Thursday, November 11, 2010

"I'm not gonna lie Doc."

Sometimes first impressions are....absurdly funny.

I walked in to a patients room this morning with this history: 50-something male who blacked out while driving Sunday, losing control of bodily functions, crashed his car into a pole, woke up and decided to drive himself home, then spent the next few days occasionally blacking out while continuing to drive himself around town. That is, until he decided to drive himself to the emergency room.

He had a history of cancer, drinking, and has enjoyed more drugs than there are ways to "just say no".

I'm real excited to meet this dude.

I head into the room, and he looks like he's been rode hard, dragged through some cacti, and put away wet. He has multiple scratches and thick blood-crusted scabs and bruises on him. His hair is thin all over. He is painfully thin. He looks a little wild-eyed. Then there's the trach that he cleans with his hand (imagine you could reach into the back of your throat and pull out all the snot and spit with a swipe of your hand, only to wipe it on the front of your gown before offering your hand to shake with the doctor).

"How are you doing today?" I lead with. Pretty benign, usually. He grunted something and grabbed his belly just around his stomach under his ribs--you can't talk and use both hands at one time with a trach, you need one to push your speaking button.

"Does your stomach hurt?" I asked next. He responded by clutching his stomach, holding up one finger in a "just one moment please ma'am" gesture, then, jeez this deserves a new paragraph:

He then took that one finger, pushed his trach button, and without a word, turned to his left, and projectile vomited coffee ground looking emesis, managing to arc it from his bed into a trash can.

This was not that man's first time around a vomit.

I am positive my head left a dent in the wall behind me because my first and only instinct was to back up so fast I flattened myself against the first surface I hit. Seriously, I moved so fast my arms flew up; it's probably more like a snow angel impressioned in the paint.

The guy had just had coffee, otherwise as you know if you're in the medical field seeing actual coffee colored emesis means the dude is BLEEDING in his throat or stomach, both of which could happen in a man with his history.

When he was done, he turned back to me, pushed the speak button in his trach and said, "SORRY. BEING AROUND PEOPLE MAKES ME NERVOUS."

"That's ok. I might throw up myself," I said.

Probably not the most doctorly thing to say, but come on, I'd just about given myself a concussion and two weeks ago I wouldn't have even been able to get words out before I yakked on his hospital bed. But it actually worked out; this guy started to laugh, and I could tell he was visibly more comfortable with me after.

The title of the blog comes from other events in this guy's day. A few conversations passed to me:

Neurology: "How much do you drink?"
Mr Bad Decisions: "I don't drink."
Nurse: "Your blood alcohol is still 0.05%"
MBD: "I only drink to take the pain away."

My attending: "So, you're having a hard time without alcohol? (the patient is in florid withdrawal by this point).
MBD: "Doc, I'm not gonna lie to you. I ran out of my Vicodin two days ago and I hit the vodka instead. It's the only thing that works for the pain. So I been drinking a lot."

Ladies and gentlemen, my favorite patient of the day.

Wednesday, November 10, 2010

I have work to do.

Right now. But I'm putting it off to dash off a blog.

I worked 91 hours last week. It is getting old. Some days I look at radiology attending positions just to remind myself that it won't be like this forever.

A patient I got really close to is probably going to die tonight. I've gotten in the habit of checking on her several times and day and again one more time before i go home. It's especially hard to leave oncology patients for some reason. I guess because most of them were going about their business when they got a crappy cancer diagnosis. It's a little different than the ones who seem to come in and out of the hospital playing the Poor Me card for painkillers or attention.

I think I actually like the Palliative Care patients the most right now. Since I'm not the final decision maker on treatment, something I can do really well is explain things to families and offer comfort.

Friday, November 5, 2010


Sometimes nurses do not know when to leave me alone. I'm sure that today it was because a very angry patient would not leave them alone, but for craps sake when I'm taking care of 16 patients, sometimes I can't answer a page for five minutes!

Anyway, the point is, if you hear me use my slow, measured, somewhat quiet voice, you do not want me to have to come to the nurses station.

After being paged repeatedly and having my attending called despite asking for a few minutes to figure out what was going on with the patient, I stomped down the hall ready to rage to Death Star, a cute little nickname one particular unit in our hospital earned for having spazzy, constantly-paging nurses who somehow manage to miss things like, a blood pressure of 80/40. What do they page about? I spent two weeks and several nights on call and I still can't tell you.

"You paged me repeatedly on this issue. I have a patient with a systolic blood pressure >200, asked for five minutes to figure out what's going on, and every time you page me all patient care gets put off until I can answer the page."

I lead in with that for drama, then since I can never trust my hormones' next move, the urge to really mess with them came over me. "I have had use the bathroom for two hours but can't because I'm getting paged. I have to pee so bad my belly looks like THIS!" I then opened my white coat and gestured wildly at my newly bumped preggo belly. These nurses didn't know I'm pregnant, so the looks on their faces when they thought of how long I must have had to go before I looked like someone stretched a dress over a watermelon was PRICELESS.

"Oh my gosh I'm so sorry there's a bathroom right there I'll leave you alone!"

"Nah, I'm kidding. I'm pregnant. But seriously, I still have to go."

I am very concerned that unless I find ways to deal with the frustrations of intern life, I will have a rage baby who does nothing but cry until he learns how to yell obscenities. So I have to find ways to bring a little funny to the workday. I actually don't feel stressed the majority of the time despite working 70-80 hours a week. Of course, I say that this minute...

Wednesday, October 20, 2010

Pain and suffering

I started oncology today.

It's been difficult to write lately for various reasons:
1. I work all the freaking time
2. When I am home, I don't really want to think about the hospital. I've actually spent 4 years honing the Dr. Kelso skill of dropping my cares off when I leave the hospital. That clip is in Spanish, but it's really the faces that count.
3. Looking at a computer for a long time makes me want to vomit. Really.
4. Because I'm pregnant.

It's added an extra spice to my usual demeanor at the hospital. When I was on night float I was about 7-8 weeks along. Not eating at the normal times, sleeping about 5 hours a day and dealing with the massive stupidity that passes for RN's at night time (not all were terrible, let me clarify) meant I spent my free time eating the two things that sounded good--all fruit popsicles and English muffins, both of which I can't look at now--and popping Zofran to keep myself from throwing up too many times.

When someone woke me up for a blood pressure of 150/80, I wanted to burn the whole unit down. I am not kidding. I am seriously afraid my baby will have rage problems because of the time I spent on the night shift.

Starting Oncology has depressed me for various reasons. Like everybody is dying. And, I have to be at work at 6am 6 days a week until April. I shouldn't be awake.

Today I saw a young guy with a son who looked like he was around 5 years old. This kid was CUTE. And his dad was going home on hospice. I started to feel the crush of sadness settle over me, then I thought about the tiny baby who was at the mercy of my moods. Part of me worried about whether this would ever happen to me. Then a better part of me said, "Just flood that baby with love. That's the best thing you can do now."

I certainly wish I'd thought to do that the other day when I cried for ten minutes over an episode of Battlestar Galactica just because of a scene where a somewhat nerdy character was eating alone and looking sad and lonely. Yeah.

In the end, I really don't give a crap about this year. I am being forced to do a year of internal medicine do to an archaic system that is slow to change due to money and IM departments reluctant to give up their cheap smart labor (anyone who gets into a competetive residency that requires a prelim year is usually pretty darn competent. I don't know how I got in.) It was always going to be difficult, whether or not I was especially hormonal or occasionally throwing up. I had the thought this morning that it would be a year I'd look back on and wonder how I survived. Usually I don't realize that until after I've had the year. :-)

And now, after that round of wallowing in self-pity, you can see why I don't always blog! I'll have a funny story next.

Sunday, October 17, 2010

Dryer than a Popcorn Fart

My elderly patients crack me up. Sometimes they are whiners, but sometimes they are the funniest things this side of an emergency room.

That title was one of my favorite quotes from one of my favorite patients. This guy got up like every other day of his life, gave his neck a pop, and broke it.

Yes. He broke his own neck.

I’ve known this could happen for years. By known, I mean the grotesque image has run through my mind whenever I see someone crack their neck, and I try to stifle my shudder and use my doctor voice to convince them of something I’m sure of, namely, that they are going to break their own necks right in front of me.


Anyway, though I believe I was proven right, I guess I should add something else to the story. He had cancer he didn’t know about, and it had grown metastases in his spine, weakening it. So he still broke his own neck, but his neck did have a few fragile spots.

Unfortunately, the cancer/contrast from the scans that found the cancer also shot his kidneys. The man has been in a halo (he has screws coming out of his skull, yes, through his skin that attach to a halo with a fabric-covered harness down over his shoulders midway to his belly button. He can’t sit up for dialysis in an outpatient clinic, so he can’t go to a nursing home. None of the Long-Term Acute Care facilities (kind hospital-lite) will take him to chemotherapy, so he can’t go to an LTACH. He’s been stuck here for over a month for no reason other than administrative policies. Plus at first they gave him a crappy renal diet, then by the time we figured out to give him whatever he wanted, the chemo had already made him lose his appetite.

You’d figure the guy has every reason to be a grump. But he’s not. He’s always upbeat. He always says, “Oh, I’m doing pretty good!” when you ask him how his day is. Every now and then he says something like, “I need you to blow me out again.” (the first time he said he was constipated, I told him I was going to “blow him out because that was one thing I know how to do well.”).

