Follow the leader.

"This is another bullshit admission."

That's what my senior resident said while shaking her head hard. Her cheeks were pink and flushed, partly from the stairs she'd just climbed up to the ward but mostly because she was mad. Our call day had been extremely busy so far. Mostly, in her opinion, because of patients that the Emergency Department brought in similar to this one.

"What is it for?" And by "it" I meant the admission. Which kind of makes me cringe when I think of it that way.

"A man who ran out of his medications, like, a thousand years ago who now has--surprise!--a high blood sugar and blood pressure. Ugggh!" She plopped down into a chair and checked her pager. "This is the kind of thing that bottlenecks the system. It's such complete bullshit."

Bullshit. Wow. Well, if she thought it was that then it had to be just that.

Didn't it?

See, I had immense respect for this particular resident. I was just under the halfway point of my internship and she was one of the seniors you wanted to have covering you. She was smart. She was decisive. But most of all, she simply knew what to do and always had a clear idea of how to get things done. Whether she knew it or not, she was a leader and one that I often sought to emulate.

She tossed an index card in my direction. "I have some of the information from the admission here but you'll have to check the archival for background stuff. I'd also call his pharmacy if I were you."

Oh yeah. Call his pharmacy.

"They can tell us his compliance history with these meds and exactly what he took last. Go and see him and if I can get our attending up here maybe we can discharge him before they pass the dinner trays." She laughed at that last part and I followed with a nervous chuckle of my own.

I quickly scrambled to grab the card and stood to my feet. "Okay," I responded. "No problem."

"And hurry up because we'll probably get another one soon. More bullshit from the ED, but plenty of work, still."

"Okay."

So down to the ED I scurried. I walked as fast as I could to get over to see this less than ideal admission--the same one that we fully intended to send on his merry way should all of the attending stars fully align.

"Hey there. I'm Dr. Draper." I reached out and shook his hand.

"Hello!"  His voice was raspy with tobacco damage and his teeth beige with what was likely the same culprit.

"I came here to see you from the medical team. I heard you've been out of your medicines."

"Yes, unfortunately," he said with a tiny shake of his head. "My insurance stopped and I couldn't pay for them. So I stretched them as long as I could and then just ran out. I was hoping to see a social worker and that's it, but my blood sugar was pretty high when I got here so they wanted to keep me."

"Hmmmm."

"They were checking my blood to see if I had gotten acid in it from the high blood sugar. My blood pressure was up some, too."

"Yes, sir. I saw your lab work and you don't have acid in your blood. Have you ever had what they call diabetic ketoacidosis--that is, acid in your blood from diabetes?"

"Naaaah. It's never gotten to that point. And I've been diabetic for almost fifteen years."

"Okay."  I jotted that down on the card.

Next, I took an inventory of his symptoms. Chest pain? Headaches? Visual disturbances? Foot ulcers? Shortness of breath? Dizziness? I asked the whole battery of things for every body part, none of which yielded answers in the affirmative.

With his permission, I did a physical exam. Inspected his neck veins with my novice eye, placed my stethoscope onto his supine chest and closed my eyes as I left it there while listening. Maybe there was an extra heart sound consistent with longstanding blood pressure, but nothing ominous from what I could tell. I completed my assessment by pressing my finger tips into his ankles to check for any tell-tale swelling and there was none.

My resident was right. This man probably could have forgone an admission.  But since he was admitted, then this probably was, as she'd so colorfully put it, "bullshit" indeed.

"Where do you live, sir?"

He described the duplex he shared with his daughter's family on the other side. That's when I learned that he had plenty of support but had just been proud about troubling anyone with his medication issues. In fact, his daughter had driven him to the hospital and had left only to get her children from school. All of it--the admission, that is--was a bit of a hassle for this man and his family. But he had decided to fully cooperate with the doctor's instructions which, this time, meant he was getting admitted.

Even if he didn't need it.

"How would you feel about NOT getting hospitalized?" I asked. I knew it was kind of bold of me to go there as an intern but I just had to know.

"Well. That would be fine with me so long as somebody could help me with sorting out my medicines." And even though this took place in Cleveland, Ohio and not at Grady Hospital in Atlanta, even then I knew that social services are often the lifeline to a solid medical plan no matter where you are.

And so. I bit the bullet and decided that I'd take it upon myself to advocate an un-admission or rather a discharge on his behalf. This meant talking to the attending physician in the Emergency Department who I'd noted to be one I'd worked with during my recent month rotation there.

I still remember that attending. He liked to be called by his first name no matter who you were and why you were calling it. In fact, he insisted upon it. This helped me to get to know him because it was very much against my medical school upbringing to call any faculty member by their Christian name. But John, as he repeatedly pressed me to call him, was a different kind of faculty. He'd had another career before all of this and it was simply his style to flatten the hierarchy. For him, that worked well and always made him a bit more approachable and fun to work with. Plus he was middle-aged with graying hair so the whole first-name basis never seemed to undermine his authority in any way.

Anyways. I went over to where he was and found him talking to one of the upper level ER residents. Since he was such a nice guy, he immediately smiled when he saw me. "Welcome back, Kotter!"

I chuckled at that goofy 1970's reference and replied, "Hey there, John. How are things going?"

"It's the emergency department. Things are always going!" He passed a chart back to the resident in front of him. I loved the way he always made things look so relaxed and easy. "Is everything okay with you?"

I was glad he gave me an opening to talk about my patient. The attending who'd seen him earlier was now off of her shift so all of this would be brand spanking new to John. And so I carefully discussed this man and his lack of insurance which led to his lack of medicines and blood sugar and pressure control. John listened intently and nodded his head with each layer to the story. I also noticed the body language of that upper level resident. Her arms immediately stiffened and a ripple of discontent rolled over her face the minute I said the name and room number.

"So, do you think we can get him a definite game plan for follow up?" John asked.

"I feel certain that if I hustle right now, I totally could." I felt my pulse quickening. He was listening to me--the intern--for real listening to me. Hearing the story and trying to make sense of it. I couldn't wait to head upstairs triumphantly to tell my resident that I'd officially "blocked" my first admission.

A "bullshit" admission, no less.

"I will go and see him again. I can't see why that should be an issue," he said while staring at an EKG tracing. Then he looked up at me and smiled. My face felt warm because as interns it wasn't every day that your voice felt so heard. John always had a way of doing that with every single learner, nurse, patient and person around him and I could tell, even then, that it was a decision that he'd made long ago.

And so. John and his senior resident disappeared behind the door leading to that patient's room. A few moments later they returned and confirmed that our man with his missing medicines would indeed go home and return the following day for follow up in the clinic.

Yes!

I nodded and quickly paged my resident. As soon as she called back I proudly told her of how this patient--the "bullshit" admission--was an admission no more. And she patted my back as best she could through the phone and affirmed me for a job well done. I was over the moon.

Just as I hung up the phone, I saw John walking in my direction after finishing with his senior resident. I stood at attention to be sure my body language signaled deference. "Hey, can I do anything?" I asked.

