Stolen

Back before I broke up with the geologist, I had ordered him a Christmas present that I couldn’t find in town. I had thought long and hard - then consulted Dee, who knew him longer than I had - and finally come up with something just personal enough but not too over-wrought for a new relationship just before the holidays. I was rather pleased with the choice, as was Dee (who was still quite invested in the success of our relationship), as I put in the order and waited for it to show up.

It never did.

It was scheduled to arrive right about the time that the geologist and I broke up. I got distracted, I started a hospital rotation, it somehow didn’t seem so important. I figured it would show up eventually, and then I would send it back for a refund. A couple weeks later, it dawned on me that it was probably not going to show up. I put in a complaint with the company; they referred me to UPS, which had a tracking number stating it had been delivered at my back door on the day it was supposed to. The damn thing had been stolen. The company refunded the money anyhow, but for the next three weeks I fielded near daily phone calls from UPS about whether I had checked the front door, the back door, the deck, the neighbors’ roof, or any other convenient area it might have ended up.

No, I told them emphatically, it’s just not here. You can’t prove you left it, but assuming you did, I’m gonna have to say it was stolen.

And that, my friends, is pretty much the most perfect metaphor ever for my relationship with the geologist: stolen. And no matter how much UPS or Dee or anyone else thinks it’s just going to kind of work out and come back or show up or something, it’s not. It’s dead. It’s gone. It’s broken. It was perfect and lovely and well-thought and wrought out of love and it was stolen. So stop bugging me about it already, eh? It’s just gone, and there’s no bringing it back.

Air pollution

There is a strange place in the universe where classical economists and die hard tree huggers come together in a strange whorl of priority and strategy. This place has to do with things like pollution, and it goes like this: there are two ways to get people to limit pollution. One is to limit every polluter to some maximum - tons per year, parts per million, whatever your medium of measurement du jour. Then there is the concept of pollution credits: you put a certain limit on the overall number of, say, carbon tons you will accept in the air in a given year, put those carbon tons on the free market in the form of trade-able credits, and let industry battle out the right to pollute. The idea is that industrial installments that value being able to pollute - ie. older plants for whom it would be prohibitive to upgrade to clean technology - would find it cost-effective to buy extra pollution credits, while others (clean new plants who don’t need all their pollution credits) can sell theirs to others who need it. You cap the total pollution emission wherever you want, the market settles out who actually gets to emit it by the most economically efficient means, everyone goes home happy. Economists love this shit. Some environmentalists love this shit. Some don’t, particularly those who live downstream from a raft of old smoke-belching coal-fire power plants. But I digress.

The Science Project and I, we both have some training in classical economics. He more than I, but then, I think I got more of the practical end of it, while he got more of the theoretical neo-con laissez-faire baloney than I did. But we’re both rather interested in it, and tend to get all geeky about it every once in a while.

So several of us were sitting around one day bitching about work, and in particular, this little thing known as support group. Support group is mandatory. Only two of the six of us can stand it. Most of the rest of us try to ditch it as often as possible, and have been regularly reprimanded for it. The Science Project, much as he loves to hear his own voice talk about himself, luuuurves the support group thang. I can tolerate it on most days, but then, I usually make excuses and sip coffee while other talk. I only came close to blowing my stack once, which is when people used my talking time (I kid you not, they actually use a stopwatch and block out time for each person) to have a conversation, then shushed me (almost violently) when I made a single (and supportive) comment during someone else’s talking time. I cannot say how thoroughly and absolutely I hate this contrived support shit; there are not words strong enough in the world. So just take my word for it or I will be forced to get all whiny and adamant and shit, and no one likes that.

The Science Project had noticed that some of the rest of us do not like to talk, but that he does. So he hatched a plot, one that only he and I would understand, but that I immediately jumped on.

“OK,” he said one day, “you know how economists love that concept of pollution credits, how you can trade air pollution credits? When you don’t need them, you can trade them to someone else who does?”

I got it immediately. Everyone else looked markedly blank.

Uh huh, go on, I encouraged.

“I propose that we do this with support group. I love support group. I love to talk. You guys hate to talk. We each get five minutes. We always have support group in a coffee shop. So how about this: I’ll take your time credit off your hand by buying you coffee. You get free coffee, I get your time credit. Just like those pollution credit scenarios. What do you think?”

I burst out laughing, as in this scenario, his yammering on about himself was the metaphorical equivalent of air pollution. I’m not sure he computed that into his equation or not. Didn’t matter; I fully agreed - he buys my coffee, he can have my five minutes of air time. And he can pollute the sound range of the coffee house with whatever it is he wants to yammer on about on that given day. Free coffee for me, narcissistic indulgence on his part: throw in the part where I get out of having to talk about myself, and it sounds like a pretty fucking fair trade to me.

