Saturday, June 30, 2012

Weekly Whine: Useless stores

In any neighborhood, there's some turnover of stores. This can be a bad thing when a store you like closes, or a good thing when a great new store opens up.

Recently we had a large bookstore close down near us. I don't buy books at bookstores since I think they are incredibly overpriced, so I was eager to see what would replace the bookstore. A restaurant? (Good) A Babies R Us? (Great) A Trader Joe's? (Awesome!)

It wasn't any of those things. It was a store that sells party supplies.

You know what would have been better than a store that sells party supplies? ANYTHING ELSE.

Who shops at a store for party supplies anyway? Can't you get anything you need for a party at like a Target or something? What kind of crazy parties is everyone throwing where such a store would actually be profitable?

Anyway, there was another giant lot near me that's been undergoing construction for about six months. I was pretty excited to see what was going to be there. I was hoping for a gas station because there aren't any between my work and the daycare without a detour, so that would have been perfect.

So today I found out that what they're building in the lot is... a bank.

I was literally furious when I discovered this. There's already a bank right across the street. How many freaking banks do we need? Why do people keep building useless stores?

Friday, June 29, 2012

Tales from Residency: Weekends

One thing that really irritates me is when the attending covering a service for the weekend changes all the meds. I'm of the philosophy that weekends are just for emergencies and it's arrogant to think that you are better at managing a patient you just met than the primary team, who knows the patient very well. So I think orders should only be written when absolutely necessary.

But some of the attendings I rounded with during residency seemed to look at the weekends as an opportunity to fix all the patients' problems. I remember one attending Dr. McGill was particularly bad about it. She would flip through all the charts, saying things like, "Why is this patient on so many medications? She shouldn't be on this many medications!" Then we'd decide on a Sunday morning if the patient really needed that second dose of Colace.

Seriously, on Sunday morning I don't think it's appropriate to start changing all of the medications of a patient I just met. If that makes me a bad doctor, then so be it.

But situations like these were the most annoying of all:

Dr. McGill: "Why is this patient [that you never met before] on Zosyn?"

Me: "Uh... well..." [checks sign-out sheet] "He has MRSA pneumonia..."

Dr. McGill: "Yes, but he's already on Vancomycin."

Me: "I guess the Zosyn is to double cover."

But my hypothesizing wasn't good enough. Nor was the fact that the primary attending Dr. Brown's note from yesterday said "Vanco/Zosyn for MRSA pneumonia" and the signout said something similar.

So after discussing this for several minutes, Dr. McGill said, "Call Dr. Brown at home and ask him why the patient is on Zosyn." (She had his number in her PDA.)

Me: "You... you want me to call him at home on a Sunday morning?"

Dr. McGill: "Yes. He won't mind."

Me: "But... what's he going to tell us? He knows the patient is on Zosyn. It was in his note. Do you think it's a mistake??"

Dr. McGill: "Just call him."

I was pretty horrified by having to do this, but like a good soldier, I did it. And Dr. Brown said exactly what I thought, which was that the Zosyn was for broader coverage. I honestly didn't get why we had to call him. Did she think that he was suddenly going to realize that he made a big mistake by putting the patient on Zosyn and Vanco? Dr. Brown is a really good physician and I know he wouldn't have made a mistake like that.

Anyway, this is one of the many reasons I hated weekend rounds.

Thursday, June 28, 2012

Why every hospital needs EMR

EMR = Electronic Medical Records

When I was an intern in the ER, one day I came back from lunch and my attending gave me this really dirty look and said, "You know, you wrote to give D5 that diabetic guy with the blood sugar of 500." (i.e. I wrote to give sugar water to a diabetic with really high blood sugar)

"I did???"

He shook his head at me, clearly baffled by my stupidity. "I guess you didn't do it on purpose, but I just wanted to let you know you made that mistake."

I couldn't imagine why I would have written to give him D5, even by mistake. I hadn't ordered that all year. The only thing I could think of was that maybe I had meant to order something else and I checked the wrong box, but I knew I couldn't have actually WRITTEN it.

Finally, I got the order sheet to look at what I wrote. Under NS, I had written 0.5L and they had mistaken my 0.5 to say D5. OK, I guess that's not ridiculous, but why would I have written D5L? What does that even mean???

Regardless, the patient almost got sugar water pumped into his veins.

Wednesday, June 27, 2012

Pregnancy is not an excuse

During my first year of residency, I had a situation with an inpatient where I suspected he had a very elevated INR (I'm not going to get into the background story).

We sent a stat INR. An INR of about 1 is normal. If you want to anticoagulate someone (for most things), you want the INR between 2 and 3. We were concerned his INR might be upwards of 10 and my attending and I were planning for this situation.

Anyway, an hour or two after the stat INR was drawn, I checked in the computer and not only was the stat lab not back yet, it wasn't even pending. I called the lab and the tubes of blood had never even made it down there.

The lab asked me how the blood had been sent, so I called the nurse over and asked her. By now I was getting very agitated because I was afraid for my patient and now it seemed like it was going to be another hour or two of waiting. The nurse said she had "tubed" the blood to the pharmacy... apparently, the blood was now lost in the tubes system.

I went over to the nurse to ask her to redraw the blood. As soon as I walked over to her, she said to me, "You know, you were very disrespectful."

I was totally baffled. "What?"

