medicine


Another example of how MICU doctors managing surgery patients doesn’t work well:
We get this man back from the OR after a long surgery, with blood loss of the type where it’s pouring onto the floor, the whole surgical team is wearing knee-high boots (which I hate, but you need them for this), the anesthesiologist starts the case running blood and crystalloid simultaneously, and at the end of the case you almost have to stop and give the patient a bath because everything is soaked in blood. (And the circulator stands there saying, “Who made this mess? I can’t walk over to the other side of the room, because I need to keep my shoes clean. When are you guys doing this again? Because I’m not going to be around.” I thought maybe she was joking, so I said, “Or you could just put shoe covers on.” She shook her head: “I’m not coming in this room again.” How she thinks she can work in an OR and keep her shoes clean, I don’t know.)

So here we are back in the unit, and the patient is oozing blood. We check coags (or rather, the nurses send coags, and ask us to sign). The INR is mildly elevated: enough to be of interest in a bleeding patient, but not disastrous. I and the MICU attending are notified at the same time. My answer: “Let’s give a few units of FFP (fresh frozen plasma, a blood component which contains the major clotting factors).” I figure there’s been so much blood and fluid lost and replaced that the clotting factors must be out of balance, and will benefit from immediate replacement. The MICU attending’s answer: “Let’s give 10mg of vitamin K iv.” (Vitamin K is the usual catalyst for the liver to make four clotting factors; this will begin to take effect in about three days, and is usually given to people who’ve been on coumadin, which inhibits the liver’s synthesis of clotting factors. This is a young patient with no liver dysfunction and no history of coumadin use.) I’m not saying he’s wrong, just that I am unable to comprehend his line of thought. We each ordered what we thought best, so I’m not unhappy, just puzzled.

Today was very satisfying because I seized the chance to do both an arterial line and a central line, largely unsupervised, by acting faster than the medicine team. I’m learning that when there are more than two nurses in a room, it’s time to head in, not keep sitting and chatting at the nurses’ station. The nurses may be beginning to respect me as a potential source of help when the patients are in trouble; and I was successful on my first independent lines.

My med student tonight confessed to being a black cloud. It was either that, or my four nights of complaining about inactivity finally boomeranged on me. My beeper went off non-stop, the three-pages-at-a-time way, for the first half of the night, and barely slowed down for the second half. Once again, Brad was similarly tied up in the ICU, so I spent several hours running around, trying not to imitate a chicken with its head cut off, juggling way too many people with chest pain, shortness of breath, tachycardia, fever, and low urine output. (Not all in the same person, thank God.)

Partway through, amid a flurry of non-serious trauma pages, a real code came in. I went down to hang out, and the chief waved me in. “You want to do the chest tube?” “I’d love to.” Sotto voce: “Um, have you ever done one before?” This was actually one of the few procedures I did as a medical student, so for once I could reel off the landmarks and steps. It went fairly smoothly (amazing how much violence a patient will let you perpetrate with enough lidocaine in the area), and at the end the chief confided, “Thanks for doing that; I really hate chest tubes.” Any time, man, any time!

In between all this, there was a medicine patient crumping accelerando, whom they kept paging me about. Folks, I really like medicine people, but distended abdomen ≠ surgical abdomen. If you can press into it, it’s not rigid. If you say “acute abdomen,” it means you seriously want the OR team paged in and the patient rolled down within an hour. I’ve been laughed at enough by surgeons for saying “acute abdomen” that I’ve learned not to say it unless I mean it. I’m sorry that your patient is tachycardic, febrile, confused, and short of breath, but doing an exploratory laparatomy with negative results is not going to make him any better. Running some fluids wide open might help with some of that, considering as he’s been oliguric most of the day. I don’t understand the medicine team’s reluctance to do things like place foleys, NGs, central lines, and arterial lines. To us, those are simple, minimalist interventions. One more reason to stick with surgery, I guess.

That’s where the American healthcare system is heading, and barring a massive outcry from both physicians and patients, I don’t see any chance of stopping it.

