Like pulling teeth.

Yay!  My first blog comment.  Who cares if it's from my little sister?

Just to follow up on yesterday's topic:

Today, I called the central scheduling to confirm an appointment for one of my patients.  All I wanted was the name of the doctor and the time/date of the visit.  It was like pulling teeth.

Me:  Hi, I'm taking care of Mr. Whatsit, he already has an appointment scheduled at the family heath center, but he doesn't remember the date or who it's with.  Can you give me that information?

*I provide all the information so the lady can look up my patient on the system*

Confused Lady:  Hm, I found the appointment.  It's Wednesday at 2pm.  But I can't see the doctor's name.

Me:  You can't see the doctor's name?  Do you mean that the appointment isn't with a doctor?

Confused Lady:  No, it's with a doctor, I just can't see all of his name.  I just see the first three letters.

Me:  You don't know which doctor's last name starts with those three letters?  How do you let patients know what doctor they have for their appointments?

Confused Lady:  The letters are D-A-V.  Does that help?

Me:  (trying to be helpful but also a little facetious) Can you try clicking on it or something?

The conversation went downhill from there.

Phones are the bane of my existence.

I'm slowly beginning to realize how grossly inefficient medicine is.  You may think medicine is all about sitting at the bedside and talking to patients... but that's not it at all.  Residents, interns and med students spend most of their day calling consults, entering orders, and making follow-up appointments.

Nothing is more frustrating than phone calls.

I'm currently on a rotation away from the main university hospital.  It's a private hospital just 15 minutes away from my apartment.  I'll just call it "Grace" Hospital.  I like it a lot.  The cases are simple, "bread and butter" type things: old people with pneumonia, syncope, or venous stasis ulcers.  The only problem is that this place is grossly inefficient.  Even more so than the university hospital (ant that's saying a lot).

Let me give an example.  Let's say I want to make a follow-up appointment for Mrs. X with her primary care provider, who is affiliated with the hospital.  At the university hospital, most doctors have a nurse practitioner or secretary that knows the doctor's schedule and patients.  Things usually go something like this:

Me: Hi, I'm currently taking care of Mrs. X.  She just got admitted for pneumonia, and we want to schedule a follow-up appointment for her.

Helpful Nurse Practitioner: Oh, Mrs. X?  Of course we know her.  Dr. Blank is full this week, but we can squeeze her in next week.

Me: Great, thank you so much!

*Arrangements are made.  I hang up the phone satisfied.*

MISSION ACCOMPLISHED

Conversely, at Grace Hospital, making follow-up appointments with hospital-associated doctors is an exercise in patience.  Here's how the conversation usually goes:

Me: Hi, I'm currently taking care of Mrs. X.  She just got admitted for pneumonia, and we want to schedule a follow-up appointment with her primary care doctor.

Operator: Please hold.

*light music plays for 5 minutes*

Some person: Hello?

Me: Hi, I'm currently taking care of Mrs. X.  She just got admitted for pneumonia, and we want to schedule a follow-up appointment with her primary care doctor.

Some person:  This isn't the number you call for that.

Me:  Oh, I'm sorry, I was just transferred to this number.  Is it incorrect?

Some person:  I'm not sure.  Let me check with my superviser.

Me:  Okay... Is there an alternate number I can use?

Some person:  Um, please hold.

*light music plays for another 10 minutes*

 Some person:  You can try 123-456-7890

Me:  Thanks.

*I hang up and dutifully call the number.  It rings a million times.  No one answers.  I hang up and try again.  It continues to ring with no answer.  I wait 10 minutes, and try again.  Finally...*

Ornery Lady: What???

Me:  Hi, I'm currently taking care of Mrs. X.  She just got admitted for pneumonia, and we want to schedule a follow-up appointment with her primary care doctor.

Ornery Lady:  Who???

Me:  Ms X.  Her PCP is Dr. Blank.  We need to get an appointment in next week, if possible.  Her medical record number is...

Ornery Lady:  (interrupting) You'll have to call Dr. Blank's answering service.  I can't do that.

Me:  Wait.  I'm sorry - is this not the number I call to make appointments?

Ornery Lady:  Yes it is, but I can't make an appointment.

Me: What?  I guess I don't understand.

Ornery Lady:  I can make an appointment for February.  I can't overbook Dr. Blank.

Me:  But it's November.  What do you do if patients have to see the doctor earlier?  We had to change Mrs. X's hypertension medications, and she really needs to see Dr. Blank soon.

Ornery Lady:  (avoiding the situation) Will you hold???

*Light music plays for 10 minutes*

Ornery Lady:  Hello???  I can't make any appointments that would overbook a doctor.