Apparently, she was really upset that I had called out her name to have her come over to the phone to help me. I tried to explain to her that I was talking to the lab and it was very important and that I needed to know what happened to that blood. I apologized for being disrespectful and said I was just worried about the patient, and I really didn't think calling out her name was that horrible... I was on the phone, I didn't want to lose the connection by putting the phone down... and I could see her sitting at the next table over a few yards away, not dealing with a patient or anything. I just wanted to know where the blood was.

"I tubed it to the lab," she said. "I have witnesses."

"I never said you didn't," I said. (It never for a second had occurred to me that she didn't do exactly what she said.)

"I have witnesses," she repeated.

I was totally confused. Did she think that I thought she just tossed the blood in the garbage can? I didn't think I accused her of anything. I was just trying to track down the blood to run the tests on it. She kept telling me that she always treated me with respect, which wasn't untrue but it wasn't like anyone treated me with THAT much respect. I mean, nurses were constantly calling out MY name. While she yelled at me, there was another nurse who was just sitting there, listening to the whole thing, not saying a word.

This is a situation where I was particularly peeved at being yelled at. First, because she was wasting time yelling at me instead of redrawing the blood. Second, because I honestly hadn't done anything wrong (yeah, what else is new?). And last, because I was hugely pregnant and I thought it was a special brand of awful to yell at a woman who's very pregnant.

On that last point, I have to admit, I always did expect to be treated a little nicer when I was visibly pregnant. It just seemed like something that should have been done, considering everyone knows pregnant women sleep badly, feel crummy, and have raging hormones. Plus, yelling at a pregnant lady is slightly like yelling at a newborn. And you know what? I never was treated different. Nobody treated me even a bit nicer due to being pregnant, as far as I could tell. In fact, one time when I was eight months pregnant, I was looking for a seat on the ward so that I could write a note, and nobody even offered me that. I almost cried.

And if I started yelling and acting like a lunatic while pregnant, I very much doubt anyone would have given me a free pass, saying, "Oh, don't mind her. She's pregnant and her hormones are out of control." Which is okay. I never expected anything like that, which is why I had to make an extra special effort to be nice while I was pregnant. I don't think raging hormones are an excuse to be a bitch to the people you work with. (Only having your name called out in an emergency situation is an excuse to be a bitch.)

Anyway, in case you were wondering, that patient's INR was fine.

Tuesday, June 26, 2012

3 Things

When I was in college, for a writing class I was taking we played a game to "get to know each other." The game was that you name three facts about yourself, two of which are true and one of which were made up.

Because it was a writing class, most of the people told these crazy, elaborate stories about themselves, and we had to guess which one of these embellished stories were true. But I kept it simple. These were my facts:

1) I have never read anything by Shakespeare in my entire life, including sonnets.

2) I have shaved a man completely bald.

3) Jerry Seinfeld is my second cousin, and several years before his TV show, we saw him in a club in NYC and didn't think he was all that funny.

Which one is false? My class couldn't guess.

Monday, June 25, 2012

Evolution of the White Coat

I guess there are some attendings who do wear white coats, but nobody where I work does. I'm just thinking about it and I truly don't think I've been to a doctor who wore a white coat in a while.

What do you think? Should attendings wear white coats?

Sunday, June 24, 2012

Weekly Whine: I'll never read your blog again!

Sometimes I'll write something on this blog or another that some reader finds offensive. I don't think the things I write are that terribly offensive, so it's probably a matter of the reader having a bit of a chip on their shoulder.

I certainly don't expect everyone to agree with everything I say. I always appreciate a respectful argument without any namecalling.

Here's what bugs me though: when the person writes something like, "I find your post incredibly offensive and I'm never going to read your blog again."

If I were running a restaurant and trying to make ends meet, threatening to never buy my food again would totally suck. But I don't make money per reader. I don't need more readers to attract advertisers. So why exactly would I want someone who hates my writing to be reading my blog? I'd prefer they didn't. I feel like my response to that threat should be, "Thank you."

Of course, the implication of writing such a thing is that I will now lose all my readers. Because people who constantly say offensive things never attract an audience or their own radio talk show.

Actually, the truth is, when I write something "offensive," it's basically a guarantee of a big jump in my hits and lots of new followers. But I don't do it that much because I don't feel like that's the purpose of this blog.

Anyway, here's an idea: if you ever decide not to read this blog anymore just stop reading. No need to inform me of your decision in a dramatic fashion.

Saturday, June 23, 2012

Fun with Consults, Part 2

Why all the residents at Staywell Rehab Hospital hated doing consults:

Me: "Hey, you said you'd staff this consult with me if I finished it before 2:45 and it's 2:30 now. Can you see the consult with me?"

Attending A: "Well, something came up and I'm kind of busy. Can you ask Attendings B and C?"

Me: "Oh. Okay."


Me: "Hey, do you have time to see a consult with me?"

Attending B: "Did you ask everyone else?"

Me: "Um..."

Attending B: "Well, maybe. If nobody else can do it. But I have to see another patient first. I'll call you when I'm done."

Me: "Call me where? I'm just at a random phone."

Attending B: "Oh, then I'll page you."

Me: "But do you have my pager num--" [phone is dead]


Me: "Hey, do you have time to see a consult with me?"

Attending C: "No." [hangs up]


Me: "Nobody will see the consult with me! Are you sure you don't have time?"

Attending A: "I can't. But you should make Attending B or C do it. I'm sure they have nothing to do right now."

Me: [sighs] "Okay."


Me: "Do you have time to see a consult with me?"

Attending D: "No, I have two admissions. And don't even bother asking Attending E, because she's in a conference. And Attending F left for the day."

Me: "Oh."

