Problem Solved

It’s just an unfortunate truth that patients tell lies. In this month of night float I’ve seen at least one or two patients who complain of chest pain every night. A common cause of chest pain, especially in the area I serve, is Cocaine. So, it’s just a fact of life that when someone comes to the Emergency Room complaining of chest pain one of the most important questions is how many white lines they polished off that night?

Of course, a patient-doctor relationship is based on trust and I do my best to establish that trust while ate the same time verifying truth. Unfortunately, to do that requires betrayal as I send their urine for a toxicology screen. On the average, once every other night, one patient who vehemently denied drug use shows up positive. But fear not, all is not lost.

It is said that everything in the universe serves a purpose. With a little help from the chemistry lab I believe that I’ve found a great benefit to be derived from such patients. Currently, all we’re missing is a little research money and a sharp mind.

I often blog about the amount of loans medical students assume to pay for their education. Actually, I mostly blog about my debt and how it’s effecting my wife and I and the decisions we make. Through the wonderful talented minds here at the Mad House we’ve found a way to repay everyone’s loans in one year. Actually, we’re hoping to cut that time estimate to half a year, with a little promotional scheme.

If we were able to crystallize Cocaine and Heroin from the urine of patients who test positive than we can repay our loans in no time, maybe even buy a nice mansion or two in the rich sector of town. Here is how it would go.

A patient comes to the Emergency Room complaining of squeezing type chest pain. We’ll send a tox-screen. He’s positive. Now, a few ethical violations have to be committed, but as my grandfather says “Ethics Shmantics”.

We ask the nurse to stick a Urinary catheter (Urine catheter) in the young man (Completely unnecessary). Then, we hang IV fluids at 300 ml/hr (A mega dose). Proceeding to step three, we give him 100 mg of Lasix through his IV access (Enough Diuretic to dry up an elephant) and all that’s left to do is watch as the money slowly trickles in, our pure yellow pot of gold.

Judging by the amount of patients who currently test positive I estimate we could have one to two tons of Cocaine and Heroin ready for consumer distribution in less than three months. Some advantages:

1. Technically, our patients will be our suppliers and dealers. They, thus, will be subject to drug trafficking charges and, viola, one less drug addict on our streets.
2. If somehow we happen to "misplace" a dime bag or two, the poor, unfortunate Crack smoker will surely end up with chest pain and eventually return to our ED, only to be diuresed again. A never ending supply.

Now all that’s left is checking with the good folks over at the Drug Enforcement Agency how they would feel about such a project. After all, they stand to benefit if medical students are able to pay off their loans, this is federal money. With a little active promotion and advertising (ie: We got a great cocaine chaser here at the Mad House) we could really build a small Fortune-Five-Hundred company in no time.

The money of course would go for beneficial causes. Like paying off said debts and buying a few Ferraris for residents so that they’re never late for work again. Maybe even one or two mansions in the rich part of town so we can all sleep well.

My wife advises attaching a disclaimer: I am in no way promoting the use of Cocaine, nor, am I promoting the distribution of drugs of any kind to achieve any purpose including paying off outrageous student loans. This is for purely comical relief. Even if some genius finds a way to crystallize the metabolites found in urine and sells these, I am not taking any responsibility for supplying the idea. In reality, this is not real cocaine anyways, just metabolites, so if you want to pay off your outrageous student loans go work, you ass.

Mad House mAd school: Grandpa is Crazy, Again!

“72 y/o female Nursing Home resident who was sent by the nursing home complaining of new change in mental status”
“No man, please, I hate these admissions”
“Sorry, I don’t have anyone else”
“Whatever”
“Look, she was here last month and her discharge summary says she has mild dementia. Now, she’s alert and oriented times zero”
“Not so mild I guess”
“Shut up”
“So what do they think?”
“So far everything is negative, they’re tapping her now”
“Tapping? Wow. Who down there had the initiative to do the LP?”
“No one, I just told them the patient isn’t going anywhere without one and, VIOLA, LP is done”

An old lady who comes with acute change in mental status, meaning, she wasn’t this confused before and, over hours to days, she now is. It’s a very common admission and I thought I’d teach a few aspects of real life and med school medicine that goes into the thought process of what’s happening with crazy Grandma.

The condition is termed “Delirium”, literally “off the tracks” in Greek. It’s easily confused for Dementia but the main difference is that Dementia occurs over a longer time period (ie. Months to years, not hours to days). It’s an important distinction for many reasons, including which consults get to sleep through the night and who gets to be woken up.

Hospital Late Night Medicine:

Medicine Residents hate admissions for Delirium. I shouldn’t generalize, so actually, this medicine resident hates delirium admissions, because they are actually difficult admissions. The patients can’t give a good history (They’re loopy remember) and there are many different causes. It makes the actual diagnosis very difficult.