"No. . . . he said, but I do want to give you some advice." His voice was decidedly serious and it kind of made me nervous. He pointed at his chest and then at me. "Us, all of us, are in this thing together. Our goal is to do what's best for the patients and nobody wins when we're more interested in ourselves than our patients."

Ooooppph. That kind of hurt. I felt a lump developing in my throat. Had I acted too elated when I'd learned that the patient wasn't being admitted? Perhaps I had since that's exactly how I felt.

"Kim, your resident was rude and confrontational. She is passionate, yes, but was proud. Too proud to have a conversation that felt collaborative for the patient. I heard you when you called her and was a little disappointed to hear what you said."

My mouth fell open. Which part had he heard?

He put me out of my misery. "You said, 'The BS admission is OTD.' (OTD = out the door) And, Kim, that was not only insulting to my resident, but to my department." I felt my eyes stinging with embarrassed tears. I coached myself not to cry while holding his gaze. "You know, Kim, that gentleman was one that deeply concerned my resident. She was afraid that he'd fall through the cracks and had noted two other times that someone had tried to manage him as an outpatient. She'd given thought and consideration to that decision and hearing it all referred to as, well, 'bullshit' was a little offensive. And surprising coming from you since we'd worked together before."

"I'm sorry, John." My voice was thready and anemic, which made sense considering I felt like all of my blood had drained down and pooled into my feet.

"Your resident doesn't realize her power. You see, I've worked with her and she's a good doctor and leader. And you know? I see a leader in you. A real, true leader. But always remember, Kim-- we have to be good stewards of our influence. We must."

And John left it right there. Left me with that deep statement to ponder and chew upon for the rest of the day and perhaps, my life. I never, ever forgot that lesson. Not ever.

That patient did well and, though I'm not fully sure where she is, I imagine that my resident did, too. But this morning I was just reflecting on that sage advice that John, the attending-on-a-first-name-basis, had given me nearly sixteen years ago.

"We have to be good stewards of our influence. We must."

And so I think of this. I think of this when I talk to people in hallways and when I get dressed each morning. I remember how John knew the names of the custodians and how he bought Diet Cokes for nurses and interns on his way to the vending machines. But most of all, I remember the way he spoke of the patients. Almost always in a collaborative spirit and rarely, if ever, in anything else.

Collaborative with his learners. Collaborative with consultants. Collaborative with nurses and pharmacists. Collaborative even with the people passing trays from the cafeteria or the person emptying a waste basket. But especially collaborative with the patient. Which matters most of all.

I still appreciate that feedback and him telling me directly that he saw me as a leader. It was a pivotal moment for me and is one I return to regularly.

Yeah.

So today and every day, my intention is to be a good steward of my influence. Some days, I get it right. And the other days? It's a work in progress.

***
Happy Tuesday.

Now playing on my mental iPod. . . . some old school New Jack Swing for you--Guy singing "Gotta be a leader."


. . and some Eric B. and Rakim. . . "Follow the Leader." That's the jam!

Love, Lake Erie, and Lessons Learned.

Cleveland, Ohio on Lake Erie.

When I started my internship back in 1996, I was new to Cleveland, Ohio. Because I hardly knew anyone there, I pretty much went to work and went home every single day. Occasionally, I would join my co-interns for meals or drinks or even rollerblading in the park. But other than that, my personal life wasn't too exciting.

This was fine because internship is hard. On most days, I'd go home and crash on my couch in front of my television. But there was this one month I had that wasn't too strenuous and I began to realize how blah my life outside of the hospital had become. I told myself that I really needed to "get out more" and"meet more people" so I dug through a drawer and found a scrap of paper that a friend had given me prior to my move there. It was the name of one of her "good friends" who was one of those people who "always knew where the party was." Now most of the time when people suggest such things to me, I pretty much smile and say, "Oh sure, okay" -- knowing deep down that I will never ever call or email or whatever they are suggesting.

But this was Cleveland, Ohio and I wasn't from there. I was officially desperate.

Now. Before any of my Cleveland friends give me the hairy eyeball for that statement, let me just digress for a bit and say a few things about my observations of Cleveland, Ohio. First of all, the city gets a bad rap. It is definitely not "the mistake on the lake" as folks used to call it. In fact, Cleveland has some of the most gorgeous neighborhoods I've ever seen and autumns that absolutely take your breath away. Oh--and hands down Cleveland STILL has the most perfect summer climate of any place I have ever lived.  Seriously. (And I'm from Los Angeles, remember?)

But.

Cleveland, Ohio is filled with one thing in great, great abundance. And that is people from Cleveland. And if they aren't from Cleveland, they are from some other part of Ohio or married to someone from Cleveland. So what does this mean? Well for me, the twenty five year-old woman who was living there at the time, this meant that everyone socialized around their families and old friends. Everyone. And though that is one of the very sweet things about Cleveland, Ohio, at times, that was one of the hardest things about living there and not being from there.

"The Jake" -- which I think is now called something else.

Case in point:

Me on my day off: "What are y'all doing tonight?"

Friday night? "Bidwist and Spades at Auntie Carol's house! Wanna come?"
Saturday night? "My cousin Marco is having a cookout! Or my high school buddies are all meeting up somewhere! Wanna come?"
Sunday night? "Oh yes! (insert - mom, grandmama, mama and grandmama, sister, uncle, cousin, great auntie, et.) is making Sunday dinner. Wanna come?"

Arrrgghh! This is no exaggeration.

And that was hard for me because I was one of the rare transplants there. And that was rough.

The Rock and Roll Hall of Fame, Cleveland, Ohio

So this phone number belonged to this dude who not only LIVED in Cleveland, but who allegedly was one of the very, very few who was not FROM Cleveland. In fact, the dude was from Brooklyn, New York which I decided sounded cool enough for me to save the number.

And even call.

It turns out that this dude was indeed the "dude to know." The day I rang him up, he was coincidentally having a house party that very night.

"Come through, yo," he said in this voice that was definitely a cross between genuine interest and whatever-ness. But it had that touch of New York on it that intrigued me. I then did something totally out of my character--I got dressed and went to a party across town given by a total stranger and full of other total strangers. Just great.

And so. I go to this party which is packed full of people. The girls are all cliquish because clearly they all know each other from high school or from Ohio State. (Or Miami University of Ohio.) Um, yeah. The dudes are carefully eyeing me over and wondering who I'm there with. Eventually I meet Brooklyn-to-Cleveland Party Dude and he greets me with that same hybrid of genuine interest-slash-whatever-ness. "Hey! What's up, yo?"

So after that, I was alone again and sitting on a chair tapping my foot to the booming rap music. I figured that bopping my head would look lame although what I was doing probably was pretty darn lame already. Anywho, I'm minding my own business alone on a folding chair when one of my favorite old school rap songs comes on. Yes! Eric B. and Rakim's Paid in Full -- which is my JAM. There was no one around to high five, so I tap my foot even more and give up on not bopping my head. And since that song is my JAM, without thinking, I begin reciting the lyrics under my breath with rapper hand gestures:

Thinkin' of a master plan
'Cause ain't nuthin but sweat inside my hand
So I dig into my pocket, all my money is spent
So I dig deeper but still comin up with lint
So I start my mission- leave my residence
Thinkin how could I get some dead presidents

That's when this guy attending the party says to me, "Damn, you know all the words to that song?"

