Clinic patient. New to me. Looking at past notes.
"Male, 45, cuddly."
Excuse me?
I go in to see him.
Cuddly would not be the word I would use...
But I suppose it puts a more positive spin on "obese"
...
Wednesday, February 29, 2012
Tuesday, February 28, 2012
No more fast food, except twice a day
Patient note: one year ago
Counseled pt on weight loss. He expressed desire to lose weight, said he would stop eating fast food, exercise, consider Weight Watchers and aim to lose 30 pounds. Gave him referral to nutritionist. Pt was motivated, realistic about difficulty of changing habits.
I see the patient again today.
He has gained 35 pounds over the past year.
"Yeah, yeah, the diet lasted like three days. Sorry, doc."
"Don't apologize to me-- apologize to your future self. It's your health I'm concerned about."
"Well, there's been one good thing about the weight gain though."
"Yeah?"
"My brother did, uh, gastric bypass a few months ago. So now he wears my old clothes, and I wear his. It's awesome."
"It's not that awesome."
"I have a whole new wardrobe."
"You really need to lose weight."
"I gave him my old clothes. I can't afford new ones."
"You really need to lose weight."
"I'll stop eating McDonalds for breakfast."
"What do you eat for lunch and dinner?"
"McDonalds."
"That's the problem."
"Not breakfast?"
"That's the problem too."
Counseled pt on weight loss. He expressed desire to lose weight, said he would stop eating fast food, exercise, consider Weight Watchers and aim to lose 30 pounds. Gave him referral to nutritionist. Pt was motivated, realistic about difficulty of changing habits.
I see the patient again today.
He has gained 35 pounds over the past year.
"Yeah, yeah, the diet lasted like three days. Sorry, doc."
"Don't apologize to me-- apologize to your future self. It's your health I'm concerned about."
"Well, there's been one good thing about the weight gain though."
"Yeah?"
"My brother did, uh, gastric bypass a few months ago. So now he wears my old clothes, and I wear his. It's awesome."
"It's not that awesome."
"I have a whole new wardrobe."
"You really need to lose weight."
"I gave him my old clothes. I can't afford new ones."
"You really need to lose weight."
"I'll stop eating McDonalds for breakfast."
"What do you eat for lunch and dinner?"
"McDonalds."
"That's the problem."
"Not breakfast?"
"That's the problem too."
Monday, February 27, 2012
Oh, just one more clinic patient
"Doc, I know it's 5:00, but can you just see one more clinic patient? One of the interns is overbooked. This one's easy, she's just complaining of leg pain, no other problems, shouldn't take long."
"Uh, yeah, I guess. Sure, if it's a quick one."
"Definitely. Just leg pain."
I knock on the exam room and walk in.
The patient is in a wheelchair.
Both of her legs, amputated.
"You're here for..."
"No English..."
I call the translator phone.
"You're here for..."
"Leg pain."
"Your legs are..."
"Oh, yes. Pain where they used to be. Also, I may be pregnant. And I have a lump in my right breast. And a persistent cough. And night sweats. And panic attacks. And a mysterious sore on my genitals. And no feeling in my left hand. And I was hoping for a sleeping pill. And some allergy medicine. And I've never had any vaccinations. And a rabid raccoon may have bit me."
Okay, okay, I'm kidding about the last one.
An hour and a half later, I finish up with her.
Why are the last-minute add-ons always the most complicated patients ever?
"Uh, yeah, I guess. Sure, if it's a quick one."
"Definitely. Just leg pain."
I knock on the exam room and walk in.
The patient is in a wheelchair.
Both of her legs, amputated.
"You're here for..."
"No English..."
I call the translator phone.
"You're here for..."
"Leg pain."
"Your legs are..."
"Oh, yes. Pain where they used to be. Also, I may be pregnant. And I have a lump in my right breast. And a persistent cough. And night sweats. And panic attacks. And a mysterious sore on my genitals. And no feeling in my left hand. And I was hoping for a sleeping pill. And some allergy medicine. And I've never had any vaccinations. And a rabid raccoon may have bit me."
Okay, okay, I'm kidding about the last one.
An hour and a half later, I finish up with her.
Why are the last-minute add-ons always the most complicated patients ever?
Saturday, February 25, 2012
Hospital "Cuisine" ?
Someone sent me a bizarre article from The Wall Street Journal about hospitals with "executive chefs" who custom-cook dishes that are healthy for patients, but also delicious-- and designed to deal with the patients' specific challenges (dulled taste buds, etc).
Is this an early April Fools article? Did we suddenly get transported to the future? A world where hospital food isn't awful, utterly incompatible with patient health needs, and reheated from who knows what kind of pre-cooked bags of nonsense the cafeteria is delivered?
The way I know my patients are truly ill is if they're not complaining about the food. Anyone who says they think the food is good, I call for a neuro exam.
They used to serve hospital-catered food at Grand Rounds, but there was a mutiny and now they order the worst pizza imaginable, and it's still ten times better.
The hospitals mentioned in this article should prepare not only for an onslaught of new patients, but a heck of a lot of inquiries from doctors about job opportunities.
Given that we're supposed to be helping patients stay alive, the quality of the food is close to inexcusable.
Is this an early April Fools article? Did we suddenly get transported to the future? A world where hospital food isn't awful, utterly incompatible with patient health needs, and reheated from who knows what kind of pre-cooked bags of nonsense the cafeteria is delivered?
The way I know my patients are truly ill is if they're not complaining about the food. Anyone who says they think the food is good, I call for a neuro exam.
They used to serve hospital-catered food at Grand Rounds, but there was a mutiny and now they order the worst pizza imaginable, and it's still ten times better.
The hospitals mentioned in this article should prepare not only for an onslaught of new patients, but a heck of a lot of inquiries from doctors about job opportunities.
Given that we're supposed to be helping patients stay alive, the quality of the food is close to inexcusable.