Usually, a whole bunch of tests are run, basically like fishing in a big pond. The most painful of these is the LP, or Lumbar Puncture. Basically, it’s sticking a big ass needle into a nice little old lady’s back and drawing some spinal fluid. Really, not fun, not for the patient and not for the resident. The procedure requires cooperation and these patients are obviously suboptimal.

My Medical Admitting Resident blocked the admission so that they would do the LP downstairs in the Emergency Room. This was huge. Not even small time huge this was GIGANTIC huge. The third year Resident saved my sorry exhausted ass a half hour to forty five minutes minimum, not to mention all the aggravation.

Sometimes the admission is fun. Mainly because Interns make the mistake of calling Psychiatry right away and end up saying something like “We have this old lady whose suddenly gone nuts” (I may be changing the text slightly but basically that’s the meaning). Usually the poor intern gets dished out by the psych resident for an obvious failure to recognize an ACUTE change in mental status which is technically a medicine problem and has nothing to do with psychiatry. I love watching interns apologize. Really, just ask Shrinkette, she gets tons of these consults, she told me so.

Medicine Aspect (Mainly for me to review, really, you shouldn’t read this. Really. GO AWAY!)

The main symptoms of Delirium are a sudden clouding of consciousness, Illusions, Hallucinations and difficult maintaining or shifting attention, as well as disorientation. The patient above was Alert and Oriented times zero, which means she didn’t know her name, where she was, or what day, month or year it was either, she was mentally kaput.

In elderly patients delirium is often a presentation of an underlying illness, most commonly an infection. Usually it’s in their piss, sorry, they have a “Urinary Tract Infection”. Patients with preexisting dementia are especially susceptible, grandpa with Alzheimer’s can really lose it with a little E. Coli.

The “official” DSM-IV Criteria: (the DSM is the manual for Psychiatric illnesses)
1. Disturbance of consciousness. (Being oriented to zippo).
2. Change in cognition that is not better accounted for by a preexisting dementia. (Don’t call Psych yet, pretend to TRY to do something first).
3. The disturbance develops over a short period (usually hours to days) and fluctuates during the course of the day. (They drive you crazy at night. You will want to calm them down, they won’t calm down. The Nurses will want Haldol, you won’t. They will scare you, telling you the patient will fall. You will give in and prescribe Haldol).
4. Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. (Good luck with that).

Some common reversible causes are: (Long list, ready?) Hypoxia, Hypoglycemia, Hyperthermia , Anticholinergic delirium , Alcohol or sedative withdrawal, Infections, Metabolic abnormalities, Structural lesions of the brain, Postoperative states, Miscellaneous causes, such as sensory deprivation, sleep deprivation, fecal impaction, urinary retention, and change of environment. Oh yeah, another is just being in the Hospital, so psycho may be nuts because she’s here and not here ‘cause she’s nuts.

In summary, here are the basic five categories: Infectious, Metabolic abnormalities, Hypoperfusion States, Structural changes and Toxic. Sometimes having your body sliced in half can do it too so it’s very common after surgery.

Hope you enjoyed my first ever attempt at sounding intelligent. I may do more of these, mostly because Blogging is interfering with studying so I decided to combine the two. You may one day even get to graduate the Mad House mAd school.

Homer in a White Coat

On most evenings I arrive for my shift in the early hours of the night ready to assist my fellow colleagues in handling the business of the moonlight. Such are the duties of the night float, cover difficult patients, help the interns, admit whoever decides to experience difficult and life changing events that require immediate medical care. Mostly, it’s the garden variety Internal Medicine stuff: Pneumonias, Cancer, Heart Failure. Excitement at night is unwarranted and largely unwanted as not enough people are there to help.

Occasionally, there are nights that remind you of why you became a doctor in the first place, like last evening. Last night all the Fascinomas in the community congregated before my shift and decided they will all come in together, a sort of intimidation tactic. A night where I wished I could hold on to the cases a little longer, at least until I figured out what, in god’s name, is going on.

These cases are complex and intriguing but instead of feeling amazed one become amazingly overwhelmed as one’s vocabulary instantly expands. It is truly incredible how many intelligent ways there are to write “I don't know”. A few of my favorites: “unclear origin of source”, “questionable significance of finding”, “consider idiopathic origin”. Heck, I'd write “Dahhhh” and scratch my head if I didn't think more was expected of me.

So if on some unfortunate evening you run across my path in your hour of need and I say something like “Well Mr. Smith, this finding is nonspecific and once the tests come back we'll have a clearer picture of what's going on”. I suggest you take out a magic marker and color me yellow, add two hair shafts on the top of my head and call me Simpson. I'm just doing my intelligent impression of Homer in a white coat anyways.