I looked over at him and smiled while still nodding my head. You know--in that way you do when your JAM is on and you still want to hear it all? That way that says, "Uh huh, now be quiet 'cause this is my JAM." So with a smile in his direction I close my eyes and keep spitting the rhyme:

But now I learned to earn 'cause I'm righteous
I feel great!  so maybe I might just
Search for a 9 to 5, if I strive
Then maybe I'll stay alive
So I walk up the street whistlin this
Feelin out of place 'cause, man, do I miss. . .

And next thing I knew, this guy was sitting on the chair beside me chanting the rest of the song in unison with me (complete with hand gestures):

A pen and a paper, a stereo, a tape of
Me and Eric B, and a nice big plate of
Fish, which is my favorite dish
But without no money it's still a wish
'Cause I don't like to dream about gettin paid
So I dig into the books of the rhymes that I made
To now test to see if I got pull
Hit the studio, 'cause I'm paid in full. . .


Then we both started laughing. That's when I realized that he was kind of cute. Even more than that--he was very cute. We chatted some more and I learned that he, too, was one of the few Cleveland transplants who'd come to this party just to get out of the house. After lamenting a bit about what it feels like to be in Cleveland but not from Cleveland, we agreed to exchange numbers and meet up some day.

Simple enough, right?

Well that "meet up" became a date. And subsequently became a relationship. In fact, it was one that got quite serious, actually. So serious that I forgot all of my criticisms of Cleveland, Ohio and found myself complimenting things like the Rock and Roll Hall of Fame and Jacobs Field because they'd proved to be choice locations for budding romantic outings.

We officially became a couple. A transplant couple hanging out all around Lake Erie. One year later, work transferred him to another city pretty far away. But we continued a long distance commitment. I'd see him on all of my vacations and he'd visit often. He was nice to me and for the most part, there was nothing much wrong with the relationship other than the fact that we were broke and in separate cities.

Two plus years into our relationship, he decided to apply to graduate school. I'd been asked to be chief resident at this point so that meant once he started school, we'd both have two more years before finishing up. I naturally assumed that grad school would be somewhere at least driving distance to Cleveland. Or better yet, at Case Western.

Anyways. Around that time, I had gone to Columbus to visit my friend and med school classmate Jada. Jada and her husband Felix had moved to Columbus for Jada's residency and having them so close was a godsend. On this particular weekend, I was chatting with them about my relationship and my honey's upcoming grad school plans.

"That's great that y'all will be closer together!" Felix said. "Ohio State, Case and even Michigan are all close. Is that where he's looking?"

I actually wasn't sure. So I said that. "I'm not sure. I'm assuming so."

And Felix said, "Once Jada and I got very serious, I knew I wanted to be wherever she was. Sometimes it's not in your control to be together. But when you have it as an option, what you do with that option says a lot."

He kind of just left it at that. I let that marinate and remarinate. I thawed it out and marinated it again. Something told me to pay attention to those words, so I stuck it on a post it note in my head for later.

With Jada on my wedding day

A few months later, I was visiting my man-friend during a vacation. We had just toasted to our two and a half year anniversary and to me getting asked to be chief resident. And that's when he dropped the bomb on me.

"Good news. I've been accepted at UC Berkley and at Emory."

And that needle scratched the record loud as hell at that moment. UC WHO? Emo-WHAT?

Unless there was a University of Cleveland at Berkley, neither of those options sounded close. And the operative word there was "option."

"Did you get accepted to Ohio State? Or Michigan?" I implored.

He looked down and sighed. "I didn't apply there. I just really wanted to go somewhere outside of the midwest."

My head was swirling and my feelings were definitely hurt. He had an option. He did. What did this say about me? About us? Nothing? Everything? I wasn't sure.

"Did you apply anywhere near where I am?"

Without making eye contact he shook his head no. "I accepted the position at Emory."

And that was that. No discussion beforehand or anything of the sort. I lived in Cleveland, he lived in far-away-from-Cleveland and had been given an option to go somewhere-anywhere and had chosen to move to even-further-from-Cleveland.

"This doesn't mean we can't make it work," he mumbled. "I just. . . I just wanted to go to a better city."

A better city? That stung even more.

Now. Let me be clear on something: This guy was not a bad boyfriend. He was thoughtful and romantic and reliable and kind. As far as relationships go, this wasn't a bad one by any stretch and I would be hard-pressed to find some awful quality he had that made him such a horrible person to be with.

But still. He had an option. This time, even if it meant a bit of sacrifice, he had an option. And his option was not selected with me as a major factor.

A surprising amount of peace and clarity came over me after that announcement. I remembered Felix saying "I just wanted to be wherever she was." And yes, I recognized that Felix was Felix and this-guy was this-guy but still. That made me wonder about our two years and where I stood on the priority totem pole with him.

When he dropped me off at the airport at the end of that trip, I looked over at him with tears in my eyes. "You know what? I'm not her."

And he said, "Huh?"

"I'm not 'the one.' If I was, you would have found this decision harder to make. It would have involved me more and the thought of being apart for two more years would have been more of a struggle. If I were 'her' -- or 'the one' -- I may have even been able to compete with cooler cities. But I couldn't since I'm not her. And you know what? That tells me that you aren't 'him'."

He looked crestfallen. "Are you breaking up with me?"

"You broke up with me already," I replied quietly. "And it's okay. I'll be okay."

"But I don't want to break up," he said. "I don't."

"I don't want to be in a situation where I'm an afterthought. I don't. The man for me would have at least applied to Michigan or Ohio State. And the woman for you would have made you want to do that."

I have no idea where this zen came from. But it came from somewhere strong that I didn't even know was inside of me. And I'm so glad it was.

Yes, I am.

Today I am a forty-one year-old married woman and I know how wonderful it feels to be a forethought and not an afterthought. And it was worth the wait.

When Harry and I were about to get married, we had this lovely rehearsal dinner where people stood up and gave these heartfelt toasts. One of the toasts was from my maternal grandmother who had known over fifty years of marriage to one true love. She shared a few words about her experiences and after the dinner was over, she pulled us aside for more words of wisdom.

There's wisdom behind that smile.

"Remember," she spoke firmly,"marriage is an unselfish walk. Every marriage that fails--every single one--they fail for one main reason: selfishness. Not spending time with your spouse? Selfish! Spending all the money? Selfish! Not helping around the house? Selfish! Only doing what you want to do? Selfish! Not helping with the kids? Selfish! Not making love because you don't want to? Selfish!"

And, of course. We both knew there were caveats like addiction strongholds, mental illness, and tragedies. But she was talking about her experiences with most marriages. And she had earned some authority on the subject. Us? We were riveted. She was preaching, do you hear me? Preaching! And she didn't stop there.

