Spooky Grand Monday

And I thought Grand Rounds were a Tuesday thing. Oh well, it's Halloween, strange things happen.

Those Difficult End of Life Decisions: trick or TREAT. Happy Halloween Everyone

How Many Have You Killed?

Yesterday my most stable patient arrested. She was admitted as a purely social admission one week back, she was found without food or a place to stay and was brought to be placed in a homeless shelter. It was around lunchtime that her heart stopped beating and I was told that she was found with food in her mouth, turning blue and unable to breath. Shortly afterwards her heart arrested and we were able to bring her back fifteen minutes later. The chance of meaningful recovery is miniscule and I’m afraid that she would have probably been better off dead. My only conclusion is that she most likely aspirated her food.

I have to admit that the news really shook me. Whenever a patient dies I question myself as a physician. What was missed? Was I to blame? Was there something I did to provoke this? Could I have prevented this? Was there something I should have been doing differently? Were there any clues?

Sadly, the clues are often hidden. Which makes hindsight so cruel because it makes so much sense. But interpreting a human being is so difficult in real time. Looking back, my patient lost a lot of weight; she vomited once or twice during the week she was there. Last week she hinted that sometimes she has trouble swallowing and I was monitoring her to see if it was true. After a few days of trouble free intake I concluded that her ability to swallow was intact.

I’d like to say it’s the first time I failed to put two and two together but that would be a lie. Unfortunately, experience in medicine is paid in the blood of others. How many will pay before my mind and senses work as one god only knows. Until then, the clues will hide in scripted notes written by interns and residents and consult notes. One day the hints will jump off the page and present themselves as clearly as the moon in the night sky. Until then, I will be the evelasting student.

How many have you killed?

Hindsight is so cruel to the physician.

Conversation

Random conversation with an acquaintance

"Oh man, my back is killing me, I should sue that bastard"
"how long have you had it?"
"Ever since the accident"
"What accident, are you talking about that one you had when you were twenty?"
"Yeah, the Orthopedic repaired my pelvis after it was shattered, my whole acetabulum. After that they laid me out in bed with pulley's connected everywhere. My right leg is slightly longer than my left due to that idiot and now I have this chronic back pain"
"So now you want to sue him?"
"yes"
"Because you have pain in your back"
"yes, if he didn't tell me to lay in bed I wouldn't have this pain"
"Yeah, but didn't he save your life?"
"What do you mean?"
"If he wasn't there to put your pelvis back together after you fell asleep behind the wheel you would have been crippled for the rest of your life. At least you're walking now"
"Yeah but I have this pain sometimes"


Why do some people fixate on the most insignificant details while missing the big picture? We've been spoiled. Rotten now.

It's Been a Long Time. Grand Rounds

The Grand Rounds are up at Hospital Impact and it's been a long long time since I've plugged it. Shame, it's where I first got started and got noticed as a wildly entertaining and informative blog. Right?

Looking through some of the posts I'm amazed how I've managed to not notice all these new medical bloggers out there. There's some great med-blogging going on and some fantastic new writers. I guess it's time to update my link list.

Other Updates: the Amazon ad has been removed from this blog just in time to hide it's author's desperation for medical school loans repaymeny funds. Well, don't worry about it. This blog is free and I don't ask a penny of you to read it. Not one penny. Even though I waste my precious time solely to entertain my readers. Time when I could be making money to feed my ten starving children and my anorexic, not by choice, dog. But really, don't worry about it, you just go ahead and enjoy this blog. BTW, thanks for buying from my amazon portal. The 92 cents I made are now invested in a retirement fund. I hope to net 32 cents by the time I'm 65.

My links were updated last week. I managed to remove some of the now inactive blogs and to add one new one. This, no longer anonymous med-blogger (since he's been on the 'blogs of note' this month) Ah yes Medical School. It's pretty entertaining and he's chosen the blue template. The same one I chose to begin with before I updated to this new and much more hip template- That I really need to change.

Grunt if You Like It

GruntDoc recently gave an interview to Kent Bottles that he posted on his site. In spite of his own assessment I found the interview interesting. I also thought that it was entertaining to hear what he actually sounds like.