Thursday, February 23, 2012
Tips for Dating Residents
In the comments, someone asked for a post with tips for non-medical people to keep in mind when dating residents. I thought this was a fun idea. Hence:
TIPS FOR DATING RESIDENTS
1. Feed them. Residents work long hours. They are hungry. If they are working a late shift or overnight, you win huge points if you offer to bring them food. Even huger points if that food includes a cookie. Enormous points if you made that cookie yourself. Infinite points if you recognize that even though they tell you they can come down to meet you and grab the food at a certain time, something might come up, and they might be delayed. Maybe even for an hour. It is not their fault. They do not want to be leading a rapid response. They do not want to be performing CPR. They would rather be eating the food you have brought for them. They would rather be seeing you. Don't blame them. Don't make them feel bad. They are trying their best.
2. Listen to them. Residents have crazy things happen to them, often multiple crazy things on the same day. You may not actually care about what happened to Patient Smith. And you don't have to care about what happened to Patient Smith. But if your resident wants to talk about Patient Smith, and wants reassurance that he or she didn't accidentally kill Patient Smith, try and listen. If, on the other hand, your resident doesn't want to talk about Patient Smith, or Patient Anyone, don't push. Talk about your non-medical day. Non-medical things are interesting to residents, especially after a 27 hour shift talking only about medicine.
3. Learn some basic medicine. This is a hard one. I am sure that there are couples out there who don't know many details about the other person's job. People in law or finance or medicine or anything technical. I'm sure. I can't imagine how that works. Without someone having at least a basic understanding of what I do, I don't know where to start the conversation. If you are dating a resident, try and read some stuff about residency. Blogs might be the easiest place to start. (Hey, there are archives here!) Books are good too. Intern Blues is the first one that comes to mind. At least then you know what your resident is talking about, a little bit. Ask questions, sure, but starting with some base of knowledge makes things easier. It's not mandatory, of course. But it helps. Read relevant articles in the newspaper, perhaps. At least it's a start.
4. Tell your family not to ask for free medical advice, or, even worse, prescriptions. Your resident is not automatically your family's new free doctor. Your resident probably doesn't know enough to actually help, even if he or she wanted to -- and, most likely, he or she doesn't want to. In an emergency, sure. But that knee pain, or those warts -- tell them to see their actual doctor, and hold the questions. Your resident does not want to perform physical exams at Thanksgiving.
5. Recognize sleep deprivation for what it is, and not a larger sign of relationship trouble. Your resident is cranky? It probably isn't your fault. That's not an excuse, but understand that on the rare day off, maybe 13 hours of sleep is what your resident needs, even more than a delicious brunch that you even made a reservation for. Your resident is not trying to be difficult, or selfish, or lazy. Your resident is tired, and emotionally drained.
6. Indulge your resident's use of the pause button on the DVR when watching shows with medical elements. It is likely very frustrating for your resident to watch Grey's Anatomy or its television siblings. Your resident will likely stop the show multiple times and try and explain to you why the surgical resident would never be called in to consult on the child with the stomach virus. Your resident will grow frustrated as he or she sees the doctor touching infected blood with bare hands. Understand the frustration, and let your resident vent for fifteen seconds before continuing the show. Also understand if the last thing your resident wants to watch on a day off are shows about medicine. Good grief.
7. Let your resident shower before you approach. The hospital is nasty. Your resident wants to protect you. Don't make that difficult by complaining it's late, there are dinner plans, and there is no time to shower. There is always time to shower. Especially when covered in MRSA.
Other ideas in the comments?
TIPS FOR DATING RESIDENTS
1. Feed them. Residents work long hours. They are hungry. If they are working a late shift or overnight, you win huge points if you offer to bring them food. Even huger points if that food includes a cookie. Enormous points if you made that cookie yourself. Infinite points if you recognize that even though they tell you they can come down to meet you and grab the food at a certain time, something might come up, and they might be delayed. Maybe even for an hour. It is not their fault. They do not want to be leading a rapid response. They do not want to be performing CPR. They would rather be eating the food you have brought for them. They would rather be seeing you. Don't blame them. Don't make them feel bad. They are trying their best.
2. Listen to them. Residents have crazy things happen to them, often multiple crazy things on the same day. You may not actually care about what happened to Patient Smith. And you don't have to care about what happened to Patient Smith. But if your resident wants to talk about Patient Smith, and wants reassurance that he or she didn't accidentally kill Patient Smith, try and listen. If, on the other hand, your resident doesn't want to talk about Patient Smith, or Patient Anyone, don't push. Talk about your non-medical day. Non-medical things are interesting to residents, especially after a 27 hour shift talking only about medicine.
3. Learn some basic medicine. This is a hard one. I am sure that there are couples out there who don't know many details about the other person's job. People in law or finance or medicine or anything technical. I'm sure. I can't imagine how that works. Without someone having at least a basic understanding of what I do, I don't know where to start the conversation. If you are dating a resident, try and read some stuff about residency. Blogs might be the easiest place to start. (Hey, there are archives here!) Books are good too. Intern Blues is the first one that comes to mind. At least then you know what your resident is talking about, a little bit. Ask questions, sure, but starting with some base of knowledge makes things easier. It's not mandatory, of course. But it helps. Read relevant articles in the newspaper, perhaps. At least it's a start.
4. Tell your family not to ask for free medical advice, or, even worse, prescriptions. Your resident is not automatically your family's new free doctor. Your resident probably doesn't know enough to actually help, even if he or she wanted to -- and, most likely, he or she doesn't want to. In an emergency, sure. But that knee pain, or those warts -- tell them to see their actual doctor, and hold the questions. Your resident does not want to perform physical exams at Thanksgiving.
5. Recognize sleep deprivation for what it is, and not a larger sign of relationship trouble. Your resident is cranky? It probably isn't your fault. That's not an excuse, but understand that on the rare day off, maybe 13 hours of sleep is what your resident needs, even more than a delicious brunch that you even made a reservation for. Your resident is not trying to be difficult, or selfish, or lazy. Your resident is tired, and emotionally drained.