Attending D: "What about Attending A? Or Attending C?"

Yes, the above actually happened to me.

I finally went to where Attending B was seeing a patient and camped outside the room until he was done. He saw the consult with me, which took maybe 15 minutes. I think I spent longer paging every rehab attending in the hospital than it took him to see that consult.

I remember there was one evening when it was like 5:30PM and I got a totally non-urgent rehab consult, and the chairman happened to be right next to me and wanted me to see the patient immediately. His exact words were, "In the real world, when someone asks you to see a consult, you have to say YES." I later wished I had recorded his words, so I could play it back in situations like these.

Friday, June 22, 2012

Fun with Consults, Part 1

In residency, at Staywell Rehab Hospital, we had no dedicated consult resident. So the resident on the least busy inpatient service held the consult pager and was supposed to do the majority of the consults. If the resident holding the consult pager couldn't staff a consult, she was responsible for finding someone who could.

During my last rotation at Staywell Rehab Hospital, the resident holding the consult pager was named Caitlin. I was on an EMG rotation at the time. Caitlin seemed to be chronically busy, and I sort of took pity on her and would let her know if I had some spare time between EMG patients to see a consult, so she wouldn't have to go around begging. But sometimes it just got ridiculous.

Caitlin: "Fizzy, I got two consults today. Can you see them both?"

Me: "Well, the clinic resident Valerie doesn't have any clinic scheduled today, so I'll see one and maybe she can see the other."

Caitlin: "Okay."


Valerie: "Omigod, Caitlin just asked me to see a consult!"

Me: "Yeah....."

Valerie: "I'm taking a STUDY DAY today."

Me: [thinking] "What the hell is a study day? Can I have one of those?"

Valerie: "Why can't Caitlin see the other consult?! She doesn't have any admissions!"

Me: "True."


Caitlin: "Hey Fizzy, Valerie won't see the other consult. She says she's taking a study day. Can you see them both?"

Me: "Is there anyone else who can see the consult?"

Caitlin: "We're all REALLY BUSY."

Me: "Well, I'm kind of busy too. I think the Valerie needs to do it."

Maybe I was in the wrong, but I sort of feel like there's a limit to how nice I'm willing to be.

Of course, there was a big reason we all hated doing consults. Stay tuned for Part 2 tomorrow.

Thursday, June 21, 2012

Why I Didn't Do Dermatology

I've mentioned on this blog before that I had good grades and scores in med school, although not freaking awesome. So it seems like the reason I didn't do dermatology should be obvious: I wasn't freaking awesome. And that's what you need to be to match in derm these days.

But between you and me, I actually did have a possible opportunity to do derm. My cousin is a big cheese dermatologist and assured me multiple times that he'd get me a residency spot if I wanted it. I don't know if this was a true offer, but needless to say, I didn't take him up on it. It was tempting, for sure. Dermatologists make good money and have a great lifestyle. I like procedures and dermatologist get to do lots of those. Part of the reason I didn't try was because of location (yet again), but there were some other reasons:

1) I looked at the people in my class who matched in derm and I thought about those people being my colleagues for the rest of my life, and I felt ill.

2) I felt that as a dermatologist, the pressure to have perfect skin would be too intense, and would cause me to break out.

3) I have a slight inherited tremor in my hands that I worry might get worse with age and keep me from doing really fine work.

4) I didn't like the idea of getting a spot through nepotism. Everything I've ever gotten in my life was earned through my own hard work and it didn't feel right to take a coveted spot just because of connections.

All that aside, I feel angry at the culture of dermatology. When I was in med school, a young girl came to talk to our class about her experience with bullous pemphygoid and how it inspired her to want to be a dermatologist, and all I could think was, "Good luck with that." Here was a person who was genuinely interested in skin conditions, yet she had very little chance of becoming a dermatologist because it's so damn competitive. Your dermatologists don't have a passion for skin, trust me.

I've heard that the number of dermatology spots are intentionally limited, so that it continues to stay competitive and salaries remain high. This is why we have to wait so long to see a dermatologist. Plus a lot of the females who go into the field do it for lifestyle, and the first thing they do after graduating is to cut back to parttime. I can't personally throw stones at that, but it kind of sucks to limit the number people going into a field, when many of those people don't intend to work full time.

In general, I don't think it says anything great about physicians that the most competitive fields are the ones with the highest pay and best lifestyle. But again, can't throw stones.

Wednesday, June 20, 2012

Shake on it

When I was doing Sports clinic during residency, I always entered the room the same way:

First, I knocked. Then without waiting for a response, I opened the door.

Me: "Are you Mr. Jones?"

Patient: "Yes."

Me: "Hi, I'm Dr. Fizzy, I work with Dr. Attending." [holds out hand] "Nice to meet you."

Golly, I was polite.

Anyway, I got in this habit of shaking everyone's hands. However, when I was doing my rehab clinic, I never shook hands. Mostly because a lot of patients had strokes, brain injuries, or spinal cord injuries, and had limited hand use. Have you ever tried to offer a handshake to a high quadriplegic? It's a little awkward, to say the least. Also, a lot of patients brought in several family members and I didn't want to be shaking hands all day.

However, I remember one day in rehab clinic, I saw a patient in the afternoon who was in the room all by herself, albeit sitting in a wheelchair. So without thinking about it, I reached out to shake her hand as I introduced myself.

And she just stared at my hand.

My first instinct was to be totally embarrassed because maybe she couldn't shake my hand. But then she said, "I don't do the hand shaking thing. You've probably shaken a lot of hands today and I don't want your cold and flu germs."

