Toms Story

Published: Sunday, December 20, 1998

St. Paul Pioneer Press

RESIDENTS DO HARD TIME IN TRAINING

MARATHON SHIFT A FORCED MARCH ALL DOCTORS ENDURE

LESLIE BROOKS SUZUKAMO STAFF WRITER

8 a.m., 8-South, General Medicine, Regions Hospital, St. Paul.

Dr. Tom Scheider says we're going zebra hunting today.

Most patients on the floor are still asleep. But Scheider started rounds on his patients an hour ago. There's a faint touch of excitement in the 26-year-old doctor's voice.

``I just saw an interesting lady,'' Scheider says. She's had right upper quad pain for the past year-and-a-half. No one knows the cause. She's had a million-dollar workup. Now we're starting to chase zebras.''

``Zebra'' is medical slang for a patient with a mysterious ailment. It comes from an old medical school saying: ``If you hear hoofbeats, think horses. There are many horses but few zebras.''

It means, don't overlook the obvious or commonplace when you diagnose a patient.

But Scheider thinks he has a true zebra, a bona fide mystery. The patient, a 38-year-old Rice Lake, Wis., woman, was airlifted from the Amery Regional Medical Center in Wisconsin the previous day after she collapsed with excruciating pain.

Her local doctor and hospital were stumped. So they sent her to Regions, a bigger and better-equipped facility and, coincidentally, a teaching hospital.

She has been assigned to Scheider, a first-year resident physician in family medicine, commonly called an intern.

Interns are new doctors. They have graduated from medical school and earned the right to wear the long white lab coat of the doctor, but they still need a few more years of ``residency'' or post-graduate training in a specialty.

Scheider's specialty is the broadest: family medicine. It requires knowledge of nearly every other medical specialty, and the training doctors, called ``residents'' in a hospital, rotate through one- and two-month training stints in nearly every hospital department.

Medical schools and the managed-care industry have pushed for more primary-care physicians such as family practice doctors to strengthen the backbone of the medical system. They want half of the nation's doctors to be in primary care, handling 90 percent of what ails us.

At current graduation rates, however, it will take another 40 years for the U.S. doctor supply to achieve that balance, medical experts estimate. Most doctors still work in higher-paid but more narrowly focused specialties.

But when he graduates from his three-year residency in the year 2000, Scheider and the rest of his residency class at Regions will join the growing corps of family practice doctors entering the market.

The core of their training is conducted in the hospital, a medical apprenticeship closely supervised by older, more experienced doctors.

The hospital experience, used for the past 100 years to train new doctors, is valued because it boosts the learning curve of new doctors, exposing them to a far greater volume and variety of ailments than they could get in a private practice.

But hospital duty is a trial by fire that tests the limits of their knowledge, endurance and, occasionally, humanity.

Scheider today is in the middle of a one-month rotation in one of the more demanding specialties, internal medicine -- the treatment of adults. He is on-call, and will stay overnight at the hospital for a grueling 36-hour-plus shift when all the other doctors in internal medicine go home.

His mission is to admit new patients overnight until he's relieved, treat the patients he already has from his day shift and either discharge them or refer them to specialists or another resident before he goes home tomorrow evening.

Most of the doctoring is routine. No case is routine, though.

One of his first patients, 31-year-old Raelene Roper, was admitted after she suffered a severe asthma attack. She forgot to refill her prescription because she was in the middle of moving from the East Side into a new house in

Minneapolis.

The problem is her house. It's an older home, full of mold and dust that got stirred in the move, and there's a construction project across the street kicking up more pollen to boot.

Scheider checks her chart and doesn't foresee any major problems. ``So she is going to get out of here,'' he said. He whips out a calculator and punches in some numbers for her new medication dosages, and adds, distractedly, ``I hope.''

Roper lies in bed on her back, her breakfast tray on her table, the TV murmuring in the background, her feet fidgeting under the covers. She talks in alternately worried and hopeful tones to Scheider.

``I didn't sleep too much all night,'' Roper says, and she points to her cardiac monitor.

``My heart was going real fast.'' She was in Regions for a severe asthma attack once before, and although she's moving to Minneapolis, she came back to Regions.

Scheider reassures her that her pulmonary functions look much better this morning, but he'll call for a pulmonologist ``to come by and give a big stamp of approval'' before he discharges her. He gives her a smile. She smiles back.

``Because of all my allergies, it was almost a relief to be in here,'' Roper tells Scheider, who responds, ``I can't blame you.''

Later, after Scheider leaves the room, Roper tells how she met the doctor the day before, when she was still gasping for air.

``He's very thorough,'' she says. ``I've been here one other time, and they weren't that thorough.''

He's also nice, she adds. ``That makes the visit easier, too, when they're nice. Nobody likes a crabby doctor.''

