This christmas season, I am monstrously busy as one always gets in the health care world during that magic interval between thanksgiving and Xmas, where everybody trying to hang out until after the holidays crashes either gracefully, i.e., the 12 days before Xmas….. or ungracefully on Xmas eve.
Apropos of nothing in particular, other than paper charts, I recall my first Xmas in medicine as an Intern on call of course on Xmas Eve…… admission at 0300 hrs……. of course it was paper documentation (I bought a 128K Macintosh as a 2nd year resident—— and suffered the slings and arrows of my staff man who criticized the purchase cause it was too expensive, a toy computer, no software, too little memory….. etc, etc, etc……oh did I mention he had is IBM XT for two weeks and working 3-4 hrs per night, still hadn’t penetrated to the Heart of DOS-ness (the technical manual was apparently written by Joseph Conrad’s Great Grandson) enough too yet successfully open and print a file……. my little toy machine allowed me with some creative application of MacDraw & MacPaint to put together a reasonable set of printed pages transformed by the copier at work into transparency overheads for a resident lecture I gave the day after getting the machine,……..) but I digress (it is in the holiday spirit of course) …….. and I was sooooooo tired that horrors, of horrors, I lost the handwritten H&P I did on the admission between 5AM when I finished it, and 7AM by rounds …. part of this was because as I was just finishing up the writing task, a patient crashed on Tele ….. I overheard two nurses complaining about a Xcover patient who had been suffering from violent nightmares all night (violent and/or dramatically colorful dreams are the classical symptom of nocturnal hypoglycemia), and now she was not very responsive to them……. asking if she was diabetic, and hearing she was, I grabbed them and went to the patient’s bedside, where she was unresponsive, diaphoretic, ashen, and pre-coding…… No IV line of course……. so, in what equals any NBA playoff Hail Mary shot from backcourt with the buzzer for 3 points, the game, and instantaneous fame (or if you’ve ever watched the unwatchable Escape from LA, Snake Pleskin’s basketball shot from one basketball basket to the other basket the length of the court, or have seen as I once saw, a Lacrosse Goalie clear his net and pitching it as hard as he could to take the pressure off his fumbling defense, thru the ball the length of the Lacrosse Field putting the ball into the opposing goalies goal with one bounce - unbelievable )…… I took an injectable ampule of D50W, frantically palpitated the femoral artery, than plunged the injector’s 18 or is it 16 G needle into the closely opposed femoral vein, aspirated for blood….. yes it will draw up a little blood and than pushed the entire amp as the nurse grabbed a Accuchek glucose which came back unmeasurably low…….. the poor lady, began to deepen her respirations and improve her pulse amplitude, color and consciousness…….
To get back to the workup……. when I came back from this excitement, I found I couldn’t find the workup in the chart (Cardiac R/O patient) and for the only time I was an intern, I was overwhelmed, and in a state of agitated pre-grief, as I knew I couldn’t remember one damn thing the patient told me without my cheet sheet/workup….. and I was crying from the anticipatory fatigue related to staying later than I would otherwise have to stay at least two hours latter on Xmas day (missing my oldest sons 7th and my 10 month olds 1st Xmas morning)…… Using the Wisdom of Solomon I told my attending I’d come back later in the day to redo the work…….. the nurses on the ward, tore the place apart, while I was gone, and when I returned mid-day….. I found to my amazement that they had found the workup….. which as those of us who remember not only the paper but the physical ‘charts’ and how they clipped onto the reams of paper or had various hole systems that you had to punch and line up (and the ICU had 3-hole paper punches and the wards 5 hole paper punches……. resulting in God only knows how much useless work prepunching all the papers when making transfers from Unit to Ward……
Why didn’t we buy universal holed papers your ask ….. it is the last great unsolved mathematical conundrum theorem …. now that Fermat’s Last Theorem and the Kadison-Singer conjecture (‘whether or not each pure state of "beta" is the extension of some pure state of some maximal abelian algebra’ (where "beta" is the collection of bounded linear transformations on a Hilbert space” has been solved……that there is no definable mechanical punch that can place 8 holes in a top edge of a paper so that the holes line up for a 3-hole as well as a 5-hole paper chart…. the so-called Paper Pushers Topological Conundrum and Ward Clerks Full Employment Act……..
