patient relations

The service has slowed down a bit. When one of our members goes on vacation in a few days, leaving me twice the work, things are scheduled to speed up. I love how that works out. I’m sure it happens whenever I go on vacation, too. That’s why I feel guilty about being away even for one day. Something invariably happens when the team has fewer working members.

There was a lady last week who absolutely drove me crazy. I’m sorry to report this, since she was quite nice, and so was her son. But somehow they were terribly aggravating to talk to. All her previous care had been at an outlying hospital, so we had minimal records. The conversation went something like this:

Me: “Well, ma’am, since you’ve been admitted with a probable pneumonia, do you have any coughing?”
[and please don't ask me what pneumonia was doing on our surgery service; my attending loves his patients, what can I say? or maybe he just wanted to increase our skill in internal medicine, since this lady seemed to be a walking textbook]
Patient: “What’s that? I don’t hear so good these days.”
Me: repeat three times, enunciating till I feel absurd
Patient: “Oh no, I’m not nauseated at all. In fact, I’ve been eating real good lately.”
Son (yelling): “No, mom, she said, are you coughing?”
Patient: “Oh no, not coughing at all; just my usual, you know, every now and then.”

Some time later, having established that she coughs about five times a day for the last year, not really productive, certainly no blood in it, we’re on to the next topic.

Me: “You’re not coughing, but are you having a fever at all?”
Patient: “Oh yes, I burp a lot. Do you know anything that could fix that?”
Son (yelling): “No, mom, she said, do you have a fever? No, doc, she hasn’t had a fever.”
Patient: “Except for that time, my temperature was up to 100.8. Does that count as a fever?”
Son: “She means last December. Mom, that was when you had the UTI. The doctor means right now.”
Patient: “Oh, no, no fever now.”

A good while later, having established a complete lack of symptomatology, I proceeded to get a past medical history.

Me: “Do you have any medical problems, ma’am?”
Patient: “Oh, no, quite healthy, dear, quite healthy.”
Son: “Mom, you have cancer.”
Patient: “Oh, yes, I do have cancer. It was diagnosed last summer. You see, my legs were feeling a bit swollen, so after my husband and I went on our usual vacation to South Carolina – we go to South Carolina every year. Charleston is such a beautiful city. Anyway, I went to see my family doctor, and he was concerned that I might have a blood clot or something, so – “
Son: “Mom, she wants to know about what’s going on right now. Tell her about your pacemaker.”
Patient: “Oh, yes, I have a pacemaker, and my heart is doing great, I just got it checked last month.”
Me (sensing a disappearing glimmer of light): “And why did you have the pacemaker put in?”
Patient: “Oh, my heart went a little fast.”
Me: “Was it irregular at all? [to the son] Did she have atrial fibrillation? Do you remember ever hearing that name?”
Patient and son together: “Oh no, not irregular at all. Just fast.”

A long time later, having elicited a medical history containing a disorder in every single organ system, I asked for a list of medications.

Patient: “Don’t you have them in the computer?”
Son: “I don’t have a list, but I know them by heart. Not the dosages, though. She takes lasix, aspirin, coumadin – “
Me: “Coumadin? Why does she take that?”
Son (with great patience): “It’s a blood thinner. She takes it to thin her blood.”
Me: “But why is she taking a blood thinner?”
Son: “I have no idea.”
Me: “She must have atrial fibrillation. Isn’t that right, ma’am? You have atrial fibrillation?”
Patient: “Oh yes, but it’s been just fine since they put the pacemaker in.”

That was the longest surgical history and physical I’ve done since I was a medical student. Apparently lately all my patients have been either coherent, or so demented that their children were obliged to be intelligible. I’d forgotten what it was like to have a patient too alert to ignore, but too forgetful to be helpful.

Much later, the chief came by to check on her. As he wound up his explanation of our plans and headed for the door, the patient smiled at me from the bed and inquired, in an unconcerned voice, “So then they think it will need surgery?” Since under no circumstances would we do surgery for pneumonia, nor could I imagine what we had said to lead her to that conclusion, I threw a wild glance at the son. “I’m sorry, I have to run, could you please explain it to her?” And dashed ignominiously out to keep up with the chief, who was escaping to see our ICU patients.

I really do not understand the way my patients think.

This one lady, for instance, had surgery. She has pain from the surgery. So for the last two days, she’s been asking every doctor who walks into the room why her right side hurts more than her left side. We’ve all given her, repeatedly, essentially the same explanation: there’s a larger laparoscopic incision on that side, and a little more manipulation was done there.

