5.31.2007

How funny...how true...

This is a great post by Panda Bear MD

I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you

The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

5.23.2007

A Doctor's Value

Imagine this: As a junior college student, you decide "I want to help people, I think I'll be a doctor." You study hard, go into tons of debt, and sacrifice lots of life luxuries...and for "privilege" of being someone's doctor. You choose ER, because you really want to make a difference. A County ER, because that where people *really* need help.

As a medical student you notice how evil the residents seem. They call their patients "rocks" if they have extended hospital stays. They have acronyms for people, like LOL in NAD, (little old lady in no apparent distress), or CTD (circling the drain - when someone is dying). And those are the nice ones - some are
much worse.

You think "how can these docs be so jaded...so mean?" Then you see a hard working resident, sacrifice his marriage, his relationships, work 36 hours w/o food, nor sleep, working for less money per hour than poverty wages...to be shown no appreciation by his patients, his program, his hospital, nor his society."

A common response is: "well, no one forced Dr. Hardworking Resident to be a doctor? He knew what he was getting into, besides he'll make tons of money when he's out"

To that I say: There are lots of things that are...wrong in this world. And, the solution isn't "well, that's just the way it is." That may, in fact, be the way it is, but you work towards change. Medicine is no different. The process of becoming a doctor is flawed. The cost is outrageous (on multiple levels). The work hours are insane. And the sacrifice huge. Still male dominated, and by in large, female/family unfriendly. And the lifestyle, not what most people imagine. Yes, there are some good things (lots of good things) about being a doctor (I'll get to those another day)...but that doesn't eliminate the bad.

So when a surgeon complains that "the hours are too long," we should listen. Afterall, one day, you just might need a surgeon....and one that's well rested is better than one that's running on 20 minutes of sleep over the last 36 hours. It's not appropriate to say "well, you chose surgery...you knew what you were getting in to." That's like telling the police officers asking for bullet proof vests to "suck it up...you knew you'd be getting shot at, and that death is a possibility." Just because there are problems, doesn't mean that those who have the courage to speak out for positive change should be silenced, and told to "suck it up, deal with it."


Somehow doctors are expected to be...martyrs of sorts. I wonder why? Is it because society holds doctors in such high esteem? (the rate of frivolous malpractice lawsuits show that that's not the case). Is it because society helps subsidize the doctor's medical education, and therefore has a financial interest in doctors and their training? (Oh wait, they don't, actually, so that can't be the case). Is it because the doctor and his/her family are "taken care of" in *their* time of need, like the village witch-doctors of civilizations past? (Not counting on that). [hand raised high over my head, waving back and forth] I know, it's because doctors make tons of money, and people who make tons of money are held to a higher standard? (Well, 80-200,000K year is hardly a "ton"...and along this line of logic, where's society's accountability of Trump, Gates,
insurance company CEOs, Enron's CEO, Delta's CEO...and so forth and so on).

Maybe in the end, it's because there's something "inside of us" that makes us superior, ethically...??? But if that were true, doctors would have more say-so over the direction of health care, and wouldn't be undermined by everyone on the healthcare team (i.e non-physicians)...because, afterall, they'd be innately ethically superior.

***
But, as it is, everyone wears a white coat, pretending to be "doctor." (Because in polite society it's not nice to
hurt people's feelings by telling them that there may be someone else that's more valuable to the organization than they are. God forbid we call a secretary, a secretary). The doctors have allowed themselves to be side-lined (and marginalized) by this "healthcare team theory," instead of upholding the coveted 'doctor-patient relationship'. The doctors don't have a strong voice in matters pertaining to healthcare, since the AMA, CMA, and other professional organizations just sit on their asses, so it's no surprise that the non-physician, self-promoting organizations, have (almost) successfully sold this "healthcare team model" to society.

The only problem is...patients still want to see *the doctor*. Patients still *want* that sacred doctor-patient relationship. And in the end, they don't want to see a PA, or a nurse. They don't want HMOs or insurance bureaucrats coming between them and their doctor. And, I think they realize that this 'pimping the physician' isn't good for healthcare. Afterall, it has become quite apparent that one would be amiss to expect the doctor to see his/her position as anything other than *a job* if they are 'demoted' to "healthcare provider," (i.e. just one of the team members). A job that ranks lower than their family, than their relationships...and like most Americans, a job that isn't some sacred calling. A job.