Grand Rounds

The Grand Rounds at Cut To Cure are posted and they look great. After reading this version I decided to repent for some of my sins and punished myself so that I may remember the lesson:

"Don't make fun of Surgery anymore, Don't make fun of Surgery anymore, Don't make fun of Surgery anymore, Don't make fun of Surgery anymore, Don't make fun of Surgery anymore, (AUGMENT): "I will TRY not to make fun of Surgery anymore, I will TRY not to make fun of Surgery anymore, I will TRY not to make fun of Surgery anymore, I will TRY not to make fun of Surgery anymore (Unless they do something extraordinarily stupid, or behave like Surgeons).

Mad House Brainwashing

On Saturday I braved the snow and winds in order to spend some time with my wife while we attempt to have some fun. We went to see Million Dollar Baby, the Clint Eastwood movie, a wonderful film BTW.

I haven't been to the movies for quite some time and was rather disappointed to find that we had to endure eight commercials before even the first preview began. Didn’t I pay the movie theater so that they don't have to resolve to brainwash their cliental? Isn’t this precisely the reason I came to the movies, to get away from everyday stressors like commercials? I have the same complaint of cable television, but that's another topic for another time.

It did get me thinking about advertising in general. I figure it’s only a matter of time until ordinary bloggers like you and I will have to resort to commercialization in order to attract readers. Can you imagine advertising, psychological profiling, age sector readership analysis for the average blogger? And what would a television commercial for this blog look like?

Follow me, it’s the ICU and a young Jack Nicholson emerges from the shadows wielding a syringe filled with Haldol, insanity apparent in his smile, unshaved shadow. He proceeds to inject every patient, one at a time, with the potent antipsychotic. The beds in the Unit rise and fall in unison while the nurses gather at the station and joke, ignoring the unreasonable picture. Nicholson (In a cross between “The Shining” and “One flew over the Cuckoo’s Nest”) appears intermittently, sprinting across the small unit presumably having a nervous breakdown, laughing hysterically.

Then, all at once, the patients rise from their decrepit condition and do a dance number, tap dancing on their beds as the beds escalate and fall. Suddenly, the Nurses enter in the background in a perfect line high-stepping it in a long chain, the Rocket’s in nursing scrubs.

How about the background music? I think “Welcome to the Jungle” may be appropriate. How much more disturbing would it be if the scene was set to something soothing, something along the lines of “What a Wonderful World” by Louis Armstrong. How truly insane and troubling would that be? I love it.

Of course I need a voiceover? Do I want the excitement guy? (ie: Next summer, one Resident...), or, would I be more comfortable with a story teller, someone like Morgan Freeman; “He was raised in a conservative family with deeply religious parents. Little did they know that their son was walking the thin line between genius and madness and he would continue to walk this line for the rest of his life…”. Can you hear him? Listen more closely and you will hear him breath.

Hey you never know. Coming soon to a theater near you: More Brainwashing.

Chaos

I’ve blogged about this before, this time it’s panic induced.

As most of you may have caught on by now deep thinking is not my forte. I tend to speak my mind, often wisely, commonly not. Easily affected by emotions, I let them influence my actions and my reactions. In fact, I can recall a number of instances when a few of my readers became upset at me for doing just that.

My wife, on the other hand, is quite the opposite. If ever a rule did apply we were meant to be with each other. If not for her there would be chaos running rampant through this house. As if enough doesn’t exist at work.

Well, to my point. Due to this gross immaturity I have stayed away from our checkbook, knowing full well that certain things are better done by those who are more apt and saner. Until yesterday!

Yesterday, I first got a glimpse, in an array of colors that made up our pie chart, of what we make, where we spend, how we spend, and most importantly, how most of it is now going to good old Uncle Sam, and I don’t mean taxes. My wife enters our income and expenses into a wonderful program called QuickBooks. This devious program pretends to be friendly and graciously accepts entries and performs its own calculations, how wonderful. All this work culminates in an emotionally charged finale, the summary pie chart.

Nearly half the pie to student loans? WHAT THE F#$$%%!

I am so past the being upset part, or the cursing part, or the ranting about how ridiculous this is part, or about the mental breakdown in the kitchen with a bucket of ice cream part, or about the calling it quits and declaring bankruptcy and moving to Mexico part, or even about this enormous run on sentence part. Oh, I am so past all that.

What I need now, mostly, is the advice part. Oh my god, I have a mortgage and a half on my head. Where do we go from here?