6. Indulge your resident's use of the pause button on the DVR when watching shows with medical elements. It is likely very frustrating for your resident to watch Grey's Anatomy or its television siblings. Your resident will likely stop the show multiple times and try and explain to you why the surgical resident would never be called in to consult on the child with the stomach virus. Your resident will grow frustrated as he or she sees the doctor touching infected blood with bare hands. Understand the frustration, and let your resident vent for fifteen seconds before continuing the show. Also understand if the last thing your resident wants to watch on a day off are shows about medicine. Good grief.
7. Let your resident shower before you approach. The hospital is nasty. Your resident wants to protect you. Don't make that difficult by complaining it's late, there are dinner plans, and there is no time to shower. There is always time to shower. Especially when covered in MRSA.
Other ideas in the comments?
Wednesday, February 22, 2012
Lost
An elderly man, unshaven, in what looks like pajamas, approaches me in the hall, confused.
"Doctor, I'm looking for the 7th floor."
"You're on the 7th floor."
"No, I'm looking for the 7th floor of the hospital."
"This is the 7th floor of the hospital. Let me help you get back to your room."
"My room? I'm not a patient. I'm here to visit my son."
"Doctor, I'm looking for the 7th floor."
"You're on the 7th floor."
"No, I'm looking for the 7th floor of the hospital."
"This is the 7th floor of the hospital. Let me help you get back to your room."
"My room? I'm not a patient. I'm here to visit my son."
Tuesday, February 21, 2012
Happy hour? Not so happy.
No, fellow resident, I don't want to go to happy hour with you.
I know that makes you think I'm anti-social, but, really, I'm just tired of talking about medicine and would rather talk about anything but that thing you found inside that patient yesterday. And even though nothing is forcing us to talk about medicine at the happy hour, I know from previous happy hour experiences that medicine is all that will be talked about, and I will want to leave four minutes after I arrive, will instead stay for an hour, and will feel contaminated by dirty gossip when I finally get to leave.
I would rather watch The Voice. Which is saying a lot, because I find The Voice pretty unwatchable, and end up spending most of the episodes trying to diagnose various psychiatric illnesses in the contestants and judges. Narcissism is a good default if nothing else comes to mind. Borderline personality disorder. Antisocial personality disorder. Different (of course) from the anti-social behavior I exhibit by avoiding the happy hour.
One of my fellow residents asked me if I would give her a guy's perspective on her OK Cupid profile. I am trying to decide if that means she likes me. She also asked my opinion about something to do with treatment for a patient with scabies, which is the opposite of what you would talk about with someone you like, whether as a friend or more than that.
And you know what makes happy hour especially not happy? Everyone always talks mostly about patients who have died. Talking about dead patients is not my idea of happy. Talking about live patients isn't awesome either, but dead ones, really, not happy.
I know that makes you think I'm anti-social, but, really, I'm just tired of talking about medicine and would rather talk about anything but that thing you found inside that patient yesterday. And even though nothing is forcing us to talk about medicine at the happy hour, I know from previous happy hour experiences that medicine is all that will be talked about, and I will want to leave four minutes after I arrive, will instead stay for an hour, and will feel contaminated by dirty gossip when I finally get to leave.
I would rather watch The Voice. Which is saying a lot, because I find The Voice pretty unwatchable, and end up spending most of the episodes trying to diagnose various psychiatric illnesses in the contestants and judges. Narcissism is a good default if nothing else comes to mind. Borderline personality disorder. Antisocial personality disorder. Different (of course) from the anti-social behavior I exhibit by avoiding the happy hour.
One of my fellow residents asked me if I would give her a guy's perspective on her OK Cupid profile. I am trying to decide if that means she likes me. She also asked my opinion about something to do with treatment for a patient with scabies, which is the opposite of what you would talk about with someone you like, whether as a friend or more than that.
And you know what makes happy hour especially not happy? Everyone always talks mostly about patients who have died. Talking about dead patients is not my idea of happy. Talking about live patients isn't awesome either, but dead ones, really, not happy.
Monday, February 20, 2012
No, friend, I'm not going to prescribe you Ambien
"Hey, I know we haven't talked in a while, but I just thought I'd call to catch up."
"Oh. Okay. I guess. I didn't even know you still had my number."
"I got it from [mutual friend]."
"Oh. Okay. Great. What's up?"
"I don't know. Not much. You're still doing the whole doctor thing, right?"
"Yep. Third year of residency. Almost done."
"Great. So you already have a medical license and everything."
"Yes. That is something I have. You're still at the bank?"
"No, no, haven't been there for about a year. I got, uh, I decided to do something else."
"Cool. You hated that job, right? So what are you doing now?"
"I'm in between, uh, still figuring it out."
"Okay, well, cool. I guess."
"Yeah, yeah. So, I was just thinking, you wouldn't happen to be able to prescribe me some Ambien, would you? I've been having a lot of trouble sleeping."
"Uh, you should talk to your regular doctor about that."
"I don't really have one. I just thought this might be easier."
"Easier, maybe. But I really can't. I'm not your doctor."
"But it's just a sleeping pill."
"I really don't feel comfortable. You should talk to a doctor, though."
"I don't really have insurance anymore."
"Free clinics..."
"Come on, what kind of doctors are working at free clinics?"
"Doctors like me. Residents. I think it'd be fine, especially if you're not working and can wait for a couple hours in a waiting room."
"Ugh. That sounds terrible. What if I pay you-- not like you're selling drugs or anything like that, but if I'd have to pay a doctor anyway, I may as well pay a friend what I'd pay."
"No. That's not something I'm comfortable with at all. I'm sorry-- have you thought about maybe talking to a psychologist, if you're having trouble sleeping? Maybe you're a little anxious, from the job search and everything?"
"I'm not crazy."
"I didn't say you were crazy. But sometimes therapy can help. Independent of any sort of sleeping pill or no sleeping pill. It might be something to look into. I can probably get you a recommendation."
"For free?"
"The recommendation? Sure. The therapist? Probably not, but they have a sliding scale, lots of them. I can ask around for someone who doesn't charge something crazy."
