Cheech

Two explorers are shipwrecked off of a tropical island. They swim ashore to be greeted by a tribe of natives, who promptly tie them up and bring them to their village. Out of a hut walks a man who is obviously the chief. He walks up to the first explorer.

"Death or cheech?," he asks.

The two explorers look at each other quizically. The first explorer, thinking that anything must be better than death, answers "Cheech, I suppose..."

His boundings are cut and he is dragged into the forest. For the rest of the day and night, the second explorer hears his blood-curdling cries which are eventually silenced.

The next morning, the chief comes to the second explorer. "Death or cheech?," he asks.

The second explorer, not wanting to live through whatever the first went through, answers "Death." The chief replies, "Death it is. But first, some cheech!"

The term "cheech" (having nothing whatsoever to do with anything named "chong") is a term that, if not specific to my institution, certainly originated here and virally spread. Much like the structure of the modern residency program. The origins of the term is a mystery, but the legend attributes it to the above story. Cheech is like The Force: it surrounds us, permeates us, and binds us all together.

Cheech is hard to define except by example. A patient with new arthritis may get the classic rheumatology cheech bomb dropped on them: ANA, anti-DNA, ANCA, Ro/La, Smith/Jo, C3, C4, RNP, RF, CCP, RPR, HIV, HepB/C, cryoglobulins, anti-cardiolipins, Russel's Viper Venom test, etc. A new cardiomyopathy has an echo, SPEP, UPEP, ANA, HIV, HepC, TSH, ceruloplasmin, urine copper, ferritin, iron panel, left cardiac catheterization, perhaps a fat pad biopsy, and maybe a right heart catheterization with endomyocardial biopsy. Don't get me started on a new liver, heart, or lung transplant evaluation. May as well open the computer ordering system, start at the top and work your way down.

A story from my intern year epitomizes cheech. A patient presented with a new finger ulcer. Among the workup suggested was cryfibrinogen and cryoglobulin. The lab cannot draw these samples, as it needs to be kept at body temperature from the patient's room on the fourth floor until it gets to the appropriate laboratory incubator in the basement. Cryoglobulins are a pretty standard lab, and I assumed cryofibrinogen was the same. So post-call Ed ordered the tests, and dutifully took a tourniquet, butterfly, and a red top with the necessary accoutrements to the bedside, drew the blood, put it under my armpit, and walked it to the lab incubator. Ahh, the lab tech says, cryofibrinogens go in a green top. Back to the patient's room, tourniquet, butterfly, green top, and accoutrements, apologize, draw the blood, in the armpit, speak to three or four different lab techs in the basement, and find the appropriate incubator (a different one). The lab tech, however, has another problem. No control specimen in the hospital, so they can't run the test. So post-call Ed puts his coat on the back of the chair, rolls up his sleeve, and has a control cryofibrinogen drawn by the tech, who puts Ed's blood in a tube, into the armpit, and back to the same incubator. The patient was cryofibrinogen negative a week later when the test came back.

The first rule of cheech is that not all work is cheech, but all cheech is work. My god, is it work. It's like extra-virgin work.

The second rule of cheech is that scut is not cheech. Cheech may sometimes by scut, but never the other way around. One could draw a Venn diagram:



The third rule of cheech is that it must be indicated and appropriate. It's not hard to find an indication, but it still chaps my hide when a methylmalonic acid and a serum lead level is sent in the first round of a workup for an anemia in isolation. We can't go hog wild because we want to ensure a future of cheech and Mr Obama happens to be relatively nearby.

The fourth rule of cheech is that the more cheech done early, the quicker to discharge. Disposition is first. Cheech flinging is not only encouraged, but expected out of those overnight on-call interns (and unit residents).

The fifth rule of cheech is that in order to be considered cheech, it needs to be gratuitous. It's sometimes hard to make rule three and rule five jibe, but such is the nature of cheech.

And yes, there is no rule six of cheech.

Now you may ask what relation does cheech have to being a good physician? Hard to say, really. Some cheech bombs are detonated reflexively, like a package of unclear provenance at a federal building. And sometimes, those packages are bottles of fine port from the Portugese consulate. But we spend so much time mastering cheech, it's hard not to think that it is one of the primary things I'll be taking from residency. Cheech forces us to think about disease pathophysiology and about disease mimickers right from the time we put in admission orders (rule four). It's not all cheech for cheech's sake.