This is where we are today - being a doctor is a job, not an identity. This is why you have specialists
bailing on their oncall responsibility. This is why you have 10 minutes with your primary doctor (PMD)...oh wait, it's now PCP (primary care provider), and they may not seem as interested in your health as you'd like. This is why the doctor-patient relationship...is weakening.

Practically, it can only be one way: either the doctor is team-leader (the "team" can still exist, and it's probably beneficial that it does), the valued decision maker, held in high esteem, the doctor-patient relationship the most coveted aspect of healthcare; but in turn expected to be...ethically superior, and somewhat of a martyr in exchange for the privilege of being called "doctor." OR....doctors are just a member of a 'healthcare team' with equal vote...where everyone wears a white coat, and decisions are made by the group.

Seems to me, that if decisions are to be made by the "healthcare team," (with everyone possessing the same clout as the doctor) then the team should have malpractice insurance...and when someone fucks-up and kills someone, it's the *team* who takes the hit (not the physician). The team should have patient care ratios. If one member on the team gets a raise, we should all get raises. We should be compensated for the amount of time we spend training, with consideration of the average cost of obtaining that education (both time value, and actual dollars). A *true* team, is a team when lives are being saved...and when someone foolishly cleans the surgical equipment with hydraulic fluid. And, finally, it should be all the members on the healthcare team that are taxed 2% to pay for universal healthcare...or none of us.

So the doctors had better get a clue, organize, speak up, and hold these professional organizations accountable....or watch healthcare completely fall apart...and pay a 2% tax to boot!!
***

Here's an interesting excerpt adding perspective:
(advice to a pre-med)

The first thing you need to do is to cool your jets. Medicine is a good career but it’s just a job. I’m sure you will meet some zealots who seemingly breathe, eat, and live medicine but for the most part, by the time you get into residency you will find that most of your colleagues want pretty much what other working people want, namely a useful job with good pay and decent hours. In this regard, maybe the years of working long hours for little of no pay like you’re going to do in medical school and residency beats the idealism out of people but I prefer to think it teaches them the difference between professionalism and fanaticism. Naturally you have to pretend to be driven to get into medical school as showing passion is a de facto requirement. Your real reasons for wanting to be a physician, while perfectly legitimate, would sound trite and self-serving if you even dared breathe them aloud. Just between me and you I didn’t want to save the world either and just applied to medical school because I thought being a doctor would be kind of cool.

Suppose you need to borrow $40,000 per year. That's $160,000 in debt added to the $240,000 opportunity cost of medical school plus the $60,000 dollar opportunity cost of a three-year residency where you will make about forty thousand a year. That’s almost half a million bucks, not even considering the time value of money which is not working in your favor. if you match into pediatrics and make $90,000 per year, your net benefit from all of those long years will be $30,000 a year which, again ignoring the time value of money, puts your break-even point sometime in 2031. This explains perfectly why American medical school graduates eschew the lower-paying primary care specialties. They are fairly intelligent and can do the math.

Because medicine is a high risk profession that deals primarily with an unhealthy and irresponsible public, the simple act of plying your trade will routinely place your home, your livelihood, and your savings in jeopardy. Think about how you’ll feel having your wages garnished to pay the widow of a crack dealer on whose discharge instructions you forgot to write, “Follow up in the Emergency Department if your chest pain returns.”


5.22.2007

Some insight - Edith Isabel Rodriguez

A heavily armed man burst into the emergency room of the Los Angeles County-University of Southern California Medical Center on Monday, shot three doctors and held two women hostage for several hours before surrendering.

The doctors were shot at a desk near the entrance where they examined patients to expedite treatment in the crowded trauma center. One of them, Dr. Richard May, 47, was reported in extremely critical condition today with a gunshot wound to the head. The two others -- Dr. Glen Roger, 41, and Dr. Paul Kaszubowski, 44 -- were in serious condition.
NY Times article

***
It's easy to pass judgment on a group, on their actions, their attitudes, and their thoughts, when you're not apart of that group...and only have an outsiders perspective. As a physician, you see people getting their ass kicked, royally, by random patients all the time. People that they're only trying to help. After a few close calls, you start to get a bit skittish when people start acting "crazy" in the ER. When people start getting mad...screaming and yelling...you just kind of wait until they settle down. Sometimes people are being crazy because they're sick. But usually, they're being crazy because...they're high, drunk, or, just crazy. As an ER doc, you realize that your life and safety aren't less valuable than that of your patient's. And, as explained below, hospitals are reluctant to show police presence for fear of negative perception. This attitude completely undermines our efforts in the ED to keep everyone safe. The hospital is not (and never will be, a damn hotel). Safety, and saving lives, trumps customer service!! I think everyone can agree on that (but try explaining this to "those who wear black suits and sit behind big desks all day, making tons of money, while providing very little to healthcare")

***
"A drunken, 50-year-old Salem man was brought to Beverly Hospital for treatment. As Richardson helped him get ready to leave, he lunged at her, grabbed her crotch and tore through her hospital scrubs. He refused to let go."

