Crying Uncle

My first introduction to “cheech, counter-cheech” happened on the cardiology service. Late one night, I got my final admission: a 47 year-old tax attorney with chest pain. It was his 12^th hospitalization in three months and the nurses knew him well, referring to him as one of their “frequent fliers.” As I reviewed his chart, I became increasingly daunted: despite dozens of caths, stents, and surgeries, no one could identify the source of his pain, or cure it.

Still, the odds were with me. A “ROMI” admission (short for “rule out myocardial infarction”) is an intern’s best friend in the middle of the night. It’s quick, brainless, and almost always predictable. Most people with chest pain do not have the dreaded heart attack; most suffer from reflux, sore ribs, or another benign cause. And, like most of cardiology, there’s a tight protocol to follow: order an EKG and blood tests to see whether the heart has been injured, start a few predictable drugs, control the patient’s blood pressure, and monitor them closely overnight, repeating the EKG and labs every eight hours. Once the orders are in, the patient is launched on autopilot and it’s usually smooth sailing from there—unless the patient has pain. Then, all bets are off.

At 1:30 pm, I got a page: “your patient is complaining of 10/10 chest pain.”

I called back immediately. “Could you please check his vitals and an EKG? I’ll be there right away.”

There was silence on the other line. Then: “We all know his chest pain isn’t cardiac,” the nurse responded.

“We can’t say that yet,” I objected.

There was a long pause, and then: “Fine!”

I heard the nurse slam down the phone, and realized it was a strangely familiar moment. It was the same Fine! I used as an adolescent against my parents whenever they asked me to do something annoying.

Sure enough, the EKG was normal. I studied it much longer than usual, searching for any sign of an abnormality, half hoping to find one just to prove her wrong. Eventually, I gave in, returning the EKG to the nurse. I ordered morphine, waited until his pain resolved, and started to leave to answer another page.

“So I don’t have to check them anymore?” she yelled after me.

It was an awkward moment. Like the boy who cried wolf, this patient had exhausted the nurses during previous admissions, but I knew there was no guarantee he was safe.

“I’d like you to continue checking EKGs until he rules out,” I yelled back.

And then the warfare began. As soon as I left the floor, my pager began to ring. And ring. And ring. The first 20 pages were: “Your patient is complaining of 10/10 chest pain, please come.” It happened again and again and again. As the hours passed, the pages became increasingly creative: “Are you covering, pt X?;” “I noticed patient Y’s INR was low this morning, why is that?;” “Pt Z’s toe is hurting, would you please come examine it?;” “Pt A has a hemorrhoid, please come.” I frantically flipped through the sheets of sign-out my co-interns had written about their patients, trying to master their stories and make decisions. I was covering 30 patients in total, and suddenly it seemed as if every one of them had a problem.

I did my best to keep up, determined to answer every challenge she dished out. As I ran to answer one of the nurse’s multiple pages, I passed her in the hall. “I’m keeping you busy tonight, aren’t I?” she asked, smiling deviously.

In that moment, I got it: we were playing cheech, counter-cheech, and I had lost.

“Yes, you are,” I responded. And, just as suddenly as it had started, it stopped. The game was over. I had cried uncle, and she had won.