Me:  (internal thoughts) So, essentially...  a computer could do your job.  Don't doctors hire people like you so they don't have to spend all day making appointments? (end bitter internal thought)

*Note:  just to give a little context, making follow-up appointments like this happens all the time.  I still don't understand why someone in charge of making appointments for a doctor has no authority to alter the schedule.  That's just silly.  And inefficient.*


Ornery Lady:  You'll have to call Dr. Blank's answering service.

Me:  Does Dr. Blank have a pager?  I could just leave a message for her.

Ornery Lady:  No, you have to call the answering service(!!!)

 Me:  (grudgingly) Okay, thanks.

*I call the answering service with the number I painfully extract from Ornery Lady.  I am immediately put on hold.  Again.*

Answering service lady:  Hello?

Me: Hi, I need to leave a message for Dr. Blank.

ASL:  Oh, you don't leave a message for the doctors here.  I need your name and number so they can call you back.

Me:  (internal thought: "Wait.  How is this different from a pager?")  Do you have any sense of when she'll call back?  I can leave a call-back number from the phone where I'm at now, but I will have to sit by this phone until she calls.

ASL:  All I know is that I need a call-back number.  I don't know when the doctor will call back.

I leave the number.  And wait for a call back.  For an hour.

Dr. Blank:  Hello.

Me: Hi Dr. Blank, I'm currently taking care of Mrs. X.  She just got admitted for pneumonia, and we want to schedule a follow-up appointment with you next week.

Dr. Blank:  Oh, I don't take care of Mrs. X anymore.  You'll have to contact my associate, Dr. Nonexistent.

MISSION FAILURE.  REPEAT PROCESS.

Dr. Cart

... and I'm back.  It's been a while.  I will not confess to feeling bad or ashamed of not updating.  Not that I spend my free time engaging in actual productive activities.  In truth, I've been watching far more anime than is probably healthy.  I'm currently obsessed with this really talented group that's abridging Dragonball Z.  It's quite fantastic, especially if you've watched every DBZ episode, as I have... twice.  Yes, that's right.  I am a medical student and I love anime.  I am also a devout fantasy novel reader.  Perhaps I simply need to escape reality.

I few weeks ago, I was on the cardiology team, which is responsible for all the "codes" that occur in the hospital.  So essentially, we had to respond to any sudden cardiac event.  At my hospital, there is an overhead announcement calling "Dr. Cart" to wherever the patient went down.  As soon as this happens, each member of the team moves into action.  So when I was on the team, the resident ran directly to the room (he's the one that directs the code), the intern ran to get the defibrillator, and I... struggled to keep up.  Anesthesiology and surgery also played a role: they intubated and placed a central line (respectively).

It's crazy during a code.  The main problem is that codes are time sensitive (so everyone rushes in to help) and... well, to be frank, they're interesting.   Even people that are not essential to the code try to push in to see what's going on.  I often felt like I was one of these people.  Even though I was technically on the code team, I wasn't really needed - indeed, I was in the way more often than I was actually helpful.  Nonetheless, I pushed in the room to claim my position.  In a few short years, I myself may be leading such codes, and I needed to learn how they work.  I convinced myself that it was for my education.

TV is riddled with images of "CPR," but I assure you it is nothing like reality.  Codes are far more visceral than can ever be expressed on TV.  Let me give you a sample of one of my code days:

It was a pretty slow day for us on the cards team.  It was already 2:00pm and I still hadn't gotten a patient from the ER.  'Can't wait for another rule-out ACS' I thought to myself ruefully.  For some reason, all of my call days on the cards team were exceptionally slow until about 5:00pm.  It was a bit boring, but made for some good nap time.  I absently rifled through the pages of the book I'd been attempting to study.  'Wish something would happen' I sighed.

Then the call came.  "Dr. Cart D607.  Dr. Cart D607" rang out from the overhead speaker.  My intern and resident were not in the workroom with me, but I knew where to find them.  I rushed out of the room, knowing the next hour would be dedicated to preserving the life of a patient that was likely dying.  As I jogged toward the cardiac ICU, I heard footsteps behind me.  Glancing back, I saw one of the surgical interns running towards the code.  He looked scared.  Maybe it was his first time on the code team.  Maybe this was the first time he had ever placed a central line by himself.  Such things are not unheard of in medical education.

The code was in full swing when I arrived.  The room was packed with bodies milling around to get the patient ready.  Though seemingly chaotic, codes are deceptively efficient.  All the overlapping and intermingled activity is centered on a single goal:  setting up the patient so we can monitor them and intervene as needed.  Nurses place blood pressure cuffs, attach CO2 monitors, and place the defibrillator pads.  Respiratory therapists bag mask the patients until anesthesiology shows up to intubate them.  Pharmacists ready the meds.  The intern unpacks the defibrillator bag and passes off the various monitors to the ready hands of nurses.  A bilobar disc is adhered to the patient's mid sternum, where compressions will occur.  All this happens within minutes of the code call.  It must.

