Tales from the Shift

Remember Tales from the Crypt, that cheesy HBO horror series based on the 1950’s E.C. comic books? Well, it’s the perfect title, because here it is Halloween season, and I am right now transcribing my intern year journal entries from a whole horrific month working 14-hour shifts in an urban emergency room.

Why 14 hours, when shifts are usually 12 hours? Because the work was never done in 12 hours, and by the Unwritten Code of Residency, you did not sign out and run out and leave significant patient care sh*t to the next person. Within reason, anyways. And even if you had wrapped up all the patient care sh*t that you possibly could, you still had to finish your charting.

Although I’m not 100% sure what would have happened to us if we had skipped out without finishing our charts. I think it would have involved some Crypt Keeper-like administrator reaching up from deep within the bowels of the hospital and dragging us screaming down to the Medical Records Department.

Come to think of it, this did happen to me at one hospital I worked at. I was paged by the Powers-That-Be and ordered to complete a required note in a patient’s chart. It wasn’t the first time I’d been paged about it. It was the first time they threatened to hold my paycheck, though.

This was before Electronic Medical Records. All documentation was on freaking paper. A patient’s chart was a tangible thing that existed in real, physical form. So, post-call and completely miserable, I made my way down to the sub-basement (which is really where Medical Records was usually located) and some shriveled, shrewy lady handed me the chart (a massive pile of papers held together by an elastic band) and pointed me towards the dictation cubicles, where I recorded whatever I could as best I could and entered the code to send it for STAT transcribing (someone had to actually type it all up) and then sprinted out of there as fast as I could, to sunlight and sanity… Ah, memories.

So I’m working on a book project, and as such, I’m going through my journals from 20+ years ago. I journaled consistently starting in college, then all through medical school, residency, and fellowship, capturing the whole damned experience in a series of funky notebooks. It’s all just whatever I experienced that day jotted down in practically illegible chicken scratch, but there’s enough to jog my memory.

I’ve been trying to use these little journal entries to inspire the creation of larger, more complete stories. But many details are lost, and I find myself trying to fill in the blanks, which makes the “non-fiction” label a bit of a grey area.

Lately I’ve been thinking, maybe I don’t need to do too much to these entries. See, I recently re-read Adam Kay’s 2017 best-seller This Is Going To Hurt, which is a book made up of his journal entries from his time as a Junior Doctor in the NHS. He was training in OB/GYN, and wow, between that super-stressful specialty and just trying to function within what sounds like an even more fucked-up system than we have, he ended up with a lot of great material. Also, his dry wit applied to the absurdity of it all is fantastically entertaining. Even his footnotes are funny. I highly recommend his book, and so do over 100,000 others on Amazon, so maybe there is something to be said for his approach.

So here I am typing up my own memories, and here is my actual journal open to an entry in 2002:

I’m going through these entries and pretty much just typing them out. I’m making complete sentences where applicable, and also clarifying some things, wordsmithing a bit here and there… Oh and for medicolegal/ patient privacy purposes, I’m obscuring or changing the dates, crossing out or changing any names, and not naming specific hospitals.

I suspect that some entries will need more fleshing out, but in the meantime, here is one entry (with loads of footnotes):

1/29/02

Well, really it’s 1/30/02, because it’s 12:10 a.m. but whatever.

What a beautiful and terrible day. Full of the richness of life that can make it both so sad and painful and yet so beautiful also… Okay, I’m not quite sure how to put it, I’m too tired so I’ll just document.

I got to the emergency department this morning, already exhausted. Only drank half my coffee before the bitch nurse manager hid it down the hall and around the corner, in the little designated DD¹ area, where I would never see it again. The day sucked, only two interns to manage the whole A/B side². It started off bad with Mr. A, this angry alcoholic everyone knew, who demanded to be discharged and then just walked out, only to be escorted right back in by security. We couldn’t discharge him because of the PEC³. The whole fiasco took up so much of my precious time with phone calls to psychiatry and then to the guy’s free clinic physician and then back to psychiatry and then to Admissions and then to Medicine, trying to get him evaluated and out of our E.D.

Then the medical mysteries/ nightmares: Ms. Z, a paraplegic woman in her 70’s, s/p L hip fx and failed ORIF ⁴ with mysterious and painful left leg swelling. Then Mr. H and his unexplained left groin pain– an incarcerated hernia⁵ maybe? Something was clearly wrong with him. Did I try hard enough to figure it out? Pain in the left groin, traveling down the leg. He had a clean urinalysis, no WBCs.⁶ I ordered his CT scan just before signing out. Maybe an occult femoral fracture?⁷ Wonder what it showed.