With the dialysis we realized we might have been pulling a little too much fluid off of him. My attending asked, “Do you feel like you’re thirsty?” to which he replied, “Doc, my mouth’s dryer than a popcorn fart!” I don’t even know what that means, but it was awesome to see my attending try to keep a straight face.

Thursday, September 16, 2010

Pooh continued

A lot of my phone calls involve bowel movements. I don't know if patients just don't get up the nerve to talk about them before 8pm, or if the night nurses just want something to do, but I end up dealing with other people's crap every night.

One nurse called just to tell me that a patient w/ a partial small bowel obstruction (who had orders for enemas q 2 hours until she had a bowel movement, no need to call the on-call doctor), that Mrs. Pooz had a "large bowel movement that was very green. I didn't know if you wanted to look at it or do anything about it..." Wha? Yes, she really did call to see if I wanted to hike my butt up two flights of stairs and go look at poop. One of my many talents is sarcasm, which I felt I restrained by only saying, "Thank you for that very useful piece of information regarding the patient's care. Although I am very interested in bowel movements, I will not change her care plan at this time." Nurse Literal, not getting the sarcasm, responds seriously: "Oh, I can call you if she has any more like that, I think it's interesting too!" I decided to be direct. "If you call me again for a bowel movement that has anything other than frank blood, I will make you do enemas for the rest of your shift." The funny thing is, that is the comment she didn't take seriously, and then she had a great chuckle and said how funny I was and never called me again that night. And no, she wasn't mad at me, those nurses call you for blood sugars of 90 (normal) at 3 o'clock in the morning.

This morning I had a bullshit admission (Kari, I know you're an ED resident, but sometimes I could just take a hose to the place) for a lady who has been admitted once a month for CONSTIPATION, nausea, vomiting, and abdominal pain. Ladies and gentlemen, this lady is why people whine and moan about the ED being misused by people who don't pay. If this lady had any intention of paying a hospital bill, I'll tell nursing that I want to see pooh all night tonight. But she said the magic word, "chest pain" that bought her a 23 hour obs stay courtesy of Medicaid. Funny thing is, her "chest pain" resolved with an enema, leaving her only with abdominal pain. Her troponins were negative x3 (she'd been in the ED long enough to have 3 troponins, which are drawn 6 hours apart), ECG was normal, basically I was more likely to be having a heart attack at that moment. But due to attendings who were off site and an ED doc who didn't want to reverse the previous shift's decision to admit, we had to admit the lady.

Ok. You want to fix your constipation? That is something I do well.

That lady is on Miralax, Senekot, Colace, GOLYTELY, and enemas q2. She is going to be crapping food she hasn't even eaten yet. My hope is to clean her out so well no stool will stay in her body for at least another month. You're welcome.

And no, I don't want to see it.

Thursday, September 9, 2010

You don't know the meaning of "constipation".

A few highlights from my first night on night float. Most of these are dumb pages from nursing. You'll have to wait til tomorrow to see the dumb things I did myself when I was tired.

Twenty minutes in, while getting report from one of the day teams, I get not one but TWO pages from a nurse on a specific unit (I will find this to be the troublesome unit all night). While I was answering the first the second one came across (they are not supposed to page during checkout), the nurse worriedly says, "Mr. Toots hasn't had a bowel movement in four days and he doesn't have a bowel regimen AT ALL."

"Is that what both of these pages were about?" I asked. "I'm doing checkout. If he hasn't had a bowel movement in 4 days (which is a daytime issue anyway), waiting 20 minutes while I do checkout isn't going to change his situation. Just put him on Colace 100mg BID."

I didn't get any more calls about his BM's, but I did get a call on an AIDS patient who had liquid bowel movements. I went up to see him (because it's just common courtesy before you agree to put a tube in someone's rectum) and the nurse says, "It's still here (the BM) if you want to see it." "Really?" I wanted to say. "I'm going to trust you on this one." But I wanted to check out his possible peri-rectal erosion to make sure I wasn't going to hurt him with the tube, so I met my first patient of the night ass-first covered in narsty. This nurse was great though, and she'd taken care of him for a few nights so I relied on her to let me know what his baseline was.

I also got paged at 10:30 because Mr. Gaggles "is nauseated and doesn't have any IV meds" I looked at my patient check out sheet, which lists the medications the patients are on (because I don't know these patients well enough and there are too many to try to remember safely without looking in the chart.)

Dr. Al: "He has compazine and Zofran PO written. Have you tried those?"
Nurse Incompetent: "Well, I gave him the compazine and it didn't help."
DA: "Ok, did you give him the Zofran?"
NI: "Well, I ordered it but it hasn't come up from pharmacy."
DA: "Sooooo that's a no. He has two anti-nausea meds written. Give him those two anti-nausea meds and then see how it works."
NI: "But he doesn't have any IV nausea meds."
DA: "Is he throwing up?"
NI: "Well, no. But he's dry heaving."
DA: "It's the same med. He doesn't need IV if he's keeping PO down. You already have Zofran ordered, plus there is a dissolve-able form. Give him that and if it doesn't work at max dose call me."

At 10:30 I am much more open to having that conversation. Besides, this has apparently happened before, as it was specifically in my checkout to ask this nurse if she'd given the ordered meds before prescribing new ones.

At 1:30, when I was woken up from my nap (I probably won't nap anymore, but it was my first night and I had trouble switching over) for this call.

DA: "This is Dr. Al, I was paged."
NI2: "Ms. Nightowl in 3219 wants an Ambien to help her sleep."
This is my fault for not going into her chart and seeing that she already had orders for a damn Ambien. But rule of thumb is to try simple tactics first.
DA: "Are her lights and TV on?"
NI2: "What?"
DA: "Is she in there "trying" to sleep with the lights and TV on?"
NI2: "I don't know, I haven't been in there. "
DA (thinking groggily at 1:30am): What? How the hell do you know she wants an Ambien?

Right there I should have known a nurse who was too lazy to go see the patient would also be too lazy to check her medical order sheet and see that this particular question had already been answered. But I ordered Ambien anyway.

By now, this s#$@ was getting old.

Another nurse had to call me after a patient requested IV fluids because she was going to be NPO (nothing by mouth-no food or water) for 8 hours (while sleeping, mind you) before a procedure. Otherwise she'd been tolerating a normal diet. The patient wouldn't leave the nurse alone until she called me. The nurse and I had a good chuckle, and I said no, if we all needed IV fluids during sleep we would have died out as a species a long time ago.

I came to really REALLY appreciate nurses who wrote notes that included, "this is a daytime issue and will bring it up with the primary team." Nurses who think on their feet are the best thing in the world. As a night float, I just don't know these patients as well as their primary team. I covered four teams' worth of patients last night, each team having two interns. So I had 8 interns worth of patients to cover. I didn't admit these patients, I don't see them day to day, it's really not in their best interest to have me messing in their medical care.

I did get to admit two patients. By get, I mean was slapping myself in the face in the elevator to stay awake. One poor lady was in her 40's but looked 80. She had a chronic disease, and her nursing home had snowed her on pain medications. She perked up with some Narcan, but she said all the lines and tubes in her hurt and she just wanted to go back home. I felt so bad for her.

Another came in because she's God and God doesn't need to take her anti-psychotics. When I introduced myself she said, "I remember you. You're absolutely beautiful." (though we'd never met.) "This lady isn't crazy at all!" I thought to myself.

Monday, September 6, 2010

You can lead a horse to water, but you can't make him accept the fact that he's dying.

I don't think that's the original saying, but who cares. It's very true.

I got dismissed by a patient while on Palliative Care. We disagreed on a major point in her care plan: the PC (and her Oncology team, who asked us to come), thought her uncurable metastatic stomach cancer that had spread everywhere in her body, leaving her unable to eat or even absorb nutrition through her G-tube, put her in constant pain from bony mets, and had caused a small stroke meant that she was going to die. She thought that God had told her he wasn't through with her, so we were a) all wrong. b) Were faithless, Godless unbelievers and c) were going to be sorry about it when we realized we were wrong. (HA! Doctors are never sorry about anything.)

She wasn't always like that. This is a theme that came up time and time again in PC: A patient could sense his or her body was already sending messages (like, "I've had enough of this). With the help of PC, the patient thought about what kind of life they wanted, especially if it were only going to be months or weeks. Then the family comes in. It's usually really one family member, who lives far away, who maybe feels guilty that he's been in prison/Texas/his own selfish world to see Mom, who doesn't realize how sick she is, that comes in late in the game and goes completely apeshit.

This lady's son was no exception. "You got to eat Mom, you just have to make yourself. It's mind over matter!" No, really it's mind over obstructed intestines that make everything she eats come out her nose. But I'm sure she likes the 3-a-day enemas we're giving her to try to relieve that. "I don't believe you doctors. You all don't have any faith You all are always negative. I know a guy who was told he had to weeks to live, and he's still alive!" Hmmm, has it been two weeks? "He had cancer all over and Vitamin C cured it. We need to give her Vitamin C so her immune system will cure this!" All of a sudden, Vitamin freaking C has become the wonder drug that doctors don't know about. There's probably some preacher, former ThighMaster hawker or a Reader's Digest article ("10 things your doctor is deliberately keeping from you because she is an evil knowledge-hoarding killer!") talking about Vitamin C and your immune system because many people have mentioned this to us. I'm all for trying Vitamin C. We're talking high dose IV therapy, not taking extra Flinstone's. Fine. But say your goodbyes and write your will.

