Against Medical Advice

Time for a little thought experiment here folks:

Imagine that you weigh about 500 pounds. You get one of those big boy beds with the inflatable mattress that prevents new decubitus ulcers on your ass (like the one you have at home). You haven't moved said ass from your bed since last fall. You've got a couple new-ish metal joints because your massive girth destroyed the perfectly good ones you were born with and you can't even move your own legs because of their enormity.

Yeah, you remember the glory days when you qualified for the 1980 Olympic games in Greco-roman wrestling (but didn't go because of Regan) . You were an Engineer and that white coat wearing kid is talking down to you when he explains hypertension. You don't want to eat the low-fat, low-sodium diet ordered for you and send your tray back to the kitchen. It tastes like cardboard...

However, you are too ignorant of your own health to remember that time you were in florid pulmonary edema and dyspnic back in May. You got an ultrasound of your heart showing some diastolic heart failure...but they treated you with maalox and you got better. You're on an ACE, a Beta blocker, a duretic, lipitor and aspirin...the standard care for heart failure...but no one ever told you that you had heart failure.

Now imagine that you're hungry because you've been in a few hours of tests, and all you really want is a nice big ham and cheese sandwich...an no one will get it for you. You're ordered for a cardiac diet. Now imagine that you call the nurse and demand that your diet be changed to allow you a ham and cheese sandwich...shouldn't be a problem, the doctor will fix that right away. MMMM salty ham and fatty cheese...you're really hungry. Good thing you got rid of that crappy dinner tray 10 minutes ago...too many veggies.

Now imagine that some jackass in a short white coat comes in and tells you that you have a history of CHF (Surprise) and HTN and that a low salt, low fat diet would be best for you and that he's not going to change your diet...no you can't have your sandwich. You've never had CHF, no doctor ever told you that!!! That has to be wrong, get that out of your charts.

When he's paged a second time (you really are hungry this time), he proceeds to remind you of this CHF thing that no one ever told you about and explains how a salty diet will make you retain fluid and cause you to go into heart failure and get you into the same situation you were in last time. You're livid and want to talk to an administrator to have the CHF thing removed from your record...it's 8PM on friday and you want a damned sandwich...no that fruit plate and 2 bowls of cereal won't do.

The next time he's paged that fucker pulls the echo report from may and points to the words "Dyspnea" and "Edema" under diagnoses. He explains how even though your systolic function was ok for the time being, your dilated right heart will cause you to drown in your own juices if you have a regular diet...so no ham sandwichs for you! Well, you might as well leave this place cause they're not going to feed you (that dinner tray looked too healthy) you tell the nurse that you want to sign out AMA. Someone will drop you off at home and get you into bed...you can get those Q8Hr antibiotics at home anyway...i mean you just hook them up to the PICC.

That fucker in the white coat is back with the AMA form all filled out for me to sign. You'll have to find your own way home? In the snow storm? The medicaid crane to move you back to your bed at home at 9:15PM?? No one is setting up care for you at home if you leave now and there's the chance you may die of sepsis??? That's it...you're calling your lawyer. You're going to sue everyone over a ham sandwich? They can't threaten me with death and heart failure. How? You'll find a way...you were an olympic athlete!

Oh, the nice nurse is going to get you a nice low-sodium grilled chicken sandwich from the overpriced hospital cafe...that'll work! How can that white coated guy be concerned for your well being??? He won't even give you what you want for dinner! Thank you ma'am...

Reason number 1,000,000 I will not be going into internal medicine...stupid shit like diet orders and ignorant patients.

Can we strangle patients?

Have you ever had one of those days where your stupid patients have stupid problems that the poor nurses have to page you for? Here's two dandies from today:

Patient 1- 30's female with a personal and family history of DVT, now at 15 weeks gestation with a DVT in her thigh. Should be simple enough, hypercoaguability work-up, heparinize and discharge on lovenox. Yeah, right...

• "Where was your lovenox made"- New Jersey...perhaps the one place on earth scarier than China.
• "Are there any preservatives in lovenox"- not in the single dose form that you'll be getting...but that room-temperature, unpasteurized, farm-fresh, organic kefir you're chugging might contain some brucella or mycobacteria bovis...I hear those are bad for babies.
• "I've read there are all sorts of side effects of that nasty drug lovenox"- Most of them are bleeding related...it beats a PE that could kill you and your baby! We could always try rat poison.
• "Can I eat an avocado? I read all about the food interactions of heparin and avocado was on there"- you read about warfarin, avocados and many foods interact with warfarin. Lovenox works by a completely different mechanism. Bon Apetite and I question your sources.
• "I've read that people who inject their skin with insulin loose fat at the injection site. Will that happen with lovenox?" No lovenox is not a good way to lose that pesky baby fat.
• "Why is the hematologist so interested in all of those tests...what if I don't want to know?"- Wait...you just asked me what preservatives are in lovenox and you don't want to know if you have a clotting disoder? Either be OCD or non-chalant about it...don't flip-flop.
• "What are the potential side effects of ultrasound on my baby? I've read studies about them damaging the ears and eyes and I know it hasn't been studied because there isn't a big enough group of un-ultrasounded women out there." Um...no. Actually due to your advanced maternal age, you may want to consider an ultrasound to screen for potential birth defects since women of your age are at an increased risk. The benefits would probably outweigh the risks. I bet you take your immunization advice from a porn star too!
• "What percentage of EMLA cream is absorbed by the skin into the body?" Um...adults don't generally use EMLA cream...no idea.
• "My homeopathic doctor...blah blah blah"...not that I'm skeptical or anything, but crystals and accupuncture aren't going to fix your DVT or genetically based hypercoaguability.
• "With my first baby, my membranes ruptured on Sunday and I delivered on Thursday...my midwife got a little worried on Wednesday"...Um ever hear of chorioamnionitis or GBSS? Oh, you never saw an OB or had an ultrasound?...no wonder your dates were a month off.
• How'd that lovenox shot go? ::dramatically:: "Oh it was so horrible!"

