AI. I want to give her a hug. If you know her, you probably don’t want to give her a hug because she’s pretty bitchy with the rest of the staff, but she’s chill with me for reasons unknown.

July 19: Friday

About an hour ago I received a text from my intern to go check in with Ms. AI because she is in a lot of pain. My mission was to figure out what was wrong and comfort her but offer no pain medication. After about two minutes of chatting she told me that on top of everything else going on, she is having really bad belly cramps and muscles aches from starting her period. She is also suffering from severe anxiety and depression. I talked with her a bit and regretted that I had nothing to offer her. As I was leaving, an idea popped in my head. I randomly asked her if she would like to speak with our chaplain about her anxiety and for some spiritual comfort. She loved the idea. Found a way to support her and no meds required. Take that, intern.

I am feeling more and more ill as the day goes on and my energy is gone. I just want to bury myself in my bed, under layers of warm blankets. How sick do I have to be before I can leave? We were jokingly (?) informed during orientation that we would have to require IV fluids and IV antibiotics in order to be considered sick enough to not be at work.

July 20: Saturday

10:31 am: I kind of have the urge to check Ms. AI’s medical records from my home to see how she’s doing but I am off for the weekend, so I will resist. It’s only my second day off from work in 20 days and my first full weekend off since I started third year.

My head is achy, I barely have the energy to sit up, and my ever-running nose is red and irritated from constantly being rubbed by tissues. I am not moving off my couch today. I wish I felt better so that I can enjoy my days off. Casey is on call, so I have the apartment to myself. I don’t think we’ve spent any real quality time together in days. Or months. It’s getting hard to tell whether this can be blamed on our schedules or if something else is the cause.

July 21: Sunday

11:43 am: After sleeping most of the past 24 hours I feel infinitely better and ready to leave the confines of my apartment.

It was so gorgeously bright out today that I decided I needed to spend the day outside. I was in luck. Once a month the LGBT group at my medical school hosts a potluck dinner and as a mostly-straight ally, I try to attend each month. The hosts for this month are the brilliant Dr. Neuro (who I adore) and his partner. Upon arriving to the party, Dr. Neuro took my best friend Jane and I upstairs to the balcony overlooking his pool and backyard. From this vantage point he pointed out each of the physicians and their specialty, so we would know whom to best target for networking. After about ten minutes of playing who’s who, two more people entered the backyard. Our professor confided to us, “Oh, look, that’s the medicine attending, Dr. Osler. He’s started coming out to family and friends last week, but he hasn’t come out at work yet. It’s been really difficult for him. This is his first time ever attending the potluck. I’ve assured him it’s a safe place where he can be comfortable and open.” Well, I guess there’s no safer place to run into your own med student than at an LGBT potluck/pool party?

I’m fairly certain Dr. Osler almost ran from the pool deck upon making eye contact with me. We chatted briefly and then each went about our own business of drinking and relaxing.

July 22: Monday

11:35 am: There was a mandatory CPR recertification class this morning resulting in me missing morning rounds again. It feels weird to be away from my patients three days in a row.

11:46 am: Ugh… the chaplain never checked in with Ms. AI on Friday! So much for that idea. On top of that, it turns out Ms. AI had a fall and developed a new infection. Why is she getting worse and not better?

2:35 pm: Ms. BA has been discharged. I wonder how long before she returns with her arm infected and requiring an amputation à la Requiem for a Dream.

July 23: Tuesday

6:50 am: We have a new attending today so farewell to Dr. Osler. He was easy-going and laidback, making my transition to third year smooth. I’ve heard rumors that our new attending is borderline neurotic in how she likes things done and can be a real stickler about pretty much everything.

9:26 am: Many patients seem distrustful when we talk to them. They and their families often query: “Do you know what you’re doing?” “Why am I not better yet?” “How old are you?” “Are you sure about that?” “I checked Google and I think I have xyz…” I keep thinking, “We’re doing the best we can and don’t worry; our attending keeps a close eye on us.”

11:46 am: Ms. AI has diarrhea so prolific right now that she has taken to wearing diapers. She tearfully admitted to me how embarrassing this whole situation is for her. We’re not that far apart in age. I really, truly can’t imagine being in her position; it must be so, so terrible.

2:23 pm: Super Tuesday! Hold the super.

3:12 pm: My personal life is falling apart. Can I keep ignoring that right now?

July 24: Wednesday

11:49 am: We have a patient in his 90s who is likely not making it out of The General Hospital alive. His name is 95. His daughter, who is my parent’s age, made this realization while we were rounding yesterday. She broke down crying. Not just crying, but really sobbing. We witnessed the moment where she came to understand that her father is not only mortal but is dying. My team left me with her during rounds to comfort her and I am so glad they did. I let her cry it out for a bit, then encouraged her to talk about 95 and her family. After a while, we discussed coping, strength, and surviving events we believe are insurmountable. After spending so many hours of so many days wishing I could be of service to my patients and my team this felt wonderful. This will certainly be a most memorable patient encounter.

On another note, 95 is one of the healthiest patients on our service: no diabetes, no cardiovascular disease, and no obesity. The senior resident informed me that if someone makes it to their 90s, it’s because their life leading up until that point was likely healthy. Evidently his health status is not surprising to anyone else on the team.

1:15 pm: My intern is off today, my senior is at clinic, and my attending is not here. I’m going to be a bad/lazy med student and go home. I really need to go food shopping and take a shower. It’s been awhile.