"Oh NO Cancer!"
One part about PC concerning cancer patients that drove me bazonkers is that one particular oncologist would not say flat out, "This will not cure you." I would come in to see the patient, and she would say, "Dr. Tumor told me there's a new chemo to try if I just get my strength up." Then I read the note, talk to Dr. Tumor, and what he really meant was, "If you can get your strength up to 50% of your Activities of Daily Living, which probably won't happen, we could try this experimental chemo that might shrink your cancers for palliative (comfort) goal only. This will not prolong your life or cure you."

I thought maybe this woman was just hearing what she wanted to hear. That could have been part of it. But then I actually listened to this particular doc talk to patients. All he said was "get your strength up and we have another chemo we could try." I couldn't believe it. He was hanging the rest of us out to dry, and in my mind leading this lady on, because he didn't have the stomach to say nothing was going to cure her and she was going to die. My attending practically had to beat him with an oxygen tank until he admitted that the chemo would only be for comfort.

No wonder she didn't trust my happy little ray of sunshine and death talk.

This was early in the month. So this lady, who would both say, "Well, when it's my time it's my time. God will save me if he wants" and "Do everything you can if my heart stops" (Chest compressions on a 66 y/o w/ metastatic cancer is just stupid, I could write a whole other post about Code status). Eventually got coded, intubated, and sent to the ICU. Which sucks. She then self-extubated and was sent back to the floor weaker than ever for her trouble. Last time I checked she was being visited by PC again and was DNR.

Why did it bother me that she and her family couldn't accept it? Really it was mostly a selfish hurt that they thought we were idiots and were "giving up on her." Yeah, I went to four years of medical school so I could march around a hospital giving people crappy news for no reason.

I also enjoy kicking puppies.

I guess no one wants to believe they'll die.
As far as I can tell, we all do though, and the ones who accept it seem to have a much better time with what they have left. I sure know I wouldn't want to spend it in a hospital.

Tuesday, August 31, 2010

You are all going to die.

That's the gist of my last month's work. I am finally done with helping patients die. From now on, I will be no help whatsoever in the dying process.

Ok, maybe that's a little dramatic.

It has been a very long time since I last posted. That is because my job sucked. Sure, there were moments where I felt like I'd helped a family. Or even a nurse, like when the S(urgical) ICU nurse asked me, "If we disconnect the monitors (which is something we do when people are dying so their families can hug them or get close to them or actually look at them without the monitors constantly reminding them that their loved one is circling the drain), how are we going to know when the patient is dead?"

Are you flipping kidding me? "Well, people have been dying since before we had monitors. Surely we'll find a way to figure it out. By the way, I'd like to introduce you to something I call the "Physical Exam."

I think he learned something that day.

To be more grotesque, you may not know the second someone has died. Their breathing is usually apneic (meaning long irregular pauses between breaths). I saw a guy go a minute and a half without breathing. I thought he was gone and stepped up to pronounce him, but then all of a sudden he took a huge gaspy breath. Geez. Now I wait outside until a nurse (who doesn't need monitors) comes to get me. I can't take the suspense.

Anyway, you may not know which is the exact last breath, but you know as soon as you walk back into the room. People change color. They look different. Not "oh he's on death's door" different, they're there already. I mean it is unmistakable and indescribable.

And on that note, I'm going to bed.

I'm currently on Radiology, which is AMAZING, then night float, which will probably give me some great stories about the batshit crazy. I still have some up my sleeve for this month; I just tried to forget work as soon as I got home. I got tired of having nightmares every night.

Tuesday, August 3, 2010

Dear Chiefs

Dear Chief Residents,

I'd like to take time out of my hectic life to thank you for this F#$% of a schedule.

I can tell you really put a lot of thought into what I might want to learn during this year. For example, how little you care about anyone who isn't going to do Internal Medicine for the rest of her life.

The ICU was a great place to start for someone who didn't go to medical school at this institution. Especially when she's the only intern on the service due to a little scheduling oversight (Oh, she'll be fine covering the work of two interns! )I got to spend several FANTASTIC hours those first three days learning both the computer system and how to manage 5 patients who were on the brink of crashing. Nothing like learning how to write an order when every order you make could tip a patient over the edge. What a thrill! I'm soooo looking forward to the next ICU month you scheduled me for (and I am so grateful for the chance to do TWO ICU months, when the other interns are only supposed to do one!)

Man, just when I thought things couldn't get any better, I switched to Palliative Care. Nothing like watching people die for 9 hours a day six days a week. It was such an intuitive place to put an intern who neither requested the experience, nor ever hinted that she liked patients in the first place! I'm sure you saw the fact that I was going into Radiology and just knew I was a lady who wanted to get in touch with her feelings. It's tons of fun for the attendings on the service too! I think they enjoy watching me cry several times a day--so much that they sent me home early for not handling things well! This really gives them a chance to focus on doing their job taking care of interns...I mean patients.

Well, I guess I better go get some sleep. The nightmares I've been having since all my patients started dying keep me pretty busy at night! I sure as heck don't want to be so tired I miss anything tomorrow, like the ability to control my emotions!

Thanks again for not following the ACGME recommendations for a pre-radiology clinical year! I'm sure I'm going to look back on all of this and think about how great of a time I had learning how much a real Medicine residency blows.

Your Pal Al

Monday, August 2, 2010

Oh Beverly.

It's my one day off out of the week, and a patient that I have taken care of from my very first day is leaving.

This lady was a doozy. None of my co-residents could understand why I was attached to her. I don't really understand it either I guess, but she was another patient who started out with one illness that snowballed until months later she was three weeks in an ICU stay that never should have happened. At one point she was my only patient who wasn't dying. She had a husband who visited every single day for the entire day, even after he found out she may have cleaned out their bank account in a manic spending spree.

Yet in an ICU full of patients who were either going to get better or get worse, she was the for whom I might make a difference.

Beverly was the same age as Peggy. She didn't use to run marathons, I'm pretty sure she used to eat too much and boss her husband around. You don't get to eat on a ventilator (so you basically get Ensure shakes down a tube in your throat, but on her clear days she could definitely boss her husband around.

She didn't have a lot of clear days. She had a bad case of ICU delirium, complicated by the fact that when she first came to the hospital, her home psychiatric medications (anxiety, depression, etc) were held. By the time I took over her care, she'd been without them for a week. We would NEVER recommend stopping psych meds cold turkey to a patient in the clinic. Or on a psych ward. All of a sudden, just when you're super stressed by being in a hospital, we've held the medications helping to keep your brain chemistry regular . Why patient's psych meds get routinely held when they come to a hospital is beyond me. After having seen what she went through, I'll never forget it.

I didn't figure out that she was supposed to be on these meds for another week. I was not informed by the team leaving the service, and the records were buried in a paper transfer from her previous hospital. Once we got Psychiatry on board, things started to improve, but it took another week to really get enough clear days to move her out. She couldn't go home anymore. I know it bewildered her husband. Before the surgery, she was fine. Then all of a sudden she can't get off a ventilator, she can't eat on her own and needs a tube coming out of her stomach, doctors are throwing around the words "Long Term Acute Care Hospital", and the wife he thought was healthy might not ever be home again. And I couldn't deny it. After we lost Peggy I couldn't tell him she'd ever be herself again.

Anyway, the nurses didn't see the story like I saw it. I think instead of feeling responsibility for holding her psych meds and possibly triggering the delirium, they saw a patient who could wave her arms for HOURS and a frustrated husband who constantly asked questions they couldn't answer. They really did have to deal with the brunt of her behaviors.

We were all set to send her to that care facility on a Friday (where it was less expensive, it was closer to home, and they were much better at handling ICU delirium), when she had a little problem with her feeding tube. Friday turned into a weekend when she didn't get physical therapy (they don't work weekends in this hospital), which was also the weekend that a particularly dumb shit of a psychiatry resident was on call. In the five minutes he saw her he managed to ask her every offensive psych question possible (so where do you get treated for your psychosis when not here?) and write a note that I would have spit on as a first year medical student ("Patient is going through a lot of medical stuff"). That agitation gave her another round of delirium, setting her back another WEEK.

So Thursday, when her PEG tube clogged, I knew the LTACH wouldn't take her if that tube weren't working. I felt like if she didn't get out Friday she wouldn't get out. Probably dramatic, but I didn't know who was on call for Psychiatry that weekend. "You have to get this done." my attending said, meaning I had to browbeat the interventional radiology team into taking her. "Yeah, wear your ovaries on the outside today," the fellow added.

It took hours of pleading and phone calls, some of which were spent convincing a male tech down in the department that I was the patient's DOCTOR, not nurse, before I finally told them my attending was going to yell at me if I didn't get it done and I just didn't know what to do. The lady on the other end was silent, then asked who my attending was. "Sampson." I said. "Oh. He will probably yell at you. Let me call you back."

Long story short, her feeding tube was fixed, and she went out. I have no idea if that will be the last time I see her, but I do know that she and her family were the first people I really felt like I made a difference for. In a month where most things are out of my control, I actually felt like a doctor.

Saturday, July 31, 2010

You can't make this S#$% up.

I don't even know where to start with this next patient.

First of all, he was never supposed to end up in my ICU. He had end-stage scleroderma that had hardened and was failing every organ system in his body. He didn't want to be intubated, but when he dropped a lung during an endoscopy to investigate a bleeding Peg tube (dysphagia had robbed him of the ability to eat on his own by this point), his wife said to "do everything you have to! Yes I want him intubated!"

