Stabbed in the Back

The patient was a 38 year old male brought in by his mother for two days of subjective fever and myalgia, with one day of confusion, bizarre behavior, and word-finding difficulty. According to his mother, patient started behaving strangely the morning of presentation: was putting multiple socks on one foot, tried to put a sock on his head, was attempting to speak but could only get some words out, scrawled the word ‘help’ messily on a sheet of paper. Mother reported patient came home from work early two days ago because he was feeling ill and having body aches.

The combination of fever and altered mental status raised suspicion for meningitis; thus, lumbar puncture (LP) to detect pathogens in the cerebrospinal fluid (CSF) was attempted in the emergency department. A second year emergency medicine resident attempted the LP first, but was unsuccessful. The ED attending then attempted and was also unsuccessful. Broad spectrum IV antibiotics were started in case he had meningitis. The patient was then admitted to the internal medicine service and sent upstairs.

When I entered the patient’s room in my gloves, yellow gown, and face mask, the patient’s mother was at bedside, crying. I introduced myself in broken Spanish. She asked me what was wrong with her son, why he was acting so strangely, why they had stabbed him in the back so many times in the ED. The patient was only loosely oriented, and was also extremely hard of hearing. Pretty soon we were shouting, trying to get the patient to answer some basic questions. After a few more minutes, I had to rush off to rounds. I told them I’d be back later.

After hearing my presentation of this patient on rounds, the attending felt that she should re-attempt the LP. It would have to be done quickly though, as she was rounding with multiple teams that day. The attending, senior resident, intern, and I marched over to the patient’s room and suited up in protective gear. None of us could speak Spanish. We whipped out a translator phone and started obtaining consent for the procedure from the patient’s mother. Then we asked her to go to the waiting area. We put the translator speaker phone on its loudest setting, and asked the translator to yell through the phone. The attending opened her LP kit and started positioning the patient. Via the yelling translator phone, she said to him, “Ok, I need you to get on your side and curl into a ball. Bend your knees all the way into your chest. Now stay very still. No matter how much it hurts, do not move. That’s the most important thing. Do not move.”

She motioned to me to come to the side of the bed, and told me to hold the patient’s arms and legs down, squishing him into a ball. She told me not to let him move.

At the first insertion of the needle into his back, the patient groaned and squirmed.

Don’t move!” she said. The translator yelled it.

She kept removing and inserting the needle, changing the angle and entry point slightly each time. Over and over. Maybe 12 times.

The patient was crying, trembling. Sweat and tears rolled off his face, soaking his bed. He was begging us to stop, but he could barely get the words out because he was sobbing so hard. And there I was, using my weight and strength to pin him to the table, forcing his knees into his chest. Every so often the attending would make eye contact with me when he jolted, willing me to keep him still.

I have no other way to describe this than torture. I have never seen a human being in so much agony in my entire life. Yes, there was lidocaine injected with a smaller needle before the puncture was performed with a thicker needle, but I will never forget the image and sound of this terrified and confused man curled up on this table, clearly in the worst pain of his life.

At some point, a senior neurology resident appeared in the room, ready to give the LP his own try. The attending moved over and the neurologist descended, shouting his own choruses of, “Don’t move, stay still.”

Eventually, the neurologist gave up too. He had not succeeded. The doctors ripped off their masks and gloves and threw them away, storming out of the room.

I was directed to go find his family, explain what had happened, and explain that he would be needing yet another LP today, this time CT-guided to ensure success. Because it is expensive and requires a radiologist, the CT-guided procedure is reserved for patients in whom standard bedside LP is unsuccessful. I fetched his family from the waiting room and brought them to a slightly more secluded section of the hallway. And there we stood, in a random hallway at County, talking via a translator phone that kept beeping due to calls waiting about other patients. I told them that he had been through a lot, that he was in a lot of pain, that he still needed the procedure to diagnose his possible brain infection. I was unsure of whether I believed it myself at that point.

They asked me why none of the doctors could do his LP. They asked me what I thought was wrong with him.

Later in the day he went down to the CT suite and his LP was finally successful. I wonder how much more he suffered there.

Within two days, his mental status returned to baseline. His fever resolved one day after presentation. His antibiotics were discontinued, and he was discharged home without follow up. All CSF studies from the LP were negative. When he and his mother asked what his diagnosis was, we all just shrugged our shoulders.

Meningitis? Who knows. Because the antibiotics were started before the LP was successful, the negative CSF results could reflect meningitis that was cured by the antibiotics before the sample was taken. No one can say for sure.

One of the residents half-joked, “Maybe he was just drunk and had a cold.”
I’m not sure what my $200 of medical education bought me today. Perhaps it bought me the realization that in the process of becoming a doctor you don’t lose your humanity all at once. It happens so slowly you might not even notice.

Am I Dying?

I spent the last six weeks doing my internal medicine rotation at Los Angeles County Hospital. Often the hospital is at 100% capacity, leading to intense pressure from the hospital administration to churn through patients as quickly as possible. I agree with the underlying idea: we want to provide the most help to the greatest number of people in need, so patients who are stable enough to be discharged should be released quickly to make room. In other words, the only way to remain hospitalized for more than a day or two at County is to be very, very sick. Many of the patients are dying.

