After a patient is "cured" enough from their hospital illness to go home (or go to a rehab facility or wherever), they are "discharged" from the hospital. Upon discharge, a report is written by one of the doctors who cared for them summarizing their prior medical history, summarizing the events leading up to being hospitalized, what happened during the hospital stay, significant physical exam and lab findings, then how things were looking the day of discharge and what the follow-up plan is going to be for each of the problems identified in the past, present, and future. It is an odious task to write this report, as you can imagine these summaries can be rather long. They are the responsibility of the hapless intern. They are the bane of my existence.
If my regular workday runs from 6am to ~6pm, and I have to wake up at 5am to start my day, and once I get home after work I still have to take care of my ADLs like eating, bathing, picking up the mail, and whatever else I do to remain a marginally functional person, it's basically already time to go to sleep again. So it's understandable how one might fall behind in their discharge summaries. I learned the other day that if you fall behind for a few days, you get a nasty message that basically says, "You fail at life. How could you NOT have the discharge summaries done? Die. Just die now." That's in my own words, of course; the original message, generated by the medical record keeping department, was much more graphic. But seriously, it did include the phrase "48 hour suspension" as a punishment for being a few days late in completing the summaries. At first I was elated- my punishment for not completing all my work would be to have 2 days OFF to catch up?! Delightful!!! But then I found out that the "suspension" means I still have to go to work, but my name just gets put on a list that goes to my program director. It would be more accurate to call it a "shaming" than a "suspension" but whatever.
You have two choices with the discharge summaries. You can type them or "dictate" them. I hate dictating. There isn't really a nice quiet place for you to do this since as a resident you don't have an office; you do this over the phone in a busy workroom full of your colleagues, or you try to sneak off to an empty conference room so that you can dictate in peace only to be interrupted halfway through your dictation and kicked out of the room by a bunch of vascular surgery residents who say they are rounding in that conference room imminently. You call up the dictation number and record yourself saying out loud all the information that needs to go in the report, following the proper report format [including instructions for "next paragraph" or "next line" so your transcription doesn't come out as one long ugly block of text], and this recording is later transcribed by someone in the basement somewhere, and a copy goes to your electronic inbox for review and signature. This is terrible for two main reasons.
ONE: apparently my voice is unintelligible to the trolls in the basement doing the transcriptions. I say this because, (a) I've never met ANYONE who works in transcriptions, thus I suspect they hire trolls, who toil away in the basement, (b) whenever I get the transcriptions back they have all kinds of strange words written down that I know can't have possibly sounded like anything I was trying to say at the time, so I end up needing to make extensive revisions.
TWO: the dumbest, most RAHtarded things come out of my face, and when I see them transcribed in the report it is mortifying. Did I really say, "The patient is taking a night-time dose of insulin at night, which is 15 units of lantus insulin, nightly... each night. At night." ?!? Or is a troll just messing with me? Sadly, I suspect I DID say that. ::Shame::
The only solution to this problem: the shitcharge.
Given the complexity of the patients we see at University Hospital, it takes over an hour to do a really great job on writing a discharge summary. I don't have that time. Or when I do take that time, I fall behind in my summary reports and then I get in trouble. So I can battle the trolls and try to dictate the summary, which always ends badly, or I can write the fastest, shortest discharge summary that contains what I hope is all the pertinent information. If I limit myself to less than 30 minutes per brief discharge summary, it becomes a highly efficient process. And by "efficient," I mean just "shitty" because it takes me like 15 minutes to write a decent email so you can imagine what kind of quality report I can put out in 20-30 minutes. Thus, we have the shitcharge summary. It's a fairly decent summary of the main issue requiring hospitalization, but every other relatively chronic issue is just going to be listed by name, followed by "stable," or "continue outpatient management". The goal is brevity, forsaking detail.
I have to go catch up on some S/C summaries...
Tuesday, August 31, 2010
Monday, August 23, 2010
Night Float: Assume the Position
Night Float.... 14hrs of cross-covering somewhere between 50-70 patients that you only hear a one-liner about before assuming responsibility of them for the night. We can divide these patients into two main categories: asleep, and awake.