I had heard that he didn't actually want it, but we didn't have any legal papers and he was completely unable to make legal decisions, or even say previously made ones out loud for that matter. Those kinds of decisions aren't ones we just take on good faith, "Oh, his cousin Cooter said he told him he was ready to die a few weeks ago over some beers? Welp, that settles it for me, let's make him DNR folks!" You can't exactly take it back.

Anyway. He got intubated. What's funny is, when you learn to intubate, you learn on dummies. Stiff dummies. And non-alive ones, in case a few of you smart-asses thought we practiced on the slow learners. It's very hard to recreate human skin, at least on a level that you'd be able to pay for. The guys at MythBusters seem to get ahold of good stuff. When you get to real people they are very much more pliable. Except this guy. Put the blade in his throat and instead of lifting his jaw you lift his whole dang body. Needless to say, it was neither an easy or enjoyable intubation, and required us calling Anesthesia for backup. Unfortunately, during the intubation, he aspirated a frick-ton of gut chunks. Sorry. It was gross for me too. There was really no way to prevent it, he was a very difficult emergency intubation. But it gave him a nasty case of aspiration pneumonitis and pneumonia (one's a chemical burn, one's an infection).

Fast forward one miserable week later, and this guy doesn't look like he's ever going to come off intubation. Not that it makes him reasonable. At first he was heavily sedated, but for a few days he perked up enough to spell "Eucerin cream scrotum" to let the nurses know....well, I pretended I didn't know what Eucerin was to make sure they'd take care of it. Not. My. Job.

The problem with this patient was he had nowhere to go. Every organ system he had was crapping out. And now he had a pacemaker and was on a vent and had a feeding tube, and the way his kidneys were working he'd probably need dialysis eventually. In short, the words "long-term" weren't anything we used with the family because there was no other intervention to do for him. He was just waiting for an infection to get him. Meanwhile he wouldn't be able to get off the ventilator for any kind of meaningful time period. It wasn't a bridge to improved health. It was a last resort to keep his body working. In my opinion, it probably shouldn't have been used, and that apparently was his opinion too. But when push came to shove his wife didn't want to let him go. So he laid in our ICU suffering.

That brings me to the meat of my story: the craziest s#$ goes down in hospitals. The lady I thought was his wife? Not actually his wife, but his live-in-ish girlfriend of 27 years. He'd never wanted to marry her, his family told me. Repeatedly.

I had noticed something was weird with the family a few days into the saga. For one thing, there were tons of them. For another, several family members, especially adult women, got thisclose to his face, repeatedly asking questions and trying to get him to write on a little clipboard. They were so close to his face I thougt they were sharing an endotracheal tube. They just hovered constantly. His "wife"/girlfriend/Creepy McCreeperson was especially attentive, fawning over him, fussing over him, accidentally unhooking monitor wires and IV's as she repositioned him. I actually walked in on her putting makeup on his face one day because, "he doesn't like his spots (vitiligo) to show." "Something is just off" I told my co-intern.

One thing that was indisputable was that every morning I'd look at his vitals and they would be perfect. They were something I could take to my attending and show how I had his BP and heart rate under control. Then by 11:00 nurses would be running to find me and tell me his BP was in the 190's and what was I going to do about it?!?!

I tell you what I did about it. I kicked everyone out of his room. It took some huevos, but after I realized I actually had the authority to do it (still can't remember I'm an for real doctor now), I walked into the room, re-introduced myself emphasizing the doctor part, and said, "I know you all want to be with him now, but my job is his vital signs. And they're going to Hell in an emesis basin." LOL I said the last part more like, "All the extra company and crowding in the room seems to agitate him. His blood pressure is up 30 points from when I first see him in the morning. I can't have this for my patient. We have a 2-visitor policy and we're sticking to it." The women clucked and agreed and kissed his hands 30 more times before I realized that they weren't leaving until I said "NOW." Which I actually did as I physically ushered them out. Later his daughter said, "They would not leave him alone! When you came in there and said you weren't having it in your ICU I was like "Oh good, she's MAD now!"

Things got weirder at night. I started making it a habit to go by the cafeteria and pick up my second breakfast (one to get me out the door, one to keep me from jumping out the window) and sit down to read the night nurses notes. One morning I just about spit out my oatmeal when I read the "wife" and her sister (who I didn't actually know was her sister, but whatever) came out of the patient's room and told the nurse that Terrence had asked her to marry him. Huh? The man is on a VENTILATOR. Have you ever tried to propose with a tube down your throat? Oh, he wrote it out they said. "Note showed to nursing staff did not seem to match patient's handwriting," the nurses' documentation read.

I thought it would be dropped, but nope nope nope. By now we were starting to talk extubation and "comfort care only". Things got a little more urgent. The patient also had a plastic sheet with the alphabet on it, thought being you could spell out simple words, not make life decisions or write legal documents. Wouldn't you know, the patient "spelled out "will you marry me?" on his tablet!" the girlfriend insisted.

The macrabre spectacle started becoming a part of our patient care. "Don't let patient get married." was in my checkout sheet to the night resident. "Wha..?" "I'm serious. Crazy things happen here at night. Don't let that be one of them." She brought in a chaplain one night (I was starting to wonder if the fact that I repeatedly put the kibosh on proposal-writing and man-hounding during the day is what made this a nightly occurance) and had to be told for the 10th time that we did not believe the patient was capable of making complex decisions. No, not just because of the ventilator. The powerful narcotics were also something to consider.

As she grew more insistent, so did we. I started to document in my notes that I specifically did not believe he was capable of making legal decisions. It's not something I said lightly, seeing as he knew he was dying and if he did know what he was saying I'd hate for him to not get the chance to cut that mean-looking sister out of his will. But I also saw myself getting lead down a road to one of those fake weddings you see in a movie where the heroine is bound and gagged and the deaf old minister says, ""LemmegoIdon'twantthissssshhhh? Was that a yes? Ok, very well, I now pronounce you..."

Each night she'd insist they were getting married the next day. I started hearing things like, "she told the nurse something about her name not being on their stuff. He has a car and a camp trailer I think." God knows he couldn't have had much else. The patient's mom told the medical student not to let them get married because she gave him crabs in the 1990's. She started asking what kind of doctor can declare a person legally competent to get married. One time, after clearing the room, it was just me and the medical student with him. "Ok Terrence. It's just you and me. Tell me, do you want to get married?" I asked. "" he said. "Well, I don't know if that's a metaphor, but I'll check your vent settings and try to keep you single." I replied.

One of his sisters came in with papers folded up in her back pocket that I saw her waving under his face with a pencil. His nurse told me they were papers she wanted him to sign leaving her that damn camper and car. "He promised me this stuff a long time ago" she said. "OUT." I said.

His adult children, who I now realized were the only sane ones in the bunch, told me the patient's sisters and brothers were in the waiting room dividing up his stuff. The daughter was in tears over how her family was cracking and spilling their greedy craziness all over what should have been their time to say goodbye to their dad. This is the daughter that thanked me for kicking everyone out. At the time I honestly didn't know if they'd listen or gang up on me, but I guess it's what she was waiting for so she'd get some alone time with her dad.

We got the Palliative Care team involved. They specialize in helping patients and families make tough decisions and transitions. Their attending asked me to PLEASE make sure I was documenting the patient's condition. But the woman wouldn't leave it alone.

The weird thing was, to look at her, she looked like a sweet middle-aged school teacher with little glasses and curly hair pulled back in a low ponytail. If I only saw her during the day, I would have thought it was sweet. But every other piece of evidence pointed to batshit crazy. Why would you stick with a man for 27 years who, when asked if he wanted to marry you, would have actually answered "Over my dead body" and meant it?

On the day we were going to extubate him, she showed up in all in white. Down to her new tennis shoes. "Craaaappp. This is going to be a fight." I thought. She had already bought herself an engagement ring. She had her chaplain. "I just know Terrence's last wish was to get married," she said. The Palliative attending and I got him alone again. "Do you want to get married today?" She asked. "Msmdhhmimme". He said. "Well I don't know if that was a yes or a no. Do you want to get married?" "It's time." He said. Hmm...again not really a yes or no answer. We tried again. "Yes or no, do you want to get married?" He nodded. "I'll be damned." I thought. "It's time." he said. "Romantic," I thought.

After a little ingenuity, the Palliative Care doc came up with the idea of a "spiritual wedding." One where we very clearly stated the patient would not be signing any legal document or marriage license, but if it meant a lot to the woman, they could have a marriage ceremony in the room. I thought it was freaking brilliant, but after the PC attending said of all the weddings she's held in the ICU (really?) this was the only one that made her want to throw up.

So after the patient talked to the kids and they felt satisifed that he really meant it, a "spiritual wedding" was held. It was bizzare, but it shut the lady up. "Huh, maybe all she wanted was to be married in Jesus' eyes after all," I thought.

What a dope. That night his mother called and said that Abigail had told her she and Terrence were married, they signed papers, and it was all legal.

He died the next day while Abigail was reading to him from Psalms. His kids cried and prayed over him for an hour. His sisters and brothers didn't show up. As for me, I won't be surprised if my documentation doesn't earn me a subpeona when this fight over his trailer goes to probate court.

Sunday, July 18, 2010

Emotions take time...

And I don't have it. I've started two more blog posts, but just don't have the emotional capacity or the hour of consciousness it take to finish them. So I'll pacify you with a little story.