Until this point in medical school, I had not been confronted with the task of talking so openly with a patient about his impending death. I had never been asked before, “Alexa, am I dying?”

Mr. Smith is a 50-year-old man with metastatic colorectal adenocarcinoma. His cancer had spread throughout his abdomen, and at the time that I met him the cancer had paralyzed his intestines so that he could no longer keep food down. He came to the hospital with intractable nausea and vomiting. We stuck a tube down his nose all the way through to his stomach, to suction out any food or secretions and to let his bowels rest. I performed my first paracentesis on him, sticking a large needle into his abdomen and withdrawing five liters of fluid that had accumulated because his liver was no longer functioning well. His prognosis was dismal, but it seemed as though no one had directly told him this.

Soon enough, it became clear that his situation was not improving. Tumors in his abdomen were growing so big that they were obstructing his bowels. His cancer had continued to spread despite two rounds of chemotherapy. It was proposed as a possibility that a tube could be inserted through the skin of the abdomen directly into his intestine so that he could feed himself through the tube, but because of the extent of the cancer there was a good chance that the surgical site would not heal well, or that he still would not be able to pass the liquid through the rest of his intestines.

“Alexa, am I dying?” he asked me one morning. I took a deep breath and looked back at him.

Well it certainly looks that way to me, I thought. But dying is relative. Aren’t we all dying at least a little? Perhaps the more accurate question is, how fast am I dying?

“Well, you have cancer, cancer that is not getting better. It’s actually getting worse. You are not dying today, but there is nothing we can do to fix this cancer. And this problem with your intestines is a very tough one. I don’t think you are going to be able to eat food through your mouth anymore.”

“And what about the surgery?” he asked. “Would you try to have this surgery, even though it’s risky, if you were me?”

I sat on the edge of his hospital bed. “I’ve been thinking about that all day,” I replied. It occurred to me in that moment how much power I had. He was treating me as his doctor, asking me for advice on this critical decision. I was the one who had spent the most time with him in the hospital. I had brought him a collection of tea bags from my house when he had been unable to eat food, but was wishing for good cup of tea. He trusted me. The opinion of my attending was that the surgery was more trouble than it was worth—that if successful it would not buy him much more time, and that the risks of complication were very significant. My gut feeling from the beginning had been that he should turn down the surgery too. But I wonder if things would be different if I were actually in his situation, actually the one dying, actually the one having to tell my family that I was done fighting.

“So how will I get nutrients if I can’t eat?” he asked.

“Well, you’ll keep doing what you are doing now. I think it’s the best we can do. Fifteen teaspoons of Ensure per day, spaced out throughout the day,” I answered.

15 teaspoons of Ensure per day until you die…

Then, since there was nothing else we were doing for him medically, and the hospital was full, the emergency department full of sick people waiting to come upstairs, we sent him home. I gave him a hug and wished him luck.

For the record, I understand why we sent him home. It was true, there was nothing more we were doing for him medically. Drinking Ensure at home is undoubtedly much more enjoyable than having it at the hospital. Still though, it felt grim and unfinished.

And speaking of dying, I really feel like I’m dying too. Not as quickly as the patients, but not as slowly as I was before. The days are grueling. 11 or 12 hour work days, 6 days per week, with about a half-hour break per day, plus studying on the side for a really tough exam. There is no time to think about anything else. I barely go to the gym. Groceries and cooking? Forget it. I go days and days on end without ever stepping outside when it’s light out. Sitting down for breakfast is a thing of the past, because I decided that it is actually more painful to force myself to eat breakfast before work than to be hungry for a few hours until I can eat lunch.

And the thing is, doctor culture normalizes this. By the standards of all of the doctors, the “internal medicine schedule really isn’t bad. You get nights off and a weekend day every week!” I get deemed a wimp for complaining about this schedule. My attending chuckled when I told him I felt like there wasn’t much time for studying, replying, “Oh, you think it’s bad now? You just wait until you are a resident, or until you are me.”

The thing that upsets me most is that being on rotations has forced me to make sacrifices to my own health. I am a person who has spent my whole life sleeping well, eating right, and exercising. It’s what I tell the patients to do. Do I not deserve the same?

Still, my experience in internal medicine was pivotal in my professional and personal development. I have never learned so much in a six-week period, and I am full of admiration and respect for my team of interns, residents, and attending. They work so hard every minute of every day, and know so much. Again, I am left humbled by the stories of the patients and appreciative of the incredible fortune that is my good health.

Next is family medicine. I wonder my rate of dying will decrease.

A Case Against Medical School

After a perfect New Zealand holiday with Jono and his family, I find myself full of dread at the prospect of the new year. I don’t want to go back to the hospital. Though I am happy to have made it through half of third year, all in all, it has been rough. I feel beaten down. My self esteem is at a decade (or more) low. I do not have the answers to the questions I am constantly bombarded with, I never know how to do anything, I am always lost and often forgotten. Every three weeks the cycle starts over again, and I go to a new place with new rules and a new language, where I am evaluated by a new attending. I feel a constant and pervasive sensation of incompetence.