Some very funny moments when he was asked if he would do this again. I think the awekward pause he managed to mask with the old "aaaaaaa....." (must've been thirty seconds) was hilarious. I can only imagine what was going through his mind but I know the feeling: "I would, heck no I wouldn't, yes I would, no way, yes, no, yes, no, heck I don't know, what the hell else would I do anyways..."

When asked about his favorite blogs he must've simply forgot to mention this one. I'm sure it was on the tip of his tongue but the tension of being interviewed made him forget the name "CHRONICLES OF A MEDICAL MAD HOUSE!!!!" Right???

I was also asked to be interviewed but so far I haven't come to a decision if to participate. I can't imagine I'd have anything interesting to say. Frankly, I think some of my answers really depend on which side of the bed I wake up that particular morning. Some of the things that would come out of my mouth may just really frighten my readers. Of course no one wants to hear that.

Supersize It

You remember that joke from the House of God about the patient who had a blood pressure of “Patent Pending/150”? For those who never read the book (You better read it): The words “Patent Pending were written at the top of the mercury column used to measure the blood pressure. Since the column would go no higher than this then the man’s blood pressure was “Patent Pending/150”.

So when I walked in one morning and checked my census it was no surprise that there was an extra patient or two, there usually are as the admissions that came in over night get assigned. Looking over some of the information available on the system I noticed something peculiar, and frightening. The official weight of my new admission was “>800 pounds”.

I know, you curious as to why use the “>” sign as opposed to an actual exact weight. In short, our beds can only record weights up to 800 pounds, anything over gets recorded as “Who knows, god help you” or “>”.

At first I was sure it was a mistake. Must’ve been someone who was trying to enter 80 and simply, mistakenly, pressed the zero an extra time. Could this be real? Can any human being really be bigger than 800 pounds?

When I arrived in the vicinity of the room I could already smell the stench. There was a smell that was slowly charging upon the ward and it was terrible. At that moment I had a bad feeling that this was probably the real thing. And it was.

Laying in bed, in moderate respiratory distress, was the biggest person I’ve ever laid my eyes on. His bed took up the entire room, it was the width of one and a half hospital beds and it was barely holding his massive thighs from unhinging the railings. Mr. Micheal K. had a very bad case of asthma. He was wheezing heavily. I could hear him from across the room.

I introduced myself to the giant who quickly turned out to be a gentleman of large proportions and I told him the treatment he would receive and that I hope that he’ll respond quickly and that we could return him to his home as soon as possible. I proceeded to do a physical and had to change sides of the bed to finish my abdominal exam. Palpating anything in his abdomen was impossible. My note said something like “Wheezing bilaterally, cannot effectively examine rest of patient”. I hoped to get him out fast.

Boy, little did I know.

Later on that day Micheal had a massive upper GI bleed. Finding veins for a large bore IV was impossible. Central lines were too difficult but luckily some poor surgical intern was finally able to do it, somehow. We began repleating blood. “Page GI! STAT”.

Micheal was getting worse by the minute. He had multiple large black bowel movements and was vomiting blood by the buckets. Getting a blood pressure was also impossible. Even our largest cuff didn’t come close to being appropriate. Any CT scans were out of the question since Micheal would probably break the machine and certainly would have severe difficulty fitting in the CT machine.

Due to his severe asthma, doing an Endoscopy was very dangerous and the Gastroenterologists would only agree to do it if he as intubated and only if it was done in the operating room. Somehow we pushed the bed through the halls and up to the operating suite. ENT came to do a nasotracheal intubation which was nearly impossible. It took the chief ENT resident nearly five minutes to find his trachea. Micheal couldn’t be anesthetized due to his pulmonary status and was writhing in pain from the intervention. Finally, he was intubated, awake, and bleeding.

The Gastroenterolgists went in. It took a little time but eventually we found the bleeding Duodenal ulcer that was causing the mayhem. It was cauterized and the bleeding stopped. Micheal was extubated and in severe respiratory distress.

He somehow came out of it after some asthma treatments. The rest of the hospitalization was unremarkable. He left three days later. I don’t know where he is or if he is. Hope his situation had improved but I’m a pessimist.

The WSJ Loves Me???

