Let’s Get Some Things Straight.

WARNING: RANT IMMINENT! DANGER, WILL ROBINSON, DANGER!

-When your doctor reaches out to take your pulse, he already has his hand in position to do it properly, taking into account where your hand is and in what orientation. Helpfully holding out your hand and turning it face up only complicates matters.

-A female hospital worker is not automatically a nurse. A male hospital worker is not automatically a doctor.

-Your ER doctor doesn’t give a damn about what drugs you took last night, except to know how it will affect your medical condition, and whether or not she should keep an eye out for withdrawal symptoms. She’s not going to tell the cops that are hanging out in the ER to protect her. They probably don’t give a damn either.

-Your doctor doesn’t care how much you weigh, except to the point that it affects your health and therefore makes more work for him to keep you healthy.

-Your doctor can smell whether or not you smoke, and probably even how much. You may as well just tell her.

-Your doctor sees entirely too many people over the course of his day to bother spending the emotional energy to make value judgments about you or any of his other patients. I guarantee it.

-The information in the article about your medical condition that you helpfully printed out from that website is probably information that your doctor memorized in his first month of medical school. Or it’s completely wrong. Your doctor will look over it and smile graciously at you if he’s in a good mood.

-Doctors don’t have any influence over nursing staff. Doctors and nurses are colleagues, at the same level on the pecking order, and with completely different jobs. If you have a problem with a nurse, don’t complain to the doctor. Complain to the nurse’s boss.

-Being obnoxious or demanding does not improve your care or your family member’s care. You may get what you want this moment, but you’re far more likely to be unconsciously neglected later, and you’ll have to keep on being obnoxious and demanding in order to get the normal level of care that you would otherwise receive. Nurses and doctors are human, even though they aspire to greatness and have to act professional; they don’t like being yelled at and pushed around any more than you do. The effect that you have on them will likely be inadvertent…but it will likely decrease the quality of care regardless. PS: Medical students spend more time with friendly patients. And get better histories. And tend to advocate more for them. That effect should also not be overlooked.

-Just because you’ve never “had to see a doctor” doesn’t necessarily mean you’re healthy. That’s like saying that your car runs perfectly because you’ve never let a mechanic look under the hood. For (insert your age) years.

-You can’t put anything in your body without side effects. That includes herbal/”natural” substances as well as mainstream medicines. There is no such thing as a miracle cure.

-The people who are most likely to complain about how long they had to wait past their appointment time are most likely to be the people who expect the doctor to spend extra time with them. You know, making the next patient wait past her appointment time.

OKAY, ALL CLEAR! AWOOGA, AWOOGA, AND ALL THAT.

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Published in: on March 15, 2011 at 11:33 pm  Comments (20)  
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Things I Kinda Knew I’d Probably Say At Some Point, But Still Surprised Me When They Came Nonchalantly Out Of My Mouth

“Hey, make sure I don’t go home with the blood in my pocket!”

Published in: on August 25, 2010 at 1:02 am  Comments (3)  
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Milestones: Te Conozco, Bacalao

Dear Fiancee Of My Dying Patient,

To be honest, this is not REALLY a milestone. Patients and family members threaten me all the time, with everything from reporting me to my superiors, to lawsuits, to actual bodily harm. Some people even threaten me as if it’s a joke, when they’re uncomfortable with a medical situation. Dealing with being threatened is normal for me. It’s practically a part of my job description.

But since this is the first time this has happened since I got the degree, I may as well mark the occasion.

Ma’am, your fiance has stage four lung cancer and end-stage AIDS. He is dying. And though we’ve told you this many times, I understand that you haven’t yet accepted it. It’s a tragic, impossible thing to have to figure out how to accept.

I know that you do not know that you’re grieving. I know that you’re trying to exert power in a situation in which you feel powerless.

When you go and speak to the chief of medicine tomorrow about my refusal to flip your fiance’s medication schedule twelve hours so he gets his morning meds at night and his night meds in the morning, I hope it helps you take another step through the stages of grief that will allow you to face the end with grace and dignity together.

I know this demand is an expression of your need to participate in your fiance’s care and have some power over a horrible situation.

But let’s be clear. You’re not going to have my job for refusing.

You are a family member, and therefore your needs are important to me ONLY if all of my patients’ needs have been adequately dealt with first. If they haven’t, there’s only so much time I’m willing to spend on you. I’m sorry if that makes you angry. But my time is limited, and it belongs to my patients.

