These blog posts also provide the context around the illness (https://web.archive.org/web/20061108114936/http://theunderweardrawer.homestead.com/03_02_13.html, https://web.archive.org/web/20061108120147/http://theunderweardrawer.homestead.com/03_03_01.html, https://web.archive.org/web/20061108122346/http://theunderweardrawer.homestead.com/03_03_11.html)
https://web.archive.org/web/20061108124625/http://theunderweardrawer.homestead.com/patient.html
"PATIENT"
"Sometimes these things happen, and even though it's not the ideal situation, you're just going to have to be patient and wait this thing out. You'll be admitted today, no question, and we're going to need to keep you here for five days, a week."
"Excuse me?" From my vantage point on the stretcher, I struggle to look the surgeon in the eye. Maybe he's making a bad joke.
"Like I said," he repeats, already whisking open to curtain to make his exit, "you're going to have to be patient."
It's five o' clock in the morning on Valentine's Day, and I'm in the Columbia Presbyterian Emergency Department, having just been admitted to the surgical service in Milstein Hospital for a small bowel obstruction secondary to a perforated appendicitis.
(I)
THE ER. THE CURSE OF NOT LOOKING SICK ENOUGH. THE ER REDUX.
The pain started early Monday morning, with some left upper quadrant dull cramping and vomiting. I chalk it up to gastroenteritis and stay home from class for the day. The next day, the pain is more intense, and has moved lower, to a U-shaped band under my umbilicus. I hobble around home for most of the morning, but when I realize that I can no longer stand up straight because of the discomfort, I take a cab to the CPMC Emergency Room.
Joe, my fiancée, is waiting for me at the ambulance bay as I arrive, having already spoken with the triage nurse and the attending on service, briefing them on my arrival. I am relieved to be a patient at Columbia--after all, I'm a fourth-year medical student, one of their own--and I imagine that the response to my plight will be speedy and efficacious.
I wait on a stretcher for two hours before an ER attending comes by. Despite the fact that I know that many patients in triage won't be seen for three times as long, all I can do is complain. I see residents I know from my rotations, attendings that I recognize, and wonder why they can't come over here, give me treatment, pay attention to me. I run through the differential diagnosis in my mind--appendicitis, ovarian torsion, incarcerated hernia--and will them to hurry. When my attending finally arrives bearing my chart, I see the green triage sticker over my admission vitals as feel somehow insulted. I would have thought I was at least a blue sticker.
Over the course of the next ten hours, I get an abdominal CT with contrast, a surgical consult, and a gynecology consult. I have an elevated white count and the CT is read as "highly suspicious for appendicitis," but no one is particularly impressed. My symptoms don't correlate. The time course is wrong. I have been given some pain medication by the ER attending, and by late night, feel fantastic. I am sent home after fluid resuscitation with instructions to return with worsening symptoms. "You know what to look for," they tell me as they sign my discharge papers, "you're a medical student."
Wednesday morning, I feel a little better, but receive a call from a nurse in the Emergency Department that I am to return to the hospital immediately. My CT has been re-read by another attending as "definite appendicitis," and I need to be re-evaluated.
Back in the ED, I am once again given fluids and paraded in front of the surgical residents. Aside from being dehydrated (I have not been able to eat since Sunday night) and having some moderate crampy abdominal pain, I'm feeling not too bad. I can walk around, jump up and down, and am even in a good enough mood to joke to Joe about the long wait in the ER, where I have been stuck for six hours in a wheelchair in the hallway. "If they're the ones who are so worried about my appendix, shouldn't they be rushing down here to see me?"
This time around, I am diagnosed with subacute appendicitis, sent home on a five-day course of oral antibiotics, and again instructed to return if my symptoms worsened. "You look too well to have acute appendicitis," the fifth-year surgical resident tells me. "We could go in and take it out your appendix now, and we probably would for most patients, but it would probably be normal. Anyway, you're a medical student, you're reliable, so we know that you'll come back if your symptoms get any worse." I am proud to be considered a "reliable" patient, and am happy to be able to avoid a surgical procedure that all involved seem to feel would be overly aggressive. After all, if not even the surgeons want to cut, why should I demand it?
My symptoms do not improve the next day, despite the antibiotics, and by nightfall, they are decidedly worse. The pain has become unbearable, and I have started to dry heave, painful on my empty stomach. It is one o'clock in the morning, and I wait for another hour, hoping the symptoms will go away, hoping that I will be able to sleep it off. But I know deep down what's happening is more than a night's sleep can fix. Finally, I wake up Joe and tell him that something is very wrong, and that I need to go back to the hospital.
