Suspicious?

I had a patient in urgent care a while back with a possible foot fracture. He told me that he slipped in the bathroom at home. Fair enough. The weird thing was that his BOSS brought him in to the urgent care clinic. Doesn't that sound a little fishy? I've had decent relationships with previous bosses I've had, but that seems above and beyond the scope of the boss-employee relationship.

As I see it, there are 2 possibilities:

1) The patient was sleeping with his boss as a shortcut to climbing the corporate rungs (less likely)

2) The guy actually slipped while at work and the boss was trying to avoid this turning into a workman's comp issue (more likely)

I suppose it's also possible the guy was telling the truth and he just had a really good relationship with his boss. But I tend to be skeptical of anything that any patient says.

Dr. Orthochick: Trauma patient

The trauma resident paged me around 4AM on Sunday morning and said "there's a pelvis fracture in the ER, Dr. Tenens*** said he's not going admit her and you have to."

OK then.

I went down to the trauma unit to talk to the resident and asked what the heck that was about. He said that the pelvis fracture had been transferred from an outside hospital and Dr. Tenens was really pissed that they assumed he was going to admit, so he decided he wanted nothing to do with it and he wanted ortho to admit her.

See, I have no problem with admitting a pelvis fracture if it's an isolated injury and I'm not worried the patient is bleeding out anywhere. My issue was, Dr. Tenens was pissed about someone forcing him to do an admission so he decided to, uh, force me to do an admission.

I walked down to the ER to see the patient and I examined her and decided she just had an isolated pelvis injury, it wasn't open, she wasn't bleeding, but she was going to need surgery. That being said, I still didn't think it was fair that Dr. Tenens was being a jerk about all this so I paged him and he called me back.

Me: Hi, it's orthochick
Dr. Tenens: [yelling into the phone and by extension, my ear] Are you seeing that pelvis? You better admit her. It's the only injury and it's absolute bulls*** that they expect me to use precious ICU beds when we're short enough! I don't know why they can't talk about this with ortho and just have you guys admit! Do you know what a waste of my time all this was?

And at that point, I made the mature adult decision that this wasn't worth a fight and I should just start filling out my admission paperwork. I was actually sort of proud of myself for that one.

Me: OK, sounds good. I just wanted to make sure we're on the same page about it.
Dr. Tenens: [pause] Oh. So you'll admit?
Me: Yup. She has an isolated pelvis fracture.
Dr. Tenens: Oh. So...you don't need help with anything?
Me: She has no significant medical or surgical history and she is presenting with an isolated fracture with hemodynamic stability. I'm fine.
Dr. Tenens: Oh. So you can handle everything? Do you want us to stay on as consultants?
Me: I can definitely handle everything from here myself. Thanks!
Dr. Tenens: Well...thanks.
Me: See ya later
Dr. Tenens: Do you want me to admit her and then transfer her to your service later after a thorough workup?
Me: Nah, you don't have to do that. She doesn't need any more of a workup.
Dr. Tenens: Well, thanks, Orthochick. Let me know if you need help with anything. Anything.

I guess you really do get more with honey than you do with vinegar. After all that, I probably should have made him admit.

(Also, I must really have a well-deserved reputation as a firecracker if Dr. Tenens was so surprised that I didn't put up a fight. I can only hope this means I'm getting better at picking my battles)

I think Dr. Tenens felt bad about yelling at me because I was walking through the trauma unit a little later and he stopped me and said he wanted to show me a CT scan he thought I would appreciate. Pretty sure that's the attending way of apologizing, because I can't think of why else he would show me a CT scan of a skull fracture. But OK, it was a cool CT scan, we started talking and eventually decided to work on a research project, and really, it's probably a good thing I didn't fight this one.

***The trauma attending

Helpful

So I got a page yesterday evening. Since it was Sunday, I am not really obligated to answer, but I decided to risk it.

Pager: "Hi, this is the renal fellow. Are you familiar with a patient named [Patient I Never Heard Of]?"

Me: "No."

Pager: "You don't know anything about [Patient I Never Heard Of]?"

Me: "No, sorry."