(I mean financial advice, please don’t try to make me feel better about being slammed in the ass, oh boy, I’m writing how I feel again, have to stop that)

Parody of Blog (Episode 4)- Chewing the Fat

This week's Parody features The Cheerful Oncologist and St. Nate, both fantastic reads and highly enjoyable and both available in the consult section of this blog. (Dark Yellow is a link)



“What do you think you’ll do now?”
“I don’t know, we’ll see, maybe Heme Onc”
“Can you deal with all the cancer patients and the dying?”
“Is it any different that what we have now. If it’s not heart failure it’s cancer”
“I guess”, as he throws his feet on the table, quite non-challantly.
“Guess what I have downstairs” He comes in giggling.
“You look happy, what is it?”
“No, no it’s really wrong of me. It’s not funny. But it is funny. But it’s not funny”. He hinted at a slight bit of guilt as he laughed. No, not laughed, snickered, that crafty St. Nate.
“Now you BETTER tell us”
“I have a guy who wanted to jump out a second story window”
“Get out, why is he coming to medicine?...STOP laughing, That’s not funny”
“But it is. Get this, he finally gets the courage to jump out the window. He’s all smashed from the booze and high on the cocaine and he gets ready to rush to the window and on his way to the window he faints”
“syncope?”
“HE’S HERE FOR SYNCOPE!”
“That’s fucking funny”, We all laughed. It wasn’t funny, really, but it was. Funny, really. Sorry.
“Well, sometimes even the best laid plans…”, the future Oncologist said.
“Yeah, real genius”
“I have a better one”
“Common man, I can use a break”
“Lady codes on 8 East. My Intern is in her twenty second hour of the night. The name of the patient is Ms. Smith. Well, here’s where it gets interesting. The name of the patient NEXT to Ms. Smith is Ms. Smithen”
“No she didn’t”
“Yes, yes she did”
“Get out”
“The family got a phone call, freaked, and then got another phone call and freaked again”
“What did you do to your intern?”
“I laughed at her, what else?”
“Oops”
“Oops” The life was good. It was slow, we were bonding.
“What did she tell the family?”
“Hey, you want the good news or the bad news?”
“I love Interns. They’re…Interns”
“You telling me you didn’t make fun of her?”
“All day man”
“How?”
“I kept asking her to confirm the patient’s name every time she spoke to me about someone”
“You’re going to give her a self esteem problem you know”
“Isn’t that what it’s all about?”
“What?”
“Being a doctor”
“It’s all about Relativity”
“Relativity?”
“Yes, I remember someone else who had a few screw-ups of his own?”
“Hmmmm…who might you be referring to” As he prepped for the onslaught.
“Do you really need me to point it out?”
“Na, just kidding”
“Why the hell do we do this anyways, just remind me please”
“It’s fun, in a sick, demented, ironic sort of way”
“Mostly sick and demented”
“Have it you way”

If you would like to have your blog participate in the Parody, read here.

Grand Rounds

This week’s Medical Grand Rounds are at Waking up Costs.

Some thoughts about hosting the Grand Rounds last week.

First and foremost, it was fun. Getting to read a whole bunch of new blogs which I knew were there but never quite had a chance to sit and actually dissect was very satisfying and was a great break from the extraordinary stressful situation at work that week.

Second, and the point of this post. I was watching everyone’s introduction, or link, to my Grand Rounds. Mainly to see the way in which they would characterize this blog. Some of my favorites:

DB Medical Rants: “The Medical Madhouse (our favorite pissed off resident) hosts”. Well, Dr. Centor, I am flattered. I’m just wondering, what gave the impression that I’m a pissed off Resident? What could that be? Hmmm…(Note: Every post I ever wrote)

CodeBlueBlog: “The Madman has somehow been able to put together an astute compendium despite his maddening schedule”. Yes, the schedule was maddening and yes I did manage to pull it off. How would I do that? A medical mystery of sorts? Perhaps, a future CSI Medblogs? What do you think CodeBlue?

Blogborygmi: “Thin line: Finding a narrative where others see randomness: It's either a sign of genius, or the mark of madness”. Well, thanks Nick. I think? Hmmmm…which one is it?


Shrinkette practically had to apologize for this one: “Thanks to the metaphorically-challenged doctor for including a reference to this site”. I emailed her about the "metaphrically challenegd" comment to find out exactly what she meant.

later that same day she added:
“And dear Dr. Madman, I admire your blog, very much! The words "Mad Man" and "Madhouse" evoke images, and in psychiatry we spend much time trying to counter those images. (I've posted about this before.) But anyone who aspires to medicine residency, or to understand doctors, should read Dr. Madman's blog. He brings doctors "real-time flashbacks of residency," as DoctorMental says”.

Well, I can’t be upset with her. I understand her blog is a blog dealing with psychiatry and as she states, they are trying to counter those stereotypical images. Well, I wish you the best of luck with those nutjobs (just kidding)…

And My favorite of all: “Take a hit of the Haldol salt lick at the Medical Madhouse”. Chance to Cut. I have nothing to add to this one, it is great.

Overall, thanks to everyone who contributed and everyone who came to read.

Perfect-Resident Life

It’s three AM, I am admitting Mr. Lopez for the third time this month. I’m night float, again. Yayyyyy!


I have a dream, nay, vision of a better world. In my better world Perfect-Residents exist. They are better Residents, maximally suited for today’s inpatient overload. Perfect Residents admit eight to ten patients per night. They do this by disregarding all human urges, in order so that nothing may prevent them from achieving their ultimate goal.

