Friday, February 5, 2016

Exasperating moments in medicine

This is less of a humorous entry and more about some serious situations I've seen in medicine.

-Finding out a patient was never told they have heart failure

-Finding out a patient was never told they have hepatitis C

-Finding out a patient was never told they have HIV

-Finding out someone else's notes were wrong and the patient actually has a pack-year smoking history longer than the years they've been alive

-Patients telling you they don't have any medical problems but chart review shows things like DM, HTN, HIV, HCV

-Trying to get critical information about a patient while pressed for time but they can't remember what year they had major surgery or when they finished chemotherapy

-Hearing your patient say they stopped taking the HIV medication or any other medication because "they felt better" even though being told they needed to be on it for life

-Consult service being rude to you for no reason (you have a good reason for consult and everything)

-Being shouted at by patients who are not yours, demanding a sandwich or juice

-Secondary gain.  'Nuff said

-People telling you they're in "excruciating pain" while playing on their phone comfortably and not even looking at you, asking for morphine

-People going to the ER instead of going to see their PCP they're scheduled to see in 2 days for a total non-emergency

-Getting screamed at by patients who then start making a scene because they want dilaudid and not PO pain medicine for their "2/10" headache

-People telling you they have 11/10 pain while talking on the phone to someone else

-People reacting with disgust when you tell them there's no indication for surgery

-People saying things like "my intestines are popped or something, I need to be in the hospital."  When their physical exam and all imaging and labs are normal

-People showing up to the ER because they are not taking their medication

-People showing up to the ER because they want prescriptions refilled

-Working in a specialty clinic and the patient complains about things that are out of your scope of practice even though you keep telling them that

-People who superficially Google searched symptoms and think they know more than you and they start demanding ridiculous and contraindicated interventions

so much more.

Wednesday, December 23, 2015

Residency Program Ranking Secrets

Just wanted to tell you all about things that otherwise go untold.  The devil is in the details.

One of the biggest red flags about a program can be a big intern class with less and less residents when you see their list of residents web site.  It shouldn't automatically dissuade you from ranking a program differently, but it should get you thinking.  If you like a program and you see there are residents who dropped out, you can strategically ask residents if anyone has left the program or been dismissed from it.

If you didn't know this, yes, you can get fired from residency.  Your contract isn't automatically renewed every year.  You can get disciplined, fired, and then have an incredibly difficult and near impossible time finding another job in medicine depending on the circumstances.

You want a program director and chair that will have your back and support you.  I've heard of residents being fired from different programs years ago, and some programs with bad atmospheres in stories from old attendings.  If you get a bad gut feeling from an interview day, trust it.

Residency is hard and you need a supportive environment.  You can be the toughest resident enduring all kinds of work hours and tough personalities, but if the program isnt supportive of you, you could get fired for a mistake you made or you might not even have support or enough supervision to prevent mistakes.

No one will really talk about that on interview day, but you need to gauge and see how supportive attendings and the program director and chair are of residents.

There are residents at programs in the country who feel like they are just workers and who feel like they are treated poorly, while there are others who are in the same specialty at other places and happy.

Make informed decisions.

Monday, December 21, 2015

How to be a good sub-intern/acting internship med student

I finally have a breather to blog a little more, this has been an insane year so far.

The transition from med student to intern is pretty drastic.  I've been lucky to be on some rotations as an intern when I would have a med student or two to teach, they can make grueling rotations better.  However, you shouldn't just show up and be passive as a med student.  I've seen a few students like that.

Here's what you should do to make sure you make a good impression on your team.

1.  Read up on everything about your patient.  Know when each problem of theirs was diagnosed, if they're still on treatment for those conditions, and when important imaging studies were done

2.  Offer to call consults while rounding.  That way your consulting team gets called earlier rather than later

3.  Call the lab/radiology for updates on your patients.  It's particularly useful for cultures/stains

4.  Get to know the nurses.  Usually I felt like I didn't matter to nurses as a med student, but they can provide you updates and tell you all about intake and output which are critical in the hospital

5.  Bring in a research article once or twice and send a copy to everyone by email.  Make a presentation if your attending sets up time for it

6.  Make a list of questions you want to ask the more experienced members of the team.  I had some students who told me they didn't want to learn anything and "didn't want to see that patient."  They're in it for a bad evaluation.

7.  Know that you're being evaluated and that your acting internship is a month long interview.  I've seen some people treat rotations like they're just something you go through, taking the path of least resistance everyday.  No one wants a lazy colleague.

8.  Show up early and stay late

9. Always take the new patient when your team asks.  I worked with interns who would dump patients on me because they wanted a lighter work load.  I did my work and eventually the upper level would redistribute patients and comment on how unfair it was.  I didn't complain, and I felt like the situation turned out better for that reason.  People learned I worked hard and I didn't look like a slacker like those guys did.

Tuesday, December 8, 2015

my trouble with emergency medicine

You'd be surprised at how few emergencies you'll see in the ER.

I rotated at a few hospitals on ER rotations around the country and felt really worn out lacking intellectual stimulation.