Smooth operator

The peds residents at the university, they take responsibility for something called “mommy call.” This is the on-call phone service where any patient from the network of university-sponsored peds clinics can call - any time of day or night - for advice on urgent care issues. Some times these issues are very urgent. Sometimes they are not. One of the university peds interns last year was married to a surgery intern I rotated with; he (the surgery half of the couple) used to groan at her mommy call and declare that he would shoot himself if he had to spend the rest of his life waking up at three in the morning to reassure mothers that it was ok if their baby hadn’t pooped that day. I retorted that I would have shot myself if I had to listen to his bitching and moaning all day, but then again, to each his own. He laughed.

So we don’t take “mommy call” per se, but we do get calls forwarded through the answering service every time a patient calls the clinic after hours during our call shifts. Some of these are very straight-forward; your rash that can definitely wait til Monday when clinic opens up again, your hypertensive emergency that can definitely not wait one minute longer and needs to be seen in the emergency ten minutes ago. Many are somewhere in the in between, and these are much harder to field: for example, a older lady with a history of surgical gut problems, mild but new abdominal pain, and a hearing impairment that makes an evaluation over the phone dang near impossible.

And then there’s the ones that make you want to take a shotgun to your own head that you ever decided to pursue this career in the first place.

So it was a Friday night, about 1:45 in the morning. The phone buzzed at my side and I hauled myself out of a sleeping state long enough to answer it. It was a patient call (thank gawd, not the ED with a patient to admit, I thought to myself), and the operator put her through.

The patient explained that she had been constipated, for three years. I was already not terribly excited; anything that has been going on for three years can usually wait til Monday morning. I asked if she had a particular question, as I was unlikely to be able to solve her constipation issue by phone on a Friday night.

“Yes,” she replied. “I was in clinic today, and my doctor told me I should look this stuff called Smooth Moves. I just went to the pharmacy, and they didn’t have it. Do you know where I can find it?”

I didn’t know how to answer. My first instinct was to ask what fucking pharmacy in this podunk town is open at 1:45 in the morning (apparently it’s the Walgreen’s on Main, I found out when I told this story to the oncoming team the next morning).

Biting my tongue on either that instinct or the next (which was to ask this: what the #!@$& do you think I’m gonna do to find this for you at two o’clock in the f’ing morning, lady?! And which attending told you about this stuff, so I can wring his neck too?!), I replied that if the problem was chronic, and that it had not changed (no new abdominal pain, no new rectal bleeding), it would likely have to wait til Monday until the clinic opened and she could see her primary care provider again.

I probably could have prescribed her Miralax over the phone, but I’ve been strongly advised not to do anything that encourages inappropriate use of the night phone coverage, so I did not…especially after the evening that I very concernedly answered a slew of phone calls from a woman rather deeply taken by a predictable side effect from a medication that was just going to have to wear off; I was walking her through all the warning signs that should provoke her into an ED visit when the line got cut off on her first call. I called back to the operator to see if he had got her number ahead of time, and I could just about see him roll his eyes through the phone.

“Oh, her?” he asked, “she calls at least three times every night, hoping to get a different answer. She didn’t get cut off, she hung up. She’ll call back again, you’ll see.” And she did.

Oh, and speaking of smooth things (not that I was), when I was home over Christmas my mother and sister very excitedly carved a bald patch into my moderately hirsute left arm with a product they had discovered (as! seen! on! T!V!) called Smooth Away. This is a fabulous little product that removes hair apparently by dissolving it with a rubber-and-mineral concoction so thoroughly depilating that it leaves not a trace of hair on either your skin or the device itself. We were so fascinated by this development we tried it out on several of the nieces and nephews, one of whom is recently on the cusp of puberty and probably soon to need zit cream on top of facial depilation. What we can’t figure is where the hair disappears to, and we came to the conclusion that whatever physiochemical properties are included therein most certain must be of the carcinogenic variety. “Leaving a thin layer of cancer cells with every pass,” one of us contributed in our best infomercial voice. Because this is how the women in my family celebrate Christmas: with sneak depilation attacks between opening presents and drinking margaritas by the fire, the way a good traditional family should spend the holidays.

Something happened on the way to the carina

On Saturday call one evening, I was summoned to the emergency department to admit a woman with a mysterious condition that appeared to be tuberculosis. Or perhaps a big nasty GI bleed. Maybe a big TB granuloma eating into the GI tract and causing a bleed. No matter, it’s a usual occurrence that we can’t make heads or tails of the ED doctors’ signout; I headed down to sort it out for myself.

