Medicine: Truths & Observations

If you go to the bathroom, expect to get paged.   

This happens to all of us and it defies all science and reasoning.  When was the last time, truly, when you were in a hospital, that you were able to ... take care of business without being interrupted?  If I've had a relatively quiet day in the hospital, the second I close a bathroom door it is guaranteed that I will receive a page while in an awkwardly vulnerable state, with fly open or pants down.  I don't understand it!  Can't I sh*t in peace?

Medicine breeds superstitions. 

Pitchers never step on the baselines.  Goalies talk to the goalposts.  Tennis players will tie their left shoe before their right.  It's superstition, thought to change or sustain luck.  In medicine, the same superstitions arise.  If I had a good day, rest assured I'm going to keep my routine the same tomorrow: when I wake up, eat, go to bathroom, how I dress, the order in which I see patients, do orders, take care of notes, where I take breaks, you name it.  But if I had a bad day, one of those "black cloud" days as we call it in our profession, you bet there'll be some changes made: yesterday's outfit will get bleached and washed four times over, new colored scrubs, different shoes, socks, different approach to the day; whatever it takes!  I remember back in residency, I retreated to my call room.  That night, there were endless codes (cardiopulmonary arrests).  I didn't sleep a wink.  The next call, I decided to skip the call room: I found three chairs of roughly the same height - one for the feet, one for the butt, and one for the head - and slept on one of the medical floors, in plain sight of nurses.  I was barely paged and slept several hours.  The next several calls?  You bet, I found those same three chairs!  And by the way, let me ask with regards to the previous paragraph: Have you ever not gone to the bathroom, building a bladder of steel, for fear of getting paged?  I've done it!

If you don't say "I don't know" when you don't know, you'll get burned.  

This happens to everyone.  Eventually most people get humbled into their place.  If you don't know something?  Don't make up the answer.  No physician survives if they lie.  That's a fact.  Better to become humble earlier and save the embarassment.  Especially if the site of embarassment is potentially on a stage in front of hundreds of your colleagues.  

Nice patient equals poor prognosis.  

One of the most upsetting truths is the good guys never seem to win.  It happens time and again that your mystery patient with the biggest heart and nicest family (you often refer to this person as your favorite patient) will end up with the worst diagnosis, usually a terminal cancer.  It is absolutely defeating.  The thought formation is pretty instantaneous: "She's so pleasant ... I have a bad feeling about her."  But the patient who is somehow hanging on despite numerous chronic and often incurable conditions?  That person "who won't die?"  (Yes, I've used that exact phrase too.)  There's a pretty good chance that person verbally abuses the entire staff and is what you'd consider, for lack of better words, a b**ch or an a**hole.  

Patients who come in Friday night will never leave before Monday. 

These patients come in all different shapes and sizes, but have the same things in common: sick enough to be admitted but stable enough to not need any emergent care.  Those who need nursing home or rehabilitation placement?  They'll hang around until Monday when the social workers get back on service.  Why?  Not much to be done on the weekend.  Those who have chest pain and need a stress test or a cardiac catheterization?  They too will hang around until Monday when the appropriate staff return.  Those patients for whom you'd like the assistance of a subspecialty doctor?  Cross your fingers and hope someone's on call and willing to come in out of the kindness of their own hearts.  Otherwise, again, wait until Monday.  Not much to be done on the weekend.  

Intravenous access is never easy especially when desperately needed.

A lot of times, I get asked by nurses if we can remove an IV on a patient who doesn't really need it.  I'm fine with that.  The opposite scenario is much more challenging.  And too often it happens.  The patient actively bleeding or in sickle cell crisis and can't get IV access for blood.  The patient with diabetic ketoacidosis or severe hypernatremia, and can't get IV access for those fluids.  It's hard enough to get access.  But the urgency of the scenario necessitating the need for access only adds to the stress level. 

No two procedure kits are the same.  

I've done plenty of central lines.  Have I ever used the same kit twice?  Not at all.  It always keeps changing.  Same can be said of arterial line kits, lumbar puncture kits, any kit really.  Why is this?  Is there really that much competition between companies over these items?  Or is it the same company and that there is so much technological innovation that the kits change every month?  Sure, we've done enough of these procedures so that we get the hang of it.  Kind of like riding a bike, right?  Well, I can't ride a bike.  And this stuff involves large needles and syringes.  

You will never find what you need in the medicine supply room.  

The medicine supply room is a labyrinth.  Like procedure kits, no two are alike.  The way the medical supplies are organized varies wildly.  Just because you can find gauze in Unit 51, doesn't mean you can find it in the 41-CCU.  And honestly, for us MDs who are rarely in this room anyway, when we do go, why are we even there?  Usually for some sort of urgent or emergent reason.  And there's nothing like being rushed to add to the ease of finding a needle in a haystack.  

You tube it, you lose it.  

So you've collected a blood sample or some cerebrospinal fluid and you want to guarantee that it is misplaced and lost forever?  Use your hospital vacuum tubing system.  I'm convinced that each vacuum tube site within the hospital eventually converges into the middle-earth never to be seen by mankind ever again.  But if you really want to get that sample analyzed, burn the calories, and walk the samples down to the lab yourself!  And yes, the walk will seem like you are entering into the middle-earth!

People call back only when you're already on the phone.  

