chf: congestive heart failure. your heart is a pump. when it doesn't work so well, fluid backs up in the pipes behind the heart and you get fluid in your lungs or swelling in your legs, amongst other things.
there was an interesting/silly article in the nytimes a few days ago about facebook and the odd position one can get into when deleting friends. it made me wonder if i should defriend the 2 residents from my program who friended me basically so they could ask for favors. one guy wanted me to change vacation time with him, and the other wanted to swap my ccu and medicine floor month. neither worked out, or i should say, i didn't want to do either, but now i am left with these 2 "friends" who aren't really friends. i can't help but feel that they befriended me in a effort to make it harder for me to deny my request. they easily could have emailed me--my email address is firstname.lastnmae@_____.edu. they obviously have my name since they found me on facebook. it's easy to say no in a faceless email, but perhaps not so easy to deny a "friend." fortunately, i am impervious to such chicanery, and these folks are no longer my "friends."
a while ago i mentioned that i would reveal my method for faster pre-rounding, so here it is: i don't actually see all my patients. this isn't a big secret, since i am pretty sure many other interns do this, although i don't think many of them will admit it as openly as i do. rounding is when the medical team walks around and sees and discusses each patient and then informs him/her of the plan for the day. pre-rounding takes place before this and consists of the intern gather vital signs, lab results, and other information from overnight, and then physically seeing and examining the patient so that when it comes time for real rounds one has all the pertinent information.
this might seem like a lot of work, and it can be, depending on how sick the patient is and how much data there is; pre-rounding on icu patients is both necessary and time consuming as there is far more going on with them as they are actaully sick and have the potential to die quickly if ignored. the same is not true on many inpatient medicine patients. they might be ill, but generally they are not circling the drain like icu patients. you would be surprised at how frequently people get admitted who really have no need to be inpatients. even more surprising is the fact that many people, even if they had a legitimate reason for admission, often resist discharge once they are better. furthermore, there are often people who remain as inpatients to receive treatments that they cannot easily get as an outpatient--such as iv anitibiotics--or who are simply awaiting a bed at a rehab facility, nursing home, etc.
those last 4 groups of people are not generally actively ill, so i don't really feel that i need to see them at 6am. i do eventually go back and talk to them examine them, etc., but i don't do this in the early morning, before rounds (unless something happened overnight). right now i have 8 patients and 6 fall into one of those aforementioned categories. so when i get to work i just right down their vital signs and lab results which takes about 1-2 minutes per patient. i see and examine the other 2 which, takes up to 10 minutes. all together this take less than 30 min, but if i gave everyone the 10 minute treatment, it would take me an hour or more to pre-round. this would quickly lead to sleep deprivation, more medical errors, increased crankiness on my part, and generally bad outcomes for everyone.
it's a good thing i'm so pragmatic and forward thinking.
Saturday, January 31, 2009
Thursday, January 29, 2009
no. 21: cheating death...with parsimony.
as i sit before my computer in my 6th post-call haze, i am gladdened but the fact that i only have 1 more night of being on call for medicine. hooray! but then i go to the cardiac icu, which means more call. oh well. at least i am almost to the halfway point.
anyway, the past 2 call nights have been seen me admitting patients with similar problems. last week it was infected AV fistulas and other dialysis-related woes. last night it was people with chf and falls. that is not germane to the story i am about to relate, but rather is psychological defense mechanism on my part that i am using to help me feel better for the confusion i experienced on rounds this morning. i will admit that i got some details confused on a few patients, but in my defense, there were 3 gentlemen in their 70s who all had chf and leg swelling and who all came in between midnight and 2am.
moving on from tangent #2 to my humorous yarn: mr h was, as i previously noted, a man in his 70s with chf and leg swelling. we finished taking his history and then moved to the discussion of code status, that is, does the patient want cpr, electric shocks, etc., in the event that the "worst" happens? (i use the quote there for 2 reasons: first, i never say that because it seems, well, an inelegant and cowardly way to frame it, and second, because sometimes dying is a better option for these folks. i mention the latter as it related to discussions had with families who refuse to let their father/mother/etc. die even though that is what nature had intended for them long ago and who, in my mind, is being tortured by a combination of the ability of invasive medicine to keep them "alive" and their family's inability to make the humane choice.)
as i was saying: we got to the code status conversation with mr h he promptly informed us that yes, he wanted to be kept alive...at least until april. i couldn't refrain from asking him what was different in april. he informed me that it is cheaper to get buried in the spring and summer given the difficulty of being laid to rest in frozen ground. apparently cheapness is a force that cannot be constrained by mortal bounds. this was the first conversation all night that peaked my interest, so i probed deeper. he later revealed that he had "run some cemeteries," whatever that means, so he had the inside scoop on the scene. i then proceeded to inquire why, if he had friends on the inside, couldn't he get a deal? he informed me that he had secured a plot for his final mortal remains at a substantial discount, but that there was no flexibility on the "landscaping costs," which he assured me, were "significant."
i am, after all a doctor--someone who fixes problems, so i chimed-in with my sagacious wit and wisdom. the suggestion i offered first was cremation. he said that was an impossibility as he had already secured the aforementioned deal on a plot. he also was afraid that it would "hurt." i posited that a rapid burn at high temperatures might be more comfortable than a slow decomposition in a box whilst underground might actually offer less discomfort, but he was unbending. i paused to consider this quandary and arrived at the following answer: shovels. why not have his family dig his own grave? at this point i should mention that our previous conversation had involved a lengthy diatribe on his part on the ingenuity and stoicism of his family, so that wasn't as inappropriate as it sounds. he hesitated. i suggested that this was actually a grand plan since it would provide the family with a final memory of him. what better way to celebrate the life of the departed than discussing it while digging his grave in the frozen, january ground?
mr h, however, thought there would be many more efficacious manners in which to remember him and so alas, he remains full code.