Scheider's bedside manner earns him the confidence of many of his patients. With his lanky, 6-foot, 1-inch, 185-pound frame, his close-cropped, slightly receding brown hair, his wire-rimmed glasses and laid-back style, he somewhat resembles Dr. Mark Greene, a character from television's hit series ``ER.''

Unlike most of his fellow residents in the family practice program at Regions, he's not from somewhere else around the country. He grew up in Woodbury and graduated from St. John's University in Collegeville, Minn.,before going to Creighton Medical School.

``I'm back home. Everybody I know says, `Tom's home! Tom's home!' '' he says with a grin.

Often, interns are self-conscious about assuming the role and title of ``doctor.'' Not Scheider.

``I enjoy saying `Dr.' I enjoy wearing the long coat. This is stellar! I can't believe they're paying us!'' he says with a wide grin.

Scheider heads downstairs one floor to 7 to the post-coronary care unit and his next patient, a 58-year-old St. Paul woman who was admitted with chest pains.

Beth Crawford had been admitted several days prior with what are described as ``atypical chest pains.'' She was discharged when doctors couldn't detect signs of a heart attack.

Now, three days after her discharge, she's back with more chest pains and a mysterious abdominal pain. She has been a smoker for 35 years, and she has no primary-care doctor.

Standing outside the door to her room, Scheider reads her ``H and P'' -- her medical history and physical exam -- and confers with another doctor about Crawford. She had clashed with a nurse earlier, and seemed depressed, the doctor tells Scheider.

``She seems to like me, so it might not be so bad,'' Scheider says, and then he ducks inside.

Crawford puts down a thick paperback she was reading and greets Scheider. ``Do you take on new patients?'' she asks him.

``Sure,'' Scheider says. ``I can certainly leave you my card. It would be a pleasure.'' Crawford smiles.

Scheider begins his questioning. How's your energy level? Did you get up and walk? Are you coughing a lot? He is casual but methodical, going through a checklist he memorized in medical school. She tells him about a previous heart attack in 1993, when she was taking care of a sick brother and her job changed.

The good news, Scheider says, is that, based on test results, he doesn't think she had a heart attack.

Scheider takes off the stethoscope draped over the back of his neck and listens to Crawford's lungs, then he taps her stomach, listens to her abdomen and gently pushes the places where it hurts.

``Any ideas?'' Crawford asks him. Scheider says he'll have a staff cardiologist do a cardio-scan on her to compare with her scan from four years ago when she had her heart attack.

``Let me go talk to the boss, and we'll figure out what to do with you,'' Scheider says with a wink. Crawford is reassured.

Talking to the specialists at Regions is one of the hardest things for him to do, Scheider admits.

Not that he doesn't want his patients to see a specialist, as some people suspect of primary-care doctors working under managed care.

It has more to do with his keen awareness that as an intern, he's low in the hospital pecking order.

``You've really got to know your stuff because you don't want to interfere with what they do,'' he says.

One of the most difficult things for new primary-care doctors such as Scheider to learn is when to refer a patient to a specialist and when to take care of things themselves.

To help him, Scheider, like all interns, carries the equivalent of a small medical library in his coat pockets: a forest green spiral-bound

``Manual of Medical Therapeutics''; The Washington Manual, ``a slice of heaven sent down to us mere mortals,'' Scheider jokes about the book, a reference work on internal medicine; another little green booklet called ``The Intern Pocket Survival Guide''; a brown paperback called ``Current Clinical Strategies -- Family Medicine, 1997 Edition''; a blinding yellow, laminated booklet called

``The Pocket Pharmacopoeia''; a plastic-protected ``Guide to Anti-Microbial Therapy 1996''; and a fold-out laminated card called ``The ACLS Pocket Reference Universal Algorithm for Adults -- Advanced Cardiac Life Support,'' an extremely complicated flow-chart that tells doctors what to do with cardiac arrest patients, something Scheider hasn't had to use yet.

None of the books is easy reading -- all are written in dense medical language, designed to be scanned for information.

``It saves your brain,'' Scheider jokes. ``If I didn't have big pockets, I'd be useless.''

The residents like to joke about how easy it is to tell them from the attending physicians who supervise them. Residents, especially interns, carry so many books in their pockets they look like traveling book peddlers. The attending doctors ``breeze by with just a pen in their pocket,'' one intern marveled.

Scheider carries six cheap, plastic pens in his coat breast pocket. He scribbles constantly.

Lugging the books makes it seem as though the residents don't know their jobs. But veteran physicians say there's so much to know in medicine now that a doctor's strongest skill is no longer a photographic memory but a sound strategy to find the needed information quickly. Many now visit the Internet as often as the medical library for information.

