You want Ethics. I got your ethics right here

Here's one I'm facing now:

Patient recently hospitalized and discharged 3 days ago. On recent hospitalization, although patient was medically futile, he expressed his wishes to be full code (to be resuscitated and intubated if necessary). He now returns completely unconcious and the health care proxy wants to make him DNR (Do Not Resuscitate).

The health care proxy does not mention any recent chage of heart that the pateint spoke of. You're the doctor, what do you do now?

Yes, I watched the movie

I saw the movie, I also thought it was excellent. Luckily, I was taught to have a keen sense of observation and to be aware of the slightest detail. It was no surprise then that I completely missed this point.

So Whadayathink?

I would like to introduce everyone to the Madman. He is the cration of Michael from Balisgraphics and is currently the leading character to be the future logo of the Mad House. Maybe I’ll dress him up with a stethoscope. I am searching for more and soon, hopefully, will be able to update things around here.

Future Intern is late. Maybe a sign of the misery Future male interns will have to endure. I'll try to steal some oxytocin form the Gyn floor.

422

On my way to the cafeteria I sneak a peek into room 422. Inside, a husband holds his wife's hand as she lays on the bed, grasping for breath, for oxygen. His look is unforgiving, defeated. He is fatigued, his will for eternity broken long ago. The lines on his forehead bend down imitating its host.

He met her in college. After the tragedy that befell his father he had to drop out and work to support the family. She stood by him and along the way would pitch in with whatever little money she could from her part time job. Eventually, after their golden years of falling in love they got married. He was able to sell off his car and barely raised enough money to afford the ceremony and a humble party. The white in her dress reminded him of snow, of innocent times and he remembers that now. How innocent she is and how unfortunate that it should end this way. How much he loves her knuckles and her fingers and the way they caress and indulge his. How beautiful her fingers were before they engorged to the size they fill now, with fluid.

Together they raised three beautiful children, enduring all the heartache and the pain, and the tribulations. Some years were good others were horrible. Nonetheless, they continued to each other, unrelenting.

Now, thirty five years later she is diagnosed with cancer. She fought, honorably at first, with force. She was confident, sure, she would overcome. Four chemotherapy cycles later there is no alternative to the dark. As she lays there, her days numbered, he holds her hand, her fingers. Although his face lacking emotion his fear tears through this superficial calm, wasting away his energy, he is surely exhausted.

Sometimes Room 422 shatters courage.

Beirut. who knew?

It is said you should write about what you know. I will break that rule, eventually. For now I'll just link an interesting blog out of Lebanon which discusses some of the events happening there. Great first hand stuff. Very exciting changes in the middle east.

And I thought I was Crazy

Check out the Onc man

The Round Carnival

It's Tuesday,

Grand Rounds at Catallarchy. An excellent blog everyone should be reading.

Tangled Bank tomorrow at the Scientific Indian.

Tomorrow, COTV at Pundit Guy

Haveil Havalim, we missed it this sunday. It's a Carnival about Israel related posts. If you are interested, head on over.

The Life of a Consult

Having spent the last week as the official Renal consult I think that I’ve begun to understand what the life of a consult resembles. Ideally, you are called into a situation where others have little idea of what is really happening or if there is a specific question that needs answering. The answer, often, lies in the past. One critical event that sent the situation spiraling out of control. Is hindsight really 20/20? That is not always the case, I assure you.

On a typical day I receive anywhere from two to six consults. I thought it be entertaining if I describe a typical consult, as well as my thoughts while it occurs (In yellow).

Consulting Physician (CP): Hi, is this Renal? Listen, I got a guy who just walked in here and he’s got a history of Congestive Heat Failure, diabetes, and hypertension. Anyways, his primary physician sent him cause on the latest lab his creatinine went from one to four. (Creatinine is a sign of kidney function)

Me: Really. What do you think is happening? (Of course, as a physician, you are calling me to support your hypothesis. Obviously, you, a diagnostic machine, a shining knight among the commons, must have an id..)

CP: I have no idea.

Me: Aha!...Ok, so is he on any new medications recently? (Knowing full well, after your extensive training, that medications are likely to be the culprit you asked him a detailed history of recent medications as well as any others which may have caused his sudden decline in kidney function. Why, not since the kingdom of Solomon has such wisdom descended upon the face of the Earth. You are a beacon of light which..)

CP: Wait, I have to ask him that.