SC
anyway, the past 2 call nights have been seen me admitting patients with similar problems. last week it was infected AV fistulas and other dialysis-related woes. last night it was people with chf and falls. that is not germane to the story i am about to relate, but rather is psychological defense mechanism on my part that i am using to help me feel better for the confusion i experienced on rounds this morning. i will admit that i got some details confused on a few patients, but in my defense, there were 3 gentlemen in their 70s who all had chf and leg swelling and who all came in between midnight and 2am.
moving on from tangent #2 to my humorous yarn: mr h was, as i previously noted, a man in his 70s with chf and leg swelling. we finished taking his history and then moved to the discussion of code status, that is, does the patient want cpr, electric shocks, etc., in the event that the "worst" happens? (i use the quote there for 2 reasons: first, i never say that because it seems, well, an inelegant and cowardly way to frame it, and second, because sometimes dying is a better option for these folks. i mention the latter as it related to discussions had with families who refuse to let their father/mother/etc. die even though that is what nature had intended for them long ago and who, in my mind, is being tortured by a combination of the ability of invasive medicine to keep them "alive" and their family's inability to make the humane choice.)
as i was saying: we got to the code status conversation with mr h he promptly informed us that yes, he wanted to be kept alive...at least until april. i couldn't refrain from asking him what was different in april. he informed me that it is cheaper to get buried in the spring and summer given the difficulty of being laid to rest in frozen ground. apparently cheapness is a force that cannot be constrained by mortal bounds. this was the first conversation all night that peaked my interest, so i probed deeper. he later revealed that he had "run some cemeteries," whatever that means, so he had the inside scoop on the scene. i then proceeded to inquire why, if he had friends on the inside, couldn't he get a deal? he informed me that he had secured a plot for his final mortal remains at a substantial discount, but that there was no flexibility on the "landscaping costs," which he assured me, were "significant."
i am, after all a doctor--someone who fixes problems, so i chimed-in with my sagacious wit and wisdom. the suggestion i offered first was cremation. he said that was an impossibility as he had already secured the aforementioned deal on a plot. he also was afraid that it would "hurt." i posited that a rapid burn at high temperatures might be more comfortable than a slow decomposition in a box whilst underground might actually offer less discomfort, but he was unbending. i paused to consider this quandary and arrived at the following answer: shovels. why not have his family dig his own grave? at this point i should mention that our previous conversation had involved a lengthy diatribe on his part on the ingenuity and stoicism of his family, so that wasn't as inappropriate as it sounds. he hesitated. i suggested that this was actually a grand plan since it would provide the family with a final memory of him. what better way to celebrate the life of the departed than discussing it while digging his grave in the frozen, january ground?
mr h, however, thought there would be many more efficacious manners in which to remember him and so alas, he remains full code.
SC
Monday, January 26, 2009
you say pessimism, i say realism; no. 20.
i expect the worst when i go to work. i plan that everyday is going to be long and painful. that patients will be sick and difficult and whiny. i set my sights low for what time i will depart. what i'm saying is, i fully expect that each day of work will be like the 7th circle of hell. well, maybe not the 7th...maybe the 4th or 5th.
anyhow, there is a method to my, err...madness. no, i mean sensibility. my general reasoning is as follows: if you enter into something with the expectation that it will be a horrible disaster, and it turns out to only be half a disaster, then you leave feeling good. the converse is that if you expect warm, happy, pleasant things, and in the end someone coughs bloody phlegm onto your new tie, well, you would be disappointed, to say the least. some more examples: if i think that i am going to go home at 330pm, and i leave at 530, i wind up angry for the rest of the evening because i left 2 hours late. however, if i plan on a 5pm departure and i actually get out at 430pm i am overjoyed because i left "early." i excel at convincing myself of things like this. similarly, on call days, i fully expect to admit 6 new patients (the maximum we can admit on any given call day). it's not hard to see why--if i plan on an easy day with 3 new folks and i wind up with 5, i fly into a rage, but if i expect 6 and end the night with 4, i feel blessed.
it is truly amazing to me how quickly i have been able to convince myself that my life isn't so bad by merely keeping my expectations low. i also frequently adopt the "it could always be worse" position.
does this sound a bit morose? well, it shouldn't. consider the alternative: i expect great things every day--that patients will be compliant and truthful, that i will not get a surfeit of inane pages from nurses at 3am, just as i have fallen asleep (eg, on my last call night i got called at 445am by a nurse who just wanted to know if it was acceptable for the patient who had requested a stool softener at 11pm who was now sleeping to get in the morning and or if she should wake him up and give it. you be the judge. strange that i got called about this but not the man with pyelonephritis (infection of the kidney) who had a blood pressure of 74-48--i discovered this when checking vitals on my patients the next morning), that i will go home at a reasonable hour (yes, i know i have brought that up many times, but i work 80 hours most weeks, so forgive me if i want a little extra free time), or that each day will not be worse than or equal to the day that preceded it. if i behaved that way i would quickly become the facinorous man i was last year as a surgical intern. that would not be beneficial to anyone.
so i will continue on this way, willfully ignorant of the way things are, but smiling each morning when i get to work. well, perhaps not smiling, but perhaps not scowling, which is more than i can say for some other residents i know.
anyhow, there is a method to my, err...madness. no, i mean sensibility. my general reasoning is as follows: if you enter into something with the expectation that it will be a horrible disaster, and it turns out to only be half a disaster, then you leave feeling good. the converse is that if you expect warm, happy, pleasant things, and in the end someone coughs bloody phlegm onto your new tie, well, you would be disappointed, to say the least. some more examples: if i think that i am going to go home at 330pm, and i leave at 530, i wind up angry for the rest of the evening because i left 2 hours late. however, if i plan on a 5pm departure and i actually get out at 430pm i am overjoyed because i left "early." i excel at convincing myself of things like this. similarly, on call days, i fully expect to admit 6 new patients (the maximum we can admit on any given call day). it's not hard to see why--if i plan on an easy day with 3 new folks and i wind up with 5, i fly into a rage, but if i expect 6 and end the night with 4, i feel blessed.