The residents also hold regular meetings mid-morning to discuss patients and exchange ideas on how to treat them. Scheider's team, R-5, contains another intern like him, a third-year medical student from the University of

Minnesota, a second-year resident who supervises him, and an attending physician who watches over all of them.

In the team meeting, Scheider outlines his problems with Crawford, puzzling over her abdominal pain. He tells the team he's going to order more tests on her and keep her in post-coronary care until he can figure out what's wrong so she doesn't end up coming back again in a few days.

``No more bouncers,'' agrees Dr. Sue Inoue, the second-year resident who supervises Scheider. That's hospital jargon for patients who are discharged only to be readmitted a few days or even hours later. No one likes bouncers -- doctors such as Scheider catch them on the rebound like basketballs that must be put through the hoop again.

Scheider's interaction with Crawford also illustrates the complicated, time-pressured dance that doctors must perform with their patients. During the team meeting, when discussing her case, Scheider complains.

``She really sucks up your time,'' he tells the rest of R-5. ``You ask her when the pain started and she starts to tell you when her son moved in with her.

``I mean, it's fine that you get a full history, but'' he waggles his head and rolls his eyes in exasperation.

Crawford, however, felt none of Scheider's anxiety. ``He makes me feel secure,'' she says, after he leaves the room. ``I don't have a primary-care doctor, so it's hard when you don't know anybody.

``He seems to know what he's talking about, and he makes me feel he's listening to me,'' Crawford adds.

With each year of training, the residents are expected to increase their efficiency with patients by 50 percent, until their third year, when they finally are handling the industry average of four to six patients an hour. That's roughly one patient every 12 to 15 minutes.

Besides Crawford's chattiness, the lack of a clear diagnosis hampers him, Scheider admits.

``It's difficult to spend time with her and alleviate her fears when you don't know what's wrong with her,'' he says. ``It's frustrating because medicine is supposed to be a science, but it's an art. There's more than one way to do

a test, and more than one way to treat something.''

The time crunch doesn't faze him, however.

``I'm really glad I'm doing family medicine because, sure, when the patient comes into the clinic, you see them for only 10 or 15 minutes. But you'll see them again for 10 to 15 minutes, and before long, they'll know you've spent quite a bit of time with them,'' he says.

It's now late morning, and Scheider revisits Crawford. He delivers good news: Enzymes in her blood show she did not have a heart attack. He already has told a nurse to ``dc,'' or discontinue, her heparin, a blood-thinning drug that Crawford was given immediately as a precaution when she was admitted.

He also tells her the mass that showed up in her abdominal X-ray could be stool, and there was a quick and easy way to check through cardiology, which he was going to refer her to that afternoon.

``Now I want to talk to you about your smoking,''Scheider says.

Crawford makes a sour face. Scheider immediately shifts gears. ``But that's something we can talk about later,'' he says.

``That's something I've wanted to do something about -- if I could do something about it,'' Crawford says, somewhat wistfully.

Scheider touches her arm reassuredly. ``Well, we can talk about that later,'' he says. Then he brightens up. ``You're not smoking now!''

``No!'' Crawford perks up, too. ``See!''

Scheider eases his way to the door. He tells Crawford he'll probably see her later that evening because he's on-call.

You'll see me every time if you check in every fourth day! he jokes. The interns go on-call every fourth day, year-round their first year.

``We'll have to stop meeting like this,''Crawford cracks.

12:36 p.m. Grand Rounds.

Scheider's late. Grand Rounds is a regular lunch-time lecture to keep doctors abreast of the latest information or to help them brush up on old skills. Today's topic is lead poisoning. Between bites of salad -- sandwiches, soda pop

and cookies also are provided by the hospital at all Grand Rounds -- Scheider talks about how his life has changed as a doctor.

``As (medical) students, sure, you work hard, but you don't have to carry this burden of responsibility,'' he says.

His greatest conflict now is trying to make sure he takes care of his patients and himself, too, balancing the demands of the job with the dangers of burnout. The residents have a support group that meets twice a week for a bit of therapeutic griping, but Scheider says that family medicine is a good career choice because it's an accommodating practice.

``There's a wide variety of patients, and you learn to adjust and to work with what the patient can give you,'' he says.

1:50 p.m. 8-South, general medicine.

Scheider's back checking lab results for his ``zebra.''

As expected, the news is not good. ``Her red blood cells looked like they were torn apart, and today the white blood cells have toxic granules,'' he notes.

Her magnesium level also continues to be low despite three straight days of magnesium injections.

``I want to find something else to give her,'' Scheider says half to himself as he flips open the green Washington Manual and then his yellow pharmacopoeia. He's standing in the middle of the brightly lit ward, which was recently remodeled with seafoam green carpet and textured beige wall coverings to make it look less institutional and foreboding.