I am more than happy to be your bad guy. I’m everybody’s bad guy. Just look in popular media. The doctor is ALWAYS the bad guy.

People never think twice about threatening the bad guy.

It. Happens. All. The. Time.

If you don’t believe me, consider this:

I have been a ward doctor for ten days.

Ma’am, I wish you the best. I’ll see you tomorrow.

And I’m very good at smiling at you.

Love,

Dr. Grasshopper

(Posted with trepidation.)

Picture from: stacie-siddha.iblogsfree.in

Published in: on August 11, 2010 at 11:16 pm  Comments (7)  
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Stories From Med School: Hyperthermia

As a fourth-year medical student, you’re supposed to know enough about what’s going on in a patient’s treatment to be able to follow along with the rest of your team, and even to contribute a few aspects to the patient’s care. As a result, a fourth-year student at my med school is often distinguished from a third-year student by the title of “Sub-Intern”, or “Sub-I”.

I did my Sub-I in internal medicine at the county hospital, and then I requested a rotation in Intensive Care in the same hospital, with one of the toughest old-guard docs the hospital had. I figured I’d learn a lot. And I did.

Anyway, this story is from my ICU month.

—–

One Tuesday at four in the morning, when I was on call with my team, a patient came onto our service in really, really bad shape. He was a young guy (younger than me, which still gives me a touch of existential crisis when it happens), in his teens.

He had been running away from the cops with a stash of cocaine, about eight ounces in a plastic bag. He realized that he was going to get caught, so he decided to get rid of the evidence.

By swallowing it.

And eight ounces of cocaine entered his system. He was unconscious within minutes.

Here’s what cocaine does to you. It cranks up the thermostat in every system in your body. Your heart rate goes through the roof (which is why you can get heart attacks from cocaine use), your blood pressure goes through the roof, your breathing ramps up, et cetera. Your temperature also skyrockets.

When we assessed our friend, his temperature had reached 106 degrees. That’s well into brain-damage territory. If we didn’t bring his temperature down, and fast, he’d die. And if he didn’t die, he’d likely come out of this in a permanent coma.

I’ve never seen my team move so fast.

So, we started an IV of refrigerated saline, and set the drips as fast as they would go. We packed him in ice, and covered him with a cooling blanket that would draw even more heat from him.

If you need to cool someone down, the best places to put the cooling sources are in superficial (close to the skin) areas with high blood flow. In practical terms, that means neck, armpits, and groin.

But that apparently wasn’t even enough. The cocaine was still raging through his system, telling it to RAMP UP! RAMP UP! RAMP UP!

We had to bring his temperature down even faster , and it had to happen SOON! The only other thing we could do was to blow cool air on him in addition to the other measures.

Which meant we needed a floor fan. And as the junior member of the team, it was up to me to obtain one.

In retrospect, the team might have just needed me out of the way; the fan wouldn’t help THAT much. But I didn’t realize it at the time. At the time, it seemed like the most important task in the UNIVERSE!

—–

Let me tell you something about the county hospital. It’s a huge old building with maybe ten floor fans in total. They are all located at the nursing stations.

In August in that part of the country, floor fans become a desperately sought-after commodity, and are fiercely guarded by the nurses. Understandably. That hospital is not the friendliest working environment, temperature-wise, and nurses spend their entire day running around.

But if you need a floor fan in August…especially if you’re a medical student…you need to either run across a really, really understanding nurse…or you need to risk pissing one off.

I did not have time to find a really, really understanding nurse. There was a kid dying in the ICU. And a floor fan would help.

Cue Mission: Impossible music.

I ran through each ward on each floor of the hospital at top speed, taking stairs between floors two at a time. Patients and nurses eyed me curiously as I flew past. A doctor running in a hospital usually means an emergency. But a med student running at four in the morning? Who knew what that meant!

Finally, I located a precious fan on the fourth floor, cooling off the momentarily empty 4 East nursing station.

I then called an elevator.

And made a mad dash.

Three things happened at once.

1) I unplugged the fan and hefted it against my shoulder.
2) The night nurse appeared from a patient’s room.
3) The elevator dinged down the hall.

We both started to run. And we both started to yell.