Grandmama never has been shy.

"And not forgiving each other? That's selfish, too. If you aren't ready to think about someone else as much if not more than you think of yourself, then you aren't ready for marriage. And you definitely ain't ready for marriage with children. But if every day, you get up and you think about how you can make each other's life easier and better today? You will always be together. So talk to each other. Listen to each other. Put each other first and make sure the other person always feels that way."

I remembered all of those words and always will. I think of that advice nearly every single day.

We keep this photo on our wall to serve as a reminder of what Grandmama said.

Today I was reflecting on my marriage to Harry and how --- dare I say it? -- easy it has been. I am thinking about how good it feels to be first on his agenda. And my grandmama was right. That takes an unselfish heart. But now I know it also takes a level of maturity and readiness that some don't ever have. I also know that the right person can ready even the wrongest person. If and only if they are the right person.

Sometimes? Sometimes you just have know when you're not "her." Or not "him." Because sometimes, you're not.

Just because a person is nice and cool and attractive and unmarried and in a relationship with you doesn't mean that they are "the one." And just because they know all the words to one of your favorite old school rap songs and just because they make you a mix tape with that song and twelve others on it, does not a future spouse make. Nope. It could mean that they're bored. Or scared. Or just waiting for someone other than you.

Gasp!

I said it. Other than you.

It's been said many times over, but I'll say it here, too. Perhaps--just perhaps--whoever it is just isn't that into you. And the kind of "into you" you need for drama-free love takes a helluva lot more than nice biceps, straight teeth and a shiny car. Or maybe they just aren't ready to be unselfish for you. Just maybe something about you doesn't make them deeply yearn to put aside their immediate desires for yours. And you know? It is what it is. After two years? It's either it's a green light or a red one--whether you want to believe otherwise or not.

I'm just saying that it just shouldn't be that hard. And when it's the right person? Living in a crappy city is a sacrifice you will at least consider.

But again--you have to be ready. And you can't make anybody get ready. No matter who they are and how much you try or how many kids you have or how much history you have together. It isn't exactly an age thing either because there are some very ready young people and some really NOT ready older folks. Again, it's either a green light or a red one--and even if you choose to keep running those big red lights, that doesn't make them turn green.

Oh yeah--before I forget.

I'm sure you thought--Emory? That-guy went to Emory? What ever happened to that-guy? Did you see him? Do you see him? Uuuhhhh, no. My guess is that at some point he met the right person and was ready. He was a nice guy, so I'd imagine this is the case. And no, I don't know for sure because while I do love black history, I don't generally unearth it when it comes to my romantic past. No, I do not. (That could be a whole 'nother post, now couldn't it?)

I am thankful, however, for what I learned from that experience. The strength it took to love myself that day is probably what ultimately positioned me to receive someone as wonderful and ready as the BHE once I came to Atlanta. (Who, after all of that, just so happened to be from Cleveland, Ohio.)

Ironic huh? I'd say.

You know? One thing my grandmother didn't say that I will say someday to my kids or grandkids should I be so lucky to give them advice on the eve of their nuptials:

"The only way you can be ready to put your spouse first is to have first had practice doing the same for yourself." 

Other than that, I'll say everything else she said.

Wisdom sealed with a kiss.

I know. I haven't been married 50-something years. And no. I don't know exactly what the future will hold. But I do know this:  When people show you who they are -- and where they are -- especially in relationships, you should believe them.

***
Happy Sunday.


Now playing on my mental iPod. . . . this. . . . .(I apologize in advance for this being stuck in your head all day.)


. . . .and this. . . . .


. . .and especially THIS. . .because I am so thankful for the BHE coming into my life! I can rock out to this for hours--it's one of my BHE anthems!

Last night an R.N. saved my life.

*names,details, etc. changed to protect anonymity. . . .blah, blah. . you know the deal.

(These are really ICU nurses.)

"Called you on the phone

No one's home

Resident, why you leave me all alone

And if it wasn't for the nurses

I don't know what I'd do, yeah.

Last night an R.N. saved my life

Last night an R.N. saved my life

from a pulseless heart. . . ."

(the ICU intern remix of Last Night a D.J. Saved My Life.)

____________________________________________________

When I was a brand-spanking-new intern, I remember taking a call that was so scary that it nearly caused me PTSD. This fearless senior resident was supervising me and thank God she was because the way people were coding all over the place felt exactly like stepping on landmines. My senior resident was the "Black Hawk Down"/Army Ranger of residents; she had already secured a spot in a Pulmonary/Critical Care fellowship, and was virtually like a mini-ICU attending. To that, all I can say is hallelujah.

Hallelujah, because the ICU scared me. Every single page that came through was about something really, really serious. No "can you write for a stool softener, please?" or "can I get a verbal for some pain medicine?" calls. Nope. Every beep was for the hell that was breaking loose in some part of the unit--and let me tell you--hell was sho' nuff breaking all the way loose. I am so glad that I was being covered by someone who knew what the hell to do.

As I already mentioned. . . .since this was the intensive care unit, for the most part, all calls were "real calls." ICU nurses are, by definition, "bad ass" and generally don't go bothering folks with simple things (unless of course they hate you.) These nurses were not only knowledgeable, but excellent teachers for new interns. So, despite my panic, between the unit nurses and my hard core resident, I had great support.

Hell kept breaking loose for most of the night and eventually slowed down some. The unit was full, and my resident told me that this "was a good thing because now we couldn't get anyone new." I decided to believe her, relaxing my new-kid-in-school expression and even laughing at a few jokes.

I guess I got a little too relaxed.

All that easygoing laughter must have made me look more confident than I was. That's the only explanation for what could have possibly given my mini-ICU attending/senior the unwarranted faith in me to nonchalantly shrug her shoulders and say to me, "I'm gonna go and get me a few winks since I have clinic tomorrow. I'll be back in two hours and then you can go get a couple of hours before rounds. You hold down the fort, okay?"

Say whaaaat?

Dude. It was 2 a.m.! That meant I had at least five hours of potential hell-breaking-loose-ness remaining!

Awww hell naww!

This resident was responsible and hard working, and I know that she would have NEVER left me if she didn't think I'd be able to manage things. But the thing is, I didn't agree with her. I was NOT ready for prime time. And being alone in the ICU at 2 a.m. was sho' nuff prime time. I offered her a sick smile but tried my hardest to look easy-breezy. Behind the cool expression was somebody screaming and waving her hands like a wild woman, "MAMA! DON'T LEAVE ME MAMA! I DON'T KNOW NOTHIN' 'BOUT BIRTHIN' NO BABIES!!"  (Well, not exactly that but you get the picture.) She didn't catch on. "Call if you need me, okay?"And before I could say a single word, she had disappeared through the automatic doors. Just like that.

(This is really a picture of me circa 1996.)

Lawd. Lawd. Lawd.