This morning, the same question again: Why does the right side hurt? I mentioned that there had been a larger trocar there, and she said, what’s a trocar? Well, I guess that’s a fair question; I have no idea of the etymology, myself. So, having not much to do this morning, I stopped and explained the mechanics of laparoscopic surgery in some detail: one site, in this case supra-umbilical, for the camera to go through, and several others, spread around the abdomen, for various instruments. Her surgery had required a stapler, so a larger port had been needed on the left. Thus the larger incision, and more pain from the acrobatics needed to get the stapler oriented correctly.  I thought I did a pretty good job: no words longer than two syllables (except “laparoscopic”), layman’s terms, openings for questions, and so on.

Half an hour later, the attending walks in. Same question: Why does the right side hurt more? I couldn’t believe it. What did I miss? Did I give her too much information? Doubtful, since for her elective surgery, I knew she had received several explanations of the precise anatomy, including diagrams. Was it too early in the morning? But it was 6:45am; that’s not horribly early (is it?). Did I use more technical terms than I recognized?

It seemed to go on all morning. I had an attending covering, so the patients weren’t really his. On such occasions, the attendings expect the residents to have everything neatly bundled up before they arrive. When covering on weekends, the attending cares even less for the details than usual. But my patients seemed determined to quiz him about all the minor details that I’d already addressed on pre-rounds. I guess some of them think that the big tall male attending will give them a different explanation than the small female intern. Maybe. But by their conversation, a lot of them seem to think I’m a partner with the attendings; so rank differences can’t be the only thing.

I am coming to suspect that people in the hospital are never very close to rational. Perhaps it’s the narcotics. Perhaps the element of irrationality in almost every patient I’ve had all year (even the nicest still seem to fixate on some irrelevant point here and there) is due to the drugs, and I’ve just never recognized it before. Either that, or the American non-education system has truly succeeded beyond Dewey’s wildest dreams, producing a populace incapable of proceeding from A and B to C. But outside of the hospital, once properly dressed, and returning for follow-up visits, most of these people seem much easier to talk to. Nevertheless, I’m starting to think that it really doesn’t matter how carefully I explain things, because so much of the time none of it seems to stick. The fact that I did stop to talk does seem to remain though, so perhaps simply the lingering impression of friendliness and helpfulness is worth the efforts at coherence and simplicity which seem to fall so flat.

We’ve now arrived at that peculiar time of the month, when the service is drawing to a close, and I am divided between sadness to leave the patients I feel responsible for, and attendings I’m now slightly comfortable with, and eagerness to move on to something new. At the beginning of the month I was disappointed in the high hopes I’d had for this rotation, but in the last week or two I’ve enjoyed the work that I actually am doing, rather than focusing on what isn’t going to happen. At last, with only two days left, I dare to recognize that I’m actually doing a good job. Which in the world of an intern means that it’s time to switch to a new subject about which I know nothing.

But perhaps it is time to move on. Today I was utterly disgusted to discover that, like every other intern by this time of the year, I hate my patients. Underneath all the other motivations and emotions, I hate my patients. I had about five or so lined up to be discharged today. One after the other, either while I was checking on them during pre-rounds, or later when the attending came around, they all discovered ways to stay in the hospital another day or two. I hadn’t previously felt much animosity towards any but one of them, but by the end of my list, I was seething. How dare they? “I think I’d just like to stay another day.” “I don’t feel quite up to going home yet.” “I don’t like the nursing home that has a bed for me; we’ll have to find another one.” The attendings, of course, blithely accepted these excuses, and even came up with some of their own: “He’s a little queasy today.” “Let’s have her work with physical therapy another day.” “The family’s not comfortable with the plan.” And every single one of the five is another ten minutes that I can’t sleep tomorrow morning, which I could have done if they would have left the way I wanted them to. 3:30am, again.

 So I’m disgusted with myself. I calmed down, of course, and said what a splendid idea it would be to keep five or six extra people on the list for another day. (They’ll leave tomorrow, but tomorrow is an OR day, so the list will still grow, despite my discharges, so the next day will be no better.) I went around later in the day and checked on them politely, and didn’t even flinch when they observed that they won’t have a ride till tomorrow evening around six, or maybe a little later (so I will be frowned upon for allowing my patients to loiter so late, occupying beds that could be used for new patients). Maybe I should dispense with my polite formulation about how we don’t evict people from the hospital, and just frown outright at such weak dilemmas?