it is truly amazing to me how quickly i have been able to convince myself that my life isn't so bad by merely keeping my expectations low. i also frequently adopt the "it could always be worse" position.
does this sound a bit morose? well, it shouldn't. consider the alternative: i expect great things every day--that patients will be compliant and truthful, that i will not get a surfeit of inane pages from nurses at 3am, just as i have fallen asleep (eg, on my last call night i got called at 445am by a nurse who just wanted to know if it was acceptable for the patient who had requested a stool softener at 11pm who was now sleeping to get in the morning and or if she should wake him up and give it. you be the judge. strange that i got called about this but not the man with pyelonephritis (infection of the kidney) who had a blood pressure of 74-48--i discovered this when checking vitals on my patients the next morning), that i will go home at a reasonable hour (yes, i know i have brought that up many times, but i work 80 hours most weeks, so forgive me if i want a little extra free time), or that each day will not be worse than or equal to the day that preceded it. if i behaved that way i would quickly become the facinorous man i was last year as a surgical intern. that would not be beneficial to anyone.
so i will continue on this way, willfully ignorant of the way things are, but smiling each morning when i get to work. well, perhaps not smiling, but perhaps not scowling, which is more than i can say for some other residents i know.
Thursday, January 22, 2009
no. 19: please, let me die.
to those who know me and/or care about me, this is my living will:if i am ever involved in a horrible accident and the prognosis is poor, please, if you love me, pull the plug. i do not want to spend days, months, years, etc., rotting in an ICU. if my condition, as judged by my doctors, is is not likely to lead to a meaningful recovery, put me out of my misery. no feeding tube, no trachs. nothing. let me die in opioid-induced bliss. in addition, i don't want you, my family and friends, to be the people coming to visit the sorry lump of flesh that was me, saying and doing silly things that will make us all the subject of ridicule.
let me go. it's been a good ride for me, for the most part, and i don't want to check-out covered in bed sores, emaciated and stinky, taking up valuable hospital resources and the time of residents who are forced to care for me even though they know my case is futile. spare us all, please!
i want to be cremated. not, under any circumstances, do i want to be buried. no prosaic funeral with a lame-ass photo of me on the coffin. you can celebrate my passing, by make it something that i would have enjoyed. high quality gin, some single malt scotch, maybe some wine. there should be plenty of food too, including sweet things. and for god's sake, don't invite people who didn't know me very well who just want to jump on the sympathy bandwagon. i don't have many friends, but i don't want them hobnobbing with a bunch of jerks who want to pretend like they cared about me when i was alive now that i am dead.
there should be plenty of crying, not really for my sake, but for the lack of joy there may be given my absence. i also expect that you who know me best will make plenty of jokes about my death that make others feel extremely awkward. please do this not only in the immediate days and weeks after my demise, but for years to follow. that's how i would have wanted it.
in closing, please understand that i say this all with sound mind. this is what i truly want. do it for me, cause i would do it for you. and if you don't be forewarned: i will haunt you from beyond the grave!
yours in eternity,
SC
let me go. it's been a good ride for me, for the most part, and i don't want to check-out covered in bed sores, emaciated and stinky, taking up valuable hospital resources and the time of residents who are forced to care for me even though they know my case is futile. spare us all, please!
i want to be cremated. not, under any circumstances, do i want to be buried. no prosaic funeral with a lame-ass photo of me on the coffin. you can celebrate my passing, by make it something that i would have enjoyed. high quality gin, some single malt scotch, maybe some wine. there should be plenty of food too, including sweet things. and for god's sake, don't invite people who didn't know me very well who just want to jump on the sympathy bandwagon. i don't have many friends, but i don't want them hobnobbing with a bunch of jerks who want to pretend like they cared about me when i was alive now that i am dead.
there should be plenty of crying, not really for my sake, but for the lack of joy there may be given my absence. i also expect that you who know me best will make plenty of jokes about my death that make others feel extremely awkward. please do this not only in the immediate days and weeks after my demise, but for years to follow. that's how i would have wanted it.
in closing, please understand that i say this all with sound mind. this is what i truly want. do it for me, cause i would do it for you. and if you don't be forewarned: i will haunt you from beyond the grave!
yours in eternity,
SC
Wednesday, January 21, 2009
the list
i carry a pager at work so that anyone can get a hold of me at anytime of the day or night. the following is a list of the pages i received in the 30 hour period from 6am on jan 20 to noon on jan 21. for simplicity, i will note what i was asked to do.
730: order tylenol
735: paged on a patient who was not mine
804: is mr x leaving today?
810: when can mr x leave?
811: is all the paperwork for mr x done? (of note, all these questions were addressed by me at 804)
840: mr x's family wants to talk to you
900: please change diet order
930: you have a new patient in the ED
945: new patient arrives on floor (i had to leave the patient's room to answer this one)
1130: call the hospital operator
1215: you have 2 new ED patients
1259: you have a new patient in the ED
1320: your 2 new patients are on the floor
1400: please put in orders on your 2 new patients so they can eat
1410: please put in orders on your 2 new patients so they can eat
1420: please put in orders on your 2 new patients so they can eat
1445: please put in orders on your 2 new patients so they can eat (i didn't do this earlier because the patient who arrived at 1259 was very sick and had to be transferred to the icu--more important that putting in diet orders)
1523: mr y is agitated
1529: ms d has a blood pressure of 165/69
1630: other medicine team wants to sign-out
1710: 2nd med team wants to sign out.
1810: dinner has arrived. yay!
1900: family of mr z is on the phone and wants to talk to you (i don't know this patient at all)
1950: mrs u is agitated
2020: please renew orders for restraints
2050: patient has a blood pressure of 190/100
2200: your new patient just pooped blood.