I remember standing in one place, kind of like some city dweller plopped in the middle of the Amazonian rain forest at night. That, or that terrified kid who video taped himself in that creepy Blair Witch Project movie. I was scared to move, speak, or breathe. All I did was pray in my head, "Please let nothing happen, please let nothing happen." I felt my stomach rumbling and my pulse quickening. I repeated my pleading prayer. "Lord, please let nothing happen. Please let me not hurt anybody. Please let nothing happen." 

(This is really an ICU intern.)

And for like ten minutes, nothing happened.

I sat in the nearest chair gripping my sign out cards. I jumped every time I heard a beep or an alarm on one of the vents. For a little while, I even held my breath. And eventually decided to put my head down on the nurses' station. Exactly one second after I laid my head down my pager went off. Before I could even dial the number, I overheard Ida, one of the ICU nurses, yelling for me to come.


"Doc! Doc! Are any of you guys still over there?"

The urgency in her voice made me feel sick. I knew this was going to be something and not nothing. I wanted so bad for it to be nothing. So bad.

I scuttled over to Ida and, in my most confident voice, asked what was going on. To answer me, she handed me a strip of paper with an EKG tracing on it. Intermittent runs of ventricular tachycardia---the kind of heart rhythm that precedes a cardiac arrest. I sifted through my brain for a logical approach to what was surely about to be a problem.

Mr. Jones was the 71 year old patient in question, and had just turned the corner after a near-death experience with multilobar pneumonia. He'd been intubated for nearly a week, and had just been extubated earlier that day. According to my sign out notes, he was now in a step down bed and was "doing just fine with nothing to do." Nobody said anything about V. Tach.

Damn.

My brand-spanking-new intern brain wasn't on auto pilot yet. I took a deep breath and thought for a second. Electrolyte abnormalities? Was his potassium high or his calcium low or his magnesium low? Was he hypoxic? Were his medications some how screwed up?

Ida must have read my mind. She'd been an ICU nurse for waaaay longer than I'd been an anything so before I could say a word, she rattled off answers my short list of thoughts.

"Lytes are all normal--potassium is 4.1, calcium and mag are stone cold normal. Tolerating the 40% ventimask just fine and oxygenating at 95%. Renal function is also fine." I swallowed hard as I listened to all of that. Shit! Now what? Ida went on. "We were going to transfer him to the floor earlier today, but the attending decided to just watch him overnight to be safe since he'd had such a tenuous course. That was a pretty nasty pneumonia he had, you know?"

I nodded while staring at Mr. Jones. He didn't look good. His face had a grayish cast over it and his brow was covered with sweat. The whites of his eyes looked unusually white, enhancing what I am sure was an expression of fear. A sinking feeling rooted in my stomach and suddenly I recognized something that my senior had been trying to teach me for the past few weeks--the sense of impending doom.

Impending doom. That gut feeling that tells you that things are not right. It's how you know who is sick and who is sick-sick. This man was sick-sick.

"Mr. Jones? Sir, are you okay?" I asked. Which was a dumb thing to ask because he obviously wasn't okay at all.

His response was a widening of his eyes and an anxious pant. I looked at Ida.

"Come on, buddy. We're okay." She tried to prop him up with some pillows and readjusted the pulse oximeter on his finger. She pushed a button to recycle his blood pressure. "Doc, I sent off some cardiac enzymes and checked a twelve lead EKG on him already. Other than a few premature beats it looked okay."

The cuff slowly deflated and eventually displayed an error sign across the LED screen. Ida grabbed a manual blood pressure cuff before I could register what that meant and began attempting to check his blood pressure. All of a sudden, she pulled her stethoscope out of her ears and growled, "Dammit! We don't have a pulse!"

Famous last words. We. Don't. Have. A. Pulse.

No. WE don't have a pulse. Nor do we have a spine. I am 100% sure that, had I had time to eat dinner that evening, I would have evacuated my bowels right then and there. This wasn't supposed to happen. I wasn't supposed to be the one leading a code on Mr. Jones. He was supposed to wait until my resident was awake to have his v. tach and his no pulse.

"We need some help in here!" Ida bellowed to her fellow nurses. They quickly ran to her side.

Things started moving fast all around me. Ida quickly let down the head of his bed so that his feet were elevated. This position, called the Trendelenburg, assured blood flow to the brain when patients became hypotensive. Before I knew it, the room was filled with ICU nurses, industriously positioning themselves to save Mr. Jones' life.

good ol' Trendelenburg.

But the problem was, there were no other doctors.

Crap. Crap. Crap.

See, here's the thing. The ICU nurses already knew what to do. They had paddles nearby and were assessing his cardiac rhythm. They were doing chest compressions. They were drawing up meds and handing me gloves. The respiratory therapist pushed a mask over the now somnolent patient's face and began bagging in oxygen. And me? I just stood there with my gloves on. Paralyzed with fear. Terrified to say or do the wrong thing.

Ida saw the terror in my eyes and whispered in my ear, "Come on, baby. You can do this. We got you, baby. Just think it through. We got you."

And you know what? They did have me. They really did. I carefully walked through the stepwise interventions in the Advanced Cardiac Life Support protocols as experienced nurses helped me through it. They gave me gentle suggestions and firm "uh uh, baby's" when things weren't going in the right direction. It was like walking a tight rope with pillows all around you.

Finally, we regained a rhythm for Mr. Jones and they Anesthesia team reintubated him. Shortly after, my resident came in and helped with the rest of his stabilization. We confirmed his ventilator settings with the respiratory therapists and reviewed the stat lab results that had just come back. After a few more tweaks, he had turned the corner. "Strong work, Kim!" my resident said while suturing down an arterial line in Mr. Jones' wrist. "You saved Mr. Jones' life." 

I saved Mr. Jones' life? Uuuhh, I don't think so.

I glanced over at Ida who was now across the room giving report to the nurse on the next shift. She smiled and gave me a thumbs up. I tried to profusely thank her before she left that morning, but she disappeared before I could.

And so.

Mr. Jones' lived. The sun came up a few hours later. I gathered information on my patients for that upcoming morning. And rounds happened at 7 am.

That morning on rounds, my resident told our attending, "Kim saved Mr. Jones' life last night!"

To which I admitted, "The nurses were amazing. Especially Ida."

Because they were amazing. And, no, I can't exactly say that I saved Mr. Jones' life that night. We did. Together. . . . 

Yeah.

As I remember it, that night an R.N. saved my life.

***
Shout out to all the nurses who save patients--and doctors--every single day. 'Preciate you.

Now playing on my mental iPod. . . . .(insert "RN" for "DJ"). . .


Who's saved your life. . . or your butt?

Duty Hours Pre-Form Part 2: No Sleep 'til (or in) Brooklyn.

*NOTE: no YOUMAN beings were hurt or injured during this blog post.

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"Foot on the pedal - never ever false metal
Engine running hotter than a boiling kettle
My job ain't a job - it's a damn good time
City to city - I'm running my rhymes. . .