Well, I never! (I did spritz myself with alcohol before entering the room.)

If you want an inkling as to whether or not your patient is crazy, the fact that she won't shake your hand is a pretty good indication. Even if she was right, it's still not a normal thing to do. She also wouldn't let me examine her, because she'd "been examined enough." Fine with me.

When I told my attending she wouldn't shake my hand, he asked me if it was because she thought I had cooties. I had to admit that it was. And she was probably right. *Achoo!*

Tuesday, June 19, 2012

Safe Driving

When I was a resident, there was a hospital that I used to drive to that was a short distance from my house. The fastest and shortest way to get there was to drive past a school. However, I used to be nervous about taking that route, because I noticed there were always a lot of kids hanging around and I was scared of hitting one of them with my car.

So instead I took an alternate route that was about five minutes longer. It was on a four-lane road (two lanes in either direction) where there were a couple of stoplights and cars went about 40 MPH. There were some crosswalks for pedestrians, but I had never actually seen a pedestrian attempting to cross. It seemed safer to me.

One day, I was driving in the rain. I was in the left lane and I noticed the guy next to my right was slowing to a stop. I had very poor visibility of the crosswalk, but long story short, I managed to hit my brakes just seconds before mowing down a guy marching through the crosswalk.

I was shaking. I couldn't believe I almost hit someone on a road I specifically was taking to avoid hitting anyone.

After the guy walked past me, I continued on my way and the guy continued through the crosswalk. Out of the periphery of my vision, I saw another car slam into him and he flew about ten feet in the air.

Lessons learned:

1) From then on, I started driving past the school, because at least then I was expecting people to leap in front of my car.

2) Even though in a court of law, this was likely the fault of the car that hit the pedestrian, when you march into a crosswalk, it's probably better to make sure the car have stopped before you leap in. I used to cross at a crosswalk on my way to work and there was little chance this could have happened to me, because I didn't budge unless there were no cars in sight or the cars were stopped. Yes, it might not technically be your fault. But that wouldn't make you any less paralyzed from the neck down. (Spoken as a true rehab doc.)

Monday, June 18, 2012

Should you go to med school?

A while back, I made a flowchart to help people decide if they should go to medical school. I was really into flowcharts back then. Now I'm really into quizzes.

Should you go to medical school?: A quiz for the indecisive and/or incredibly bored

Because if an internet quiz can't tell you if you should go to med school, then how could you possibly know?

Sunday, June 17, 2012

Chalkboard musings

A friend of mine and I walked into the med student lounge one day and saw the following written on the chalkboard in there:

My friend didn't like the message, so she changed it to:

I wasn't happy with that message, so I changed it to:

Saturday, June 16, 2012

Weekly Whine: Jenny

This is a story about one of the most annoying residents I've ever had to work with. I've been hesitant to post it forever, because I was nervous about Jenny discovering it and realizing I was writing about her. I actually got to like Jenny a lot (later) and I don't want to hurt her feelings. But then I just figured, fuck it, she'll never read this.

Anyway, it gets a little long, but hopefully still entertaining:

I was doing a general rehab clinic rotation with a PGY2 resident named Jenny. I was a PGY3 but I hadn't done this clinic before, so it was both of our first times in the clinic.

Jenny was slow. Very slow. In general, I would see twice as many patients as she did. So if 9 patients were scheduled, I would see 6 and she would see 3. But okay, she was a year behind me, so I could sort of sympathize with her not being as fast as me.

Except what really bothered me was things like this: one day, when I got out from seeing my fifth patient with the attending (while she had only seen three), there was a new chart (for the final patient of the day) waiting in the bin, yet Jenny was just sitting there. She was totally done with her work, but she was making no move to see this final patient.

After I finished up the paperwork on my fifth patient, I said to Jenny, "Um, are you going to see that patient? Or should I see him?"

Jenny said, "Oh, whatever." Then she turned away. With the attending in the room, mind you!

I was like fuck this. I just went and saw the patient since they seemed easy anyway (which they were). But that was seriously rude. It's one thing if she's just slow, but to intentionally not see a patient that's waiting in order to make me see it? Lame.

She also tried to see a patient out of order because that patient had a smaller chart. At the time, I thought it was an honest mistake, but then later I wasn't sure.

She would consistently arrive late to clinic. Not very late, but never on time. Clinic started at 8:30 with two patients scheduled and she'd usually stroll in at 8:40 or 8:45.

On one occasion, I had already seen the first patient and staffed the case by 9AM. I was finishing up the scripts for the patient when I saw that our other 8:30 patient was just first being roomed (he was late due to a language barrier and having no insurance). My attending was in the room and was freaking out a little due to having to catch a plane after clinic.

I looked over at Jenny, who was on the phone with some attending from the wards, for some inexplicable reason. (She hasn't worked on the wards in two months.) My attending kept looking at her and grumbling, "What are they still doing on the phone??" Finally, I just went ahead and saw the second patient too.

I finished up with the second patient quickly and staffed him as well, and the nurse put out a THIRD chart to be seen. Jenny was STILL on the phone. I was looking at that chart and thinking, "You've got to be kidding me. I'm not seeing three patients before she even sees one! Does she want me to see this entire clinic by myself??" Finally, Jenny got off the phone and actually saw a patient.

Then at 11AM, she did something identical, except she was on the phone with her car insurance company. She didn't finish up with the 11AM patient until nearly noon and she claimed it was because they didn't room the patient till 11:20, except that I saw them put two charts out at 11 and I took one.