Me: Ohhhhh K….So what did the urine electrolytes show? (After four years in medical school and one year of internship I know that you must’ve sent the most important lab by now, knowing full well that the urine electrolytes may give us a lead on what is happening. A Hero of Rome, a Titan among men such as yourself would never call another physician without having done a thorough and extensive…)

CP: Haven’t sent it. You think I should?

Remember, I said “ideally” you are called into a situation where others don’t understand what is happening. More often, you are called into a situation where no one even tried to find out. Thus is the life of a consult.

Invitation

The Mad House Madman would like to extend his invitation to all medbloggers to write something MAD.

If you’ve been reading my blog you know what I mean.

I would like to begin to host guest writers. Of course, I will give you credit for the piece along with many links to your page (If you wish). I would love to see some of the more serious writers submit something a little off color. I will be happy to post it here (just in case it’s a little too off color for your page).

Sincerely,
Madman

Parody of Blog: Episode 5

This week’s Parody features NY Escort. Be forewarned, the writing is quite racy and adult. If you’re game, you probably will enjoy Alexa’s writing, as it’s great. As always, the site is available in the consult section of this blog.

A slow night by definition means it’s quite boring. So hanging out in the Emergency Department of a class one trauma center can sometimes be an entertaining experience. Hang out long enough and something is bound to happen. Tonight, we wouldn’t have to wait long.

Our third admission of the night, Mr. Gomez, was waiting for the intern to come escort him upstairs. He’s been there all day and by now, obviously, quite upset. Finally, at twelve midnight Alexa arrived. She was a new intern. Word quickly got around that the hot new doc on the floor came from some Midwestern med-school and was one of those highly recruited by the Mad House. It was the first time we met her and in she walks, all confident, “Hello” Mad Docs. Hellooooo Indeed!

Awake we were and more wired than a Wallstreet broker. She grabbed the chart off the rack and effortlessly swung open the curtains to reveal Mr. Gomez and his inverted smile, as they quickly shut close behind her.

With the ER now silent we keenly listened to her sultry voice as it echoed from the walls.

“Hi Mr. Gomez, how are you?”
“Not Well”
“Why not Mr. Gomez?”
“I’m couging”
“Oh, we’ll take care of that momentarily but before we do I need you to answer some basic questions. Do you smoke?”
“No”
“Any drugs or alcohol?”
“No”
“Are you sexually active?”
“What does that have to do with anything?”
“Just answer the questions Mr. Gomez”
“No, I’m not”
“Masturbate a lot?”
“What”
“Do you like to lick feet, any other fetishes, anything like that?”
“What?”

Mr. Gomez was confused. So were we. We were quite confused, very intrigued, turned on, but quite confused. The ER became more silent.

“Do you like Golden Showers?”
“What?”
“How about defecating on people during sex?”
“No”
“Raping your wife, anyone else?”
“What the hell are you askin..”
“Just answer the question Mr. Gomez. How about sex with animals, that sort of thing”

We quickly tiptoed closer to the curtain. A mass of tense males with stethoscopes and third legs attempted to remain as quiet as possible so as not to disturb the entertainment.

“No, I don’t have sex with animals”
“How about flashing, do you like to flash people on the street, you know, show them your inner world?”
“Oh god, do you have any more questions”

“No, not really you pervert”

And as the curtains swung open they revealed a crowd of salivating, tense and flabbergasted physicians. Each fighting to catch his breath, armed with the sort of protrusion scrubs don't hide well.

to participate in the Parody, read here.

The Skeptics Circle is up

All the skeptics met in this bar, and then one got up to speak and then.

Orac does a fine job creating his own Parody, sorry, Skeptical Parody.

The Round Carnival

Every week I write an entry promoting the Grand Rounds and, almost always, I completely ignore the COTV. Well, introducing the weekly installment called the Grand Carnival. Here, I will plug both the Grand Round and the COTV in ONE entry.

This week's Grand Rounds have been outsourced to India and are over at Sumer's Site. She is a Radiologist in training who always comes up with the coolest pictures.

This week's COTV will be hosted tomorrow at Soccer Dad. I've found many interesting new blogs there and great reading alike. Go and enjoy.

If there are any other carnivals I should promote (Would like to promote Skeptics Circle although I have no part in it and don't remember when it is) drop me a line.

I now moved on to a Renal elective. Mostly, I take care of people who check in for hemodialysis three times a week so that they can STAY alive. amazing. Makes you contemplte what was Kurt Cobain thinking?

