… right then.  If that’s not my cue to call it quits for a day, I don’t know what is.

But mostly, it just reminds me of the year I spent as a waitress at a 24-hour diner in The Middle of Nowhere, America.

Luckily, most of the experiences and skills have transferred to the ED.  For example:

1. Dealing with drunk people making poor decisions.  Though I’ll admit, the drunks at the diners were mostly making the kind of poor decisions that could be worked off with a few hours at the gym.

The ED drunks’ poor decisions are a bit more..excessive.

2.  Everyone is always pissed.  The servers are pissed, the customers who’ve been waiting forever are pissed – and even the customers who actually got the right meal at the right time are pissed because of some trivial crap like how the vegetables on their plate are touching their mashed potatoes, or how they can’t have their cell phone with them in the MRI.

(Granted, if the nurses or cooks are pissed, it’s because I did something either incredibly unhelpful or stupid, so they have a right.  But it still sucks.)

3.  You’re running around trying to remember 15 things at once.  Which is actually really satisfying and an awesome way to make the time pass quickly – but it does tend to mean that – statistically speaking – something’s bound to slip your mind every other shift or so.

… I much preferred the worst-case scenario being “Forgetting to refill the diet pepsi at Table 15″ to “Forgetting to check the results of the head CT in room 4.”

4.  People are crazy.  And by “crazy”, I don’t mean merely psychotic.  The psychotic people are GREAT.  The real crazies the people who just have this warped view of the world where they’re convinced their bloody knuckles deserve to be seen before the guy with crushing chest pain, or that they should be able to substitute the side of coleslaw for “a side of ‘steak’” without paying any extra.

I’ll take the mentally ill over the crazies, every time.

5.  The cynicism always wins.  I don’t know if the atmosphere actually changes you, or if it just weeds you out if you don’t meet specifications – but there are plenty of optimistic and happy new nurses, medical students, and diner waitresses out there.

But there is nobody on earth more crotchety or intimidating than a career-long ED physician, nurse, or waitress.

Nobody.

Yes, NBME – you created a uniformly hated test but kept it mandatory despite the fact that it has a 97% initial pass rate and – even worse – a retake pass rate of 94%  - and never made a cent.

… dude.

That is some Grade A nonsense right there.

• A 3rd year resident who “just snapped” one day.  In the middle of a busy work day, she took out every single patient chart and simply wrote an order to “D/C home”.  3 hours s/p CABG?  D/C home.  Hematocrit of 4?  D/C home.  Still on a ventilator?  D/C home, damnit.

• A surgical intern who left a case, started yelling nonsensically in a hallway and then locked himself in the team room.  They had to call security to make sure he was still alive, but when they unlocked the door, he was just sitting there, chilling.  (He allegedly was leaning back in a chair and drinking a soda, but I don’t know if I can buy that part – no matter how awesome the mental image is.)

• A patient who sent her kids off to school, packed her husband a lunch for work, kissed him goodbye, and got in a car and drove to a totally random city 5 hours away with no plan.  Found lying on a park bench, memory totally intact, tox screen negative.

• One of my classmates, before our first anatomy exam.  (I don’t feel like I even need to supply details because it’s surprisingly easy for most medical people to imagine the kind of crazy things someone might do in this situation.)

The point is, nervous breakdowns are a thing.  People who are under a lot of stress occasionally “just lose it” and act like a crazy person, and can never properly pinpiont why afterwards.  And these are people without histories of psychosis – and they usually never have another episode.

And it would be sincerely, 100% helpful to me and probably the medical profession at large if I could use it as a diagnosis.

I’m full of fun facts like that these days.  It’s no wonder the party don’t start ’til I walk in.  *tightens scarf and adjusts giant sunglasses*

2.   My OB-GYN evaluation is in.  And it was incredibly confusing and sorely disappointing – until I checked notes with my rotation partner.  Turns out an attending got our names confused and we both had several specific scenarios and criticisms that were meant for the other student.

TREMENDOUS. That's tremendous.

That’s… a fairly major mistake.  I was incredibly depressed when I thought the attendings graded me harshly for “not showing much interest in OB”, because I loved it, damnit.  I feel so much better knowing they actually realized I loved it, graded me fairly, and just thought I needed to work on “following up with patients”.

(Plus, on the first evaluation, in addition to mentioning shit that didn’t happen, they praised my surgical skills.)

… Hopefully by the end of 3rd year, when we’re officially graded on our rotations, the OB attendings will have worked out which med student is which.

I don’t ask for much.

3.  Med Student ER Stories:

Attending:  What’s the primary contraindication to performing a rectal exam?
Student:  Being an attending.
Attending: … Huh.  True.  Full points.

2.  Don’t punch trees.

3.  Don’t punch walls.  You’ll still be just as angry as you were before, except now you’ll have a hole in the wall, your hand, and your wallet.

4.  No, seriously, don’t punch trees.  It does not care that it’s in your way.  It’s not moving.

5.  Don’t punch faces.  And if you absolutely must, at least don’t punch them with your own fragile hand.

… The “stop hitting yourself” game is probably still fair play, though.

5.  Don’t joke about punching your wife.  At this point in the day, no one will find it very funny.

6.  Especially not your wife.  

7.  Married hand surgeons don’t wear rings.  Even when they’re not working.  The general consensus among them seems to be “hand injury + ring = congratulations, you no longer have a ring finger.”

(Though a more cynical person might come up for some alternate explanations for that one – possibly ending with the phrase “congratulations, you no longer have a wife.“)

Best quote: “… Gives hockey fans and sports lovers everywhere a reason to stamp their feet and whistle–at a rare display of eloquence and common sense.“

Seriously though, it rocks, and you should bookmark the hell out of it.  (I’m not ashamed to admit I’m a 25 year old who freaking loves tumblr – in general – and this one especially.  Haters to the left.)