"A safe workplace is the right of every worker, yet emergency medical staff are exposed daily to violent patients who can jeopardize the safety of everyone in the ED. Despite official recommendations, many hospitals have yet to implement security protocols."
Postgrad

Nationally, crimes against nurses and health care workers are as common as assaults on police and correctional officers. One study completed this year indicates hospital assaults often go unreported. Mass nurse

Nursing advocates say hospital administrators don't like to talk about workplace violence because it ruins the "hotel-like image" hospitals want to project. "The mindset is, 'This is a hotel and the client—the patient—is always right,'" said Evelyn Bain, who studies workplace violence for the nurses association.

"When administrators tolerate verbal or physical violence (in the healthcare setting), they send a message to the public and to (hospital staff) that they are not valued."


Being violent and threatening in the hospital should be held in the same regard as those same actions in the post office (isn't treating the sick, and saving lives as important as sorting the mail?) Can drunks come into the postoffice? Yes. Can crazy folks threaten violence against aircraft staff? Of course. But what happens? They are promptly subdued, and dealt with. Actions first (to protect the safety of everyone involved), then evaluation and the sorting out of potential reasons done later, in a controlled environment. When someone comes into the ED, and shows their ass...they should be "dealt with." After being subdued, we can then work to determine the cause (sickness, intoxication, psychiatric issues, etc), and implement appropriate therapy.

As long as the hospital administration, by default, relies on the ED staff to ignore their survival instincts, and go out on a limb and help "potential crazy people" out in the waiting room...with inadequate support for doing so...we, as a society, can expect many such 'Rodriguez' incidents...most which go unrecognized by the general population.

King vs. The Times - The Rodriguez incident

The gist of the story:

In the emergency room at Martin Luther King Jr.-Harbor Hospital, Edith Isabel Rodriguez was seen as a complainer.

Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

(...she continued 'acting crazy'...so forth and so on until)

She was wheeled to the patrol vehicle and the door was opened so that she could get into the back. When officers asked her to get up, she did not respond. An officer tried to revive her with an ammonia inhalant, then checked for a pulse and found none. She died in the emergency room after resuscitation efforts failed. The times article

***
The Responses*:

"Classic! Blame it on one person and the rest are not to blame. I love the scapegoat!"

Maybe the fact that she was previously seen and discharged only hours before, coupled with a history of repeat visits and what sounds like excessive histrionics, played a part in nobody "bothering" to take "the most minimal interest in her."

It is really an indictment of the overwhelmed collapsing health care system particularly in our inner cities. Do you really think those doctors and nurses went in to the field so that they could ignore dying patients who were writhing in pain? Of course not. When everyday you are confronted with an unending stream of patients, some of whom are truly sick and dying and many who aren’t but think they are dying, it is hard not to become cold as you become overwhelmed. Everybody else looks at the video and sees a dying woman on the floor. The triage nurse probably saw someone who had already been through the ER many times and was probably just looking for attention. I’ve actually watched patients walk across the parking lot completely normally, only to collapse in pain at the triage desk. The resulting callousness isn’t right but it is nearly inevitable.

The employees at King aren't "cold and indifferent", but rather they were forced to be jaded. The triage at King is a chaotic no-man's land with homeless people, gang members, and psych patients. 2 inches of bulletproof glass separates the patients from the triage desk. It's not uncommon to have several patients screaming, while another one bangs on the window demanding immediate service. The situation is almost impossible to deal with. I never ventured into that waiting room when I was there. It was quite frightening.The lady described in that article is just like fifteen other IVDA patients I knew there. They would smoke crack, or shoot up, then run out of money and come to the ED. They would go into fits of histrionics for chest pain, abdominal pain, or for any other complaint. The problem was, that a small percentage of the time these people were actually sick, but you couldn't tell the difference between when they were sick, and when they were trying to abuse the system. Every time any of these people were discharged it was like a roll of the dice. Apparently the physician who last discharged this lady lost that dice roll.