Luckily, a lot of them will be sleeping for most of your shift. But that doesn't stop the nurses from calling you- for medication clarification (including questions they know you can't possibly answer, like why the primary team switched one medication for another sometime during the day), order clarification ("I don't see a time for the pre-meal finger stick glucose checks. What time did you want those done? You should clarify the order." It's 11 o'fucking clock! You think this can't wait for the day team, who will be here, in the day, when the patient is actually eating?!?), medication list cleanup ("So I was reviewing the medications and I noticed that the patient has 2mg IV Dilaudid as needed for pain, and also 4mg IV Dilaudid as needed for pain. Can you just delete the 2mg Dilaudid order? I think it would look neater that way." WHO CARES if they have two PRN pain orders?), to ridonculous requests ("I noticed this patient has not had a bowel movement in 3 days. The primary team wrote orders for stool softeners but not an enema. Do you want to write an order to try an enema now?" Side note: it is like 11pm and the patient is asleep.)
Ok, second category: unfortunately, a lot of these patients are going to be awake. You get paged about the fact that some of them are awake like it's a problem (as in, the nurse asks for a sleep medication to give the patient because she wants the patient to go to sleep so she can comfortably ignore them and go back to shopping for shoes on zappos). You get paged about pain medications. You get paged about breathing treatments. You get paged anytime somebody falls down, and you have to go evaluate them. ("You fell off the commode in the dark? Did you hit your head? Did you hit your head???") You have to run and evaluate anyone having chest pain, shortness of breath, bad headache/abdominal pain/random other complaint. The patients you are cross-covering are scattered in different wings between the 4th and 12th floors. And your pager is going off incessantly. There were several times that my pagers were going off simultaneously WHILE I was returning another page. That's another thing- you're carrying three pagers, like little beeping grenades, just waiting for them to go off at any minute.
Alright. Highlights from my weekend of night float:
1. Patient admitted for chronic pain exacerbation spent 15 minutes yelling at me about how the Emergency Room doctors had given him too much morphine the night before when he was being admitted to the hospital ("Y'all fucked up, BIG TIME!") and how in general we, as a hospital, as a whole, suck. Here's a thought: he probably got too much morphine because he was harassing the ER nurses for more pain meds. Anyway, after debasing the hospital, and being rude to me, he managed to offend everyone else in the room by accusing us of "tricking" him and putting him on a psychiatry ward rather than a general hospital ward, saying, "Oh I know crazy- this mind is STRONG [points to his own head]- don't even TRY to play mind games with me!!! I know this floor is full of nut jobs- including THAT one!" [gesturing obviously over to his hospital roommate. Who was sitting in bed, alert and not crazy at all, with family at bedside. All of whom heard this and glared.] I later found out from his nurse that he also accused me of being a psychiatrist, masquerading as a medicine intern. No comment. Anyway, why was I called in the first place? He wanted more morphine. OF COURSE.
2. The electronic medical record went down for "maintenance" for 4 hours on Saturday night. Hilarity ensued when we had to write STAT orders. I had completely forgotten how to write paper orders. The nurses had to guide me through step by step.
"Ok, first you write the date. The date. That's not the date. Ok, then the time. Yes... then the order. Yeah. And don't forget to specify if it's routine, urgent, or... ok, that's ok, it's still legible. Good, now sign it. Sign it. Do you know your PI#? Ok, good, you're all done. ...what do you mean 'where does it go now?' We fax it down to the pharmacy. Where did you think it went? Ok... ok, nevermind doc. Thank you, thank you...BYE."
3. The best: the fake AMA patients. Unless a patient is under a psychiatric hold or for whatever reason doesn't have mental capacity, they are free to leave the hospital at any time. But if they are leaving against medical advice, they have to sign the AMA (or "Against Medical Advice") departure form. Sometimes certain patients, ohhhh let's just say the kind who have a substance abuse history and are on chronic methadone/actively using heroin/abusing a ton of painkillers at home, will "threaten" to leave AMA. When you ask why, they will throw out a litany of complaints... that inevitably leads to their "pain not being addressed", and they will suggest that if they could get that 12mg IV Dilaudid push, they might just be able to be persuaded to stay the rest of the night.
Even though I'm complaining a lot, I got very lucky since no one coded, had chest pain, stopped breathing, or otherwise had a medical calamity on either my shifts. Thank you, hospital gods, for shining your fluorescent rays of mercy upon me.
