Grand Rounds 10- Psychiatry Must Pay

(Fiction Part 2)- Here for Part 1

The sudden disappearance of Diff and Overworked sent shock waves through the Madhouse. The consequences of which remain to be seen.

Frankly, watching our Interns abducted before our eyes by the Brutes from Risk Management was a troubling warning sign. My Co-Resident and I held a meeting of all Residents the following day. The meeting was called on an emergent basis and held in secret principally to avoid detection by the Attendings, especially the *COMMISH. We concluded that big circle and 1.1.1. were indeed a code and we were confident that with a little digging we could get to the bottom of this.

That same day we headed directly to the Risk Management office. We wanted our Interns back, immediately. Of Course, there would be hell to pay if we would have to draw the bloods and do our own rectal examinations for another day.

The door was locked but we persisted. Ten hours later, Diff and Overworked emerged from the office; their eyes dilated and glazed over in confusion. Blogborygmi grabbed me from behind and told me that the *Students and *Sub-Is got a tip that my Interns were hypnotized. Our suspicion was immediately confirmed when Psych consults Shrinkette and Intueri followed not far behind.

As to the role of the Psychiatry Department in this incident, we are still pondering the best course of action for our revenge but we are sure it will include some Ativan, a lot of Haldol and all the wrist and ankle restraints in this hospital. Meanwhile, we felt that the two shrinks should be shadowed at all times and so we sent the Students Med School Blues and Med Body to keep us informed of their movements. For now, our revenge will have to wait.

We headed immediately to the Radiology suite where Codeblue would be. We had no doubt that if anyone could break this mystery he can. Of course, Big Circle and 1.1.1. were not great clues to go on but if Codeblue knows who killed Yasser Arafat this should be no difficult task. If all else fails we may go to the MOL or even Charles, and we’ll ascend up the latter as needed, even to the *COMMISH.

Because no one messes with our Interns!

Meanwhile, check out Grand Rounds #10 at Doctor Mental. I think the Madhouse was published again.

Mars

Saturday was my day off. I decided to spend it talking to my brother who very recently ventured off on his own and started an internet price engine. We spoke about his new business and the general state of the market. During the two hour conversation he told me about how "web crawlers” were “hitting his site” and “indexing pages”, therefore he had to track “IP address” and different “browsers” to decide what charges would be incurred. Of course, I knew my brother was cursing at me. Foul words in a language of I had no knowledge. This truly shocked me, my ignorance that is.

Although I smiled and laughed I understood NOTHING. Who's “browsing”? What's a "crawler"? Is it a night float resident walking through your files? Why is he “indexing” files, shouldn’t he be sleeping?

When did it get to this? We speak English mostly everywhere but even our English is divided into Spanglish, Slang and Rap. Then there's Ebonics and Spanish and in certain areas you can't get along if you don't speak the local vernacular.

I was so glad that as a part of the medical community we are not privy to these types of miscommunications, everything is plain and simple and written in crystal clear language.

So, when a Surgery consult came to ask me to clarify what was written in the chart of a patient I had recently admitted I stared at him in disbelief. Why it’s clear as night and day. The chart read, "64 y/o m was in USOH 2 d/ PTA, BIBEMS w/ c/o pain in LE and SOB, please r/o DVT/ PE. Obtain duplex, get a V/Q, D-dimer and spiral CT/ PE Protocol".

Where did this guy come from, Mars?

Jumble of Falling Musicians

(“Nearer, my God, to Thee” was not the hymn played by the band as the Titanic went down. The band, a brave group if there ever was one, played “Autumn”. It ended as the ship tipped over in a jumble of falling musicians and instruments)

Dedicated for the patient who coded last evening

I read this scenario a hundred times over. But that was a scenario and this is you. You are a mother, a wife, a daughter, a provider and many people love you and they don’t want you to die. And I don’t want you to die. And you are dying. Stop dying! Please.

When I entered the room you expected me to save the day. I was paler than my white coat. Made you nervous? Guess what, I was very nervous. Underneath this white coat I am only human and as many times as I poke myself it still hurts, I still bleed and continue to be every bit as human as you.

Have you made mistakes before? I’ve made mistakes and continue to make them. Did your mistakes cost another life? Did your mistakes cost someone an arm or an eye? Do you want that responsibility?