Yes, definitely time for a new month. Or maybe a new year? I think definitely I’ll feel better in, say, July. Then, I’ll just have to get my patients out of the unit, and then the intern can worry about them.

I think 8:30 is the latest I have ever stayed in the hospital yet this year. It felt kind of crazy, walking around to check on the patients, saying “goodnight, I’ll see you in the morning,” and considering that “morning” means 4am, less than eight hours away.

But I don’t particularly mind. I picked up a case in the ER, and got to take it to the OR within a few hours, and do a lot of the procedure. Quite satisfactory. Of course it was another one of those ugly, boring cases that no one but an intern wants; but I had fun.

That took till the end of the afternoon. Then, I got called to the ER for an intubated patient. I was trying to figure out what could cause a surgical patient, no vascular issues, to present, intubated. That’s not usually the scenario, when you’re not on trauma. Often enough we have to re-intubate people post-operatively; but to come in like that?

Turned out to be a nice old gentleman, holding his daughter’s hand and nodding at her, in spite of being intubated. His blood pressure was too low to handle any sedatives, and his mental status was poor enough, so he was on hardly any drugs at all.

I got a surprise walking into the room. I started to introduce myself – “Hi, I’m Dr. Alice, one of the residents. . ” – and the daughter interrupted me. “Oh yes, Dr. Alice, I know you!” She’d been identified as a respiratory tech, so I assumed she worked at the hospital, and we’d been together during some crisis or other. I couldn’t remember any crisis involving respiratory which would lead to such a warm greeting, but the patient was in too much trouble to spend time on reminiscences.

Half an hour later, one of her remarks finally clicked. She doesn’t work at this hospital, she’d been here as a patient on one of my previous months. She’d been one of the nightmare patients (the way healthcare professionals often seem to be when they do get sick): the nurses used to argue about who would have to take her, and the senior residents sent me to her room by myself, until something major required their attention. The catch was that I could never relax with her, because she actually was sick, and every so often one of her “crazy” complaints turned into a really serious problem. I learned a lot taking care of her. By the end, though, I did dread getting called by her nurse; but apparently I masked that feeling pretty well.

The whole time that a group of surgery residents spent in the room, working on her father, she kept smiling at me, directing all of her answers at me, and remembering things we’d talked about in the past (when I was being conscientious, and stayed in her room to chat). One of the chiefs was there, big, tall, impressive guy – and she didn’t pay any attention to him, just Dr. Alice.

I feel so guilty. I really didn’t like her at all when she was a patient, and I did my best to stay away from her. She seems totally different, quite a reasonable person, now that she’s better, and taking care of a sick relative. On one hand it’s good that I behave professionally enough for a patient to like me even when I didn’t particularly like them; but I feel bad about being on the receiving end of such good feeling, when I didn’t reciprocate it at all until I felt flattered by her memory and shocked by the difference in her behavior.

Today was a Friday kind of day. Some of my patients were angry at me again (maybe I need to start thinking in terms of borderline personality, although I hate that psych nonsense; it would make their vagaries easier to take). Everyone declined to be discharged, and my attendings seemed to be scouring their offices for people to admit. I somehow found myself in the ICU with a sick patient for part of the morning, which also threw off my plans to keep the floor in order. The senior residents were struggling too; somehow it’s worse all around when no one on the team is on top of the game.

The lab produced terrifying results to some lab tests, which sent me scurrying all afternoon to take care of the people; and then the repeat labs came back stone cold normal. So I called the lab and asked them whether I ought to be worried about the originals, things like massive leukocytosis and hyponatremia, or whether I ought to be concerned about their machines being broken. They were still thinking about it when I finally signed out.

One of the seniors used some obscene colloquialism, and I had no idea what he was talking about. He repeated it about five times, in context, until by his laughter I figured out what he had to mean. Then, just when I understood enough to want to drop the subject, the medical students realized that they didn’t understand, and started asking questions. The resident was doubled up with laughter. I’m glad he thinks I’m funny; I wasn’t trying to be.

I’ll be working all weekend, so “Friday” doesn’t mean much to me; but everyone else in the hospital will feel good after the weekend, so hopefully the gestalt of the place will improve.

First time ever: I felt obliged to go spend some free time in the library, reading Mastery of Surgery, a massive set of two volumes which combines discourses on the pathogenesis, presentation, and diagnosis of every single surgical illness, with lengthy instructions and illustrations on how to perform every procedure which could possible be desired – and many which are now only of historical interest. Senior residents have told me that when dictating a procedure for the first time, one could simply read passages of this book out loud, and be correct.