Perfect Residents travel attached to IV poles, a waste basket of human shortcomings that bears containers of urine and stool that are the final common pathway for the catheters that emerge from the orifices mother nature, unfortunately, installed. In my vision of the future, Perfect Residents run on hydrogen and emit only water as a waste product. Genetic alteration testing is already underway and we are going to have a working prototype by mid-summer, we’re hoping.

Their Gastric tubes are continually fed by a mix specially designed by our Pharmacy Department to include a potent form of caffeine and all the legal available amphetamines in the institution. Perfect Residents are continuously conscious having overcome the need for sleep, powered by chemical energy. G-tubes offer the distinct advantage of delivering efficient fuel that does not have to be purified and thus I believe it will make a more convenient and cheap solution. We must be cost-savvy, of course.

Thinking, as a general exercise, will be outsourced. We’ve found a center in India that is willing to do our Thinking for a fraction of the energy and manpower that we spend now. Of course, we’ve found that the Current-Resident Thinking is skewed and easily affected by fatigue and other such unimportant factors. Not to mention that intern thinking has been proven to be an exercise in futility. We at the Mad House believe that thinking should certainly be left to those who can do it for cheap, while leaving all the manpower and hands we have available for more important manual labor.

I predict a revolution. By mid-summer, with a new model up and running, Perfect-Resident will be a reality, a reality which will shake Graduate Medical Training at its core. Get ready for the new improved prototype of graduate whose soul purpose in life will be to admit, obey and do as little thinking as possible.

Doctoring and Medical “Errors”

I was asked to explain the word “Doctoring”. What does it really mean? What is it that we do?

I have dedicated a lot of my fatigued, emotionally drained brain power to this and I’ve come up short. There really is no way, without including exceptions, to define "doctoring". To the best of my knowledge, it would be: To have the patient’s best interests in mind at all times and to act on behalf of these interests.

A number of dilemmas arise and they are best explained in this example. What if your patient is eighty year old, is extremely demented, is unable to get out of bed, unable to communicate and is being fed by a tube. What if he’s become only a shred of the powerful, energetic man you once knew and that, as his physician, you know that he would never have wanted to live like this. BUT, he never wrote that down officially, anywhere.

Now, what if this same patient has a very weak heart and according to the "standard of care" you really should insert an internal defibrillator. On the one hand, you’re a good doctor and you want to protect your patient from dying and, of course, you from getting sued. On the other hand, death would be a blessing and an end to his suffering and sometimes that’s "doctoring".

Now I know, you’ll say something like talk to the family, explain this and that, etc. You will find it upsetting when I say that lay people do not understand medicine and don't have the ability to comprehend prognosis. Family members are often unrealistic in their hope for recovery and often that forces us to do things that we normally wouldn’t do just because an “indication” exists.
If the family wants everything done then we do it.

Did we act as doctors then? Is this a medical “error”? We have failed the patient but satisfied the guidline. No official error committed. How about unofficially?


p.s. If one of you can come up with a better explanation of “doctoring”, please comment.
p.s.1: Please make a health proxy now and make him/her aware of all your wishes for end of life issues: DNR in any case, nutrition and hydration. All this becomes unbelievably important regardless of your current age.
p.s. 2: I didn’t mention lawyers, although, they are ultimately the problem behind all of this. J.D. type away!

Grand Rounds: Welcome to Scut Hall

The electricity was in the air and the Mad House was buzzing. Even the *Commish and the *Giants were ecstatic, excited at the thought of the greatest minds coming to lecture at this most prestigious of medical places. Being Residents, we knew that our pagers would never allow us a moment of calm and so we devised a plan to avoid interruption during this grandest of all medical events.

And so it was that on Tuesday, the eleventh of January, that all the stretchers were collected and burned, the elevator was suddenly made to “malfunction”, and we bought the Patient Transport Department lunch, a little benefit for conveniently disappearing this fine Tuesday morning. For the few hours we needed, patients would remain where they rested and no new admissions would make it to the floor. Our pagers were to remain peaceful until the day’s end.

As the Bloggers entered Scut hall a hush filled the air and anticipation descended upon the Housestaff. As the *Commish made his way to the podium to anounce the commencement of these Grand Rounds it became clear that this was no ordinary day. And as the gavel pounded our eyes lit with anticipation, the Grand Rounds were officially in session.

First to approach the podium was the Cheerful Oncologist. He discussed a gut wrenching dilemma of foregoing surgery for quality of life at the expense of cancer growth and ultimate death. Our Surgery Attending, Respectful Insolence, empathized with this Oncologist and reminded the audience of how Surgeons often face this same dilemma and how multiple factors must always be taken into account. Ultimately, he stressed, everyone deserves at least one chance. After his speech the Surgeons and Oncologists exchanged glances in what can only be described as gleams of admiration.