July 25: Thursday

6:52 am: As I pre-rounded today, Ms. AI told me to not be so nervous when presenting in front of the new attending. I was touched to realize that this patient, someone so sick and brittle, had noticed how my bedside presentations changed with the new attending. She is absolutely right. This new attending definitely makes me jittery. I just wish my team could do more for Ms. AI. She appears to be fading before my eyes, every day more pallid and frail than the day before.

11:52 am: My team went into 95’s room during rounds. While discussing the plan for 95, his daughter walked into the room. When she saw me, she walked right over and gave me a big hug, then looked me in the eye, thanked me, and told me she’d never forget me. Great way to start the day! It would have been just as wonderful if my team wasn’t present to witness her gratitude, but having the team there was a bonus.

7:35 pm: As part of my end-of-rotation evaluation I was scrutinized while taking a patient history and doing a full physical exam. In general, the feedback was positive. My attending taught me how to properly palpate the spleen during the physical exam. From now on I won’t have to awkwardly pretend as if I know what I’m doing during that part of an abdominal exam. My attending remarked that I am skilled at quickly developing relationships with my patients. It’s nice to feel that I’m good at something since most of the time I am fairly lost. Patients do not act the way we were taught they would.

There’s a NY Times article about patients developing post-traumatic stress disorder (PTSD) after ICU stays. Patients at higher risk tend to be young females. I wonder if PTSD is plaguing Ms. AI during her hospital stay.

8:36 pm: I am actively ignoring the fact that Casey told me on Monday night that he doesn’t know if he ever sees us getting married.

July 26: Friday

11:30 am: Turns out that 95 is a trooper. He’s doing great and will be going home tomorrow. Yet another patient this rotation that my team had written off for dead but will be going home very much alive.

2:15 pm: I had a final feedback session with my senior resident today. He said he was pleased with my progress and went on to explain, “I don’t want to use the word aggressive… No, your assertiveness in offering to do and watch procedures was great.” I told him I tried to keep an open mind during the rotation, but we agreed that internal medicine probably isn’t for me. Like in any way. At all. Ever.

I’m happy it’s my last night of call with inpatient internal medicine and tomorrow is my last day at the hospital. The next four weeks will be outpatient internal medicine.

Since tomorrow is my last day, I really need to go say goodbye to Ms. AI.

3:35 pm: Timing. Not a minute after typing the previous sentence the code pagers went off. I took off running and was halfway down the hallway to the patient’s room before it clicked that I was heading towards Ms. AI room. She was unresponsive, so a rapid response was called. Then she started posturing, with her arms and legs extended stiffly at her side. The doctor pinched her skin and tried other painful methods to rouse her. I wanted to yell at him to stop. I stood frozen near the doorway of her room and watched her get intubated while the residents discussed whether or not she may have developed a bleed in her head.

The scene played out exactly the way she described to me that she was afraid it would happen. Masked, yellow-gowned docs swarming around her bed and shoving a tube down her throat. She was sent for an emergent head CT, so I went with her, and then I followed her to her new room in the ICU. I kept vigil at her bedside for some time, unable to imagine how I would feel if one of my nightmares came true. One of the attending docs stopped by and asked me if I was ok. He kindly updated me that her CT scan was normal. I’m usually good at hiding my emotions but this was too much to witness. She can’t die. She can’t. Of all the patients… not her. Please not her.

5:45 pm: Time does not stop and our team is busy. There is a new patient for me and I almost vomited in his room because of the stench emanating from him.

6:50 pm: Lots of new patients are rolling in, including two who are psychotic. Psychotic patients are fascinating to me, and today they are also distracting me from thinking about Ms. AI. One new patient kept yelling at me and calling me Bessy. The other one is intensely paranoid and believes she is part of an FBI conspiracy and film project. She seemed relieved (though I think slightly disappointed) when I told her firmly “no” we are not making a movie about her. Though, she will get a part in my book. I didn’t tell her this.

July 27: Saturday

6:45 am: Today is my last day on inpatient medicine. I would’ve said goodbye to Ms. AI but she is still intubated in the ICU. I will, however, go and say goodbye to 95 and his wonderful family once we’re done with rounds.

1:30 pm: Wow, what a great note to end on. I spent nearly 40 minutes sitting with 95 and his wife of forever. They have many children and even more grandchildren and great grandchildren. 95’s wife revealed to me in a conspiratorial tone, “Every time he thought I wasn’t busy enough he got me pregnant again.” My favorite exchange went something like this:

Wife: “I couldn’t have found a better man, I am so blessed.”

95: “You could’ve found a richer man.”

Wife: “I guess so.”

95: “Eh, but he probably wouldn’t have you let you spend all his money the way I let you spend all of mine!”

The two of them busted out laughing.

95’s wife asked me if I had a boyfriend. I replied “yes,” and she told me that he better be treating me right. She added that he must be worried all the time about other doctors hitting on me. I’m not so sure about that, but I just nodded and smiled and left it at that. There were lots of hugs and well-wishing when I left the room. I am in awe of their relationship. You could see the love between them, radiating from them. My grandparents, my mom’s parents, were like that. Hugging and kissing and holding hands up until the day my poppa died. My relationship with Casey isn’t like that; it hasn’t been like that in a long time. Maybe in the past, but not recently. I’m dreading going home today and discussing the state of our relationship, but I can’t put it off any longer.

Before I leave the hospital and officially finish inpatient medicine, I go turn in my pager that never went off.