2245: ms g wants something to help her sleep
2250: ms g has a bp of 85/44
2300: ms g has a bp of 106/82
2301: can i still give ms g that sleeping pill?
0030: mr s has a heart rate of 200 (this one was serious)
0032: mr s has a bp of 51/19 (this one came while i was going to see this patient)
0100: can mrs h have something for constipation? (while mr s is actively trying to die)
0120: can mr v have something for sleep? (same nurse from above, knowing i was occupied).
0150: mr p is spitting at his roomate and screaming
0205: mr p has a blood sugar of 61
0330: please renew restraint order
0335: are you covering mr b?
0530: are you covering pt x? no!
0630: intern #1 wants sign-out
0645: intern #2 wants sign-out
0700: do you want some coffee?
0750: is mr t your patient?
0755: is mr t your patient?
0915: is mr b going home?
1000: is mrs l going for her CT scan today?
1010: family of mr b wants to see you.
1050: mrs s just had blood in her stool.
1110: mr s just tried to escape.
1140: mr c has a bed in the psych hospital
1205: mr s just tried to escape again. then he tried to punch a nurse--"i'm no longer in the hospital."
730: order tylenol
735: paged on a patient who was not mine
804: is mr x leaving today?
810: when can mr x leave?
811: is all the paperwork for mr x done? (of note, all these questions were addressed by me at 804)
840: mr x's family wants to talk to you
900: please change diet order
930: you have a new patient in the ED
945: new patient arrives on floor (i had to leave the patient's room to answer this one)
1130: call the hospital operator
1215: you have 2 new ED patients
1259: you have a new patient in the ED
1320: your 2 new patients are on the floor
1400: please put in orders on your 2 new patients so they can eat
1410: please put in orders on your 2 new patients so they can eat
1420: please put in orders on your 2 new patients so they can eat
1445: please put in orders on your 2 new patients so they can eat (i didn't do this earlier because the patient who arrived at 1259 was very sick and had to be transferred to the icu--more important that putting in diet orders)
1523: mr y is agitated
1529: ms d has a blood pressure of 165/69
1630: other medicine team wants to sign-out
1710: 2nd med team wants to sign out.
1810: dinner has arrived. yay!
1900: family of mr z is on the phone and wants to talk to you (i don't know this patient at all)
1950: mrs u is agitated
2020: please renew orders for restraints
2050: patient has a blood pressure of 190/100
2200: your new patient just pooped blood.
2245: ms g wants something to help her sleep
2250: ms g has a bp of 85/44
2300: ms g has a bp of 106/82
2301: can i still give ms g that sleeping pill?
0030: mr s has a heart rate of 200 (this one was serious)
0032: mr s has a bp of 51/19 (this one came while i was going to see this patient)
0100: can mrs h have something for constipation? (while mr s is actively trying to die)
0120: can mr v have something for sleep? (same nurse from above, knowing i was occupied).
0150: mr p is spitting at his roomate and screaming
0205: mr p has a blood sugar of 61
0330: please renew restraint order
0335: are you covering mr b?
0530: are you covering pt x? no!
0630: intern #1 wants sign-out
0645: intern #2 wants sign-out
0700: do you want some coffee?
0750: is mr t your patient?
0755: is mr t your patient?
0915: is mr b going home?
1000: is mrs l going for her CT scan today?
1010: family of mr b wants to see you.
1050: mrs s just had blood in her stool.
1110: mr s just tried to escape.
1140: mr c has a bed in the psych hospital
1205: mr s just tried to escape again. then he tried to punch a nurse--"i'm no longer in the hospital."
Monday, January 19, 2009
sorry to bother you, but...
i had my 3rd of 7 days on-call last friday. all things considered, it wasn't too bad. things did get a bit gnarly for a few hours when it was brought to my attention that a patient was in danger of dying at any second due to a previously undiagnosed aortic dissection. once that was dealt with, it was basically smooth sailing.
i tried explaining to a non-medical type what being on-call means, and why it can suck. it basically means that you are the person in the hospital who takes new admissions to your service. for me, it currently general medicine. in my opinion, the admitting new patients is not what really sucks, but rather it's the coverage of other patients that drags me down. what i mean is this--i am on call every 4th night, which means i stay in the hospital for 30 straight every 4th night. on the other days i go home around 4 or 5pm. what happens to my patients between 4pm and 7am the next morning? the on-call person takes care of any acute issues that arise. when i am on call i cover the other patients. since it is every 4th night, there are 4 total interns, which means that on any call night there is 1 person covering for 3 other people. the on-call person is really there to deal with acute issues, but this, as you will see, is generally not what happens at all. what tends to occur is that the on-call sap gets called to straighten out items overlooked by the primary team during the day (ie, things they forgot) as well as answer the inane nighttime requests of patients, including, but not limited to: requests for more pain meds, requests for sleeping meds, requests for enemas (no, i am not joking), requests for explanations of why they are here, etc. the second set of requests comes from nurses, asking for orders for tylenol, restraints, and all kinds of other things that don't require immediate attention by a doctor--or anyone for that matter--at 3am.
the latter are difficult to deal with in that initially, when interns are new and inexperienced, they take everything very seriously. this is ok, but at some point one has to triage these late night calls as there are up to 40 patients being covered by 1 intern (although it's usually closer to 20). once they have some experience they learn that not everything they are told by a nurse is a) true, and b) needs immediate attention. then it almost becomes a "boy who cried wolf" thing with the nurses requests--there are so many garbage requests (say 85%, while certainly less than 5% are true emergencies) that one becomes inured to them and eventually is less likely to respond quickly, because it's so difficult to tell when something is urgent. i know this sounds callous and unreasonable, but it's physically impossible to run full-speed to every "emergency" called by nurses when it turns out that the situation is not as it has been described. a few examples--i got called that a person was "unresponsive." i tear-ass down 4 flights of stairs into the patient's room only to discover that he was not in fact unresponsive; he was, in actuality, verbally abusive. my second example is a call that a patient was "coughing up blood." once again, i run like a mad-man to the room only to discover the source of the hemoptysis (medical word for coughing up blood) was from a nose bleed, which the patient informs me she gets all the time. these were not emergencies. next time the same nurse calls me i am less likely to trust her judgment. obviously, there are certain things that one has to take seriously everytime, but at some point, one cannot physically be in multiple places at once and i will be less likely to believe this rubette (the female version of "rube").