What I found was a woman whose blood pressure was in the toilet, who was probably bleeding from her gut, and who had quite seriously one of the most twisted and tortuous chest scans I had ever seen. I couldn’t make heads nor tails of it, and usually I can at least figure out which part of a scan represents the lungs (apparently the radiologists were confused to; the read referenced some kind of lumpy tumor, which turned out to be the heart - only it was located somewhere over in the right chest where a lung had been removed).

When I hit the button to check a blood pressure and found it came back and forty over zero, I summoned a nurse and told her to get me the ED attending without delay. Somehow this woman was still conscious and complaining, but I suspected she would not remain so much longer. The ED doc, so summoned, poked his head in, looked bored, and disappeared.

What the motherfucking hell, I thought to myself, and realizing I was about to get zero help from the ED doc, I called my attending post-haste, who was at home. He arrived within a few minutes, and fortunately the patient did not crash and burn before then. We opened up several liters of fluid through two large-bore IVs, she stabilized while we called the blood bank for an emergent transfusion, and we began the process of transferring the patient to the ICU.

Once secured into the care of the intensivists, we sat down with the ICU attending to look over the CT scan. He furrowed his brow and followed the trachea from the top of the scan to the branching point where it should become two large bronchi - a point known as the carina. He couldn’t find it; instead he found the entire length of airway laid over on its side as a single bronchi lead to one very large lung. The other, apparently, had been collapsed or removed during her TB treatment thirty years earlier.

He broke into a broad grin; “You know what they say…something happened on the way to the carina!”

Something sure did. Something also happened, or didn’t, on the way to the ICU. And I almost wrung the neck of that damn ED attending who couldn’t be bothered to help - one, because until I sign an admit order, the patient is still technically his responsibility; and two, because mother of fuck, she was about to code on me. Would it be too much to ask to get someone a little more experienced to back me on that little matter? The help, ya know, woulda been nice.

Loss

I was standing the cafeteria one night when a scrub-clad person I did not recognize called me by name, gave me a wide smile, and asked if I was coming on shift or getting off work.

I hate these moments. They happen more often than I like to admit.

I made some small talk: just coming on…can you believe it?… another night shift…how are things up on the floor? Hoping that if I hinted around enough, she’d tell me what floor she was from, thereby sparing me the dire embarrassment of admitting that I had no idea where she knew me from. I didn’t elicit the goods from her, but found out soon enough when I ran smack into her on the L&D floor a couple hours later. Ah, yes, one of the labor and delivery techs: of course. D’oh!

Sandy, her name was. Sweet as the day is long, lipstick always a little to bright, brunette hair bleached a few too many times, always with a smile, and if you caught her at the right time of day she always had a trashy celeb magazine she was just finishing up that she might pass on to you to help pass the early hours of the night, when it’s too quiet to get anything done but still too early to justify getting any sleep in.

One night, I was booted unceremoniously out the call room off the lounge we share with the obstetrical service. Technically, no one has first dibs on the call room; functionally, the FP service is the one that always there, so it is usually ours by default. Rare is the OB who throws us out, but there is one particularly ballsy one - a dude, no less - who will stake out his territory if no one else has pissed out the corners of the room before he arrives. The backup call room was already taken, and that left me sleeping on the hallway floor. About two in the morning, I stumbled over to L&D to find out if anyone knew the combination to the call room of last resort: technically, it was the room reserved for breast-feeding mothers. Since it is a rare breastfeeding mother that lactates at two in the morning, we can use that room to sleep if none others are available. The problem is, no one knows the code to the door.

Sandy was sitting at the desk, snapping gum through her gaudy pink lipstick, twirling her twice-bleached hair, reading a trashy celeb mag. “Oh,” she said, “I’ve worked here forever. I’m not sure I remember it, but I bet if I messed around with it long enough, I’d be able to figure it out.” Sure enough, it took her about ten minutes, but she persisted, and the lock clicked open to a waiting bed. I thanked her profusely and caught a couple hours’ sleep before morning rang in.

A week later, Sandy’s husband found her dead at home. She was sleeping one afternoon, she didn’t wake up when she said she would, he knocked, no response, he pushed the door open and found her pulseless and without a breath left in her. She had suffered from an inflammatory disorder for some number of years, but no one had any right to suspect she wouldn’t wake up every morning for the next thirty years just like she had for the last. She couldn’t have been five years older than me.