“Where are you taking that! Come back here! What are you doing?” She didn’t know why I was taking the fan. She just knew that the nursing station would be practically unliveable for the rest of the night without it. Like I said, who can blame her?

“I’m the Sub-I on the ICU team!” Oh, there was no way I was stopping! Patient care trumps nursing comfort, and Sub-I safety! “My pager number is 123-4567! This is for a patient! I’ll bring it back! I promise!”

The elevator doors started to close. The night nurse was right behind me.

I dashed in, just in time for the doors to close behind me and right before the nurse could catch the elevator. I punched the button for the ICU floor so the nurse would not be able to call back the elevator.

I’d made it.

I ran back to the ICU as fast as I could, and we set up the fan. And we worked. And we worked.

—–

The kid was in the ICU until the end of my rotation. On the last day of the rotation, he woke up a bit.

“Hello,” we said.

“Hello,” he carefully said back.

“How are you?”

“Fine.”

Success! We had saved enough of his brain function that he had at least retained enough processing power for a simple conversation! We grinned at each other like idiots.

I left the ICU service the next day, so I have no idea how much function he recovered. But he survived to see his family again. So I call that a win.

And the floor fan was there, helping him stay cool, until I left the service.

—–

On the last day, I took the fan back up to the nurses’ station on 4 East, and plugged it back in.

The nurses all exchanged looks. They knew who I was. And I was all alone, the baby gazelle on the Serengeti of the county hospital wards.

And I slunk out of there as fast as I could.

—–

Bonus round! Which branch of the autonomic nervous system predominated in every single person in that story? Especially the teen?

Dr. Gritchhopper. Or, “Lessons From Residency Orientation”

-The worse the communication abilities of the speaker, the angrier they get when you don’t have a clue what they want you to do. And the more likely that they’ll blame you for the problem.

-There are fifty ways to say the same thing.

-Each way takes longer than the one before

-When you work for three hospitals, and two of them do a joint orientation, they don’t coordinate about subject matters. They just have one person from each hospital give a talk about the same topic. During which they say the exact same things. One after the other. Over and over.

-Even after a few years of up-close experience about the awful things people do to each other, pictures of babies with strangulation marks on their necks and full-thickness burns on their hands can still make me feel physically ill.

-I still can’t sit in auditorium seating without pissing off the people in my row. Darn foot-bouncing habit. This is why I never went to class once the lectures were put online.

-The prettier the day, the longer-winded the speaker. And the worse your mosquito bites itch.

-You can take pretty much any one of those stupid “comprehension tests” without having heard any of the orientation lectures. The questions’ wording leads you by the nose.

-There are an awful lot of statistics in the world that I just don’t care about.

-Hammocks make everything better….unless they’re at home and you’re inside in an endless orientation, dreaming about sitting in them in the perfect weather you’re also not sitting in.

-You have a serious problem if your orientation lasts from 8 to 6, three days in a row. It’s an even more serious problem if there is ABSOLUTELY NO INFORMATION disseminated in that time, and none of the MUST DO BY YOUR START DATE tasks get done either.

-There are some jobs that just shouldn’t exist.

-Paperwork is endless and Whac-A-Mole-esque. If you’re not careful, it’ll eat you and everyone you love.

Published in: on June 27, 2010 at 1:29 am  Leave a Comment  
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Lessons from ACLS

I’m studying ACLS this week! (That’s “Advanced Cardiac Life Support”.) Basically, what to do when someone’s heart stops. In a hospital, that’s called a “code”. I believe I will use the following procedure when I am called to run my first real code:

You know, except for that awkward not-really-love-scene-in-a-closet thing.

Anyway.

When performing chest compressions during CPR (Cardio-Pulmonary Resuscitation) during a code, you’re supposed to deliver about 100 compressions per minute. (Note: Spelling “resuscitation” correctly took me four tries….)

Major workout.

But, like all workouts, it’s better with music. Because who wants to learn how to count at a rate of 100 beats per minute?

So.

There are two songs that you can use to control the speed of compressions.

One, interestingly, happens to be “Staying Alive”.

The other, ironically, happens to be “Another One Bites The Dust”.

I guarantee you practically every healthcare provider has one of those two songs running through her head as she gives chest compressions. If she doesn’t, her ACLS instructor was likely a zombie. She was lucky to escape ACLS class with her life.

