“What’s something you didn’t expect about medicine?” A med school applicant asked me on the phone as I crawled down the southbound 405. While squinting in the haze, nothing in particular came to mind. My mind was about as sluggish as the traffic — I had worked 82 hours over the last week, and on my day off I heroically decided to see people, because I had been putting it off the last month.
I hadn’t expected how much of medicine would be “dispo,” short for “disposition.” It’s not a surprise for emergency medicine doctors. In emergency medicine, the primary question is primarily not “what is going on in this patient?” The primary question is, “where is this patient going?”
Like Grand Central Station, the emergency room is a fork in the road for patients. Is this patient well enough and well-connected enough to go home and follow up with their primary care doctor? Is this patient so sick they need to stay in the hospital? Do they go to a floor or an ICU? Do they get sent directly to the OR? Are they mentally unstable enough to require a stay in a psychiatric unit? After the decision was made about a patient’s physical trajectory, we could rest assured that someone else, probably someone more expert and with more time on their hands, could do the Dr. House-ing if they so desired.
Still stuck in the “what” mindset, I have made the mistake of over-investigating things that didn’t affect disposition. On a patient admitted for psychosis, I noticed a strange anemia — his hemoglobin was low, but not low enough that he needed blood. Further analysis of his tests showed that he most likely had a thalassemia, not uncommon for folks of Mediterranean descent. But did that investigation matter? Did it change the fact that he’d go to the psych unit? Did he need any treatment for it? Nope. Just a little brain-tickle exercise.
What I didn’t expect was how much the services in the rest of the hospital struggled with disposition. The thing is, it’s easy and safe to say, “Hey, you’re sick. Let’s watch you until you get better.” It’s difficult and tricky to discern when you can tell someone, “Hey, I’m confident that if I send you home right now, nothing bad will happen.” Sometimes patients fear being sent home without adequate pain control. Others don’t have enough support at home to get food or take care of themselves without nursing assistance. Still others have no shelter at all. And in the inevitable liability-dodgeball game that one plays after receiving a full medical license to practice, it is often easier to keep someone another day than to send them home, even if it means poor use of limited hospital space or a more devastating bill for the patient.
I’m on a few back-to-back rotations inpatient, and everywhere I go there’s the same issue. Patients who can’t leave. Patients who don’t want to leave. And new patients, who trickle in at a steady pace in the ER waiting room, are left clogging up the ED.
My brain feels congested, too. Inpatient rotations aren’t exactly harder than emergency room rotations. There’s more regular breaks to get meals and use the restroom. But there are many more unfamiliar tasks. In the emergency department, I never have to order the specific brand of baby formula mixed with electrolytes that I do on a daily basis in the pediatric ICU. I never have to think about whether the calories I’m feeding a patient will be enough to support their metabolic needs. I don’t have to count the number of stools someone has to make sure they don’t need an enema. I don’t have to fill out and fax paperwork to prepare an OR for surgery, or add patients to a team list. It’s so late in the academic year that when I ask for help, I feel like the residents around me, all of whom have been doing these elementary tasks since July, quietly sigh in exasperation.
The hours, too, are exhausting. I’m not working more in an inpatient shift than I am in a shift in the ED, but somehow sitting at a desk and idly reading CNN, and sometimes responding to pages feels more tiring than running around desperately trying to clear a waiting room. Inpatient residents simply work longer than emergency residents—ICU rotations touch fingertips with the legally mandated work hour restrictions. One 24-hour period a week off. 80 hours a week, mostly 13-hour shifts, though it can stretch longer if I accept a new patient right before the time to sign out comes. When I went from Trauma surgery, which oscillates between 67-hour and 93 hour weeks (it averages out to the legal 80, in an ideal world), to the pediatric ICU, my work-hour logging app asked me to explain why I broke the law by working too long. I wrote, “I was scheduled to work.” I have four more weeks left of MICU, the adult ICU, which I hear is even busier. In comparison, my average ED week is 4 shifts a week, around 40–50 scheduled hours, even 60 on a bad week. Of course, it doesn’t count the time I stick around after shift to finish up my notes. I calculated it from my take-home pay: for the last 4 weeks, I have made an average of $14.12 an hour. That’s a little over two gallons of gas in West LA. If I drive at 65 miles an hour in our 2007 Corolla, I can spend as much money driving as I earn working.
Even so, I feel like the weeks are just gliding my. Having R at home is like being on life support. When I stumble into the kitchen at 4:30 AM, I find iced coffee waiting for me in the fridge. Mysteriously, the dishes are washed when I come home, and there’s always a package of King’s Hawaiian (my hangry snack of choice) on the counter. One morning I noticed I was down to my last pair of compression socks; that evening I came back and all of my socks and scrubs were freshly laundered, folded, and tucked away. R even spent some time one afternoon helping me get bloodstains out of my dingy work clogs.
The last two nights, R has been busy. I came back home to a quiet apartment and tried to imagine a life without R. Even though I only see him an hour or two a day, I can’t imagine these rotations without him.
The ICU is full of people thinking about everything we take for granted. If a tiny body doesn’t breathe, we breathe for them. If they can’t eat, we deliver calories one way or another, tube or IV. If they can’t poop, we make it happen. All they have to do is live.
Things that I enjoyed lately: there’s a kid in the heart transplant part of the pediatric ICU who is obsessed with Wonder Woman. He has a big Wonder Woman banner across the door of his room. His parents take him on walks every day and he fist-bumps all the nurses as he walks by. His face is one big chubby grin.
R and I drove up to the Antelope Valley Poppy Reserve and all we said over and over again was, “It’s so… orange.” Of course we were awed and delighted, but the word orange is too mundane to convey the fey romance of rolling hills ablaze, and we don’t speak poetry the way we write poetry the way we see poetry.
The residency went on retreat, ostensibly to give formalized feedback about rotation structure and logistics at our various hospital sites, but really to facilitate “bonding.” We hit covid-shaped piñatas, sunbathed, built the ultimate party bus Spotify playlist, and got lost a lot in a resort in the middle of the desert. When I got back, I polled residents from other residencies and their retreats are a half-day meeting where they discuss residency policy. I think I chose my crew well.
My ID card gives me a daily quota of money for food that refreshes every midnight, so when I know I don’t need any more food for the day, I buy as many jalapeno potato chip bags as I can and hand them to any of the staff I see on my way out of the building. One security guard and I are homies now; he traded me a banana for the chips, which means we share a sacred connection.
I had a four-year-old patient who came in after he was hit by a car going 40ish miles per hour. He was on a tricycle. When he rolled in, my heart dropped. He had a seizure on the table, was intubated, and transferred to the ICU. He had a broken femur, his liver and spleen were cut in multiple places and bleeding internally, and he needed tons of sedation to keep him from pulling out all of his lines. Over the next three weeks he slowly woke up. His first words after getting off the ventilator were, “I want ice cream.” He got all the ice cream he wanted.
I wrote most of this post on a lighter day in the PICU, but didn’t publish for almost a month. Now I’m in the last week of MICU and crispy as a potato chip. More to follow, if I can muster the energy.