Luckily, a lot of them will be sleeping for most of your shift. But that doesn't stop the nurses from calling you- for medication clarification (including questions they know you can't possibly answer, like why the primary team switched one medication for another sometime during the day), order clarification ("I don't see a time for the pre-meal finger stick glucose checks. What time did you want those done? You should clarify the order." It's 11 o'fucking clock! You think this can't wait for the day team, who will be here, in the day, when the patient is actually eating?!?), medication list cleanup ("So I was reviewing the medications and I noticed that the patient has 2mg IV Dilaudid as needed for pain, and also 4mg IV Dilaudid as needed for pain. Can you just delete the 2mg Dilaudid order? I think it would look neater that way." WHO CARES if they have two PRN pain orders?), to ridonculous requests ("I noticed this patient has not had a bowel movement in 3 days. The primary team wrote orders for stool softeners but not an enema. Do you want to write an order to try an enema now?" Side note: it is like 11pm and the patient is asleep.)
Ok, second category: unfortunately, a lot of these patients are going to be awake. You get paged about the fact that some of them are awake like it's a problem (as in, the nurse asks for a sleep medication to give the patient because she wants the patient to go to sleep so she can comfortably ignore them and go back to shopping for shoes on zappos). You get paged about pain medications. You get paged about breathing treatments. You get paged anytime somebody falls down, and you have to go evaluate them. ("You fell off the commode in the dark? Did you hit your head? Did you hit your head???") You have to run and evaluate anyone having chest pain, shortness of breath, bad headache/abdominal pain/random other complaint. The patients you are cross-covering are scattered in different wings between the 4th and 12th floors. And your pager is going off incessantly. There were several times that my pagers were going off simultaneously WHILE I was returning another page. That's another thing- you're carrying three pagers, like little beeping grenades, just waiting for them to go off at any minute.
Alright. Highlights from my weekend of night float:
1. Patient admitted for chronic pain exacerbation spent 15 minutes yelling at me about how the Emergency Room doctors had given him too much morphine the night before when he was being admitted to the hospital ("Y'all fucked up, BIG TIME!") and how in general we, as a hospital, as a whole, suck. Here's a thought: he probably got too much morphine because he was harassing the ER nurses for more pain meds. Anyway, after debasing the hospital, and being rude to me, he managed to offend everyone else in the room by accusing us of "tricking" him and putting him on a psychiatry ward rather than a general hospital ward, saying, "Oh I know crazy- this mind is STRONG [points to his own head]- don't even TRY to play mind games with me!!! I know this floor is full of nut jobs- including THAT one!" [gesturing obviously over to his hospital roommate. Who was sitting in bed, alert and not crazy at all, with family at bedside. All of whom heard this and glared.] I later found out from his nurse that he also accused me of being a psychiatrist, masquerading as a medicine intern. No comment. Anyway, why was I called in the first place? He wanted more morphine. OF COURSE.
2. The electronic medical record went down for "maintenance" for 4 hours on Saturday night. Hilarity ensued when we had to write STAT orders. I had completely forgotten how to write paper orders. The nurses had to guide me through step by step.
"Ok, first you write the date. The date. That's not the date. Ok, then the time. Yes... then the order. Yeah. And don't forget to specify if it's routine, urgent, or... ok, that's ok, it's still legible. Good, now sign it. Sign it. Do you know your PI#? Ok, good, you're all done. ...what do you mean 'where does it go now?' We fax it down to the pharmacy. Where did you think it went? Ok... ok, nevermind doc. Thank you, thank you...BYE."
3. The best: the fake AMA patients. Unless a patient is under a psychiatric hold or for whatever reason doesn't have mental capacity, they are free to leave the hospital at any time. But if they are leaving against medical advice, they have to sign the AMA (or "Against Medical Advice") departure form. Sometimes certain patients, ohhhh let's just say the kind who have a substance abuse history and are on chronic methadone/actively using heroin/abusing a ton of painkillers at home, will "threaten" to leave AMA. When you ask why, they will throw out a litany of complaints... that inevitably leads to their "pain not being addressed", and they will suggest that if they could get that 12mg IV Dilaudid push, they might just be able to be persuaded to stay the rest of the night.
Even though I'm complaining a lot, I got very lucky since no one coded, had chest pain, stopped breathing, or otherwise had a medical calamity on either my shifts. Thank you, hospital gods, for shining your fluorescent rays of mercy upon me.