"I really just think I'll try the Ambien."
"Not from me you won't."
"Come on. Be a friend?"
"Not a cool thing to want me to do, I promise."
"Oh, well. Figured I'd try. See you around?"
"I guess. Sure. Let me know if you want to grab coffee sometime."
"I don't think so."
"Oh. Okay. I guess. I didn't even know you still had my number."
"I got it from [mutual friend]."
"Oh. Okay. Great. What's up?"
"I don't know. Not much. You're still doing the whole doctor thing, right?"
"Yep. Third year of residency. Almost done."
"Great. So you already have a medical license and everything."
"Yes. That is something I have. You're still at the bank?"
"No, no, haven't been there for about a year. I got, uh, I decided to do something else."
"Cool. You hated that job, right? So what are you doing now?"
"I'm in between, uh, still figuring it out."
"Okay, well, cool. I guess."
"Yeah, yeah. So, I was just thinking, you wouldn't happen to be able to prescribe me some Ambien, would you? I've been having a lot of trouble sleeping."
"Uh, you should talk to your regular doctor about that."
"I don't really have one. I just thought this might be easier."
"Easier, maybe. But I really can't. I'm not your doctor."
"But it's just a sleeping pill."
"I really don't feel comfortable. You should talk to a doctor, though."
"I don't really have insurance anymore."
"Free clinics..."
"Come on, what kind of doctors are working at free clinics?"
"Doctors like me. Residents. I think it'd be fine, especially if you're not working and can wait for a couple hours in a waiting room."
"Ugh. That sounds terrible. What if I pay you-- not like you're selling drugs or anything like that, but if I'd have to pay a doctor anyway, I may as well pay a friend what I'd pay."
"No. That's not something I'm comfortable with at all. I'm sorry-- have you thought about maybe talking to a psychologist, if you're having trouble sleeping? Maybe you're a little anxious, from the job search and everything?"
"I'm not crazy."
"I didn't say you were crazy. But sometimes therapy can help. Independent of any sort of sleeping pill or no sleeping pill. It might be something to look into. I can probably get you a recommendation."
"For free?"
"The recommendation? Sure. The therapist? Probably not, but they have a sliding scale, lots of them. I can ask around for someone who doesn't charge something crazy."
"I really just think I'll try the Ambien."
"Not from me you won't."
"Come on. Be a friend?"
"Not a cool thing to want me to do, I promise."
"Oh, well. Figured I'd try. See you around?"
"I guess. Sure. Let me know if you want to grab coffee sometime."
"I don't think so."
Friday, February 17, 2012
Oh, of course, it's... you!
"Hello, Ms. Patient. It's good to meet you."
"Meet me? I know you. You're my doctor."
"No, I don't think so."
"Sure you are. I've been trying to make another appointment with you for months. I call the clinic and request you specifically, every time. I've referred two friends here to you also. I've been telling everyone how terrific you are."
"Oh."
"Yeah, you don't remember? I had untreated syphilis..."
"Um... that doesn't necessarily narrow it down. But, uh, sure. I'm glad you had such a positive feeling about our one appointment."
"Three."
"Oh. Wow. Let me take a quick look at your chart. Hmmm. Those do indeed seem to be my notes. I'm sure it'll all come back to me as soon as I read through... no... no, nothing's seeming too familiar...."
"So you really don't remember me?"
"I think I should probably say I do."
"It's okay, I understand."
"And you haven't changed anything about your appearance since I last saw you?"
"Uh, no... I don't think so... oh, except now I'm dressing as a woman."
"You've had a sex change...???"
"No, I was just kidding. You just don't remember me, do you?"
"I'm sorry. I don't."
"I may stop referring my friends to you, if that's okay."
"No, I understand."
"Meet me? I know you. You're my doctor."
"No, I don't think so."
"Sure you are. I've been trying to make another appointment with you for months. I call the clinic and request you specifically, every time. I've referred two friends here to you also. I've been telling everyone how terrific you are."
"Oh."
"Yeah, you don't remember? I had untreated syphilis..."
"Um... that doesn't necessarily narrow it down. But, uh, sure. I'm glad you had such a positive feeling about our one appointment."
"Three."
"Oh. Wow. Let me take a quick look at your chart. Hmmm. Those do indeed seem to be my notes. I'm sure it'll all come back to me as soon as I read through... no... no, nothing's seeming too familiar...."
"So you really don't remember me?"
"I think I should probably say I do."
"It's okay, I understand."
"And you haven't changed anything about your appearance since I last saw you?"
"Uh, no... I don't think so... oh, except now I'm dressing as a woman."
"You've had a sex change...???"
"No, I was just kidding. You just don't remember me, do you?"
"I'm sorry. I don't."
"I may stop referring my friends to you, if that's okay."
"No, I understand."
Thursday, February 16, 2012
So I put the contraceptive patch where...?
Oh, clinic patients, how I missed you.
"So I put the contraceptive patch in my vagina?"
"No."
"Can I get a gas pain in my ear?"
"No."
"What if I put food in my ear? Then can I?"
"No."
"I have a stomach pain. Does that mean I'm pregnant?"
"No."
"If I use the nicotine patch and the contraceptive patch, do they cancel each other out?"
"No."
"What if I get them confused?"
"Don't."
"If I use condoms while I'm using the patch, do they cancel each other out?"
"No."
"My friend has some kind of ring she uses as birth control. Can I get that even if I don't know my ring size?"
"So I put the contraceptive patch in my vagina?"
"No."
"Can I get a gas pain in my ear?"
"No."
"What if I put food in my ear? Then can I?"
"No."
"I have a stomach pain. Does that mean I'm pregnant?"
"No."
"If I use the nicotine patch and the contraceptive patch, do they cancel each other out?"
"No."
"What if I get them confused?"
"Don't."
"If I use condoms while I'm using the patch, do they cancel each other out?"
"No."
"My friend has some kind of ring she uses as birth control. Can I get that even if I don't know my ring size?"
