Amen to that.

Hours awake: 7 Chance of quitting: 18%

Chapter 20.

I get an easy admission in the afternoon: a young woman with a diagnosis of pyelonephritis (kidney infection). I feel like I've had a lot of pyelonephritis cases since I've been here, although I'm beginning to notice that 90% of all patients at County Hospital share one of the following ten diagnoses: 1. Chest pain, rule out heart attack 2. Heart failure 3. Cirrhosis (liver failure) 4. Emphysema/asthma 5. Kidney failure 6. Pyelonephritis 7. Stroke 8. Pneumonia 9. GI bleed 10. Alcohol/drug intoxication/overdose I guess that's how you get to pretend to know everything: pretty much everyone has the same ten diagnoses.

This patient is named Carla Canady and she's twenty years old. Her age is good news since young patients don't stay long in the hospital and my service is gigantic. The other piece of good news is that they put her in a room with Mrs. Jefferson. That saves me at least a little bit of running around. I think I walk the equivalent of a marathon while on call.

From Ms. Canady's social history in the ER note, I discover she's the mother of a two-year-old girl. I have to say, the patients at County are making me feel like I ought to have popped out at least three kids by now. By twenty, everyone has a kid, sometimes two. And there's a tiny voice in the back of my head that wonders if I'm not doing things the wrong way. Wouldn't I be happier if I were taking care of my baby now instead of pyelonephritis patients? Isn't procreating what nature wants me to do?

Not that I have anyone to procreate with right now. Not exactly.

Ms. Canady's other problem is that she's diabetic. And she's not taking very good care of her diabetes. Actually, that's an understatement.

The test we use to measure diabetic control is called a Hemoglobin A1c. An A1c of less than 6 would mean excellent control of the diabetes. An A1c of less than 7 is good control. Ms. Canady's A1c was 13. That means she's essentially treating her diabetes with sugar pills. Literally.

I go in to talk to her, and she reminds me a lot of my teenage cousin who is always rolling her eyes and saying, "Whatever." She has on way too much make-up, especially around the eyes, especially considering she's sick and in a freaking hospital. I can't believe this girl is a mother, although she does look much older than twenty.

"You guys are giving me way too much insulin," she tells me when I come to see her.

I think if she thinks it's way too much insulin, it's probably just the right amount. "When you're sick," I say, "it's really important to keep good control of your blood sugars."

"I just have an infection though," Ms. Canady says. "Don't you treat that with, like, antibiotics?"

"Right," I say. "But if your blood sugar is controlled, your body is in better shape to fight the infection."

"But doesn't sugar turn into energy to fight infections?" she says.

I almost start to launch into a big explanation, but instead I decide not to waste my breath. "No," I say. "It doesn't."

"Whatever," Ms. Canady says and rolls her eyes. But at least she doesn't protest any further. For now. I have a feeling this battle is only just beginning.

_____.

I end up down in the ER with Alyssa for a GI bleeder. The woman has blood coming out both ends, if you know what I mean. We were all set to admit her to our service when her blood pressure took a nosedive and she earned herself a trip to the ICU instead. Unfortunately, by the time we get done in the ER, it's after 7 p.m., meaning the cafeteria is closed.

I comment on as much while I ride upstairs in the elevator with Alyssa. As I say the words, my stomach growls pointedly.

"You should have stashed some food from lunch," Alyssa points out. I don't know where she expects me to store food since we have no fridge. In my cheeks? She whips her phone out of her pocket.

"I'm going to call my husband and ask him to bring over some fast food," she announces.

For a moment, I actually think Alyssa might offer to have her husband pick up some food for me as well, but that doesn't happen and I certainly am not going to ask. I think I'm going to have to take my chances on the food cart. I finish up a few notes and head downstairs.

Luckily, the food cart is actually there this time so I can eat something aside from popsicles. As soon as I get out, I can smell meat heating up in a big vat of oil-the stench permeates a 20-foot radius surrounding the food cart. They have a wide selection of red-checked boxes containing the various deep fried options. After quickly surveying the possibilities, I buy a box of something thickly breaded, possibly shrimp, with a side of French fries and a soda. I carry it up to the resident lounge.