A systematic review published last month in the Journal of the American Medical Association examined 183 studies from 43 countries, finding the prevalence of depression or depressive symptoms among medical students to be 27%, with suicidal ideation in 11%. In the wake of recent tragedies at my school, one of the new wellness interventions from the administration is to give third and fourth year students one weekday off every six weeks. We are informed of this day in advance, so that we can get our teeth cleaned or our cars fixed or whatever. When we tell our residents that we will be missing a day at work for our wellness day, some of them are bitter because they never get days off. One of them said to my classmate, “Someone in our program should kill themselves so we can get a day off too.”

Before I came to medical school, and in the first couple years of med school, I encountered a lot of bitter doctors. When I would go into the hospital to shadow, or when I would find myself in a group of residents, they would try to talk me out of going to medical school. In a half serious way, they would say, “You really shouldn’t come to medical school. There are a lot of other good careers, a lot of other ways to be happy. You should get out while you still can. I wouldn’t recommend this.”

I remember being annoyed by this sort of talk. I wrote them off. I was so happy and excited about going to medical school. I thought it would be different for me, I guess. But now I get it. If a 20-year-old pre-med came to me and asked if I would recommend medical school, I would say overall, no. It is fascinating and stimulating and rewarding, yes, but it is also completely overwhelming and stressful. There are much easier, cheaper, more direct ways to have a meaningful life and career. You can even work in medicine and give up much less in life. At work I encounter nurse practitioners, physician assistants, and social workers and think about how awesome their jobs are. Basically, I’m saying that it is possible to get a lot more in life for less than medical school and residency take out of you. If you can find another career that will make you happy, choose that. Medical school should be a last resort. Perhaps my opinion will change 10 years down the line, but I think it will still be worth acknowledging that halfway through my third year I hated everything so much.

I think my evaluation of the third year experience is somewhere in the middle of the evaluations my peers would give. Three of my close friends say that they are very happy overall and that medical school was the right choice. Another says she can’t help but feel exploited and disillusioned—that being a doctor was portrayed as this shiny dream job where she would get to help people, but it turns out that residents have awful lives and that all it really means to be a doctor is to frantically run around the hospital all night, trying not to let anyone die before morning. The absence of punishment is the only reward for good work. Now $200,000 in debt, she feels that even if she seriously wanted to quit, it would be impossible. One friend who is currently an intern says her goal is to finish residency so that she can steer her career away from patient care. After seeing what the lives of residents are like, four of my peers are looking for ways to use their MD degrees after med school that do not involve residency.

And myself? As much as I resent med school, I do still want to be a doctor. I cannot think of anything to study that could interest me more. I must acknowledge the insight into the human condition that I have been privileged to gain this semester—to watch somebody die, to hear someone’s deepest secrets, to take care of someone on the worst day of her life and know that doing your job will add meaningful time to her life, is an honor. I am not depressed, but I believe with 100% confidence that the only reason for that is because I prioritize sleep and exercise over my grades. No wonder I’m not a great medical student. And there it is again: (what feels like) the unforgiving choice between my happiness and my academic/career success.

But for all that this year has taken out of me, it has also made me kinder. When I see people who are lost around the hospital, or even just on the street, I stop and try to help them, and it is always the best part of my day. I will always remember this time in my life, when I felt so small and so lost that my hobby became finding lost randos and pointing them in the right direction, so desperately wishing that someone would do the same for me. When I drove home I hoped that the homeless guy on my freeway exit would be standing there, so that I could give him a dollar and make him smile. I go out of my way to introduce myself to any newbies I meet, acutely aware of how it feels to be alone and inexperienced.

At a particularly low moment this year, I told Jono I’d rather do anything than become a doctor. He told me to name some things I’d rather be. As we drove, I looked out the window and started naming everything I saw. A postal worker, a yoga teacher, a barista, a sandwich maker at Subway. From then on, it became Jono’s favorite party joke to announce to everyone that I’d rather work at Subway than become a doctor. The joke never lands though because people don’t know whether to laugh. They think it must not be true so they laugh a little, then they nervously look over to see my reaction. I do think it’s funny, but only because it’s not 100% false. I’d rather be a doctor than work at Subway, but I still feel like I’m clawing my way out of some hole I fell into, and that someone keeps pouring truckloads of dirt into the hole to keep me from seeing the surface. I usually have pages of new year’s resolutions, but not this year. I have no athletic, musical, creative, or academic goals. My sole resolution for 2017 is to just keep going, to keep slowly climbing out of this hole.

 

Mount Victoria Lookout, Wellington, New Zealand

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Don’t Mention the Spaceships: Tales From the Locked Psychiatric Ward

I spent the second half of my psychiatry rotation in LA county’s locked inpatient facility, where we’d send patients from the psych ED who needed to be hospitalized for more than a couple days. On our first day, we were given a security briefing. All doors to the ward needed to be manually double-locked. We were instructed to first look through the small window in the door at a dome-shaped mirror on the ceiling, making sure patients were not hiding behind the door, ready to jump out and escape. The hospital administrators were careful never to use the word ‘escape’ though, instead preferring the term ‘elope.’