Wednesday, February 15, 2012
Valentine's Day, or I Hope No One's Heart Stops Beating
In the comments the other day, there was some discussion of my personal life. And what better day than Valentine's Day to address that in a post.
Except I didn't post yesterday, so maybe that tells you something.
Or maybe it doesn't. See, if I were to tell you, say, that I was dating a cardiology fellow who didn't know about this blog, that would be a silly thing to reveal.
So I'm not going to reveal anything about that. At least not today.
Instead, how about a post about patients who think they're at a flea market when they come to their doctor's appointment.
"You prescribed me two pain pills a day, I want three."
"The dosage is two."
"I need three. You should give me three."
"I'm not giving you three."
"Then how about allergy medicine?"
"Do you have allergies?"
"Yes, I have allergies. I need allergy medication. And my friend has an itch cream. Will you prescribe me an itch cream?"
"For what?"
"And do you have samples of anything? Can you throw in some samples? Maybe you have some samples I can try."
"I don't have any samples of anything to give you."
"So I'm getting the pain pills, the allergy medicine, the itch cream-- can you throw in anything else?"
"No."
"What if I don't take the itch cream? Is there something I can get instead?"
"No."
"Can I get another appointment?"
"Why?"
"I don't know."
"Great."
"What about some latex gloves? Can I get a box of those?"
Except I didn't post yesterday, so maybe that tells you something.
Or maybe it doesn't. See, if I were to tell you, say, that I was dating a cardiology fellow who didn't know about this blog, that would be a silly thing to reveal.
So I'm not going to reveal anything about that. At least not today.
Instead, how about a post about patients who think they're at a flea market when they come to their doctor's appointment.
"You prescribed me two pain pills a day, I want three."
"The dosage is two."
"I need three. You should give me three."
"I'm not giving you three."
"Then how about allergy medicine?"
"Do you have allergies?"
"Yes, I have allergies. I need allergy medication. And my friend has an itch cream. Will you prescribe me an itch cream?"
"For what?"
"And do you have samples of anything? Can you throw in some samples? Maybe you have some samples I can try."
"I don't have any samples of anything to give you."
"So I'm getting the pain pills, the allergy medicine, the itch cream-- can you throw in anything else?"
"No."
"What if I don't take the itch cream? Is there something I can get instead?"
"No."
"Can I get another appointment?"
"Why?"
"I don't know."
"Great."
"What about some latex gloves? Can I get a box of those?"
Monday, February 13, 2012
Why nursing homes have a great reputation!
We discharged a patient last week to short-term sub-acute rehab in a nursing facility. Usually this would be the end of my involvement, except I got paged by a family member who had been very involved in the patient's care (and not in a way that made me want to stab him!), and ended up giving the rehab facility a call on the patient's behalf to push to make sure they were following the plan we'd sent the patient out with, and taking care of his needs appropriately.
And... now I understand why my parents are afraid of ever ending up in a nursing home.
(1)
"One of the things the family member told me he's concerned about is the diet his father's being served. As the social worker said in the discharge, he's supposed to be on a cardiac and diabetic diet, so I just want to make sure that's what he's getting."
"Oh, yes. Our cardiac diet is the same as our regular diet. And the diabetic diet here means we do not give him the ice cream."
"Yeah, we're hoping to keep his salt levels managed."
"We follow all state regulations for the diet."
"It's just that I was told that he was getting some meals that didn't seem particularly heart healthy-- meat loaf, chicken parmigiana, clam chowder, things that apparently he was finding very salty. So I just want to make sure."
"We don't add salt to our products, but many of the products do come with salt in them. The soup is from a can, and I believe there is salt added."
"Canned soup is very salty, sure."
"And the meat loaf, I'm not sure how much of that we prepare on-site and what packaged products we're using."
"Is there at least a way for him to get the nutritional information so he can make appropriate choices?"
"No, we don't provide that information to patients. But we follow all appropriate laws and regulations."
"Is there a dietitian on staff?"
"Sure."
"And he believes these meals are appropriate for patients with these restrictions?"
"We follow all laws."
(2)
"The family is also concerned about wound care. The patient apparently says he was woken up at 2 AM to have his dressing changed, but the nurse didn't have the right supplies, and left his wound uncovered until the day shift came in, hours later?"
"That does not make sense."
"I know. It didn't make sense to me either. It seems really inappropriate."
"No, it doesn't make sense because there wouldn't be anyone on staff to deal with any issues at 2 AM. I don't know who would possibly come into his room at 2 AM. No one would be able to address a wound at 2 AM."
"So no one is available for medical emergencies?"
"No, our PA is here from 9-3, Monday to Friday, so all issues are dealt with then."
"Wait, is there even a doctor? It's just a PA?"
"The doctor comes on Tuesday mornings."
"What?"
"This complies with all regulations."
"So a doctor hasn't even been involved in his care yet, since he came in last Thursday?"
"No, the doctor will see him on Tuesday, if he has time."
"And how is his therapy going?"
"I don't see any record of any therapy yet."
"Yeah, that's what the family said too."
"Would you like me to arrange therapy?"
"He's supposed to be there for therapy, yes."
"I'm not sure that was in the chart."
"What?"
"I do see something about an allergy, though."
"Yes, he has an allergy to penicillin."
"Oh, I'll write that in. It just says allergy, but doesn't have the details."
"That's an important detail."
"I'm writing it down."
"Thanks."
And... now I understand why my parents are afraid of ever ending up in a nursing home.
(1)
"One of the things the family member told me he's concerned about is the diet his father's being served. As the social worker said in the discharge, he's supposed to be on a cardiac and diabetic diet, so I just want to make sure that's what he's getting."
"Oh, yes. Our cardiac diet is the same as our regular diet. And the diabetic diet here means we do not give him the ice cream."
"Yeah, we're hoping to keep his salt levels managed."
"We follow all state regulations for the diet."
"It's just that I was told that he was getting some meals that didn't seem particularly heart healthy-- meat loaf, chicken parmigiana, clam chowder, things that apparently he was finding very salty. So I just want to make sure."