If it had occurred to me that Alyssa would be in the resident lounge, I definitely wouldn't have brought my food there. I can't eat in front of Alyssa-it gives me indigestion. But instead I burst in on what is practically a party.

First of all, Connie is there, also eating a fast food burger that Alyssa clearly bought for her. And along with her is Alyssa, a pale man in his thirties with thinning black hair, and an incredibly cute toddler who is walking around the room with a French fry in each hand. The toddler has a visibly runny nose that is dripping nearly into his mouth.

"Oh," I stammer, unsure if I should stay or not. As much as I was looking forward to some time away from Alyssa, I feel like it would be rude to leave. I force a smile. "Hi."

Alyssa nods at me. She makes no motion to introduce me to her family.

I sink into one of the chairs, keeping my food on my lap. It's so deeply fried that it's hard to eat, but I force myself to take in a few bites.

The whole time, I can't stop watching Alyssa's kid. He's very cute, mostly because he looks nothing like Alyssa. He takes a bite of one fry then alternates with the other fry. And then every minute, he runs to his mom for a kiss. I wish I were one year old. Life is so simple when you're a kid. You don't even know how good you have it. Lucky bastard.

The kid's runny nose is bothering me though. He's come to Alyssa for a hug at least a dozen times and not once has she made a motion to wipe it off. Alyssa is so anal that I sometimes worry if I have one hair out of place, she'll reach over and pluck it out of my skull. How is she letting this runny nose go unchecked? Even I want to wipe up the snot, and trust me, I'm a huge slob.

Eventually, Alyssa's pager goes off and we all jump like a foot in the air. "You better go," she tells her husband.

He nods. "Do you think you'll be home for lunch tomorrow?"

"Probably not," Alyssa says. "My interns are still really slow."

Hey, Alyssa, said interns are sitting right here! And are not deaf!

Admittedly, we are pretty slow though.

Her husband picks up their child. He flies into a sudden panic when he realizes he's leaving. His tiny round face turns bright red, and he reaches outstretched little arms in Alyssa's direction, hollering, "Mommmmeeeeee!!!!!"

It's sort of heartbreaking, actually. Her husband raises his eyebrows at her, but Alyssa shakes her head.

"Just go," she says. "It'll be easier."

After Alyssa's son has been dragged screaming from the room, the snot bubbling from his nostrils, she turns to us, her interns. I see whatever sadness she had is magically being converted into fury.

"Are you still eating?" she snaps at me.

"No," I say, quickly tossing my fried something (still not sure what the protein was) into the trash besides me.

Thankfully, my own pager goes off at that moment. And I'm almost happy to hear that Carla Canady is refusing her insulin shots because it gives me an excuse to get the hell out of there.

_____.

"I don't need the shots," Ms. Canady says to me. "I'm fine. Seriously."

"Your blood sugar is 326," I say.

"That's not so high," she says.

It horrifies me that she said that. A normal blood sugar is around 100. A sugar of 326 is really high. Maybe not high enough to send her into a diabetic coma, but pretty damn high. High enough that if she keeps walking around like that, she's going to end up being a frequent flyer at that hospital.

"I really think you should take the insulin," I tell her. "Having uncontrolled diabetes can make you really sick."

Ms. Canady just snorts and looks away from me.

"I mean, you have a daughter, right?" I say. I think of Alyssa's son being wrenched away from her. "You want to be in good health for your daughter, don't you?"

"I'll be fine," Ms. Canady says.

That's when we both hear it. The bellowing voice from the other side of the curtain, loud and pleading. It's Mrs. Jefferson.

"Please, honey, take the shots," Mrs. Jefferson says. I feel like I can nearly see her puff of white hair behind the curtain. "I have diabetes too and I used to be just like you. I never took care of it and one day I woke up half blind. You don't want to be blind. My kidneys have failed and my body has fallen apart because I didn't take care of my diabetes. I only got one leg now. My other leg-it's gone."

I see Ms. Canady staring at the curtain, her eyes wide. Mrs. Jefferson goes on: "I have a daughter too and I want to stay alive for her. I just want to see her and my grandbabies, but instead I'm stuck here in the hospital. Please, honey, take care of your body. Don't let yourself fall apart like I did. If I can convince you to do anything, please take your insulin and take care of yourself."

