Did They Really Learn More?

I call ‘em ‘When I was…’ stories.

Any time an old-school doc starts a sentence with ‘When I was….’ they quickly see I have totally lost interest. Invariably, s/he is going to wax reminiscent about the days when docs worked 36 hour shifts routinely. And, frankly, those stories – unlike those ‘walked to school uphill both ways’ stories – are true. 36 hours was TYPICAL and happened ever 3rd or 4th night. It really was brutal and I have to wonder what kind of care those doctors provided. But I still don’t care. That was then. Scorn me if you want, but that ain’t now.

I’m not the only one who scorns anyone who works that much. As most of you know, there are work hour regulations in place these days. Some residency programs still mess with those hours and have ways of making their residents work more than what the regulation permits. But for the most part, a good majority of residencies are very serious about being compliant…and they are getting closer and closer to compliance with the rules.

What are the rules? Can’t work more than 80 hours in 1 week. Yeah. DOUBLE the federal qualification of full-time. And for the same salary – around 40k/yr – that most entry-level 40hr/week jobs pay for your average college educated graduate. It’s ok if a given week exceeds 80 hrs, however, it has to balance out over the course of 2-4 weeks. So, we can still put in weeks of 100 hours and nobody’s going to get in trouble. Residents also can’t be on for more than 30 hours straight at a time – although they can do paperwork beyond that (just not patient care). And they have to have at least 10 hours off between shifts.

So, things are better. Those rules may seem pretty lax, but they’re WORLDS better than it used to be. Even so, I HATE the ‘When I was…’ stories. Every older doc has them. They wear their workaholism around like a badge of honor. Honor…by the way. That IS how this whole system sustained itself, in case you didn’t know. There was a deep sense of accomplishment to stay up for days and days and still be in control of everything. Residents competed – tacitly or occasionally in the open – to see who was tougher. When they were finished with their training programs, they each felt as though they had endured a trial of fire. Each of them were willed with a fierce pride that you see in few other places besides special ops and Marines Corps.

For years, do you know what the excuse was to continue the inhumane training programs? “It’s the way it was for me.” Honestly, that was the first answer of most doctors. Stupid, I think. Reminds me of the Roast Story: Daughter sees her mom cutting the end off of a roast before she puts it in a pan and cooks it. When she asks her mom why she does this, the mother replies, “I don’t know. My mom always did that. It’s just how we prepare roasts.” Later the daughter calls her grandmother and gets the same answer. So the girl calls her great-great-grandmother and asks the same question. Great-grannie’s answer, “Pan was too short.”

One other reason to justify looong work shifts is that many typical disease processes traject along an arc that lasts, coincidentally, about 36 hours. From the time of admission, a person is either stable, discharged, discharged or dead within about the first 36 hours. So, a shift that long provides excellent learning opportunities.

That’s another stupid one, I say, unless they line up all the sick people who will need to come into the hospital and don’t let them in until the oncoming resident can evaluate them. Then we can tell them, “Good thing you’re getting in right when the resident starts his shift! By the time he leaves tomorrow – too tired to know his name – you’ll either be going home, still sitting here and sick…or just completely dead. Have fun! Thanks for waiting.

I guess I’ll never know if the docs of old were smarter at my stage of training than I am. Well, I’m sure some of them were smarter in 5th grade than I am now. But you get my meaning. I do know that I admitted a patient this past Saturday at about 3pm. Since I was on call that whole night, I saw her again the following morning. In days past, I might have hung around all day Sunday too before I went home. But since this is a new day, my shift was only 26 hours of sleeplessness, and I was out of the hospital by 10 am on Sunday. Nice. But this patient I admitted had overdosed on SSRI’s, something I’d never seen. The result can be catastrophic. Called serotonin syndrome. And I don’t know if this happened to her or not. She was looking pretty good when I left.

But then again, as I read about serotonin syndrome last night, I was intrigued to see that the symptoms of this life-threatening syndrome frequently don’t show up for…oh, about 34-38 hours.

Touche, Old Guard.

If I’m Not Depressed, Why Am I Sleepy?

I have a pt. who is taking more than one anti-depressant. At one point, she was so depressed she could barely come to the office to ask for more help. I think if she could have arranged for tube feedings, she would have just laid in bed for the rest of her life.

Depression is a crazy thing. You can have just gotten married, have a good job, be generally healthy, have some friends – like my patient – but still be totally depressed. You’d think that all this stuff would protect a person from major depression, but it doesn’t. The best definition I’ve ever heard about depression is “socially-acceptable rage”. Depression is often angst about the way things are. It’s about perception of what is. It is a habitual analysis of reality that regularly leads to unhappy conclusions. You can have a lot of cool things in life and still think about life in dark themes.

One of the bright spots in depression treatment is…depression treatment. Didn’t use to have much for the problem at all except shocking the hapless patient’s brain (shock therapy is still used, actually, but rarely). Often it is said that medicine created the “magic bullet” when antibiotics were invented but haven’t thought up something as brilliant since then. In truth, antidepression meds are are the magic bullets of our time. They really have changed lives…arguably as well as cardiac catheterization or colonoscopies or CT scans. Just one little pill, and life gets better.