One reason Jenny was so slow was that she didn't write directly on the patient notes. She made notes on a scrap paper or in her head, then wrote the note after she left the room. It took for freaking ever.

And god forbid she got a patient with psychiatric issues. A patient with PSYCH PROBLEMS??? OMG, that means you can't see ANY MORE patients for the entire rest of clinic. When she saw 2 patients and I saw 7, I really wanted to strangle her.

After I had just seen two patients in a row while she was still working on her new patient with OMG PSYCH PROBLEMS (and she was just working on the NOTE--she was completely done seeing the patient), I came out of the room with what I thought would be my final patient of the day. I came out to see the chart for the last clinic patient just sitting in the bin while Jenny was STILL writing her goddamn note. I was completely shocked. Well, not that shocked, considering Jenny has pulled this shit multiple times before.

I was going to ask her if she planned to see the patient or if she just wanted me to do the entire clinic while she wrote one note. Then I looked over his shoulder and saw that her note on the new patient wasn't even halfway filled in! I was just like, Fuck it, and I saw the last patient. Just because Jenny was slow as ass, that didn't mean the attending should get punished and have to stay there forever.

But I was kind of passive aggressive about it and slammed the door.

The best part is that I finished seeing the final patient and came out, and she was STILL writing her note and not even close to done.

Jenny and I used to go to the main hospital together for lunch. I would have to drag her back because we'd have 3-4 patients scheduled at 1 and she'd only start to get up to leave at 1:15 if left to her own devices. I was so pissed off when she proudly announced to the table (including an attending) that she'd often shows up 30-45 minutes late for clinic. But that usually there wasn't a patient waiting. Why oh why could that be??? Possibly because *I* always got stuck seeing the first patient because she wasn't there??? I was nice enough not to say that in front of the attending.

And then, just as I'm practically physically pulling him out of her seat...

Jenny: "Wait, just one second..." [turns to attending] "Dr. S, what books would you recommend for physiatry residency?"

I swear, I thought she was teasing me or something. But she wasn't.

On another occasion, I had a bad cold, but still showed up to work (of course). As usual, Jenny showed up half an hour late, forcing me to take the first patient as usual. She did seem to have picked up speed slightly. I was only one patient ahead of her at about 11AM. My attending suggested Jenny might "pick up the slack" in clinic because I was sick, a statement which caused me to laugh.

So I had a new patient to present and see with the attending. Jenny and the attending had just finished seeing her patient, so Jenny was "next up" for a patient, and there was a patient chart sitting in the bin. But instead of seeing the waiting patient, Jenny decided to dictate her last patient (we dictated all new patients).

I was a little annoyed because I would never start dictating if a patient was waiting, but I figured it was the second to last patient and we were roughly on schedule. So I went with the attending to see my patient.

We came out of the room with my patient and Jenny was STILL dictating and the patient chart was still waiting. I fingered the chart and looked up at my attending, "Well, it's her turn, but I hate to keep the patient waiting, so maybe I'll just go ahead and see this guy."

"No, it's HER turn!" the attending said. "And this is a really difficult patient with a lot of psych issues. I mean, you can see him if you really want, but it's Jenny's turn."

So with the attending's blessing, I instead decided to go ahead and dictate my last patient.

I finished my dictation. Jenny was still only on the physical exam portion of her dictation.

I went to go to the bathroom and clear out some phlegm from my throat. I came back about five minutes later and Jenny was still dictating.

At this point, the nurse put out another patient chart, so I decided to go ahead and see the "crazy" patient.

See, the thing about Jenny was she acted like she was being a better clinician because she was so "careful," but at least I cared enough about the patients not to make them sit there and wait forever.

At the end of the first month, Jenny officially crossed a line.

Once again, she started dictating a new patient while there was a patient outside that was waiting to be seen. The attending actually tapped her on the shoulder and said, "Hey, there's a patient waiting." And Jenny just continued (slowly) dictating.

There was another junior resident who was in the room and the other resident's jaw dropped open. That resident later told me he couldn't believe the way Jenny was acting. I felt vindicated.

I felt sorry for the attending in all this. He was one of my favorite attendings and he had to stay later because Jenny did her dictations between patients rather than at the end of the day. I picked up the waiting patient's chart and said, "I can see the patient. It's really not a big deal."

"No, it's okay, it's not your turn," the attending said. "But it's been duly noted that you offered."

Don't think I allowed this all to take place without saying a word. I politely talked to Jenny several times about needing to pick up her speed. I had a talk with her about note-writing, because I still kept seeing her coming out of patients' rooms with blank notes. I said, "It's okay, you can write the note while talking to the patient! It's okay!" She was resistent.

She told me in some previous family med clinic she did, she wrote all the notes from scratch at the end of the day. I asked her how she remembered enough to write a decent note. She said, "Well, it's family med."


Then one day, a miracle happened:

I got back from lunch at a few minutes after 1, and I saw that one of the 1PM patients had already been roomed. But for some reason, their chart wasn't out. I was really perplexed. I started looking all over for the chart and finally asked the nurse what happened to it.

As it turned out, Jenny actually showed up on time to the clinic and was seeing the patient when I arrived! This had never once happened before, which is why it didn't even occur to me. I was more ready to believe that the chart vanished into thin air.

After that, things were a little better.

And Jenny, if you're reading this: I love you, girl, but you know you did all those things!

