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.

Tuesday, April 6, 2010

Sign of a High IQ

This morning in rounds one of the uppity attendings had a settle to score. I suspect it had to do with him sleeping through his alarm clock and completely missing 7am night shift checkout, then having to testify in court against one of the hospital's disgruntled (or more likely, dumb money-grubbing) former patients.

During one of the resident's patient presentations, the resident (who is prone to nervy spazzes) said something like "number of walled-off fluid collections in the abscess", for which he just as easily could have said "loculations". "Loculations." the attending said. "Well, they are fluid pockets but they are walled off from each other, " the resident replied. "Yes, that would be the definition of loculations," the attending insisted. The resident, now twitching, goes, "Yeah, loculations. That's what I said, wasn't it?" "No, you used 15 words instead of one." Ok, the attending had a point, we were all saying loculations in our heads, and that was probably why this resident's presentations always took twice as long as the other residents. I think the resident knew what a loculation was. Hmm...where did he go to med school...But then Dr. PressnBadger had to cross the line. "We're all doctors here. You can talk like a doctor. There have been studies about differences in IQ, and it's a sign of high IQ that you substitute one appropriate word for multiple words." "Well, mine's not very high," the resident mumbled into his lap. "No, no, you are intelligent. Now use the doctor words."

Meanwhile I'm at the end of the table, thinking that instead of saying, "Persistent attending who prefers to teach using methods last seen at the Inquisition" I could show my high IQ and just say "Jerk". But I didn't know the attending well enough to get away with saying that out loud so I just shuffled my papers until it didn't seem so hilarious. Honestly I can't think of any boss I'd know well enough to say that out loud. Herd dynamics are very important in the rounding room, and my nose is behind a lot of asses.
"If anyone so much as steps a toe out of this chain of command,
I will straight up choke you with my "Badass surgeon's only" scrub hat."