Last month’s Atul Gawande article in the New Yorker has been a hot topic of conversation in the Mad House and the surrounding Blogosphere. The Surgeons admire this hero, as he is one of their own. So when Joan from Oasis of Insanity called the article Irresponsible it got quite a negative reaction from the surgical housestaff and they threatened to boycott the Rounds. Jim Hu from Blogs for Industry quickly negotiated calm by softening the accusation and pondering if the article should have been written differently?

On a more serious note, Dr. Jim Baker from Mental Notes, commented on the new perspective of American Psychiatry gleaned from post-Tsunami Sri Lanka, including unbearable living conditions. After his commentary the crowd stood in silence for one minute as we honored the tremendous loss of life incurred in this great tragedy. The Madman would like to thank everyone in the blogosphere who took it upon themselves to help with this catastrophe, by contributing and by linking to other organizations attempting to aid the suffering. Special hat tip goes out to Shrinkette for being at the forefront of directing our readers to the proper destinations.

Dr Tsai, from Morning Retort, reminded the Interns that tragedies also exist at home and discusses the case of life on a plantation with an example of children who leave traits to be desired.

Quickly sensing that the mood was becoming gloomy in the great hall, St. Nate rose to the occasion and delivered a speech about alcohol, our favorite beverage. How interesting that Journalists and Physicians have something in common, a love for the bottle. Our cravings were calling and my *Sub-I began to salivate. We knew there would be mischief in the call room tonight and many drunken housestaff officers.

On the other hand, we immediately envisioned how alcohol and violence often unite and lead to the unfortunate cases we see in our ER. That’s when Diana, from The Write Wing, was heard ranting in the corner about the new ACLS guidelines for rape victims. She was livid about the fact that there’s no mention of emergency contraception?

As the audience was getting restless calming Diana, Dr. Charles began a heated debate with the lawyers in the back row. He Included a compendium of facts released by the AMA about the current malpractice crisis. Then, a war of words broke out in the comment section. Suddenly, Grunt Doc and Bard Barker jumped in with some words of their own about the Bush medical liability plan and before we knew it we were holding the surgeon back. Dr. Henochowicz, from Medviews, quickly calmed the enraged physician by reminding him that liability law suits have never been proven to reduce medical errors and that what is really needed is changes in the system.

The curious character arguing the Attorneys standpoint held his own and wasn't even slightly intimidated. As the room became more hostile he stormed out of the room exclaiming “I will get my own Blog and then we’ll see”. The argument was brilliant, punching and counter-punching on different Urls which collided somewhere along these electric synapses. It was war, dare I say, keyboard to keyboard ‘Blogo e Blogo’ combat. (We still love you JD, even though you’re on the wrong side of the fence).

Next, Cathleen from the Philippines requested permission to speak. She discussed how her government is finally acknowledging the meningococcemia outbreak and also expressed her frustration of being unable to help. Emer, from Parallel Universe, pointed out that it’s no surprise she is confused and afraid as the local health officials are putting out inconsistent statements. We calmed the young student of medical magic and reminded her that she will have her chance to save life when she is finally ready. To pick up her spirits, Geena, one of our own CCU nurses quickly added a story of a nurse who left the profession because of all the red tape and how after all the forms and signatures we are still living the dream.

Interested Participant interjected to explain that medicine in the US is unlike medicine in any other country. He added; just imagine if you lived in England where hospitals are actually asking people to stay away!

On a more scientific note, Journal Club approached the podium and discussed this week’s New England of Medicine articles correlating CRP levels and cardiovascular events. Then, a chant of “Vioxx..Vioxx..Vioxx” filled the auditorium. Risk management, fearing legal repercussions, sprang into action to quiet the crowd.

We asked, how can lower CRP levels be beneficial for heart disease when the best medications for lowering CRP are COX-2 inhibitors? Haven’t they been proven to increase the risk of heart disease?

Robert Centor calmed the outrage by postulating that cardiac inflammation is probably different from inflammation elsewhere but Jonathen Wilde, from Catallarchy, riled the crowd again, reminding us that every person has the right to decide what chemicals he/she wishes to put in their body? And what exactly is an "unsafe" drug anyway?

Grabbing the cue on drug development, Issemelweis from our Pharmacy, pondered who is truly navigating the ship when it comes to the development of medication? Is it the Insurers or the consumers?

Obviously, this was a deep question and easily left the surgical side of the auditorium looking very perplexed. Medications?...Hah? Blogborygmi quickly recaptured their short attention span by describing his experience with Ultrasound use in unexpected places. And no, he doesn't have Tourette's.

Kevin M.D then presented a case report on a very interesting patient with some tingling in his fingers and a fascinating new rash. We wondered if some Vioxx might help?

To close out the day’s events, Respectful insolence regained the podium to deliver his best Jeff Foxworthy “you just might be an altie if” imitation that left the audience in stitches.

Our great day was over and the audience left the great hall of Scut in high spirits.

