25 August 2013



I look idly at the hand grasping the laundry basket. “That’s a beautiful vein,” I think. “Someone would be lucky to get to slip an IV into that.” And like everything that gets accidentally carried back from the hospital—venipuncture kits, 4cm x 4cm gauze (think: measures I am learning), alcohol swabs, tape, fecal occult blood cards and guiac solution, gloves—I have the materials to do it. But I’m not the one I would need practice on. It’s the patients with scarred veins  (drugs, fistulas, too many hospital visits) or overloaded with fluid—the “vasculopaths”— that take skill. A patient with good veins is a good patient. Ones that don’t roll or slip away from you. Ones that leap to attention under tourniquets and alcohol.

We are vampires not only at night.

It’s using your hands (not trusting your head), taking ownership of each step of the process, delegating tasks (most) that don’t take a medical degree to yourself.
I’ve caught myself thinking “I wish I had a med student for this.” To get patients’ weights while standing (find the heavy scale, wheel and weave it through the hallway, support the hesitant frame). To get orthostatic vital signs (vital. Life. Here, to check the difference in how fast and how hard the heart beats, how much the veins and arteries contract and relax, when equilibrating between lying down and standing up). It takes minutes. Five. Or more. I picture third year of med school, two hours per patients, an afternoon to sit and talk…

Or carry blood.

It’s the beginning and the end of the day’s menial tasks. I learned to relish the quiet moments, years ago—coffee and morning labs. Keeping track of numbers. Comforting shapes (mean: which value is this. Which electrolyte, element, atom. Which part of your blood) scattered across the paper—it used to be the pride, the insider-ness of using them and starting to understand what they meant. Now, it’s the morning labs. And in the evening, it’s entering orders for the next day’s labs. (What do I need to know about the inside of you. What am I following). It’s still trying to be careful and responsible with language, when entering notes into the permanent medical record. For example: patient refused the dose.  Or, patient declined the dose. Patient refused the exam. Or, patient declined to participate in the exam. Participate in the exam. Or follow commands. Or not.

For so much of the day, it’s numbers. Numbers correlated with symptoms. Refusing the medication lactulose, for example, means Ms. A’s liver disease will cloud her mind. I picture a shroud of permanent damage (cirrhosis. Hepatic encephalopathy). Septic flood waters rising into the brain. We have a medication for that. And we’ll titrate it, we’ll base our decisions upon how many bowel movements recorded in a day. The septic systems pulled down from the brain, down, down, and out. It’s one of the most important medications. It’s critical.

“Patient refused the dose.” And sometimes, this is followed by documentation of “Dr—notified.” And sometimes not.
The patient’s mental status is a temporarily soluble problem. There are so few problems we can fix. This one. We can help. But she refuses.
Because a 57 year old woman who brought up her (I found out today) 28-year-old severely autistic niece, who used to draw caricatures of tourists on the street, whose house slippers are red, does not actually want to soil herself and the bed (how many do I want) four times per day. When I read the “1”, “2” in the morning I’m disappointed. So I increase the dosage. It’s not working. It’s not working. And she can barely move to get up, and when she does, it’s certainly not swift enough for something this powerful.

In the middle of the day, I know this. At the end of the day, I finish my progress notes. “Ms A was cloudy today because she declined two doses.” But, I think, upbeat, she has a PICC line (peripherally inserted central catheter). It’s an IV inserted through the arm into the heart. It’s a longer-term and deeper-inserted IV, which is so easy to use and consistently get abundant blood flow for labs that it’s equivalent to a sigh of relief anytime I realize I need more information about my patients’ insides. Patients with PICCs are the sicker ones, whomever will need that many blood draws and that many days, weeks of IV medications.

I want blood from a sick patient. These labs will be quick. I’ll draw them myself. This is the one easy moment of the day.

I sit down, on the bed or in a chair pulled close, with the labeled, carefully colored-tubes beside me, and biohazard bag, two syringes full of sterile saline, gauze, alcohol swabs, and vacutainer adaptor. And gloves. For the one minute I’m here, knowing that I’m not causing any pain or discomfort, and doing something almost effortless and overflowing with potential, I am completely relaxed. I am accomplishing something – to check off – necessary.

And my patient and I can talk.

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