The ward was dark and gloomy. The walls and floors were concrete, the building very cold. There were no windows. Patient rooms sleep between one and five people. Mostly, patients keep the lights in their rooms off, and many spend most of the day sleeping. Going into a room to wake a patient up felt like going into a pitch-black cave—it got darker and darker as I ventured deeper into the room, the only source of light coming from the hallway.

We met with each patient every day, and they all wanted to know when they would be leaving. Every day, the same: I’m not sick, I don’t need medications, you can’t keep me here, when can I go home, I need to get out of here. On multiple occasions, patients tried to elope. One dressed up as a painter. However, to actually escape, a patient would have to make it through three sets of double-locked doors and the same number of hall monitors and security guards, as well as find her way through the complicated maze of the hospital. It is hard enough do it with keys and a badge. One woman made it through two doors, but then got lost and gave up. She resigned herself to the couch in the common room of a different ward, and was later found making new friends.

Needless to say, taking care of involuntarily hospitalized patients is a thankless job. Sometimes I felt like a jailer. Very often, the patients hated the treatment team. The decision to involuntarily keep a patient was not taken lightly though, and it always felt justified. Every patient was sick enough to need to be there, and would have had real trouble surviving on the streets, which was the alternative for most patients.

My psychiatry rotation was the first time I saw cases of antisocial personality disorder—the people referred to as sociopaths in popular culture. They were true bullies, manipulating staff and beating up other patients, completely aware of what they were doing and the consequences of their actions. They showed no remorse and were truly dangerous. I got chills listening to a patient tell me in graphic detail how he struck his girlfriend in the face repeatedly with his gun, his expression calm and almost playful. It made me wonder what the right way to handle such patients is. If a person shows consistent and violent disregard for others and the law, and he is aware of the consequences of his actions, and he does not have delusions or hallucinations, perhaps he belongs in jail and not the hospital. More often the reverse is true though; it is a tragedy that in the U.S. there are more mentally ill patients in jail than in the hospital system.

Every week the ward had a community meeting, where the patients and all of the ward staff would come together and listen to the patients discuss things about the ward they wanted to change: snack times, movie nights, board games, music, food, etc. Most weeks we never made it past the first task though, which was for each person to state her name and where she was from. The patients would talk over each other, or all fall silent. One would start echoing whatever the person before him said and another would start rambling about how the water was unsafe to drink because it contained blood, while another laughed at the rest and called them crazy.

Speaking of crazy, the range and detail of delusions was truly incredible. One man put screws in his own head as part of a religious ritual, believing he was God. Another man was so disturbed by the color red that he had to walk backwards whenever he saw it. Another couldn’t sleep on his mattress or use blankets because he believed there were evil spirits in them, instead choosing to sleep on the frigid cement floor. One woman denied every day with remarkable conviction that she had been found face down in the train tracks before she was brought to the hospital. She would yell louder and louder, “IT WAS THE PLATFORM, NOT THE FUCKING TRACKS. I’M NOT SUPPOSED TO BE HERE.” The psychiatrists joked with each other that merely uttering the magic word—spaceship—would get you a one-way ticket to the locked unit.

It was fascinating to be in a facility where patients stayed for more than a few days. I got to know them, and saw many of their illnesses improve drastically with antipsychotic medications and the absence of methamphetamine. (It turns out meth is the drug of choice in LA; I spoke to over 50 patients on meth throughout the course of my rotation.) The biggest problem, though, was the profound lack of insight. In psychiatry, insight is a term used specifically to indicate the extent to which a patient understands her illness, as well as her need for therapy, hospitalization, or medication. I saw many patients get dramatically better, then talk on discharge day about how they were excited to get out of the hospital so that they could stop taking medication. “Good thing I’m finally getting out of here, because I’m not sick and I don’t need medication.”

Inevitably, these patients end up back in the psych ED and then back in the hospital for multiple days, again and again. If a person cycles through the system enough, the court can appoint a conservator, which is a proxy who will make the patient’s medical decisions. In a separate court ruling, the patient can be mandated to take medications. Many psychiatrists are frustrated with this system; they feel that it takes too long for patients to reach the point when they are forced to take medication, and by then many patients have fallen through the cracks, maybe overdosing on drugs or winding up in jail. Other countries are much quicker to force meds on patients, at the expense of patient autonomy. It’s a complicated issue.   

I watched electroconvulsive therapy, ECT. It has gotten a horrific reputation from portrayal in books and movies, and I know historically it was in fact horrific. Now though, it’s better. Patients are paralyzed, anesthetized, and sedated, and a 25-second seizure is induced with electrodes on the temples. It is one of the most effective treatments for treatment-resistant depression, psychosis, and mania. The case I observed was an older gentleman who voluntarily comes to clinic for ECT three times per week. He said that ECT is the only thing that has worked for his severe depression, and didn’t seem fazed by the procedure at all.

All in all, being in a locked psychiatric ward was unsettling and enlightening. The patients were very sick and trying to escape the hospital, yes, but they were treated with dignity and respect. At the end of the day, yes, the ward is an old, locked basement with no windows that is made of concrete. However, the psychiatrists, nurses, social workers, occupational therapists, and recreational therapists are all incredibly invested in the patients. The psychiatry residents are the kindest and most well-adjusted I have encountered so far. They seem so normal and happy compared to other types of residents.

I didn’t expect it, but psychiatry ended up being my favorite rotation so far. I loved it.

Don’t Get Punched: Three Weeks in the Psychiatric Emergency Department

“Ok, I’m going to yell for them to open the door. You ready? Don’t forget the number one rule.”

It was my first day in the psychiatric emergency department, and I was about to do my first patient interview. The patient had been brought in by the police and was waiting in the police bay, a small concrete room attached to the psych ED. I could hear the patient yelling incomprehensibly through the door. I was nervous. My resident had told me moments before about the number one rule of the psych ED: don’t get punched.

“Door!,” shouted my resident, and we were buzzed in.

And there she was—an unassuming, middle-aged woman wearing a cotton dress, her hair messy. She was looking down at her feet, her hands handcuffed behind her to the bench she was sitting on. She was the only one sitting, and surrounding her were the two police officers who brought her in, my resident, another medical student, and myself. I would be leading the interview while everyone else watched. After my introductory statements, she launched right into it.

“Well I didn’t do anything wrong. I was just yelling for someone to help me. The gangs have been following me for years, and they don’t let me get anything I want. I went into Starbucks to ask for some hot water for my cup noodles, and the clerk told me to get in line, but when I went to look back at the line, it was getting longer and longer and longer. The gangs knew, so they all started standing in line at the same time so that I would never get there. I was just yelling for help.”

“I see. That seems very frustrating,” I offered. “It says here on the police report that you were threatening to kill other people, other customers, in line. Is that true?”

She considered it. “Well the gangs don’t allow me to talk to anyone unless they torture me or the people first. That’s why I don’t have any friends. I can’t. The gangs kill them. That’s why everyone has shunned me. They’ve paralyzed my mouth. Look at my mouth. It used to be like yours but now it’s very small. The gangs punished me by shrinking my mouth. And my arms get shorter every day, and my throat is so long it stretches from my stomach to my neck now.”

“I’m sorry to hear that the gangs do all those things to you. That’s very concerning. Do you ever hear things that other people don’t hear?”

“I hear these noises all the time. Everyone in America is in a gang. So many loud clicks and clangs. That nurse over there is doing it right now, very rude. She’s smacking her gum at me to torture me.”

Later in the interview, I broached the ever-impossible topic of medications. “You know, for some people who are bothered by extra noises, medications can sometimes help. They might be able to help you feel less anxious that people are always after you.”

“Medications?” she asked indignantly. “I already told you, I don’t have any medical problems. I’m not sick. Are you even listening to me? I’m going to get tortured. Medications can’t make the gangs go away, I always get the opposite of what I want, EVERYONE IN AMERICA IS IN A GANG.”

And so my adventures in psychiatry began. When I had first arrived that morning, my attending pulled me aside for a safety briefing. He told me to take my stethoscope off from around my neck, and not to wear my lanyard either—both were strangling hazards. He said to always keep my distance—that I should stand at least 1.5 leg’s distance away from the patient at all times, and that I should always position myself between the patient and the door. Never turn your back on the patient, he said. Never give them possible weapons, including pens and packets of papers with staples in them. He explained to me that everything in the psych ED was designed to prevent self-injurious behavior. The door handles are levers that you push and pull, so that patients can’t hang themselves from them. The same goes for the handles on the sink and the controls on the shower.

One of our main jobs in the psych ED is to determine whether each patient needs to be hospitalized involuntarily. I learned that there are three legal reasons to start or continue someone on a psychiatric hold: danger to self, danger to others, or grave disability. Grave disability is the inability to utilize basic resources as a result of a mental illness, even if you are given said resources. For example, if you were to provide a patient with food, but she was unwilling to eat it because she believed it had been poisoned with meth (not a particularly uncommon belief, as it turns out), she could be deemed gravely disabled. Each day, every patient in the ED is reevaluated to see whether she continues to meet hold criteria. If a patient is able to state a reasonable plan for food and shelter, and can convince you that she does not plan to hurt herself or someone else, she can be discharged. If a patient needs a longer hospital stay in order to be stabilized on medications, she will be transferred to another psychiatric hospital after one or two days in the ED.

The psych ED is an eerie place because no matter the time of day or night, and no matter how much commotion or yelling, most patients are sleeping. The wing is set up into two large, open, connected rooms. Patients’ beds are lined up next to each other, almost touching one another. When patients get admitted, they are injected with a 5/2/50, which is a magical potion made of antipsychotic and sedative medications, capable of putting almost anyone to sleep. When they wake up many hours later, they are allowed to get up to use the restroom or shower, or to participate in group activities like coloring at specified times, but otherwise they are required to stay quietly in their beds. When they start yelling or singing at the top of their lungs or refusing to stay in bed, they are given another injection, and down they go. Particularly naughty patients are put in restraints or taken to the seclusion room, a tiny concrete room with a single bed.