Addendum: Skeptics Circle this Thursday at Orac. Don't miss this week's Parody here this Thursday as well. Instead of making a weekly Parody the schedule, as you can tell, has changed to "whenever I get inspired" Parody. I got inspired. I am also working on changing the template as soon as I can, have a great idea.

On the brink of the arrival of the Future Intern. Will let you guys know.

Big things are coming.

Lady Problems

As a third year med-student I filled with trepidation at the thoughtof interviewing a patient. What if the patient didn't like me? What ifI offended them or said something wrong. What if I touched them in an inappropriate manner, or at least, which they construe as such? All these thoughts crossed my mind and would often fill my stomach with butterflies.

Nearly four years later I am impressed with my progress. Now, the thought of meeting new patients doesn't scare me one bit. My approachis nearly identical at all times. First, I introduce myself, shake hands and smile before moving on to the standard questions. I've become somewhat automated, in a good way, and it is rare that I get thrown off my natural progression. There is but one patient that continues to plague my weakness and shake my composure from its baseline.

Interviewing a young woman still needs perfection. To be completely honest, and I know you expect nothing less of me, if she's especially attractive than all previous progress to this point goes to shit. Tongue gets tied and sentences get jumbled and mumbled and all shook up. I'm not sure if it's the boyhood anxieties that return, or the fear that haunted me in my younger days but something about the sight upsets the higher thought processes and sends my neurotransmitters into disarray. My smile ends up looking plastic, at least, I imagine it does and I look paler than my white coat.

The thoughts that race through my mind are revealing. "Maybe she's intimidated by me? Maybe I'm intimidated. Why am I intimidated? I'm the doctor damn it". "Maybe it's because I'm too good looking? Shut upMadman, you narcissistic idiot she's the attractive one here".

The physical exam becomes a torture of anxiety and all hell breaks loose in my head. "Touch there or don't? But I have to touch there, but will she think I have to touch there or not? Oh god. Need bag, h y p e r ve n t i l a t i n g, vision fading b l a c k..

After much introspection I think I've finally elucidated the etiology of my failure.

I'm too horny.

Medical School Debt: Part 2 (Why should You Care)

In Part 1 of this series I discussed the average financial outlook for today's Medical School Graduate. In this segment I would like to discuss how these numbers translate to real life problems, not just for the physician

The Brain Drain:

The total number of applications in 2004 for medical school were 35,000 while in 1996 that number was 47,000.

With the average salary of physicians slowly trending downwards less students are willing to invest in such costly education and time before seeing profit. Although there is no hard evidence to support this, it is likely that less top students now choose medicine as a career, Thus, a brain drain of sorts is created. What once was the ultimate of professional goals is slowly losing its appeal.

Inequality:

The high costs of tuition have created inequality among the classes and races. Currently, nearly two thirds of students applying for medical school come from families in the top 25% of income. This statistic is raising concerns that the current cost of medical education may be out of the reach of even middle class families. In addition, a recent survey of these under-represented students indicated that cost was the number one concern and reason for not applying.

Recently, an Institute of Medicine report found that though Hispanics constituted 12 percent of the population, they accounted for only 3.5 percent of all physicians, and though 1 in 8 Americans is black, fewer than 1 in 20 physicians is black. The trend has far-reaching consequences for the national health care workforce, which needs diverse physicians in order to address the needs of an increasingly heterogeneous patient population.

Primary Care:

The latest match conducted by the National Resident Matching Program shows a continuing decrease in the number of medical students pursuing careers in primary care (37 percent in 2003, as compared with 49 percent in 1997) and an increase in the number gravitating toward "the ROAD" to happiness (careers in Radiology, orthopedics, Ophthalmology,and Dermatology, which offer higher discretionary income and easier lifestyle, ortho excluded).

"Pick your specialist, pick your disease"

The primary care physician is the central coordinator of multiple medical problems. Integrating these into the care of a human being as a whole. It is an underappreciated artform. In medicine the Primary Physician, or PMD, is the quarterback running the team, better yet, the maestro orchestrating the symphony.

The shortage of Primary Physician will lead to greater dissatisfaction with the medical profession as many patients will find themselves coordinating medical matters of which they have no understanding. The resulting unnecessary workups and tests will only add to the costs of medicine and put more patients in harm's way.

In conclusion, the current medical school debt burden influence not only the student's future career goals but will also influence the level of care the average patient can look forward to and will likely cause more frustration with medical care as a whole. The decreasing desire to pursue medicine as a career will likely only decelerate the advancement of new treatments and a better future.

