Saturday, October 25, 2014

Weekly Whine: Been there, done that

I can't tell you how many times I have gotten an amazing idea for a blog entry. I get really excited about it, because my goal is to entertain you guys, and I'm happy when I get a really good idea.

Then I do a quick search of my blog, and it turns out I already wrote about that topic. Like, three years ago.

I have had this blog now for about five years. I have written about a lot of topics that are important to me. Most of the things that I feel strongly about are things I have already written about. Often more than once.

Obviously, new things are always happening to me and there are situations at work that are frustrating, funny, or interesting. But I am really careful not to write about anything actually happening at my job. I feel that is just asking to be burned. Usually when I say something happened to me yesterday, I mean yesterday six years ago.

So it can be a big challenge to come up with new content for this blog that isn't just same old, same old. I hope the effort is appreciated, whether or not it's entirely successful.

Thursday, October 23, 2014

It's easy to be a jerk

I was recently reading an article on why doctors can be such jerks.

I wouldn't describe any physicians that I currently work with that way but I've certainly worked with plenty of jerks in the past. There are jerks everywhere, but it does seem like the percentage of doctors that are jerks is maybe somewhat higher than average.

This article talks about why doctors are jerks. The two reasons are first that doctors become arrogant and look down on their patients, and second that doctors become jerks when they're frightened or stressed out, which is obviously common in medicine.

I think part of the problem is that it's often easier to be a jerk then not to be a jerk.

For example, I was recently trying to reach a doctor at another hospital with a question on a patient. I had been waiting an hour for them to call back, and when they did, a random nurse picked up the phone, and told them that nobody was trying to reach them and then hung up, without even asking around.

I was so angry, rightfully so, I believe. It would've been so easy to snip at that nurse for what she had done wrong, and I'm sure I would've gotten away with it, considering what she had done had compromised patient care. It was much harder to take a few deep breaths and calmly explain the situation to the nurse, and then go through the process of reaching that doctor again.

Or to give a less obvious example, often when I walk onto the ward, immediately everyone descends on me with questions, before I've had a chance to catch my breath or get my bearings. It can be very tempting to snap at everyone that they need to step back and give me a minute.

Taking care of patients can be really frustrating, and it is actually really hard to calm yourself down and continue to be kind to the people around you. The staff on my unit call me the "nice doctor" because I try so hard to be nice and approachable, no matter how frustrated I am, no matter how much I feel like if somebody asks me one more thing, I'm going to punch a wall. I monitor every word that comes out of my mouth, to make sure that is not something that would hurt another person's feelings.

You'd think that would be easy. And some days it is. But many days, it is a real challenge.

Tuesday, October 21, 2014

Dr. Orthochick: The Hoarder

The nurse walked over to me and said "just to warn you, the woman spells like cat pee and human pee and the house they found her in looked like it was out of Hoarders. And we don't know why she's here, even though her son is with her and he lives with her. I think she might have fallen."

This 75 year old lady actually did smell like many different types of pee. I'm not sure which species were represented, but i'm pretty sure half of the domesticable animal population had left their scent on her. In addition, there seemed to be a few days' worth of human pee as well. Because that's not gross enough, when I asked her to roll to the side so I could listen to her back, I discovered her back was covered in dirt. And little twigs. And dead leaves. As far as I could tell, she had been lying in filth for days. I asked her what happened but she told me to mind my own business. Then she said she was at walmart that morning. I asked the son if she had, in fact, gone to walmart that morning, but he said he didn't know. So I decided to try and get the story from him.

me: OK, so what happened?
Son: What?
Me: I heard that your mother fell?
Son: Did she?
Me: Do you live with her?
Son: Yes
Me: So what happened?
Son: I don't know.
Me: Why did you come to the emergency department?
Son: What?
Me: WHY ARE YOU HERE?
Son: I don't know
Me: OK, let's talk about this morning. Why did you call an ambulance?
Son: I was going to take her to a checkup but the ambulance brought her here.
Me: Why were you going to bring her in an ambulance? Is she not able to walk?
Son: She says she can walk
Me: Can she?
Son: I don't know
Me: Well...don't you live with her?
Son: Yes
Me: So...do you see her walking?
Son: I don't know.
Me: OK, when was the last time you saw your mother before this morning?
Son: I think it was a week ago. I don't know.

