Nescafe rabbit


OK - my cameraphone's LJ client went berserk when I visited YouTube yesterday, and posted Without My Permission. The previous child in this post was NOT Miricups.

However, the video that child is in is adorable:

And Miriam is still blonde :)

Here are a few pictures of her with the Dallas Cowboys Cheerleaders, and Grandpa's Mardi Gras Beads

Baby cat


Gary Gygax Memorial Cat

Nothing witty to say this morning. I'm exhausted, burnt out, and just trying to make it two more days until vacation. Then, I get Spa Services and five days at the Gaylord Resort in Texas.
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Kendo mouse


Z let me know that the DNR patient did finally die...this was accomplished by the expedient measure of arranging for her to go home with Hospice. It's a rule of residency: If you want someone to die in the hospital, arrange for them to go home with Home Hospice. They will die on the day before discharge, but after the equipment has been delivered. Usually, when their family have gone to get the first hour's sleep in the last week.

Other Rules of Residency:
- Really Nice People on Staff Medicine who have an unclear diagnosis have a Bad Thing wrong with them and will die.
- Cocaine saves heart cells. You can do cocaine when your heart is pumping at 1/5 its recommended capacity and stay alive for years. If you are a clean liver, you will require Home Hospice.
- The crazier you are, the less likely Psychiatry is to recommend you be admitted to their hospital when medically stable.
- All pill ingestions which result in survival could not possibly have been serious, so don't expect Psychiatry to tell you your patient is really suicidal.
- The code siren only goes off when you are on the extreme opposite end of the hospital from the trouble in question, unless you are not required to respond, in which case you are Right Next To The Room.
A side note: Our code siren sounds exactly like the 'sandwich is done!' bell on the panini maker at Starbucks on the second floor.
- Alcoholics come in two varieties: Very Nice People who are genuinely sorry for their problem and eager to accept any help you offer, just like the last 345346094534 times they were admitted, and Complete Jerkoffs who will require doses of benzodiazepines sufficient to anesthetize most of the San Francisco zoo just to satisfy their craving for a high. The latter will force your cross-covering resident to interrupt a night of unexpectedly blissful silence in order to explain at length that people die of alcohol withdrawal before leaving anyway against medical advice. See Cocaine entry.
- When you enter the Emergency Department, people who were ready to walk out and go home happy suddenly develop crushing chest pain or fall over screaming, Just For You.

Tonight, I am feeling cynical. It may be because I had a patient today tell me that she couldn't possibly go to her Psychiatry appointment (which we have arranged three months in advance) because her bangs were too long and she looked like "Fluffy the dog".
This, too, shall pass.
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Cane Chinois

One more river...

Done with Med Chief, for a little while, at last.

A few days before I wrapped up, we had an interesting encounter. My first-year calls me up to let me know that we have, in her words, "a patient that got made into an ICU admission." This woman had been discharged from St. Elsewhere's earlier in the day and still had her DNR bracelet on when she came to our ED with a sudden onset of seizure activity and unresponsiveness. Our ER physician, for whatever reason, urged by her unknowing family, felt she had agonal respirations and popped a tube down her throat. Before we got there, without trying more aggressive noninvasive measures. So then we have a patient with bad lung disease, maybe some CHF, a brand-new golfball-sized bleed in her right temporal lobe, and oh-by-the-way we've confirmed with the rest of her family, who knows her well, that she wants to be a DNR, and now she's on a ventilator and what do you do now?

In an ethical sense, withdrawing care and withholding it are equal. In a very real and patient-in-front-of-you sense they're two different things. But several long discussions with the family later about how we had no idea what was going to happen if we took her off the vent, but we suspected it would not be good, they decided that she would never have wanted to be on it, and that it was right and good to take her off. So after 2342359784353 people filed by to say goodbye, we extubated her and waited. And waited. She was initially apneic, dropped her sats to 0-9%, and then started breathing spontaneously and brought them back up to the 80's on her own.

And she's still on my computer census, days later.

We've been discussing this at some length, intermittently, because the question remains: what might-have-been? It's unclear what kind of quality of life she'll continue to have - our neurosurgeon suspects she'll be aphasic, or unable to speak, at the least. It's unclear what would have happened if she hadn't been ventilated for 36 hours. A lot of things are terribly mucky in this situation, and I can't help but wonder whether we're prolonging her suffering or whether we've done some accidental good. She told her family, just before she collapsed, that she was "ready to meet Jesus", so my suspicion is that we have been unfair, but I don't suppose I'll ever know for sure.
Spay or Neuter

Best. Chart. Note. Ever.