The new emerging class are alarming since the current cost of medical education is only trending upwards. With the already established class and race divide the gap will continue to widen. In many parts of the world medical education is wholy subsidized by the government, eliminating this gap.

In a country which prides itself on allowing migration of class thorugh hard work can we allow this to continue?

In the next Part of the Series we'll discuss how to stop this alarming trend.In the final piece, I will try to do some research on creative solutions to pay off medical school debt. Until then, try to win the lottery.

( Reference: Morrison)

Sick of Feeling BLUE

I am tired of this template. It's so BLUE. BLAH.

I need something more Jazzy, something medical but fun, colorful, mad. I hate all the other blogger templates. what's a madman to do?

Wax Lyrical. Badly.

To the ER again
to complain of his pain
And his hiccups that just wouldn't stop.
All he got were some rays
Which showed he had slim chance
and sent ID into a craze.

In his lungs was a monster
desguised as a smudge
That took up a space
producing some sludge
as he coughed and he hiccupped
it was blood that emerged
And, as always, isolation was urged.

To isolation he went
and masks were adorned
And everyone who came to visit forewarned
That TB can be deadly and painful the same
and that hiccups can sometimes drive someone insane.

As he left three days later
We all had rejoiced
that the smudge was not serious
Just a quirk that annoyed.
He left on his way
all cured and cough free
Thanking the doctors
waving with glee.

How little he knew
now unconcerned
we did little for his problem
as his hiccups returned

Inspired by Point to Point and the Omnificent English Dictionary in Limerick Form (OEDILF)

Grand Rounds

Once again the best posts of the week are up and running. Check them out at medmusings. Great stuff.

Mad House mAdschool: Patient Evaluation

Interviewing is the exchange of relevant information about the patient for the interviewer's professional purposes. It is the premier skill in medicine; it is the vehicle for the physician-patient interaction in virtually all circumstances, through which is derived most of the information about an individual patient.

History Taking is the most important part of the interview. often, I meet patients under the impression that a physical or an expensive test is going to make the diagnosis. It can, but more often, the tests and physical exam are used to confirm a diagnosis or differentiate between a number of suspicions. The history portion of the meeting accounts for nearly 90% of the information learned. The physical and tests account for the other 10%.

How should a good history be performed?

Nearly everyone agrees that a good history often takes the form of any other good interview. Meaning, start generally and become more focused. A good opening line is "What brought you to the hospital today?". Some patients may answer "The ambulance". Let this not deter you.

Once you have an actual complaint (ie: Chest pain), and REALLY try to nail down ONE complaint, then continue asking more generalized questions about the pain and focus more narrowly in follow up questions to pin down a hypothesis.

Patients often don't realize that any one complaint can have a multitude of causes. For example, chest pain can range from a fulll blown heart attack with deadly consequences to heart burn or just a muscle spasm. Off the top of my head I can name 15 causes of chest pain right now and I'm just second year resident. I will not get more specific here because chest pain should always be evaluated by a doctor. ALWAYS!

Any standard questions?

Sure. Every history usually includes list of medications. So remember yours or bring a list (ie: white pill this big means absolutely nothing to us. Do you know how many white pills this big there are?).

Every history includes allergies, social history (smoking, alcohol, drugs, type of work) and if the practitioner is really good he will ask a sexual history (This is the sign of a GOOD doctor, do not be offended).

Any trick questions?

Well, sort of. I like to ask some questions that may be misleading. For example I often ask how much alcohol a patient drinks? Sometimes I get "Just a little" as a response, or some variation. My follow up is usually "One six pack or two?" I ask this as if its common practice to drink two six packs a day. It's happened many times that I get a yes, or something like "Naaaa..not two six packs, that's too much, just 5 or 6 beers". FIVE OR SIX beers, aha. In my neck of the woods the follow up to that is "The big cans or the small ones?". You don't want to know.

There are different theories on the technique best utilized for interviewing. Mostly, everybody has their own style, some better than others. Medicine, you'll find, is a science applied through experience perfected art.

CodeBlueWhy????

CodeBlueBlog calls for medical Bloggers to submit their posts and materials to Carnivals like COTV and the other Brainchildren of Siflaya. At the same time he takes a stab at a little startup blog that peaked my curiousity (check it out here. go ahead, it's short).

I will try not to take it personally. His point is well taken though and is something that I have been thinking about for quite a while.