Neither do I. Every day I wake with heaviness in my chest. A pressure so immense I have problems differentiating if something is truly wrong. This is taking its toll. I seem slow, groggy? I’m not really. But once you’ve made costly mistakes you really understand the importance of oversight. Oversight.

Every day this coat feels heavier and heavier. On occasions, I want to rip it off my shoulders and leave, never turn back. Too much invested now. Like watching captains go down with the ship. Cue the orchestra. In many ways this coat feels like a

A cage. I feel trapped in my white coat.

Happy $%#%@@^ Thanksgiving

I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over. I'm thankful Residency is half over.

I'm thankful I haven't commited suicide- yet. I'm thankful I haven't commited suicide- yet. I'm thankful I haven't commited suicide- yet. I'm thankful I haven't commited suicide- yet. I'm thankful I haven't commited suicide- yet. I'm thankful I haven't commited suicide- yet.

I'm thankful I'm on call today, tomorrow, and the next day. I'll be very thankful if it's slow. I'll be ultra thankful if it's slow and I get to watch football.

I'm thankful I am healthy

I'm thankful I can still count- my blessings

Happy Thanksgiving to all

Grand Rounds 9- Diff and Overworked- Missing!

(Fictional Piece- Part 1)

Something strange happened this morning and the Mad House is buzzing. All was peaceful when Diff and Overworked entered the CCU. I was standing across the room on the other side of the nursing station. They were both obviously trying to get my attention.

As I turned to face them Overworked was yelling across the room at me but I couldn’t hear her muffled voice over the loud ringing of the monitors. Suddenly, and with the precision of a mafia kidnapping, they were both tackled by two brutes from Risk Management and whisked away. I gave chase and came within sight of Diff. Her mouth was covered with tape and she was trying to convey a message to me by hand signals. She held up her index finger in three repetitions (like 1.1.1) and then she waved her arms in a big circle. A Big Circle? 1.1.1? What does it all mean?
I’ve yet to figured it out, but be sure that I will keep you updated.

Meanwhile, check out this week’s Grand Rounds at my psych consult Shrinkette. It look great with many entries including TYTD. When you finish them you must take 20 minutes to read this. It’s a little long, it is serious and it is a must read.

By the way, do any of you know where my interns are? If they think I’m drawing bloods this morning they have another thing coming.

Divided by 1 Jew +1 Female

(In a pathetic attempt to boost my own ego and lick my wounds I will clearly outline the reasons that I would make a great *Chief Resident)

The position of *Chief Resident has long been a coveted position in the life of a resident. Therefore, it has become a rank highly influenced by hospital politics and such. The Chiefs should reflect the makeup of the program and at the same time incorporate the best former residents for the job. Difficult, since the best residents who find fellowships in their second year refuse the nomination.

Hospital Politics:

Chiefs must reflect the makeup of the program: The Mad House is a city hospital and the makeup of the program is by and large Foreign Medical Graduates (*FMG). We tend to get one to three US graduates per year as residents, but mostly this is an *FMG program.

There are four *Chief positions and they should incorporate the finer of the Residents in each year: Since the best usually leave for their fellowship after their third year that leaves the upper crust of the Second Year Fellowship Rejects (*SYR).

The chief residents must vary in their backgrounds (eg: some foreigners): Classically, at least here, that results in one female, one American Graduate (*AG), one Jew (*Wonderful Human Being)-just kidding, and one to two foreigners (or any combination thereof).

Thus:
Good Chief Class=( {Good Resident + *SYR + Varied background (+/- *FMG)} multiplied by 3 + *AG. ) Divided by 1 Jew +1 Female

My case:

1. Since I am a Good Resident by what they tell me and well liked by my students, I qualify.

2. Judging by the amount of interviews I received (Zero) thus far. My chances of getting a Gastroenterology fellowship this year are bleak. Thus I am high on the *SYR list.

3. My most beneficial quality: Since I am Jewish and an *FMG that makes me special. I also grew up in the US thus I am a Quasi-*AG. Because I am also a wuss I qualify as pseudo-female.

Therefore, nominating me would be like killing close to four birds (pseudo quasi-FMG/AG/Female/Jew) with one stone. Let’s call it killing two birds and injuring two (one severely- almost dead bird).

Since I cover almost all the criteria, the program can always point to me when asked about the chief positions and I can be a beacon of inspiration.