Recently, the Wall Street Journal published an article regarding medical blogging (Republished here). I was surprised to see this blog mentioned. It’s described as “An anonymous medical resident blogs about the often chaotic world of doctors-in-training”. Which got me into thinking, is this really about the chaotic world of doctors in training?

I think it’s more about my perception of this world. It’s about both my personal and professional experiences and the thoughts that they provoke. Everyone’s experience differs and my experience is, by no means, universal.

I began this blog because I love to write. In the beginning, I wrote more personal things. Eventually, I stopped writing this way for various reasons. I began to discuss some relevant medical issues, but let’s face it, this blog is medical in the same way that porn stars are actors, meaning, if you think it is than you’re really not paying attention.

I never wanted to be a physician. In high school I was a brat. So, I was accepted to a city college. I dropped out twice. The first time it was because my father got sick and I needed to help at home and the other because I found nothing that interested me. I rarely studied in college which earned my rightfully deserved Bs and Cs. Actually, I always saw myself as a businessman rather than anything in the medical field. Probably, I would have made a much better malpractice lawyer than a malpracticing physician.

Later, after getting fired from my third salesman position I decided that I would be better off a professional. After returning to college and discovering medicine I took all the pre-med classes in two semesters and applied to medical school. So it was no surprise I was only accepted in Israel, in spite of doing extremely well on the MCAT. In the end, those slacker years (and the GPA they destroyed) returned to bite. So why am I telling this story?

According to the article I am the representation of the common thoughts of “doctors in training”. I really doubt my fellow residents have the same thoughts as I. Many of them grew up wanting only to be doctors. They are more serious, more committed and more devoted to medicine than I can ever be. I constantly question why I entered this field and if it’s the right one for me and it reflects in my writing. At times I write about how happy I was to save a patient or how sad I was to lose one. Sometimes, I hate this field. I can also write about how to kick patients out or how disgusted I am with malpractice litigation and the patients who decide to sue. I run the gambit on dispositions and moods and it often reflects what my experience is at a certain point and time.

Not for one minute do I think that this is a universal experience and neither should you. I make no apologies for what I write simply because I don’t write it for others, I write it for me. It’s my therapy and if it upsets you than don’t read it, it’s there to save me the money I would spend on psychotherapy. God knows I need it.

Don’t misunderstand, I am honored to have been mentioned in the article along with some of the really fine medical bloggers out there. I’m very happy some of you take the time to read through my posts. But please don’t take this to be the thoughts of every doctor in training you meet. It’s really the random, crazy, obnoxious, passionate and personal feelings of a business career gone haywire.

First Rule of Residency, Eat When You Can

Friday: the Worst thing I ever asked my Intern to do. Poor Intern

Back on the wards and, as my readers know, this means the "Friday 10 Random things I asked my Interns to do today". However, today I asked my intern to do something so infintismally (is that a word?) gruesome that I automatically deferred the other nine for next week.

As we were rounding on our 450 pound man with horrible CHF who can't even get out of his oversized bed he decided to give us the most colossal of complaints (for him). He said "Doc, I'm having the worst pain in my ass that I've ever had". I mean, those words (and their implication) produced substernal chest pain in me to the point of admission. Luckily, I already served my punishment in my first year of residency with my 800 pounder (let me know if you want the full story). So the joy of this complex rectal was all my intern's to do. Do you remember that joke, the one that goes "How many Interns does it take to perform a rectal exam on a bedbound 450 pound man?"

Four! and it is quite a scene.

You Guys are Even Meaner, I Love It

In Response to the prior post, with which I expected half a dozen readers to write about how disguisted they are, some of the readers actually surprised me. How you ask? Well, it seems that some of you have a mean streak I could only dream of For example, Barbados Butterfly who really would let this patient have it:

- order a 24h urine collection & QID blood sugar levels with your diabetic work-up.
- find an embarrassing illness & discuss it loudly on ward rounds (tinea, bleeding haemorrhoids, some rash that isn't scabies but by golly it could be, we really should start scabies treatment & put him in the room with that other guy with scabies. Caution: do not do this if it will mean that the patient needs a single room).
- that rash won't get better if you shower with hot water. It should be somewhere between cold & tepid.
- no smoking & no alcohol. Cigarettes are tools of the devil. Make your patient understand this. And you need to put him on an alcohol withdrawal scale chart. Particularly overnight.
- strictly enforce a sitting out of bed policy between 0700 and 2200. You don't wanna get DVT, do ya?
- get physio to crack the whip. There'll be no slackers on this ward! NB. Check first that your ward physiotherapist is not a petite, svelt, attractive blonde.
- send every medical student in the hospital to do a long case on the patient. Send the short, slow medical student with the weird laugh. Tell him that you want a full dermatological, childhood and sexual history. Ask him to get some skin scrapings from that rash. Possibly even a punch biopsy.
- order chlorvescent rather than slow K for potassium replacement. I've only met two patients who liked the taste of chlorvescent; both were demented.
- vitamin D levels are often low. Caltrate tablets are big.
- Hip protectors are really cool, dude/dudette. And they're for your own safety. Put 'em on.
- Strict bowel control. A bowel chart with faecal descriptions. There could be colorectal cancer. We want regular bowel actions & we're gonna give you all the bowel meds you require to get you there. (this does not work if your patient ENJOYS discussing his bowels).
- early morning urine collections (three) for TB. What time is early morning? You decide.
- Nasogastric tubes.
- Abdominal ultrasounds. They're indicated for many reasons, require patients to be nil by mouth & often the non-urgent ones get delayed, & delayed, & delayed. Especially if there's some confusion as to who is ordering the test.
- Nightly reviews by the night intern. "Sorry to wake you, just wanting to check how the bowels/rash are going... and did you see that storm in Texas?"
- If there's a higher than usual risk of DVT you might need to order q8h subcutaneous heparin rather than just the standard q12h. Certainly don't give daily enoxaparin.
- If the IV is just a little dodgy you can avoid causing the physical pain of the IV insertion while inflicting the pain that is an iMED beeping ALL NIGHT LONG.
- Barium or gastrograffin swallows and enemas.We know the Shem Rules and how to do as much nothing as possible. But some patients need you to go all out if you are to get them back in the community where they belong.

And the best of all from Kel since I would have never thought of it:
The patient was discharged home and refused so the bed was discontinued from his room.

Oh boy, that's evil. I'm so proud.

The Resident’s Guide to AMA

There were also patients that were grateful. It’s certainly hard waking at five in the morning to get to work but the satisfaction of knowing you helped a soul in need is more than enough to provide the necessary burst of energy. I slaved away most days collecting samples for various tests and running between families. Such was my intern year.

Yet once in a while, I won’t lie, there was that one patient, just one patient, I hated. Maybe “hated” is too strong a word. I didn’t hate him but I certainly wished something bad would happen to him. Deep in my soul, and believe me that I felt guilty, I wanted him to hurt. He was verbally abusive, he would put me down, he wouldn’t follow any of my recommendations and he would waste my precious time. He didn’t need to be in the hospital but he knew we couldn’t discharge him and this would turn into a very expensive hotel bed, with his own private doc.

There are patients you’ll hate for various reasons. Maybe they're ungrateful, verbally abusive, unlikable, strange or just plain unnecessary work. For me, they were usually the ones that didn’t need to be in the hospital but refused to leave. Yes, there are patients who refuse to leave. They are usually homeless and therefore, legally, they cannot be discharged or they are foreigners with no visas who need chronic care. So they stay.

Don’t misunderstand me, most of them are kind people and I have no bad intentions towards them, they understand the unfortunate circumstance and try to stay out of your way, creating very little problems. Rarely though, there is that one patient who’s mere presence incites nausea.

The only way to rid yourself of these patients whom you cannot discharge and don't want to leave is the AMA (Against Medical Advice) form. As soon as they sign this form they are free to roam the earth, free as birds, away from your wonderful efforts and your daily notes. Half way through my intern year I realized that, although I am only an intern, I have no obligation to absorb disrespect, or better yet, abuse. In fact, I realized something else slightly more sinister, although occasionally this borders on the unethical.

There are methods, when employed effectively, that can ameliorate some of this unnecessary workload. You will now discover the Madman’s Resident's Guide to obtaining the AMA. Follow these steps and your patient will leave, I promise.