So, now you can sing along the next time you see someone on TV giving CPR! And if they’re doing it at the wrong speed, you’ll know! That way, you can mock them appropriately!

Let’s practice! (Some of these involve spoilers, I think.) Anyway, I give you: A Parade of CPR Absurdity!!!

Note: Guidelines change faster than the epidemiological spread of zombie-ism. So, when some of these were filmed, it’s possible that they were per the guidelines at the time. Some of them.

Added bonus: If you sing out loud, you can make your dog and/or significant other stare at you with an adorable, quizzical look!

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If you use this as if it were real medical information, I’ll start singing “Staying Alive”. I may or may not accompany myself with chest compressions. Regardless, it will not be pretty.

Stories From Med School: Impetigo

Caution: yucky picture below.

I went to Honduras during my Last Summer Vacation EVER, between my first and second year of med school. We worked for a month in an emergency room in a small coastal town called Trujillo. It was a fantastic experience.

As I was heading home on the plane, I got a sore throat. Probably picked it up in the ER right before I left.

A day or so later, I developed a rash across the bottom half of my face. It looked like I had grown a beard made of strawberry ice cream.

It itched like crazy.

Of course, it turned out to be impetigo, a manifestation of either a staphylococcus or a streptococcus infection. (In this form, I read at that time, they are clinically indistinguishable.)

It looked a little like this. Over the entire bottom half of my face.

Quiz time!

After I was diagnosed, was my first reaction:

A. Crap! If I didn’t get the chance to treat this in time, it could have progressed into necrotizing fasciitis and disfigured me for life if it didn’t kill me!

B. Wait till my med school buddies see this! They’ll love it! I gotta do a call-around!

I’ll give you a hint. I made sure I had some exam gloves, in case people wanted to poke at it.

You are welcome to draw any conclusions you like about my mental health.

Published in: on June 15, 2010 at 1:18 am  Comments (15)  
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High-Stakes Hippie Love-Fests: Doctor Edition!

I love this song. I love the almost unforgivably peppy bounciness of the thing, and I adore how the brashness of the ascending modulations near the end of the song just pulls my mood right up with them.

But I also enjoy (some of) the lyrics: “Stand in the place where you work…” and think about it for a minute. And “wonder why you haven’t before.”

I do that all the time, actually. As a writer, I’m a constant people-interacting-with-surroundings-watcher. And by all that is good and writerly, there is no more fascinating place to observe humanity than in a hospital.

I’m not even talking about the patients, or their families, though you will never see a more honest cross-section of humanity anywhere else.

I’m talking about the staff.

If you’ve worked in any kind of service profession, you know how much it sucks when one of your customers is having a bad day. They take it out on you, right? And it can completely ruin your day.

In my job, EVERY PERSON I INTERACT WITH is having one of the worst days of their entire life. They’ve just been told they have cancer. Their child may not live to see the sun rise in the morning. They haven’t slept in a real bed for days, months, or years, and they’ve been poisoning themselves with nothing but hospital food. They’ve been cut open and had a leg or a kidney or a section of their intestines removed from their body. They’re in pain, they’re scared, they’re lonely, they’re dying.

That’s baseline.

Now think about the people who are there every day. Who not only interact with patients and families in a pleasant and patient manner, but also are expected to work miracles, teach complex concepts, learn complex concepts, be scientifically brilliant as they make life-and-death decisions, and get along well with their co-workers. On 30-hour shifts. With a sometimes abusive patient load. In danger of catching hepatitis or HIV from a slip of the wrong needle.

Stand in the place where you work, indeed. In an environment like that, your very survival might depend on your team.

You’re exaggerating.

Well, yeah, maybe about the “very survival” part. (I always thought the “your very survival” was a silly grammatical construction, by the way. You can’t say it except in an overdramatic exaggeration.) But I’ve been on good medical teams and bad medical teams, and you wouldn’t believe the difference it can make.

If you’ve ever been in a hospital (at least, a teaching hospital), you’ve probably been the focus of an experience in which ENTIRELY TOO MANY PEOPLE IN WHITE COATS crowd around your bed near the beginning of the day (probably waking you up in the process), talk about stuff incomprehensibly, and leave. You might see those people individually over the course of the rest of the day, each breezing in and out with some random task or question. You probably have no idea what anyone’s name is.

That’s your medical team.