i am, once again, on call tomorrow night. i will log all the pages i get and share them in an effort to bring you closer to the experiencing the agonizing pain in which i spend every 4th night.
i tried explaining to a non-medical type what being on-call means, and why it can suck. it basically means that you are the person in the hospital who takes new admissions to your service. for me, it currently general medicine. in my opinion, the admitting new patients is not what really sucks, but rather it's the coverage of other patients that drags me down. what i mean is this--i am on call every 4th night, which means i stay in the hospital for 30 straight every 4th night. on the other days i go home around 4 or 5pm. what happens to my patients between 4pm and 7am the next morning? the on-call person takes care of any acute issues that arise. when i am on call i cover the other patients. since it is every 4th night, there are 4 total interns, which means that on any call night there is 1 person covering for 3 other people. the on-call person is really there to deal with acute issues, but this, as you will see, is generally not what happens at all. what tends to occur is that the on-call sap gets called to straighten out items overlooked by the primary team during the day (ie, things they forgot) as well as answer the inane nighttime requests of patients, including, but not limited to: requests for more pain meds, requests for sleeping meds, requests for enemas (no, i am not joking), requests for explanations of why they are here, etc. the second set of requests comes from nurses, asking for orders for tylenol, restraints, and all kinds of other things that don't require immediate attention by a doctor--or anyone for that matter--at 3am.
the latter are difficult to deal with in that initially, when interns are new and inexperienced, they take everything very seriously. this is ok, but at some point one has to triage these late night calls as there are up to 40 patients being covered by 1 intern (although it's usually closer to 20). once they have some experience they learn that not everything they are told by a nurse is a) true, and b) needs immediate attention. then it almost becomes a "boy who cried wolf" thing with the nurses requests--there are so many garbage requests (say 85%, while certainly less than 5% are true emergencies) that one becomes inured to them and eventually is less likely to respond quickly, because it's so difficult to tell when something is urgent. i know this sounds callous and unreasonable, but it's physically impossible to run full-speed to every "emergency" called by nurses when it turns out that the situation is not as it has been described. a few examples--i got called that a person was "unresponsive." i tear-ass down 4 flights of stairs into the patient's room only to discover that he was not in fact unresponsive; he was, in actuality, verbally abusive. my second example is a call that a patient was "coughing up blood." once again, i run like a mad-man to the room only to discover the source of the hemoptysis (medical word for coughing up blood) was from a nose bleed, which the patient informs me she gets all the time. these were not emergencies. next time the same nurse calls me i am less likely to trust her judgment. obviously, there are certain things that one has to take seriously everytime, but at some point, one cannot physically be in multiple places at once and i will be less likely to believe this rubette (the female version of "rube").
i am, once again, on call tomorrow night. i will log all the pages i get and share them in an effort to bring you closer to the experiencing the agonizing pain in which i spend every 4th night.
Thursday, January 15, 2009
Wednesday, January 14, 2009
does this beard make me look fat?
i have not used a blade to shave my face since a friend of mind got married over labor day weekend. i do not like shaving. he is a good friend and i was part of the wedding, so i figured it was the right thing to do. i am not rocking a rip van winkle style, however; i do shave every now and then, just not with a blade. i use some electric clippers, which work just fine, but they are really for hair cutting, not beard cutting, so in order to be effective i have to get 4-5 days of stubble going before they will work. so that's what i do: i trim every 4-5 days. now that it's winter i am sporting a tasty beard--i ride my bike to work so the beard is like a natural balaclava. therefore, all the trimming i do is on my neck, but again, only every few days.
why do i bring this up? well, i'm going to explain. we get anonymously evaluated by our superiors and i occasionally read these in a effort to better myself. one such comment i read noted that my lack of daily shaving was slightly unprofessional. first of all, i wonder why this fellow couldn't just say something to me directly? actually, i think i know the answer, as i am fairly certain of the identity of the commenter as he used some phrasiology in his evaluation that he often used in person. the first possibility is that he was intimidated by the overpowering vibe of masculinity that i exude; opntion "b" is that he is a redneck, white-bread, chicken-shit motherfucker who doesn't understand or appreciate the value of diversity. it's probably some of both, but i don't think my personal opinions are the issue here.
what makes me so angry is not the comment itself--i've been called much worse--but the fact that this remark is filled with ignorant sanctimony. given the chance to reply, i would ask: "is your bad grammar unprofessional?" it is not proper to end a sentence with a preposition! "where have your blood sugars been at?" NO, NO, NO! nor is it correct to ask a patient if she feels "nauseous." this word is the equivalent of "poisonous." what this troglodyte wants to ask is "are you experiencing any nausea?" substituting "nauseous" in the preceding sentence would imply that the patient could somehow make those around her feel nauseated. i admit that the strength of this argument is somewhat obviated by the fact that many of these patients are dim bulbs themselves and don't know the difference, but my point is that my reviewer likely believe that there is some objective, higher standard to which we, as doctors, should adhere, even if patients are not aware of it.
further interlocution would find me asking if it professional of him to be wearing a dingy oxford-blue shirt with visible armpit stains, a poorly tied tie, and a white coat with a mustard stain on the lapel? not to mention the khakis he frequently wore that seem to never see the inside of a washing machine. further unprofessional transgressions included lapsing into some kind of homeboy/ghetto dialect when speaking to black or hispanic people, constantly saying "fustrating," and walking into a meeting with a family while eating a donut. despite all this, my less-than-frequent shaving raised his ire. in my opinion, this man has somewhat spurious--or at least incomplete--notions of the meaning of "unprofessional." i would prefer a ruggedly handsome, stubble-ridden doctor, to one with poor grammar and a dirty shirt.