The *Interns and *Residents of the Medical Mad House would like to thank Jacob Reider for Medlogs and thanks for sticking us on the students page where no one ever goes, yeah Jacob, thanks. (Just kidding)

Next week’s Grand Rounds will be hosted by Waking Up Costs. Thanks to Nick from Blogborygmi for arranging this whole event. E-mail Nick if you would like to host.

About the Chronicles: This blog is my escape and a way of expressing myself, my reality and ,sometimes, my imagination.

Welcome to a Resident's escape, I hope you enjoyed.

Competency

A private inside look at the end of an era. See previous posts here and here

“This patient is crashing, this is the *ABG. What do you think?”
“I don’t know, what do you think?”
“This is Metabolic Acidosis?”
“If you think it is then you should treat it”
“This is the CCU, You’re the Attending, what do YOU want me to do?”
“I want you to figure this out”
“You’re suppose to help me”
“I don’t know what this is”
“Yes, I’ve noticed that you don’t”
“What does THAT mean?”
“I think you understand what it means”
“Maybe you should clear things up for me, you little shit”
“You want me to clear things up, OK, what is this patient here for? What happened to her?”
“She had an *MI”
“It’s the CCU, Everyone knows she had an *MI. What’s the main issue with her now?”
“How am I supposed to know?”
“Because I’ve told it to you for the last four days”
“You have?”
“Yes”
“I don’t remember”
“I’ve noticed”

Attending giant will hang up his stethoscope after this rotation. He told me so.

Last Call for Grand Rounds

This Tuesday's Grand Rounds are quickly arriving. Deadline for submission is January 10th, Monday night at 9 p.m. Please submit your entries to madhousemadman *at* gmail.com.

If you have not recieved confirmation from me of reciept I did not recieved the entry.

Old Nightmares

While flipping through some of the archives yesterday I came across this reader who wrote the comment below in a post about cancer:

I watched my husband die of Lung cancer about 10 years ago just before he turned 50. My belief in a great God let me know that he could be healed on earth or in heaven he could have complete healing and a new body... God can heal or call us home. If we love him, we will follow him... What bothers me most is that when I got cancer last year and I looked into alternative medicine I was shocked to learn about the Rife Frequency machine and how there has been a cure for cancer for almost 50 years. It amazes me how the FDA can pass so many bad things and squelch so many good things.... I guess in thic corrupt world money buys lots of things. I'm thankful I have a God that is in control of my life But gives me decision making power.... That is SUCH A BLESSING

First of all:
1. Please don’t ever leave a comment in an archive entry that is this serious. I don’t go through them, almost never.
2. Please run to your oncologist NOW! No alternative therapy has ever been proven to cure cancer, including the Rife Frequency Machine. Oncology may not be perfect but at least has shown success in many forms of cancer. Please RUN to your Oncologist now.
3. I don’t have the ability to have something like this on my conscience. I won’t be able to sleep at night. Again, don’t put serious things like this in the comments of Archives because I almost never see it. I cannot take responsibility for things left there. I am not taking responsibility for anything on this blog. Please consult with your doctor.

Devine Limitations

Ms. G has returned to see me. As if by some miracle she managed not to get lost. As if this meeting was supposed to take place, it said so in the stars.

She is an elderly lady, quite a devout Christian and a wonderful person. Having said that, there is one focus of frustration which she continues to add to my life, Ms. G is the chronic non-compliant patient. She attributes this to her strong belief in god and the fact that, regardless, god will save her.

“Well” I say, “the pills don’t work in the bottle you know”.

“God will save me”

“God helps those who help themselves” I said.

“Science without religion is lame, religion without science is blind. That’s Albert Einstein Doc”.

“Religion alters the mind…Tony Follari”, I retorted.

“God's Word, contained in the Bible, has furnished all necessary rules to direct our conduct…Noah Webster”. A war of quotes? Well, I certainly wasn’t ready for this.

“If you give 100%, God will make up the difference, Anonymous”, my comeback.

But it was weak, very weak. As the tide shifted in her favor she gave me a look of disappointment at this frail attempt. I saw grandmother’s eyes looking at me with those puppy eyes and I missed grandma.

Immediately, I added, “Superstition is religion that has grown incongruous with intelligence, John Tyndall”. She was taken back by this, she didn’t see it coming. Her smile made its way up towards those mature eyes, I became more nervous.

“There remains something subtle, intangible and inexplicable. Veneration for this force beyond anything that we can comprehend is my religion, Albert Einstein again, Doc”. Damn it. She continued rambling “Submission to God's will is the softest pillow on which to rest, Anonymous” and “See God in every person, place, and thing, and all will be well in your world, Louis Hay, Doc”.

Feeling outwitted I said "Surely, this must stop if you're to get better, Ms. G". She said "It must not and don't call me Shirley, Airplane".

With that all of my future plans for Ms. G’s workup went out the window and replaced with one line non-compliant patient. Alert and definitely oriented.