That's the LA Times for you. I take everything that I read from them about King with a grain of salt. The times has an agenda....

***
Take home point?
This sort of thing shouldn't happen - but it does. It happens all across America, everyday. King just happens to be under the microscope these days, but don't be naive and think that it doesn't happen...everywhere (even at the uspscale hospitals). Until a better system is established, it's important to realize that any of us could have been this patient. But here's a tip that just might make a difference for you, or your family member - When you go to the ED, it's best to *not* show your ass. Just act...normal. If you act crazy, people think you're crazy...and you will be treated as a crazy person (i.e ignored). Sick people tend to be...quiet...and dying. And eventhough the nurse was wrong about this one...it's the patient who really lost. So...if you happen to be a sick patient one day and come into the ER - cooperate, communicate, and pull it together enough to not be dismissed as crazy (and tell your family/friends to do the same).
- especially if you happen to be at County.



(*responses from multiple people, on a message board)

5.18.2007

TV medicine

An asthmatic child presents to our ED the other day. After multiple nebulizer treatments and steroids, she continues to decompensate. I tell the mother...

"I'm going to have to intubate your child. Intubation means, I'm going to put a tube - "

The mom interrupts me with a sheepish grin "I know what intubation is...I watch Grey's Anatomy."

***

I love medical shows on TV. I've been watching ER since....I was a child. I think (or used to think) Scrubs was the best show on TV ever, bar none (the Cosby Show a close second). I love House MD...and really get a kick out of the way he kinda...just says what we're all thinking. And, Grey's Anatomy is (mostly) fun to watch. I like Trauma, Life in the ER. I like Untold Stories in the ER. I even TiVo Dr. G, Medical Examiner.

My husband often asks me "How can you do that all day...then come home and watch it on TV."

I don't know. I just love medicine. I just love seeing elements of my experience played out on TV.

That's why I fell in LOVE with Scrubs. The early episodes, with JD, Elliot, and Turk as interns....were the best. The interaction with the nurses, patients...even Janitor represents the various "Pencil Monitors" I talk about from time to time. We used to have Janitors sleep in our call rooms...and have attitude if you asked them to scoot over. It's like they took my experience, my thoughts, my emotions...and made it into a sitcom. Like a fly on the wall in the residents lounge. They even managed to have a diverse cast, and have them interact in a way that wasn't 'forced' or 'weird'. Excellent. It was the most realistic medical TV show made.

- but now, they're all done with training. The story lines are...kind of pointless. There are too many references to ethnicity (with the whole "Mexican thing" with Carla, or the whole "Black thing" between Turk and JD). They've made Elliot weak and...a dumb blond. The characters are no longer color-blind, and their interactions are 'weird.' They don't touch on the real issues in medicine like before (malpractice, uninsured, universal healthcare). And there's not enough actual medicine involved. Not my favorite show anymore. It's no wonder ratings are down, and the sitcom was almost canceled from the Fall line-up.

House was great. Plenty of times I'm like "oh no he didn't just say what I think he said." The time he told that mom that "just because she took a high school biology class, she's no expert in medicine." Sometimes, when parents are being difficult, and are not listening...I wish I could say something like that. The diseases, although weird zebras, actually required thought...and sometimes even helped me in real life clinical practice. I'd do it like House...white board....differential diagnosis....let's try this...let's consider that....

- but then, the disease processes became inaccurate, and outrageous. Every episode started looking the same. I didn't like the fact that House was a drug addict. He became mean, just to be mean...instead of being mean as a reaction to patient stupidity. But, I think recent episodes are better than last season.

Grey's Anatomy is a fun show. I like the diverse cast. I like the narration, and the way it captures the thoughts of interns and residents. I like the interaction between the cast members. My criticism from the beginning has been the medical inaccuracies. This is important because the public "learns about medicine" from these shows...and I feel that Shonda (the creator of the show) has a responsibility to *not* depict medicine as 'magical.' If people come into Seattle Grace in full traumatic arrest...and live. Or have a submersion accident, prolonged ACLS, and come back neurologically intact...it skews reality, and subsequently our real patient's expectations are out of the realm of actual possibility.

The interns would not be able to cut an LVAD wire, move a patient up on the transplant list, perform open heart surgery on an elevator, and get away with these things with no knowledge or input from the nurses, residents, and attendings. There would be no prom on the surgical floor (cafeteria perhaps).