some decidedly un-professional facial hair:
i do not look like any of these folks.
why do i bring this up? well, i'm going to explain. we get anonymously evaluated by our superiors and i occasionally read these in a effort to better myself. one such comment i read noted that my lack of daily shaving was slightly unprofessional. first of all, i wonder why this fellow couldn't just say something to me directly? actually, i think i know the answer, as i am fairly certain of the identity of the commenter as he used some phrasiology in his evaluation that he often used in person. the first possibility is that he was intimidated by the overpowering vibe of masculinity that i exude; opntion "b" is that he is a redneck, white-bread, chicken-shit motherfucker who doesn't understand or appreciate the value of diversity. it's probably some of both, but i don't think my personal opinions are the issue here.
what makes me so angry is not the comment itself--i've been called much worse--but the fact that this remark is filled with ignorant sanctimony. given the chance to reply, i would ask: "is your bad grammar unprofessional?" it is not proper to end a sentence with a preposition! "where have your blood sugars been at?" NO, NO, NO! nor is it correct to ask a patient if she feels "nauseous." this word is the equivalent of "poisonous." what this troglodyte wants to ask is "are you experiencing any nausea?" substituting "nauseous" in the preceding sentence would imply that the patient could somehow make those around her feel nauseated. i admit that the strength of this argument is somewhat obviated by the fact that many of these patients are dim bulbs themselves and don't know the difference, but my point is that my reviewer likely believe that there is some objective, higher standard to which we, as doctors, should adhere, even if patients are not aware of it.
further interlocution would find me asking if it professional of him to be wearing a dingy oxford-blue shirt with visible armpit stains, a poorly tied tie, and a white coat with a mustard stain on the lapel? not to mention the khakis he frequently wore that seem to never see the inside of a washing machine. further unprofessional transgressions included lapsing into some kind of homeboy/ghetto dialect when speaking to black or hispanic people, constantly saying "fustrating," and walking into a meeting with a family while eating a donut. despite all this, my less-than-frequent shaving raised his ire. in my opinion, this man has somewhat spurious--or at least incomplete--notions of the meaning of "unprofessional." i would prefer a ruggedly handsome, stubble-ridden doctor, to one with poor grammar and a dirty shirt.
some decidedly un-professional facial hair:
i do not look like any of these folks.
Saturday, January 10, 2009
untitled.
yay! i have the entire weekend off for the first time in a very long time. i am celebrating with expensive food and wine in a city different from the one in which i currently live. i am also not thinking about the world to which i must return in 2 days, starting...now. i am enjoying myself. there is also the possibility that i will purchase something that i don't need and probably cannot afford in an effort to make myself happy. it has not worked in the past, but i am cautiously optimistic this time.
here is a photo of my weekend host:
see you in a few days.
here is a photo of my weekend host:
see you in a few days.
Wednesday, January 7, 2009
no. 13, sub-section b, paragraphs 2-6:
i apologize for the silliness of my prior posting; i was so filled with regret that i decided that i had to rectify the situation. rather than deleting the aforementioned abomination, which would be the humane thing to do, i have opted to leave it visible as a reminder to myself of what jackassery i am capable. (of note, none of the preceding statements apply to the chewy picture, which, of course, is awesome.)
so to make up for it, i will quickly describe my current work assignment: i have spent the last 2 days on inpatient medicine (herein "medicine"). exactly what this entails is sometimes difficult to understand for those not in the medical field. it is basically what most people think of when then hear "my mom is in the hospital." if you have a run-of-the-mill illness, you go to a basic medicine floor--think pneumonia, chest pain, urinary tract infections, asthma flairs. what it is NOT: surgical patients, intensive care unit work, etc. the patients are too sick to be at home, but they probably aren't about to die either. often patients are admitted not because the are really sick (ie, near death) but rather because the treatment is not something they can get as an outpatient (ie, at home) such as IV antibiotics, IV pain medications, continuous nursing care. people will also frequently get admitted to "rule out" something gnarly, such as a heart attack.
in the coming month there will doubtless be numerous rants about the difficulties i encounter for no other reason than "that's the way it always been," but today i will start with something that riles me quite severely: the amount of time i am forced to be in the hospital compared to the amount of work there is to be done.
right now i have 5 patients under my care. i got to work at 7am and went home at 4p; not too bad, right? it isn't so bad until you consider that, given the amount of work i had to do i could have left by noon, probably sooner. even if you tack-on a few hours for pure learning, i could have been home by 1pm. what is most enraging is that one might spend 15 minutes on three unique occasions discussion the same issue, and still not arrive at a decision. multiply this by 12 patients and you can see where the time goes (i say 12 because while i have 5 patients, the other intern on my team has 7).
as i said, i walked through the hospital doors at 7am; by 1030am, i hadn't done a single bit of actual work. i had talked about doing work, but had not actually accomplished anything. if i had been in the ED for the same time period, i would have seen and been in the process of working up approximately 5 patients. this number is not arbitrary, it is based on historical data from the ED in which i work. interns see approximately 1.4 patients per hour. granted, i think the ED is overcrowded/understaffed, but still, it is an example of what one can do in a given time period.
let's do some more calculating, shall we? i work 18 12 hour shifts per month in the ED, so if i see an average of 1.4/hr, then i'll see about 17 patients per shift, and 300 new patients per month1 now let's see what my medicine brethren are doing in the same 28 day period: interns are on call every 4th night, so in a 28 day block that is 7 call days. you can admit a maximum of 6 patients per call day, and you only admit on these days. that's a total of 42 patients in 28 days, roughly 14% of the patient load in the same number of days. there's more: i work about 214 hours (12hrs x18 days) per month in the ED; medicine residents work closer to 320, or about 1/3 more hours. granted there are significant differences in what one does to inpatients versus those being seen in the ED, and as i said, the ED shifts are non-stop work (which i don't think is ideal), but this still highlights the striking difference in what can be done in a given amount of time. neither is ideal, but even if we split the difference in hours (106/2) that is 53 fewer hours that i could be working! that's more than the average person works in a week; it would be like getting an extra week of vacation.