Friday, August 20, 2010
The End of an Era
This is my last week of ambulatory block. The last few days were great- all my afternoon patients canceled or no-showed on Wednesday so I just went around saying it was Robot Wednesday and doing the robot dance with the residents, nurses, medical assistants, etc. in the medicine clinic. Thursday I had two patients in urgent care, and I can't remember much about the details of the patient encounters which is usually for the best. I do remember one of the MA's asked what the theme for Thursday would be, and I said "Lie to Me Thursday" or "Let It Be a Surprise Thursday," ie, I did not want to be told ahead of time when my patients arrived, that their blood sugars were wildly out of control, that they had 9 chief complaints, etc.
Then today in the morning the interns had "admin" time to complete paperwork or clinic notes from this block. I like to finish all my notes before I leave clinic, so I spent that time at home singing along to Katy Perry songs. Loudly. Sorry neighbors. Then in the afternoon I had two patients cancel again (can you believe the good fortune!!), and stupidly offered to help one of the residents with their urgent care clinic. Theme for today's clinic: talk in a spooky ghost voice when you have to present a patient. The best was one of the third year residents: "This is a 49 year old lady with diaRRHEEEaaa... DIArrrrhEEeeaaAAaaa..."
Goodbye, Ambulatory Block, I will miss you!
Next up: entire weekend of night float, then a month of wards.
Then today in the morning the interns had "admin" time to complete paperwork or clinic notes from this block. I like to finish all my notes before I leave clinic, so I spent that time at home singing along to Katy Perry songs. Loudly. Sorry neighbors. Then in the afternoon I had two patients cancel again (can you believe the good fortune!!), and stupidly offered to help one of the residents with their urgent care clinic. Theme for today's clinic: talk in a spooky ghost voice when you have to present a patient. The best was one of the third year residents: "This is a 49 year old lady with diaRRHEEEaaa... DIArrrrhEEeeaaAAaaa..."
Goodbye, Ambulatory Block, I will miss you!
Next up: entire weekend of night float, then a month of wards.
Saturday, August 14, 2010
Gyn Clinic, Continuity Clinic, and Urgent Care
County Gyn Clinic. If I liked gynecology, I would have gone into it. I didn't go into it. This is the county clinic, so you can basically expect it to be an STD-screen-for-all and PAP-fiesta. One young woman said the best place to get a copy of her prior PAP records was a state prison. Enough said. What I will say is that I genuinely like the patient population; the people I saw were surprisingly grateful and patient.
In my continuity clinic I saw one young lady who wanted her electronic medical record to be blocked from access by medical students. When I asked why, she revealed she had dated a medical student, and did not want him having access to her chart. I explained that although there is no way to block access to her record, all movements in the medical record are tracked. Keystrokes are tracked. The amount of time spent looking at any given page, report, or image is recorded. So if her electronic chart was accessed inappropriately, there would be a record of it, and the record can always be audited. There are also pretty significant repercussions, professionally and legally, for inappropriately accessing medical records. But she did bring up an interesting point; now our health information is becoming digitalized, it is more accessible than ever before...
And lastly, in clinic I had a patient try to tell me he got gonorrhea from a cat. He had already been told that he had gonorrhea... but apparently not what gonorrhea is (it's an STD). He immediately launched into a story about how all his symptoms began when his housemate got a cat, which pranced around the house, just touching everything... I asked him if he was aware that gonorrhea is a sexually transmitted disease. Long pause. OHHH.
Let's wrap it up. What am I trying to say here? If you've been wronged by a cat or a med student, the door to my clinic is always open. You might want to wash your hand after you touch that door handle though...
In my continuity clinic I saw one young lady who wanted her electronic medical record to be blocked from access by medical students. When I asked why, she revealed she had dated a medical student, and did not want him having access to her chart. I explained that although there is no way to block access to her record, all movements in the medical record are tracked. Keystrokes are tracked. The amount of time spent looking at any given page, report, or image is recorded. So if her electronic chart was accessed inappropriately, there would be a record of it, and the record can always be audited. There are also pretty significant repercussions, professionally and legally, for inappropriately accessing medical records. But she did bring up an interesting point; now our health information is becoming digitalized, it is more accessible than ever before...