Alas, it would seem that I am of the less desirable kind. Two of the four chief positions have been delved out. Two more positions will be offered this week to secretly selected Residents. More to come.

Overworked is Bored

And so am I. After one week of covering the night shift in my CCU I am transitioning to days. It’s been three weeks of night work now (two night float and one CCU) and I am excited to get back to daytime. I feel like that guy in the sprint commercial with Catherine Zeta Beta (or whatever her name is).

Let’s face it, the day is soooo much better. Things happen during the daytime. People get placed on drips, on pressors. Patients leave during the day, both through the front doors and by way of the *BUS. There are codes and more staff and people to joke and gossip with, I love it.

The night is depressing. It’s just the nurses and me and they have me intimidated. They clearly outnumbered me and I was shaking in my white coat. Now I’m on with my gang too, they have my back. Try to pull one over on me now nurse! Do you feel lucky? punk? Do you?

Of course as soon as I come on there are only two patients to follow. TWO patients. How exciting is that? Overworked is watching them and so am I and together that makes for overkill. We get excited about every fluctuation in heart rate. “You mean he was going at 65 before and now he’s 68? We better investigate”. We’re even concerned about bowel movements. “Repeat after me- you will poop and you will do it now!”

No Crazy Crashing Patients to discuss, no fun anxiety to deal with. Just two, really boring, really stable, pathetic excuses for critically ill patients. Just Stable enough to be in my CCU.

What an Asshole

(This post was first published on Election Day. I wanted to give readers a break from the standard voting coverage. Retrospectively, I now believe that regardless of the winner, it was, unfortunately, ironically appropriate)

I clearly remember my first ever rectal examination, that is, I remember the first one I gave someone else. I recall feeling as if I had violated him. As if I was tormenting my patient all for the sake of learning what a prostate is supposed to feel like or just what the feeling of sticking your finger in a stranger’s ass feels like.

It’s kind of an uncomfortable subject to discuss both here and also with my patients. I never really knew how to approach it. As an intern I used to say “This is something I have to do, unfortunately, but we have to check if you’re bleeding down there..or back there” (whatever). Then I would watch them wince in horror and I’d try to laugh it off.

Now, after a year of apologizing for a necessary exam I think I’ve lost all shame in it. In fact, there are times when a rectal is really necessary and if I could stick my finger up the patient’s ass without even saying “hello” I probably would.

Now, I say things like “flip over, WE have to do a rectal examination” (As if he’s participating or maybe he gets to give me one afterwards). Or even better yet (snotty English accent) “Oh intern, we need a rectal exam on Ms. D, would you kindly skooch on over there and do it?”

I’ve found, strangely enough, that I usually connect much better with the patients whose assholes I explored. In a way, it brings us together. In a really sick, kind of demented way.

Rectals are also a great way to punish patients. At least the really annoying ones or those that try to take advantage of us. I’ve lied to patients before and spent an extra long few seconds checking out a prostate. Really checking it out. You now know why this blog is anonymous right?

On the last hour of his rotation my Student told me he had made it through three months of medicine wards without ever doing a rectal exam. He did 15 rectals that last hour alone and our service was 100% free of colonic bleeding. I believe his finger now graduated medical school.

In fact, I have no idea what the horrible reaction is for. I’ve had other doctors give me rectals before, I’ve even had a colonoscope shoved up there. You know, once you get used to it it’s kinda fun. (I didn’t just write that, did I?)

Well…If this post didn’t have you pissing in your pants then I give up. I don’t really have any more rectal exam stories to tell. I do have one of a manual dis-impaction I did my first year. Wanna hear it?

My Differential

My CCU team, composed of one Resident and two Interns is smaller than my previous entourage, still, it is a cohesive group ideally designed to optimize patient care. As always, medicine is the backdrop for our overly human delinquencies.

My first intern “Overworked” is a brilliant young lady who recently moved to this country from overseas to fulfill her husband’s (she hates it here) career goals. She knows TOO MUCH and rarely listens to anything I have to say. Unfortunately, she has terrible luck and maxes out on admissions whenever she’s on call. We’ve redistributed patients multiple times to even things out. Usually, those that were redistributed spontaneously heal and leave (The so called DIFF effect) .