90% of the "emergency" cases I saw were:
1. Chronic wounds patients are not taking care of
2. Non-emergency outpatient problems (ex: constipation for 2 days)
3. People lying about having chest pain/vomiting blood/other problems when they just want a sandwich and juice for free
4. People coming in for medication refills  who do not have any emergency problem
5. Chronic shoulder/joint pain
6. Congestion that people have not tried any medication for
7. Chronic rectal bleeding no one has seen a doctor for
8. Chronic vaginal bleeding no one has seen a doctor for
9. STIs/herpes/syphilis
10.  People faking seizures for attention
11. People combative/agitated on drugs who get in accidents and kill people for driving drunk/altered

Really find out whether you want to be an "emergency" doctor.

Friday, November 6, 2015

the time I caught a hidden stroke

I was covering two different units, working with a lot of critically ill patients requiring sedation for trauma and illness.  I was getting a page every 5 minutes from nursing, 95% stuff that could be put off until the next shift..

I kept assessing an unstable, sick patient with a bad head injury while getting hammer paged and running around the different units dealing with half a dozen cases of refractory septic shock, coagulopathic surgery patients with low EFs..and then a nurse tells me that the patient with the head injury vomited.

I run, I go do a neuro exam, I think for a second.  The neuro exam is stone cold stable from previous multiple exams..but the patient vomited, this is new and there's a high chance of increased intracranial pressure.

I order the stat head CT and call neurosurgery stat.

There's a hemorrhage in the brain and the neurosurgeons rush the patient to the operating room for a stat crani.

I managed to save someone's brain because of vomit.

Monday, November 2, 2015

death, dying, and being an intern

I've had the "worse" months of intern year frontloaded and I can finally see the sun rising over the horizon.  I've had way too many goals of care discussions with families that are really emotional for everyone involved and that's been exhausting for everone.

I've had so many patients who have their prognosis described to them objectively by no less than 3 teams of experts from different specialties and the patient and family still want all heroic measures taken.

Many times the patient gets so sick and requiring so much medicine that they can't make decisions on their own, or their so elderly with severe dementia.  I've seen family members decide that it's somehow better for that family member to get a tracheostomy so they can stay connected to a ventilator and stay "living" when that patient can't even interact with them anymore.

I do my best by explaining what "full code" means to families and patients, and how it isn't a magic intervention without side effects like anoxic brain injury or becoming dialysis dependent from circulatory shock.  I'm also a little disappointed by neurology teams who have given families unrealistic prognoses.

I tell people CPR breaks ribs, can cause pneumothoraces, patients end up requiring ventilator support and sedation and dialysis, all because their body is too weak to run it's own life supporting processes.

I've seen way too many people die on ventilators in the middle of the night when their families aren't around.

I can tell you I don't want a tracheostomy and I don't want to be full code if I'm in my 80s with an incurable illness.  I want a good quality of my life for the remainder of my life.  At home.  With family.

Not in some dark hospital coding overnight, sedated on a ventilator with people lining up to crush my chest with chest compressions and then surgery getting paged to throw a chest tube in me and dying unable to interact with the world.

Life is a warm and beautiful thing.  There's nothing wrong with hospice or comfort care and passing away at your home.

Tuesday, October 27, 2015

going from student to doctor

I haven't been writing nearly as much.  I'd like to breathe new life into my blog and have it reach more people, so feel free to share it.

Anyway, the transition from student to physician is all too real.  You're always thinking about what's right for the patient, but there's a lot of playing it safe and being overly cautious because of the potential for unintentional harm to a patient.

You often get pressured by nursing staff and ancillary people to "put this order in" or "write for this" and you can get burned by doing that without thinking it through.  You get so busy that you don't always get to write orders in a timely fashion and you start feeling a little bit of friction.

I'm a little frustrated with nursing at this one hospital, because I want to know how much of X medicine someone got or how many fluids they got and I keep hearing "this is my first time with the patient," like it's somehow okay.  I get that nurses are busy doing tons of stuff, but you can jot things down here and there.  I wish nursing was more assertive about urine output and that they include us in their sign-out to each other instead of ignoring me when I'm right there.  I end up pushing myself into their report because it's my patient and I'm writing orders.

There has also been a lot of great nursing.  I wouldn't be happy having to move 300+ pound patients around, doing all the cleaning of urine and fecal matter and vomit for 12 hours a day, day in, day out.  A lot of the nurses around keep a good attitude and I have a few favourites I hope I get to work with the next day.  The hospital usually has the same nurse continue to follow the same patients over and over so there's some continuity, which is really helpful when you're tracking a patient's clinical status over time.

There are a lot of brave nurses who stick around a combative, agitated patient and who give great care to people coming off from cocaine and meth despite being in danger sometimes.

I'm going to miss a couple of the nurses in the unit once I leave, they've been there to talk me through orders or know what to call me for so we avoid crises.

Being a doctor is a great feeling (most of the time) but you're always under the microscope for everything you do and every word you write in your patient notes.

Then you get sucked into a lot of family drama and potential legal drama with families who make their frail actively dying loved one with say, several significant strokes, heart attack, metastatic cancer, renal and liver failure, maxed out on pressors and mechanical ventilation be full code and continue aggressive medical measures even though you explain to them over and over that their loved one is sick and will not recover.

It's hard.  It's rough being a doctor.  I wish I could be a student again sometimes, you know.