It’s also eerie because just by looking at the room full of patients, you can tell that something isn’t right. Perhaps it’s the intensity of eye contact, or the way someone is furiously highlighting a magazine, or the way someone is wearing her hair, or the sight of someone putting his nose one centimeter from the wall, closing his eyes, and laughing hysterically. Or maybe it’s the fact that it’s all happening in one room. It just feels bizarre.

Mornings were always amusing. My attending would stroll around the beds and shout, to everyone at once, “Good morning! Please wake up! My name is Dr. Smith. I am your psychiatrist. How are you feeling today? Is anyone ready to go home? I’m looking for any patients who feel ready to go home. If you are ready to go, please tell me your name and where you plan on going, and then we can discuss your discharge.”

Those seem like simple enough questions to answer, but they are not. Everyone starts talking at once, as if completely unaware of the other people in the room, talking over each other about spaceships and the CIA and Obama and evil spirits. Perhaps one patient out of 20 would be able to calmly state her name and a reasonable plan of where she would go if her hold were discontinued.  

Interviews in the psych ED are not like other medical interviews. Firstly, they are not private at all. The patient’s bed is wheeled away from the wall, into the center of the room. Imagine the large room with 13 hospital beds along the perimeter, with one patient wheeled out into the center of the room. We wake the patient up by shaking the rails of her bed. “Hello! Good morning, Ms. Brown. How are you feeling today?”

“I’ve been drugged. When can I get out of here? I need to leave today,” she slurs.

“Well, that’s what we’re here to talk about. Do you still feel like killing your sister?”

Even though most patients aren’t listening, that question catches the attention of Ms. Brown’s two neighbors, who make uneasy faces at each other. Another patient is wearing a helmet, gnawing on his arm. Another is standing at the foot of his bed, without pants on, swinging his hips around in a circle, as if hula hooping. The interview continues for another minute before Ms. Brown starts shouting.

“YOU HAVE NO RIGHT TO KEEP ME HERE. I’VE BEEN DRUGGED. YESTERDAY YOU TRIED TO KILL ME, EVERYONE IS WATCHING, WHY DID YOU ERASE ME.”

Against our requests to stay seated, she gets up and storms over to the nursing station. She yells and pounds both fists on the plexiglass with all her might, yelling at the top of her lungs.

“THEY ARE TRYING TO KILL ME, I’M DYING, YOU TOOK IT OUT OF MY BRAIN, I’VE BEEN ERASED.”

A code gold is called, and everyone backs away from the patient. A few minutes later, the patient is held down and injected with a 5/2/50, then she goes back to sleep. We move on to interviewing the next patient.

 

All in all, I had a wonderful time. I find psychiatry fascinating. I am endlessly amused by the patients’ delusions, and the conviction with which they hold them. These are their realities. We speak to each other in English, but it is not actually a common language. Studying neuroscience as an undergraduate brought me no closer to understanding how the brain chooses these specific, bizarre realities for people. It’s impossible not to think about how severe mental illnesses like schizophrenia and bipolar disorder affect so many people—about 1% of people, and how next it could be me or someone I am close to who becomes convinced that her arms are getting just a bit shorter, day by day. 

A Week of Emergencies

I spent this last week working in the emergency room at Los Angeles County Hospital. It’s one of the busiest emergency departments in the country, seeing an average of 465 patients per day. The average patient wait time is 7 hours. I was nervous going into it—at the start of the week, I thought it 70% likely that emergency would end up being my specialty. I really wanted to love it. I worked five 12+ hour shifts in six days, one of which was at night.

Day 1 – North Wing: emergency department (ED) for patients with mostly internal complaints (abdominal pain, cancer, chest pain, stroke symptoms, cough, etc).

The emergency department has very few doors. Each wing has a couple central stations for doctors and nurses with desks and computers, and the patient areas line the perimeter of each wing. The rooms have curtains that don’t close all the way, so as you walk around you can peek into any room and see what’s going on.

I got introduced to the grind. In emergency, the patients never stop. Every time a room empties, the next time you look into it there’s a new patient in the bed, waiting for you. I followed my resident for the first few hours as she walked room to room, sitting down every once in a while to write imaging or prescription orders. Soon she gave me my own patients to see, and I’d come out to present my thoughts and findings to the attending. When my stomach was rumbling around 1:30 pm, I asked if I could grab lunch. She said, “Definitely. Just go eyeball your next patient around the curtain really quick and see if she looks like she’s stable. If she looks ok you can go eat.” That was the moment I realized that in emergency, you have to deal with this nagging feeling that no matter how fast you move, how many breaks you take or don’t take, your patients are still lined up and waiting for you.

In the evening, I walked through the resuscitation wing to discover a horrifying scene—a ten year old boy who had just been run over and dragged by a truck, his chest splayed open on the table. The senior surgery resident was doing internal cardiac massage. Someone exclaimed that the boy’s mother was coming into the ED. “Close the curtain! Quick, someone throw a blanket on his chest while we take him up to the OR so his mom doesn’t see.” They rushed him up to the operating room, but he didn’t make it.

Day 2 – overnight shift during Halloween weekend in the resuscitation (“resus”) department. This is the ED for critically injured or ill patients.