My gripe is that...it's not difficult to make things medically accurate. The show would lose nothing by being more realistic. Actually, I think they'd have a wider audience...and would be doing more for the public (and for the doctors), by paying attention to medical detail.

And the finale...was horrible. After all that, Christina and Burke didn't even get married. After all that drama, breaking up a marriage, dumping McVet...Meridith can't commit? Then Izzie, after all that Denny stuff...and after knowing George for a year...now that he's married she decides to screw up his marriage? You go from actually liking her, to thinking she's a whore. Then the chief resident thing. Why is an ortho resident chief of general surgery? The Chief thing...why would an OB/Gyn even be in the running? The 'intern test' doesn't get you thrown out of any residency program (probation maybe). And I find it a bit offensive the way they refer to the ER...and the lack of ER participation on all levels. Incoming trauma, field medicine, and every procedure done in "the pit," is all surgery. That's not reality. How hard is it to squeeze in an EM resident or two? Maybe now that George is kicked out of the surgery program, he'll apply for ER?

I really liked this show....but I think it may have jumped the shark.

Then there's the all time classic - ER. I must admit, I love ER. To date, that is the most medically accurate show on TV. It educates the public well. It reveals difficultly with the healthcare system. Did you see the last couple of weeks, with the ED closed because of Joint Commission regulations? Classic. Or Lukas's malpractice fiasco with the crazy patient? Not sure I liked that whole Darfur thing...but it shined a light on a situation that we should all be aware of. And I'm okay with that. I like the diverse cast, and the snippets of 'life' we see them live outside of the hospital.


I like medical TV. I like Addison, and I'm looking forward to Private Practice in the fall.

5.14.2007

In my pocket

My daughter is almost 5 years old, and is *very* excited about starting Kindergarten soon!! There's a pre-kindergarten summer program that she begins in a few short weeks.

I remember seeing her for the very first time on ultrasound. The little light blinking representing the cardiac motion. I remember holding her at one day old, in the hospital, trying to kiss her cheek, but she actually pulled away (at 1 day old). I remember she started crying while my friends were holding her as a newborn; they passed her to me like 'what's wrong with her?' I was like 'hell if I know...I just met her too.'

I remember going to my very first ER shift after having her. I was so *nervous*, and very torn. I was excited to *finally* begin my training to become an ER doc, but...I so wished I could stay home with the baby. Actually, I wish I could have somehow carried her around with me during my shift in my pocket.

My husband was a stay-at-home dad for over a year, so I felt very supported...and very comfortable leaving for work. Soon, I realized just how nice it was to have a balance...and actually looked forward to going to work after a period of time at home. And I looked forward to coming home after a period of time at work. There were actually times, after a busy day at home, that I was like "I'm so happy I have to go to work in 2 hours..." Sometimes home is more work than work.

I remember taking her to daycare for the first time. I chose the place with such care. I took both sets of grandparents to the facility for feedback. Then, the first day of daycare...was hard for me. My daughter is the type of girl who's like "goodbye Mommy....leave...go....see you later." But, I hung around....looking for any hint that I should take my baby and run. Leaving that day was hard. I was determined not to be a wuss and cry. But, it was difficult to drive away.

We've gone thru various schools, for various reasons. There was the one, in what was supposed to be an 'upscale area,' that had a gunman chase down some dude right outside the facility while my daughter and I were loading up. There was the big, beautiful one where every teacher had an advanced degree in some aspect of child education/development....but wasn't personable enough, and my daughter actually asked to be demoted back down to the 'baby class' so she could be recognized and attended to. There was the Montessori school...where the kids got to do whatever the hell they want to do. We were actually fortunate enough to get into a preschool where movie stars actually sent their children...which was the nicest. I mean, if the school is good enough for Don Cheadle's kid....someone who has the pick of the lot, the school would probably work for my little girl. The only problem I/we had with that school was...the other parents. I just hate stay at home moms who are bitter and jealous of moms who manage to (or choose to) work outside the home. Then, there was the school that, didn't open until 9am, and closed at 5. (What working parent can pull that off?) Then, to spend over $2500/mo (for preschool) wasn't fun. I know, that's absurd...at least to me. But, it was a great school, both kids could be together, the location was perfect...the price tag was the only drawback.