I gave up, did a full trauma exam on the woman, which probably exposed me to every pathogen present in pee (and yes, I know pee is sterile, but that's only when it's in the bladder. On its way out the urethra it gets exposed to a ton of bacteria) and also got dirt all over my hands and stethoscope. She had bedsores on her hips and she couldn't raise her arms above her head or lift her feet off the bed. (The son said "she's pretty strong" after observing his mother's inability to lift her legs) She looked pretty dehydrated. So we ordered the standard "patient fell" workup (pelvic and femur x-rays, chest x-ray, head CT, EKG, bloodwork) and called internal med to admit her.

My attending also ordered carbon monoxide levels on her after hearing about the level of acuity demonstrated by the son.

I don't really know what's going on, but this looks like elder abuse. Or, at the very least, elder neglect. I'm not saying it's intentional because the son didn't seem to have two brain cells to rub together, but it's a little scary how people can fall through the cracks like that. I tried calling the last PCP she had and he said he hadn't seen her since 2005. I found an ER report from December in a different city where they noticed her appearance and filed a complaint with adult protective services, but that means that there's a good chance this woman hasn't been out in public for 5 years. Clearly she doesn't have a competent caretaker, and I'm guessing she hasn't been getting her meds since neither she nor the son could tell me what they were. And I didn't see the house she was living in, but judging from her appearance, it should be condemned. So you have her and the son living together in squalor and no one else knows/cares and so no one gets her (them?) help.

Monday, October 20, 2014

The Inevitable



I have a couple more, but they're pretty silly/NSFW. I can't decide if I should post them or not.

Saturday, October 18, 2014

Weekly Whine: Me

Some of you may or may not remember my story where I got into a fight at Kmart over a pair of sunglasses that took me half an hour to buy. This is part two.

About a week after the Kmart situation, Mel and I went to the Painted Penguin chain. It's one of those stores where they have pottery that you can paint. It's one of her favorite places to go and we had a little time alone together, so I took her there.

The pottery is organized on the wall by price. You can pay anything ranging from about $10-$30. Considering I knew the pottery would either end up in a drawer or broken by her baby sister, I told her to pick something from the $10 wall.

After some deliberation, Mel picked out some Pokémon pottery. We went to pay for it, and it rang up about five dollars more than I thought it would. I thought it was probably some sort of surcharge they had added, so I casually asked about it.

Cashier: "this pottery came from the $15 wall."

Me: "no it didn't. We got it from the $10 wall."

Cashier: "well, maybe somebody put it back in the wrong place. But it's a $15 pottery."

Me: "but it was on the $10 wall."

Cashier: "I don't know what to tell you."

Obviously, I don't care about an extra five dollars. I had been perfectly willing to pay it when I thought it was a surcharge. But the whole thing pissed me off because I had gotten it in the right place and it was their fault that it wasn't where it should've been. It's their responsibility to make sure pottery gets put back in the right place. What's the point of the walls if they mean nothing?

I told Mel that we were going to pick out a different piece. I mean, it's not like that stupid Pokémon pottery was so wonderful. But apparently it was, because she started to cry. So I had to suck it up and buy it.

I couldn't resist saying to the cashier, "you know, this sucks. The pottery was in the wrong place and now my kid is crying, so what am I supposed to do?"

But I was pretty much talking to hear myself speak at that point.

Anyway I got over it, and Mel painted her Pokémon. Then afterwards, we went to the supermarket. They had a little bin of beanie babies, which were marked down from $8 to $2.

Mel asked if she could get one, and I told her she could. And I figured we had to get one for her sister too, otherwise there would be major jealousy. So we took two beanie babies and went to pay for them at the self checkout.

Naturally, the second beanie baby rang up as eight dollars.

But here's the reason I'm writing about this. The second I saw the beanie baby ring up as eight dollars and commented on it, Mel said to me, "mommy, please don't get angry!"

And that made me feel really bad. I mean, I don't think I was wrong in either of those situations, but I hate to think that I'm getting worked up enough that it's upsetting my daughter.