As many have noticed I've begun to post about topics which I find interesting and serious. I am even contemplating starting something of a Mad House mAdschool series, such as the one featured here. My dillema is simple and is probably the point my mentor at CodeBlueBlog was trying to make. How can I continue to write serious blogging under the name of Mad House Madman? Shall I emerge from the shadows of anonymity in order to be taken seriously or must I at least change my title?

I will be pondering all this weekend as we are moving (real apartments that is).

BTW, some of you have been asking. The wife is doing great and is quite ready to hang an eviction notice inside her uterus because its already getting uncomfortable. Future Intern needs to finish her residency. NOW INTERN!

Parody Of Blog- Episode 4

This week’s Parody features only Respectful Insolence. Great writing is the rule and Orac knows how to do it. As always, the link is also available in the consult section of this blog.

As the massive tumor that has ravaged this young girl stared at us from its place inside her breast we finally understood the strength of denial. It was not that she didn’t notice the growth but just how much she did. Unfortunately we knew that it will lead to demise and her indifference would be her conclusion.

Orac was no stranger to this foe. Having lost beloved patients and friends he has dealt with this willing of the soul for ignorance. His introduction to the world of Oncology Surgery was grueling and three years later, on this anniversary, he was still fighting this never relenting foe. Unknowingly, he knew that this fight will last the rest of his life. He fights in the name of the countless others who had gone before.

This enemy will keep reinventing itself and Orac will take his best shots wherever he can. One win at a time, one treatment , one patient, one case. Sometimes giving in, even not fighting, can be a silent victory.

For the next Parody, read here.

Medical Student Debt: Part 1 (The Problem)

I decided to compile a series on medical student debt. It’s a topic I feel strongly about since it affects my life and the choices I make and will make in the future. It will also, by the way, affect your life as well. I hope you will find it interesting.

Data compiled over the last twenty years concerning medical education and the debt burden of medical students reveal a troubling trend. For one, the average student debt is rising faster than the consumer price index (CPI) and parallels the rise in medical student tuition which is rising considerably faster than the CPI.

Why should you be concerned? We will get to that shortly. I believe, however, that a first necessary step is acknowledging the problem.

Data has shown that private medical school tuition has grown 435% since 1960. A closer temporal comparison shows a rise of 65% since 1980. Public institutions haven’t done much better. The average tuition for public medical schools has grown 387% since 1960 and currently is rising even faster than private tuition and will soon catch up.

Take a closer look. Average tuition and fees at public medical schools during the 2003–2004 academic year amounted to $16,153. For private schools the figure was $32,588. Add $20,000 to $25,000 for living expenses, books, and equipment and that brings the estimated cost of four years of attendance to about $140,000 for public institutions and $225,000 for private medical schools.

Compare this, in the 1984–1985 academic year, average tuition and fees were $3,877 at public medical schools and $12,973 at private schools. The average debt carried by 1984 graduates was $22,000 for public school and $26,500 for private school. By 2004, the debt had increased to $105,000 for public school and $140,000 for private school. Only 20 percent of medical students graduate with no debt.

Although tuition makes up the greatest part of student debt, additional expenses are also partly to blame for the increase in total debt incurred. More students, for example, are now entering medical school with debt already incurred from undergraduate Universities, whose increasing tuition rates are also alarming. The interest accrued on loans over time can significantly add to the total financial burden. In addition, there is an increase in “nontraditional” students, like parents with children to support. More students now live in apartments, marry during medical school, need to buy cars to travel to outpatient healthcare facilities and also need to buy computers and other expensive electronic study aids. These additional costs have increased the price of medical education dramatically.

For those who’d like the numbers I believe that these are the most staggering:

63 % of medical students graduate with debt of at least one hundred thousand dollars.

According to the Association of American Medical Colleges, the average debt by graduates of the class of 2004 is a staggering $115,218.00, truly an additional mortgage hanging over their heads.

What does this all mean?

A 2003 graduate with $100,000 in debt who begins repayment after a three-year residency will generally pay $15,000 per year for 10 years. Consolidating the debt and extending repayment over a period of 25 years will result in payments of $12,000 per year for a quarter-century.

In 2003, the consolidated interest rate for Stafford loans was only 2.82 percent. When interest rates reach the maximum allowable rate of 8.25 percent, as they have been known to do, or when students need to borrow additional money from private sources, repayments will surely exceed these estimates.

In the next piece of the series I will explain how this increase in medical student debt has affected the choices of future physicians and how it will affect your future.

Grand Rounds

This week's host is Daily Capsules. Go on over and check it out.