Here’s a story in the Washington Post about how doctors around the country are being penalized by inaccurate rating systems which 1)  don’t collect data correctly, or 2) measure fake outcomes, or 3) measure outcomes for which there is no evidence. For instance: patients who’ve had a heart attack are supposed to be on beta blocker medicines. Ok, fine. That is well-documented (in studies funded by the drug companies, but we’ll set that aside), and accepted clinical practice. But how is one of the high-school educated clerical workers reading through records to determine compliance going to know that the family physician decided to use a different method of blood pressure control in a little old lady who can’t tolerate even the lowest dose of beta blocker because she develops postural hypotension and has been falling because of it? It should be documented, but it might be written in a way that our clerical worker (lowest common denominator here) can’t understand, or perhaps the documentation was made a couple years ago, not in the chart that’s being reviewed right now.

That’s just one example. We could go with others: such as that there is little research backing the concept that patients with community-acquired pneumonia benefit if antibiotics are started a couple of hours earlier in the ER, although this is now such a key quality measurement that I’ve seen several elderly patients’ charts with colored notes from the efficiency folks inquiring about whether antibiotics were started early enough. Or how about heparin for DVT prophylaxis in surgical patients? Accepted surgical standards state that for young patients or those with low-risk surgery, methods such as aggressive ambulation, TED stockings, or SCDs (sequential compression devices; half my patients hate them, half think they’re getting a free massage) are sufficient to protect against DVTs and pulmonary embolism. Nevertheless, Medicare guidelines now require heparin use, pre-op, in all surgical patients. This can be circumvented by mentioning in your op note why you chose not to use heparin (fear of bleeding, etc). But why do we have to document a useless statement about a criteria for which there is no evidence? Why do we have to waste our time jumping through these hoops trying to make bureaucrats understand how we think?

It’s going to take nine years for me to learn to think like a doctor. And we have bureaucrats and medical coders judging us on this? When did they get their medical degree? We worked hard to get here. They come into their offices at nine o’clock, and sit down in comfortable chairs to pick holes in our decisions. What do they know about it? (I got a lecture today about how any plan of action which involves a surgery intern arriving at the hospital later than 5am on any day of the week has to be flawed.)

Reading Sabiston’s surgery textbook is actually useful. I’m kind of handicapped because I decided to do surgery relatively late in medical school. I didn’t spend the time soaking up their practices the way most medical students on this career track do. But today I discovered that the first fourteen chapters in this huge volume explain all the lore that I keep getting tripped up on. It’s complicated, you know. There are all kinds of risk assessments for patients with any kind of pre-existing medical disease that you’d like to name. There are a million different possible complications to be aware of and plan ahead to avoid. And this is all before we actually start doing any cutting.

You folks out there want bureaucrats practicing medicine, or would you perhaps prefer that those of us who were trained for the job, do our jobs? It’s your health. You are the consumers. If only you  knew what was happening, you could have a strong voice.

I promised myself that when I got to be a doctor, a real, live MD, I would get myself a proper black bag, and stock it up, so as to be useful in emergencies away from the hospital.

I now discover that I still don’t know much that I would rate as “useful in emergencies,” at least not outside of the hospital, away from all our supplies. Even my ambition doesn’t stretch to including an ambu-bag or an oxygen tank in my black bag.

So what would be 1) useful to me, 2) not too cumbersome, and 3) not too difficult to obtain legally? (In the adventure stories, morphine out of the first-aid kit always comes in handy when someone’s broken their leg falling off the cliff, or been shot by the villain; but I have a feeling the DEA would not look kindly on me attempting to stash vials of morphine – let alone dilaudid – in a black bag. Besides, that might make life too interesting, if the wrong characters found out I had it.)