I declared my first death the other day. Lucky for me I had a.) Expected it and b.)Not caused it. The senior residents gave us a little booklet with various how-to's they don't have time to teach you in medical school, such as how to declare a death, so when the nurse asked me to pronounce it I trudged to the room, thumbing through the booklet.

Step one is introduce yourself. These people knew me, because before it was imminent (to me) that the man was going to die, I'd kicked the majority of them out of the ICU for hovering around him asking him which of his possessions they could have. I didn't care who got his boat, I cared that his blood pressure spiked 70 points when they were in the room. How do you ask a man on a ventilator to sign a will? ("because he promised me these things before he was on a ventilator" was the answer)

Next up explain that you have to do a physical, see if they want to leave (they still didn't), and then spend an awkward five minutes assuring the person is dead without upsetting the family. How would YOU make sure a person is dead? No, really dead, not just "Oh, I think he's dead but we should call the authorities." You ARE the authority, and if you say he's dead and he isn't, well, I don't want that skeleton in my closet.

Suffice to say, I check his wrist like I'm feeling for a pulse and squeeze the bejeezus out of a fingernail.

You also have to do things like check the wristband to make sure it's the right patient (wonder what happened to get that rule put in place), say his name out loud, listen for heart sounds for FIVE WHOLE MINUTES, which quite frankly is five whole minutes longer than I care to spend in the company of the deceased, and check for pulses in several places.

There are a few things the guide did not mention.

After I'd done each of the steps, I have to admit I was afraid that being freaked out by touching a corpse so repeatedly for the first time since anatomy had made me possibly miss a heartbeat or pulse. I didn't want to just phone this one in, so for good measure, med student by my side, I put my fingers where his radial pulse should have been one more time.

That's when his arm jerked.

Just poop yourself? Because I practically jumped out of my white coat when it happened. I actually physically jumped back and flung my arm up. The slow-reflexed medical student was still frozen beside me when it dawned on us. "I think that's his pacemaker," his spiritual wife (another story) said. Thank God Thank GOD she was focused so much on his body when he jerked she didn't see me swallow my tongue.

So, moral of the story, if someone is going to die, FOR THE LOVE OF GOD CALL MEDTRONIC AND HAVE THEM TURN OFF HIS PACEMAKER! If I didn't know the patient well enough to remember he had it, I may have tried to shoot him in the head.

I hope you all know that's how you kill zombies.

Wednesday, July 7, 2010

And today was his birthday

We had husbands crying all around the ICU today.

I wish I could find humor in it, but today was so stinking sad that I just can't. Today wasn't about finding humor in life, it was about making hard decisions and offering comfort.

One patient has been in the hospital for months. Before that she lost her legs in previous hospitalization, and before that she was a marathon runner. She's in her late 50's, and I don't need magic glasses to see what she was like, I can just look at her daughter who can barely stand to come by the hospital now.

I have been taking care of her for a week, and every morning I'd go in to see her, and every morning she wouldn't respond. She might open her eyes, she might even follow me around, but she didn't answer questions or even reveal any understanding of what I was saying to her. Her skin is puffy and weeping from edema, her face is encircled and squished by the ventilator straps (yes, you can be conscious and on a ventilator-I was not really aware of that). I couldn't tell if she were in pain or not. As a doctor that seemed like the one thing I could really do for her, but I was really just standing there by her bed stupidly repeating the same questions and wondering if she was screaming at me inside her head. Her husband was broken up over this change in his wife. In a lot of people's minds, you're either going to get better or you die. Three months in and we didn't know. That's very hard to understand.

This morning she nodded. She nodded! "Are you in pain?" I asked. She shook her head. "Are you having trouble breathing?" She shook her head. Can you nod your head for me? She nodded. I was elated. I bounced around telling the nurses and other residents that Peggy had cleared up and answered questions for me. This is what I'd been waiting for! We could extubate her! She would breath on her own and then slowly but surely get better and then go home to her sweet husband who brought bags of chocolate for all the nurses!

Then her CT scan came back. She had both persistent and new areas of abscess in her pancreas. You can't get rid of abscesses with antibiotics. You have to drain them or cut them out. Interventional radiology could reposition or replace the drain, but the attendings knew from their previous visits with her that every other time her drain had been repositioned or replaced, she went septic, getting sicker and taking longer to recover each time.

We had a family meeting with her husband today. He was alone in the room with her, dapper in a cowboy hat and boots with a yellow button down shirt. We explained the CT and what it meant, and asked him what he wanted to do.

He said, "She was fine until all this started. Then she got sick the first time. Then it killed her when she lost her legs (during her septic shock her legs infarcted from too little blood, becoming gangrenous) but she said she wanted to be fitted for her prosthetics. Now each time she goes down she comes back worse. She looks like a corpse. It's tearing the kids up to see her. I don't know if I can get my wife back. I know her face; I know the furrow in her brow. I can't see her in agony all the time like this." At this point her nurse started to cry. It took everything I had not to let the tears leave my own eyes. We asked her what she wanted, but she couldn't talk and couldn't answer complex questions. You could tell she recognized her husband. When we asked if she knew what she wanted she didn't answer. When we asked if she was scared her eyes grew big and a tear dropped down her face.

He asked the attending point blank what he would do. The attending thought and said that if it were his mother, he would consider how it would take months of everything going perfectly to get her to her best possible level. And that we didn't even know if that level was going to be where Peggy would want to live at.

In the end the husband decided to pull her ventilator. She is breathing on her own, and we are still giving her antibiotics, but it's only a matter of time before she gets septic again.

Today was her husbands birthday. I hope she makes it a few more days so he doesn't have to remember every birthday like this.

I don't know how the nurses can handle it. They are with these patients for months, get their hopes up, and then sit with the families when there isn't hope left. One nurse drove two hours home to see her parents after a patient suddenly died this week. I made sure to hug my own sweet husband extra tight when I got home today.

I wish

I wish I had a pair of magic glasses. That way I'd see child hugging his mother, instead of an elderly man leaning over a shell. That way I'd see a little boy holding his mother's hand, instead of a stubborn old fool trying to keep a corpse alive. That way I'd see how they used to play together instead of how he tries to manipulate the system for her. I'd understand how he didn't want to leave her the first day of school, then maybe I'd see why he's willing to put tubes and lines in her 90 year-old body so she won't leave him now. To him it doesn't seem to matter that her memories are gone, her consciousness addeled, her speech stopped. As long as her heart doesn't stop beating he still has a mother.

I hope I remember that when we pull her ventilator tube today. Because right now I feel relief for her and pity for him.

Wednesday, June 30, 2010

Tomorrow, Life Is Over...

Or it begins. I suppose that's how I should look at it.

A short list of things I know or assume:

1. I'm telling myself someone will die tomorrow. I start in the ICU; it's a fair guess and maybe this way I won't freak out if it happens.

2. I'll probably feel like I'm drowning all day.

3. I'm pretty sure I'll see someone's ass. That's just the way it happens.

4. It's cruel that the department didn't think to give me access to patient charts until MIDNIGHT tonight....meaning I'll have to go in around 6 (or earlier depending on when I wake up) to get started.

5. Thank God I get to wear scrubs. I don't intend to look good this entire month.

6. I have a long coat!!! Finally, after years of that dorky short coat that made the word "Eager" come to mind whenever I saw someone wearing it. And I hate the word "Eager".

7. Even after a tour I STILL don't know where I'm supposed to go tomorrow.

8. I think I'm going to throw up.

Thursday, June 24, 2010

Another One Bites the Dust

I'm about to start residency. It is a mix of joy and nausea to be honest. Nice that I can finally answer the phone with "This is Doctor...." when telemarketers call ("I'm sorry, I can't talk about new siding, I need to go back to SAVE SOMEONE'S LIFE! ). Really nice that I'll finally FINALLY get paid. As one of my friends said, "It's your first real paycheck of your whole life!" I'm 26 years old. How sad is that?

I start out in the ICU however. I'm mentally preparing myself for the idea that someone's going to die every day. Then when it happens, maybe I'll remember that they were in the ICU because they were very sick, and 30 years ago they probably wouldn't have made it anyway.

Of course, if any of you are my patient, you should know that's not a treatment goal, that's a consolation so I don't go crazy when people smoke their last cigar on my watch.

I have to brush up on ACLS. It's the algorithm and protocol you follow when running a Code Blue. It involved drugs and electricity. On the surface, it is awesome. In practice, I should probably avoid caffeine and/or wear a diaper. Btw, some things that I find hilarious:

I kid you not, I am authorized to shoot you with this.

1. The advice old hands give to interns regarding Code Blue: "If they're in Code Blue, they're already dead anyway. All you can do is help; you certainly can't kill them twice."

(btw, far fewer people survive Code Blue than Grey's Anatomy let's on. It's not a 2-for-3 thing, it's more like a 1-in-4 thing. And even then they ain't always right. Could YOU go 30 minutes without a heartbeat or proper blood flow to your brain without being a little "off" when you came back? It's rare.)

"If this were Grey's, I'd be using my tongue."

2. Chest compressions are one hell of a workout. Especially triceps. And again, what you saw on that episode of Saved By the Bell where Zach and Slater do CPR on a homeless man that happens to be the father of Zach's new (also homeless) love interest who only eats apples for lunch is crap-ola. You don't just shrug your shoulders up and down while your hands happen to be on someone's sternum. It's as if Death himself were stuck under that ribcage and your hands are the only thing than can unlodge him.