. . . .NO . .  SLEEP.  .  'til BROOKLYN!"

from The Beastie Boys 

____________________________

Today we continue the saga and fireside tales of life during internship and residency--pre-duty hours reform (aka "back in the day when nobody cared how long you worked," aka "The  Other Fight Club").

This is partly to underscore why having some limits on how long young doctors (and hell, old doctors) can work is a good thing. But like any great story, it's also to just a chance to just chronicle it--and then shake our heads while asking, "Dude, what were you THINK-ing?" Anyways. There's just something about hearing something that's cringe-worthy in that Seinfeld-y/Curb-your-enthusiasm-Larry-David-y/trainwreck-y kind of way that intrigues most folks. . . .okay, me.  

As promised, in a Reflections of a Grady Doctor first, we bring you this story from another sho' nuff and bona fide Grady doctor. . . . .

Now y'all put your hands together and show some gradydoctor love for Dr. Neil W. . . .
(Oh yeah--and just a suggestion--imagine a wonderful New York accent as you read this--makes it much more fun!)

______________________________

 No Sleep 'til (or in) Brooklyn: A series of unfortunate events.

Bellevue Hospital-- America's Oldest Public Hospital

 The date was February 1^st, 1994—my first day in the medical intensive care unit (ICU) at NYU/Bellevue Hospital. Normally I would’ve been a bright-eyed and bushy-tailed intern, ready to get cracking. The problem, however, was that I was tired, like really tired. The night before I’d been on call finishing my month on the medical wards and rolled into bed at 3am. Dragging myself in, I was hoping to suck it up, push through the day and start fresh tomorrow. *

*(Those who read Duty Hours Pre-Form Part 1, already know that this isn't how it always went down.)

Bright-eyed and bushy-tailed: Neil W.'s (pictured on left) first month of internship, July 1993

When I arrived in the ICU, the first order of business was to determine the call schedule. (Normally the chief residents did this, but for some crazy reason we were left to figure it out for ourselves.) The interns rotated overnight every fourth day, and somebody had to be first. I hoped that my haggard appearance would prompt one of my three colleagues to step up and offer to take the that night's call. 

The only thing was that all of them looked equally run down. . . .  

Houston, we have a problem. . . . .

Turns out that every intern was busting their butt on call the night before! For those less familiar with residency training, the odds of this happening are incredibly small (1 in 256 to be exact--wait, actually even smaller than that now that I think of it.) Rarity or not, someone still had to tackle this first overnight shift, and for whoever it was, it was going to royally suck.

Nowadays a calamity like this would send the residency leadership into a mad scramble to produce a fresh body from the "jeopardy" (emergency backup) schedule. Back then however, you didn’t go crying to the administration with every work hour-related problem (probably because we’d be simply told to suck it up)-- you fixed things internally. 

So we decided to do it the democratic way and drew straws. As fate would have it I pulled the shortest one. After a brief sulking session (and contemplation of demanding a recount) I rolled up my sleeves and got to work.

gradydoctor commentary: Unlike mine, this double-call was NOT voluntary--OUCH! (image credit)

That first day (and night) was a blur; getting to know the super-sick patients in the unit as well as the ones who were getting admitted rapid fire from the emergency department. Before I knew it the following morning had arrived without me getting even an ounce of sleep. My fellow interns arrived well-rested and were sympathetic to my plight. That said, there were still too many loose ends to tie down, so I plowed ahead into the early afternoon. With my back-to-back calls finally done (50 + hours), I headed out at 2:30 pm.

I walked to the Bellevue parking garage and jumped in my dad’s car, a 1977 Cadillac Coupe De Ville as mine (an 84 Eldorado), was in the shop. 

(Yes--the Winawers love late-model Caddys.)

It was the middle of winter in NYC and a snowstorm had blanketed the streets while I had been working. I headed out cautiously on the 30 minute ride back to Brooklyn, and as I neared my apartment house the driving became progressively worse over the unplowed snow. As I pulled into my driveway, towards the backyard parking lot, the wheels began slipping on ice and the Caddy became stuck, blocking several cars. After several minutes of flooring the gas and rocking the car in “drive” & “reverse”, I gave up. 

I pushed open the huge coupe’s door and landed in thick snow. Leaving a quick note (to apologize for temporarily blocking anyone who needed to leave) I waded several blocks in my scrubs to a local hardware store. I lugged back bags of rock salt and sand, strategically tossed the mix under the tires and gave it another whirl-- but the Caddy still had no traction. Finally, after several more gear changes and wheel spins, it was clear that this car wasn’t budging. Luckily I saw some friends passing by who graciously took pity and helped push out the car onto the street.

With my tumultuous afternoon finally behind me, I glanced at my Swatch which read 5 pm.

gradydoctor commentary: A SWATCH? Damn, now THAT'S old school, for real!

WARNING: This is where the story gets crazy. . . .

Okay, right then and there I should’ve called it a day and slept til morning, but you see, I had this basketball game back in Manhattan at 8 pm. I know, it sounds so incredibly ridiculous thinking about it now, but like Kim said, during your residency you’ll do anything to make yourself feel human. 

For me, it was basketball. I had played in college and breaking a sweat once a week while seeing my former teammates was the only connection I had with the outside world. My plan was to set the alarm for 7 pm and see how I felt. The game was on the Upper East Side, close to my girlfriend (now wife) Tamara's place, so I would just crash (bad omen) there.

I worried that a nap on my bed would turn into a full blown snooze fest, so I sat cross legged on the floor, back against the bed with my head slumped forward. I was trying to drift off, when a realization suddenly overwhelmed me with nausea. 

In all the excitement and rush to get some rest, I had locked the keys in my dad’s car.  

Now the spot where I lived--though close to the medical school I'd graduated from the year before (SUNY Brooklyn)--was in a very tough neighborhood. A typical Friday or Saturday of studying was always punctuated by gun shots in the distance followed by sirens. But hey, if you were a student they pretty much left you alone and the rent was dirt cheap. So even though I knew I'd be working in Manhattan,  I decided (after NYU’s subsidized housing fell through) to commute. In other words what I’m trying to say is that my dad’s car was not safe out on the street--let alone with an inviting set of keys in the ignition. I dragged myself up and proceeded to get a wire hanger out of the closet.

I was no stranger to breaking into cars to retrieve keys so I pretty much had the coat hanger loop trick down. But this Caddy had a metal frame running around the window which made it impossible. After an hour or so of trying, I gave up. I then realized that the security office at my old medical school might have a “Slim-Jim” to help me break in. After walking several blocks and waiting for what seemed like an eternity, the officer emerged and gave me the disappointing news.

“We can’t seem to find our Slim-Jim, but there’s a homeless guy who lives in a car on the corner gas station. I know he’s broken into several students’ cars to get their keys. “ (Not making this up).

I headed out to the gas station and sure enough in an unregistered car was this scraggly looking dude.

“Excuse me, are you the guy that helps break into cars?”

“Yep, that’s me.”

“Can you help me out? I left my keys in the ignition.”

“It’ll cost you 20 bucks.”

“I got 17 in my wallet.”

“Let’s go.”