And lastly, in clinic I had a patient try to tell me he got gonorrhea from a cat. He had already been told that he had gonorrhea... but apparently not what gonorrhea is (it's an STD). He immediately launched into a story about how all his symptoms began when his housemate got a cat, which pranced around the house, just touching everything... I asked him if he was aware that gonorrhea is a sexually transmitted disease. Long pause. OHHH.
Let's wrap it up. What am I trying to say here? If you've been wronged by a cat or a med student, the door to my clinic is always open. You might want to wash your hand after you touch that door handle though...
Thursday, August 12, 2010
That was just someone who looks like me...
Today while walking to clinic, I fell down on the sidewalk. I didn't trip on anything, I just fell over for no apparent reason. I paused for a second, unhurt, and bewildered, then jumped up and brushed myself off, saying to my (laughing) fellow intern, "MAN, I'm glad nobody else saw that!" I turn to my right and there is a hospital shuttle bus full of patients. The bus was dropping off patients at the clinic where I work.
Big-time awesome.
Big-time awesome.
Tuesday, August 10, 2010
Urgent Care Clinic
The patients scheduled for my urgent care clinic were:
1. Young man with left hand tingling/numbness
2. Middle aged lady with "mold spot" growing on her head and "bruises all over."
3. Youngish woman with "malodorous vaginal discharge" x 1 week
4. Middle aged old lady for follow-up after breaking her foot
Summary: dammit!!!
So the first thing's first in urgent care clinic: you hope for no-shows.
All of my patients showed.
Excellent. Yay patient care yay. Yay.
Anyway, so the first guy is huge- he's like 7 feet tall. He leans on his left elbow all day at work, then comes home and leans on his left elbow for another six hours while he watches TV. He has tingling in his left fourth and fifth fingers that sometimes radiates to the elbow. Any takers? Any takers?
Boom- ulnar neuropathy! Done! Easy!!!
Next lady shows up. Early. Thank goodness, I didn't want to miss out on this head "mold." So first of all, it's a small, discrete, brown "stuck on" appearing growth.... a seborrheic keratosis (benign ugly growth). She is happy to hear this. Next: she has "bruises all over." Ah, she actually has one tiny bruise on her outer arm and another little one on her knee. Show me someone who DOESN'T have any little bruises over any of their extremities. Next, she wants to talk about what her future treatment options are for her chronic sciatica. Then she wants to talk about what some good recommendations are for exercise she can do to-OKAY, THAT'S ENOUGH THANK YOU, this is URGENT CARE clinic, not BRING ALL YOUR UNSOLVED LIFE PROBLEMS Clinic.
Next lady. "Malodorous vag discharge" for a week. Great. That's the best! So after the attendings jokingly (kind of) argue between the two of them about who should have to staff this one, eventually we get the vag infection taken care of. But oh wait, as soon as I try to leave the room she mentions she has this weird neurologic past medical history and OH BY THE WAY, part of her face has been tingling for a day. Daaaaaaammit. Ok then, tell me about your face. Ok, came up with a plan for face problem. Good. Try to leave again- OH BY THE WAY, she doesn't know if she believes in taking antibiotics and wants a convincing argument. Ok, done. Try to leave the room again- OH BY THE WAY, she wants to know what her weights have been trending over the last several months because she thinks she's losing weight. !!! So I look up her weights and show her clearly that over the past two years, her weight has been the same. She insists on getting a recommendation for nutritional supplements to safely gain weight. Okay. Whatever you want. Try to leave again- OH BY THE WAY ($#%&*@!!!) she has breast lumps that come and go and she's been told they were benign and that is normal, but is it REALLY normal??? SWEET JESUS! Once again, this is not "BRING ALL YOUR UNRESOLVED LIFE PROBLEMS TO CLINIC DAY." We were just kidding when we said "Urgent Care" clinic, what we really meant was "Let's Relax and Sit Down at a Table and Just Talk About Every Problem You've Ever Had in Life Over a Cappuccino" clinic. Let me know when you're done with your life problems so we can get started on mine!
AAAAA!!!