That’s just too young, that’s just too soon, that’s just too wrong.

Captain Chaos

A couple of new folks were hired on in the fall, literally, a couple. He is an FP attending, she is a midwife. Some day I will get on my high horse about the midwife service (I have nothing against midwives or the way they practice - just about the way they are horning in and taking deliveries away from the residents), but for now, it’s the dude half of this couple I have a rank bit of commentary on.

I think this guy might have an overactive thyroid problem. Or one of those attention deficit issues that could be well doped by a good dose of amphetamines. Because he talks even faster than me, and that’s an accomplishment few humans can achieve without the help of either speed or a couple of eight balls on a Saturday night.

When he chooses to be, he is an excellent teacher. When he chooses otherwise, he is a horse’s arse extraordinaire. He seems to have taken an especial disliking to me, and on particularly rank days he starts three of every four sentences to me with the phrase, “You’ve been a resident here for how long and you still don’t know that?” This has been in reference to everything from the particulars of a picky orthopedics question to the phone number of a consult service. Why I would have the latter in my head I do not know; the former…well, I am a resident, I am still learning, welcome to the world of the teaching hospital.

Most amusing, however, is morning check-out when this particular gentleman has been on call overnight. The phones provided by the department have a peculiar function where they block the sound of incoming voice so long as you are talking; I wouldn’t have known what the glitch was except my personal phone has the same annoying property. The hospitalist attending will put this dude on the speaker phone, and for the next twenty minutes he runs the list without taking a breath. Since he cannot hear us - and does not stop for hell, high water, or questions from the peanut gallery - those of us actually at the hospital listening in by speaker phone eventually delve into a snorting laughter, even though he could hear us if he ever paused his monologue for more than a second or two.

“Jay,” the hospitalist says firmly, and he proceeds obliviously. “JAY.” Still no response. “What a fucking freak,” she goes on. “Does he ever stop talking?” And the rest of us dissolve into giggles while he is pontificating on the potassium level of the latest admit, before moving on to the fascinating ten-minute topic of an admission that we all know better than he does.

“Captian Chaos,” the other resident opines, and we all laugh, no longer bothering to keep it under our breath. Thank goodness he never stops to take a breath - otherwise he might actually get wind of our running commentary and peals of giggles at his expense.

Tap 'em, tube 'em, send 'em on

A little ways before my time, the inpatient service up here at the rural program was run by a two full-time FP hospitalists. One was a graduate of the program, the other came from elsewhere and had done his time in one of the truly rural hospitals, a reservation somewhere in the southwest where he himself was the only resource he had. This latter dude, he still works at the hospital even though he will have nothing to do with us anymore. He is referred to by some of the former residents who know him better as “a real badass.” He was also described by my current roommate - a traveling ICU nurse - as “that guy who looks like Shaggy…you know, from Scooby Doo.”

Both of these invocations are pretty fair. The latter because, indeed, he has a loose shock of reddish hair and some slightly unkempt whiskers. The former because this dude is known about town for fearing no patient, no disease, and no procedure.

In matter of fact, we sometimes get patients he has accidentally admitted to his service before it is discovered that they belong to us. By the time they get to us, they have usually been so thoroughly worked over, we don’t know whether to thank him for his services or shake a fist in his general direction for his over-wrought interventions. His interventions usually go like this:

Got a headache? Get a spinal tap.

Got a fuzzy spot on the chest x-ray? Stick a needle in that chest.

Got a bit of a cough? Intubate.

Perhaps I exaggerate. But really, not much. I do swear that I have been in the ED when he is on service with the hospitalists, and he is merely walking from room to room intubating the entire floor. I sometimes wonder if I look too drowsy during a particularly epic night call if I might be next to get the tube down the throat.

It’s a mixed bag, you know. On one hand, any intervention is not without danger, and these things should be done only with the risks and benefits in mind. On the other side, really…I’d love to be able to do this kind of shit. I would love to feel so comfortable with the urgent and the emergent end of medicine that I could quietly run the ED when the emergency attendings are busy doing other things. I would like, one day, to be that badass. Right now, I get twitchy when the word “intubation” rolls around because my skills at it are limited to a dozen tries in the OR back in medical school. And more than that, I still don’t have the sense of when it’s necessary, except, ya know, when the dude on the table has simply ceased to breath (and by then it’s usually too late anyhow).

Badass, unfortunately, is not the name of the family medicine service. Mostly we manage diabetes and low-risk labor. Maybe some day I’ll get a go at this kind of stuff; hopefully, it will be a controlled burn and not a crash land into the realm of badass-ery.