Anyway, today we went to visit my daughter's new soon-to-be Kindergarten. This school is a K-8. We decided to go to the kindergarten playground during recess. The kindergartners were so...big!! My little 4 year old daughter seemed so tiny next to them. She wanted me to play with her...but I told her to go 'make a friend' to play with. She skipped over to the jungle gym. As I watched from a distance, she seemed to introduce herself to 2 girls nearby. At first I thought they'd all play together...then the 2 girls started laughing and left.

My heart dropped. Those bitches! :)

My daughter wasn't fazed, she just continued climbing, looked in my direction, smiled and waved. I waved, with tears in my eyes. She seemed content...playing all alone on a playground full of kids.

Then it was time to go: "You go Mommy, I want to stay here."

I just wish I could carry her around in my pocket...forever!!

5.13.2007

overview, the process

Doing emergency medicine is very...scary. You never know what's going to come thru the doors...and you'll likely see lots of stuff you know absolutely nothing about.

Emergency medicine is also very frustrating. Much of what you see is the end result of people being dumb-asses. Drinking too much, racing cars on the freeway, fighting over city blocks that belong to the taxpayers. You see people who have no primary care, and use the ER for said care. And you have those vagueomas - those people who come in with no real emergency, that complain of everything (multiple vague complaints)....most of which you can do absolutely nothing about.

If I had one wish for patients with regards to coming into the ED, it would be to know exactly why you're there (more on that another day).

***
As a medical student you feel pretty good about yourself. Eventhough you get your ass handed to you regularly by attendings and senior residents...at the end of the day you probably actually know more than most people give you credit for. (Actually, you get no credit at all, for knowing anything...so it's not hard to know more than 'nothing'). Not very stressful.

As an intern, you know enough to know...that you know nothing. But, everyone seems to expect you to know everything. Nurses are calling you...asking you stuff. Patient's and their families are calling...asking you stuff. The attendings are calling...asking you stuff. Very stressful.

As a junior resident, you're super stressed (at least in my program). You realize that, in fact, no one actually expects the intern to know anything. And the student is just in the way. But you....you should know. At King, it was the junior resident who took care of the sickest patients. The full arrests, the traumas, the pediatric codes, the premature labors and deliveries in the ED. You took the calls on the box (the paramedic runs) and directed the paramedics to various facilities as appropriate based on the type of patient they had, their problem, and the capacity of the surrounding hospitals. As a junior at the Kingdom, you were plenty busy.

Personally, I would arrive for my shift a full hour before. I would get my critical care space ready with intubation tubes, IV lines, scalpels, suctions...everything. I would take unofficial sign out, and start my progress notes, because once my shift actually started, it wasn't easy to stay on top of things. And overnight shifts were especially stressful because in the morning we had rounds with the Chairman. And after a long night of critical patients, I had to stay an additional 2 hours for pimp rounds.

During these rounds, it was expected that the residents present the case in detail, know everything about the patient, be able to recite lab values, go thru the differential diagnoses, the treatment plan, the outcomes of the various treatments, the ultimate dispostion. Then be prepared to get pimped on the subject matter. How many times did we simplify a complicated patient to "pneumonia"....just so we could anticipate and prepare for the pimp session that is rounds. Also, we had to stand in a semi-circle, and look directly at the Chairman (and *only* at the Chairman). If you're presenting to someone else in the Chairman's absence...and he shows up...you must immediately refocus or feel his wrath.

So...I remember this one time. I had a patient in congestive heart failure. We worked on him all night, and by morning he was better.

side note:
Sometimes is so much easier on rounds when the patient is in a coma because there is no "feedback" from them.

For example: "Good morning Dr. Chairman, this patient is a 65 year old gentleman - "
The patient interrupts with an attitude: "I'm not 65...I'm 63!!"
Who gives a shit? Doesn't really matter dude.
So you can imagine what it's like when you totally forget the past medical history...or get the medications wrong, in the presence of a patient who's alert and paying attention.

okay, back to dude:
He presented in near arrest, but after treatment he was alert and interactive. So, on rounds I knew his history, meds, and could recite the ED course. But, I got caught giving eye-contact with someone other than the Chair. He interrupted my presentation "I AM THE CHAIRMAN OF THIS DEPARTMENT, YOU LOOK AT ME!! YOU PRESENT ONLY TO ME!! IF YOU WANT TO GRADUATE FROM THIS PROGRAM WILL YOU *NOT* DISRESPECT ME"