So here’s the basic structure of a medical team, at least at the teaching hospitals I’ve been working in. Try picking it apart next time the flock of white coats surrounds you while they round on you. Remember that there can be pretty much any combination of these roles on a typical team.

At the head you have the Attending Physician. The head honcho! The big cheese! That “here” whence the fabled “buck” doeth “stop”! (Is that a proper use of “whence”? I couldn’t decide, so I figured I’d just run with it.) The Attending is in charge of the service, and is ultimately responsible for the patient’s treatment. If there’s one relatively much older person in the group, that’s most likely the attending.

Sometimes a service will include a Fellow. (This can be a guy or a girl; it’s the name of a position in this case. Not replaceable with “feller”. Believe me.) The Fellow is a doctor who has completed medical school and residency, and is specializing further in their field: cardiovascular medicine, pulmonary critical care, endocrinology, or whatever else. I don’t know exactly how fellowships work; I’m not there yet. But I love having Fellows on the service; they are the most knowledgeable on the medical team (with the exception of the Attending), and they tend to be a little more accessible for questions. All of the Fellows I have been on service with have run very, very good teams.

Next on the ladder, we have the Resident(s). Residents are doctors who have completed medical school and are in their “apprenticeship” period. This is the time when they really learn how to practice medicine: decision-making, knowledge base, and leadership. The Resident on the team is usually responsible for the ultimate design of the treatment course (with the approval of the Attending and perhaps the assistance of the Fellow). The Resident is also in charge of managing the team that is taking care of his patient, and is responsible for making sure the day-to-day tasks of patient care are taken care of. The quality of a patient’s treatment really depends on the quality of the Resident. I’ve worked with fantastic Residents and awful Residents. They can really make or break a team.

And one step down are the Interns. This is actually the step I’m about to take. Internship is the first year of residency; Interns are full doctors for the first time. They are often the workhorses of the medical team. They are the patient managers. They are the hands that accomplish the tasks of patient care. They are often the ones who take calls from nurses, especially overnight. From everything I’ve heard, intern year is brutal. And the learning curve is steep. This is both exciting and terrifying to me.

In my experience, Interns tend to be the most cynical and angry people on a medical team. They work HARD, and it’s hard work. Under massive amounts of stress. For very little pay. Here’s a song that pretty much catches the general attitude of intern year, at least as I’ve seen people react to it. Note: I’m actually rather hesitant to post it, because it’s very patient-unfriendly…but it’s honest, even if it’s angry. And it’s very, very angry. Not safe for work.

Next (sometimes), you have Sub-Interns. These are fourth-year medical students. Like me. We try to act like Interns. But we have less ultimate responsibility, so ultimately less existential stress.

And then, the Medical Students. These can be either third- or fourth-year students, depending on the setup of the team.

I think this video pretty much says it all:

If you’re lucky, your team might have a Pharmacist and/or a Nurse Practitioner and/or a Physician’s Assistant on it. These people are freaking life-savers. For everyone, patients and staff alike.

People rotate in and out of the teams on a biweekly or monthly basis, depending on the service and on the schedules of the team members. So a medical team is in a state of constant flux. This can be a good thing or a bad thing; it breaks up bad teams after a while so you don’t have to work with malignant people forever, but it breaks up the good teams, too.

So where does the “high-stakes hippie love-fest” come in?

I love working on a medical team. For whatever reason, it just suits me. And I love it when the team really gels, even when it’s destined to break up at the end of the month.

I’ve been on teams where people practically ran down the hall, jostling good-naturedly for the privilege of holding the door for the rest of the team during rounds.

I’ve been on teams where, first thing after rounds, everyone descends on the post-call team member and asks to help with her work so she can go home sooner after she’s worked 30 hours… no matter how much work they have to do themselves.

I’ve also been on a team where the resident actively undermined his team members, not even always to make himself look good.

I really do prefer the functional teams. I guess I’m a little sensitive to group dynamics, and it just makes life easier when everyone supports each other, respects each other, and generally gets along.
Because the hospital environment can be physically and emotionally as dangerous as a world on the other side of a Stargate. And facing that kind of peril, it’s so much nicer to step through with people who have your back.

What is your work environment like (if you have a day job)?

Picture: http://www.shipbrook.com/jeff/raytrace/graphics/stargate.jpg

Published in: on March 7, 2010 at 5:59 pm  Comments (8)  
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