The guy then pried up the metal frame with a screwdriver (Why didn’t I think of that?) and asked me for my looped hanger (hey don’t I get some additional discount for tool rental?) Before I knew it, he had the door knob hooked and pulled open.

“There you go, my man,” he remarked as he headed back to his car seventeen bucks richer.

Okay, NOW I had the keys back in my hand, but my window of opportunity for sleep AND basketball for that matter had come and gone. It was now 8 pm.

gradydoctor commentary: Am I the only one wondering why Neil's so skilled at car break-ins?

WARNING: This is where the story becomes painful.

Any rational person would’ve then marched their butt right into bed, but I was so aggravated, so frustrated and hyped up, that I knew that it would take a while for me to settle down. I really needed to share my “day from hell” and sadly, I also knew that when I did finally settle down, I would need a mule kick to get me going again. I called Tamara and asked if she'd mind ordering dinner from my favorite pizzeria on 79th and 1st Avenue. I was on my way.

I headed out and crossed over the Brooklyn Bridge onto the FDR parkway with very little fan fare. I exited at 42nd St. and turned right at the United Nations, stopping at a red light. I still remember Beck's "Loser" blaring on the radio as I started accelerating up 1st Ave. . . .

“Soy un prededor,

I’m a loser baby, so why don’t you kill me?”

Darkness suddenly overwhelmed me. I fell away into an absolute calmness and serenity, devoid of any conscious thought. That was until. . .  .

BAMMMM!!!!

My flaccid body lunged forward and was catapulted into the steering wheel at high force as the car’s momentum came to an abrupt halt. Parts of the dashboard went flying as I was thrown back into my seat. For a moment I had no idea what happened, let alone where I was.  I squinted up at the overhead street light and saw myself to be on the corner of 52nd Street.

People came running out of the nearby restaurant and I heard one concerned patron through my clouded consciousness.

“Hey man, are you alright? It sounded like a bomb went off!”

I motioned I was okay and slowly got out to survey the damage. 

 What had happened. . . .

Heading north on 1^st Ave I had drifted across several lanes of traffic and veered right, eventually running out of real estate and colliding with a parked car along the southeast corner. The first vehicle I hit was a Toyota Corolla, whose trunk was now in the rear seat. Walking further ahead I noted that the Corolla slammed forward into the back of a Renault Alliance, crushing its rear bumper. As I walked even further, I cringed when I saw that the Renault had rocketed into the back of a brand new Benz--with the owner idling inside. 

He was no worse for wear, but the car did get pushed into the intersection--luckily with no oncoming pedestrian or automobile traffic. If I hadn’t been stopped by those parked cars, I might’ve drifted further rightward, over the curb and into the window of that busy restaurant. All I can say is thank God no one was hurt. 

It wasn’t long before the police were on the scene. I showed them my Bellevue ID and shared my story.  (Just for the record, there’s a bond between inner city police officers and inner city doctors--which reminds me of another story that I'd be happy to share upon request. . .)

One of the officers pulled me aside and I never forgot what he told me:

“Listen, we peel people off the side of the road every day. Just feel fortunate you didn’t hurt anyone. This here is property damage (30K + worth to be exact). That’s why you have insurance. Just use better judgment next time.” 

I thanked him and called Tamara from a pay phone (no cell phones back then if you can believe it). She hopped in a cab and arrived immediately.

While the Caddy sustained some damage to its grill and front bumper, the car was a tank and was otherwise unscathed. Unfortunately I couldn’t say the same for the other vehicles, as the tow trucks were lined up to whisk them away. With Tamara’s help, the Caddy cruised the final 25 blocks to her apartment.

Took a licking but still was ticking. . . . .

I did immediately notice however, there was a problem with the radio. While it could tune in stations, a tremendous amount of static was ripping through the speakers, even after the car was turned off. Why would the radio still be getting power? I knew the battery would be dead in the morning but I was too spent to deal with it. We went upstairs, finally had that Italian food I’d been looking forward to and slowly calmed down. 

After that I slept like a baby, but had to be up early to take my dad’s car on the 50 mile trek back to Long Island.  I called the Bellevue ICU and told them the news. My colleagues were amazingly supportive and offered to cover me while I was gone (the only sick day I would take in three years of training).

When I got back in the Caddy, the radio static was still roaring. I expected the car not to start, but surprisingly it turned over. I made it home and together with my dad, brought the car to the owner of a local auto body shop. I told him about the radio problem and looked confused when he asked for the keys and walked to the back of the car.  

WTF? Clearly the radio had been damaged from the frontal impact. 

He opened the trunk and right there--clear as day--was my brother’s boom box, which had slammed forward from the impact. It was turned on some random AM frequency, and was bellowing static with its speakers face up. I got the hairy eyeball, as he slammed the trunk shut, not even bothering to turn it off. I just looked down in embarrassment; things had to get better from here.

***

Living to tell: Neil and Tamara W. now.

Taking it to the Bridge: Grown Man Commentary 

Amid much controversy, the work hour rules for residency finally changed in 2003. Now, as Kim mentioned, they have changed again as of July 1, 2011. First year-fresh outta med schoolers (aka interns) will only be able to work 16 hours straight, whereas upper level residents can work longer. Is this a good thing? Certainly for the well-being of the trainees it is. The harder question is whether physicians will be as well trained and whether patients will be safer. Now I don’t want to be a hardliner and dare say that the hours we worked in training was an acceptable practice—it wasn’t. However, I also want to be clear (from the comments/questions raised in Duty Hours Part I) there are significant differences when comparing medicine to industries like trucking or aviation. When a driver passes over the truck keys or a pilot taxis into a gate there is very little information transfer required. Safety will be determined by the competency/alertness of the driver and a rudimentary checklist of operating systems. In medicine, information transfer is everything.

Getting to know a single patient with all their complexities takes time. When doctors have to leave the hospital they pass on this information in the form of a handoff. During that process as many as 10 patients may be handed over to the on call intern. That on call intern will then receive similar handoffs from 2 other doctors.  So you can see that information communicated during this period, if it is vague, poorly detailed or not thoroughly understood can mean all the difference in a patient’s outcome. Now envision that the on call intern who has received these handoffs needs to go home (16 hour rule in effect). That person will now have to handoff his own patients AND the ones he/she knows little about. It’s basically the telephone game with human lives in the balance. That is why critics of work hour restrictions believe we are simply trading one problem for another. They also worry about a “punching the clock mentality” which will erode professionalism.

The old way clearly needed changes but the pendulum may have just shifted too far in the other direction. It will be up to all of us in the medical community to design innovative strategies that maintain the rigorous standards of the profession while ensuring the safety of our patients.

 ***

Shout out to Neil W. for a great post--worthy of a Grady doctor fo' sho! (Now y'all know how we treat "company" when they come by to visit us. . . .drop a comment, why don't you?)

*** 
Now playing on Dr. Winawer's mental iPod. . . .

 
and still playing on mine. . . .


***
Happy Sabado, y'all.

Duty Hours Pre-Form Part 1: Can you even do that?