In spite of her incompetence “DIFF” is loved by her creator. We were on call yesterday when we had an admission of a fifty year old man after a bad heart attack. His MI was severe enough that he was rushed to cardiac catheterization before coming to the CCU. After placing a few stents in the arteries that supply his heart he’s doing somewhat better. While we were taking a history DIFF asked what type of pain it was? Was it burning? Was it sharp? Did it improve with Tylenol? Who the hell cares! What is she doing? There’s no DIFFerential diagnosis for a guy who went to the cath lab and left with two stents. There just ISN’T!

The Master of Lines (MOL) is our Attending and so named due to his above average (way above) ability to speak magic when analyzing an E.K.G. Electrical vectors reveal galaxies in this man’s eyes and I am constantly amazed by the amount of information he can deduce from this simple tracing. Over the last week I have dedicated hours to perfecting this art once even teaching MOL something he never knew, COMMISH (check side dictionary) would have been proud.

On morning rounds Overworked and DIFF were trying to analyze an interesting EKG. Thus two interns analyzing an EKG, a true double blind study. Upon handing the tracing to MOL he diagnosed third degree AV block that had gone unnoticed by the entire staff (side note: with rapid junctional response for my cardiac junkies). He then took a whiff of the paper as if it was a fine Cuban cigar, turned to me with a coy smile and said “and halitosis”.

No way!

Of course, as soon as he turned the corner I ran back to my patient, toothbrush in hand.

Ben the Life Saver

An update for my readers: Today TYTD left the hospital WITH her defibrillator. Thank you Benjamin Franklin for your gift of life.

Too Young To Die

(Disputes between physicians and patients over medical care have tended towards resolution in both courts and ethics committees, with each of these bodies ultimately deciding that the informed, competent patient must be the final decision maker)

TYTD wants the internal defibrillator TAKEN OUT. I spent an hour earlier this morning arguing with her about how I would “highly prefer” if she find a way to live with it. She is a young lady and, as stated earlier, too young to die (TYTD). It discharged while she was holding her baby and she nearly dropped the little girl, it scared her, it should. I don’t blame her but I know that those wires are the only thing standing between us and her funeral.

I told her I refuse to take it out. I won’t even talk about it with my Attending. I refuse. She told me she’s having it taken out. Period.

Murder by proxy and the proxy is I. A highly intelligent woman who now decides she would rather not live at all than have to constantly live under the threat of an electrical shock, even if she knows it was an angel in disguise. Is this ethical? Is this what they had in mind?

Tomorrow will come and I will watch TYTD walk out of my CCU, defibrillator free as she requested. And I will know that she will be lucky if I ever watch her being wheeled back in.

There Are Even More of Us- The Grand Rounds

Dear Readers:

This weeks Grand Rounds are up on DB's site. They really look interesting.

A Natural Catastrophe

It’s 1 am in my CCU. I’ve barely had time to put on my jacket when the charge nurse called me with the news that one of my patients, a young lady, is in Ventricular Tachycardia (V-Tach). She also told me to “relax, as this happens to her all the time”. The words “Relax” and “Ventricular Tachycardia” sound funny to a novice when used in combination. Naturally, I panicked!

I must’ve done record sprint time from my call room into the CCU. As I entered the room, I found this too-young to die (TYTD) female quite comfortable, talking, slightly hypotensive and in Ventricular Tachycardia. The confusion and concern on my face, I guess, was evident. She looked at me and said “don’t worry doc, this happens all the time”. Really? Because every other time that it happened to me I was staring at an impending corpse (IC). So I chose to “PAGE CARDIOLOGY” STAT!

The fellow calmed me down and said that this particular patient has a rare disease called Errythmogenic Right Ventricular Dysplasia, a condition that predisposes these patients to all kinds of arrhythmias. Basically, she’s been walking the rope between suddenly dropping dead and life for quite a long time. Sure, that calmed me down. Of course! TYTD was now threatening to become IC and I was to stand by because she’s been threatening for quite a long time. Makes sense.

Faced with the sudden combination of deadly conditions with words of reassurance made me think of a few other well-constructed warnings:
“Hi, you’re having a deadly asthma attack, just chill out”
“You’re hemorrhaging internally, how about that”
“I can’t feel a pulse, how about we continue to observe”

You can make up some yourselves, I’m fresh out of ideas. Leave yours in the comment section.