3. In order to help the people doing the compressions to keep a correctly timed rhythm (ie a regular heart rate), there is a song you're told to sing in your head: Stayin' Alive by the BeeGees.
"Aren't we worth coming back for?"

4. Unfortunately, there is another song with the same rhythm: Another One Bites the Dust.

"Give it up and you could look like thissss YEAHHHHH!!!!"

Thursday, June 17, 2010

Did you say, "Caulk Gun?"

More adventures at Home Depot.

I needed to buy caulk and a gun to seal our screened-in porch so I of course went down the street to HD. The very friendly hippie behind the paint counter showed me to the section, and then helped me pick out caulk and a gun.

"It doesn't really matter which one you pick. They're all pretty much the same," he said. "You have no idea", I thought, as I picked up one resembled the Crap-o-matic we had to use last year for defecography. "Just write 'Surgical Grade' on the label and you got yourself...well, disgusted is what you got yourself."

He went on to describe how to use it, and as he mock squeezed the trigger I couldn't help but flashback to the poor lady who was up in the air with a bowel full of putty just as the x-ray camera went on the fritz.

"Oh, I know how to use it." Then my face turned very red and I snort/laughed while simultaneously trying to decide if I further explain why I knew it. I decided that it was a little too much for a Sunday evening, thanked him, and walked away with a huge grin on my face hoping he didn't think I was laughing at him.

Unfortunately, though I thought I knew what I was doing, caulking a seal requires a lot more finesse than caulking And there's the line.

Monday, June 14, 2010

All Bats Have Rabies.

I am a new homeowner.

It's pretty great, actually, especially considering that I've moved 12 times in the past 9 years. I no longer qualify as "transient/homeless" at free clinics (good thing since I'm the doctor), and I think for the first time in my life my checks, driver's license, billing and mailing address will all be the same...and current. Also, my parents took the opportunity to get rid of all evidence that I once lived in their house. If anybody wants a Ginger Spice barbie doll (New in the package!) or a collection of floppy disks, let me know.

Of course there are downsides to being a new homeowner. Well, let me put it this way. There are downsides, especially if the homeowners are a doctor and an engineer. One is a "can't see anything but the repairs necessary to make the house the most efficient structurally sound environmentally healthy protected against any future wear or problems "Preventative Maintenance" is my middle name" kinda guy, and the other is a "Maybe you need protective eyewear for this and full coveralls for that don't cut yourself and I will absolutely not go into the attic because it probably has bats and all bats have rabies" kinda gal.

There are many reasons I believe medical school has scarred me, but when it comes to bats, I am absolutely certain it has. Our house is old. It has a comical amount of insulation. We would save at least half the cost of insulation if we put it in ourselves, but I will not WILL NOT go into that attic.

During the first year of medical school the Infectious Disease docs get an open mic during a series of lectures on viruses, bacteria, and general pathogens. They use it to scare the bejeezus out of us. For one thing, I don't know if I've mentioned it before, but something is wrong with those ID folks. I don't suppose I could volunteer in an STD clinic every Tuesday night without coming out a little "off" either. One of them has made it his mission to mention the how the HPV test should be used on men as well, the punchline being "I'd call it a "Crap smear!" He then pauses for effect and looks at the students to make sure they aren't total idiots and understand his humor. After that he goes and takes a smoke break.

Another colleague gave a speech at our senior banquet last month. He took the opportunity to get buzzed and click through a powerpoint presentation made up entirely of drunken facebook pictures he'd apparently found by befriending the one person who takes all the stupid pictures in our class. While providing a running commentary ("Hello ladies!"). My husband, who I don't think really understood me when I'd tried to explain these people before, alternately laughed his ass off and asked me, "What does this guy do again?"

Anyway, I digress.

I don't remember which one it was, but one doc gave a speech on viruses that included the rabies virus. I still remember him saying "All bats have rabies," probably because he repeated it OVER AND OVER and finished the lecture (which had moved beyond the rabies virus) by repeating, "Get checked for STD's, and all bats have rabies." There might have even been audience participation: "What do all bats have?" "Rabies." "What do you do if someone has been in close proximity with a bat?" "Treat them like they have rabies."

In case you aren't familiar with the details of rabies, it travels up your nerves until it gets to your spinal cord, after which it travels everywhere your CNS goes. So everywhere. It then makes you bat-shit crazy and afraid of water. You are delirious and in pain. And then you die. The treatment is to get shot, but you have to have it before the virus reaches your spinal cord. If you get bitten on the toe you have a little longer than if you get bitten on the neck. Once you have symptoms, it is almost always fatal. 3 people survived in the 1970's, and one 15 year-old has "partially recovered" (their words, not mine) from a case in 2004.

These guys generally work at the Veteran's Hospital. They actually tell a story about an old veteran who DIED of rabies after being bitten by his "pet" bat. His family did not bring him to the hospital immediately because it was his "pet" bat.

I hope by now you understand why I asked my friends at Home Depot if they sell bat-proof coveralls. And I call them friends because by now the guys in Paint recognize my voice on the phone. As I explained to anybody willing to listen, I am not necessarily afraid of bats. I am afraid of the rabies virus. With good reason!

"I repeat, we are ready to move in; let's insulate this attic!"

Point being, I'm taking bids to insulate that attic.

Another thing you should know: Raccoons actually have the highest incidence of rabies. Yet another reason to hate those rat/bear trash-eaters.

Sunday, June 6, 2010

And How Many Drugs Have You Taken Today?

I try to leave work at work when I can. Though I fail miserably in inopportune places (I'm pretty sure I haven't gone an entire family dinner without saying something disgusting in 4 years), I don't go around shopping malls diagnosing people under my breath, "Parkinson's. Neurofibromatosis. Chronic alcoholic. Teenager."

Unfortunately, when I turn off my medical mind, I generally revert to the naive small-town idiot I am. Whereas in the hospital or office I don't trust anything, if someone I meet in a coffee shop tells me he's the prince of Nigeria, I won't give him any money, but I will probably go home and tell my husband about the nice man I met. This baffles him. "Al, our kid could smoke pot in the room next to you and you'd have no idea." How can you play "name that drug" in the hospital and not be able to smell the weed in a snowboard shop?

I do not know. Apparently it's an all or nothing switch. If I turn it on, I'll know that the shifty-eyed loon in the corner is on PCP, but I'll also tell the donut shop lady to have that mole on her neck checked out. Which, unless you then follow up by saying "I'm a doctor" (which will either make you look like a pompous ass or the Prince of Nigeria) is not socially acceptable. I'm finding out.

When I was on Family Medicine this April, we got some strange ducks. It was in an older low-income part of town, so even the attendings saw a lot of new faces (as opposed to the usual way clinics in teaching hospitals run, with the residents getting the patients with lackluster follow-up and the attendings having a relatively cush patient roster). I was always sent in first to scope out the situation and listen to the wandering complaint list. My job was to find 3 specific things the patient wanted out of that clinic visit.

One time I had a patient who looked like Diana Ross. Just as the 80's would have left her. I actually thought maybe I had found a rip in the universe and had time traveled back to the 80's by walking through the door. She had enormous hair, false eyelashes, gold eyeshadow, and a spandex/sequin outfit that would have made Freddie Mercury cry with Jealousy. Her eyes bugged out of her head. Not in a thyroid-problem way (I checked anyway), but like someone kept simultaneously pinching her and yelling "BOO". She would gaze off in the distance, but every once in a while decide to pay attention and freak out. Even once the attending got in there, anything we said what greeted with a "WHAT?" and that spooked expression. I couldn't figure out what drug she was on, or if she was mentally ill. I guess she had paranoia with a severe case of disco fever.

I don't know how else to describe it. Imagine if you had a Solid Gold dancer in your examining room and every time you said something as innoculous as, "sinus drainage" she acted like you'd just told her disco had been murdered. She was just bizzare.

I think if I'd seen her on the street, I would know something was not right. That's pretty hard to ignore.
"What do you mean, colonoscopy!?"

Friday, April 30, 2010

A small story

One poor guy was sent in with his three kids for well child checks while Mom went to work. I actually don't think they were all his kids. I don't know if any were his kids. I asked if he was Dad and his reply was, "Yeah. Well, stepdad. Or something...yeah" I would have been like, "Hey you perv, why are you here with these kids, diligently checking on their health?" but he produced a document signed by the mom in the kids medical records (all the kids had different last names, but their first names started with the same letter. That's how I knew they were related.) that read, "To whom it may concern, I authorize my boyfriend, Mr. Nice Guy Doormat, to bring my children in for medical care and authorize shots."

Three kids under 5 with one "Dad" to corral them is a lot. He actually did pretty well, he was really attentive and knew where they all were at one time! In seriousness, he really did stay on top of their behavior. When the little guy (I think about 3) started to act up and try to escape, the man asked him to come back. Undeterred, little man kept trying to escape. "Excuse me, last time I checked my name is "Daddy." I don't think the kid quite understood what was happening. He replied, "Well my name is Junior!"

There really is nowhere to go from there. The kid was right. I've tried that in my home life now, but since I'm no longer an adorable three year old and my name actually isn't Junior, it hasn't had the same effect.

Thursday, April 22, 2010

Fair enough.

Two days ago I was getting my morning coffee from the clinic cafe and thought "I don't really need this. I should just stop drinking coffee." Then I looked down and realized in my morning fog I'd just put iced tea into my coffee cup. "Fair enough," I thought.