Yet at the same time, I'm not just going to sit there with a smile when I'm getting shitty customer service.

(In case you were curious, I called customer service over and ended up getting the second beanie baby for free for some reason.)

Thursday, October 16, 2014

Doctor Finder

A little while ago, I was calling to arrange a patient cardiology follow-up after her discharge. (Yes, my job is very glamorous.) I called the hospital she had come from and the operator informed me that there were no cardiologists on staff there, and anyone who had seen her had just popped in for a consult.

Me: "so how am I supposed to get her seen by cardiology?"

Operator: "well, I could put you through to Dr. Finder."

Me: "he's a cardiologist?"

Operator: "…"

Me: "sorry… Is that a she?"

A minute later, the operator had put me through to Doctor Finder, a service for helping you find a doctor. Talk about feeling dumb …

Wednesday, October 15, 2014

Choice

I recently wrote a post about the interventions that should or should not be done on elderly people. One complaint a lot of people had is that they didn't want the decision to be taken out of the hands of the patient or the family. I would like to share a personal story about why I think it should.

When my favorite grandmother turned 80, she started to develop dementia. It happened very quickly. In a matter of months, she went from the woman who used to make me all my favorite foods and discuss books with me to having weird delusions and hallucinations. She was not pleasantly demented. She became very confused, agitated, and emotionally labile.

Eventually, my mother had to put her in a nursing home because she could not be left alone anymore. She didn't receive horrible treatment, but she never seemed very happy, which was probably due to the many small infarcts that caused her dementia. Every time I talked to her she would start crying.

About four years later, she suffered a massive hemorrhagic stroke. The doctor told my mother that on the scan of her brain, "there was more blood than brain."

For reasons beyond my control, she had been made full code. The doctors told my mother and my uncle that there was essentially a zero chance of any sort of meaningful recovery. But because they had the option, she had a craniotomy to remove some of the blood from her brain followed by a tracheostomy and feeding tube placement.

She never again regained consciousness and died on a ventilator a few months later.

My mother knew that there was no chance of her recovery. The doctor knew it, I knew it, everyone knew it. But because she was given the option to keep her mother alive, she felt she had to do it. I couldn't talk her out of it.

Meanwhile, I feel like my grandmother was robbed of the dignity of a quick death from a stroke.

Why are people given a choice of a procedure that has essentially no chance of working? At least in her case she was unconscious through the whole thing, but plenty of people spend the rest of their short life in agony due to treatments they never should have been offered.

Some people may say it's heartless, but I think sometimes the most humane thing is taking away that choice. Of course, nobody likes feeling that their choices have been taken away. So I propose a system where the patient can choose to act in their own best interest:

I think when people get to a certain age (75?), they should be offered an option for a quality-of-life based healthcare insurance. The insurance would not pay for an ICU stay, being intubated, CPR, major surgeries that are high-risk and expensive, cancer treatments that are not palliative… You get the idea. Instead, the insurance would provide services that would improve quality-of-life, such as extended hospice services or nursing services to come to the patient's home (this exists now, but isnt good enough yet to keep many people out of nursing homes). Considering how much money is spent (wasted) on extending the life of elderly people for short periods of time, I think the insurance companies would jump at the chance to do this. Plus it would keep people out of nursing homes, which I genuinely think most elderly people fear even more than death.

Then when it comes to those risky procedures, that choice is gone, and you were able to use your health insurance for things that actually made your life better.


Tuesday, October 14, 2014

Contest Deadline TOMORROW

I know people in medicine love to cut things down to the wire. Entries for the First Annual Medical Humor Writing Contest are due tomorrow! I will allow submissions until midnight tomorrow, in whatever time zone you live in.

Dr. Orthochick: Back surgery

Dr. X paged me while I was operating so I called him back after I was done.

Dr. X: I have this patient in room 321, I did a [spinal] fusion on him the other week. He fell and now he can't move his legs. We got a CT scan and it showed a T3 fracture. So I want to extend his fusion. I need you to explain to him and his mother, who's an idiot but she's his legal guardian, that he may have a spinal cord injury and could be paraplegic and then I need you to get consent for the surgery. Oh, and make sure they hold his heparin tomorrow.