Pager: "Well, [Patient I Never Heard Of] never showed up to dialysis today and we've been looking for him. We've been calling everywhere. Do you know how we might find him?"

Me: "No."

Pager: "Oh."

Me: "Sorry I can't be more helpful."

I guess he was just going through a list of everyone who worked at the hospital and paging them one by one?

Weekly Whine: Belts

It seems like more and more, my belts are all ending up breaking in half at my most used notch, like this:



So I went shopping for some belts. Except it seems like every belt is completely ostentatious and ridiculous. For example:



I certainly couldn't wear that to work. I wouldn't even want to wear it in public. Or for that matter, walk around with a giant MK on my belt:



Are there any belts out there for normal human beings???

Transplant

I did a month of inpatient renal in med school and we saw a ton of transplant patients. And one thing that was obvious was that people who got kidneys from living relatives always did much better than those who got them from cadavers.

We saw a few patients who got kidneys from their kids, and I have to say, I always deeply disapproved of that. Giving up a kidney is not without its significant risks, and I'd rather be on dialysis or even die than ever allow my kids to risk their health for me. I feel like that's the natural order of things.

Dr. Orthochick: When EMR goes bad

So in our EMR, you can just copy and paste the note you wrote from the previous day and add or subtract as needed. Which means it takes 3 seconds to write a note, because generally not much changes over the course of the day. The downside to this is, if I want to read someone else's note, I'm stuck sifting through three weeks of respiratory culture results and discontinued pain meds until I actually get to the "plan" section, because all of that stuff carries over. Plus when the note is copy-pasted, I get the feeling no one else can find the stupid plan either, including the person writing the note, because it is not particularly helpful since it doesn't get updated all that often. Don't get me wrong, I love being able to see what everyone else is writing from my computer at home, but I would love it even more if reading all this gave me some grasp on the overall plan for the patient, instead of 5 days worth of sodium values.

Anyway, the other day I got paged down to the ER at 4AM to evaluate a lady who was having arm swelling and numbness after falling. I had pretty low suspicion for compartment syndrome but I had no idea what it actually was, so I checked her compartment pressures, they were normal, and I discharged her with a prescription for Norco. As luck would have it, she came back, (again while I was on call) and I still didn't know what was wrong, except by this point she was also having numbness and tingling in the other hand as well. I did a CT of her cervical spine (normal) and then gave up. She got admitted to internal med, I wrote a note saying I had no idea what she had but it wasn't a surgical problem.

I was on call on Wednesday and I got paged to do a consult. I spoke to the consulting physician and it turned out it was for the same patient during the same hospitalization.

Me: I've already seen her. Twice. We didn't really know what she had, but it didn't seem like a surgical problem since her nerve symptoms were diffuse and she didn't have compartment syndrome or a drainable hematoma or something like that.
Internal med doc: Oh, I'm sorry. I didn't realize Hand Surgery had already seen her.
Me: If you want, I can see her again to see if anything's changed.
Internal Med Doc: No, you don't have to do that if you've already seen her. I don't think anything's changed.

See, the thing is, everyone's note, from the initial internal med doc who saw the patient 4 days before that to the internal med doc who consulted me, contains the phrase (and I quote):

"Hand surgery has evaluated the patient and feels no surgery is indicated. Appreciate hand surgery input."

Seriously people, you don't have to read my note, but you could at least read your own. I'm sure that was just carried forward from the last guy to write a note, and I know it's a pain to write your own note, but I'm not going to be too impressed if your own note acknowledges that I've already seen the patient you consulted me on.

I'm not saying the EMR is a bad idea, because I think it has a lot of potential, but I'm not sure it's working out quite the way it's supposed to. There's no point in having easier access to records if we're not reading them to figure out what they're saying.

Med student syndrome

Weekly Whine: Charity

We donate a fair amount of money to charities, mostly picked and doled out by my husband. He's been doing this for years, and as such, he's gotten himself on a lot of lists. Once you donate, I guess your name gets passed on (sold?) to all the other related charities.

The other day, I walked in on him practically yelling at someone on the phone. Apparently, some charity he'd given to was calling him frequently and repeatedly to harass him for more money, and he'd finally lost his patience.