I have read this book before; but today was the first time that I finished reading a chapter, and was immediately paged to go see a patient with that problem. I felt extraordinarily intelligent while talking to him, and to the attending. I shall have to repeat the experiment.

On the other hand, it seems as though my well-behaved collection of patients has fallen apart. All the nice ones have been discharged, and every one who is left is miserable, and angry at me, and at the nurses, and at the whole hospital.

You have to understand. For all that I’m six months in, I’m still very understanding and compassionate, even gullible, towards patients’ complaints. I usually will give as much pain medicine as you could want, as long as there’s the slightest reasonable evidence that it’s warranted. I’ll listen to your complaints about the attendings not talking to you, or not answering questions, and apologize for them. I’ll accept complaints about dietary services. If you need something straightened in the room, I’ll do it, or find someone who can.

But today, it was just too much. Every single patient was furious, about food (or the lack of it), and pain medication (or the lack of it). And again, I feel that I’ve failed to take proper care of my patients if they have to call night float for pain meds. I should be able to adjust things during the daytime, or at least talk through it. But tonight, I signed out in a bad mood: “This one, give her whatever she asks for, it’s not worth fighting. This one, and this one, are going home tomorrow, regardless of what they say, so don’t under any conditions give them iv medications. This is the only happy one on the floor; please be polite to him.”

We had progressed through all the floor patients, and were in the ICU, having a fairly interminable discussion about one of our sicker patients. (I don’t understand physiology the way it’s handled in the ICU at all. I know theoretically what CVP and SVR and CO are (central venous pressure, a measure of intravascular volume, systemic vascular resistance, which affects blood pressure, and cardiac output, which could be low for a lot of reasons), but the medical and surgical ICU residents throw these words around, and derive logical arguments from them which I cannot follow at all. I need to find a book which teaches this the way it’s actually practiced.)

A patient was wheeled into a nearby room, and the nurses started doing their preliminary assessment. As soon as they put the thermometer in his mouth, he started screaming at the top of his voice, and cursing out everyone in the vicinity in the foulest language. Somehow you don’t expect that from nursing home residents. I remarked, “If he does that just with a thermometer, imagine what he’d do if you touched his belly.” Meaning, since he seems to have nonspecific pain, or is just delirious, an abdominal exam would certainly appear positive.

Teach me not to say things like that. Half an hour later, I got paged. “We have a consult for your attending; he was just brought in from a nursing home, febrile, they think he either has cholecystitis, or urosepsis, or possibly ischemic bowel. He’s in room 23, and he. . .” I stopped the nurse. “You mean the guy who’s cursing at the top of his lungs?” She dropped out of her official report mode. “Yeah, that’s him; we just gave him some haldol, I don’t think it’s making much difference.”

I knew my senior was not going to believe this. I went to see him, and sure enough, as soon as I touched his belly, he started screaming. Not that he’d really ever stopped. The haldol wasn’t touching him at all. The nurse was just working on her records; she’d given up trying to talk to him at all. On the other hand, if I touched his hand, or his shoulder, he screamed too. Also if I didn’t touch him at all.

The attending was thrilled when we called him.

It got back to me through the grapevine that my chief told someone, “Alice is a decent intern, but she’s just too nice to be a surgeon.” Which is a compliment coming from medicine people; but from my chief, who is good but not nice, I’m not sure. Anyway, as long as she thinks I’m doing my work semi-competently, it’s fine; she is good at what she does, and I respect her, but I don’t want to be good the way she is. I want to find a different way.

 The other day I discharged the loveliest little old lady. This is the one who thinks I saved her life; at least I was present on the occasion. She reminds me so much of my grandmother: a tiny delicate little bird, perched in a cocoon of blankets, with wavy white hair and sparkly blue eyes. Like most of her generation, she hardly ever complained except when she was nearly dying. She always woke up with a smile when I came in at horrible hours of the morning. (It’s awful, but I’d rather wake the older patients up first on my pre-dawn rounds; they’re more likely to be pleasant about it than the younger folks.) On the day of her discharge, I finally made time to sit down and ask about her trip to Israel several years ago. She described how her son had bought her the tickets for her birthday, only a few years before he himself died. We reminisced about places in the Holy Land: the Mount of Olives, the Temple Mount, the banks of the Jordan, the hills of Galilee. What between her son, and Israel, and her rather unexpected recovery, and me missing my grandmother, we both ended up crying and hugging each other. (Contact isolation is for the birds, anyway. Especially when she’s being discharged.)