sigh...only 26 more days to go.
up next: what is "pre-rounding" and how do i make it require less time?
so to make up for it, i will quickly describe my current work assignment: i have spent the last 2 days on inpatient medicine (herein "medicine"). exactly what this entails is sometimes difficult to understand for those not in the medical field. it is basically what most people think of when then hear "my mom is in the hospital." if you have a run-of-the-mill illness, you go to a basic medicine floor--think pneumonia, chest pain, urinary tract infections, asthma flairs. what it is NOT: surgical patients, intensive care unit work, etc. the patients are too sick to be at home, but they probably aren't about to die either. often patients are admitted not because the are really sick (ie, near death) but rather because the treatment is not something they can get as an outpatient (ie, at home) such as IV antibiotics, IV pain medications, continuous nursing care. people will also frequently get admitted to "rule out" something gnarly, such as a heart attack.
in the coming month there will doubtless be numerous rants about the difficulties i encounter for no other reason than "that's the way it always been," but today i will start with something that riles me quite severely: the amount of time i am forced to be in the hospital compared to the amount of work there is to be done.
right now i have 5 patients under my care. i got to work at 7am and went home at 4p; not too bad, right? it isn't so bad until you consider that, given the amount of work i had to do i could have left by noon, probably sooner. even if you tack-on a few hours for pure learning, i could have been home by 1pm. what is most enraging is that one might spend 15 minutes on three unique occasions discussion the same issue, and still not arrive at a decision. multiply this by 12 patients and you can see where the time goes (i say 12 because while i have 5 patients, the other intern on my team has 7).
as i said, i walked through the hospital doors at 7am; by 1030am, i hadn't done a single bit of actual work. i had talked about doing work, but had not actually accomplished anything. if i had been in the ED for the same time period, i would have seen and been in the process of working up approximately 5 patients. this number is not arbitrary, it is based on historical data from the ED in which i work. interns see approximately 1.4 patients per hour. granted, i think the ED is overcrowded/understaffed, but still, it is an example of what one can do in a given time period.
let's do some more calculating, shall we? i work 18 12 hour shifts per month in the ED, so if i see an average of 1.4/hr, then i'll see about 17 patients per shift, and 300 new patients per month1 now let's see what my medicine brethren are doing in the same 28 day period: interns are on call every 4th night, so in a 28 day block that is 7 call days. you can admit a maximum of 6 patients per call day, and you only admit on these days. that's a total of 42 patients in 28 days, roughly 14% of the patient load in the same number of days. there's more: i work about 214 hours (12hrs x18 days) per month in the ED; medicine residents work closer to 320, or about 1/3 more hours. granted there are significant differences in what one does to inpatients versus those being seen in the ED, and as i said, the ED shifts are non-stop work (which i don't think is ideal), but this still highlights the striking difference in what can be done in a given amount of time. neither is ideal, but even if we split the difference in hours (106/2) that is 53 fewer hours that i could be working! that's more than the average person works in a week; it would be like getting an extra week of vacation.
sigh...only 26 more days to go.
up next: what is "pre-rounding" and how do i make it require less time?
i can't do this all on my own.
there were 2 new episodes of scrubs on last night. it was both hilarious and shown on a new network. i enjoy this show not for it's medical content, since the ersatz medicine they depict is riddled with obscene errors. if i practiced the medicine as it is seen on scrubs, i'd be out of a job. the show is funny for other reasons, which i will not expound up here. the reason i brought it up in the first place was to pontificate on the fact that zack braff is now wearing a beard. i also sport a beard. perhaps now i will gain more acceptance? that would probably be furthered if i actually trimmed my beard more often and shaved my neck with a blade every now and again. hmm...you be the judge. below is a photo of me before i went to work:
ok, ok. i didn't really look like that. i had on a tie. but seriously, if you were in the hospital, would you let chewbacca be your doctor? i would.
i don't think any of this is as funny as it was in my mind when i conceived it. i should probably stick to discussing medical-type stuff.
ok, ok. i didn't really look like that. i had on a tie. but seriously, if you were in the hospital, would you let chewbacca be your doctor? i would.
i don't think any of this is as funny as it was in my mind when i conceived it. i should probably stick to discussing medical-type stuff.
Monday, January 5, 2009
no. 12: the black death.
i walked out my back door this morning with my bike in-hand and promptly fell down the stairs. it was icy. fortunately, my arse is doughy so i was unfazed. i picked myself up and walked down the second set of stairs to the driveway, where i promptly fell again. apparently, some sort of freezing slippery substance fell from the heavens last night. my first thought was not of my ripped pants, the possible damage to my spine, or the future spills i would take while riding to work. no, my thoughts were of the countless rubes who would doubtless be carted into the ED after discovering the invisible but deadly ice covering their front steps. from 717 to 843am no fewer than 8 such people arrived by ambulance with a chief complaint of "fall." 8 might not seem like a lot, but these were only the 8 seen by me. i had to call orthopedics 4 different times: 2 wrist fractures, 1 arm fracture, and 1 ankle fracture. i sent 2 people home with cervical collars for persistent pain despite negative imaging studies. three individuals gave the same story: "i walked out my front door, took one step, and the next thing i new i was on my ass." literally, they all said those exact words.
on a positive note, i had a tasty lunch: kung pao tofu. and someone left some tasty christmas mints in the resident's lounge, which were a perfect compliment to my spicy lunch fare.