Patient 2: 25 yo guy admitted for a CF tune-up, ended up having an exlap for an intussiception, on a PCA for pain control. POD#3, just got the NG tube out and starting to eat. Still has PCA (Patient Controlled Analgesia) pump with dilaudid.

• He pounds down his liquid breakfast tray in under 10 minutes, and has belly pain shortly there after. Covering SubI (who witnessed the first episode of belly pain leading to surgery 4 days ago) was paged. Explains that the bowel "goes to sleep" after surgery and while taking opiates. Downing his tray so fast was probably a bad idea...take it easy on the food for now.
• SubI paged for worsening abdominal pain. Now rolling on the floor, howling in pain, patient is still able to text and talk about his wife and make a few jokes. Benign exam...I'll reassess in an hour
• SubI paged for worsening abdominal pain. "This feels like right before the surgery"...patient not texting any longer but still a benign exam. SubI orders STAT labs and imaging and pages surgery, discusses with medicine attending who agrees to examine the patient and is not very impressed either but agrees that labs should be sent anyway. SubI calls his resident to cosign STAT orders. Writes progress note re: plan.
• SubI reassesses patient after ordering labs. Patient eating dinner tray, talking on phone to wife, pain well controlled with PCA pump. "Yeah, I just decided to start using my PCA pump again. I feel ok now man! Hey do you play Dungeons and Dragons?" SubI explains the finer points of the PCA machine (Push the green button until the pain is tolerable...if you're unconscious, you're gonna get a rude awakening). And no, but I do play fantasy baseball and football...no you're not getting a draft invite.
• "I get lonely in here...thanks for talking to me man" SubI checks his not-ringing pager, excuses himself to answer his phantom page, calls resident to cancel STAT orders because the patient is a fucking idiot, writes a progress note that the patient is a fucking idiot, bangs head on desk and questions so many of his poor decisions in life...like going to medical school.

It was a long day...and I only covered 12 patients...I felt bad for the interns who had to cover dozens of them and the resident getting killed in the ED with admissions...more fun tomorrow

Stupidest dispo of the week

96 yo M- medically cleared for transfer to Inpatient Psych Unit for suicidal ideation

Listen...if I ever make it to 96 (and I plan on killing myself with a lifetime of bacon, red meat, beer, scotch and family cardiac history long before that) and I feel like dying, just put me on Comfort measures and send me to hospice so I can have some compassionate care instead of medical wards or the fucking locked psych ward!!! The poor guy will get knocked over by one of the aides or another patient, break a hip and throw a lethal DVT...please rethink that one kids.

Words of wisdom

I love old folks because they drop these hilarious little pearls off the cuff without thinking twice.

Yesterday from an 81 yo guy:

"You know you've become old when moving your bowels is better than sex ever was."

Man, I hope I never get old.

my whereabouts

I know that I've been a bad blogger...but 4th year has been sort of more than I thought it would be.

What have I been up to since October when I used the blog as a procrastination tool for step 2?

1. Training for my first marathon in March, sort of half-assing it through partly due to weather, partly due to interviews/traveling and partly due to laziness
2. Residency interviews- invited to 16, went to 14 and ranked 13 with some really phenomenal programs in the mix. We'll see where that goes on March 18th at noon. There's a significant chance that I could remain a Bostonian in NY for a few years to come...saving me that awkward blog transition.
3. I was either at home doing nothing worth writing about, on the road, skiing or sitting in the library on my tox rotation...nothing really to write about
4. SubI- I'm on my medicine subI right now and it is everything I hate in the medical world with a fucking beeper attached to my hip. And it never stops buzzing for the stupidest shit...case in point happened today:

• "Are you covering X?"
• no, I was last night though
• "Do you know who is?"
• nope, there's like 100 patients on the medicine service, 12 interns and 6 subI's. If you look at the bottom of any progress note, the pager number for the intern is there
• "I didn't want to have to walk alllll the way over to the chart rack"
• glad I could help

Anywho, subI is crushing my soul and providing plenty of fodder, rage and learned helplessness for me to polute the interwebs with. You'll note the new privacy settings...I was getting sick of spam comments. Anyway...gotta get up in a few hours, might as well sleep.

~BinNY