"We don't add salt to our products, but many of the products do come with salt in them. The soup is from a can, and I believe there is salt added."
"Canned soup is very salty, sure."
"And the meat loaf, I'm not sure how much of that we prepare on-site and what packaged products we're using."
"Is there at least a way for him to get the nutritional information so he can make appropriate choices?"
"No, we don't provide that information to patients. But we follow all appropriate laws and regulations."
"Is there a dietitian on staff?"
"Sure."
"And he believes these meals are appropriate for patients with these restrictions?"
"We follow all laws."
(2)
"The family is also concerned about wound care. The patient apparently says he was woken up at 2 AM to have his dressing changed, but the nurse didn't have the right supplies, and left his wound uncovered until the day shift came in, hours later?"
"That does not make sense."
"I know. It didn't make sense to me either. It seems really inappropriate."
"No, it doesn't make sense because there wouldn't be anyone on staff to deal with any issues at 2 AM. I don't know who would possibly come into his room at 2 AM. No one would be able to address a wound at 2 AM."
"So no one is available for medical emergencies?"
"No, our PA is here from 9-3, Monday to Friday, so all issues are dealt with then."
"Wait, is there even a doctor? It's just a PA?"
"The doctor comes on Tuesday mornings."
"What?"
"This complies with all regulations."
"So a doctor hasn't even been involved in his care yet, since he came in last Thursday?"
"No, the doctor will see him on Tuesday, if he has time."
"And how is his therapy going?"
"I don't see any record of any therapy yet."
"Yeah, that's what the family said too."
"Would you like me to arrange therapy?"
"He's supposed to be there for therapy, yes."
"I'm not sure that was in the chart."
"What?"
"I do see something about an allergy, though."
"Yes, he has an allergy to penicillin."
"Oh, I'll write that in. It just says allergy, but doesn't have the details."
"That's an important detail."
"I'm writing it down."
"Thanks."
Sunday, February 12, 2012
Spellchek
My intern can't spell. Or type. I don't know which one. Probably both.
This seems like a silly problem, and, indeed, I've spent weeks trying to persuade myself that it's a silly problem, not even worth mentioning, except that when I'm asked to explain a patient note that details our treatment for an "erotic anorism," it becomes a problem.
I feel like a jerk to pull someone aside and tell them that the patient came in with the flu, not the flew, and that it's herpes, not herpees. But if anyone ever reads these notes, they're going to close this hospital.
I've been going through and correcting things-- often having to sound them out just to know what he's trying to say-- saroses? Oh... cirrhosis! Right?! And somehow this person got through college, and medical school (I hope). In this country, even.
He's not stupid. And if it's a learning disability of some sort, dyslexia, something like that, then I certainly don't want to call attention to it that would make him uncomfortable. But cholesterol doesn't start with a K, and diabetes only has one D, and no Z, anywhere in the entire word.
It will serve him well that doctors are expected to have poor enough penmanship that no one will even know what he's writing, let alone be able to notice the spelling. But, gosh, I didn't realize that part of the job of a resident is copyediting.
"Patient is obeast."
Excellent.
This seems like a silly problem, and, indeed, I've spent weeks trying to persuade myself that it's a silly problem, not even worth mentioning, except that when I'm asked to explain a patient note that details our treatment for an "erotic anorism," it becomes a problem.
I feel like a jerk to pull someone aside and tell them that the patient came in with the flu, not the flew, and that it's herpes, not herpees. But if anyone ever reads these notes, they're going to close this hospital.
I've been going through and correcting things-- often having to sound them out just to know what he's trying to say-- saroses? Oh... cirrhosis! Right?! And somehow this person got through college, and medical school (I hope). In this country, even.
He's not stupid. And if it's a learning disability of some sort, dyslexia, something like that, then I certainly don't want to call attention to it that would make him uncomfortable. But cholesterol doesn't start with a K, and diabetes only has one D, and no Z, anywhere in the entire word.
It will serve him well that doctors are expected to have poor enough penmanship that no one will even know what he's writing, let alone be able to notice the spelling. But, gosh, I didn't realize that part of the job of a resident is copyediting.
"Patient is obeast."
Excellent.
Friday, February 10, 2012
No hablo ingles?
"Hello, sir."
[no response]
"Hello. Do you speak English?"
[no response]
"Habla ingles?"
"No."
"Habla espanol?"
"Si."
I turn to my med student. "I think we should get the translator phone."
"Yeah, he definitely doesn't speak English."
So I get the translator phone set up. Translator comes on the phone. We have a very slow 10 minute conversation, where much of the time it seems like the patient isn't following what the translator is saying.
"Translator, is the patient following?"
"Uh, doctor, I hate to tell you this-- I don't think he really speaks Spanish."
"Then what does he speak?"
The translator says something to the patient. He responds, haltingly.
"He speaks English."
"What?"
"Mr. Patient, do you speak English?"
"Yes. I do."
"So, all along, you've understood us?"
"Yes."
"Why didn't you say anything?"
"I don't know."
"I don't know either. I think we're going to get a head CT now."
[no response]
"Hello. Do you speak English?"
[no response]
"Habla ingles?"
"No."
"Habla espanol?"
"Si."
I turn to my med student. "I think we should get the translator phone."
"Yeah, he definitely doesn't speak English."
So I get the translator phone set up. Translator comes on the phone. We have a very slow 10 minute conversation, where much of the time it seems like the patient isn't following what the translator is saying.
"Translator, is the patient following?"
"Uh, doctor, I hate to tell you this-- I don't think he really speaks Spanish."
"Then what does he speak?"
The translator says something to the patient. He responds, haltingly.
"He speaks English."
"What?"
"Mr. Patient, do you speak English?"
"Yes. I do."
"So, all along, you've understood us?"
"Yes."
"Why didn't you say anything?"
"I don't know."
"I don't know either. I think we're going to get a head CT now."
Thursday, February 9, 2012
It's not TV, it's HBO.
"Doc, my TV is broken."
"I think there's a sticker on there with a number you can call."
"It doesn't get HBO."
