Confessions of an Intern

Week 41 and 42

Week 41 and 42

These last two weeks ran together in a blur. I am happy to report I have not hit the doldrums my last inpatient service sent me into. Thankfully, my patients are getting better and going home. Or leaving "AMA"...against medical advice. Most are staying and getting done what needs done, but on occasion, some leave when we aren't ready for them to go. Sometimes, it's kind of like "good riddance", but other times, we worry they will go home, only to die. It can be scary. Some of the big points I've had driven home to me this week include the sayings"

"You can't work harder than your patient is willing to work themselves."

and

"Everyone is allowed to self destruct."

Maybe you could call it nihilistic, but there comes a point when we realize no matter how much we learn, how hard we try, or how much our patients need something, that you just cannot do more. A good friend of mine in residency and I had a chat on the elevator about how we've both become what we never wanted to be: cold, callous and fatalistic. While neither of us is that way naturally, and it is not how we act all of the time, there are some patients that can draw that part of us out. It is depressing and somewhat heartbreaking.

Now, don't get me wrong. I am still fired up about medicine and I love my job, but we all need some protective mechanisms in order to deal when stuff goes wrong. It is better for me to not let if affect me when a young pregnant woman leaves the hospital, who is in her first trimester, probably to have yet another abortion because she doesn't like morning sickness. It's her body, her choice, right? Still doesn't give me the warm fuzzies. Oh...and I'm not allowed to have an opinion on those types of things. It is my place to be scientific and unbiased in order to foster a strong doctor-patient relationship. I really don't have a problem letting others make their own choices, but I would like to be able to have an opinion that may be different without it making me out to be judgemental.

I've also seen thousands of wasted healthcare dollars because of the position I am in, unable to make a judgement call that is not based in defensive medicine. Our "clientele" is more likely to sue if they do not get what they expect. Many have a lot of experience with the legal system if you know what I mean. But no, I cannot say "No you are not being admitted for the sixth time this year for chest pain or belly pain, because it is always because you ask for narcotics." God forbid they have a real medical problem and have cried wolf half a dozen times and you never know what is real or not. Then you have those with real problems come in and you've become so jaded by the folks who know what to say to get morphine or dilaudid, that you have to back pedal before you lump everyone together.

It is so pathetic that our hospital has to modify the way we give drugs in order to deter drug seeking. I say, offer pain medicine IM first (intramuscularly--you know, a shot in the butt). If someone is in pain or needs it, they will say yes. Those who want it easy through an IV will put up a fight. We might be able to weed out some of the folks who don't need to stay. I know, I know sounds evil doesn't it? It costs about $300 to start an IV on the first attempt. A shot costs the medicine and a syringe, bandaid and about 5 minutes of nursing time. Maybe $50. Then we have these folks who come in so often after drinking binges, PCP abuse, and illegal prescription narc abuse with no veins left. We are sticking IV's in their necks for God's sake. Then they have the gall to ask for a port-a-cath (and implanted permanent IV used for Chemo) because they are tired of us having to search for veins and not getting their meds fast enough. Come on people! I was a nurse for years. Did we forget how to give IM meds? People do not need an IV for everything!

Okay a little rant of mine. I really do love people and am one of the first to jump in defense of chronic pain patients. I'll save my disability rant for another time. I think I've already gone there, anyway.