Thursday, November 29, 2007
Sid Schwab's recent post about his time at San Francisco General Hospital got me reminiscing about my experiences at Cook County Hospital in Chicago. The place is closed down now; they built a brand new building just behind it five years ago. But I spent my first two years (the grunt years) as a surgical resident in that old claptrap. Rush has an integrated residency program where residents spend half their time at the Mother Ship (Rush) and half at the County. The disparity in care was striking. At Rush, you could count on air conditioning, clean supplies, efficient phlebotomy teams, rapid OR turnovers, VIP suites, and everything else you expect when you enter a modern American hospital. At the County, you could count on ... well, nothing. You'd see hundreds of employees milling around in the halls and common areas and it wasn't clear exactly what it was any of them did. We drew all our own blood. We wheeled patients down to radiology ourselves. We set up all the necessary discharge arrangements. We called patients at home the night before surgery ourselves to make sure they remembered to come in. You couldn't take anything for granted. Not even vitals. Ninety percent of patients on the wards would coincidentally have the exact same vital signs; 120/80 RR20 HR80, as if some mysterious magnetic force was compelling all the patients to breath and circulate blood simultaneously. You always checked pulses on your own. It was a culture of incompetence and laziness. No one seemed to care. It was the County system. That's the way things were. You could either fight the system and go home every night maximally frustrated or you could say hell with it and just be a bad doctor.
My first month as a surgical resident was at the County. It was July in Chicago and the temperatures were running in the high nineties. I remember the moment I first set foot inside the side entrance. A wave of heavy, stifling, steamy air swamped me and almost took my breath away. It was sweltering hot. My button down was saturated by the time I had walked twenty paces. It was if I had been magically transported to some jungle hospital in the middle of Cambodia. My instructions were to meet on the sixth floor at Ward 60. There were two options to get there. You could go up six flights of stairs. Mind you, these were real flights; 15 steps each direction back and forth. You'd pass overweight/out of shape residents paused on a flight, half way up, sucking air. It seemed there was always a code blue in the ICU (7th floor) when I was downstairs in radiology or somewhere and I'd have to race all the way back upstairs, jump on the bed and start pumping some lifeless body with chest compressions. Half the time you needed to be hooked up to the EKG monitor as well. The other option was to stand in the lobby with about 35 other people and wait for one of the two functional elevators to arrive. The wait could stretch as long as 30 minutes. The elevator would arrive and another few minutes would elapse as 15 or twenty people filed out. Then you had to get past the elevator operator. Yes, that's right, an elevator operator. These folks would make an East German border guard proud with the way they scrutinized ID's on people trying to get on board. No ID, no entry. It didn't matter who you were or what you looked like. A white lab coat, stethoscope hanging out your pocket, gauze and scissors and patient lists and xrays, nothing mattered except your picture on a laminated piece of plastic. The chairman of the department of surgery was once denied entry because he had left his ID in his office. He ended up taking the stairs. The elevator operators basically rode up and down all day in this tiny, suffocatingly hot little cubicle. Such a mode of employment attracted some interesting characters. There was the Jesus lady, who dressed like a nun, but wasn't one, who would sing everything to you rather than talk, like you were trapped in some horrid musical. May jesus bless you, she'd sing as you squeezed your way off at your floor. She actually had a nice voice. There was Carl, the black power advocate who was always reading some tome by Malcolm X or one of the Black Panthers. All the African-American men and women were addressed as Brother So-and-so or Sister so-and-so. Have a great day My Black Sister, he would say as they exited. Short white doctors like me weren't really acknowledged, maybe a grunt if you were lucky. There was a younger guy who frightened us all because he never spoke, just rhythmically banged his forehead into the metal wall and muttered unintelligible things as we rose through the shaft. Most of them brought chairs or fans or something to read. I can't imagine doing what they did all day long.