"I actually don't think it's supposed to get HBO."
"You gotta be kidding, come on."
"No, I really don't think the TV gets HBO."
"I don't understand. First they tell me there's no sushi, then I find out there's no bathrobes, just this stupid gown, and now you're telling me no HBO. What kind of a place is this?"
"A hospital."
"But I have good insurance."
"No insurance is that good."
"You don't know what I pay."
"I can imagine."
"For what I pay, there should at least be some little bottles of shampoo I can take home."
"Not a hotel, sir."
"At least we get room service."
"I think there's a sticker on there with a number you can call."
"It doesn't get HBO."
"I actually don't think it's supposed to get HBO."
"You gotta be kidding, come on."
"No, I really don't think the TV gets HBO."
"I don't understand. First they tell me there's no sushi, then I find out there's no bathrobes, just this stupid gown, and now you're telling me no HBO. What kind of a place is this?"
"A hospital."
"But I have good insurance."
"No insurance is that good."
"You don't know what I pay."
"I can imagine."
"For what I pay, there should at least be some little bottles of shampoo I can take home."
"Not a hotel, sir."
"At least we get room service."
Wednesday, February 8, 2012
What? I can't hear you.
For a few days now, Patient, in the hospital for something relatively complicated, and entirely unrelated to her ears, has been complaining of trouble hearing. Apparently reports a history of ear wax. So it's probably ear wax. Patient wants us to do something about it. I call for an ENT consult. The ENT laughs at me. That's not an inpatient issue. She can deal with it when she's discharged. The patient, not too happy to hear that. So, today, I go into her room.
She's holding up a sign.
It says: "I can't hear anything."
"And that also means you can't talk??"
She scribbles on her paper: "What? I can't hear you."
I indulge, and write back: "Are you able to talk."
She looks at it for a few moments. Then, very loud, and slow:
"Oh. I guess I can talk."
"You can talk lower."
"What?"
"You can talk lower."
"What?"
I write on her paper: "Talk lower."
"Oh, am I talking loud? I can't hear myself."
I write on her paper: "Yes. You can't hear anything?"
"No."
"So I guess you didn't hear when I said we were discharging you."
"I'm going home?"
"Aha!"
"I mean... I was lip-reading."
"You were not."
"Why can't you just clean out my ears?"
"That's not a hospital procedure. We don't even have equipment to do that here."
"You should buy some."
"You should stop pretending you can't hear anything."
"I thought it would make you help me."
"It won't."
She's holding up a sign.
It says: "I can't hear anything."
"And that also means you can't talk??"
She scribbles on her paper: "What? I can't hear you."
I indulge, and write back: "Are you able to talk."
She looks at it for a few moments. Then, very loud, and slow:
"Oh. I guess I can talk."
"You can talk lower."
"What?"
"You can talk lower."
"What?"
I write on her paper: "Talk lower."
"Oh, am I talking loud? I can't hear myself."
I write on her paper: "Yes. You can't hear anything?"
"No."
"So I guess you didn't hear when I said we were discharging you."
"I'm going home?"
"Aha!"
"I mean... I was lip-reading."
"You were not."
"Why can't you just clean out my ears?"
"That's not a hospital procedure. We don't even have equipment to do that here."
"You should buy some."
"You should stop pretending you can't hear anything."
"I thought it would make you help me."
"It won't."
Monday, February 6, 2012
"No, sir, your cervix is just fine."
"So, my wife was diagnosed with chlamydia," said my clinic patient. "And her doctor said maybe she got it from me. Which seems a little crazy, since she's the only woman I've ever been with."
"Hmmmm."
"Apparently she also has gonorrhea. Could I have given her that too?"
"Ummmm. And you've been with no one else?"
"Nope."
"And she...?"
"Oh, she would never cheat on me."
"Okay..."
"They put me on antibiotics, just to be safe."
"Sure, because they wouldn't want the two of you passing these things back and forth...."
"Her doctor also said she has some pre-cancerous changes on her cervix."
"Hmmmm."
"Am I at risk for that too?"
"Hmmmm."
"Apparently she also has gonorrhea. Could I have given her that too?"
"Ummmm. And you've been with no one else?"
"Nope."
"And she...?"
"Oh, she would never cheat on me."
"Okay..."
"They put me on antibiotics, just to be safe."
"Sure, because they wouldn't want the two of you passing these things back and forth...."
"Her doctor also said she has some pre-cancerous changes on her cervix."
"Hmmmm."
"Am I at risk for that too?"
Sunday, February 5, 2012
Hiccups
There's a patient who's had a bunch of complications in his care, side effects, unexpected setbacks, an underlying issue he came in with but wasn't discovered right away. Nothing that's necessarily anyone's fault, but still very frustrating for him and for his doctors. I go in to see him this morning.
"Doctor, I want to ask you: why have I had so many hiccups?"
"Well, you know, every patient is complicated, and even the right treatment doesn't always work out perfectly. But I think we've been able to get ahead of the problems now, and we see a path toward recovery. So, the road has been long, but we're getting there."
"No, doctor, I meant why have I had the hiccups for the past day?"
"Actual hiccups?"
"Yes."
"Oh. I don't know."
"Doctor, I want to ask you: why have I had so many hiccups?"
"Well, you know, every patient is complicated, and even the right treatment doesn't always work out perfectly. But I think we've been able to get ahead of the problems now, and we see a path toward recovery. So, the road has been long, but we're getting there."
"No, doctor, I meant why have I had the hiccups for the past day?"
"Actual hiccups?"
"Yes."
"Oh. I don't know."
Friday, February 3, 2012
Great consult, just one problem...