We all deal with this scenario.  You need to contact two people.  What are the chances they call back at the same time? you think to yourself.  So you page both.  The first one calls you back.  Only when you're already on the phone with the first person and deep into the conversation, that the second person calls you back.  The calls are never sequential.  Why?  I never page two people at once any more; the end result is always the same.  And when you try calling back the second person?  Of course, they never pick up!  I know one colleague who double phones.  I don't have the mental dexterity to do that.

No one understands the code system in their own hospital.  

In each hospital, everyone knows the code equivalent of a patient with a cardiopulmonary arrest; this may be in the form of a Code Blue or Doctor 99.  All the other codes after that?  None of us really know for sure.  A few years ago, during the summer, I heard a Code White overhead.  Snow? I thought.  Later that day, I found out it meant there was a problem with the IT system.  How about when they call a Code Brown overhead?  Yes, we all laugh to ourselves.  Environmental emergency, perhaps?  That could make sense if there was blood spilled on the ground.  Code Black?  I don't even know what that means.  Melena?  On Grey's Anatomy, a Code Black had to do with a bomb.  (Now that I think about it, Code Red should be universal for fire.)  I once heard a Code Green: that meant a patient had eloped.  I didn't figure that out until much later.  By that point, the patient must have escaped for sure.  

Scrubs are gold.  

Scrubs are hard to find, especially for us not regularly in the operating room.  I remember in residency, particular at Grady Memorial Hospital, it was a potpourri of hospital scrubs.  It was like a scrubs convention!  Scrubs from hospitals all over the country!  Scrubs in every color including every possible shade of green and blue!  Some with the hospital names printed on it, others without!  But alas, no two physicians had the same scrubs.  It was mind-boggling.  Yet, how did we each accrue our own rations?  From a surgical rotation in medical school or we knew someone who had access. 

There is never healthy food at a cardiology conference.  

Pizza Hut?  Maybe Chick-Fil-A.  

The computers are both good enough and bad enough.

We are entering a world of increasing dependence on computers, electronic medical record-keeping, and computer order entry.  The complexity of computer-based healthcare delivery systems and the relative lack of IT professionals to keep our computers up-to-date and up-to-speed have led to this unusual state of hospital computers: They're good enough so that they don't need to be replaced, yet they're bad enough so that it makes you cringe and squirm.  The nuances are particularly underscored when you're in a rush or bad mood.  For example, you are paged by a nurse to take care of the patient's discharge paperwork so they can promptly be taken to their nursing home.  When you do medication reconciliation, the computer freezes for a second with each medication you click.  There are twenty medications.  Not terrible in the grand scheme of things.  But in this scenario?  Excruciating.  How about the mouse that kind of works, but sometimes doesn't?  Or the keyboard with the sticky Spacebar key?  Internet Explorer won't load?  Playing the game: Which Computer Can Show CT Scan Images?  Billing system down?  And why aren't we allowed to use Firefox or Google Chrome?  

The ratio of chairs to computers is never 1:1 (or in favor of chairs).

I still have yet to pick my favorite position when posed with a computer sans chair: kneeling versus standing?  Well, where do those chairs go?  Have you ever noticed the relative wealth of chairs in the conference room where the nursing staff has lunch?  Just a thought.

If you're on an overnight call, pack a sleeping bag.  

It seems counter-intuitive that a hospital would have deplorable call rooms for its on-call staff.  These places, if featured in a movie, would have eerie background music.  God knows how old the sheets are or when they were last cleaned or "cleaned."  One of my co-residents was known to bring a sleeping back every time she was on call; very, very smart.  Then the bathrooms: Has anyone ever met any medical person who has showered in a call room bathroom?  They are in worse condition than most bus terminal bathrooms.  Setting foot naked into one of these showers is a setup for infectious disease.  Another observation to note.  At Emory University Hospital Midtown, the call rooms have showers with the floor of the shower at a higher level than the rest of the bathroom or call room, with a downward-slanting ramp.  Think about that for a second.  If you can get past the risk of infection, why then would you shower knowing the water would run towards the main part of the room and away from the drain?  Talk about an immense design flaw.  These bathrooms were created for one reason alone: to remind you to keep your own bathroom in pristine shape.  

Don't drink the water.  

There was an outbreak of Legionella at Grady last year.  Think of all the sick patients condensed into one building.  You can imagine the superbugs infiltrating every inch of the hospital.  Don't drink the water. 

The hospital gift shop can save you in a time of need. 

I'm not talking about sodas or cravings for Doritos.  Last winter, we had the worst snowstorms in Atlanta's history.  I was on service and, like the rest of my colleagues, we were staying at a hotel across the street from the hospital since conditions were too treacherous to go home.  I stayed there for what ended up being three days.  That created a problem.  Not a problem of getting away from the hospital or yearning to be home.  The dilemma?  Underwear.  I packed only two pairs of boxers in my overnight bag!  That's a problem!  Some people I know, including my boss, went home after two days, braving the road conditions, because they, well, ran out of underwear.  I went to the gift shop.  I noticed a crowd of people, staff and non-staff.  They weren't in the snack section or by the soda machines.  I heard someone call out, "Pass me a large!"  They had underwear!  Now, I don't prefer briefs, but on this occasion, I was quite content.  And yes, I stayed that third day.