Illness drives us to illogical decisions, and that’s one of my pet peeves in medicine. As doctors, we think that we know what’s best for our patients and frown when they disagree with us. We are even trained in medical school and residency to put ourselves into their shoes to help guide our decisions. Yet with such extensive preparation and almost a year of clinical practice behind me, I still am unable to rationalize some of the decisions my patients make.

Last evening I was paged by nursing that one of the asthmatic patients demanded to be discharged from the hospital, at 10:45pm. She was taking multiple anxiolytic agents, along with sedatives. She complained that her wheezing had not improved since admission, and that she “needed” to leave. Earlier in the evening outside of visiting hours, she had a visitor who demanded to meet her in the hospital lobby. When security denied their rendezvous, she threw a fit.  I gave her a standard discussion about leaving against medical advice, and that I did not believe it would be ideal if she left in the middle of the night while she was ill.

Over the next hour, she demanded to speak to me over 5 times. I presented the AMA form that relieves the hospital of any wrongdoing if she left and told her that she could even die with untreated asthma. Around 2am, the nurse notified me that the patient had left the hospital.

I guess she was probably withdrawing from some illicit substance, like a third of my patients predictibly do (I am working at an inner city “Outside Hospital”).  Afterward, I felt disturbingly relieved that my patient had left–I wouldn’t have to write a progress note on her in the morning.

medicine medicine, rant

You’ve probably heard about the outbreak of swine flu in various parts of the U.S. and Mexico recently. We even received a page via the UrgiCare service that one mother believed that her daughter had swine flu today! Talk about mass panic.  Interestingly enough, the swine flu is of a similar in subtype to the flu that caused the 1918 Spanish influenza outbreak (H1N1).  Google has set up a tracker to follow all of the suspected swine cases in North America:

View H1N1 Swine Flu in a larger map

medicine humor, medicine

As I specialize further in my career, I increasingly wonder how much my time is worth. In the hospital, we often see a strict division of labor. Physicians seldom perform phlebotomy or vital signs–this is the job of lab techs and nurses.  Our time is valuable and should be spent on tasks that require our many years of specialized training.

Does this division of labor exist outside of the hospital? Numerous medical residents have told me that they hire housekeepers to maintain their homes or apartments simply because “it’s not worth my time”. Other chores that I’ve heard residents renounce include: 1) mowing the lawn 2) cooking 3) washing dishes [including putting dishes into the dishwasher].

I’ve renounced cutting/logging trees ever since I entered medical school, mostly because I find that operating a chainsaw may prematurely end my career as a physician before it even begins. I don’t particularly care for logging trees either. But what about other tasks? What tasks can you refuse to do before being labeled a pampered snob? Read more…

medicine, misc food, life

I’m at the point in my internship that taking overnight call on the inpatient floors is more of a chore than a challenge. We admit patients, and field a few dozen nursing pages that are usually manageable. I walked into call yesterday with my 95 year-old lower lobe pneumonia patient rolling into atrial fibrillation with a rapid response rate of 180. For some reason her blood pressure was also elevated to the 180′s systolic, which isn’t as common in a-fib. The kicker was that she wanted to be full code. Great.

As I was ordering a diltiazem push, an ICU nurse had materialized at the scene–apparently the floor nurses called a rapid-response code (RRT) behind my back. RRT codes are usually called when a patient needs of prompt attention when housestaff aren’t available immediately. I was, however, already at the scene. No time for hurt feelings though–I was glad that help had arrived, especially since my senior resident was nowhere to be found. My brain had already closed down to internal medicine knowledge, as I’ve since mentally moved onto starting ophthalmology residency.

Soon afterward, a cardiologist arrived to evaluate her. We transferred the patient to the ICU later that morning, and started her on a diltiazem drip. She stabilized for the next 12 hours until the evening rolled around. She then became delirious, pulling out her lines, jumping out of bed, and muttering nonsense…all typical of ICU psychosis. As I was redirecting her back to bed a third time, she decompensated, and spiraled down to a rapid heart rate again. She further deteriorated and required intubation.

Daytime soon rolled around, I signed out to the day team. I now have a 95 year-old woman on a ventilator. Great. I wonder what other excitement will be had when I come back on Monday…

medicine medicine

I laughed the first time I read this question on my risk management training exam, which I am hoping to finish in between the 90hrs I anticipate being in the hospital this week:

The blunt end of the healthcare system can be described as:

a) action by clinicians

b) latent errors

c) inaction by clinicians

Oh boy, I have quite a bit to learn…

medicine humor