Ms. Canady and I are both looking at the curtain, waiting for any other words of wisdom to emerge from beyond the partition. But Mrs. Jefferson is silent.

"So," I say hopefully. "Will you take your insulin shot?"

Ms. Canady rolls her head away from the curtain. She looks me straight in the eye.

"No," she says.

I tried. Nobody could say I didn't try.

Chapter 21.

At around midnight, I get a page I've never gotten before. It's a nurse I vaguely recognize with a no-nonsense New York accent. "Dr. McGill," she says. I don't hear the scare quotes when she says "Doctor," which makes me feel good about myself, until I hear what she has to tell me: "Mr. Hoffman just died."

I stare at the phone, my heart pounding. "What? Why didn't you call a Code Blue?"

The nurse sighs. She's like a nurse version of Alyssa. "The patient was Comfort Care. Terminal colon cancer."

"Comfort Care" means just that. The patient is no longer being treated medically, but we are keeping him comfortable until he passes away, which is expected to be imminent. Pain medications are all right, but CPR or antibiotics are not.

"So what do I do?" I ask. It seems like my work is over if the guy's dead. I mean, that's what I'm here to prevent.

"You have to come over here and declare him dead."

"Oh."

I march over to the floor where Mr. Hoffman is located. I somehow expected things to be a little more somber because a man just died, but it pretty much looks like business as usual. Two of the nurses are having a loud conversation about laxatives.

The nurse who called me, Kaitlin, is waiting for me at the nurse's station. I've worked with Kaitlin a few times before, and have always been incredibly intimidated by her. She's got at least two decades on me in age and experience, and it shows on her thin, lined face. She always wears her gray-laced black hair in a tight bun that reminds me vaguely of Julia, and today she's wearing solid purple scrubs.

"Dr. McGill?" she asks. None of the nurses know us by our names yet-we probably all seem identical to them.

I nod.

Kaitlin crooks her finger at me and leads me to Mr. Hoffman's room, which is the last one in the hallway. The lights are dimmed inside and it's very quiet, at least for a hospital room. There isn't one machine beeping or alarming. I've never met Mr. Hoffman before, but he looks like he was pretty sick (obviously). He's got huge hollows in his cheeks, gray stubble across his chin, and his toothless mouth is parted in a silent O. Just before a really sick patient dies, their mouth often opens that way. It's called the "O sign."

Kaitlin folds her arms across her chest and waits for me to proceed. I stand there for a minute, biting my lip.

Finally, I break down and ask, "Um, what do I do?"

Kaitlin raises her eyebrows. "You've never done this before?"

I shake my head.

She sighs. "Okay, feel for his pulse. But you won't feel anything."

I press my fingers into the grove of his wasted wrist where the radial artery runs. At first I almost think I feel a pulse, but then I realize it's my own pulse. "Okay..."

"Now you listen to his chest and make sure you don't hear anything. You won't."

I place my stethoscope on Mr. Hoffman's still chest. Silence.

"And now you check his pupils."

I reach out and lift his eyelids up with my fingertips and shine a light in his pupils, which are slightly obscured by his cataracts. They don't budge.

Yep, this guy's dead all right.

The next part of the process involves paperwork, which is now my area of expertise. Essentially, I am discharging this patient. But instead of discharging him to "home" or "nursing facility," I check off the box to discharge him to "expired." Even I can't screw this one up.

As I'm flipping through the sign-out given to me on Mr. Hoffman by the intern taking care of him, I notice that under "code status," he has written: "Full Code." Full Code means that in the case of Mr. Hoffman going into cardiac arrest, a Code Blue should have been called.

We were supposed to try to save him.

And then I have a heart attack.

"Kaitlin!" I scream.

She drops what she's doing and rushes over to where I'm sitting. "What's wrong?"

I point out where the intern had written Mr. Hoffman's code status. My heart is pounding. If we were supposed to try to save this guy, then... well, it's not my fault. They told me he was Comfort Care! Why oh why didn't I check the sign-out before I let him just die? Wait until Alyssa finds out about this...

"Oh," Kaitlin says, looking unconcerned. "Mr. Hoffman's definitely Comfort Care. That intern is the biggest idiot in the hospital."