Thursday, June 14, 2012

My First Call

My first call as an intern began at 7:30AM. I started out feeling optimistic, even sort of looking forward to it. Ha.

My spirits started to fall when I got my first admission of the night. It was a Russian-speaking guy on dialysis who had chest pain and shortness of breath. Because he spoke no English at all, we called for the translator, who took about an hour to show up.

Me: “How are you feeling, sir?”

Russian patient: [string of Russian]

Me: “What did he say?”

Translator: “I don’t know.”

Russian patient: “Nyet!”

Apparently, because he didn’t have his false teeth, he had become unintelligible and even the translator couldn’t understand him. It was kind of a challenging situation. We got him into dialysis and hoped for the best.

My second patient of the night was a homeless, alcoholic, heroin addict with hepatitis C. He also had chest pain and shortness of breath. I noticed when I was examining him that he had a heart murmur, which I mentioned when I presented my H&P to my resident Susan. She went in to examine him herself:

Susan [accusingly]: “OH MY GOD, this guy has a HUGE systolic ejection murmur.”

Me: “Yeah, I mentioned—”

Susan: “This is the LOUDEST MURMUR I’VE EVER HEARD. You could hear it in the hallway.”

I got another patient at that point, a diabetic guy with diplopia (double vision). After examining the patient, I decided that he had a lateral rectus muscle palsy, probably caused by an infarct to the sixth cranial nerve. I thought I was totally clever figuring out the diagnosis and started feeling somewhat confident in myself.

Me: “I think the patient has a cranial nerve VI palsy.”

Susan: “Yeah, that’s REALLY OBVIOUS.”

I admitted one more patient, which gave me a total of four for the night. The other intern only admitted two patients and the sub-intern admitted two, but I didn’t get any chance to pat myself on the back, thanks to continual disparaging remarks from Susan.

Susan: “Man, I am so tired. I forgot what it was like not to get sleep during call.”

Me: “You usually get sleep during call?”

Susan: “The interns I had before you were really good.”

Well, gee, thanks. It was only my second freaking day.

My confidence dropped to about zero at some point during the night. I kept getting paged about questions on my patients that I had no idea how to answer. I knew they were easy questions, but I just didn’t know the answers. I kept paging Susan to ask her, and I could tell she wasn’t happy with me. It got to a point where if the question wasn't all that important, I just made something up. Some questions I got:

"Doctor, your patient's blood sugar is 62 but she's NPO for a biopsy. What should we do?" Uh....

"Doctor, your patient's blood sugar is 405. What should we do?" Uh....

"Doctor, your patient's BP is up to 195/82. Do you want to do something about that?" Uh....

"Doctor, you wrote for an ADA diet, but you didn't say how many calories. How many calories do you want?" Uh....

By around 3AM, I wanted to strangle anyone who called me "Doctor." I still felt ridiculous returning my pages as "Dr. McFizz" and it also felt ridiculous that nurses who knew about 100 times as much as I did kept saying, "Doctor, what do you want me to do?" (If you are a nurse reading this, please just tell the poor interns on their first call what to do. You know that you know.)

I found some comfort in eating massive amounts of junk food. During the call, I ate a big bag of Doritos, cracker jacks, gummy worms, and a giant bottle of Coca Cola. I felt sickened by how much junk I ate. Yet the moment of putting the food into my mouth gave me just a tiny jolt of pleasure in my otherwise miserable existence.

At about 5ish AM, we finished our admissions for the night. I hadn’t slept at all but I was oddly awake. It was probably all the adrenaline.

Susan: “We’ve got some time before you need to pre-round. Why don’t you go sleep for an hour?”

Me: “Nah, I’m sure my pager will go off and just wake me up right away.”

Susan: “If you have an opportunity to sleep, you should take it.”

So I set off trying to find the call rooms. They were in some hidden, undisclosed location, and I failed to find them. I finally went to the resident lounge and lay down on the couch. I dozed off eventually and woke up about two minutes later when my pager went off.

I may not have felt tired, but my brain was definitely sluggish. When Susan asked me to order a transthoracic echo (TTE) on a patient, I went to the file cabinet of forms to order the echo.

Me [opening file cabinet] “What the hell was I looking for again?”

I checked my notes and remembered I was looking for the echo form.

Me: [after searching for a couple of minutes] “Damn, what was I looking for again?”

I did eventually, miraculously find the form. Of course, it couldn’t be that easy. I couldn't figure out what box to check to just get a normal TTE. The options seemed to all be words I didn’t understand. I checked the wrong box, naturally, and when Susan found out, she acted like I was the biggest idiot in the world. I maintain, years later, that there was no way for me to have figured out how to fill out that form on my own.

My organization paid off somewhat. I made checklists of everything, so I couldn't forget to do anything. Our attending even commented that I was very organized. Of course, I was a little jealous of everyone who seemed to remember everything about their patients on zero sleep and no checklists. My co-intern never wrote anything down. I don’t even think he had a pen.

I managed to get out of the hospital by 1:30 (30 hours), which was a bit of a miracle. The cross cover sign-out guy was really nice and he was like, "Go home! Enjoy your night and get some sleep!"

Wednesday, June 13, 2012

Father's Day Gift

What should you get Dad for Father's Day?

You've already gotten him a tie for the last twenty years, so that's out.

Oh, I know!

Get him a copy of A Cartoon Guide, which is 20% off on Lulu until June 15! (Used code CRACKED)

WTF pages

11PM urgent page:

Nurse: "Doctor, respiratory therapy was just in patient Ms. Smith's room and...."