"FMR1 H&P reviewed and discussed in rounds. Patient interviewed from doorway but not examined secondary to radiation precautions in place. She feels poorly. Will continue current therapies pending clearance from radiation control."

This woman grew up in a house backing onto an Agent Orange manufacturing plant. They used to throw dioxin at each other on the playground. No wonder everyone in the house has multiple cancers. She's in for radioactive iodine for thyroid ablation.
Altar cross

Ethical considerations (the real post)

Spent two weeks as Chief of Medicine recently, which is a sort of junior faculty position. You spend a lot of time seeing patients, and you're supposed to teach the other residents. It's a great way to learn just how much you don't know about medicine.
Two case studies to talk about, both from what I learned and from the questions they present...this is the first.

F came into the hospital via EMS after being found unresponsive on the sidewalk. The story he gave us the first day was not so simple.

So he says to me: I got this letter from the PNA inviting me to a firing squad on Saturday. So this Saturday I got in my truck and I drove out to the suburbs and they were way out there, at this house. It was me and a half-dozen other guys. They dumped me in a trench, and the guys said "How long you been here?" And I said "About 30 seconds."
They lined us up so they could take our temperatures and stuff, and they checked my blood pressure and they said "Man, your pressure is too high. You need to go to the hospital." So they loaded me and three other guys up on a flatbed truck and took us to the ER.
I hear they're telling people they found me outside my house, but that's not true. Where is my truck if that's true?

The term, O Best Beloved, is fixed delusion, and it means good luck talking him out of it. And this man who otherwise was completely with it and oriented ($hospital, room $room, Doctor...) seemed condemned to live believing he'd been rejected from death by firing squad.

The next day I walked in and he was most apologetic. Listen, Doctor...I guess I had it all wrong. I talked to my neighbor and he got me straightened out. Guess it was a dream...but it all seemed so real.
Our best guess is that he had a cardiac event (that's Medical for either a heart attack or a serious arrhythmia) and suffered a complex sort of hallucination while his brain was figuratively gasping for air.
Once we got the firing squad worked out, he was a nice guy, pleasant, adamantly a No Code Blue. The sort of patient you're sure Something Bad is going to happen to, so it was no surprise that he required dopamine support for his blood pressure, and then his kidneys failed, and he just sort of faded away.

Well...The first time he tried to die on us I made the mistake of asking someone in the throes of oxygen deprivation to confirm a no code, and got "Give me a tube."
So what do you do? (I'll give you a hint: I shouldn't have asked in the first place.) We called his daughters, the power of attorney, and discussed it. They were scrambling to get to his bedside from the other side of the country, a few days before Christmas, and they were adamant. "Dad doesn't want that." And we hemmed and hawed and decided that intubating the patient would be (a) futile, since it wasn't his lungs that were failing, and (b) not in accordance with his previously and repeatedly stated wishes. The nurses were ready to kill me for asking. The first-year whose patient it was was frozen with indecision.
We called Respiratory and put him on BiPap, which is the last step before a tube, and he got a little better...better enough to rationally reconfirm his No Code Blue and his Do Not Intubate. Better enough, in fact, for his daughter to make it to his bedside. And when she did, we started weaning his dopamine and turned off his lab draws. We talked him through his as-needed morphine order (one of the things morphine does, O Best Beloved, is reduce air hunger - stop the horrible feeling of suffocation that comes with low oxygen levels) and his daughter the Hospice-trained home health aide made things easy.

He didn't make it out of the hospital alive, but when he died it was with his daughter at his side and with as much dignity as one can muster in a hospital bed - quietly, in peace.

If he hadn't asked for the tube, I wonder if I would have thought to put him on BiPap. I wonder if we would have been quite as aggressive in our management. I wonder a lot of things. And in the end I think that we did the best we could do, and it was the best thing for him and his family.

A good death is one with dignity and peace, a death without fear. And it is possible to achieve. In the process of learning to heal, every now and then I am privileged to be touched by a good death.
Nescafe rabbit

Ethical considerations.

Spent two weeks as Chief of Medicine recently, which is a sort of junior faculty position. You spend a lot of time seeing patients, and you're supposed to teach the other residents. It's a great way to learn just how much you don't know about medicine.

Two case studies to talk about, both from what I learned and from the questions they present...

F came into the hospital via EMS after being found unresponsive on the sidewalk. The story he gave us the first day was not so simple. "About a week ago I got a letter from the PNA, inviting me to a firing squad..."

...OK, wasn't supposed to auto-post from LJ mobile yet. I'll try and finish the story this weekend...
Nescafe rabbit

Things that drive me crazy.