You Dirty Bastard

A little about me

This is my second year of residency in Internal Medicine and this is the time that we apply to our desired fellowship or specialty. This is a little premature since during our first year we’re little more than scut monkeys and pretty much end up doing much of nothing other than all the grunt work. This hardly leaves time to think much less come to the realization that one would like to do a specific something for the rest of his life. However, this is the state of affairs and who am I to challenge it.

Throughout medical school I’ve always felt a certain attraction to the field of Gastroenterology (GI) and it was my love. I’ve chosen to apply to GI earlier this year and I am now waiting for the results of my applications, negative thus far. Here’s the problem, over the course of my first year I hated Cardiology but since the beginning of my second I’ve taken a real liking to the field. Enough to really consider being an EKG man forever.

Now, I feel really naughty. I’ve taken the time away from GI to go and flirt with someone new. An affair so heart pounding it sends palpitations through my myocardium and into the apex of my soul. Such a horrific betrayal. Thus my affair has turned into an intoxication of electrical impulses, an obsession.

Madman, you little flirt. And you’re married too!

My Personal Insulin Assistant

(In between my first shift tonight at the CCU and my boredom, I propose the following)

As a child I was always impressed by the amount of money the rich would spend on their watches. I always wondered how impressive would it be if, for the same amount of money, one would hire a personal “watch” assistant to travel along wherever he goes. Imagine this:

Frank: “Hey Joe what time is it?”
Joe: “I’m not sure, Watch?”
Watch (Well dressed male traveling alongside Joe): “At the sound of the beep it will be exactly 12:30 pm, beep”

Quite an impression wouldn’t you say?

Well, to my point.

The amount of money wasted on patients who are habitually non-compliant and miss their medical appointments and medications would stagger the general public if it was made known. The unnecessary hospitalizations, tests and man power are tremendous. Maybe it’s time that we change our approach.

A solution (for the worst offenders only): We hire a personal medication man who’s sole responsibility in life is to make sure these patients take their medication and come for clinic. He would take their fasting glucose twice a day and adjust their insulin. He would force them to take their Epivir or Lactulose, whatever.

We would pay well, say fifty thousand a year. Still, the savings would be tremendous. In addition, the psychological lift it would give these patients to have their own personal medication assistant would be great too and maybe next time they come to the hospital they might actually be pleasant.

I look forward to a future where Ms. C (my own personal patient nemesis) would come into my office (she would actually make it to the office and not the ER) with her own personal entourage. I would say:

Me: “Hi Ms. C, nice to see you today”
Ms. C: “And you too Dr.” (?????????????????)
Me: “How is your Diabetes”
Ms. C: “Well, why don’t you ask Richard, my diabetes assistant”
Me: “Richard, how’s her diabetes?”
Richard: “under control doc, we’re doing well”

Oh, Serenity.

Good news: Over the next two weeks I am headed back to that wreck of patient disaster central called the CCU (Coronary Care Unit). Back to Basic crashing patients.

The All Powerful

The last two weeks have been deficient on patient interaction but great for getting to know the people I work with. I managed to come out of my depression and the patients managed to stay alive, at least until the AM. As a result of this slow down I’ve had a lot of time to talk with friends and “hang out/complain” in/to the Emergency Room.

My distaste for emergency physicians is well known to my readers and I have certainly commented on it before. The most important reason is that things tend to be treated as “emergencies” even when they are clearly not. However, I will allow other medically oriented blogs discuss this, as I am certain they are more capable.

Over the course of the last two weeks numerous admissions were, to say the least, “questionable”. Last night’s two admissions of Man with chest pain after football game (clearly traumatic) and lady with no symptoms and a heart rate below 60 (ie:.Fifty Nine, at rest!) raise my concerns. The most troubling thing is that once the decision to admit is made it is nearly IMPOSSIBLE to talk the EP (GOD) out of it.

Me: “But I’m just going to send them home as soon as they come upstairs”
ER: BLANK

It’s useless.

Dear Readers, a fair warning: Whatever you do, don’t come to the Emergency Room if you are absolutely healthy. You may, unfortunately, have to deal with characters the shades of me which were sent to impose upon you by the likes of GOD. By the end of the evening GOD may even diagnose some horrible disease like “Snoring too loudly” or “Being too cheerful in the ER”. After that, you’ll be admitted and we’ll perform unnecessary tests, painful blood draws and you may even end up having a big ass needle or two shoved into some body part you kind of need.