- Albuterol. That should be useful for either asthma or COPD, and could – conceivably, imaginably – be handy if we were in a remote area when a crisis occurred.
- Bandages. Lots of bandages: rolls of white gauze, and also ACE wraps. Useful for all kinds of wounds and sprains, and not too heavy to carry, or too expensive to stock up on.
- Tape, to fasten bandages. And maybe some duct tape, too, because it will fix whatever the bandages don’t.
- Vicodin. Maybe the DEA would approve of just a few of those?
- Stethoscope, of course, whenever I’m not actually wearing it (and hopefully those occasions will become fewer; surgeons stick stethoscopes in their pocket, because if they can’t hear the heart murmur from the door, it’s not interesting).
- A flashlight, both for practical purposes, when lost in the dark, and for assessing pupils.
- Reflex hammer, because it’s small, and I don’t want it in my pocket, and if I put the heavy metal one there, it might come in useful for hitting a bad guy with.
- Technically, a gun would be even more useful for such purposes, but even my affection for the Second Amendment admits that a doctor’s bag is not the correct place for a pistol.
- Tylenol and Motrin. There, the DEA can’t object to those, and they’ll work for a lot of things.
- Sudafed, because whenever you don’t have it, you’ll need it.
- Gloves, just in case.
- Some packets of nylon and vicryl suture, and a needle-driver, if I can find one lying around. For sewing things up in remote locations, or perhaps for controlling [peripheral] arterial bleeding.

I can’t think of anything else with a high use-for-weight ratio, except maybe phenergan. Any other suggestions, folks?

Today was up and down. I’ve had really enough of internal medicine. I’m back to jumping up whenever I heard the word “surgery,” no matter what the context – even if it’s just a “past medical history.” We had a lady with abdominal pain admitted overnight, and as soon as I heard in report that she might have the slightest chance of needing surgery, I hurried to assign her to myself.

Then, of course, we did have to consult surgery for her. The resident was certain that a potential abdominal abscess is a surgical problem, and I was pretty sure that recurrent diverticulitis is an indication for colon resection. Fortunately, it was a junior resident that I had to talk to, a friendly one that I knew from previous rotations. Even so, as soon as he asked a question, I froze up, and became certain that it was a very dumb consult (which I kind of knew to start with, because her belly was soft, and in fact non-tender this morning; by now I know that if the patient isn’t either writhing or rigid with pain, surgeons aren’t interested). It didn’t help that my resident was nearly as petrified when she had to call the surgery chief resident and tell him about it.

The nurse taking care of her had to call the surgery resident at one point, too, and she became so flustered that she started apologizing to me, I’m not sure what for. And these are nice surgeons. I’ll have to remember this in future; people are so petrified at just the name of surgery – there’s no need to make things worse by actually acting up to your reputation.

On the other hand, we had another patient whose story and history were so significant for a PE (pulmonary embolism) that we didn’t even bother to scan him (ok, plus the fact that his kidneys were failing, and wouldn’t benefit from dye). He needed an ABG this morning, and, although I wasn’t excited about doing this painful (and for me, tricky) stick on an alert patient (having previously practiced in the ICU), I made myself volunteer. To my total surprise, I got it with the first stick and a little readjustment. The patient didn’t complain at all, and it went smoothly for him. I was on cloud nine. Maybe I will be able to learn how to do central lines, and even become the expert at it that a surgeon is supposed to be.

I’m sorry there aren’t that many patient stories coming up here lately. In my opinion, medical blogs should be at least half of the story – they are, after all, our raison d’etre. But somehow I can’t find anything to say about medicine patients. Chest pain, yadda yadda, shortness of breath, blah blah blah. . . I know it’s serious for them, and for these residents, but it really doesn’t matter to me. I can’t wait to get back to surgery – and I am terrified about how little I know on the subject. I need to go read a textbook. . .

This morning was fun. The rest of the team somehow disappeared – my intern to discharge a patient who had an urgent appointment elsewhere, the senior to see a patient in the ER, the other intern mysteriously vanished – which left me and the attending to round on my last patient. I had acquired a whole list of orders, partly from the intern’s hints, and partly from my own assessment. The attending agreed with them, and signed them for me. Cool. That’s what a sub-internship is supposed to be like.