Ok. Fourth lady (by the way, somehow I am almost an hour behind at this point thanks to 1 million + 1 problems lady). She was diagnosed with a broken foot at an Outside Hospital. Outside Hospital took an xray, gave her a brace and some vicodin, wished her good luck and told her to take her problems to University Hospital (where I work). This was more complicated than it sounds (sigh) and took some time to sort out. As I'm presenting her to the attending- GUESS WHAT- she volunteers that she has had intermittent numbness and tingling in the left hand. OH LORD. She also volunteers she has been having blurry vision. At this point the attending asks, "Okay- are there any other problems that you're going to share with us?" It took several more minutes to elicit the history that the tingling also occurs alternately in her right hand, and it is precipitated by LEANING ON HER ELBOW. BUGGAR!!! Ah- also, her fundoscopic exam is normal and her vision is 20/30 bilaterally. Oh how I wish that my vision could be that "blurry." Anyway, after several more minutes of talking to her it sounds like what she meant was that her vision had been gradually getting worse over the course of a long period of time.
Somebody must have told her about the cappuccinos....
1. Young man with left hand tingling/numbness
2. Middle aged lady with "mold spot" growing on her head and "bruises all over."
3. Youngish woman with "malodorous vaginal discharge" x 1 week
4. Middle aged old lady for follow-up after breaking her foot
Summary: dammit!!!
So the first thing's first in urgent care clinic: you hope for no-shows.
All of my patients showed.
Excellent. Yay patient care yay. Yay.
Anyway, so the first guy is huge- he's like 7 feet tall. He leans on his left elbow all day at work, then comes home and leans on his left elbow for another six hours while he watches TV. He has tingling in his left fourth and fifth fingers that sometimes radiates to the elbow. Any takers? Any takers?
Boom- ulnar neuropathy! Done! Easy!!!
Next lady shows up. Early. Thank goodness, I didn't want to miss out on this head "mold." So first of all, it's a small, discrete, brown "stuck on" appearing growth.... a seborrheic keratosis (benign ugly growth). She is happy to hear this. Next: she has "bruises all over." Ah, she actually has one tiny bruise on her outer arm and another little one on her knee. Show me someone who DOESN'T have any little bruises over any of their extremities. Next, she wants to talk about what her future treatment options are for her chronic sciatica. Then she wants to talk about what some good recommendations are for exercise she can do to-OKAY, THAT'S ENOUGH THANK YOU, this is URGENT CARE clinic, not BRING ALL YOUR UNSOLVED LIFE PROBLEMS Clinic.
Next lady. "Malodorous vag discharge" for a week. Great. That's the best! So after the attendings jokingly (kind of) argue between the two of them about who should have to staff this one, eventually we get the vag infection taken care of. But oh wait, as soon as I try to leave the room she mentions she has this weird neurologic past medical history and OH BY THE WAY, part of her face has been tingling for a day. Daaaaaaammit. Ok then, tell me about your face. Ok, came up with a plan for face problem. Good. Try to leave again- OH BY THE WAY, she doesn't know if she believes in taking antibiotics and wants a convincing argument. Ok, done. Try to leave the room again- OH BY THE WAY, she wants to know what her weights have been trending over the last several months because she thinks she's losing weight. !!! So I look up her weights and show her clearly that over the past two years, her weight has been the same. She insists on getting a recommendation for nutritional supplements to safely gain weight. Okay. Whatever you want. Try to leave again- OH BY THE WAY ($#%&*@!!!) she has breast lumps that come and go and she's been told they were benign and that is normal, but is it REALLY normal??? SWEET JESUS! Once again, this is not "BRING ALL YOUR UNRESOLVED LIFE PROBLEMS TO CLINIC DAY." We were just kidding when we said "Urgent Care" clinic, what we really meant was "Let's Relax and Sit Down at a Table and Just Talk About Every Problem You've Ever Had in Life Over a Cappuccino" clinic. Let me know when you're done with your life problems so we can get started on mine!
AAAAA!!!
Ok. Fourth lady (by the way, somehow I am almost an hour behind at this point thanks to 1 million + 1 problems lady). She was diagnosed with a broken foot at an Outside Hospital. Outside Hospital took an xray, gave her a brace and some vicodin, wished her good luck and told her to take her problems to University Hospital (where I work). This was more complicated than it sounds (sigh) and took some time to sort out. As I'm presenting her to the attending- GUESS WHAT- she volunteers that she has had intermittent numbness and tingling in the left hand. OH LORD. She also volunteers she has been having blurry vision. At this point the attending asks, "Okay- are there any other problems that you're going to share with us?" It took several more minutes to elicit the history that the tingling also occurs alternately in her right hand, and it is precipitated by LEANING ON HER ELBOW. BUGGAR!!! Ah- also, her fundoscopic exam is normal and her vision is 20/30 bilaterally. Oh how I wish that my vision could be that "blurry." Anyway, after several more minutes of talking to her it sounds like what she meant was that her vision had been gradually getting worse over the course of a long period of time.