Wow!! It took *everything* in me to keep from running to the bathroom with my arms waving over my head and crying out loud like an infant. Suddenly, I couldn't remember anything about the patient. His name, his chief complaint...nada. So...I do what every good resident does when they don't know something....I made it up on the spot. As I fubbed my way thru the rest of the case, the patient looked at me smiling, nodding in agreement (eventhough, as I mentioned, nothing I was saying was accurate). Then, after I completed my 'story' the pimp questions came. And, this poor patient actually tried to help me by interrupting rounds to answer questions and defending me. This...brought tears to my eyes. After we'd moved on...I hung to the back of the semicircle. As I make eye-contact with the patient, I hear him say..."don't let him get you down, he's an ass-hole." Smiling inside...I was able to move on.

***
Anyway...I'm done being a medical student (where you learn about medicine). I survived internship (where you learn to be a doctor). I made it thru that very stressful junior year (where you learn how to be an ER doc). Then as a senior resident...I realized that I actually did know some stuff. Supervising interns and medical students. Supporting the juniors. Running the floor (i.e. taking care of all the patients, either directly myself, or indirectly by supervising junior residents/interns). Delegating tasks.

As a senior resident, people start to really take you seriously, especially if you're a chief resident to boot. You can successfully argue, now...and even challenge the attendings (if done correctly). You talk more sh*t to the interns from other services when their "professional opinion" is...stupid. It's like, "I'm done talking to you...either get down here and see this patient, or get your resident to call me." You feel very confident...a bit arrogant even.

Then...you become an attending. Suddenly, it's all you. You're not a senior resident with an attending to take responsiblity for all your fuck-ups. It's all you. That's scary...on a whole nother level. Then, the supervision of residents....sucks. You realize that they don't listen, don't follow thru, and they (get this) lie on rounds!! Imagine that? How irresponsible. You can't trust them. And they always talk back!!

Sometimes I miss being a senior resident!!

5.12.2007

Auto vs. train

The paramedic trauma run.

Rescue 23: "This is rescue 23 to Base with a trauma run."

Me: "Rescue 23, this is Base, go ahead with your run. "

R23: "We're here one the scene of an accident; auto vs. train. There is an approximately 22 year old woman here who was apparently trying to outrun the train according to bystanders, and was hit by the train while in her car. We've just extricated her, and she appears to be about 8 months pregnant. She is non-responsive, has no pulse, and no respirations. She has open fractures to all of her extremities, and an open head wound. She is in full spinal immobilization, and we've established 1 large bore IV. We are unable to intubate after 2 attempts, and she is difficult to bag. You are the closest trauma center. Our ETA to your facility is 2 minutes, over"

Me: "I copy that rescue 23...we'll see you in five in our trauma center. "

-overhead speakers-
*Code yellow to the trauma center. Code yellow to the trauma center. Code yellow to the trauma center....*

As I leave the box and run over to the trauma center, I hear the sirens.

Quickly we suit up, masks, gloves, gown. We set up airway equipment. Since the patient is reported to be pregnant we call a 'code purple' - for the OB team/crash c-section team. We call a 'code pink' - pediatric full arrest. By the time the paramedics are backing into our trauma center, everyone is ready.

They roll in a woman in full traumatic arrest, with all of her extremities dangling from obvious open fractures, blood dripping as the gurney is rolled thru the double (security) doors. She appears to be 8 months pregnant.

As the EM resident, I get to intubate her. It's a difficult intubation with blood everywhere, and cervical collar in place. Once the airway is secure, we do follow ACLS protocal, but full arrest from blunt trauma...is...not good for your health. Death is almost always certain.

After 15 minutes of unsuccessful resuscitation, we divert our attention to the fetus. OB performs a bedside ultrasound. It's difficult to see much of anything. No fetus is clearly seen, but perhaps her uterus perforated?? Perhaps the fetus is much younger than we thought. The OB detects 'movement.'

"Movement" is enough. So we perform a perimortum c-section. The senior resident gets to cut her abdomen open, and deliver the baby.

So he cuts. We huddle around. And 'ta-da'. No baby!! The uterus is small, and in her pelvis.

No way?

This happened over a year ago, and to this day, the family insists we 'stole' the baby from her uterus. A lawsuit is pending, no doubt.

Nursing ratios

4:1 nursing ratio...sounds like a good idea on the surface.

Basically, nursing ratios are not good for the patients when there are already not enough nurses....
...unless, of course, you're one of the first 4 to arrive.