Later that day a 16 year old came in to get rechecked for a surprise chlamydia attack (she had no symptoms, the clinic just has a policy to screen all teens and early 20 somethings during their annual exam). "Did you tell your boyfriend about the chlamydia?" I asked. "Oh he's NOT my boyfriend anymore." "Ok...Did you tell that jerk who gave you chlamydia that he needs antibiotics?" "Yeah I did that." "Have you had any new partners since then?" "No no no, I'm kind of afraid to have sex now." Fair enough.

How do you answer that?

Ok, really, you keep your preachin' to yourself and say something like, "The only sure way to prevent STD's is total abstinence, but condoms are also a fairly effective method. If you do choose to have sex again, definitely use a condom." And a ten-foot pole. And another form of birth control. And maybe go talk to the other 16-year old I just saw with a baby. As I told my little sister when giving her one of my awesomely informative "Life Talks", you should always use a belt and suspenders unless you want to be caught with your pants down.

Wednesday, April 14, 2010

I'm no lady, I'm a doctor.

Sometimes when we have gentlemen patients over a certain age, they get embarrassed in front of the "lady doctor" and don't want to talk about what's bothering them. Usually they get over it pretty quickly.

We had a string of those patients today. One wanted to talk about sexual problems, another needed a digital rectal exam (not by me, I'm going into radiology!) another had absolutely enormous testicles. Which had not previously been enormous. Oh wait, excuse me, he said they'd always been big, just not the size of softballs.

Obviously, they get over their shyness.

I remember riding in the car one day and my sister (or was it cousin?) going, "Hey Al, tell me a story about the balls you've seen." I would have been offended if I hadn't worked several summers at a nursing home in preparation for medical school.

Anyway, when the gentleman who probably had bilateral hernias saw that the attending was also female, he said to the (male) resident, "I don't know why you keep bringing in ladies. I don't really want to show this to any more ladies." "She's not a lady, she's a doctor," I said, before thinking about how that came across. Luckily the attending concurred. "Parts are parts, and I've seen them all," she reassured him before giving him the hernia what-for.

I'm trying to think of examples that would make my sister puke, but I can't even come up with any right now. I think they have a shelf life of about 5 hours in my brain, less than that if I happen to have had a margarita at dinner.

Seen it.

Point being, you may think you have something weird going on, but most likely we have seen weirder. And we really don't care or even notice so much, unless it's testicles the size of basketballs. Then we just feel terrible for you because you seem like a nice man and it's not fair to add insult to old age. Or if you have legs hairier than a yeti up in the stirrups. I don't mean you didn't find time to shave in the last week or five. I mean if it's so bad we think ALF decided it was time for his annual, that is something we will notice. Or old man toenails. Yeech.

Oh that was gross. I am no lady.

Monday, April 12, 2010

Can I keep him?

I started the clinic part of my rotation today. I'm at the hospital an hour and a half later than when I had to start for inpatient. It's quite awesome.

A few highlights of the day:

Cutting a sebaceous cyst (a sweat gland that has lost its connection to the surface of the skin--so imagine one sweat gland saving all it's output for two years) out of a lady's back. "Yep, there's the locker room smell," the doctor said as he squeezed thick yellow-green crud out of the incision. "I've been mouth-breathing for the last ten minutes, I can't smell anything," I replied. I do love a good excision.

We had a twenty year-old with a sprained ankle. I was in the room alone, doing a prelim exam, and decided to do a drawer test for stability. As I've mentioned before I am not good with grotesque jointsNot only did her ankle move way too far, it also popped grotesquely in my hands--I was not expecting it. I shot backwards across the room on my rolly-stool shrieking, "HhOOohhhhhHH I'm gonna throw up!" Then I took a few deep breaths with my head in my hands and we had a talk about what not to say when my attending came to the room.

Most of the patients just didn't show up, but the last patient who did was a mother with a history of abuse and neglect bringing in her latest victim for his one-year exam. The doctor I was with told me the woman had been hotlined several times for neglect, so I went in ready to think the worst. "Mean face," I thought immediately. Then I saw the baby. I expected to see Sally Struthers crouching behind the exam table. This kid wasn't the worst I've ever seen, but in my humble opinion he was one of the worst I've ever seen in person. I can't put my finger on exactly what was wrong, but overall he just looked shell-shocked and gaunt. His hair seemed too thin. His face looked sunken. He wasn't as active as the one year old we'd just seen in the previous visit. He didn't cling to his mom when we poked and prodded. And his eyes. His big brown eyes looked too big for his face and just stared at me. "I'll take you home baby," I thought to myself. "I know where to buy diapers. I have friends with kids this age--I could figure it out." I didn't actually say it out loud of course, with his mother being batshit crazy and all. But if she had offered, I think my husband would have been surprised when he came home tonight.

"You are getting very sleepy....Now take me home feed me sweet potatoes...."

It's hard enough to not want the well-cared for adorable kids. When you see babies and wonder what kind of life they have ahead of them, it stays with you long after they go home.

Sunday, April 11, 2010

Do You Understand Why You're Here?

During my first week on this rotation, I was reminded once again that our best medical opinion isn't worth a bowel movement if it doesn't work for the patient. It is so hard to accept that, especially when you think what you're telling the patient is going to save her life.

While I was on call the first week of this rotation I got a patient I knew was going to be interesting. For starters, we were told her name was something like "Gerthard". The nurse spelled it out. And then I noticed it said "Male" on the patient ID stickers in her chart (I don't think the nurse had referred to her as a "he" or "she", but I thought it was a lady patient). It wouldn't have been the first time I'd had a transsexual patient, but these are just things I'd like to know before I go make an ass out of myself in a patient's room.

When we walked in, I still wasn't sure. I said, "Gerthard?" "NO! My name is Gertrude! I don't know why my name tag says that!" Ok, question no. 1 answered. I wasn't about to come right out and ask about the other one, so I tried to observe. No clear answer. It could really go either way. The surgical history saved me--no one with a hysterectomy could be a male. And she was carrying quite a frou-frou purse.

Anyway, that is not the point of the story. The point is, she was one of those, "I haven't needed to go to the doctor in 30 years!" patients. When a patient says that, you might think, "Oh, they must be really healthy." No. Definitely no. I suppose the rare patient might be like that, but usually that phrase means: "I've been smoking and eating sugar-coated fried crapsticks for 30 years and didn't want to spend the money to have a doctor tell me to stop."

What brought her in today? "Well, I've just been having a little trouble catching my breath." Uh. Oh. This could be something easy or something like when my dad said he was "having a little trouble moving around" and ended up having bypass surgery three days later. Then she said, "I went to the clinic"--GOOD for her! She went to a clinic first in case it was something easy to fix!--"and they said my oxygen was really low so they sent me here."

Not only were her O2 sats in the 80s resting (should be around 95-100), I heard an honest-to-God S3 when I listened to her chest. Medical students get very excited about this because it's something we have to memorize out of a book but spend half of third year not understanding what we're hearing when we listen to a heart. Instead of the usual "lub-DUB" heartbeat with lub being S1 and DUB being S2, hers sounded more like "lub-DUB-dub...lub-DUB-dub..." with the last "dub" being and S3 beat. It sounds like "Kentucky", vs a "Tennessee" "lub-lub-DUB....lub-lub-DUB". That's an S4. Neither S3 or S4 should be there, and if I were at a hospital with medical students, they would have announced that clear S3 over the intercom and lined up the short white coats and shiny stethoscopes outside her room to take turns listening for it.

S3 usually means heart failure, S4 makes you think it's a stiff left ventricle (usually due to years of high blood pressure). SOB + S3 and 2+ pitting edema in her legs probably equaled heart failure. She was a really heavy lady, so her chest x-ray was kinda crap, but it clearly showed fluid in her lungs.

The lady had a neck like a tree stump. She told us how she liked to play solitaire at her computer, but lately would just "fall asleep" sitting upright during a game. I assume she has obstructive sleep apnea due to that bullneck and the extra weight on her chest, but I don't know if she was falling asleep due to OSA or passing out due to too much CO2 in her system.

So we know she's a lifelong smoker. We know she's in heart failure. We pretty much know she has sleep apnea. Thanks to the multiple BP readings in the 170s/100s, we know she has high blood pressure. She had a remote history of "asthma" that she only used a rescue inhaler for--4 times a day. After I listened to her lungs I added COPD to that list. Do you have diabetes ma'am? "Oh, no." Yeah whatever. If you don't have diabetes I'll take my pants off and do a lap around the STD clinic's waiting room.

We put her on the standard regimen for heart failure and suspected COPD exacerbation, as well as HTN, and diabetes (yeah, her HgA1c was nearly 9%), and admitted her to the hospital.

The next day her arterial blood gas (usually we take blood out of the veins because it hurts like watching a 5'1 girl date a 6'5 guy (That's for you, Beth) showed a Co2 level twice what's normal, and it was rising from yesterday. The intern who admitted her and I were really worried about this lady. She was a nice woman who liked to talk about her grandkids and did not understand that she was literally dying. I think some people know their decisions will catch up to them (she frankly admitted she needed to quit smoking and that she was way overweight and ate too much), but they think it will happen "when they're older". She knew she should take care of herself, but was in denial that she could actually be in end-stage disease in her early 60's.

Our biggest battle came when we wanted her to wear a bi-pap machine. It would force her lungs to stay open as she exhaled, helping her to get rid of that trapped CO2. She was headed for respiratory failure. As her CO2 level rose, she was going to get stuporous, then comatose, and require intubation. Intubation on her was going to be ugly, and getting her off the ventilator would be just as hard for a patient with her problems. At least, that's the worst case scenario as we saw it.