While holding on the phone for St. Joseph's Hospital and looking for Crawford's X-rays and charts from her previous heart attack, he is paged on another call and finds himself on two phones at once. The pager clipped to his waist is a constant nag. Pages chirp-chirp-chirp regularly, forcing Scheider to excuse himself, find the nearest phone and respond.

``I think half the job is just getting down the routine -- how to get ahold of people and coordinate things and find things . . . '' he says out the side of his mouth while cradling the phone to St. Joe's.

2:47 p.m., still 8-South.

Scheider must wait. Wait for the pulmonary department to finish with Roper. Wait for gastrointestinal to finish on his zebra. Wait on Crawford's cardio test results.

``There's a lot of hurry-up-and-wait kind of thing,'' Scheider said. He takes advantage of the lull to trot down eight flights to radiology on Level 1 -- like all doctors, he typically takes the stairs because it's quicker than the often-packed elevators. He checks his zebra's X-rays.

Besides showing him that she had a little fluid in one lung and that she's a smoker, ``nothing jumps out at me,'' Scheider says after staring at them intently.

3:20 p.m.

Scheider hits the residents' lounge, a rest stop for the on-call training doctors. It's usually stocked with coffee, sandwiches, pizza and pop -- ``dog food,'' the residents call it -- and offers a refuge from work.

He takes stock of his patient load – he potentially can discharge two patients today. He'll split the admissions to the internal medicine ward tonight with another resident also on the same duty tonight.

The last time he was on cross-cover, he admitted seven people in a 36-hour shift with only three hours of sleep.

``I hope not to repeat that,'' he says, propping up on a lounge table his well-worn Birkenstock sandals. Like most doctors, he wears the most comfortable shoes he can find because he's on his feet all day. He bought a pair of closed-toe sandals for surgery and a couple of pairs of Doc Marten boots, too.

``I have made the leap and spent the money on expensive, comfortable shoes,'' he says, half-facetiously.

Money is a concern for doctors everywhere these days, particularly for interns. Scheider gets paid $33,288 a year as an employee of HealthPartners, making him a cheap source of labor for the hospital. It's the way teaching hospitals have survived for generations -- without residents, the hospital system in this country would collapse.

After he passes his residency in 2000, however,Scheider and other family practice doctors can expect to make $100,000 in the Twin Cities or up to $150,000 in some rural towns.

He doesn't expect to get rich, though. He owes Creighton $150,000 for medical school, payable as a 10-year loan at 8 percent interest, he says. More medical students are being warned not to expect to make the kind of money earlier generations of doctors enjoyed.

He chose Regions for his residency because the Twin Cities is where he wants to establish his practice -- where he grew up, near his family, with his friends, Scheider said.

``Part of family practice is making connections,'' he explains.

Scheider's local roots are deep -- his mother is an outreach pastor at Guardian Angels Catholic Church in Lake Elmo, and his father works in information systems at The St. Paul Cos. Rushing through the hall earlier that morning, he whirled around suddenly at a familiar face: it's his Cub Scout den mother, who now works at Regions in the administrative offices. Delighted, he says hi.

3:48 p.m.

The pager chirps. It's the first page of the evening shift, when he starts cross-cover.

``So it begins,'' Scheider says, waggling his eyebrows up and down.

One by one, weary-looking residents check in with Scheider, handing him blue cards that carry information on that doctor's patients. The first card is for a patient who likely will die tonight, his doctor says.

Scheider listens to the doctor's report, taking notes. ``Excellent, good, good,'' he mumbles distractedly as he scribbles while the doctor recites the patient's case history.

He will collect cards from four teams – the other cross-cover intern collects cards from four other teams. Scheider has eight patients now, and any four more who come in the door from now until tomorrow morning's shift change.

All the teams haven't checked in yet, but Scheider can't wait. He finally has time to revisit his zebra, whom he hadn't seen since first thing this morning. He heads for 8-South.

She is Irene Leitner, a painfully thin, exhausted, 38-year-old manufacturing quality assurance manager from Rice Lake, Wis. Leitner, a single mother, has a college-bound teen-age daughter who makes her visibly swell with pride every time she mentions her name.

She also has a nightmare abdominal ailment that doubled her over in pain a few days ago.

She has lived with the mysterious bouts of abdominal pain for a year and a half. ``When these things come on, I can't move, I can't walk or sit or stand -- it's devastatingly crippling,'' she says in a voice that crinkles like tissue paper.

``It feels,'' she says, ``like my spine is going to explode.''

``It's been very frustrating,'' she continued. ``If they go and tell you you've got cancer, at least you know at that point. Once you know what it is, you can at least start the (treatment) regimen.''