Called an ID (infectious disease) consult on a patient. The guy comes in, a little harried, grabs me and we head over to the patient's bedside--
"So, Mr. Patient, good afternoon. I'm from the infectious disease department, your doctor called me in because we're concerned about your intermittent fevers, your white blood cell count has been elevated--"
I try to interrupt. "Excuse me, I--"
"No, no, I'm in a bit of a rush, so let me just finish-- Your doctor brought me up to speed on your situation, so I know we're dealing with a bit of a cough, and you were complaining of a sore throat. Interrupt me if you're currently experiencing any of the symptoms I start naming--"
"Excuse me, just--"
"Come on, let me finish with him-- okay, stomach pain, headache, chills, any sort of bone pain, just stop me if you're experiencing any of this--"
"Doctor, he doesn't--"
"I see, he doesn't seem to be having any of these problems. Well, I think for now we're just going to monitor, and let me know if you have any questions--"
"Sir, he can't--"
"I want him to talk for himself. If he doesn't have any questions, Dr. Resident, you and I can do the rest of this over the phone a little later. Mr. Patient, it was great to meet you, I'll check back tomorrow."
We walk out of the room.
"Well, that was easy."
"Sure, and thanks for the consult. Except what I was trying to tell you in there-- the patient doesn't understand English."
"So, Mr. Patient, good afternoon. I'm from the infectious disease department, your doctor called me in because we're concerned about your intermittent fevers, your white blood cell count has been elevated--"
I try to interrupt. "Excuse me, I--"
"No, no, I'm in a bit of a rush, so let me just finish-- Your doctor brought me up to speed on your situation, so I know we're dealing with a bit of a cough, and you were complaining of a sore throat. Interrupt me if you're currently experiencing any of the symptoms I start naming--"
"Excuse me, just--"
"Come on, let me finish with him-- okay, stomach pain, headache, chills, any sort of bone pain, just stop me if you're experiencing any of this--"
"Doctor, he doesn't--"
"I see, he doesn't seem to be having any of these problems. Well, I think for now we're just going to monitor, and let me know if you have any questions--"
"Sir, he can't--"
"I want him to talk for himself. If he doesn't have any questions, Dr. Resident, you and I can do the rest of this over the phone a little later. Mr. Patient, it was great to meet you, I'll check back tomorrow."
We walk out of the room.
"Well, that was easy."
"Sure, and thanks for the consult. Except what I was trying to tell you in there-- the patient doesn't understand English."
Thursday, February 2, 2012
Do everything! Well, everything except that.
I just spent a few minutes reading all about Jehovah's Witnesses and what kinds of blood products they will and will not accept. Because I have a patient who needs blood and won't accept any.
"You understand that you need a transfusion."
"I do."
"And without it, you have a much poorer prognosis."
"I do."
"We need to talk about your code status, in case something happens. Would you want to be kept alive artificially."
"Yes."
"And you would want us to do whatever we can do to help you."
"Yes, definitely."
"Except give you blood."
"Right."
"So we should intubate, put you on a ventilator, all of that-- some of which may well be avoidable if you would let us actually treat you the way we are recommending."
"Yes."
"So we should do everything. Except give you blood, which would probably help us avoid needing to do these other, more invasive things."
"Yes."
"So do everything, except the easiest and most useful thing we could do."
"Yes."
"Great."
"You understand that you need a transfusion."
"I do."
"And without it, you have a much poorer prognosis."
"I do."
"We need to talk about your code status, in case something happens. Would you want to be kept alive artificially."
"Yes."
"And you would want us to do whatever we can do to help you."
"Yes, definitely."
"Except give you blood."
"Right."
"So we should intubate, put you on a ventilator, all of that-- some of which may well be avoidable if you would let us actually treat you the way we are recommending."
"Yes."
"So we should do everything. Except give you blood, which would probably help us avoid needing to do these other, more invasive things."
"Yes."
"So do everything, except the easiest and most useful thing we could do."
"Yes."
"Great."
Wednesday, February 1, 2012
I'm fine, but how are my plants?
Patient 12 hours post-surgery, and we're trying to be extra-vigilant about possible bacterial infection causing altered mental status. Which is hard when baseline mental status is a little eccentric.
"How are you doing?"
"I'm fine, but how are my plants?"
"What plants?"
"I went to therapy two days ago and potted a plant. I want to see him."
"Him?"
"I want to know how he's doing. I don't know what happened to my plant."
"Sir, can you tell me what year it is?"
"2012. I want the plant."
"What month?"
"Is it still January? Is there someone I can call to track down my plant?"
"I'm concerned about how concerned you are about this plant. It's making me worry about your mental status and whether it may be affected by your infection. Can you try and disregard the plant for a moment, and let's talk about something else? Which doctors have you seen today?"
"I don't know. Some doctors. None of them knew about the plant."
"Are you feeling any pain?"
"I don't know. When I sit up, a little. But what I'm really worried about is the plant."
"Why are you so concerned about the plant?"
"The plant is very important to me."
"Why?"
"I don't know."
"I'm going to have the nurse draw a fresh set of labs. You're not doing a good job of convincing me that there isn't something going on here."
I feel like Altered Mental Status: The Game Show could be a real hit. Panel of celebrities, they meet a patient, vote on what they think, I'm not sure of the logistics, but I think it could work.
"How are you doing?"
"I'm fine, but how are my plants?"
"What plants?"
"I went to therapy two days ago and potted a plant. I want to see him."
"Him?"
"I want to know how he's doing. I don't know what happened to my plant."
"Sir, can you tell me what year it is?"
"2012. I want the plant."
"What month?"
"Is it still January? Is there someone I can call to track down my plant?"
"I'm concerned about how concerned you are about this plant. It's making me worry about your mental status and whether it may be affected by your infection. Can you try and disregard the plant for a moment, and let's talk about something else? Which doctors have you seen today?"
"I don't know. Some doctors. None of them knew about the plant."
"Are you feeling any pain?"
"I don't know. When I sit up, a little. But what I'm really worried about is the plant."
"Why are you so concerned about the plant?"
"The plant is very important to me."
"Why?"
"I don't know."
"I'm going to have the nurse draw a fresh set of labs. You're not doing a good job of convincing me that there isn't something going on here."
I feel like Altered Mental Status: The Game Show could be a real hit. Panel of celebrities, they meet a patient, vote on what they think, I'm not sure of the logistics, but I think it could work.
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