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

Since a portion of my web traffic originates from the medical community, I’ve decided to provide an update on a web technology that you’ve all probably heard about, Twitter. We see links to Twitter on websites, news links, and even television ads. Just what does this ubiquitous, cute bird do, and what role can he play in the medical field?

Those of you using Facebook are also probably wondering whether Twitter is any different from your Status. Well, the truth is, it’s not. To take a step back, Twitter serves as a one-way bulletin board. You can post whatever you want on it for the world to see, but others cannot write on your bulletin. Your viewer do not require an account on Twitter, nor do they ever have to log in. In contrast, your status page on Facebook can only be viewed by your designated friends.

The strength of Twitter lies in its accessibility. The owner can post links via SMS, website, email, desktop application, or portable application. It is concise, and viewable by the public with any of the aforementioned posting media. Your followers can receive automated updates on your bulletin. Therefore, it is an expedient means of communication.

I first saw the use of Twitter in medicine from Henry Ford Hospital, where they broadcasted updates directly from the OR. This was innovative, because it was a means for the public to become involved in the operating room. Imagine receving real-time updates on the carotid endarterectomy from OR #12:

“The shunt has been bridged!”

“EEG shows activity!”

“The resident calls for the yellow-tails!”

I would certainly try to incorporate the medium in my OR. Twitter’s application can also be extended beyond the OR. You can post updates from the clinic via Twitter.

“Dr. is running late today.”

“Two openings at 4:15pm today. Okay to walk in.”

The key is, of course, not to abuse posts to the extent that your patients become sick of getting updates. There is certainly a fine balance to be had. That’s it. Go to Twitter.com. Open an account. Play with it. In the meantime, you can follow my Twitter, also viewable on the side column. Real-time. Real news. Good stuff. If you have questions, contact me.

Update (4/23/09; 9:07pm): Mayo Clinic has even jumped onto the Twitter bandwagon, holding a webcast presentation on Twittering. Great stuff.

computing medicine, tech

I just finished a week of night float at what is probably considered one of the “outside hospitals”.  The nursing pages are painful. I’d typically receive a page every evening notifying me that a patient had not moved his bowels in 3-10 days, and that the constipation protocol was just initiated. Other times, nursing would demand that I order Seroquel to knock out patients who were simply irritating. While I don’t mind constructive advice on patient management, I don’t appreciate illogical verbal pressure from unqualified people to medically subdue a non-hostile, non-psychotic patient who asks for ice chips.  These select ancillary staff workers leave a foul air that mars the reputation of nurses and techs, and I have to remind myself that not all nurses are lazy assholes. On weekends where I’m in the hospital for 30-36hrs, my pager goes berserk every 10 hrs with 10-15 pages within 2 minutes for inconsequential order clarifications–this corresponds to the nursing shift changes. They tend to forget that my shift spans four of theirs.

On Tuesday, my co-resident and I caught a rotund technician lurking around the resident’s lounge. He stated that he left a “paper” somewhere in the lounge and promptly dashed off. Later, we noticed that half of my co-resident’s iced tea was missing, and his sandwich was gone. We should have confronted the tech in the lounge, since all other staff is forbidden from hanging out in our lounge.

While hospital staff that outright harm patient care are terminated, the majority of the subpar group continue to maintain their duties without penalty even though the hospital administration is aware of them. It is unfortunate, but there is a shortage of qualified nurses in American hospitals. I believe that the shortage is expected to worsen in the next decade; it does not look good for inpatient medicine from this aspect. Hopefully, I will be out of the inpatient business by then…

medicine medicine, rant

Paperwork is the bane of the U.S. health system. Hospitals hire trolls to ensure that physicians and nurses document every last detail of a patient’s bowel movement in case of legal dispute. Social workers hound us to document minutiae so that the hospitals will receive their cut of the bill. I was recently told to draw a down arrow along with “K+” to document hypokalemia so that the hospital will be able to bill for the medical condition.

I am in the process of registering to work in a new hospital system in another state. The other day, I received a huge packet of poorly photocopied paperwork to be completed before I get hired. One of them is a statement that I will not sue my employer under any circumstances. Another form states that if I choose to work at this hospital, I am forbidden to moonlight in my free time. Other forms include various tax withholding forms (W-4′s, IT-2104′s), applications for employment, background check forms, and a variety of nondescript forms with a blank to sign and date.

To think, these forms are only for residency training! How much worse is the paperwork for a real job? I would have thought that the blood and sweat ended after I matched, but I’ve come to realize it’s a lifelong journey.

Do doctors in other countries have to go through the same harrowing process simply to practice medicine? What if I moved to France or China? Would there be as much paperwork? The thought of practicing medicine outside the U.S. is intriguing….

Readers! Please share your thoughts!

medicine humor, medicine, rant

In the research arena, there is always a “conflict of interest” declaration to enumerate any reasons why the researcher may benefit from favorable results of a study. Many times, the researcher’s lab is sponsored by the very same company whose drug  is being studied. Other times, the primary investigator holds stock in the pharmaceutical. Regardless, any conflict of interest is often viewed with critical skepticism, based on the notion that research should be purely scientific.

I’ve never had any financial disclosures in research. Is that good? I’ve begun to reconsider. Would it not be a privilege to be able to state that you are a primary shareholder in a pharmaceutical company? After all, don’t you have to be an important person to be in that situation? Don’t we all want to be important?

My next goal: strive to generate as many conflicts of interest as possible. More to follow…

medicine humor, medicine