This is Leitner's first visit to Regions. She hopes to go home tomorrow, but recalls that her mother had admonished her to not leave ``until they tell you what's wrong with you!''

After consulting with his attending physician, Scheider decides to keep Leitner overnight for observation, try to control her pain and run more tests.

Leitner approves of Scheider's manners. ``He's pretty thorough and up-front,'' she says. ``He speaks to you like a human being and not a machine.''

``Lots of times, you go to a big-city hospital and they speak to you and totally lose you,'' she adds.

Scheider moves on. He checks in with Roper, telling her he's going to discharge her as soon as he writes new prescriptions for her asthma medications. He scribbles furiously.

``Hot dog!'' he says in triumph. He finishes her discharge orders. It's 5:23 p.m. One of his patients gets to go home. But he's still got 13 patients from other doctors to watch tonight, plus his own two.

At 5:36 p.m., while washing down his turkey croissant sandwich with a Diet Coke in the resident's lounge, he gets word his first admission of the night has arrived by ambulance from Osceola, Wis. He hurries off to 7-West, the post-coronary care unit.

``Donde esta Senora Neidermire?'' he asks a red-haired nurse. She smiles and points to the patient's chart. Room 756. Cecilia Neidermire, 63. Transported with chest pains.

Teamed with Inoue, his immediate supervisor, Scheider starts checking Neidermire. He orders ``everything'' from the blue ``Current Clinical Strategies'' in his coat pocket, a book of admission orders for a variety of situations.

But the pager beeps before he can finish.

6:10 p.m.

Another patient he discharged a few nights ago has returned. ``They're bouncing back with a vengeance,'' Scheider observes.

6:11 p.m.

R-7 checks in with two more patients for Scheider to watch tonight. Then R-6. The interruptions distract Scheider from writing orders for Neidermire. His patient count is up to 19. He can't remember when he has had that many.

6:38 p.m.

He gets a page to see an angry patient of another doctor who left for the day. Scheider is writing furiously, but the pager keeps interrupting, like the buzzer on a demonic game show.

``Oh, this is so -- yucky!'' he says in frustration, as he hangs up one call and another page comes in.

He pops in on an elderly woman who is being admitted. She asks for her doctor.

``He had to go home to sleep,'' Scheider tells her. ``I'll be taking care of you.''

``When do I go home?'' she asks weakly, a feeding tube hanging out of her nose.

``I don't know that yet,'' he tells her. The elderly woman is thirsty, but another doctor has ordered that she not be given anything to drink or eat to keep her stomach empty. Scheider asks a nurse to feed her ice chips and hustles out the door.

He runs smack into the family members of Ruth Olson, who are milling about the nurses' station on 8-West. The 81-year-old Olson was brought in from a nursing home with lung problems and numbness in her left arm. Her family has been here all day and wants to go home, but first they want to talk to a doctor about her condition.

``She's conscious and sharp as a tack,'' says Lyle Hardenbrook, her 64-year-old son who drove his 30-foot motor home from Kettle Falls, Wash., when he got word that his mother's condition had deteriorated earlier that week. Until recently, she had lived in her own home, with hardly sick a day in her life, her son says.

The family members are visibly tired and frustrated. They've been waiting since afternoon to talk to Olson's doctor in R-10 about the results of a CT scan and they want to go home. Scheider doesn't know how to reach R-10, but he doesn't want to keep the family waiting any longer.

So, even though she's not his patient, he picks up her chart and reads it.

His face, normally animated and amused, becomes expressionless. He calls the family to a private room to talk. The family allows a reporter to sit in.

The CT scan shows that your mother has cancer in her lungs, liver and adrenal glands, Scheider slowly and carefully tells the family. A sudden stillness hangs over the room, a brief instant when it seems everyone has had the wind knocked out of them at once. One of Olson's daughters starts crying noiselessly, her shoulder heaving. The family is stunned.

Scheider tells them he can't determine where the cancer originated without a tissue biopsy, but he suspects that, given the number of sites, it developed slowly over time, without her ever complaining or even suspecting what was wrong.

``We could do chemotherapy or radiation therapy, but I don't know if it's worthwhile doing,'' Scheider candidly tells them. The cancer is metastatic, meaning it already has spread to many sites, he explains.

``If it's incurable, it's incurable,'' says one of Olson's younger sisters. ``Don't make her suffer.''

Another sister adds, ``One thing we've decided is: She's 81 years old; she's had a good life. We don't want her to suffer. Don't go monkeying with her.''

His voice shaking, the son, Hardenbrook, asks:``On a scale of 1 to 10, what is her chance for treatment?''

Scheider shakes his head sadly. ``Knowing what I know -- no. This is the sort of situation you don't cure. You treat the symptoms.'' When he was in medical school, Scheider volunteered at a hospice. He's had practice delivering this kind of news.