By the way: If I use any nickname you are not familiar with, please refer to new dictionary posted in sidebar, only limited by my imagination.

Whiney Baby

Well, our baby is on the way. She is due soon and she looks cute as a button on ultrasound and, at least on paper, unbelievably expensive. All the “preparations” have brought on a grim realization. It seems that I would have been far better off had I played a doctor on TV, learned to dunk early in my life, kick a ball well or maybe even learned to lip-sync and do a well choreographed dance at the same time.

As medical students we were berated by Residents telling us how awful their lives were and to get out now. They all complained about how much they owe (nearly $200,000 on the average) and how little they get paid, most importantly, how much they work. As medical students we pretty much dismissed these complaints, thinking they were just overworked and overstressed.

Nothing could be further from the truth. Now, the weekly bills don’t stop, student loan companies demand their money and the rent is due. I run to work and let my wife deal with the stress but it’s not really fair.

I hate to whine because most people just say “Well, at least you know that in the long run you’ll make money”. Truthfully, I probably will still make more than the Average Joe, but did the Average Joe give away thirteen years of his life to higher education. In addition, unfortunately, that doesn’t even seem to be the case any more.

After four years of college, one year masters, four years of medical school and three to six years of residency most physicians don’t make a whole lot. We pay for overpriced malpractice insurance to protect ourselves from the people we’ve invested our whole lives to help and have now demonized us into monsters with a syringe. We have tremendous educational loans to pay back. We have very high expenses from clothing (they expect that we look like doctors, right?) to office expenditures and our compensation continues to dwindle.

When my little girl finally arrives I will make sure she puts down that book, practices her free kick, grows long blond hair, gets big boobs and learns a hot well choreographed “number”.

Electricity

The night started out slow. Beautiful slow night. All the patients were sleeping, even the nurses managed to sneak in a good nap in the corners of the stations. No supervisors around and we managed to have a little fun joking around and surfing the net, just wasting time.

It’s been a while since I’ve seen the wife. Since I started working nights our intimacy time which used to amount to not much has dwindled down to nothing. Along with the stresses of city hospital night floating come the needs to release those same stressors. At three AM in the morning my testosterone level seem to soar and if there’s no immediate problems on the floor my observation skills, so well taught to me in medical school, begin to look for additional observations to “observe”, and my imagination begins to take control.

The old stories of blond beautiful bombshell nurses were either a myth all along or are now long gone, especially where I practice. Our nurses suffer from the general obesity crisis which plagues our children and doesn’t make for a bright bombshell nursing future. Our medical students and interns though, well, that’s a different story. When we say “student” we speak of twenty something bright eyed geniuses who stare at us with smiles of admiration. At 3 AM my subconscious speaks to me in ways too filthy to mention here. It is exactly at those times that I hope for a patient in distress, maybe a code or two, maybe a “shortness of breath” somewhere on the floor, any kind of diversion.

Or maybe, just maybe, we’d all run to save some poor soul who’s myocardium has decided it had enough. We’d sweat over him and we’d beat his heart to death. In our chaos we’d flash a g-string over here and skin over there. And all that adrenaline and all that rush of energy would ignite our passion. We would beat on that heart and we would shock and we would suffer together and maybe after it’s all done we'de find a call room and…

Oh god…I miss my wife!

And The Hits Just Kept On Coming

“I’ve been getting killed here man. I have seven admissions waiting for you already” and his face did that awful contortion we do when we tell someone they have cancer or something.

I really felt for him. It’s not bad enough that the Medical Admitting Resident (MAR) is a powerless job, a triage secretary of sorts, but all he ever gets to do is give bad news to Residents and Interns who end up bitching at him and he ends up bitching about the Emergency Physicians (EP). It’s a sort of insult pyramid we pay strict adhesion to, we bitch about him (MAR), MARs bitch about the EP, EP’s bitch about Everyone Else.

Well, I admitted ten patients overnight, myself. The other nightfloat added another ten and various other Residents added fifteen more. All together, a really busy f--king night. There was a lot of insulting, bitching, yelling, laughing, and general downright putting down but it all added up to the Medical Madhouse Record of total patients admitted overnight.

When Cardiology COMMISH came in the morning he nearly peed when he found out how many patients we had to “discuss”. We had him “EKG’d-out” by the tenth patient and all “Chest-X-Raid fatigued” by the fifteenth, all "damn the CT" by the twentieth and all "Screw Neuro" by the twenty first.