Oh. OK.

Just to recap, that means I need to go talk to some patient who I've never met and know nothing about and tell him that he may be paralyzed for life. Then I need to explain to him that he needs more surgery. I need to convince him and his mother. I've never met this guy before. I don't really understand what's going on. I have nothing to do with any of this.

Seriously people, do your own damn dirty work.

So I went to talk to the patient. He seemed a little slow in that he was having a conversation with the phone while it was ringing, but he definitely understood what I was telling him. As in, I walked in and asked him how he was, he said he was terrible because he couldn't move or feel his legs, I said we wanted to do surgery to fix the broken bone in his back and he said "Oh G-d no, not more surgery. I'll do anything but that." Then he started crying. Because I have no tact, I pushed forward and I said we wanted to also look at his spinal cord while we were operating because there was a chance that whatever it was that was causing his paraplegia could be reversed. The thing is though, that's probably not all that accurate. So I had to say that there was a good chance if he was paraplegic now, he would always be paraplegic. I think my exact words were "It's likely that you will spend the rest of your life in a wheelchair."

He understood that.

Then, because his mother was his power of attorney, I had to call her to get permission for the surgery. She understood what was going on after I told her that he might never walk again. She said 'it sounds like he might not be able to walk again even if he has the surgery." I said that was true. She said she was still OK with him having the surgery. So I got consent, called the primary team to tell them the plan, and made sure he was appropriately pre-opped. The whole thing took about an hour.

See, this really does not sit well with me and I was actually pretty pissed about the whole thing. I know I tend to be more anal than most people when getting consent because i don't want a surgeon who can't sit down with me for two minutes and explain the surgery and the risks and benefits and I get that not everyone is like that and it's fine, but I really think it's inappropriate to have someone else deliver bad news to your patient. I mean, I don't think anyone enjoys telling people that they'll never walk again (and this is my second time in a week and really, the experience has not improved with time) but I feel like if you're the one who has the relationship with the patient, you should be the one to tell him. I don't think it's fair to the patient or to me to stick me in this position. I don't know anything about the patient or his history, so I really can't answer any questions. He doesn't know anything about me, so why would he trust my opinion on anything?

The patient said "I wish I'd never had the first back surgery." It was hard to argue with that logic so I slunk out of the room while he and his mother cried together over the phone.

It's really hard being a surgeon sometimes.

Monday, October 13, 2014

Die at 75

I was recently reading an article written by a guy who said he wanted to die at 75 years old.

I thought for sure I was going to disagree with every bit of the article. There were definitely parts that I didn't agree with, such as foregoing some basic cancer screening. (I think I would do anything to keep from dying of colon cancer.) I don't agree with the basic philosophy, that once you slow down significantly, life is not worth living. Plenty of people over 75 have wonderful and worthwhile lives, even if they can't do with they could do when they were 30.

That said, with the aging population, I do think medical treatment to people over 75 (to set an arbitrary cut off) should be limited.

I do think the elderly should have access to antibiotics, flu shots, and medications, and should see physicians frequently. But nobody in their 80s should be allowed to be full code. It just doesn't make any sense in terms of expected recovery. Furthermore, I think cancer treatment should be palliative only at that point. Any major surgeries, such as a bypass surgery, should be avoided. Nobody over that age should be allowed to have a trach or feeding tube. The chances of recovering and having a reasonable quality of life after these interventions is just not high enough to justify it. Frankly, I think it's just cruel to the patients, in addition to being a waste of medical resources.

The most important thing is that the decision ought to be taken out of the hands of the patient or family members. It feels so ridiculous when we ask a 90-year-old if they want to be full code. A lot of the time, the patient or family will say yes, because they just don't understand what it means. They think not being full code means we won't treat their family member, but what it really likely means is it their family member will not have to die on a ventilator. Or alternately, they do understand what it means, but feel guilty making any other decision. I am still angry with my mother for putting my grandmother through a "life prolonging" surgery instead of withdrawing care when the doctor essentially told her there was no chance of recovery, but she said she felt guilty doing anything else.

For starters, I think everybody over the age of 80 should automatically be DNR. And we should seriously consider what other medical interventions should be offered to people who most likely won't benefit from it.