Hardenbrook nods silently, head down.

7:49 p.m. still 8-West.

Nine minutes later, at the nurse's station, Scheider runs into a young doctor like himself, casually strolling up with a medical student in tow.

``Are you R-10?'' he asks. Yeah, the doctor says. Scheider mock-kicks him and says, ``Ruth Olson.''

R-10 blanches. ``I was just in with the family and told them about the metastatic cancer,'' Scheider tells R-10.

R-10 apologizes profusely. Scheider briefs him before he goes in to talk to the family.

``I don't know if you've ever been in a situation like this before, but I've found that the best thing to do is to take a deep breath and talk slow,'' Scheider says, emphasizing the last two words.

Scheider is not surprised Olson's cancer went undetected for so long. She probably shrugged off early aches and pains, never seeing a doctor until she was felled by the stroke that landed her in Regions.

``It's amazing how much punishment the human body can take,'' Scheider says. He sighs and smiles wanly. ``Oh boy, I need a drink.''

He rushes off to visit a lymphoma patient in isolation with an antibiotic-resistant bacterial infection, first donning a white, disposable isolation suit. Then he races back to 7-E.

Now it's Scheider's turn to get chewed out. Inoue finished the admission paperwork for him on Neidermire while he rushed off to see the other patients pouring in. It has been more than three hours since he has seen her.

``If you ever suspect coronary arterial disease, write an order for nitro,'' an irritated Inoue tells Scheider. She did it for him. Her voice is soft but each word is carefully enunciated and carries a keenly honed edge. OK, Scheider meekly answers.

The beeper sounds again. Scheider is running down the hall again. It's 8:55 p.m. He has one more hour handling the admissions on cross-cover before handing off the beeper to another doctor who comes on at 10 p.m.

``I . . . hate . . . this . . . cross . . . cover. . . beeper,'' he hisses through gritted teeth as his Birkenstocks pound the hall.

9:11 p.m.

Scheider races to intensive care on the seventh floor. An agitated, elderly patient has extubated himself -- pulled out the oxygen tube placed down his throat.

``I don't know what happened, how it happened. I don't know where I am. I don't know when I'm going to get out of here,'' the patient rasps, his voice nearly destroyed by a lifelong, three-pack-a-day smoking habit.

He glares at the nurse trying to calm him down. His voice picks up. ``And, I don't know when I'm going to get something to eat!''

9:51 p.m., 8-West.

After his extubated patient is sedated and re-intubated, Scheider drops in on the patient who is expected to die in the coronary care unit.

The patient's central catheter, the IV that was surgically placed into a major vein in the patient's chest, has accidentally been pulled out. It delivers the painkillers that keep him comfortable.

If a nurse cannot get a smaller line in his arm or leg, Scheider must ask permission of the family to reinsert the central catheter in his chest, a surgical procedure that carries the risk of puncturing the patient's lung. The family has put a do-not-resuscitate order on the man, but there apparently is disagreement within the family about what to do.

Scheider talks with family members by telephone.

10:30 p.m. 8-West.

He hands off the pager to the doctor just coming on shift. She'll handle any new admissions for the rest of the night. Scheider has more than enough new paperwork to do on the patients who checked in while he was on cross-cover.

11:14 p.m. 8-East.

After a short break in the residents' lounge, Scheider is back on 8-East when he's paged. This time it's his girlfriend, a rookie Roseville police officer. She has just finished her first night on the job, riding with a uniformed officer.

``So, you couldn't yell, `Stop, in the name of the law!' ?'' an amused Scheider asks her over the phone.

Another admission -- yet another bounce – comes in, this time from Good Samaritan at 11:40 p.m. Scheider is yawning.

1:30 a.m. 8-West.

He finally has time to finish the charts of the patients who poured in at sundown. It's quiet, except for the murmur of nurses at the doughnut-shaped central desk and soft, tinny radio music from a distant room.

2 a.m., still 8-West.

Scheider begins refilling a form for patient Crawford to replace a wrong form he wrote earlier. Hospital paperwork is ubiquitous, uncompromising and uniformly cursed by doctors. Scheider has his own coping strategy: ``I just sign where the nurses point,'' he sighs.

2:12 a.m.

He's finished. Scheider trudges to the on-call rooms in the back of the hospital -- cramped, dorm-like rooms with a few beds for the on-call residents to catch some winks between calls.

On the way, he finishes the dessert he started 10 hours ago -- a Heath Bar cream pie. He spills some on his smock. ``Damn, it's the clean one, too,'' he says.

Lights out. Another exhausted on-call resident is snoring loudly in the next bed.

4 a.m., residents' quarters.