A couple women in costume arrived wrapped in bloody towels. They had been stabbed by a stranger in the face, arm, and back while celebrating Halloween at a bar. They had copious amounts of costume blood and real blood on themselves. 20 minutes later, their assailant was also wheeled into resus, agitated and strung out and with a swollen ankle. Ultrasound showed that one of the women had blood in the space around her lung, so the second year resident put a chest tube into the space, through her back.

A teenage boy came in, also the victim of a brutal stabbing. His bowels were protruding from his abdomen. He was rushed up to surgery.

I put a few staples in some guy’s head.

I got to sew up multiple stab wounds. I have a feeling if I were at another hospital, somebody besides a third year medical student would have sutured a facial laceration, but there I was. I did my best and I was proud of the way it looked.

Why are there so many stabbings?

In the early morning, I walked out of the hospital, exhausted. I looked down at the blood on my sleeve and couldn’t match it to a patient’s face. All I remember is that sometime in the night during a chaotic trauma team activation, I looked down at my arm as I was bracing someone’s neck and realized it was all bloody.

Day 3 – more resus

A yelling man gets wheeled in, strapped to the bed, a spit mask over his face. A spit mask is like a mosquito net that goes over your face, with an opaque sock-like part that covers your eyes. It keeps you from seeing anything, and prevents your defiant spit attacks from reaching anyone. I get assigned to one of his legs, and I do my best to hold it down while he gets jabbed with some meds for his agitation. Who knew I’d be using all my CrossFit strength to hold down patients every day. I chuckle as I remember one of the core CrossFit mottos: “Training for Life.”

They take his mask off, and he’s bucking his whole body, trying to get off the bed. “Let go of my leg, you fucking bitch. I swear when I get out of here I’m going to go get my gun and come back and kill you all.” Earlier this year I think this kind of thing would have bothered me, but it’s amazing how quickly you can just stop caring about it.

A very sick patient is quickly crashing and needs to be intubated. The attending yells to the second year resident, “How confident are you that you can get this intubation? You’re only going to have about 30 seconds.” The resident takes a deep breath and says he feels pretty confident. He nails it, and everyone in the room cheers and slaps him on the back.

I realize that these are the moments that emergency residents live for. They are total adrenaline junkies. They wait for these moments when they are asked whether they are willing to bet a patient’s life on their procedural skills. I will never be a person who craves this moment. I am not a thrill-seeker. Maybe this is not for me.

A mother comes in screaming, holding her 3 year old daughter to her chest. They lay the kid on the bed, a gaping stab wound extending halfway across her chest, and another across her back. The trauma team rushed the girl up to the OR, but she died. I will never forget the look on her mother’s face, standing there in the resus hallway, sobbing and shaking, her white T-shirt completely drenched in her daughter’s blood.

Day 4 – Jail ED

The jail ED is a bizarre place. There are a few patient areas—a row of private rooms with curtains for the sicker patients, a big room filled with 12 hospital beds, a row of chairs in the hallway, and a couple isolation cells with heavy metal doors. There are guards in uniform everywhere. There is pop music playing. All the patients are handcuffed to their hospital beds, or they are sitting in the hallway, handcuffed to the bench.

One patient had attempted suicide by taking a stash of meds he had been accumulating, day by day.

Another was brought in for a medical evaluation after filing a claim that officers had used physical force against him. He gave official videotaped testimony, showing his injuries to the camera, right there from his hospital bed. The guards were standing all around him, questioning and recording him.

In the afternoon, we could hear a patient coughing and yelling up a storm in the hallway. Pepper spray had been used on him, the report said. They took him to the isolation cell, and five of us went in there to physically subdue him in order to inject him with some meds. As soon as we entered the cell, I could taste the pepper. All five of us started coughing. We held our breaths as we restrained him so the nurse could give him a quick jab. A few seconds later when we tried to open the door, we realized that it was locked. Now we were the ones coughing on pepper spray fumes and banging on the cell door and yelling. It was probably only 20 seconds before we were let out by a guard. Oh, jail.

Day 5 – West Wing: ED for people with mostly arm, leg, back, eye, breast, and vaginal complaints. No one is actively dying.

I learned how to ultrasound an eyeball. Watched my intern use a power tool to cut a ring off of a guy’s swollen finger. Watched my resident cut open a guy’s infected toe to search for a piece of the stick that he had stepped on a month ago at the beach. Watched an ultrasound on a pregnant woman with abdominal pain who was concerned about her pregnancy. Regular emergency room stuff, basically.

Conclusions

I can’t believe how much I saw in five days. The patients kept coming and coming and coming. The emergency doctors know how to manage any condition acutely, and also do a lot of procedures every day. I have tremendous respect for the breadth of the specialty.

I feel anxious about my own impending residency, no matter which kind I decide to sign up for. These people work so hard every minute of the day for about 13 hours in a row, with maybe a 30 minute lunch break. The second year resident was telling me that on her ‘day off’ tomorrow she has four hours of lecture, then the next day she will start back in the hospital for eight days in a row. ED residents get 4 – 7 days off per month, and alternate every two weeks between day shifts and night shifts, for the duration of the four year residency. How on earth am I going to make it through four years of residency when I am so tired after one week?