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When I was an intern I was once on a rotation where we took call every third night. While it wasn't as bad as the "24 on/24 off" schedule that the Surgery residents did--it was still pretty sucky.

So yeah. One in three. That meant that on any given day you were either on call, post call, or post-post call (which everyone knows is twenty times worse than being post call.) Anyways. For those still confused, it meant that every single weekend you were guaranteed a crappy schedule.

Friday: On Call
Saturday: Post Call
Sunday: Exhausted and dreading on call.

Your weekdays were equally crappy:

Monday: On call
Tuesday: Post call and staying around because there's only two other interns.
Wednesday: Post-post call and stuck with all the work because you're the one nobody feels sorry for.

That's pretty much how it worked. This was also before anyone gave a hoot about duty hours or sweatshop working conditions which meant that this little schedule was even more heinous than it sounds. Let's examine the old school, pre-ACGME Duty Hour Rules era call schedule a wee bit closer, shall we?

The dreaded post call in clinic schedule:


Wednesday: On call and with out a single drop of sleep all night.
Thursday: Post Call
Thursday morning: Post call morning report in front of the whole department.
Thursday later in the morning: Getting grilled on rounds with more questions as if the ones you got on morning report weren't enough.
Thursday at noon: Sitting in noon conference while writing progress notes because you have to be at noon conference yet you have clinic at one p.m. and need to get them done.
Thursday at 1 PM: If this were today, you'd be starting your car. But back then, you bought a cup of coffee, jumped into a call room to change clothes, and then sprinted to clinic.
Thursday 3PM: Asking patients the same questions over and over and over. Because you are sick with exhaustion.
Thursday 4PM: A bizarre second wind comes over you. Seeing patients, answering pages, kicking ass and taking names. Who's better than you? Answer: Nobody.
Thursday 5PM: Running from clinic back to the UNIT to join the sign out rounds. YES. I said "Go back to the unit." At 5PM. Post call.
Thursday 5:30: Leaving the unit because you "got to go first since you're post."
Thursday 6PM: Fall asleep at every single stop sign on the way home.
Thursday 6:20PM: Eat two poptarts. Fall asleep with all of your clothes on. On the couch.
Thursday 7:30 PM: Classmate calls and asks, "What's up!?"
Thursday 8:00PM: Jump in the shower to get ready to meet your classmates because you know that this is the only chance to do anything fun and this is your "Friday."
Friday 5:30 AM: Staring at alarm clock tearfully and fearfully.
Friday all day: Walking around like a zombie and getting worked to death because you are the only one who isn't "on call" or "post call" -- which is why that day always sucked.


So here is what's extra crazy. That month with that schedule, my co-resident and I decided that we each wanted two consecutive days off. So like the sleep-deprived idiots that we were, we made this executive decision to each take two calls in a row. Yes. In a row. Oh, and did we ask anybody's permission to do this? Uhhhh, of course not. That would be too much like right.

So check it. That was the plan. I take call on Friday-Saturday, my classmate would do Saturday-Sunday the next week. Stupid as hell! I know! Anyways. I come in with my bag on a Friday go through my heinous work day and then admit all night. And that night? Oh it was a rough one. No sleep whatsoever. So Saturday morning I'm sitting at the nurses' station with my head down on my folded elbow likely in a pool of disgusting slobber. Then I hear my attending's voice:

"Rough night, Kim?"

I popped up and looked at him with blood shot eyes. "Uuuuhhh, huh?"

"How many did you get?"

"Many what? What patients? Uuuhhh, I think we got like. . ." I pulled out my cards and started counting, "uuuhhh, like six people. They were okay. Well, one was kind of. . .uuuhhh. . .no, it was fine."

The attending narrowed his eyes and looked at me like I was a little off. This guy was just covering for the weekend so didn't really know me so well. If he had known me well, he would have known that I was off because not only was I nauseatingly tired but simultaneously stupid enough to be admitting for the next twenty four hours. Again.

"So, you're post call obviously," he said. I'm still not so sure I appreciated that little "obviously" dig. Then he looked around the unit and asked the dreaded question. "Where's the on call intern? It's 7:30 and I'm ready to rock and roll."

I wanted to splash my face with water or something to convince him that I wasn't as dangerous as I looked. No time for that. "Uhhh. . .yeah. . . the funny thing about that. . .yeah. . .well, I'm the on call intern."

He furrowed his brow and froze. "You? But you're post call."

"I know, sir. But I'm taking Kevin's call today so that we could each get some time off."

"You're taking two calls in a row? Can you even do that?"

I shrugged my shoulders and tried to smile. I wanted to give him as few words as possible. Besides--Kevin was no where near that hospital and he damn sure wasn't coming in to take call.

"Have you seen all of the patients and written notes already?"

"Yes, sir. I did." Which was true. Haggard, yes. Sloppy with work, no.

He shook his head and sighed. "Okay, then. Let's rock and roll." And that was that. No threats to call my chiefs or my program director. No screaming fit about how awful it is to put my patient's--his patients--in danger with our selfishly asinine plan. Nope. Just a head shake and a request to do what the man came to do. Rock and roll.

So that's exactly what we did. We rocked and we rolled. And then he left. And I stayed to admit seven more people that night. I did get like twenty minutes of sleep--which everyone knows is twenty times worse than getting no sleep when you're that tired.

Anyways.

On Sunday morning, I was in a stupor and I had altered mental status for real. I fell asleep standing up twice and wrote notes in charts that looked eerily like hieroglyphics. Not good. Not good at all.

I am pretty sure that nobody got hurt, but really? Two calls in a row--voluntarily? Really?

Okay. So today I'm reflecting on this new rule effective July 1 that prevents interns from working more than 16 hours straight. The hours can be longer for upper level residents, but first year-fresh outta med schoolers must keep it under 16. Wow. I'm so marveling at how sharply the pendulum has swung in less than fifteen years.

That two call in a row story used to be funny to me. But you know what? It's really not. It was one of the stupidest and most dangerous things I ever did in my entire residency. My friend Kevin and I told that story like old Army Rangers talking to young privates; "when WE were interns we worked for 53 hours straight!" Now that I am actually writing what we both did, it sounds even worse.

But the thing is. . . .as an intern and now, I intensely yearned to have a personal life away from work. I needed a minute, a real minute, just to be me and to breathe. And I needed some time to do it. Even if it meant working for 53 hours straight.

Isn't that terrible? Needing to risk my life and that of my patients just to have a minute to breathe? That's a damn shame.

Okay. So now it's kind of built into the rules for residents to have balanced personal lives--or at least to have time to try.

So what's the moral of this story?

It's good that things are different now. It really is.

Oh. And if you are currently an intern and you don't have a life? Blame yourself for being lame. Not temporary insanity. Or your crappy schedule.

***
Stay tuned for part 2: "No sleep 'til Brooklyn"-- The story about when Dr. Winawer mowed down a row of parked cars post call in Manhattan. You think I had temporary insanity? Laaaawwwwdddd. . .