1. Diet modification: The way to a man’s heart is through his stomach. So what if your charming patient’s diet order needed renewal and you happen to suddenly suspect he’s become a diabetic who’s developed chronic kidney disease. I know no one who would blame you for being prudent and ordering a “Low sodium and potassium, No concentrated sweets” diet, at least until the hemoglobin A1c comes back…”What? You say the test takes five days to return? Well, better safe than sorry”. In that case you may even be justified leaving him NPO for the next meal until you sort out if he needs immediate access. "What you say, his kidneys are working just fine?"

Phlebotomy: Of course your patient is refusing blood draws, you know that. But, you also know that having a phlebotomist wake you at three AM is simply irritating and if done religiously can damn near drive someone insane. So if you happen to continually order three AM labs you can’t be blamed, you were simply optimistic that this time he would consent. What he didn’t? Damn it, maybe tomorrow.

Intern Rounds: Instinct will sway you to see this patient last. But don’t do this, see him first and as early as possible. When arriving in his room be very dramatic, open all lights, swing open all the curtains, make a lot of noise. Ask very specific questions, stuff he’ll really need to think to answer. Forget the “how are you doing today?” instead try “Did you see the storm in Texas yesterday? How much snow did they get again?” This makes it really difficult to return to sleep (especially after you’ve turned on the lights and pulled open the curtains and asked him to sit up and walk for you so you can observe). The harder it is to sleep, the quicker he’ll get agitated. Do this often, several times every day, unnecessarily. Don’t be apologetic!

Nursing and Bed Board: (**Should only be used when all other measures have failed)Fortunately, there are two patients in every room. Presumably, you have no control over who the other patient is. But, knowing the right people can sometimes pay off, big time. I mean, dementia and incontinence and uncontrolled flatulence big time. I mean, vomiting and delirium in a loud old lady big time. I also mean ventilator and multiple alarms in the middle of the night. What do you mean he wants to move rooms? Sorry, doesn’t work that way here.

Have an AMA form ready in the chart. Instruct the signout person not to put up a big fight. The patient will be in another ER and someone else’s problem very soon.

Again, you didn’t hear this from me.

Is This Private

This new month offers a different experience for a third year pro such as I. Off the city beat, I'm currently in a private, posh hospital full of private attendings and private patients. This experience is leaving me somewhat disappointed with the current state of affairs.

When people ask what I do I usually say Internal Medicine. "So you're a general doctor?" they ask and being so tired of trying to explain it I say "well, sorta". "So you take care of colds and give referrels for specialists and stuff like that?" that's the usual follow up comment. I often feel like smacking these folks but knowing quite well this may get me in trouble I just waive it off and say something like "I usually don't need a consult, I can take care of most things on my own".

And I can. I do. In my city hospital I am the internist, cardiologist, pulmonologist, gastroenterologist and everything else the patient needs. I only defer to these specialists when it's a problem I can't handle and that's not very often. I mean, I can read UptoDate just as good as the fellow can.

But here, in this private palace, I've being instructed to call consults for nearly everything. Patient has a cold call I.D. complaining of belly pain call GI. etc. etc.

I'm being reduced to a note reader. No, let me correct that, I'm being reduced to note reader number 4. After my intern, my sub-I, and my attending get a look at the consult notes I get to read them too. How amazing, I can read!

Is this really how pathetic Private Medicine has become?

Blog Spam

All that keeps popping up on my email are all these comments from blog spammers. You'd think that this page was ranked a PR 9.

Frankly, I don't know what the page rank is but I would bet it's no bigger than a 2. So really, how much value is there to spamming here? Try the bigger guys like some of these Attending on medlogs or something. You can check back here next year. I really don't think that you're doing such a good job of search engine optimization and maybe that's the biggest insult, I'm worthless to you so go somewhere else.

If you must spam, and I'm sure you will so I'll stop trying to prevent you, please contribute with a worthwhile comment first and THEN tell me how good the viagra on your site is.

Really, who told you I need Viagra anyways????I mean...maybe but...no, that's never really happened to me...no, Really...OK, it happened one time but I was drunk...ok, not DRUNK but intoxicated.