Three hours of lecture this afternoon. I got trapped by the chief resident helpfully lecturing the third-year students. I answered all his questions, of course, so he didn’t mind me doodling and not paying much attention. We know each other from way back; he used to lend me P.G. Wodehouse books.

The rest of the day was spent reading in the lounge – partly a novel, and partly an astonishing useful book called Fluids and Electrolytes in the Surgical Patient, by Carlos Pestana. Highly recommended. He explains in simple language how to calculate fluid and electrolyte needs for everyone. Much more enlightening than the residents’ usual explanation of, “I just guess – 125 cc/hour sounds right for him.” I’m going to have to buy this book.

Found this on Shadowfax’s blog today (boy, I should get over there more often): The Wrong Juice, in which you can see the EKG of a patient with bad hyperkalemia; read through to find out what the wrong juice was. I knew, theoretically, that hyperkalemia (high potassium) produces peaked T-waves and widened QRS complexes; but I couldn’t recognize them until Shadowfax named the problem.

Which demonstrates that knowing the right answer is very different from knowing how to take care of the patient. I think I’m almost ready to graduate, because I’ve mostly realized that there are an incredible amount of things in medicine that I don’t know, and that I’ll never have the time to understand properly. The moral being not to scoff at another doctor’s treatment plan unless you know what you’re talking about.

(Also thanks to Shadowfax for explaining the regrettable disappearance of Barbados Butterfly, a female surgical registrar (British semi-equivalent of resident, maybe a little higher on the scale) in Australia, whose hospital disapproved of her blogging. I’m sad to see her go, because her writing was tremendous and she was a role model for me, as much as you can do that over the internet. I can’t imagine why her hospital would disapprove, other than from bureaucratic dislike of openness and communication, because she had a great attitude and usually found things to praise even when discussing conflicts with other staff members. Maybe they didn’t like her frank discussion of the toll that long work hours and sleeplessness take on residents. I don’t think they’ve heard of 80-hr weeks Down Under.

Thanks for what you taught me, Barb; I hope you can come back some time.)

The first patient of the day was an older woman, taking some neuroleptic drugs, complaining of a tremor. I reported to the attending that I didn’t think she fit the picture for Parkinson’s. Of course, after a five minute conversation with her, it became clear from the questions he was asking that he thought she did have Parkinson’s.

The second patient was a middle-aged woman with very marked symptoms, just on one side of her body. The attending’s conclusion was that she has some weird Parkinson-type disease which for some reason is limited to one side (Parkinson’s does tend to start on one side first, but she had had the symptoms for years with no progression to the other side, which would be very unusual). She was kind of fun because her neurological exam was definitely abnormal, and I was able to find the problems. She also had an abnormal gait, which I could see right away (the receptionist could probably tell, too, it was so bad; but I usually can’t make head or tail of gait problems).

The third patient was an older man with a very classic story and physical exam. I announced to the attending, “Ok, I got it this time, it’s Parkinson’s; do you think we can do something different for the next case?” He smiled and said he gave great thought to arranging teaching scenarios in his office schedule. ;)

I do admire his method of explaining the diagnosis. Rather than plopping right out with the name, which would probably be rather frightening to the patient and their family, he starts with an explanation of the pyramidal, cerebellar, and extrapyramidal systems, and how they’re all necessary for normal movement. Then he says that they seem to have a problem with the extrapyramidal system, which could be caused by a disease like Parkinson’s. So he eases into it gradually, and then quickly goes on to the availability of medicines to help with symptoms and retard progression. It takes about ten minutes for the explanation, but I like it; and he tailors it to the understanding level of the different patients, whether they’re relatively young and work in a medical setting, or older and slightly demented already.

The first patient today was interesting and concerning, a lady complaining of new migraines, but with detectable and widespread neurological deficits, which made me think about brain tumors. I told the attending, “I’m concerned about this patient; I think she has something going on.” He cocked an eyebrow at me and answered, “As opposed to – all the other patients we’ve seen this week?” CT scan tomorrow, and come back to the office so he can look at it right away; should be interesting, hopefully in a no-news-is-good-news kind of way.