The Bipap machine is attached to a mask that the patient has to wear. It's pretty loud, and some patients feel like they're trapped when they wear it. This lady flipped s#$ when the respiratory tech put it on her. She absolutely would not wear it.
The intern and I played good cop, bad cop (I was good cop because she was on her last week of a long month in inpatient medicine. She told the patient how serious her condition was in, how it could kill her, and how she if she could just wear that machine for two hours today it would help her. After the lady freaked out on the intern, I gave her an hour and went in.

I tried to understand where she was coming from. She had not been to a doctor in years, then she goes to one and a day later she has COPD, congestive heart failure, high blood pressure, diabetes, and sleep apnea. Each of those diseases could kill her. In our minds, she's had all these for a long time and needs the most aggressive treatment right now. In our mind it was clearly the best treatment and clearly necessary. In her mind, she was healthy until a few days ago. Now with the oxygen and Lasix (diuretic) she's gotten some fluid off her lungs and feels much better. So she doesn't really believe us when we say that even though her O2 level has improved, she's trapping so much CO2 she might crash at any time. What the heck does that even mean? Oxygen is the important one, not carbon dioxide!

She looked at me in tears, absolutely terrified of the machine. "Have you ever been so afraid of something you just couldn't do it?" I couldn't think of anything I would rather die than do (which is how I saw it even if she didn't) so I said so. "I just don't know what to do! You are sitting here telling me I'm dying and I feel fine!" She's probably been living at an O2 sat of 90% for years, so I bet she does feel like normal. You could hear the fear in her voice, she was nearly hysterical. I figured it was a good time to shut up and sat down on the bed by her and gave her a hug. After another day of refusal (we even tried Ativan, which just snowed her and still didn't convince her to wear the bipap) I decided to treat her as if she were dying. We had told her everything we knew. She could make the decision. If she'd rather die than wear the machine I couldn't hold her down and strap it to her face. It's her life and death.

I think that was harder for the intern to take, maybe because it was her admission and would be her M&M conference if the lady died after not getting the full gamut of available medical treatment. But I think it's an important distinction to make--our recommendations are not always going to be a patient's decision. If you get exasperated or offended by a patient's refusal, often you don't understand what exactly is behind it. I think I knew what was behind hers, and still didn't agree. However treating a patient as non-compliant vs. recognizing a patient's right to make medical decisions makes a huge difference in how everyone else down the chain of command acts toward the patient. If a doctor thinks a patient is an idiot and gripes about it to a nurse, how do you think the nurse will look at the patient when he or she goes in that room? If it's her last few days on Earth, I would like to think people were nice to her instead of angrily complaining about her.

In the end, she never wore the machine. She was moved to a unit that could intubate her, but did not end up needing it. She spent several more days in the hospital than she probably would have if she'd worn the machine. She will have a large hospital bill. She will have to have O2 at home. She will probably not live 10 years. But I'd like to think she came out of the hospital thinking that people cared about her instead of shoving invasive treatments she didn't want at her. I don't care if that's hokey. People want to be treated kindly more than just about anything. Sometimes that means not getting the latest treatment.

Wednesday, April 7, 2010

Crack Makes Baby Jesus Cry

Pretty much every day we get a frequent flier back on our service. They're all new to me, but there is an exponential correlation between number of times the patient has been in the hospital and how loud the residents yell in the rounding room when they see the patient's name on the list.

We got a doozy today. Sometimes when I'm in the hospital I think, "If I tell people what really happens here, nobody will believe me." or "This is the strangest #$% I have never imagined."

This lady was apparently in because she'd done crack and had chest pain. Not that she admitted the crack part at first, but since that combo had brought her in every other time, and her urine drug screen was positive I feel comfortable in saying that was an accurate estimation of events. Last hospitalization? I think she got out just under two weeks ago. Pretty sure that this lady spends more time in the hospital than I do. Though I'm a matched fourth year, what the hell do I care?

Oh man I knew exactly which patient she was as I went walking through the ER. The one that looked like Don King. Hallucinating. (really, a lot of people in the ER look like one or the other, but both? Probably Crack Lady).

I couldn't understand what she was talking about at first, but I got the impression she was very excited about it. And it involved a suitcase. But as she calmed down and got up onto the hospital floor she started to tell us all about how ready she was to go to rehab and how she couldn't live like this anymore.

I will tell you something personal. When I was a little kid, a few of my best friends were assholes. To me. I never knew when or why they'd decide to be jerks, just that when they were done and were nice to me again, I never said, "No, you're a terrible person. Why don't you just march off to your future filled with Daddy-issues and ass-centric weight gain." I totally forgot about anything they'd done and took their word hook line and sinker that they would be nice for realsies this time. I don't know if it's my good heart or my ADD, but the point is I am still that person. If a person tells me a sob story and I sense genuine remorse (or maybe just hear what I want to I suppose), I forget about all the other times they told me they were "really done with smoking" or would "schedule a follow-up appointment for their meds".

Chief Resident wasn't having it. "When did you last smoke crack?" "Uh, a week ago." "You didn't smoke it yesterday? Or Sunday? Or Saturday?" "No, no. I haven't done that in over a week." "What did you do for Easter?"

--Another interjection--I know he asked that because a previous hospital visit was right around Christmas, and when the nurse asked her if she'd celebrated Christmas with crack, she said adamantly, "I'd never do crack on Baby Jesus' Birthday!"

Anyway, back to the story. "Why did you smoke crack?" Fair question. "Because I'm weak." Fair answer. "Where did you get it?" "Somebody brought it to me." "How did you pay for it?" Ah crap. This lady obviously doesn't have any money or job. I really hope she isn't prostituting or selling her meds for crack. "They gave it to me." Who the heck is running around the city giving out crack? "They just gave it to you? Why would someone give away drugs?" "People don't want to do it alone. Sometimes people get spooked." You learn something every day. Though I suppose I don't drink alone....

By the way, this patient made me understand why the Chief says every time he's on call, he tries to put up "Free Crack at Mercy" (another hospital in town) signs in the hospital parking lots.

"Oh my chest is starting to hurt."
"Quit moaning and hurry up, we gots to get to Mercy!"

Chief Resident treated her like she knew which end was up. He talked to her as if stern talking was what she needed to stop smoking crack. Then he left, frustrated because the work he'd done last time was for nothing and because this lady was in worse shape each time she came in. And who knows, maybe because she requires expensive medical care every time that of course she doesn't pay for. I wish I could say that the concern was purely for the patient's health. In a perfect world, it would be. I may whine and groan about these patients who abuse the system, but I really do believe that it's my job to treat each individual patient without bias or judgement. Even when they look like Don King on crazy juice.

Softer gentler resident took over after Chief walked out. He said to me "You can't let other people's biases affect how you think about a patient. If they keep coming back, something we're doing isn't working." I thought he was talking about compassion, but he said, "Oh no, this has nothing to do with that. I probably have the least compassion out of anyone. But if something's not working, we have to see if we're part of the problem." I didn't know what to say to that.

So SGR starts talking to her. She had of course done crack more recently than she'd fessed up to earlier, but she had been feeling bad for days before she came in. "Why did you wait so long to come in this time?" SGR asked. Her voice got quiet and she teared up when she said, "I was embarrassed to come back because I come so often." then "I don't want to be here, but I can't stop. I have to get out of where I live."

Sitting behind SGR, looking at her face I feel like I got punched. The way she talked (and her bug eyes) reminded me of my sister when she was a kid. Not that my sister did crack at 8 years old, more like that was probably where this woman's emotional maturity stopped. Being angry with her was like being angry with a child. And obviously, by releasing her from the hospital to the street was a terrible idea.

She hadn't been taking her medication as prescribe either. Why not? "I can't remember to take 2 pills at one hour and 3 pills at the other. I have 13 pills. When one runs out, they don't all run out so I got to wait so I can get them all together at the drugstore. I tried to take the three that the doctor told me were really important last time."

I'll be damned. Chief had angrily talked about how he'd gone over all her meds, stressing the important ones, and how it was wasted on her. But it really wasn't. She actually remembered and tried. Maybe she wasn't so non-compliant after all.

She had a good point about the pharmacy too. Chief had told SGR that he would have to personally call her pharmacy and repeat "Put all meds on the same refill schedule" in a variety of volumes and tones until they agreed to do it. Otherwise the store would refill each a few days apart, which for a lady with poor memory dependent on public transportation and angel dust to get her from place to place was really a hassle.

And why was she sent home? I guess she insisted on it last time, but now that she's willing to go to treatment I sure hope there is a place to send her. She needs intensive inpatient rehab. And she needs it paid for. You can say all you want about paying other people's medical bills, but it's just the right thing to do. Even die-hard John Gault-ers have to admit you can't hold her to the "pull yourself up by your bootstraps" logic.

I asked her if she had any family. She shook her head no. The a few minutes later she said, "I have a daughter, but my Momma has custody of her."

There is a clear cause-and-effect to her problems that could be avoided if she just stayed off drugs. You get it, I get it, deep down maybe even she gets it. But we can't settle for just repeating that over and over. Maybe now that it's April, and the service isn't flooded with flu patients, we can take a better look at the repetitive assumptions we are making when handling her care plan.

That's it. Off my soapbox. For all my snark, truly sick needy patients like her just make me grateful for the easy road I've had in life.