(II)
THE SURGICAL RESIDENT. THE NG TUBE. A ROOM OF MY OWN.
"I'm not going to force you to take it, but I'm telling you, it'll make you feel a lot better, and it will make taking the contrast easier." It's 5:30am, I'm in the ER, and the fifth-year surgical resident is trying to convince me to let them drop an NG tube.
"Do I really need one?" I croaked, already knowing the answer. I remember my third year surgical rotation on the Colorectal service all too well. What's the first thing we do for a patient who comes in with an SBO? I was once asked during a particularly protracted pimp session. "Take them to surgery?" another student suggested. "But first put down an NG tube," I piped up, proud to know the right answer. It all seemed so simple in the abstract.
The second year surgical resident enlisted with the ignominious task of dropping my tube is a nice enough guy, but not anyone I had ever imagined would be my doctor. I remember him as an intern from my surgical clerkship, a well-meaning but bumbling sort who was fun to talk to, but who didn't exactly inspire confidence. Right on cue, he fumbles the NG tube he has just unwrapped, drops it on the floor, and has to go scouring the ED for another. I am grateful for the few minutes it buys me to prepare.
I have seen patient's getting NG tubes inserted, and I have put NG tubes into patients, and all of them react the same way--spluttering, flailing, coughing, and gagging. I would tell them to swallow the tube, to help me, to cooperate. I know now that it has nothing to do with being a good patient. Having the NG tube inserted is one of the more unpleasant experiences I've had to endure, and one that I hope never to have to repeat. There's a burning and pressure high in the bridge of my nose as the tube passes, followed by the sensation of a foreign object snaking down along the back of my throat, making me choke and heave no matter how many sips of water I take to help the tube along. And it doesn't help that it takes three tries to finally get the tube down. Happy Valentine's Day.
I am finally hooked up to suction and do indeed feel better as the backed-up contents of my stomach are evacuated. I only have a few moments to enjoy this sensation, however, as another surgical resident now appears and proceeds to unhook my suction and pump two full pitchers of CT contrast directly down my NG tube and back into my stomach. I am grateful to not have to taste the contrastI doubt if I would have been capable of taking that volume of liquid by mouth anywaybut as the pressure of the contrast in my stomach builds, I have to struggle not to vomit, lest we have to begin this whole process again. Joe wanders out to the nursing station to ask the senior surgical resident, formerly Joe's senior resident during our third-year surgical clerkship, if I can be given an anti-emetic. "Joe, it's an intra-abdominal process!" the resident snaps back, just like in the old days.
I am filled with contrast and taken to CT, where I am made to lie flat, much to my discomfort. The CT tech remembers me from Tuesday. The first-year radiology resident sweeps in to administer my IV contrast, and I recognize him, a former Pediatrics resident who changed fields after his intern year. "Didn't you used to be a Peds intern?" I manage to ask. He looks surprised. "I'm a medical student here." I explain. "I worked with you in the Peds ER last year." He nods. The IV contrast goes in.
Finally, there is relief as the CT is completed and the contrast is suctioned out through my NG tube. We are told that a room has been made available for me upstairs, but it is still two and a half hours before transport finally arrives to take me there. ("You're still here?" a nurse exclaims, peeking past my curtain. "I called transport before lunch!") I am wheeled on a stretcher through familiar corridors and elevators, out of the ER, through PH, where I had walked many, many times before, back to the elevators that would take me to Milstein. The view is much different from the horizontal, from what I can observe when I can manage to open my eyes. Finally, we arrive at Milstein 7 Garden South, to Room 340, Bed B. I do not know it at the time, but this room will be my home for the next nine days.
(III)
PAIN CONTROL. THE LONG WEEKEND. THE MEDICAL STUDENTS.
"We don't give IV opiates on the floor," the nurse tells me. "You'll have to take it IM."
"But I got...IV Demerol...in the ER," I protest, the pain in my abdomen making it difficult for me to speak in full sentences.
"That's the ER. They can do that there. Here, we have to give it IM." I'm in no mood to argue, despite the fact that the needle stings, and the Demerol burns going in. I am written for IM Demerol Q4° PRN, and need ring my call button to request my dosage every single time.