I mean, here he is, doing this nice thing, and he got punished for it.

Doesn't make you feel very charitable.

Goodnight pager

So at around noon a while back, I walked onto the ward and a nurse said she had been paging me for the last hour. I checked my pager and discovered that somehow it had turned itself off! I checked it to try to figure out what had happened. Needless to say, it was a little unsettling.

Later that day, I was complaining to my husband about this:

Me: "For some reason, my pager turned itself off."

Husband: "Oh yeah, I turned it off last night."

Me: "!!!"

Husband: "Well, it was beeping."

I love you, honey! Happy Valentine's Day!

Adjectives

I was just thinking of what 5 adjectives people I work with would most likely use to describe me. This is what I came up with, based on what I've heard:

1. Curly-haired

2. Calm

3. Nice

4. Conscientious (OK, anal)

5. Little


How about you? What 5 adjectives would people use to describe you?

Dr. Orthochick: Unknown

Dr. Critical: So what do you think he has?
Me: I don't know
Dr. Critical: So what do you want to do about it?
Me: I don't know because I don't know what he has
Dr. Critical: Well, what would you do if you were the attending?
Me: It seems like a legit complaint so I'd probably refer to a foot&ankle specialist
Dr. Critical: OK, smartass. What if you were the foot and ankle specialist?
Me: Then I'd probably know what he has.

I really don't think my answers were unreasonable there.

I'm not saying the patient didn't have a problem, but I have no idea what it was. And, as any good orthochick who has completed the PGY-2 or greater level of training will tell you, if you don't know what something is, the wrong answer is to order more imaging studies. You don't order an MRI to give you a diagnosis, you order one to confirm your diagnosis. I learned a while ago, if you don't know what you're looking for, don't go looking for it.

Also, Dr. Critical had no idea what the patient had either. My guess was "sinus tarsi syndrome" he said that was a crap diagnosis but he didn't have anything better, and the whole thing was sort of a wash.

Dictation errors

What was transcribed:

"This gentleman is 51 years old and works as live diarrhea and used to be a teacher."

What was said:

"This gentleman is 51 years old and works as a librarian, and he used to be a teacher."

Weekly Whine: Acronyms

What's up with people who have like 4-5 acronyms listed after their name?

I was watching a CME lately, and one of the speakers literally had five acronyms after his name. What is the point of that other than to seem important? Plus, does anyone know what any of those acronyms actually stand for?

For example, one of them was FAPWCA, which I couldn't even figure out through googling.

What cool stuff do physiatrists do?

People are always asking me exactly what physiatrists (PM&R docs) do. Well, here's a list of some of the cool stuff we get to do:

1) EMGs

I've done EMGs to diagnose everything from carpal tunnel to ALS.

2) Fluoroscopic injections for pain

We get to go into the fluoro lab and do steroid injections to the back, hip, neck, etc. They're fun to do AND they make you glow in the dark!

3) Botox/Phenol blocks

We do botulinum toxin injections in muscles to reduce spasticity. And if they're a little left over, we might do your forehead too.

4) Musculoskeletal ultrasound

OK, this is a new one and not that many physiatrists do it yet, but we're getting there. Msk US can be used to diagnose rotator cuff tears, carpal tunnel, and guide injections. And after we're done with that, we can put the probe on your belly and see if there's a reason you've been throwing up every morning.

5) Steroid injections, et al. (Or Synvisc, PRP, etc)

We inject pretty much everything in the office. I'm most comfortable with knees and shoulders, but we do elbows, trigger fingers, IT bands, you name it. If I can find it in my injection handbook, I'll do it!

Inappropriate ads

This was the ad that was deemed appropriate for a little kids' game, where you pop bubbles with numbers on them:



WTF?

Dr. Orthochick: Rings

I recently had a hand consult from the ICU for a lady who fell when she had a heart attack and broke her wrist.

Nurse: Are you going in to see her?
Me: Yeah
Nurse: I'll go in with you.

Bad sign right there, folks.