Resident: "What's wrong? Is her O2 sat dropping? Is she in respiratory distress??"

Nurse: "No, she told the respiratory therapist that her boyfriend was abusing her at home!"

Okay, aside from the fact that everyone on the service knew that this patient was being abused by her boyfriend, is this really something that you need to page the on call physician about late at night??

I don't mean to be unsympathetic to the plight of abused women, but seriously.

Tuesday, June 12, 2012

Condom Catheters

A lot of stroke, brain injury, and spinal cord injury patients have problems with incontinence. For men, they have the option of using something called a condom catheter, which is basically an external catheter over the penis that catches urine, which drains into a tube then into a bag.

During residency, one of my patients was being discharged, so I had to order him a supply of 60 condom catheters. But I wasn't sure how to do this. My attending suggested I order it through Prosthetics, so I tried that.

A day later, I got a call from Prosthetics, where they laughed at me for trying to order condom catheters from Prosthetics. They told me to order it through the pharmacy. So I did.

Long story short, the next day, 60 boxes of Trojan condoms arrived on the ward.

The nurses found this hilarious. I came to the ward and they were all holding boxes of condoms and giggling. I called the pharmacy to try to straighten this out. I had to go through three explanations of what happened before someone could actually help me. I have this feeling they were just passing the phone around, saying, "You've got to hear this story..."

Me: "I was trying to order 60 condom catheters for my patient, but the pharmacy sent us 60 boxes of condoms."

Pharmacist: "Well, some people make their own condom catheters out of condoms...."

Me: "Um, maybe you should transfer me again..."

Finally, I reached someone who knew how to put in the order for condom catheters. Except they left out the spermicide. (Just kidding.)

Monday, June 11, 2012

The Antz Theory

I have this theory about call nights that I like to call The Antz Theory.

Remember that movie Antz? Remember how it came out at exactly the same time as that other movie A Bug’s Life? I remember it because there were like two movies from the point of view of bugs like EVER, and they both came out the same week.

And then there was that movie Armageddon, about the comet hitting earth. And then like a week later Deep Impact came out, also about a comet hitting earth. And then there was never another movie about a comet hitting earth ever again?

Well, call is kind of like that too.

On one call night, you’ll have four admissions, all with massive ascites and peritonitis. Then you’ll never have another patient like that for the rest of the month. Or you’ll get five admits with chest pain on one call and none on your next. Or if there’s some weird cancer you’ve never heard of, you’ll get two patients with that cancer on the same night.

I don’t know why this would be true, but I noticed it persistently through my whole career.

Anyway, what I’m really trying to say here is that Armageddon sucked. I hate Ben Affleck.

Sunday, June 10, 2012

Nosy McNoserson

Yesterday I was at a little fair with my mother and my daughter. There was a longish line for food so my mother got in line while my daughter and I went over to the chalkboard menu at the front of the line to pick out what she wanted.

While we were picking out food from the menu, this woman says to us, "Hey, you're not in line, you know."

"Yes, I know," I said.

"If you want to get food, you should get in line," she pointed out.

Gee, thanks for the tip.

"The line's not getting any shorter, you know," she added, giving the person behind her a look like she thought I was an idiot.

I thought maybe she was trying to be helpful with the first comment. But I could have done without the second two and the patronizing tone.

Saturday, June 9, 2012

Weekly Whine: YES

When I was a medical student, I was examining a patient who had a stroke with left neglect. As part of the exam, I showed him something I had written on a piece of paper and asked him to read it.

The patient read, "YES."

What the paper actually said: "CLOSE YOUR EYES"

The patient neglected the left side of the sentence and only read the last three letters, which happened to be an actual word in itself. Sort of fascinating from a neurological point of view.

I feel like this happens a lot on the internet. People will read something you write, pick out a quarter of a sentence they don't like, and freak out on you. For example, take the following cartoon I drew:

When it was posted on KevinMD, one woman got upset because she took it as offensive to stay at home moms. That in the cartoon, I was making a negative statement about SAHMs. Except I was in no way, shape, or form did I mean anything like that. I think if you read the whole cartoon and don't have a chip on your shoulder, that's completely obvious. But if you only look at that one panel and are sensitive about being a SAHM, then I can't definitely see how it might set you off.

Basically, when someone gets offended over something benign, it just makes me think less of them.

Friday, June 8, 2012

Oldest Premie Ever

Looking for an 80 year old stroke patient I was supposed to do a consult on...

Me: "I can't find the patient. Is he still on this floor?"

Nurse: "Oh, he was transferred to the NICU."

Me: "!!!"

Apparently, in some hospitals, the NICU stands for the North ICU (or Neuro ICU).

Thursday, June 7, 2012

Please keep your voice down...

A conversation I overheard on the ward between our very loud urology consultant and, I guess, the mother of one of his patients:






Nurse: "Oh my god, he is really loud."

Wednesday, June 6, 2012

You're hot and you're cold

My BMI is currently at a new low of 18 (normal is 20 to 25), which means I don't have much fat padding my arms anymore. (Must be all that damn fast food, eh?) It's not such a bad thing with summer approaching, but it means I am always freezing.

I came into a meeting this morning and I noticed the A/C was on. I was wearing a sweater (I always wear a sweater), but the sleeves were only 3/4 length, and my arms below that point where covered in goosebumps. I was really freezing, teeth chattering, hugging chest for warmth... you get the idea. Finally, I couldn't stand it anymore, so I went over and shut the A/C off. I still was cold, but not painfully so.

