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.