(I hate contact isolation. Not only is it a horrible waste of time, putting that stuff off and on for half the patients every morning, but you can never connect to someone the same way if you’re trying to hold their hand through a rubber glove. Explain all you like about disease prevention; those gloves and gown still say, There’s something wrong with you, I have to stay away from you, I can’t touch you. I’ll wash my hands in every room, I do believe that much about these bugs; but I want to touch my patients.)

I didn’t expect to . . . like – love? –  my patients so much. Now that they’re mine, even though I’m scurrying in and out of their rooms so fast every morning, I care about them. I hate seeing them sick. I don’t like them staying longer, and having to be rounded on every morning; but I also hate to see them looking miserable. For the first time in a while, I really dislike sickness. I wish there were some way I could cure them all. If wishing would do it, I’d have cleared the hospital out already. It didn’t bother me as much when I was a student, somehow. Maybe the patients at this hospital are sicker. Maybe I’m paying attention more, now that they’re my responsibility.

That’s the problem with surgery (ok, one of the problems). If your patients recover, it’s fast and wonderful. But if they don’t recover, it’s a nightmare: months in the ICU, months on TPN, months of fistulas draining, wounds having to be changed and dressed; months of trying to create hope and optimism for patients to whom every day seems to run together with pain and sickness. Now that they’re mine, I can’t block their suffering out the way I did in medical school.

Anyway, today was good. I talked so fast I persuaded the senior attending to let a lap chole patient go home immediately, without staying overnight. I set him up with plenty of medicines, because if he calls the attending tonight, I’ll never hear the end of it. The patient is happy to get out of the hospital, and I’m happy to have one less person to wake up tomorrow morning.

It’s getting very difficult to remember what it felt like not to be completely at home in a hospital. Only the most tragic of our patients have spent more than a week or two here, certainly not all at once. For their families, it’s probably one of the most stressful occasions of their lives: Momma’s in the hospital, they don’t know what’s wrong with her, they’re doing all these tests and no one can tell us the results, sometimes she’s not in her room when we come to see her, she has all of these medicines running into her, so she must be really sick, she has a monitor that has bright green lines, like the actors on tv right before they die, and it beeps all the time, and she has to wear oxygen to breathe, and she doesn’t look like herself at all. . . And no matter how routine the eventual diagnosis is to us, to them it’s still a shocking illness, a tremendous surprise. Even the smallest surgery – lap chole [surgeon-speak for laparoscopic cholecystectomy, if that enlightens you at all - taking out the gallbladder with small incisions and a camera] – is still an invasion that will cause pain for weeks to come, a total upheaval in the daily routine, two days spent in the hospital even if there are no complications.

I can see it on their faces, but I can’t really understand anymore, because for me the hospital is home. I spend most of my waking hours there. Someone mentioned the hospital smell. I honestly don’t know what that is; it smells like excitement and work and life to me. I know what all the different uniforms mean: who’s an OR nurse, who’s an L&D nurse, who’s a surgical floor nurse, who’s a medical floor nurse, who’s an ICU nurse, who’s a dietary worker, who’s a janitor; who are the surgery attendings, who are the psych attendings (they don’t wear white coats, because it would scare their patients, I guess), who are the medicine attendings (some of them take surgery interns seriously). I know where the water fountains and the bathrooms are, three different ways to get to the cafeteria, and three secret snack locations, and almost all of the main exits. I even know where the mailbox is. I know all the best kinds of cafeteria food, and which ones will give you nausea even if you didn’t have it before.

To a lot of our patients, especially at a tertiary care center, where you get transferred to when you’re really sick, this is one of the scariest events of their lives – certainly one of the most painful. And to us, it’s just another day: a consult from the ICU, two consults from the floor, another consult from neurosurgery (why does our service get all the PEG tubes?).

We discharge people happily to “rehab facilities” – which for our elderly patients is probably their biggest fear come true. No matter how much we reassure them that they’ll leave in a week or two, they don’t quite believe us; they know we’re putting them away. And for some of them, unfortunately, that will be how it turns out. But to an intern, it means one less complicated patient to see in the morning.

(I have to observe: medicine residents make me laugh – not bitterly, just ironically. They spend all day seeing 4-5 patients as interns, maybe 10-12 as seniors, and think they’re busy. I see, and write notes on, sixteen patients between 4:15 and 6:15am, and spend the rest of the day chasing labs, consults, results, and discharges on them. That’s just hilarious.)