Even though I found the residents to be wonderful teachers who are easy to get along with, and the content of emergency medicine to be absolutely fascinating, I’m not a thrill-seeker at heart. These residents not only thrive under pressure, it’s what gives them true joy. They are their happiest when they are doing critical procedures, sprinting through the hospital when an airway code is called, and actively stabilizing people who are on the edge. If I was 70% sure that this would be my specialty at the beginning of this week, I am now 55%.

But for now, I have a golden weekend (a golden weekend is when you have both Saturday and Sunday off). It feels sacred. I shall treasure it by just lying here perfectly still in my bed for the rest of the day.

Marry Me

“Do you think we have to wear rings to this thing?” Jono asked me.

“Ehh probably not, who knows,” I replied.

It was the morning of our wedding. We had convinced ourselves that our impending marriage was more of a formality than anything. Jono’s 90 day fiance visa had finally gotten him to America, and we had 90 days (but really more like 60 because of paperwork processing time) to tie the knot in exchange for his green card.

Getting married for a green card is a bit awkward. We didn’t feel like getting real married was appropriate—we had been dating for a year and a half, most of which was international long distance; we had never lived together, we didn’t know if Jono would even like America, neither of us fully buys the idea that you can promise somebody forever, and on and on. We joked that getting married despite the fact that neither of us wanted to was real proof of our love for each other.

We arrived at the East Los Angeles Courthouse three weeks after Jono landed at LAX. It was sweltering. We stood outside at the end of a long line of people for a few minutes, then a worker managing the line looked at my white sun dress and yelled over, “Are you getting married? Do you have an appointment? Ok, come this way.”

He led me, Jono, my mom, and Dan inside, to the bride holding room. The room had about four brides in white dresses, plus their partners and a few guests. Every fifteen minutes, a couple would be called into the next room to get married.

They called our names, and we were greeted by a familiar face—Maria, the woman who had helped us fill out our marriage license paperwork at the courthouse a week before. She explained that the person who usually performs the wedding ceremonies was gone for the day, so she’d be doing the honor. She unfolded a black nylon cape, just like the ones they use at the hairdresser, and slipped it over her T-shirt, jeans, and running shoes.

She led us into the next room. It was a windowless room with rows of plastic chairs, a wooden podium at the front, and an archway decorated with plastic flowers. She explained that the entire room was going to be ours for these 15 minutes, so we could feel free to move around and take photos. I told my mom to send a 10 second snapchat video during the ceremony.

Dan was walking around the room, taking photos, and my mom gestured at him to stop making such a ruckus. Maria interjected, “No no, it’s fine, let him take as many photos as he wants. Alexa and Jono can show these photos to their kids!”

Jono and I cracked up and rolled our eyes at each other.

“What?” Maria protested, “You don’t want kids? I swear, all the young people these days are just doing their own thing and not having kids. So, which one of you is it that doesn’t want kids, and why?”

We pushed through a few more minutes’ worth of ceremony, including some vows, then Maria gave us an opportunity to freestyle. “What else would you like to add, Alexa?”

“Well, Jono, I’m really glad you made it here and I’m very excited to be together.”

“And…?” Maria prompted. “How about ‘I love you’?”

“Oh yes, of course. I love you.” We were both trying so hard not to crack up.

After we were dismissed, Jono and I went out for a boba and some popcorn chicken from our favorite Chinese cafe. We blasted Taylor Swift’s Bad Blood on the radio and decided that it would be our wedding song.

In the evening we went to dinner with my mom and Dan and some close friends. They pooled together and bought us a gorgeous cold brew coffee dripping tower. We were touched.

It’s already been more than a year since that day. I feel happy and relieved. I was scared that Jono would move here and not like it, or that I’d be too busy with school, or that he wouldn’t be able to make friends, or that he wouldn’t be able to find a job, or that we would argue about money, or that I would end up wishing for more time alone, or that he would ruin my perfect bedtime track record, or that he would be sad that I wasn’t the carefree girl he met in Wellington during our Tinder love story. 

But it turns out that none of my fears came to life. We have so much fun together, every day. We laugh about our quirks and make fun of everyone else’s. Living together is the best. Indeed, Maria, I am very much in love with him.

I feel lucky that we were able to get Jono’s green card, and I acknowledge that it wouldn’t have been possible from a lower social status. If he were from China or India, the visa would have been significantly harder to get. If we didn’t have the thousands of dollars we had to spend on visa filing fees and our visa lawyer, as well as proof of more money in the bank, it wouldn’t have worked. If we weren’t as well-educated and willing to spend hours meticulously poring over complicated guides and forms, our application could have easily been denied. I maintain that getting Jono’s green card, in the end, was as difficult and painful as applying to medical school.

 
Marriage, like life, is what you make it. I finally started calling Jono my husband, after a year of introducing him as my boyfriend and responding to the skeptical raised eyebrows with a rushed, “oh yes well we did get married but not really.” It’s easier for him to be my husband. And these days it’s more and more natural, too.

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