L is a very nice man whose wife I've been treating for about six months now. I inherited her from another resident who graduated. Last time I saw her in the office, she brought her husband. "Take a look at this lump and tell me if you need to see him." I looked at the lump. "make a new patient appointment. Yes." It was firm and solid and on the side of his neck and probably nothing good.
So before he could come back to see me he had a coughing near-syncopal spell and wound up in the ER where they did my workup for me.
Nothing good. He has a 3 centimeter spiculated lung mass on the right lung, and lymphadenopathy that could only be tumor everywhere else.

I put him in the hospital because he was fainting. He had a spell of this on monitor. His blood pressure dropped to 60 over nothing and his pulse went to 40 something. I discussed thid with my friendly neighborhood cardiothoracic surgeon. "Sounds like this man needs a pacemaker." I called the cardiologist who'd put a stent in his heart 3 years prior. He called his electrophysiologist. They came and looked at him.

For three days he sat in the hospital while the cardiologists demanded a tissue diagnosis to put in a pacemaker and the CT surgeon demanded a pacemaker to put him under for a tissue diagnosis. And both of them kept paging me to tell me that the other one was being unreasonable. Three wasted days before they put in the pacemaker, and then only under duress. And with it in, he stopped fainting. He got his biopsy and we called the oncologist for his stage 4 metastatic poorly-differentiated squamous cell lung cancer.

I hate it when specialists won't talk to each other, and I really hate it when they waste 3 days of the life of a man who doesn't have three days to waste. If he's alive to see my daughter (he loves my baby, who rounds with me some weekends and holidays) turn two, it will be a miracle.

House by the river

Easy Money...

In case you missed it in previous posts, $hospital depends on residents to fill the early morning shifts. Specifically, there is one ER physician and one resident on every morning from midnight to 7 AM. Our Level II trauma center ER gets 52,000+ patient visits a year. That's an average of 6 patients an hour, if you lay it out evenly across the day. Fortunately, we don't. From midnight to 7 am is a little bit of a low shift, although the bars close at 2. Normally, we see about 35 folks instead of the expected 42 - I see 12 or so, and the ER docs see a whole bunch. For this service, they cover my malpractice and pay me $75-$85 an hour, which amounts to a decent takehome to cover some of the med school debt with. Some shifts are absolute murder, when the trauma call folks are in and I'm running the rest of the ER alone. Tonight, my attending had a gunshot wound to airlift to $tertiary_center and an ectopic pregnancy to send to surgery, so I handled the rest for a while. It had the potential to be quite bad.

Instead, in no particular order: A six-year old with an overanxious mother and an asthma exacerbation (99% on room air: one duoneb, steroid burst, discharge home). A colicky month-old baby (complete physical exam demonstrates farting and improvement of colic: reassurance, discharge home). A teenager with a urinary tract infection (antibiotics, discharge home). A year-old with croup (vaponefrine, observe, discharge home). A teenager who picked up the wrong cat (betadine scrub, discussion regarding the last rabid cat in Indiana in 1984 and the much higher risk of Pasturella joint infection, Augmentin, discharge home, followup tomorrow). An elderly woman sent from the nursing home with diarrhea to rule out dehydration and with an elevated INR (can't work out what's wrong with her, argue with the hospitalist, call her primary care doctor and oncologist and admit). A very nice lady who woke up in the middle of the night with pancreatitis (argue with attending that she has GI problems and not cardiac disease, admit).

Seven patients. And it's holiday dinner morning, so at 3 AM I got chicken cordon bleu, green beans almondine, and cheesecake. Not bad money, tonight. Not bad at all. I think it's time for a nap before Dermatology.
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Notre Dame des Dons

Good news...

Yesterday, K pulls me aside. "When you're done with clinic, I need to talk to you."

I got done with clinic at 1730, after putting a long-arm ulnar gutter splint on a 35 year old woman who'd fallen on the ice (I'm 80% certain something is broken that we haven't seen yet), reading an EKG on a patient with chest pain (normal), setting up an induction and avoiding all my inbound phone calls. She and S fall into single file around me as we walk up to her office. They're both smiling, although S is the master of the secretive little smile, so who knows what that means.

We walk into her office. She shuts the door, motions me to a seat.
We'd like to officially offer you the OB fellowship at $hospital for next year.

I'll be here another year, O Best Beloved, learning how to do c-sections and manage emergencies and hone my ultrasound skills, and I get to trim some of the deadwood off of my patient list while I do it, to boot. I'll be doing primary care, but focusing on OB. And maybe a little research.

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