It quickly becomes clear that the pain control I'm receiving is not enough. Two hours after I receive each dose, I need another one, and spend the next hour and a half watching the clock, until the nurse can finally give me my next shot. Additionally, both of my buttocks are becoming extremely sore from the number of injections that I've been receiving, and despite nursing's efforts to rotate the injection sites, it feels as though I keep getting stuck in the exact same spot. Two days into my hospitalization, I finally grab one of the medical students on my team and ask them if they can suggest on rounds the possibility that I can be put on a PCA. I would have asked the residents directly, but, having the misfortune of being admitted over the long President's Day weekend, I haven't seen much of anyone besides my nurses.
Fortunately, the resident agrees, and the pain service comes by surprisingly fast to help me set up my PCA. Though the machine has been set to the lowest possible morphine dosage, it is a relief to be able to control my own pain meds, to not have the anxiety of waiting between doses, to not have to receive any more IM injections. I try to use my PCA as sparingly as possible, to not use it more than two or three times an hour, but over the course of the next two days, the pain service has to be called back to up the dosage. "Why was this set on such a low dose in the first place?" the anesthesia resident asks, fiddling with my machine. "Don't you have a perfed appy?"
My attending of record, Dr. A., had seen me in the ER on Friday, but is not working over the long weekend, and is being covered by another attending. I am aware that the covering attending is busy, has many patients to take care of, and, barring emergency, has little say in dictating the direction of my care, but this is of little comfort for the first three days of my hospitalization. In fact, I feel as though I might as well not have an attending at all, given the way that he breezes in for less than a minute each time, tells me nothing, and administers perfunctory abdominal exams on me while I'm standing up.
Despite the fact that my fiancée and I are both fourth-year medical students, and my parents are both doctors, we are left as mystified and clueless as any patient, wondering daily just what the hell is going on, what the plan is, and in which direction my care is going. The only people we can manage to get a hold ofthe nurses, the third-year medical students, the cross-covering interndon't seem to have much more of a clue than we do.
The third-year medical students, all three of whom I know personally, have been helpful in their own way. They have brought magazines, helped me bring up issues during rounds with the team (as with the PCA), and generally been comforting, friendly faces during a time of stress. I am, however, surprised at how uncomfortable I become when they are asked to see me in a health-care role. One morning, a male medical student who I had known outside the hospital setting performs a physical exam on me while pre-rounding. A medical student is later sent to pull out my NG tube. A medical student is asked to draw a set of blood cultures when I spiked through my IV antibiotics.
"Well, you know what it's like, being a third-year," the intern explains, after I ask him, and not the student, to draw my blood cultures. "Everyone needs to learn."
I feel like a hypocrite, having been a procedure-hungry third-year myself, but I can't help but to feel that it is inappropriate to have a medical student treated by another medical student from the same institution. I admit that part of me wants to be treated by the "real" doctors, who had more experience, and who would less likely fumble inelegantly through a procedure or require multiple sticks for a blood draw. But I doubt I would have felt as uncomfortable were I at another hospital, being seen by a medical student from another school. I know these students. I lived in the same apartment building as them, say hello to them in the library, see them at parties on campus. And I do not want them examining me, performing procedures on me, treating me as a patient.
I ask to speak to the fifth year surgical resident on the team about the matter, and he says he understands, and will handle the matter with discretion. From then on, the medical students do not pre-round on me in the mornings, and the intern takes care of most of the daily aspects of my care. But still, I feel guilty. I do not want the third-year students to think that I don't appreciate what they've done for me. I'm afraid to have hurt their feelings.
(IV)
SPIKING. INTERVENTIONAL RADIOLOGY. PLACING THE DRAIN.
I've been on IV Zosyn for five days and still spiking fevers. There are worries that I am forming an abscess. Further imaging will need to be done. If a collection is there, I may have to have it aspirated, or a drain may have to be placed.
I ask my attending if it's possible that I could get an ultrasound instead of yet another CT to look for a collection. I've already had three CT scans over the course of the last week, and would prefer imaging without radiation if at all possible. Dr. A.agrees that an ultrasound would be an acceptable option, and I am scheduled for later that day.
Down in the ultrasound suite, I watch the screen along with the tech as the probe detects what appears to be a medium-sized fluid collection in the right lower quadrant, the point of maximal abdominal tenderness. Over the past few days, I have finally developed pain at McBurney's point, along with rebound. It occurs to me that if I'd had these symptoms when presenting to the ER in the first place, I would have been rushed to the OR immediately and this whole ordeal could be over by now. But I try not to dwell on that too much. The radiologist confirms that there is indeed a collection, and that placement of a drain is recommended. I am scheduled for interventional radiology for the next day.