Anyway, the patient said someone had told her that while she was in the hospital, she shouldn't do anything she wasn't comfortable with. So far this had extended to any cardiac procedures, medications, x-rays, or breathing treatments. I fully believe in patient autonomy and with very few exceptions (TB, meningitis) no, I don't think care should be forced on anyone, but if you're going to refuse everything anyway, why bother going to the hospital?

I was not the exception.

Me: So you broke your wrist blah, blah, blah...would you mind taking off your rings?
Patient: I'm not taking off my rings
Me: Well, I worry your hand is going to swell and then your rings will cut off circulation to your fingers. Would you like me to help you take them off?
Patient: No, you can't take them off me.
Nurse: I can take them off you.
Patient: You can't take my rings off! It's going to hurt!
Me: OK, so why don't we give you some pain meds first and then we'll try and if it's hurting you, we'll stop?
Patient: No. You are not taking off my rings. I was told to not do anything I wasn't comfortable with doing and I do not want you to take off my rings.
Nurse: I really think I can do it without hurting you
Patient: I have not taken off my rings in 50 years and I am not doing it now.
Me: The reason I'm asking is because I'm worried they could cut off circulation to your fingers and your finger could die and have to be amputated.
Patient: No one is taking off my rings. It would hurt too much.
Me: Well if you want, we could get a ring cutter and cut them off?
Patient: The only person who can cut off my rings is a jeweler. If you bring a jeweler in here, he can do it the special way. But that is the only way my rings are coming off.
Nurse: We're not bringing in a jeweler. You have two options, either we cut them off or I can get them off without hurting you.
Me: I don't want you to lose a finger.
Patient: You are not a jeweler. [to nurse] You are not a jeweler. The only person who can take my rings off is a jeweler.

...and that is why I will never be a great doctor. Because no, I am not going try and hunt down a jeweler at 10 at night to ask him to please come over to the hospital to cut off a lady's rings. I realize if this was a TV show then that's what I would do, the patient would hug me, and the jeweler would do it for free, but really, my life is not a TV show and the sad truth is, I don't care more than my patients do. If I have explained the risks of losing a finger and offered options and the patient voices understanding of the risks and still declines, then I'm done. I'm not going to move hell and high water to try and save a patient's finger if she's not willing to try a little. I tried calling her son because she said she discussed all major decisions with him, but she didn't know the number and the one in the chart was wrong so I couldn't pursue that one further. I'm not even sure how I would get a hold of a jeweler at night. I can't imagine there's the jeweler on call or something.

I also offered to splint the patient, she said no, we discussed the risks that if her fracture displaced she might need surgery, she still said no, and that was the end of that really aggravating consult. I mean, that's a good half hour of my life I will never get back that was wasted arguing with a patient about taking off her rings and putting on a splint.

(and just in case you're wondering, psychiatry had already seen her and determined that she had capacity and was therefore able to make her own medical decisions and refuse things as she saw fit. So it's not that she was demented and legally if I hold her down and rip off her rings after she's refused, it's battery.)

New Project

In my opinion, there are a lot of funny medical bloggers out there. Am I right?

I've been considering doing a project in which I'd gather humorous stories (at least 500 words) from various medical professionals and publish them as a real book on Amazon. I'd give everyone who contributed something like an Amazon gift card. And I'd donate all profits to Red Cross.

I think it would be a really awesome book.

If I were to do this, would you consider contributing? Or know someone who would? You'd get to see your name in print and get to call yourself a paid author! Plus it's for charity so that can be your good deed for 2014. I can only use so much of my own material and still call it a compilation. I'd love to get lots and lots of different contributors.

It must be:

1) At least 500 words

2) Related in some way to medicine (med, pre-med, nursing, pharm)

3) Funny

4) Well written

Please let me know if you'd like to contribute!

Weekly Whine: Standing

There's a lot of standing in one place that happens during med school third year clerkships. Some of it is understandable, like on surgery rotations, but for the life of me, I can understand why I had to stand for 4-5 hours straight during my medicine rotations.

At the university hospital, rounds would start at 8AM, and we'd walk down the hall over the next four hours, discussing each patient. Some teams would round for six hours. Six hours of essentially standing in place, discussing patients.

I'm sure there's some educational reason why this would be done, but by the end of it, all I could focus on was how much my feet hurt.