You know what they say “Write your plans in pencil but give God the eraser”

Widow Maker

This is a previous post I wrote back in my last CCU rotation. We saved her

I'd like to introduced young Ms. R, a 58 y/o female currently walking the tightrope between life and death. Earlier today she was admitted with a new onset MI (heart attack). She was rushed to the angiography lab where one of the critical arteries supplying blood to the heart didn't appear on the monitor- it was horrible clogged.

The “widow maker” was so affectionally named due to it’s effectiveness at doing exactly that. It is a commonly fatal stenosis of a critical artery that supplies the heart. It tends to affect fifty something year old men, fatally, making their wives widows, instantly. Ms. R had no idea of this horrible monster that was forming in her arteries and now it threatens to end everything that is her life.

I had to talk to her family earlier tonight and tell them how grim the situation looks, they cried, I had nothing to say to comfort them at all. I shouldn't, she has a very slim chance of survival and they better be prepared. At the moment she’s nearly maxed out on all the possible medication we can give her and the only thing standing between her and the *BUS (Big Unit in Sky) is the love of god and a resident with 14 months of experience.

I am scared. Back to work!

Grand Rounds

The Grand Rounds are coming to the Mad House. Again, I would like to request that submissions be made as early as possible as my schedule this month is quite brutal (see two prior entries). E-mail posts to: madhousemadman *at* gmail.com

For my readers: Sorry about the missing parody this week, brutal rotation.

Powerless Figurines

“Can I close the door?”
“Do you need to?”
“Yes”
“O.K. what’s on your mind?”
“I need help. *GIANT can’t help me”
“Why do you think he can’t help you?”
“He’s getting senile, he doesn’t remember anything, he doesn’t know medicine anymore”
“Are you sure you want to do this”
“Do what?”
“Challenge this guy”
“No, What I want to do is get you to tell the *COMMISH that you heard this”
“You think that the *COMMISH doesn’t know”
“Does he know?
“Everyone knows”
“What are you guys waiting for, why haven’t you made him a teaching attending or asked him to retire?”
“He built this place man, he’s the GIANT”
“He’s a danger. I’m all alone up there. You need to step in”
“I can’t do that”
“You’re the chief Resident. Tell the *COMMISH he needs to step in”
“I’m not doing that either. My neck is on the line if I do that. The *COMMISH is a good friend of GIANT”
“This can’t go on”
“Talk to *GIANT”
“You Fuckin wuss. You’re the chief resident.”
“I’m not crazy”
“Is this meeting over?”
“If you want it to be”
“What am I supposed to do?”
“Finish the month and you’ll never have to deal with him again”
“What about the next Resident, what about the patients?”
“Watch out for them yourself, you can do it”
“This is the CCU. You must be kidding right?”
“You’re not the first and you’re not going to be the last”
“We’ll see about that”
“What do you mean?”

As I storm out of the room the door slams behind me.

The Grand Rounds Are Coming

The Grand Rounds are coming to the Medical Mad House on January 11th. The *Commish, the *Chiefs and even the *Giants are excited. All the *SYRs are getting their vocal cords ready and their IBS all straightened out.

As always, the deadline is Monday January 10th at 9 pm. I am making a special request that the submissions be made as early as possible as my current rotation is rather brutal. E-mail your submissions to madhousemadman *at* gmail.com

Check out this week's Grand Rounds hosted by Rangel M.D. for this week's best medical related posts.

The Emperor

After a beautiful month in outpatient medicine I have returned to the train wreck otherwise known as the Coronary Care Unit. There are problems...

What do you do if the man who built this house is your Attending? What if that same man is your attending in the Coronary Care Unit? What if that man, in the CCU, has a large degree of senility? What do you do?

I understand the *Commish is aware. The administration has been “discussing” this for the last few weeks. They understand that two second year residents will have to run their critical care unit. This is what you do when your attending is a *Giant and has dementia. The burden falls on the rest, who lack competency for different reasons. The real problem is that no one tells the emperor he has no clothes.

I am unsure of myself, expected to be unsure of myself, only a second year resident. Call consults from the entire hospital and follow smarter advice. Attending can’t help, with dementia and respect. He’s become too proud to hang up his stethoscope.

My attending is a danger to these critically ill patients. He is a danger to our careers and a danger to the hospital. And everyone knows. So where do I turn to? If I call the authorities they will know it was me. Talking to him directly may get me in more trouble than it’s worth. It’s not my responsibility to go head to head with this *Giant, there are others more capable.

Dementia, senility, and lacking competency in the intensive care unit. This Attending is a legend who’s time has past, unfortunately. The Emperor has no clothes and those responsible to tell him have become extraordinarily blind.

Urgent: Bloggers Needed for Parody

Volunteers needed to have their Blogs patcipate in the Parody. Volunteer yours by emailing me at madhousemadman *at* gmail.com.