Later that night, a nurse comes into my room with a pitcher full of contrast, that I have been instructed to drink. It seems that IR wants another CT of the abdomen despite the fact that the ultrasound already detected a collection, and that tomorrow's drain placement will be CT guided anyway. I have been NPO for five days, not even yet advanced to sips, and now they want me to drink a pitcher full of contrast. And why in the world did they even have me get the ultrasound, if they knew that they would want a definitive CT anyway? But there's no arguing this one. Laboriously, slowly, I manage to drink the contrast, and am whisked down to radiology for my fourth CT scan in eight days.
The following afternoon, I am taken down to IR for my procedure. As of yet, I have signed no consent, received no explanation of what is going to be done to me, not even spoken with a radiologist. I'm not sure if it's because they assume that I know, or that they skipped that step in patient relations, but either way, the whole ordeal puts me on edge. A nurse starts to wheel me into the room, and I protest, demanding that I at least speak with a radiologist first about the details of the procedure, and sign a consent. Ten minutes later, a disheveled second-year radiology resident ambles over, flipping idly through my chart, and asks me, with no introduction or preamble, "What are you here for?"
"You're supposed to explain that to me!" I scream irritably. "And by the way, nice to meet you, my name is Michelle, and who might you be?" I feel like a CP lecture come to life. I have a feeling that I will be making a big effort to introduce myself to patients from now on.
The CT-guided drain placement is to be done under Versed sedation and local anesthetic with lidocaine. It is explained to me that I will be drowsy, but not asleep, and that while I would probably feel the lidocaine injection, I probably would not feel much else after that. I am more apprehensive, as my right lower quadrant, under which the abscess has formed, is exquisitely tender by this point. Even with my PCA, I jump off the table when the radiologist marks the spot with a radio-opaque pen, and wince when a hospital sheet is tucked into my pants.
Despite the Versed, I can remember most of the procedure, and can attest that it was painful. "This really shouldn't be hurting you right now," the radiologist said, acting surprised by my reaction as he first inserted the needle, then the dilators, then the guide-wire, and finally, the catheter in my abdomen. I don't remember saying anything aloud at the time, but can remember thinking quite clearly, "I don't care if this shouldn't be hurting me, what I'm telling you that it does hurt."
Post-procedure, still groggy, I spend some time in the recovery area and am wheeled back up to my now-familiar room on 7GS. When I finally wake up, I lift up my gown and look down. There, secured by an adhesive anchor and connected to a clear plastic leg bag, is a thin, white, pigtail catheter snaking out of my skin.
(V)
AFEBRILE. THE NPO SIGN REMOVED. DISCHARGE PLANNING.
The drain never puts out that much volume, not even initially, upon placement, but somehow, after my visit to IR, my temperature curve starts to drop. Maybe it was the drain. Maybe the antibiotics just needed a chance to work. Maybe my body just needed a chance to catch up. Regardless of the reason, after seven days in the hospital, I'm finally starting to get better.
Once things start improving, they start improving fast. My bowel function, stunned by the inflammation, is very gradually returning to normal. I am advanced to a clear diet, and then to regular. I no longer need pain medication, and I ask that my PCA be taken away. I begin to get restless, cranky, anxious. Now that I'm feeling better, I want to be discharged from the hospital as soon as possible. I want to go home.
I presume I will have to stay at least until Monday (after all, we all know that nothing productive happens in a hospital over the weekend), but it has been decided that I will be discharged on Sunday, after one last ultrasound to check for further collections before the drain is pulled and I am sent home.
The last day before my discharge is the longest. I have visitors throughout the day, movies to watch, books to read, but still, the time passes slowly. That night, I request my PRN dose of Benadryl to help me sleep. Ever since I stopped taking my pain medication, sleep has been difficult to come by, and the hospital bed increasingly uncomfortable. It is only 9:30pm, but I figure the sooner I go to sleep, the sooner the next morning will come.
I am wearing scrub pants and clogs, with a Columbia University sweatshirt. I am walking briskly, standing fully upright for the first time in many days, no longer guarding. In my right hand is my IV pole, which I'm wheeling along beside. I'm walking over to 7 Hudson North, where I know, from my experience as a medical student, there is a microwave in the lounge, where I can heat up a cup of hot soup to drink before bed.
As I pass the 7HN nursing station, one of the nurses does a double-take. "Are you a doctor here, or a patient?"
Grinning, I tell her, "Both."
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