He’s not unobservant, he can tell I’m not thrilled with this place. So far he seems to be putting it down to “surgeon” and letting it go. This evening, I set I deadline which I thought was plenty long enough for any reasonable office, and plenty late enough for me to ditch out, and then told him I needed to go study. He said, “What, you have a test tomorrow?” I said no, the SHELF is next week, and it was really important to study for it! He let me go. I don’t know how many more times I can pull it off, though.

I promise, I really promise, that I don’t object to 6 or 7pm in and of itself; I object to 7pm only because I’ve spent the last six hours standing still listening to what can best be described as old neighbors’ reminiscences, or perhaps psychotherapy attempted by a non-psychiatrist. Either way, not entirely neurology, not much medicine, and totally uninteresting to someone who didn’t live in the neigborhood. Six hours observing surgery was less boring; I am certain that doing the surgery will be a million times better.

(And this is why I should not be doing ob/gyn: I find, to my disgust, that I really don’t like to listen to people talking about non-concrete problems. Undoubtedly a character flaw; but I don’t want to spend my whole day commiserating with one person after another. Very unkind, Alice.)

(Lecture this morning was much better than expected: I finished a whole round in my crocheted tablecloth, the professor was very interesting to listen to, as we were all trying to decipher the neurological disorder that he unmistakably has, and he finished an hour early. We very much approved.)

The neurology office I am at is so incredibly awful. I contemplated dropping out of medical school, in order not to have to spend two weeks here. My mother talked me out of it. . .

The doctor I’m with spends 15-20 minutes with each patient. You may think that sounds great, but consider: he’s not accomplishing much while he’s doing it, partly because he repeats himself, and partly because in neurology, there never really is anything you can do except say, oh, that’s so sad, maybe things will get better in a little while, come and see me again in a few months. But the bigger problem is that he then spends 15-20 minutes doing I don’t know what between each patient. So the patients have to wait 2-3 hours to see him, he sees ~14 in a whole office day, a couple people left in disgust at the wait, and there’s a long waiting list to get in, because there’s a serious shortage of neurologists in town. So he’s wasting his time, his patients’ time, and the time of people like Anna, who seriously need to see him (that is, if you think the meds for MS are valuable), and mine, at the very end of that list.

14 patients in 8 hours. An intern could see that many in clinic in three hours. This is ridiculous. And I’m not learning a single thing from it. All I did all afternoon was fall asleep in front of the patients. I was disgusted with myself.

Plus, the office itself is crazy. They have a nice, huge area to themselves, full of large rooms, which could be made very efficient and useful. But they have half the rooms crammed with junk, just sitting there doing nothing. The only good thing is, I found an unused room with a chair in it, with a view of one of the examining rooms. Tomorrow, I promised myself, I’m going to bring two medical books, two novels, and a theology book, and my bag of crocheting, and set up in there and relax for those twenty minutes that he twiddles in the hallway.

Seriously, this office is the wrong place to put a surgical character having an attack of senioritis. The only way I’m going to survive is by changing my goals from working or learning about neurology to: finishing The Prime Minister, by Anthony Trollope, in my PDA, the fifth of the Palliser novels (Victorian political series), The Floating Admiral by the Detection Club (G.K. Chesterton, Dorothy Sayers, Anthony Berkeley, etc – detection paradise!), and maybe even, finally, Calvin’s Institutes. I don’t care if the attending thinks I’m the laziest/dumbest student he’s had all year; I worked hard the first two weeks, and those two doctors will give me good grades. I am not going to try to be diligent in an office that takes thirty minutes per patient, and finishes 3-4 hours after the last scheduled appointment.

This office is the nightmare epitome of why I want to get away from medicine, and back within sight of the ORs. I promise, I will be happy in July, no matter what they do to me, just to be with surgeons again.

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