Once on the Ward, organized chaos ensued. The other intern, who had been there for a week already, tried to orient me, but there was too much keep straight. Rounds were a blur of gauze and tape flying back and forth and rapid talking and orders barked out by the chief resident and furiously trying to scribble down notes on what was expected, what needed to be done on each patient. Then the seniors went off to the OR and the interns were left alone to do all the work. One of the biggest jobs was making sure everyone had their blood drawn for labs. The phlebotomy service was arguably the most worthless department in the hospital, although strong cases could be made for radiology and nursing. Unless the patient was a 20 year old male with ropes for veins there was basically no chance in hell that your patient was getting his/her CBC drawn. So I became a pretty darn good phlebotomist. The first day, though, it took me four hours to get everything drawn on the 15-20 patients on our service. The worst part was nighttime. The lab where the blood samples were processed was actually across the street in a separate building. After hours, there wasn't a transporter to take the vials there. You had to deliver them yourself, if you wanted results that night. Let's just say the area around Cook County isn't exactly a place you'd want your wife wandering around at dark. The other option was to use the underground tunnels that connected the buildings (the Catacombs) but no one ever did that because there was some rumor that "people" lived down there and would rape and kill you if they stumbled across you. The main entrance to the lab building was locked at night so you had to use the service entrance around back. This deposited you in the basement where the morgue was. Nothing like standing in the basement of some creepy old building waiting for the elevator to arrive surrounded by a bunch of corpses. The worst sign out was when vascular wanted you to check PTT values on patients getting a heparin drip. Sometimes you'd make three trips during the shift as you tried to titrate the the drip to therapeutic range.
Speaking of vascular, that was easily the worst rotation. For some reason they never put more than one intern on the service even though it was by far the busiest service in the hospital. Vascular patients are a different breed. The atherosclerosis that affects their femoral arteries also inevitably affects their coronaries and carotids. They're the highest risk patients in terms of cardiovascular morbidity. If you want to do elective surgery (fem-pop bypass) a huge cardiac clearance evaluation is essential. This means everyone gets a stress test and a carotid doppler ultrasound and medical and cardiology consults. Generally, in a real hospital, this can be done on an outpatient setting. Not for County patients. There's no system in place for that. Your only option was to bring everyone into the hospital and do the workup as inpatients. The patient list would be three or four pages long. You had post ops, pre ops, patients in the midst of a workup, and emergencies/traumas. The intern had to keep track of it all. Four people would need stress tests, three would have to go for ultrasound, another six were awaiting final clearance from the cardiology service and on and on. Of course it was my job to make sure the patients actually got to their specific testing areas. Transportation only happened if an intern found a gurney, wiped it off, put new sheets on, and loaded the patient onto said gurney himself. The you had to push patient/gurney complex and any IV poles solo down the hall, into the elevator, through various corridors until you got to the stress test area. It was exhausting. Then you'd race back upstairs, load the next patient, draw more blood, change a dressing, fill out Byzantine discharge forms (called CAPS), pre-op the next day's surgery patients, write orders, follow up on tests already done. By evening rounds (Flip, we called it), everything was expected to be done. Another garagantuan list of chores would be piled on by the chief resident at Flip, and you'd spend another two or three hours taking care of business. Then you either went home (usually after 8pm) or starting taking call (and cross covering multiple other services). I lived in a tiny studio in Lincoln Park that first year without air conditoning. The only window opened up on a brick wall. I'd get home and collapse in a heap on the couch, eventually pass out with a half eaten pan of mac and cheese on the floor beside me. The alarm would go off at 4am and I'd start the whole thing over again. There were no days off. No one complimented you or held your hand. The expectation was that you'd be a professional and perform. The senior residents depended on you, but more importantly, the patients depended on your efforts. You learned how to be a doctor on that service. You took care of pneumonias and diabetes. You managed acute MI's. A sense of ownership developed; these were my patients. I was responsible for them. The recent changes in residency programs involving work hour reform makes it hard to inculcate such an ethic. Interns now go home at 7am post call no matter what. There's a disconnect between the theoretical benefits of reducing a resident's sleep deprivation and building the sort of doctor that society deserves. The lessons I learned at the County are with me even now. I practice medicine the way I learned it then. Anyway, this post is starting to get too long. Future posts on this subject almost certainly will be forthcoming.....