The phone rings. Scheider snaps awake and answers it in the dark, keeping his voice down so he doesn't wake the other doctor. Neidermire's heart rate is up, and the nurses want his permission to give her next dose of meds a little early to get it back down. Scheider gives the OK and goes back to sleep.

7:10 a.m.

Scheider's Timex Ironman watch beeps, waking him immediately.

``I used to never be able to wake up to it, but I think the fear factor keeps me from being nonresponsive,'' he says.

Last night was quiet, he says.

7:50 a.m., 7-West.

After brushing his teeth and washing his face, he's sitting at a computer terminal and studying the results of Cecilia Neidermire's labs. Scheider visits with Neidermire, and tells her he's ruling out a heart attack because lab tests don't show a change in a crucial enzyme.

8:15 a.m. 8-South.

Beth Crawford is napping when Scheider pops in on morning rounds. He taps on her table to wake her and tells her he has scheduled a number of tests today.

``I don't think all the pain is coming from the heart, but I think there's something to it,'' Scheider tells her about her chest pains. ``You don't have the best heart in the world.''

Crawford remembers she had a couple of cigarettes before her chest started hurting, and Scheider notes that cigarettes can stimulate the heart rate and interrupt oxygen flow to the organ.

``Maybe it's something that I shouldn't do,'' Crawford muses. She looks at Scheider. ``You ever smoke?''

``No, thank God!''

``It's there, like a friend.''

``It's never turns you down,'' Scheider agrees.

``Especially if you live alone,'' Crawford says.

Scheider tells Crawford if she could quit smoking, she would improve her chances of avoiding another attack.

Crawford says she'll try, and Scheider offers help. He leaves her smiling.

9:01 a.m.

Scheider's pager goes off. Neidermire's clinic tells him her echocardiograms were read at Regions, so he doesn't need to get them reviewed again. He checks out another bouncer and heads for 8-South.

9:41 a.m.

Scheider makes morning rounds with his team, R-5. Everyone laughs at him because he's the only one who can feel a mysterious mass in the abdomen of Crawford. In discussions, the rest of the team refers to Crawford not by her name but as ``Tom's abdominal mass,'' the way many doctors use their patient's symptoms instead of names as shorthand.

Scheider is as guilty as other doctors of doing the same, but he also notes in his review of Neidermire's case to R-5 that she's ``an awesome gardener'' with a coffee shop in Osceola, a tidbit he picked up from talking to her and her daughters, all nurses. He tries to pay attention to her experiences and not just the illness that landed her in the hospital.

Later, after breakfast, Scheider talks about why he became a family doctor. His family, with close church connections through his mother, has always stressed serving others, and his father's background in computers fed his own interest in science. In high school, he said, he was excited to discover he could combine the two in medicine.

Family practice, he says, was a way to get to know patients well, and not always under difficult circumstances, such as now, in a hospital. ``I think it can be tiring to deal with sickness all the time; it's nice to do a well-baby check,'' he says.

Time to pop in on Leitner, his zebra. He tells her that her X-rays show a little fluid in the bottom of her lungs but the rest looks great. She'll get a CT bone scan today.

Leitner, looking wrung out, asks if she can walk outside a bit.

``Sure,'' Scheider says. Suspicion pops into his eyes. ``Are you going to smoke?'' he asks.

``Yes.''

Scheider grimaces. Leitner, feeling guilty, jokes, ``I'll meet you halfway. I'll only smoke half.''

``I know; it's stupid,'' she acknowledges to Scheider. ``I quit, but I only started again recently when my stress was up.''

Scheider asks her if she's ready to go home.

``Oh yes,'' she says. ``I just want some answers.''

Bone scans can show areas of hyper bone activity, a sign of disease of some sort, usually cancer, Scheider explains later. It would explain her large, continual magnesium loss, he says.

Scheider works the phones, the computer terminals and the floors. The hours are melting away, and without checking the clock or glancing out the window, there's no sense of time passing as the shadows of downtown St. Paul begin to lengthen. It's 2:25 p.m.

Radiology telephones with the bone scan results. Scheider frowns. ``Negatory,'' he says before hanging up -- there's nothing wrong in the scan, he's told.

``It's like I'm wishing for something to be wrong with her,'' he says. ``Because something is.'' He marches off to talk to Leitner.

It's the good news-bad news routine, he warns her. ``I have good news for you,'' he says. ``There's nothing wrong with the bone scan.''

``I have bad news,'' he adds. ``We still don't know what's wrong with you.'' He consults with his supervising attending physician, Dr. Marie-Helene Almonor, about further tests, but after a short, intense conversation, they agree that Scheider has exhausted the list of things to do.

Leitner can leave. At 3:30 p.m. she tells Scheider someone can take her home to Rice Lake. He writes her discharge papers.