In other news, my pediatrics shelf exam is in less than 2 weeks, and I’m starting to stress a little.  Peds is much worse than internal medicine – you have to know basically all of internal medicine PLUS all of the super rare two-dudes-last-names-hyphenated-together syndromes.

For example:  embryology is the bane of my existence.  Trying to memorize which congenital heart defects are associated with which glycogen storage disorder is like playing the world’s most sadistic game of Memory.

And sure, normally I’d just flashcard them obsessively 6 hours before the test and be done with it – but I’m trying to actually learn this stuff for the long-term, because I’ve actually come to the shocking conclusion that I really like pediatrics.  Not outpatient (oh god, not well-child checks) – but I like sick kids.  They bounce back.  They’re interesting.  They tend to like my awesome corny jokes.

I keep hearing people say sick kids are too depressing, but I’ve got to be honest – adult medicine is more depressing to me.  Seeing people every day who regret life choices they can never, ever take back – whether it’s smoking and developing the COPD that’s controlling and ruining their life, or not controlling their diabetes when they were younger and ending up with multiple amputations…  or even just telling you about the marriage that lasted 50 years too long and led to a life full of regret?  It weighs on you.

It’s all deeply sad.  And there’s absolutely nothing you can do to change any of it.

… Maybe it just strikes a nerve in me.

I feel like there’s more you can do for kids.  .

On the other hand, I could easily be wrong.  It could also just be that I’m de-sensitized to garden-variety pediatric sadness.  I grew up with a brother who has mental retardation and multiple developmental disabilities, turned out to have a rare cancer that sent him in and out of the ICU over the course of 3 years, and had several of his best friends from Special Olympics die before their 20th birthdays.

… so.. there’s that.

It doesn’t feel depressing to me. I have no idea what it’s like to have a brother who isn’t developmentally disabled, who didn’t develop cancer, and whose friends are all still alive.  Sure, that doesn’t make it not sad, but it does mean I really feel a bond with the families of pediatric patients that I don’t necessarily feel with Internal Medicine.

Hashtag: THINGS TO THINK ABOUT.

But first comes the shelf exam.

Today I fell asleep:

• At least 10 times
• While sitting straight up in a chair
• Listening to a powerpoint lecture my preceptor was giving to me and only me
• While only a couple feet away from him.

I felt guilty, but I couldn’t stop.  I was falling asleep in microbursts every 30 seconds – literally nodding my head, saying “Uh-huh, yes, okay” and then briefly losing consciousness.

I’d vaguely become aware of his voice, and I’d start instinctively nodding while I mustered up the strenuous levels of muscle-power needed to open my eyes and keep them open for at least 10 seconds.

… Unfortunately, all that effort to keep the eyes open left no musculoskeletal power left for focusing my eyes.  So I kept losing focus and doing the half-lidded, eyes-halfway-rolled-back-in-the-head thing before I’d jerk my eyes back to where they were supposed to be (which I’m pretty sure just made me look like I was having a seizure).

I swear to god I fell asleep with my eyes open at one point – because instead of spacing out for 2 seconds with my eyes closed, I just spaced out on what he was saying - and then the outline of his body gradually un-fuzzied itself.

(… The terrible thing was, it wasn’t even like I pulled an all-nighter last night.  I have no excuse.  I had a solid 6 hours of sleep - so I don’t even know, guys.  No clue.)

“Horrifying” would be a good word for my guilt level.  The only thing holding my body and mind together was the fact that I knew I had a 2 hour break between 4pm and 6pm, and it was going to be a nap, goddamnit.  I just needed to make it to 4pm.

TIME JUST NEEDED TO MOVE FASTER.

But, no such luck.  My hormones had bravely gathered their forces and successfully overcompensated for my sleepiness (Activate: Hyper Overdrive!), so by the time I actually got out of work and was crawling into bed, my mind was actually totally awake.

(In fact, after that powerpoint lecture I somehow managed to navigate my way through a new patient intake H&P.  And my preceptor even gave me a hypothetical “Honors” on it – albeit probably because I managed to avoid collapsing on the patient.)

By the time I got home and crawled into bed, I couldn’t actually fall asleep – but my muscles were literally too tired to move.  Damn near unresponsive.  So I was just lying there on my bed like a lump for at least an hour, totally awake and dead inside.

Two hours later I realized my body was aching all over, I had a headache, my alarm was ringing (possibly causing said headache), and I was – inexplicably - absolutely drenched in sweat, and it was 6pm, so I had to run out the door to attend 3 hours of mandatory Pediatrics lectures.

… I’m half-convinced I didn’t even fall asleep, because it sure didn’t feel like I did.  It felt like I  just passed out.

And hit a rock.

And died.

Med school!  *jazz hands*

Me:  *searches far and wide for new preceptor*  

Nurse:  *eyes me suspiciously*

Me:  Excuse me, is Dr. Preceptor is around?

Nurse:  Oh no.  His first patient cancelled, so clinic hasn’t started yet.

Me:  Okay, thanks – I’ll just wait for him, then.

13:15

Me: … Er, excuse me – is Dr. Preceptor in yet, or -

Nurse:  NOPE.

Me: … kay.

13:45

Me: … I’ll just be.. in here.  The room behind the nurse’s station.  Studying.  You know, if Dr. Preceptor shows up?

Nurse:  Okay.

14:15

Dr. McOtherguy:  Hey!  Where’s Dr. Preceptor?

Nurse:  Oh, he’s in an emergency surgery, so I cancelled his clinic.

Me: …

… And then I decided that we medical students – as a group – need an  Official Anthem of Outpatient Medicine, and it is this: