Nationwide Torture Tour

The offerings were nearly nonexistent. With the last of our patients admitted to Medicine we were able to kick back and enjoy a bit of each other, a bit of the night, some sane conversation. It was a slow night with the ambulances pouring in at a quiet pace. We gathered at the computer station and chomped down some potato chips with Doritos. All that was missing were some pretzels and we would have been in heaven, a king’s feast.

As the pure exhaustion blended with the carbohydrates, we experienced what can only be described as an amphetamine high. A tiny refuge before the alkaline tide would hit. In our delusional state we kicked around ideas as to what we would do had we won the lottery. The group exploded with laughter as I described what would be a nationwide tour where I would stop at each city, call for an ambulance and then, as I arrived at the ER, pretend to be extremely sick while giving absolutely no hint as to the cause of my illness. I would live my life as the ER resident’s worst nightmare, pure emergent tormentor.

These ER docs had a lot of experience dealing with this character and each had their own input on what the conversation would sound like. I took the liberty of writing down a synopsis of that conversation here. Those of you in the health field will probably enjoy this while the others may have a hard time understanding some of the subtle humor. I suggest you give it a try anyways.

It’s 3 a.m. in Wichita, Kansas. The Madman, half drunk, reeking of alcohol and sweat, is brought into the ER on a gurney complaining of pain.

Resident (R): Sir what’s wrong?
Madman (M): I’ve got PAIN, everywhere.
R: where does it hurt the most sir?
M: Everywhere.
R: You need to be more specific.
M: OK, it hurts all over.
R: When did it start?
M: A half hour ago?
R: What does it feel like?
M: Kind of dull, all over my chest and my left arm.
R: Are you having trouble breathing?
M: Yes very much.
R: Are you nauseous? Did you vomit?
M: Yesterday I vomited after I ate that nasty fish.

(pause…)

R: Does the pain stay in your chest?
M: No
R: Where else do you feel it?
M: I feel it traveling down to my stomach right here in the lower left.
R: How long have you had this pain?
M: About a day or so.
R: What does it feel like?
M: It’s like someone’s stabbing me, I guess.
R: Have you been vomiting?
M: About an hour ago I vomited.

(Pause. The Resident, perplexed)

R: On a scale of 1 to 10 how bad is the pain?
M: It’s bad.
R: Yeah, but on a scale of 1 to 10 how bad is it?
M: Really bad.
R: yeah, but on a scale of 1 to 10?

(Pause)

M: It’s bad.

(Pause)

R: Do you have any other medical conditions?
M: yes, I have high blood pressure and some other things.
R: Have you ever had any trouble with your heart?
M: No.
R: Were you ever hospitalized?
M: Yes, once but it was really short.
R: Do you remember for what?
M: No, they didn’t tell me.
R: Where were you hospitalized?
M: In Ecuador.
R: And you don’t remember for what?
M: No.
R: Do you take any medications?
M: About six or seven?
R: What are they?
M: One is white and this small. The other is yellow and round, you know, the yellow and round one. I take them every day.
R: Do you know the name?
M: No, my doctor has all the names, call him.
R: What’s the name of your doctor?
M: Dr. Carmen.
R: Where is she located?
M: In Mexico.

(Pause)

R: Are you from Mexico?
M: No, but that’s where I had the operation?
R: What operation?
M: The one on my heart, after my stay in the CCU.

(Pause)

Well, this goes on forever and it’s a real downhill slide. I think I’ll write one of these every once in a while for fun. Many of you can probably relate and I’m sure you’ve seen worse. Heck, many probably meet this patient every single day. Maybe, just maybe, I already won the lottery and you’ve all been meeting the Madman on his nationwide torture tour.

Genetic Future

Future Pundit has an interesting entry today about how he believes Genetic Privacy will be difficult to maintain. Basically, his conclusion borders on nearly impossible:

“The hardest part of the authentication of the identity of the DNA sample submitter would be to verify that the person who submits the sample really is the person whose sample it is. One way to solve that problem would be to require DNA samples be taken from a person in a licensed clinic. Though bribery of clinic workers could defeat such a scheme. Another approach would be to put biometric data in the form of images of irises, fingerprints, and/or other biometric information into the centralized database. Then a person submitting a DNA sample at a clinic could have their eyes or fingers scanned by a remote computer to authenticate their identity as part of the DNA sample submission process.

I still see such an elaborate regulatory system as fairly easy to defeat”.

I agree.

First, I will preface by stating that I am not an expert on the issue, not even close. However, I would think that the issue of genetic privacy would be more immediate if such information was to be used by independent for profit companies. For example, if my insurance company was to use the information gleaned from genetic testing to determine my premium (Without my permission) I would find that a violation of privacy (As a side note: Life insurance companies conducting genetic testing before acceptance of cliental in inevitable and will probably be standard procedure). Same as if an independent company acquired information of my predisposition towards Parkinson’s disease and attempted to sell me services based on this information. However, laws can be enacted against this kind of commercial information sharing.

If someone (a person) I know attains information about my DNA, by obtaining a sample and sending it to an independent lab, then I believe that to be an unfortunate consequence of an invaluable technology. I can’t see how it differs in any way then what we have today. Personal medical information is protected by law today yet, one’s medical records can easily be accessed by someone working in a medical clinic, a hospital, or a nursing home. In order to obtain someone’s private medical information one would simply bribe a clinic worker, same as the solution suggested in the above entry. The question remains, if the information is not used for the purpose of ultimate profit, of what use it would be?

Of course, companies based off-shore could easily use this information for profit. Such endevours would hardly be difficult and would resemble many that exist today. Thus, they would avoid any legal ramifications of medical privacy that exist in the US.

The most worrisome consequence as I see it is that companies, seeking to create profit, will misinform the public about their true risk of acquiring a condition based on a persons DNA profile. As always, a certain condition is usually a combination of nature and nurture, one's environment combines with genetic predisposition to create disease. The non-medical layperson would not be aware of this and thus would make himself a prime candidate for such unnecessary expenditures.

Update: Future pundit integrated this post into the entry above and answers my question, quite well I may say. so go on over and learn a little something about what's to come, it's a great read.

My Point Exactly

Symtym brought this to my attention. In a related post I wrote a few days earlier concerning some of the detrimental effects of the ER on patient long term health and the unnecessary testing some patients endure.

DB chimes in

From Rangel MD

symtym responds

Medical Malpractice Courts

Ann Althouse brought this to my attention: Via the NYT:

“New York State is ... creating a homelessness court, domestic violence courts and mental health courts. Backed by the state's chief judge, and bolstered by the court system's own research, these new courts are, among other things, trying to cut down on the number of people who appear in courtrooms over and over again.Judges - who in law school may have mastered the rules of procedure or the penal code - are now meant to know about the science of addiction, the pathology of wife batterers, the bureaucracy of welfare programs...."It's a very important new revolution" in the way courts work, said Bruce J. Winick, a former city health official who is now an academic expert on what he calls "therapeutic jurisprudence."And while New York and California are at the forefront of this movement, there are now hundreds of such courts nationwide, from Hartford to Honolulu, addressing problems like drug abuse and drunken driving; Anchorage opened a court last year dedicated to dealing with the problems of veterans”.

Interesting, especially in light of the recent proposal to create special medical malpractice courts. Do the folks at NYS actually believe that medicine is less complicated than understanding the common problems of homelessness? the science of addiction? C'mon.

I guess it’s a step in the right direction. But really, if they don’t come around real soon, well, that’s just a slap in the face.

Grey's Anatomy- A Short Update

You know that I had to miss this week's Grey's Anatomy. But what's this? I hear that Cristina Yang (Sandra "You're gtting married" Oh) is now sleeping with Attending Preston Burke?

What?

Wasn't she chewing him out the other week? I guess she really wanted to "Chew him out"! I haven't seen so many interns sleeping with Attendings since, well, since...The House of God. Even then, it wasn't with the Attendings it was with everyone. Oh man...are you telling me I went to the only asexual hospital in the US? damn it!

Grand Rounds

This week at Tony's

The Technicolor Dream Coat

This big burly Russian was obviously in severe distress, he could barely get the words out. I said “Sir, how did this happen?”

He Responded: “I am not talking to you, you are not doctor”

Not doctor? What? I often feel like an intruder in my own body but to have someone reinforce my lacking self image, well, this was a first. A patient, no less!

“Sir, what do you mean I’m not a doctor? I assure you that I am”

“No, You no wear white coat. You are not doctor”

Well, he was right. It was really warm in the ER and so I had taken off my white shell opting instead for the stolen medical school scrubs that I often sleep in.

“Yes, you’re right, but, I really am a doctor”

“No, no coat”

I left to get my coat. When I returned we were able to have a civilized conversation where I calmly explained that the information I know is, in fact, in my head. I almost never need my coat for anything, it is a pointless authority symbol.

He apologized and then asked more about his condition and what treatments would he have to undergo. I explained. He said he wanted to speak to specialist. So I paged the GI fellow overhead. He called back and took down the consult. He said he’d be there immediately. To which I responded “Don’t forget your white coat”.

Great Point

Carsten made a great point in an earlier post about the patient who came to resolve her diarrhea. It goes like this:

Wow, $400? That same workup at my facility would cost:ED Facility fee: $465ED Physician fee: $120Venipuncture: $47IV Fluids: $175CBC: $52Comp Panel: $110Stool Cx: $145Various other lab tests: $100+U/S Facility fee: $2,200U/S Radiologists fee: $150CT Facility fee: $3,500CT Radiologists fee: $200I didn't do the math, but getting clost to $10,00, and the patient was cured using an OTC medication that costs a few dollars.Isn't it great that we provide care for those who are unable to pay in the most expensive way possible - the ED?And the lawyers keep trying to say that defensive medicine is a myth.

I'm sure it costs close to the same at the Mad House. I guess my conservativ figure of $400 was, well, optimistic.

Update: Symtym decided to examine the post quite carefully, even threw in a few pennies of his own. I especially like where he says "effieciency and internist should not be mentioned in the same sentence", ouch!

Nick, for a second even thought I softened up a bit (Check out his comments)

So Who Did the Disimpaction

Via Medpundit:

Check out this photo and read the description (don't worry, the photo is vomit safe) . Then, based on what you've learned on this blog you need to guess who did the manual disimpaction:

1. The Attending
2. The Resident
3. The Nurses
4. The Intern

If you get this wrong don't ever come back here again!

Emergently Jealous

The last two weeks, knee deep in emergency room medicine, managed to redefine what I initially saw as a deficient specialty. I wondered what the need for such a specialty was. After all wouldn’t an emergency room run just as smoothly with a medicine attending on the medicine side and a surgeon on the other? In fact, I hypothesize that it would even run more efficiently. So I did a little digging that inspired this rant.

The origin of emergency medicine began with a need for physicians with multiple skills and who can handle a wide range of medical issues, more specifically, emergencies. Previously, emergency rooms were staffed with various specialists who were “covering” the ER. This would mean that a Motor Vehicle Accident victim would be seen first by a specialist unfamiliar with the intricacies of such a case (i.e. Infectious Disease specialist). Ultimately, this led to a delay in proper treatment.

The idea first surfaced during the Korean and Vietnam wars when physicians who were caring for the wounded there recognized that procedures utilized on the “front” could be used at home to improve quality of care. Previously, care often did not begin until a patient arrived at the hospital. This delay in appropriate management worsened prognosis and led to higher rates of injury and death. In 1966, the landmark report, Accidental Death and Disability: The Neglected Disease of Modern Society, described the deficiencies in emergency care and brought to the forefront the need for a more immediate response. Then, on August 16, 1968, a group of eight physicians who shared a commitment to improve the quality of emergency care met in Lansing, Michigan, to form the American College of Emergency Physicians (ACEP). Ultimately, the American Medical Association’s recognition of emergency medicine in 1979 as the twenty-third medical specialty led to the establishment of 132 fully accredited emergency medicine residency programs. In 1985, Congress enacted the Emergency Medical Treatment and Labor Act which mandated that all patients who come to emergency departments be given a medical screening examination and be stabilized, regardless of ability to pay or insurance coverage. The specialty continued to make headway from there and has evolved into what it is today.

The Mad House is a level one trauma center providing emergency care to a large underserved urban population. A level one center means that most of the truly distressing cases come our way. Over the last two weeks I’ve gotten to see the need for specially trained physicians. For example, one area where Internists would be poor would be at establishing an airway. Our training does not prepare us for this and these guys in the emergency department do it all the time. I can safely say that many of those in our community owe their lives to exactly these skills, provided at the right time.

On the other hand, unfortunately, many in our community have made the Emergency Department their primary care provider. They come to the emergency room to obtain care for non-emergent problems. This is unfortunate because the ER was not intended to provide this care and, often, they will simply stay out in the waiting room for hours on end to obtain a prescription, or seek medical advice about routine medical issues. More worrisome is the fact that many will end up receiving unnecessary tests to rule out emergent disease, as this is the primary goal of the emergency room physician. These tests carry risk, and increased cost. For example, last night a lady waited in the emergency room for treatment of acute diarrhea that she’s had from the morning. She was finally seen at ten at night. She was given Imodium, which stopped the diarrhea. However, someone noticed that her oxygen saturation was low, which led to a Doppler, and then a spiral CT scan. Nothing turned up. Forty hours and four hundred dollars later, she finally went home, free of her bowel difficulties.

I think the biggest gripes internists have with the emergency department is their lack of foresight into the continued management of the patient. This is especially important because if one knows what information will be needed they will appropriate treatment as such. As an internist, I know that the time to make the diagnosis is in the first few hours the patient presents. This is the time that lab values mean the most (for example, urine lytes), that cultures make a big difference, that an Arterial Blood Gas or a fundoscopic exam could save weeks of back peddling. Often, the need of the emergency department to rule out emergent disease, or just the fact that it is so busy in the ER, interferes with obtaining the proper evaluation. Even something as simple as giving fluids unnecessarily can make the search for the etiology new renal failure extremely difficult in the absence of urine tests before fluid was given. This is the shortcoming of the specialty. By confining oneself to acute presentations one loses a true understanding of continued management, and, in certain patients, can even be an overall detriment to the patient.

Overall, I am kind of jealous of these emergency room physicians. I think that we as internists lost a lot when this specialty came into existence. The entire chapter of “presentation” is missing from our clinical experience. “Stabilization”, an art in itself, is too. For me, this is the exciting part of medicine, when the life of the patient is in your hands and the knowledge you’ve labored to learn can really make a difference.

I often put down emergency physicians. Heck, let’s face it; I put down everyone BUT internists. They don’t deserve it. So take if for what it’s worth, my small attempt at a grammatical wink, a devilish smile. Of course, I also know how to poke fun at myself. Just not right now, we’re rounding. After that I have attending rounds, then chief rounds, then chide of service rounds. What can I say, as internists, we’re really well-rounded people.

So Serious

Oh, she is smiling now. It’s just so hard to actually capture it on camera. Every time she sees the lens she gets so serious.

There won’t be a roundup of Gray’s Anatomy tomorrow. I’m on call tonight in the Emergency Room. If any of you publishes one I’ll be happy to post it here, just email it. I know, you’re devastated!

Tangled Bank

Check out the Tangles Bank at Circadiana. Also, wish the bank a happy anniversary.

More on Grey's Anatomy

First, my Surgery consult answers.

Second, they've done the one thing you never ever want to do as an intern. They've pissed off the nurses! sleepless nights are coming.

Medical Grand Rouds are at Living the Scientific Life.

And last but not least, welcome back Charles. How about a vacation from the vacation?

Grey’s Anatomy- Shake Your Groove Thing. A Resident’s Perspective

Welcome to Seattle Grace Hospital, the setting of the new ABC show about five surgical interns trying to make it through their first year in of residency. Apparently, surgical residencies in Seattle recruit only models these days. Coincidentally, this was also one of the themes in this week’s show.

Another, BTW, was the apparent complete disrespect that Interns can show Attendings without worrying about repercussions. During last night’s show, Sandra “You’re getting married this Sunday” Oh, who plays Cristina Yang, decides to code a patient who is DNR, defying direct orders from her attending. Not only that, in an earlier scene she calls him an outright liar. Of course, Kathryn Heigl (rrrrrr) and Ellen Pompeo (rrrrrr, rrrr) both decide that it’s ok to show Attendings up as well. Aha! Yep, very realistic (If you’re aiming to lose your residency).

I have to hand it to the writers though because the plot is pretty interesting. Patrick Dempsey (Apparently playing a Surgeon who can cross cover as a neurosurgeon who needs no prior films before doing extremely dangerous procedures) is secretly dating Dr. Gray. This allows Pompeo to have a little more free time on her hands than most other surgical interns. She used this time to make a great diagnosis of a likely brain tumor, which is very impressive for a Surgery intern (Sorry couldn’t resist). Also, she has a heart to heart conversation with another patient’s wife about whether life is worth living with dementia. Let’s examine this week’s show:

This week’s plots:

1. Nurse Fallon and pancreatic cancer

On the whole this plotline was very interesting. Pancreatic cancer is one of the tragedies of medicine. Mainly because by the time it causes symptoms it usually has spread to other organs. Currently, the treatments available to cure pancreatic cancer are not very effective and most patients die. Dr. Yang (Sandra Oh) befriends this nurse in an apparent attempt to scrub in on a Whipple Procedure. When the procedure never gets scheduled she finally understands that the patient has come to the hospital to die.

This was a bit surprising because many patients who have pancreatic cancer never get operated. The Whipple is an extremely difficult procedure. Quality of life following the procedure is not great. Therefore, if a patient has advanced pancreatic cancer most of the treatments are actually aimed at symptomatic relief. I’d expect that Dr. Oh (who is highly motivated, it seems) would have already known this or that the writers would have worked it in somehow. But this storyline was very attractive anyways.

The death scene was pathetic with Dr. Oh trying to single-handedly revive Nurse Fallon, in spite of direct orders to stop and a DNR order. Not very realistic.

I would have also liked the conversation of a hospice to have come up. A much better way for terminally ill patients to die.

2. Mr. Humphrey and the prostate cancer

Mostly to highlight Kathreen Heigl’s, who plays “Izzie” Stevens, previous career as a model. Apparently, she did this through medical school to survive and keep herself out of debt.

First, I WISH I could have done this to keep myself out of debt (feel free to use the amazon link in the sidebar).

Second, it seems that the producers are motivated to keep her in underwear onscreen as long as possible (Thank You).

Third, she did highlight the fact that most medical students incur great debt to do this job. So give us a break hah!


3. Jorge Cruz, brain cancer and nails in head

Mr. Cruz mistakenly pumped his skull full of solid nails after losing conscience and falling. The x-ray films were amazing. As an internist I’m not sure that there was a real necessity to operate immediately as the patient had a stable blood pressure and pulse. But, who am I but a simple medicine Resident. I will have to refer to my surgical consults for help on this one.

Patrick Dempsey felt this was a medical emergency that deserved immediate surgery. Apparently, in addition to dating Interns he also operates on brains. Cool job.

But the story was mainly a side plot to introduce Meredith’s mother, who was a very motivated surgeon who now has early onset Alzheimer’s. Very tragic. Meredith decides to have it all out with the wife (unrealistic) about quality versus quantity of life. I liked the plotline because it discussed these underlying issues, as if Terry Schiavo wasn’t enough.

Best line: "If you make your Resident look bad she'ss torture you until you beg for your mama"

Well, that wraps it up. Overall, I liked the show. It’s a bit unrealistic but its network TV, so what did you expect. The cast seems to have great chemistry. Of course, it doesn’t hurt that they’re light on the eyes too.

We’re a Team

Our first month with Future Intern has been one of the most amazing, frightening, difficult and rewarding experiences of our life. I can honestly say that I love this little girl more than I ever imagined. I think that it’s truly amazing, this feeling, a love for something that does not give back and only demands more. Yet the love is unconditional and ever open handed. Take what you please.

In many ways I think we had no idea what to expect. It hit us like a train wreck and maimed us groggy. Sleepless nights, crankiness, horrible emotions of inadequacy, of being unable to cope with a small baby, one small baby. I care for twenty critically ill patients and one small baby had me demoralized. The winds of change in this house hit us like a tornado of chaos.

But we emerge one month later stronger than ever. We have conquered the first battle and made an ally. For now, we are better parents, we understand future interns and most of her future intern demands. Future intern is sometimes hungry, sometimes tired, sometimes she has something in her diaper and sometimes she is just damned cranky. But ohhhhhhh….Awesome!

She is going to make one awesome Future Intern.

Some posts you may have missed

This week's COTV was a disappointment. The posts submitted were great, however, the host did a less than desirable job. In fact, he upset quite a few people and some unworthy language was used in the comment section. In fact, I think that it's really not worth linking to.

This post really caught my eye. It is by Pharyngula, a purely scientific blog if there ever was one. PZ knows how to write and has easily become one of my favorite reads. This post in particular deserves special attention.

This post by Running Creek was a firsthand account of a serial killer, up close and personal.

Welcome to the NEW Mad House

I’ve wanted to change the look of this page for quite some time now. Finally, I decided on changing the template and toying with it just a bit.

I made that new banner today. I think that it’s “snazzy”. Some people might mistake it for “Chronicle of a Mad Medical House” or “Chronicle of a Medical Mad” since the word “House” is kind of hard to spot. Nonetheless, after a few different creations I decided to go with this one.

As you can see, Madman 2 who was one of the two frontrunners clearly won the competition and took his rightful place in the banner.

I also added Haloscan. Now people can have a much harder time commenting BUT I have trackbacks. Other bloggers will be able to link to my absolutely pointless stories. I promise to have more points in the future. Maybe. Actually, I take that back. I will remain pointless.

In the end, I changed to this template because I wanted the links on the left and I think that it’s easier to read. Now, I just have to figure out what else to stick in the sidebar.

Maybe more change will come, maybe not. Hmmm…the suspense is killing you isn’t it?

Thanks:
First, thanks to St. Nate who took the time to help me figure out this code thing so that I know how to add a banner.

Second, thanks to my cousin for the Madman.

Third, thanks to my readers for taking the time to read some of these pointless rambles, I promise to have many more in the future.

The Skeptics Circle

Check out todays skeptics circle at Socratic Gadfly.

Im also probably really late with this but Grand Rounds was over at Grunt Doc this week and it's a great read, especially that first post (finish what you're eating first though).

Tubing

I’ve placed so many lines recently. I’ve been pondering a career in plumbing. My rotation in critical care medicine is an experience in artificial life. The supplementation of life and energy to those condemned to die. This is a chance at recovery that was never available before, most of these people would have been long gone. Some may walk out of here now and some may leave here in a stretcher. Any which way, I still haven’t met a human being who told me to let him die.

The machines can be intimidating. I Tired of machinery. Ventilators, monitors, dialysis machines, techs, and nurses all grab for my attention at once, all of them demand it. The machine screams, apnea, cardiac arrest, false alert, defibrillate, stop this at once. Do they take out the garbage too? Yes?

My patient couldn’t breath I put a breathing tube in their throat. They can’t pee I place a line in a bladder, can’t crap I have a tube for that. I have a tube for medications and one to monitor blood pressure too. Stick a line in their nose that goes down to their stomachs. So many lines. And now they are on-LINE. All in my blog and my mentality and my dreams and my life. It’s all one, one translucent halogen life. It is taking its toll.

The Medical Intensive Care Unit

Future Intern Strikes Again

I think someone showed Future Intern her future schedule

The Lines Intersect

Future Intern has blurred the lines. Some of the latest mishaps in my ICU (usually at 3 am):

Conversation 1:

Nurse: Doctor, mister Jones blood pressure is 80/40.
Groggy, Tired Me (GTM): What is it again?
Nurse: Eighty over forty
GTM: Give him four ounces.
Nurse: What?
GTM: Similac, give him four ounces.


Conversation 2:

Nurse: Mr. Jones is agitated
GTM: Did you check his diaper?

Conversation 3:

Patient: Doc I’m having trouble sleeping at night
GTM: Do you take a bath before sleep time?
Patient: What?
GTM: Try a bath and THEN take the bottle.

I need more sleep.

Update: That last patient started sleeping a lot better now that he takes a bath before sleep time.

The Tangled Bank

I have to say that the Surgeon outdid himself this time. Orac is hosting Tangled Bank and has done such a wonderfully creative job that I couldn't resist linking to it (The fact I was included helped, I must admit) but truly it is something fantastic.

OK, I'll give it to surgery this time, but, they better not get used to it.

On Call All Weekend

So I was on call in the ICU most of this weekend. Yes, it does feel something like this.

Hat tip to Pharyngula, thanks to Yowling From the Fenpost.

Check out your own South Park Character