Then, the 26 y/o G3P2⁸ with abdominal pain, 17 weeks pregnant, said she had fallen down the stairs– she had a crackhead look about her– and now had lower abdominal pain. I did a pelvic exam, and there it was, the tiny almost translucent umbilical cord, hanging down out of her vagina.

Then, Mr. F the firefighter. We took too long to take care of him. 2nd degree burns to both hands. Glass embedded in his left thumb. He needed X-rays, then more X-rays, then a surgical consult (which took forever), then debridement. He left with his left thumb properly filleted and hands bandaged tight.

Who else? So many medical nightmares. Mr. I and his newly diagnosed end-stage liver failure. He was yellow as a traffic light with a hugely distended, pregnant-appearing belly, and he was bleeding bleeding bleeding from the crater in the side of his face where some wack dermatologist had tried to remove a basal cell carcinoma in the office. Mr. I’s PT was 37, I mean, holy shit!⁹ Thank God for very nice attendings. At one point Dr. L ran over to apply more pressure to Mr. I’s face for me.

What a day. A terrible, terrible long day. I was managing seven or eight sick emergency patients at a time. I did better than I did in September, but…

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Footnotes:

1. DD = Dunkin’ Donuts. There was one Dunkin’ Donuts in the hospital, another just outside the hospital, and more on pretty much on every city block across all of Connecticut. Their coffee always tasted burnt and caused horrible heartburn, which is why I always ordered mine “light and sweet”, which came with heart-attack inducing quantities of cream and sugar. I drank gallons of this vile concoction throughout residency, and today, even the smell of Dunkin’ Donuts coffee induces nausea and mild panic attacks.
2. A+B sides = The areas of this hospital’s emergency department generally designated for not-quite-as-emergent but still-very-serious cases that were never straightforward and always required significant workup and/or intellectual effort and/or psychosocial skills. See also: Internal Medicine.
3. PEC = Physician Emergency Certificate. This meant that some M.D. had decided this guy was a significant danger to himself and/or others and therefore required an emergency psychiatric evaluation. So they sent him to our E.D. with this piece of paper mandating that we magically make him stay put and wait, and wait, and wait for the poor shmuck assigned to inpatient psychiatric consultations, who would probably clear him to leave because we didn’t have an open bed anywhere for managing his detox and no rehab facilities in the area did, either.
4. L hip fx = Left hip fracture. ORIF = Open Reduction and Internal Fixation, a common orthopedic surgery to repair most femur (hip) fractures. Basically it’s a metal rod jammed into the bone and then fixed into place with screws. This lady’s had failed, so she basically had loose bones and hardware floating around her leg. I’m not sure why her pain and swelling was a mystery to anyone.
5. Incarcerated hernia = when a loop of intestine gets stuck inside of the abdominal wall bulge called a hernia. It is just as bad as it sounds.
6. WBCs = white blood cells, which would indicate an infection, like, a urinary tract infection. Honestly, I should have been more concerned about RBCs (red blood cells) because a kidney stone is more likely to cause groin pain, and that’s what you’d see in the urinalysis. I guess I needed to study more at that point in my training.
7. Occult femoral fracture = Sounds very supernatural and Halloween-y but it’s actually just a hip fracture that doesn’t show up on X-ray.
8. G3P2 = Gravida 3, Para 2, meaning that when she checked in, this woman had had three pregnancies total (including the current one) and two previous live births. Unfortunately when she checked out it was G3P2A1, “A” here meaning miscarriage before 20 weeks.
9. PT = Prothrombin time, which is the number of seconds it takes blood to form a clot. A normal value is, like, 12. Many of the proteins that help the blood to clot are synthesized in the liver, so liver failure is associated with clotting delay and bleeding risk. Which is why the dumb derm should have never ever attempted to excise a freaking skin cancer from this patient’s face (which is always going to be a big, deep incision) in his fancy suburban office like it was just another case. The man was the color of cheap mustard for goodness’ sake.

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So that’s one shift in the life of an intern. And that’s a plethora of footnotes. It works in Adam Kay’s book, but maybe it’s too much… we can put it to a vote. Next week I’ll post the short story I wrote about one of these shifts, because it’s a different approach to the same material. I wrote it for the medical school literary magazine, and quite frankly, it’s not very good. At all. But it tells a story that’s true and real and probably worth putting out there in the world.

Until next week– Wait, how did the Crypt Keeper sign off episodes? Ah, thanks Google:

Until next week, boils and ghouls!

*An earlier draft of this story was previously published on my own blog.