Leitner is happy to go home but adds that she'd be happier ``if I went home with some answers.'' Scheider's zebra remains at large.

4:25 p.m.

A weary Scheider finds the cross-cover doctor tonight and hands him three blue cards for Crawford, Neidermire and another patient who was admitted the previous night. He has discharged the rest, batting about .500. Time for him to go home.

``Our job here is to give the clinicians as much useful information as possible about what transpired here in the hospital -- to give preventative care and prevent future hospitalizations from happening,'' he says before trudging down the hall and out the front door.

In four days, he'll be back on-call.

Postscript

In the year since, Raelene Roper has been to Regions once more for an asthma attack. She wasn't impressed with her doctor then, but she still remembers Scheider as ``the nice, funny one.''

Beth Crawford tried going to Scheider's clinic on the East Side for a while, but it was too inconvenient for her, so she goes to the one inside Regions Hospital. She did quit smoking for four months, but started again when her brother became sick -- he died in Regions in mid-October.

``I'm getting better and better,'' she said recently. She may even try quitting smoking again, she said.

Cecilia Neidermire suffered a heart attack in the hospital a few days after Scheider finished his shift, but she has made a full recovery and gushes about the care she received from Scheider and his team.

Scheider, Inoue and another intern on R-5, in fact, visited her coffee shop last fall, where they got to see the fabulous ``secret garden''behind the shop, which she told them about when she was hospitalized. ``They're just treasures there,'' Neidermire said.

Ruth Olson died in September of last year, not long after her cancer diagnosis, said her younger sister, Annabelle Nelson, 69, of Cannon Falls.

Nelson said she wasn't sure if anyone had a chance to tell her sister about her cancer.

``She didn't like doctors,'' Nelson said, confirming what Scheider suspected a year ago. ``She didn't go to doctors too often.''

Irene Leitner died Sept. 11 at Amery Regional Medical Center. She was 39. She had been diagnosed with cancer in the fall of last year, only a couple months after she was discharged from Regions.

At her boyfriend's urging, she had been checked at the Mayo Clinic, where a liver specialist finally diagnosed her problem, she said in an interview by phone on Nov. 24, 1997. The doctor found spots in a scan of her liver and when she underwent exploratory surgery, he found cancer had spread throughout her diaphragm and pieces of her liver.

``It was quite a shock,'' she said then. ``My daughter is starting to accept it, but she's real scared. My boyfriend's real scared, too.''

Her obituary ran in a Rice Lake newspaper this past September. It said Leitner was a former member of the Women of the Moose in Rice Lake who taught Sunday school at Trinity Lutheran Church and was assistant gymnastics coach at the Rice Lake High School for the 1996-97 season. She enjoyed growing roses and doing arts and crafts.

Leitner's mother, Bertha Hendricks of Rice Lake, Wis., said that radiation treatment was ruled out because the cancer was too close to Leitner's liver, so doctors prescribed two sessions of chemotherapy.

``It didn't stop it. It didn't even slow it down,'' Hendricks said.

The doctors ended the chemo in March. They didn't think Leitner would live to see her daughter Lalisha graduate that spring, Hendricks recalled. Leitner also was depressed about using savings intended for her daughter's college on her own medical expenses, Hendricks said.

But she hung on. She helped coach Lalisha on the gymnastics team that year, and that June, Leitner saw Lalisha graduate in the top 10 of her class and be accepted to the University of Wisconsin at Madison, Hendricks said.

The university took into account Lalisha's special circumstances and picked up her tuition, the grandmother added proudly.

Leitner even lived to celebrate her mother's 72nd birthday on Sept. 6.

``She was one,'' Hendricks said of daughter Irene, ``who, in spite of all her pain, could smile, which isn't easy sometimes.''

Tom Scheider is now a second-year resident, with an intern of his own to supervise this winter. He estimates he dealt with the deaths of about 20 patients in his first year -- 11 in one month while he worked on a geriatric rotation.

Dealing with death is part of the education of every doctor. ``It happens enough that I'm getting used to it,'' he said recently. ``It doesn't happen so much that I'm comfortable with it.''

He's still going with his girlfriend the cop. And he said he is managing his time better -- he ends meandering conversations with his patients faster and keeps his schedule and notes on a Palm III, a hand-held computer organizer.

He's working more outside the hospital now. He looks forward to establishing rapport with clinic patients. He gave a well-received presentation before his fellow clinic doctors on diagnosing Attention Deficit Disorder this past fall. He's more confident, he said.

``I always felt good enough, but it's only lately that I've been able to say, `Hey, I'm pretty good.' ''

Leslie Brooks Suzukamo can be reached at lsuzukamo@pioneerpress.com or at (651) 228-5475.

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