About five minutes later, a social worker came in and said, "Oh my god, this room is like an oven." She then cranked up the A/C again to full power.

It seems odd to me that one person could say a room is like an oven while I could be shivering and covered in goosebumps. The social worker says I'll get it when I go into menopause.

In that situation, who should get preference? I say the cold person should! It's more painful to be cold than hot, in my opinion.

Monday, June 4, 2012

More afraid of you than you are of them

During my third year psychiatry clerkship, I had a bipolar patient who physically abused his wife. My classmate Maya had previously worked in domestic abuse situations and I decided to get her advice.

Me: “I’m not really sure how to approach this patient. He’s potentially violent.”

Maya: “Well, tell me more about him.”

Jake (class gunner): “The most important thing is to talk in a calm, quiet voice.”

Maya: “Excuse me, but what experience do you have with this?”

Jake: “I’ve done tons of hiking and I know all about how to approach dangerous animals like bears.”

Maya: “Bears?”

Jake: “I also trained people to deal with bears in the wilderness. I think a lot of the same principles apply.”

Maya: “People are not bears.”

Jake: “Actually, there are a lot of similarities.”

Maya: “You know what? You can talk to Fizzy because I know you don’t know what you’re talking about.”

Jake: “Also, don’t climb a tree.”

(OK, he didn’t actually say that last part.)

Sunday, June 3, 2012

Weekly Whine: Sorry

I'm sorry.

Now what's so damn hard about that?

It pisses me off when people won't apologize. Usually someone won't apologize because they believe they're in the right, so why would they apologize?

In high school, there's always one kid in the class who thinks he knows everything and won't shut up. (Sorry to use the male pronoun, but let's face it, it's a guy.) In my 10th grade English class, that kid was a guy named Eric.

One day, he got in an argument/discussion with a girl in the class named Amy. I can't remember the argument, but it finally concluded when Eric got frustrated with Amy and said, "You are the dumbest girl I have ever met in my life."

And Amy ran out of the room crying.

Honestly, I don't remember thinking Eric was wrong in his argument. And I do actually sort of remember thinking that Amy seemed pretty dumb. But what I do remember is this:

Eric refused to apologize.

He couldn't really do that, because he would have gotten in trouble. But when Amy returned to the class, you could see him squirming his way out of genuinely apologizing. Despite being an ass and hurting Amy's feelings, he didn't believe he should apologize. He just said something like, "People shouldn't say things like I just said, so apologizing shouldn't even be an issue." Guh?

If you hurt someone's feelings, just SAY YOU'RE SORRY. Really, what's so goddamn hard about that?

Of course, he was only fifteen. I see adults who do this all the time. I think the world would be a better place if people were more willing to say they're sorry.

Saturday, June 2, 2012

It is what it is

Husband: "I don't know. It is what it is."

Me: "I hate that expression. What does that even mean??"

Husband: "It means it is what it is."

Me: "Ugh!"

I don't know when I started hating that expression so much. I think it's when they started saying it all the time on reality shows. What does it mean??

Friday, June 1, 2012

DO Discrimination

Because I am in PM&R, people often ask me if I am an MD or a DO. For the record, I am an MD. But I do have equal respect for DOs.

Before I went to med school, I actually didn't even know what a DO (Doctor of Osteopathy) was. According to Wikipedia (the source of all information on this planet):

Osteopathy and osteopathic medicine are terms often used interchangeably for the philosophy and system of alternative medical practice first proposed by A. T. Still MD in 1874. Its practitioners are known as osteopaths. It emphasizes the interrelationship between structure and function of the body and recognizes the body's ability to heal itself; it is the role of the osteopathic practitioner to facilitate that process.

You can't see me right now, but I'm making the little jerk off motion.

Do I think osteopathic medicine is a little bullshit? Uh, yeah. So do most DOs. Most of them will admit to you they think it's bullshit. On my peds rotation in med school, most of the residents were DOs, and I remember there was some patient who was having a pain issue, and the chief (a DO) joked, "Hey, maybe we should do an osteopathic manipulation on him?" And everybody laughed and laughed.

Let's face it, most of the people who go to DO school do it because they don't have the grades for an MD school.

That said, I think many DOs are fantastic doctors, perhaps because your abilities in organic chemistry don't actually predict what kind of doctor you'll be. In general, I've found DOs to have a great bedside manner. And in my field, I think they come to residency with better physical exam skills. Some of the best doctors I've known have been DOs.

Because of the strong physical component to PM&R, people will ask on SDN if they should get an MD or DO. The answer is, if you can, get an MD. Unfortunately, DO discrimination is rampant and will close a lot of doors for you. For example, my own mother refuses to see a DO, even though I tell her they're just as good as MDs.

I remember in my PGY4 year, I worked with a med student who was really amazing. She was the best student I had worked with. She was enthusiastic but not overly so, had a great personality, was intelligent and willing to learn, and she spent her weekend helping us work a race. I wrote an email to the program director telling him how fantastic she was in order to make sure she got ranked highly.

I think she ended up getting ranked third or fourth on our list. As a result, I got to witness a tantrum by an attending (who who worked with her and knew she was awesome), saying, "How could a DO be so high on the rank list?? I know she's good, but she's a DO!"

By writing this, I suppose I'm putting myself at risk for some wrathful comments from DOs. But if you read the entire post and not just react to a single sentence, you should realize that I have tremendous respect for DOs. And if you're in the field, I'm sure you know it can be an uphill battle. (The same could be said of my specialty, so I can certainly relate.)