i try to make my lunches more enjoyable by reading something non-medical, in an effort to transport myself, even temporarily, anywhere but the hospital. today i read, this, a humorous product review from bike snob nyc. you may or may not find this as amusing as i do, depending on how much you know about fixed-gear bikes, hipsters and their bike culture. but trust me, it's pretty funny; except for the numerous references to his own blog. maybe i'm jealous of his readership. whatever.
but i digress...
my day ended with me putting 47 stitches into a man's leg who had torn it open when jumping off a short wall at a construction site. i had a pleasing conversation, and i think i may have convinced him to stop smoking. that is probably naive, but nevertheless, it was a nice way to end my day, and my last month in the ED for a while.
next up: inpatient medicine.
on a positive note, i had a tasty lunch: kung pao tofu. and someone left some tasty christmas mints in the resident's lounge, which were a perfect compliment to my spicy lunch fare.
i try to make my lunches more enjoyable by reading something non-medical, in an effort to transport myself, even temporarily, anywhere but the hospital. today i read, this, a humorous product review from bike snob nyc. you may or may not find this as amusing as i do, depending on how much you know about fixed-gear bikes, hipsters and their bike culture. but trust me, it's pretty funny; except for the numerous references to his own blog. maybe i'm jealous of his readership. whatever.
but i digress...
my day ended with me putting 47 stitches into a man's leg who had torn it open when jumping off a short wall at a construction site. i had a pleasing conversation, and i think i may have convinced him to stop smoking. that is probably naive, but nevertheless, it was a nice way to end my day, and my last month in the ED for a while.
next up: inpatient medicine.
Sunday, January 4, 2009
this blog goes to 11.
my thoughts have been occupied recently with the following: now that i am not the lowliest of of medical types (the hierarchy goes something like this starting from the bottom--3rd year med students, interns/first-year residents, 4th year med students, upper-level residents, fellows, attendings. 3rd years are lower than interns because they can't really do anything useful to anyone (except possibly themselves, which means learning). interns are good because they know a little and can do all the things that "need" to be done by an MD for whatever reason, likely legal, but in all reality could be completed by a trained monkey. 4th year med students are higher because they know some stuff, and can do some stuff, largely to help decrease the workload on residents. this makes them feel good because for the first time in their medical careers they appear to be useful and sought after, their work seems important and meaningful, and others actually listen to and care about what they think. attendings are super nice to 4th years, especially at the start of the year, since many of them start out on rotations in which they hope to eventually be residents. the result is that they get treated like upper-level residents--that is, work fewer hours, do the exciting parts of procedures, do far less paper work, and have lower amounts of inane responsibilities (eg, paperwork) which allows them to focus on what it actually means to be a doctor in these sense of what we all thought it meant to be a doctor, until we actually became doctors (that is, residents) and realized that its far more prosaic and onerus that we thought it would be. part of why they get treated so well is so that these feckless students do realize how much it can actually suck to be a resident. this is partly how i got duped into choosing surgery as my first career (i have since rectified that action)).
anyhow, that is not what has been on my mind, but rather, what i want to know, or what i have been trying to do is see how med student a becomes like intern b, who becomes like resident c, who become like attending. the path of any one person is not as interesting to me is what type of med student becomes what type of resident, and so on, to attending level. i have exposure to people above and below me, and people at my level of training, so what i want to do is take co-intern x and see that he is like med student z, and also like attending y. in this exploration or theory or whatever, they are all the same person, it's just that the student is the inchoate version of the attending. i want to see if one can determine a set traits or personality characteristics in a resident and extrapolate that into what sort of attending they will be by finding and matching-up those same traits in an attending.
there are vastly divergent styles of practicing as a physician, even in the same field. and i wonder if personality traits are what drive the medical behavior of doctors. are the timed, reserved folks those who order every possible test just to rule-out disease x, even though they think the chances are negligible? are the parsimonius testers arrogant fucktards who think they know everything?
stay tuned, i'm on the case.
anyhow, that is not what has been on my mind, but rather, what i want to know, or what i have been trying to do is see how med student a becomes like intern b, who becomes like resident c, who become like attending. the path of any one person is not as interesting to me is what type of med student becomes what type of resident, and so on, to attending level. i have exposure to people above and below me, and people at my level of training, so what i want to do is take co-intern x and see that he is like med student z, and also like attending y. in this exploration or theory or whatever, they are all the same person, it's just that the student is the inchoate version of the attending. i want to see if one can determine a set traits or personality characteristics in a resident and extrapolate that into what sort of attending they will be by finding and matching-up those same traits in an attending.
there are vastly divergent styles of practicing as a physician, even in the same field. and i wonder if personality traits are what drive the medical behavior of doctors. are the timed, reserved folks those who order every possible test just to rule-out disease x, even though they think the chances are negligible? are the parsimonius testers arrogant fucktards who think they know everything?
stay tuned, i'm on the case.
Friday, January 2, 2009
no. 10: groan.
how fast can a day at work go from great to god awful? awfully fast. duh. everything started well enough; it was cold this morning--15 i think--with a dusting of snow still on the ground. i ride my bike to work, but i don't mind the cold. maybe it wakes me up, or maybe it's knowing how much money i've saved on gas, or maybe it helps me not feel like a sedentary blob. i actually enjoy riding home as well, particularly after a bad day, such as today. i am full of anger and frustration when i leave and i fume on the 12 minute ride home. but by the time i climb the stairs to my chilly apartment most of my angst has disappeared, which is fortunate, since there was plenty of that today.
the point of this explication is that there was a part of my day that i enjoyed, a part--2 parts i guess--that i enjoy every day i work, even on a craptacular day like today. i quite enjoy cycling, even in the dark, even in the cold.
this is me being hopeful and positive.
on my way to work*:
*note: actual photo may not include author
the point of this explication is that there was a part of my day that i enjoyed, a part--2 parts i guess--that i enjoy every day i work, even on a craptacular day like today. i quite enjoy cycling, even in the dark, even in the cold.
this is me being hopeful and positive.
on my way to work*:
*note: actual photo may not include author
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