"Haven't seen you in awhile Dr. Scott," Gwen the Death Clerk says as I approach.   Her Desk of Demise awaits with an unsigned Death Certificate for me to fill out.  

"I've been trying to cut down," I have to admit that I've been planning on saying that for months.  Chronic bedsores have more natural spontaneity than I have.

"Just write the cause of death on this post-it note and I'll fill in the rest," she says with a smile and a grey streak in her red bob cut.

(This reminded me of one of my favorite canceled TV shows, Dead Like Me.  Easily Mandy Patinkin's best work.)

Gwen makes it so easy to sign these things.  She's saving herself the trouble of calling us back again and again to fix a misspelling or extraneous mark or sloppy p or q.  More docs than you'd expect probably can't spell "hemorrhage" correctly.  

Secret:  All you officially need to know about the cause of death is a few words on a post-it note.  

I wasn't expecting this patient to die.  She looked good yesterday.  I guess being ninety-five had something to do with it.  

According to the midnight notes, the family decided to let her go during the CPR.  So probably no lawsuit.  I didn't actually do anything wrong, but from what I've seen, that isn't always a necessary ingredient to being sued. 

Secret:  Talking to the family honestly on a regular basis is better insurance than, well, malpractice insurance. 



My new patient is on the psych unit - the top floor as usual, birds eye views and break proof glass, just to make the suicidal jumpers even crazier.  The disturbed old lady tells me about the motorcycles she's hiding from the Hell's Angels, her bullwhips, and her blue leather biker suit.  Just your typical conversation with a retiree on the AARP mailing list.  

Blue leather is hot, but on Grandma Schizo here, it's a not. 

Secret:  I used to be intimidated by psychiatrists, worried that they were always trying to psycho-analyze whomever they talked to.  But in reality, only psychiatry students do that.  The professionals are tired enough of this shit as it is.

Top Secret:  Oh, and it's the middle button behind the clerk's desk that opens the electromagnetically sealed psych doors.  Good to know. 



InternetLady52, the wife of a patient, argues with me, "Well, I've been reading on the internet...."

My anti-eye-rolling mechanism thankfully works here.

"... On the internet, and it says most infections should be gone in ten days.  In my experience, it takes even less time."

Oh no!  Her "in my experience" line bypasses my anti-eye-rolling mechanism.  She's hacked my Fortress of Intellect defense.  I react.

I ask her to elaborate on her vast medical experience - it consists of bronchitis treated at home.  I try to explain how this is different from critically ill multi-drug resistant intra-abdominal infections in neutropenic cancer patients with bowel perforations.  Somehow I feel she would understand me better if I were posting on her forum du jour with a screen name like "ilovecats55."  

Secret:  The customer is not always right.

Top Secret:  While I can't imagine a doctor wishing ill on his own patient, no one ever said anything about annoying obstructive family members. 



My old grey-haired patient has new esophageal cancer.  He also has a mechanical heart valve that will clot off unless he is on blood thinners.  Cancer increases his risk of clotting.  Every time he's on blood thinners, his esophageal cancer makes him bleed - in bucketfuls.  Then we stop the blood thinners.  Then we have to start them again.  Cross your fingers and hope not to die. 

Secret:  They never teach you about all of these no-win Catch-22 situations in medical school.



"Code Pink, stairway C.  Code Pink, stairway C," the overhead speakers echo calmly.

Secret:  Code Pink, at this hospital at least, means a child or baby is out of his room when he shouldn't be.  They call out the nearest exits and the nurses cover them.  It's to prevent child abductions or wandering kids, but 99% of the time it's a parent who forgot to tell the nurse they were going for a stroll. 

Today was a little different though.

"Code pink, elevators B.  Code pink, stairway G.  Stairway F.  Stairway G.  Stairway F.  Code pink, stairway J.  Stairway K...."

It ended up being a little boy having too much fun playing tag with security.  I had to laugh imagining Sun Su giggling on the run. 

And no, the little boy wasn't tasered.



The heart map from the cath lab has big "100"s written all over it.

"All of his major heart vessels are completely occluded," the cardiologist tells me, "His entire heart is essentially functioning on one tiny graft.  We couldn't put any stents in."  Medical treatment only, i.e., good luck with that.   

Secret:  Cardiovascular tests are the only time 100% means you fail.  Or your circulatory system is about to, at least.  Might as well write a bunch of F's in red  magic marker over his chest. 



I ask the quadriplegic with the recent spinal cord bleed to move.  After two weeks of physical rehab, he is elated that he can now lift both arms and one leg without assistance.  Three out of four ain't bad.

Rule:  The more fucked up you are, the lower your standards for "good" news. 



"NO PIZZA.  NO 2-LITERS OF POP WITH MEALS.  FAMILY MAY NOT BRING SNACKS."

Those were actual orders I entered for a 500+ pounder once.  She couldn't stick to that "diet" for two days.  She lives in a nursing home now, because of her immobilizing obesity.  She's my age.  

Ever since I changed her diet orders, she tells people that I'm mean and I scare her now.  

Lesson:  Hell hath no fury like a morbidly obese lady denied her pizza and 2-liter lunch special.



I pass by a flyer on the oncology ward for a hospice lecture entitled, "No one dies alone."

I sit next to the dying man in his room, scribbling a couple of lines in the chart.  His breathing is shallower today.  His eyes are rolled back into his head.  Did he overhear InternetLady52 spouting her latest forum fallacies too?  I've stopped by every day for a week and I never see any family present.  The palliative care notes confirm this.

His death will not be a surprise.  What's surprising is how long he's been prolonging it in this state.

I feel his pulse out of habit.  Mine might be the last hand that holds his. 

"Probably expire in 12 to 24 hours," I write in the chart.  I'm actually relieved that family isn't here during the day.  I have nothing new to say to them.  

Secret:  ... and quite frankly, sitting there next to the dying man, writing my note, is the one stress-free quiet moment of my day.  So, thank you, dear sir.  May you stick around a while longer.