Talk about terrifying.

The nurses were performing chest compressions and giving bagged breaths for a patient this morning by the time I walked into the room.

I simply stood at the foot of the bed with a deer in headlights look and asked, “What’s going on?”

After an initial smart-assed response of, “Well, he’s not breathing”, I managed to get a bit of an event progression from the nurse who was already drawing up some epinephrine into a syringe.

Lucky for me…and the patient…a few more white coats with more experience arrived just as the nurse was finishing the history. I was off the hook for “leading” the code–and the patient was better off for it.

Of course, I broke the number one rule of code situations…

I forgot to take my own pulse.

What a morning.

*Editorial Note: On Friday I carried the code pager for the day, and it did go off. I was half way across the hospital and by the time I got there the code was finished. Apparently the patient was a DNR–or some such. As such I don’t count that as the first code of my career.

Last month I worked on a consult service–so I never had any of my “own” patients.

That all changed today when I admitted a patient with pulmonary hypertension.

It was mostly grunt work–filling out orders, doing a rectal, etc. Ya know, the normal intern stuff. We got the patient a bed and I then promptly “checked out” to the intern on call for the evening. I felt a bit guilty dumping a sick patient on the overnight intern–but that’s what the 80 hour week does for us.

It’ll be my turn on Sunday when I have my first call day/night.

Should be a blast.

But I’m often amused by the way patients comprehend the disease process.

For example, I was recently seeing a young, homeless, female patient who was dealing with a simple pneumonia–nothing spectacular. But during a routine screen of her liver function via a complete metabolic panel–a series of lab tests that evaluate liver function, blood constituents, and electrolyte levels–we noticed that she had poor liver function.

I decided to interrogate the patient as to the potential causes of the bump in liver enzymes. While she couldn’t put her finger on any one process that may have caused the problem–she wasn’t drinking anymore and she rarely used Tylenol–she did mention that a bunch of years ago someone told her she had a “touch of hepatitis”.

I’m still trying to figure out exactly what a “touch” of hepatitis is.

Must be a similar condition to “a little pregnant”…

Today, in the presence of family, friends, teachers, and colleagues, I dedicate myself to the profession of Medicine.

I pledge myself to the service of humanity. I will use my skills to care for all in need, without bias and with openness of spirit. The health of my patients will be my first concern. I vow to hold sacred the bond between doctor and patient. I will hold in confidence all that my patients entrust to me. I will strive to alleviate suffering. I will respect the dignity and autonomy of my patients in living and dying.

As a Physician, I recognize my duty to society. I will work to promote health and prevent disease. I will advocate for the welfare of my community. Even under duress, I will not use my knowledge or my skills against humanity. I will acknowledge my limitations and my mistakes so that I may learn from them. To uphold these responsibilities, I will maintain my own well-being and the well-being of those close to me.

I will promote the integrity of the practice of Medicine. In the tradition of my profession, I honor all who teach me this Art. Through honest and respectful collaboration with my colleagues, I will seek new knowledge, reexamine ideas and practices of the past, and teach what I have learned.

Above all, the health of my patients will be my first concern.

This Oath I take freely and upon my honor.

That, of course, is a far cry from the original Oath of Hippocrates:

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

There are a couple of translations from the original Greek. The above is just one example.

Times have changed, no?

Would the system fall apart?

What moron decided it would be a good idea to tie health insurance to employment?* Why should those two go together? My car insurance doesn’t come with my job.

Yeah, yeah, I get the “but healthy employees are good for the company bottom line”…but are you sure about that? Does providing health insurance to your employees even help the bottom line?

The point of insurance is to pool risk. I suppose that a business is just as good as any other place to cultivate that risk pool. But why can’t the insurance business operate like the car insurance business? Pool risk from the public at large.

If you unraveled the health care industry from employers, wouldn’t they be able to spend more on employee wages and salaries thus putting cash back into the working man’s pocket allowing the working man to purchase his own insurance plan? That would give the working man…Gasp…choice! Such a dirty word.

Could I ask a few more rhetorical questions?

*Those Blue Cross folks at Baylor in the 1920′s probably get the nod for the prepaid business of health care–but the “HMO” existed for a decade or two prior to that.

The definition of eternity is the time between midnight and five AM. If you look hard enough you can almost see the clock hands moving backwards and no matter what you do, it’s always just a little after one. In fact, it will be one AM for hours. Your brain will cry for sleep and you will be totally uninterested in the mundane crap that fills a lot of your night. At the same time your most ferverent wish will be that it’s all mundane crap. No two ways around it, call, like most of intern year blows with the power of a thousand hurricanes.

Is it that close to July 1st already?

Hoover discusses this recent Jama article concerning residency work hours:

Nearly half of all months had violations during ambulatory settings and nearly 62% of months had violations where interns were working on inpatient services.

The ACGME needs to start cracking some balls if they want programs to take these duty restrictions seriously. If nothing is done, or programs are simply slapped on the wrist, the system will continue to be abused and work hour restrictions will be nothing more than fudged numbers on some slip of paper in the program director’s office.

I had mentioned in a previous comment that residency training is an odd bird. This work hour issue is one of those oddities.

Of course, I come from a fairly benign medical school–at least as far as the medicine program is concerned. I never heard much in the way of complaints about work hours from the residents I rotated with. Surgery is another issue…those poor bastards were miserable.

At any rate, who decided it was a good idea to keep people for 30 hours every 3rd night? Or 4th night? Or even 6th night for that matter? Musta been a bunch of military folks…

The New York Times has a nice profile of Dr. Gawande this week which conveniently coincides with the release of his second book, Better: A Surgeon’s Notes on Perfomance. It is an interesting read and gives pretty good insight to the life of such an accomplished and respected surgeon.

It’s the final paragraph, though, that makes me wonder if I’ve missed out on something by never reading Dr. Gawande’s work:

Pulling out his Blackberry, he said, “It seems like there’s a story in every nook and cranny of medicine,” and scrolling down a list of 106 ideas he’d saved, he picked a few. “Itching,” he said. “Nobody really understands what it is. Chernobyl. Twenty years on, what really happened there? Why weren’t there as many cancer cases as we predicted? And here’s a good one: why, if we have so many health-policy experts in this country, do we have such bad health policy?”

Maybe I’ll go and pick up his next book.

Talk about boring…sheesh.