As the medical student on the code team, my responsibility was to do chest compressions.  The purpose of this activity is to keep the patient's blood moving though his or her body so that it can continue to nourish the brain and vital organs.  Though a seemingly simple task, chest compressions are an awkward and shamefully inefficient way to accomplish this goal.  A healthy, functioning heart is an elegantly coordinated pump that sequentially shunts blood from atria to ventricles.  In contrast, CPR just squeezes the entire heart simultaneously - only a small amount of blood dribbles out with each pump.  What's more, chest compressions are - in a word - ugly.  The heart is located under a thick layer of bone - in order to squeeze the organ beneath, it is necessary to compress the patient's chest HARD.  Hard enough to push the chest wall in by a measure of inches.  Sometimes hard enough to crack ribs.  Hard enough that it's exhausting to do.  Certainly hard enough that it's uncomfortable to watch.


My turn to do compression was fast approaching.  I positioned myself by the bed, signaling to the nurse that was currently pumping that I would relieve him.  It was then that got my first full view of the patient.  She was an elderly, obese woman - perhaps in her 70's - her face a mass of wrinkles and her hair a soft crest of downy white.  Her eyes were open and glazed.  By this time, she had been intubated; the tube made an odd goose-like honk each time the respiratory therapist pumped the bag.  A recent surgical scar spanned her chest from her manubrium to xyphoid - she had recently undergone major heart surgery.  Her arms hung limply at her sides.  She was ghastly, ghastly pale.


At a command from my resident, all activity stopped for a pulse check.  Several hands reached forward to monitor for any evidence that her heart was working.  The nurse that was doing compressions stepped back, and I centered myself on the bilobar disc that was attached to the patient's mid chest with adhesive.  Meanwhile, no one felt a pulse.  It was time to resume compressions.


It's hard to express what it's like to pump someone's chest.  It's so many things all at once:  disgusting, exhilarating, exhausting.  The important thing is to concentrate on the action itself:  compress fully, allow the chest to bounce back completely, and make sure the rate is at the proper 100 per minute.  But it's hard not to think about the person beneath your hands.  Does she have a family?  Are her relatives on the way to the hospital even as I compress her chest?  What did she do for a living?  What will happen if she dies?


As I pumped, blood began to ooze from the surgical wound beneath the bilobar disc.  The adhesive lost its purchase, and my base started to slide on the patient's chest.  I gritted my teeth as I concentrated on keeping the disc centered and tried not to be occupied with the blood as it trickled out with each compression.  After only a minute of CPR, my shoulders began to burn.  I stole a glance at the patient's face.  It was waxen and lifeless.


I will not bore you with the details of how a code ends.  In reality, it's anticlimactic.  Things just sort of... peter out.  As it becomes apparent that the patient will not recover, people begin to shuffle out of the room.  Soon, the only sound is that of compressions, ventilation, and a bit of conversation between the resident and attending, debating over what more can be done to revive the patient.  Eventually, the resident calls an end to activity.  He declares the time of death.  The code is over.

I was still in the ICU as my resident was finishing up a bit of paperwork.  The nurses did a good job erasing all signs of the code.  The floor was cleared of all garbage.  Her skin was washed of all traces of blood.  They donned her with a new gown and spread a fresh blanket over her lap.  Though still pale, her face seemed to take on some semblance of peace.

The ICU rooms have glass walls so that patients can be observed by the staff quickly.  This feature also allowed me to observe the family members as they said their final goodbyes to their loved one.  It was such an intimate moment; I felt like I was intruding, yet I couldn't tear my eyes away from the patient's daughter as she wept, her face buried in that crest of downy hair.  My life had only briefly touched hers, yet the raw emotion of the moment was... indescribable.

...I'm still searching for a word to describe that scene.  I guess it can't be summed in a single term.  That woman was not my patient.  When I walked into the room for the code, I didn't even know her name.  Yet I was there at the moment of her death.  I was present for a special, awful, final moment of her life, and I didn't even know who she was.  Such is medicine.

Please do not think that I am burdened by this patient's death.  We did our best to revive her - her body was simply unable to sustain her life any longer.  It's just sad that I never had the pleasure of knowing this woman.  It's sad that I only remember her as a patient that bled as I compressed her chest.  It's sad that she passed in the hospital surrounded by strangers instead of her family.  Death is a an inevitable event that every medical student must confront during his or her education.

I'm learning a lot.