There are side-effects, most notably, antidepressants mess with sexual function. I even saw one guy who had to have a penile amputation because he had antidepressant-caused priapism (constant erection) and he didn’t get treatment for it for too long. The irony of this – the guy was trying to be happier in life, mind you – is hard to miss. But aside for these horror stories, antidepressants are pretty great.

Another problem for some people, is how antidepressants affect the “sleep center” of the brain. This is different from the short-lived insomnia that most people have when just starting out on anti-depression meds. When we sleep, we need to essentially phase through a number of different stages. Each stage should happen more than once. Sleep physiologists identify each stage by noting the different shapes of brain waves that show up on an EEG machine. Often, for some reason we don’t understand, people on antidepressants don’t create “delta” waves when they sleep. So, they go to bed tired, sleep for 10 hours, and wake up wondering how long until they can go back to sleep. They fall asleep on their way to work, in the morning after a solid night’s sleep.

I remember reading lots of Greek myths as a child, and one of the most vexing was the story of Sisyphus. He was this guy who was punished by Le Gods for being a punk (and he was a punk, so don’t feel sorry for him). Ol’ Sis was condemned to roll a huge boulder up a steep mountain, only to see it roll back down to the bottom every time he was just about to the top (note picture above: guy with HUGE thighs holding uncomfortable-sized boulder). Being a myth from The Odyessy, of couse he was condemned to do this for ALL ETERNITY. No breaks. No lunch. No smoking. No benefits, vacation, vision or dental.

Often, trying to sleep while on antidepressants is a little like life might be for Sisyphus. You get all this sleep, but you never get rest. Day after day, you sleep for 8-10, maybe 12 hours, and wake up feeling like you haven’t slept in months. Strangely, you don’t feel depressed at all. Things are good. The world is relatively beautiful…if you could just see it through your drooping eyelids.

There IS an answer. No, not colloidal minerals (apologies to the lady who left the commercial disguised as a comment on one of these posts – yur blocked). Not blue-green algae. Well, maybe that stuff works. But in the M.D. world, we have a fix too…yet another antidepressant! But it’s an older class that we don’t use to treat depression anymore. Called the tricyclics, one of the main reasons we quit using them is because, would you believe, they made people so daaang tired. Why? Well, they seem to have a strong effect of the sleep center of the brain, and seem to cause delta wave formation in many of those same brains.

So, my patient is experiementing with these right now. She gave me permission to talk about her here. I don’t know if 3cyclics will help her or not. She may have the “Sisyphean” Task of finding a way to sleep and not be depressed. But I’m hoping she will soon come larking back into my office wondering why I don’t do triathlons and opera like she does these days. My reply, assuredly, will be that I’m just too tired.

New Vignette

I’ve written another entry for the “Vignettes” tab. These vignettes are short, humorous (well, you be the judge) stories about my life in family medicine residency.

Numb Lips

I always know I’m tired when my lips get numb. It’s easy to work for so many hours that I forget when I started, which leads to forgetting at what point I should be hungry, or go to the bathroom, or drink some water. But the numb lips thing tips me off with a pleasing rush of certainty, “I am now – surely – tired.”

While it’s nice to know something like this so clearly – it explains the stumbling, the gritty feeling in my eyes, the strange metallic taste in my mouth – it often doesn’t matter. Worse, it sometimes just gets in the way. It isn’t until after a day and night on call that we’re required to make oral presentations of patients and what we did for them. Sadly, it is after call that we are, obviously, least sharp and, as is often the case for me, when my lips are numb.

“Welcommmmm, poo murning preport.” I’ll say, my thick mind wandering back to those glorious days as a kid in the Colorado snow staring with fascination at my nearly frozen fingers and watching how slowly they moved on command. I work my lips a bit and try again. “Thurvvv been about sevun-eighteen two-thritty admushings since we’ve been on shift.”

To make matters worse, usually coupled with my numb lips is a sudden feeling that some language I don’t know – let’s just call it Gerbrewfrenshish – is now my primary language. English has inexplicably become my 4th language and, despite all those ESL classes, remains tricky and annoyingly liberal with the observance of it’s own rules.

Tell ‘em about the UTI lady, quick! Everyone’s waiting! You’re supposed to be running morning report! All I need to think of is a good couple of intro words – in English – like “Our first admission was…”. But my fumbling mind, connected to my numb lips, manages to speak in tongues comprehensible to only the most charismatic, “Haciendaherr facshalom.”

My R-1, who somehow got sleep last night, looking at the pained and quizzical look on the face of our faculty attending and says, “He’s communicating good morning and telling you about our first admission.”

Will all the alacrity I can muster, acting firm and commanding but inwardly lying prostrate before my R-1, I manage to smear out the words, “Ghoood, Paahl. Why don’t eeuw prsant theshe caseis?” He looks at me with a slight smile and smoothly takes over my job. No one could be happier than me, slumped in my chair, trying to remember the pronunciation of that word English-speakers use to express a feelings of warmth and abject adoration.

Soon, my R-1 skillfully brings morning report to a close and the doctors start heading off in different directions. I yes! That’s IT! I’ve got it manage to catch the eye of my R-1.

“Tttthhhhanks, Paul.”

“Anytime.” He laughs. “Go home and get some sleep.”