My intern is Chinese. He’s very nice, but he speaks English with an atrocious accent, and he hasn’t quite figured out what some of the basic words mean. The other day, our team gathered by the bed of an unconscious female patient to discuss her situation. The intern began his report by saying, “The day before he came in, the patient noticed. . .” We all stared at him, as he went on obliviously; after a moment the attending said, “He? The patient is a woman, right? You meant she?” The intern stared and nodded. A few days later we were discussing a male patient, and the intern offered his opinion that “she” might be better off with some different medicines. Once again we all did a double take, and then the resident corrected him. After that, however, we mostly gave up on his pronouns, and now we ignore the confusion between he and she that frequently peppers his reports. Do they not have pronouns in China?

This morning we were rounding on a young woman, admitted overnight (thus new to almost all of us) for “intractable nausea and vomiting.” The attending, having read her chart, asked her what information she had from other doctors about the possible cause of her problems. She said her family doctor had had a CT of her abdomen, and told her she had pyloric hypertrophy. The attending not unreasonably inquired when the CT was done. “Oh, I saw Dr. X last week, and he told me about it.” “Yes, but when was the CT done?” “I don’t know, you’ll have to get the records from Dr. X.” “But weren’t you there? Don’t you remember when you had it?” “Stop acting like I’m lying to you! I’m telling you I had the CT – it was at South Hospital, or maybe North, somewhere in between there.” “Surely you were there? Was it last week, or a month ago, or last year?” “Everyone acts suspicious and insulting! Get the records and I’ll find it in there for you.” At that point the resident in charge of her case started shooing us out of the room and promised her to come straighten things out later on. As soon as we were a couple yards down the hall the attending muttered to him, “Get her out of here!” I don’t know what to make of that exchange. Was the patient retarded? Or was she feeling guilty about a lie we hadn’t yet discovered? Moral: Try and not antagonize the attending, it leads to swift boot therapy.

Lastly, our patient with presumed bacterial meningitis, on his eighth day of antibiotics, who continues to complain of extreme headaches, and spiked a fever this morning. His first LP was hugely consistent with bacterial meningitis, but the cultures didn’t grow anything. Our differential diagnosis currently includes: IV drug user-malingering, plain meningitis, and meningitis with something weird, like fungus, that wouldn’t grow in normal cultures. This morning I deduced that another LP was in order – even without seeing the latest temperature measurement, which was what actually decided the other doctors. The difficulty was persuading the patient to cooperate. For someone who’s been having blood draws every day of his hospital stay, has an IV in, has an IV drug history, and has extensive tattoos all over his body, he suddenly developed a remarkable fear of needles. Me and the intern and the resident spent about half an hour telling him how scary meningitis, and how much we needed more CSF, and how simple the procedue would be, and how little it would hurt once the lidocaine was injected. He asked about side effects, and spent ten minutes reading the one-page consent form; no one mentioned possible nerve damage, and I, wickedly, didn’t feel loyal enough to him to mention it when the residents didn’t. Finally, he signed the paper, and the chief resident turned up to help supervise. Earlier in the day I had asked about doing it myself, but seeing how nervous he was, I figured it was not the time to have a student talked through the very first procedure. As it was, the resident kept describing everything he needed to do to the intern, which definitely did not reassure the patient, who kept twisting around to see where the needles were, to the imminent danger of the sterile field, and demanding whether the doctor had done any of these before. Everything went smoothly. For only his second LP, and all of us hanging over his shoulder, the intern did an amazing job, getting CSF on his first try, and no blood. We’ll see tomorrow morning how many side effects the patient has – or can mimic. (You can tell that I’m becoming cynical, after all.)

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