Postcard from internship

So the other night, I'm interviewing this vet with no legs. At some point, it seemed reasonable to ask about it.

Me: Sir, I notice that both your legs have been amputated above the knees. What happened to your legs?

Him: <flinging the sheet aside, inspecting his well-healed stumps with some surprise> I don't know, Doc. Couldn't really tell you. I don't remember.

You can't make this stuff up.

Excuses

Last month, one of my ICU patients called the police from his hospital bed and told them I was trying to kill him. The police showed up at 2 AM -- I suppose they have to -- to take the patient's story and to question me. As it happened, that night was one of the busiest nights in the ICU that entire month; we admitted four or five patients over the course of as many hours, several of them desperately sick. I stopped briefly to talk with the officers as I moved from disaster to catastrophe. Of course I'm not trying to kill my patient, I told the cops. Although now that you mention it, the idea does have merit. I'm not sure what's happened since then with the investigation; I certainly haven't heard anything more from the police. And the incident did yield a dash of surreal humor to what would have otherwise been an entirely humorless night.

As luck would have it, I readmitted this delightful patient to the hospital on Sunday night.

Un-freaking-believable.

So far, he hasn't called the police again to report me (so far as I know), but every encounter with him is intensely unpleasant. This man may be the most miserable human being I have ever met. He is nasty and hostile. He is racist and sexist. I can't so much as greet him without being subject to a stream of profanity and disdain, sarcasm, rage, hate. Because he's been sick more or less continuously since July, he has been cared for, at one time or another, by many of my resident colleagues. So far as I can tell, he is universally despised. Post-call yesterday, I was briefing the dayfloat resident (DFR) who covered for me in the afternoon. As it turned out, DFR also had cared for my patient, a couple of months before, and he knew more about this man's history. Apparently, a few years ago, my patient's college-aged daughter was raped and murdered. And that's why he's so miserable and mean, DFR said.

Wait a minute, there. I certainly don't diminish the tragedy my patient has experienced. But does a tragedy -- even a horrific one -- entitle him to be hateful to strangers? Maybe I'm heartless, but I don't think it does.

California Academy of Sciences

Yesterday we took Sam to the California Academy of Sciences. He pretty much made this face all afternoon:

Great Pumpkin 2

Great Pumpkin

Last weekend, we took Sam to a local pumpkin patch.

There was a little petting zoo at the patch:

We had a wonderful time!

The more things change

I have a day off from the ICU today and I’m sitting in Starbucks, putting together a poster for the annual ASN meeting next week in San Diego. I finagled another day off for the conference and will fly to San Diego and back all in one day to present my poster and hopefully meet some of my future colleagues in academic nephrology. Catching a 6 AM flight only to fly home 15 hours later doesn’t sound like much of a day off, but that’s probably just the crazy-tired talking.

The crazy-tired does a lot of talking these days. Truthfully, the ICU has been harder than I expected. Part of the problem comes from that fact that our VA ICU is an MS-ICU, which means that both medical and surgical patients are cared for by the same ICU team. In some ways, this is a good thing. For one, my residents this month come from general surgery and anesthesia, as well as medicine, and I’ve enjoyed meeting and learning from this diverse group. For another, managing a post-CABG patient, the bread and butter at our VA, is good learning for medicine interns. Where else do you consistently encounter concomitant distributive and cardiogenic shock? On the other hand, some of the differences in approach between the two services (medicine and surgery) are -- how to put this delicately? -- frustrating.

Right now in our ICU there is a patient with severe congestive heart failure, in cardiogenic shock. Essentially, the pump function of his heart is failing and he is unable to pump sufficient blood forward to supply oxygen to his organs and tissues. One consequence of this problem is that the patient’s lungs slowly fill with fluid as it backs up behind the failing pump. The medical approach to such a patient is to temporarily give medicine to augment the strength of each heart contraction (inotropy), as well as medicines to reduce the extra fluid in the lungs (diuresis) and to lower the pressure against which the weak heart is pumping (afterload reduction). The surgical approach, apparently, is to insert a chest tube to drain the fluid around the lungs. The surgeons are also refusing to allow the ICU team to provide afterload reduction. Meanwhile, the patient is requiring ever-increasing doses of inotropic support, in the form of intravenous dobutamine, which increases his risk of a dangerous arrhythmia. Our various consulting teams are wondering, first politely, and now with escalating boldness, why -- why, exactly? -- the ICU team is mismanaging this patient so spectacularly. It’s an irritating situation and brings to mind that old joke about the various specialties: Internists know everything and do nothing. Surgeons know nothing and do everything. Psychiatrists know nothing and do nothing.

But despite the irritation and the crazy-tired, I’m doing OK. Brian is home from Japan, finally and blessedly. And Sam is Sam. And that right there is enough for today.

Puzzles and tricks

Last week Alex promised Allie more Sam videos, so here ya go! Replete with our standard gold-plated production values, to say nothing of the editing botch job. Eh. Good thing the kid's pretty cute.