In any case the workup had been pushed into the patients chart probably by me, at the time of crisis, but not with the paper being placed between the retaining clamps, and when the chart was put into the chart rack (another space occupying artifact that has been replaced by computer workstations which in summation occupy at least 2^5 times the volume of the indestructible chart rack on the wards….. anyways, when the chart was placed into the chart rack, just as the gentle fall of snowflakes is a thing of beauty and magic and absorption, my precious work up fluttered silent, demure, unnoticed and uncomplainingly in the still Xmas alpenglow of morning to the bottom of the chart rack, where in the depths of this Moloch of true biblical times (Leviticus 18:21: "And thou shalt not let any of thy seeds (children) pass through the fire to Moloch”) my work up was in this Molochical beasts fire-time queue when it was rescued by the living and breathing brute-force search algorithm known as Nurse Rachetting of my acquittance and forever indebtedness…….
And this children is how my christmas was saved from my near certain suicidial down time event precipitated by an unanticipated but well documented system feature/bugssssssssss…… which I call the God Function of the Chart Rack … No holy, no stayeee … on to purgatory……
Anyways, for those of you compulsively reading the time of this missive, I’ve not had my first or latest manic break with reality, I am working a overnight shift in a ’standalone ED’ which by any other name is a fancy way of bilking, err I mean billing, I mean firing up ER charge masters for what is in essence urgent care cliental and charging it big ED prices… .. since the business is predominately pediatric, there is a lull around the pumpkin-carriage changing hour lasting generally until 6AM…..
But the associations are a bit lose as is my tongue, errrr, finger tips, since God help me, this little corner of cyberspace has become through your kind words and indulgence in my poetical grumping about the past; I am over-joyed, over-bouyed, over-boyed, or over-achieved to consider you if not the only family I have, at least the only family I still talk too……… I am boy-ient tonight, because today I signed the Offer Letter that was sent to me by the Psychiatry Program Director offering me a slot as an entering 2nd year psychiatry resident in the program where my wife will be a third year resident 1 July 2016. I do feel a little dazed and as flamboozled as Cinderella was by her late night date AFTER the Coach returned to its essential pump-kinessence……..
At the risk of being boring, I had always intended to be a psychiatrist (the only really intellectual MD’s by the way…. except for the unusual surgeon who at his core is a frustrated historian….. all the good ones are fascinated by the history of their craft……) and I only wound up as a medical front line action hero (Cardiologist/Intensivist/ER Dude) due to my adult persistent ADHD, my personality transformation courtesy of Special Forces and Ranger training and the adrenaline to keep me going a good long time, but now I find with such universal suffering, so much media hyped angst, so much reality TV driven anxiety, so much drive to be crazy since you can’t be on the public dole for just losing the genetic lottery, or while you were talented enough to be Bill Gates, Steve Jobs, or Elon Musk you came up short on the Greed or Luck necessary to sustain the drive, so you just collapsed into a comforting haze of schizophrenic thought….. that I am going home to what has always fascinated me most in my own hopefully now longer career … the Million stories that make up the Naked City……. for it is a true beyond truth telling that Psychiatry started not with Freud but with Shakespeare who copped it from Gilgamesh, Siegfried, Beowulf, Cuchulain, & Arthur…… and that is not even recognizing the 10,000 thousands of stories from Asia/India/Micronesia/Africa/Southwest Navajo, etc……..etc……..
So gentle and indulgent reader if you made it this far, either I’ve entertained you ……. or like too many in health care, you have OCD. Lets both take a rest……. or in my case, to quote Winston Churchill….. a Change is as good as a rest….. and since at my age I am governed very much by the law of Weird Al Yankovic ….. I’ll be mellow when I am dead….. I prefer a change to a rest… the great rest will come entirely before I am ready for it…….
Merry Xmas, You’all from this little coroner (that appears to be a Freudian Slip-Not there don’t you think? But that is another story for another day) …. correction from this little corner of cyberSpace, I wish you a happy set of holidays of your choice..... a shame, the one thing and truest thing time has taught me, with enough elemental and abundant natural ignorance you can spend a lifetime never knowing enough…… and I prove that too me every day, and I am grateful for all I have learned in the past year and hopefully I have shared something of value to you all as well.
Merry Xmas, Happy Hanukkah, Joyous Kwanzaa, keep BOXING day, eh! , or Shab-e Yalda………. etc, etc, etc……
Can’t leave without telling the second best joke I know……. but, I spoil the fun, by reminding the gentle reader of the point that Duke Ellington’s Theme Song was the Billy Strayhorn Classic ’Take the A-Train’…… so, what is the first song every Canadian Jazz Musician Learns to Play?……. Take the Train, eh! heheheheehehhheeeeehhhheeee …….