And the hits just kept on coming. Two hours later, morning intake rounds turned into morning intake weekend conference and a look of admiration came upon the other Residents in the room as they had realized that we had accomplished the previously unaccomplished. Not only did we set The Record, but we had the Commish back in his chair, grasping for air, and…all E.K.G’d out!

I’m not Telling

Last night a patient I had admitted the previous night came back to the Emergency Room with similar complaints. This is what we call a “bounce back”, reason being that the intern who discharged her yesterday is now going to have her “bounce back” to his service. Well, my bounce back was there for her second seizure in two days. The first time she came in she had signs of a possible urinary tract infection to boot and I treated that. However, now that she came in the second time I was wondering if her infection could really be meningitis (a deadly infection of the fluid that surrounds the brain).

Of course, the ER attending had asked Neurology to come by and see the patient. They had recommended a CT, MRI, this and that levels etc. So I decided to ask, what the hell.
Me: “Could this be meningitis?”
Neuro: “Well, I suppose it could”
Me: “Should I do a lumbar puncture” (Not a fun procedure to have done)
Neuro: “Well, I guess if you suspect it then you should do it”
Me: “Yes I know that, but do you suspect it?”
Neuro: “Well, it could be meningitis”
Me: “Would you do a lumbar puncture if this was your patient”
N: “I may”

One of the major problems for the Housestaff is that Attendings don’t want to commit. Everyone’s afraid, everyone uses words like “could be”, “may”, “possibly”. My last CT scan result said “This may represent an effusion, possible infiltrate, cannot rule out mass”. Well, I figured I’d join everyone else in being as vague about my thoughts as I possibly can. Now when I speak to my friends our conversation goes something like this:

Friends: “What do you want to eat?”
Me: “I’m not sure, I think pasta but I can’t rule out suddenly wanting steak”
F: “How’s the wife treating you”
M: “Consistent with nice, I can’t rule out things going bad though. You mind if I use your bathroom?”
F: “sure, will you be long?”
M: “Well, this is likely a bowel movement but I cannot exclude possible urination. In addition, the cramp is of high intensity and could theoretically be representative of possible future diabetes and a current infection, although unlikely, clinical follow up will be necessary”.

We need a bill to stop ridiculous medical lawsuits. It’s driving us to insanity, case and point.

What an Asshole

I clearly remember my first ever rectal examination, that is, I remember the first one I gave someone else. I recall feeling as if I had violated him. As if I was tormenting my patient all for the sake of learning what a prostate is supposed to feel like or just what the feeling of sticking your finger in a stranger’s ass feels like.

It’s kind of an uncomfortable subject to discuss both here on this blog and also with my patients. I never really know how to approach it. As an intern I used to say “This is something I have to do, unfortunately, but we have to check if you’re bleeding down there..or back there” (whatever). Then I would watch them wince in horror and I’d try to laugh it off. After a year of apologizing for a rectal I think I’ve lost all shame in it. In fact, there are times that all I really need is a rectal exam result and if I could stick my finger up the patient’s ass before saying “hello” I probably would.

Now, I say things like “flip over, WE have to do a rectal examination” (As if he’s participating). Or even better yet (snotty English accent) “Oh intern, we need a rectal exam on Ms. D, would you kindly skooch on over there and do it?”

I’ve found, strangely enough, that I usually connect much better with the patients whose assholes I explored. In a way, it brings us together. In a really sick, kind of demented way.

Rectals are also a great way to punish patients. At least the really annoying ones or those that try to take advantage of us. I’ve lied to patients before and spent an extra long few seconds checking out a prostate. Really checking it out. You now know why this blog is anonymous right?

On the last hour of his rotation my Student told me he had made it through three months of wards without ever doing a rectal exam. He did 15 rectals that hour alone and our service was colonic bleeding foolproof. The language I use is vulgar because the act itself is barbaric. The truth is that I’ve had other doctors give me rectals before, I’ve even had a colonoscope shoved up there. You know, once you get used to it it’s kinda fun. (I didn’t just say that publicly, did I?)

Well…

Well, if this posting didn’t have you pissing in your pants then I give up. I don’t really have any more rectal exam stories to tell. I do have one of a manual dis-impaction I did my first year. Wanna hear it?