Which brings up another point: my patients are so nice. At least on this service, they’re almost all “real” people: they have families, they have/had jobs, and their illnesses are not primarily their fault. They are so patient with me waking them up at unearthly hours of the morning. Some of them even answer my inquiries by asking how I’m feeling. A couple have asked what time it is, or what time I woke up, but they’re agreeable when I explain the logistics. One of them says, “Hang on a minute, honey,” and shakes her head a couple of times to wake up, and then starts chattering as agreeably as if it’s the middle of the day. (And just to excuse my disrupting their rest: there are ivs going off, vitals to be measured, and labs to be drawn, at the same time I’m rounding, so my attempts to get going early in order to avoid an eruption from the attendings are not solely responsible for breaking up their sleep.)

One sweet little old lady thinks I saved her life (more like I stood by while another doctor whom she hasn’t seen since saved it), and she always lights up when I walk into the room. The chief and the attending think it’s funny, because they don’t know what she thinks; all they can see is that she’s picked me as her favorite member of the team. She has a beautiful warm blanket, and when I complimented her foresight in bringing it, she told me it was her husband’s, in the Marines in the Pacific during World War 2. Then she told me about a secret code she and her husband had worked out before he left, to circumvent the censors. They had a list of scores of popular old songs, and using a phrase or title from one of them would indicate a particular situation or location. Thus, she told me, she knew exactly which island her husband had landed on the day she had their first child, from a phrase about blue eyes in the next letter he sent. I can only imagine the number of subversive secrets like this that her generation are carrying to their graves.

The surgery I was avoiding is past, and the day wasn’t too bad. In fact, I ended up being so busy with calls to the ER that even if I had scrubbed on the case, I would have had to leave almost immediately. So the attendings didn’t question the fourth year being present instead of me.

The week has been busy. I’ve been spending fourteen+ hours in the hospital every day. One night the fellow and attending stayed till midnight doing a microscopic vascular repair on a crushed hand; they sent me and the students home around 9, since by that time the proceedings had become so tiny that, without benefit of microscope, we could barely even tell that their instruments were moving.

I’m still struggling with the enormity of the concept of actually being a doctor; for all I thought I’d grasped, I still don’t act like it. The fellow, bless his heart, is patiently reminding me, You’re a doctor; you can do that on your own. You can talk to the patient, you can explain to the family, you can decide for the nurse, you can undress and explore the wound – you don’t have to get permission or backup for these little things. I am so blessed that he’s willing to be patient with me, because I know that right now I’m the weakest of all the interns. Because of where I came from, I have a very high threshold for referring to the superior authorities, compared to some of the other interns, who had much more responsibility during their fourth year, and have had more stress this month so far, and are therefore already more independent.

The fact that the grouchy assistant definitely doesn’t regard me as a doctor doesn’t exactly help, though. She’s started tearing up my narcotics scripts on the pretext that I’m not allowed to write them, although every other resident or knowledgeable attending I’ve asked says I am allowed. I guess I’ll just let her write the scripts, if she cares so much about it. I’ll have plenty of work to do next month.

The other day there was a young man with an avulsion-amputation of the tip of one of his fingers. As I was evaluating him in the ER (having by now been told often enough that I did dare to take off the dressing, in spite of copious bleeding, and go digging around in it), he asked me when I graduated from medical school. Since he was being friendly and patient, I opted for total honesty and told him, About a month ago. Astonishingly, he wasn’t too fazed by that, and started asking about medical school and residency. Eventually, a couple of hours later, as I finished suturing up our revision of the wound (per the fellow’s plan, who had now left to go to the OR), he summarized his findings: “So you’re working 14 hours a day, six days a week, and you’re more than a hundred thousand dollars in debt.” There was a definitely skeptical tone to his voice.

It’s kind of sad when someone with a high school education can figure out that their career track is working at least as well as ours, right now. But actually, I was thinking later, the money part is really not relevant. They haven’t even paid me yet, and I’m content to be here for 14 hours a day. I’m doing this because of the thrill that comes from looking at a guy’s mangled hand, and being able to turn it back into something neat and usable; or starting off with a grotesquely mis-shapen chest, spilling blood all over it, and ending up with tiny neat sutures on beautiful (ok, almost; I’m being hopeful) and symmetrical breasts. The salary is just a mechanism.

I woke up later that night worrying about whether I’d splinted his hand correctly. I started going over all the muscles and tendons involved, reciting the definition of the universal splinting position, and playing with my hand to try to remember if I’d gotten his in the right angles. I’m trying not to think about it any more today, because there’s nothing to be done. He lives far away, and he’ll be back in a week for follow up.

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