Somebody must have told her about the cappuccinos....
Sunday, August 8, 2010
Ambulating On
I've completed week 2 of my ambulatory block, and week 6 of my intern year.
This past week I had Urgent Care, my continuity clinic (small panel of patients that I am following for the next 3 years or until death do us part), Hepatology clinic, and Endocrinology (where they forgot an intern was coming and had no patients scheduled - yessss!).
I honestly can't remember what happened in Urgent Care clinic. This is most likely a coping mechanism whereby my memory is selectively forgetting all of urgent care clinic. Thank you, memory.
Hepatology clinic went something like this: guess what's behind doors number 1-9? If you guess Hepatitis C, you're right every time! Except maybe 1 out of 10 it's Hep B or nonalcoholic fatty liver disease, just to mix things up a bit.
In my continuity clinic I had a patient who was scheduled with a chief complaint of "itchy warts." It didn't say where the "itchy warts" were, either. I can't tell you how relieved I was to diagnose multiple skin tags on the neck of this pleasant woman with metabolic syndrome.
Then on Friday night we had an intern scavenger hunt in midtown. I made a list of 20 items for each team to find within a certain time frame. The best item on the list: "4. Tell someone that you’re looking to get a new tattoo to celebrate your recently becoming a doctor. Ask them for ideas, and get them to draw something out either on a napkin or on you." One of the girls came back with a stick figure with one shoe drawn on her bicep. The artist had told her, "This is a crackhead. Because you're going to have to get used to taking care of lots of these. See? Only one shoe. Crackhead." Other highlights from the list: "Make an intern sandwich," and "Go up to a group of strangers and bust out in your best robot moves."
Young doctors of America. Beep beep beep. BoooooOOOooop. Rrrrreeee. (Those were my best robot moves.)
This past week I had Urgent Care, my continuity clinic (small panel of patients that I am following for the next 3 years or until death do us part), Hepatology clinic, and Endocrinology (where they forgot an intern was coming and had no patients scheduled - yessss!).
I honestly can't remember what happened in Urgent Care clinic. This is most likely a coping mechanism whereby my memory is selectively forgetting all of urgent care clinic. Thank you, memory.
Hepatology clinic went something like this: guess what's behind doors number 1-9? If you guess Hepatitis C, you're right every time! Except maybe 1 out of 10 it's Hep B or nonalcoholic fatty liver disease, just to mix things up a bit.
In my continuity clinic I had a patient who was scheduled with a chief complaint of "itchy warts." It didn't say where the "itchy warts" were, either. I can't tell you how relieved I was to diagnose multiple skin tags on the neck of this pleasant woman with metabolic syndrome.
Then on Friday night we had an intern scavenger hunt in midtown. I made a list of 20 items for each team to find within a certain time frame. The best item on the list: "4. Tell someone that you’re looking to get a new tattoo to celebrate your recently becoming a doctor. Ask them for ideas, and get them to draw something out either on a napkin or on you." One of the girls came back with a stick figure with one shoe drawn on her bicep. The artist had told her, "This is a crackhead. Because you're going to have to get used to taking care of lots of these. See? Only one shoe. Crackhead." Other highlights from the list: "Make an intern sandwich," and "Go up to a group of strangers and bust out in your best robot moves."
Young doctors of America. Beep beep beep. BoooooOOOooop. Rrrrreeee. (Those were my best robot moves.)
Tuesday, August 3, 2010
Hospice
Today as part of my ambulatory block I was assigned to spend a day with a hospice nurse making house calls.
I thought that this would be incredibly uncomfortable. This is how I imagined it would go:
::knock, knock::
::front door opening::
Us: "Oh hey you! So you're still.... alive..."
Hospice patient: "Yeah."
Us: "You're not dead yet!"
Hospice patient: "Nope."
Us: "We really expected, you know after the last time... well this is a bit awkward then, isn't it? Can we... bring you some more morphine?"
Hospice patient: "Ah, no, I'm good."
Us: "Okay. Yeah. See you tomorrow then?"
Hospice patient: "Maybe."
But I was completely wrong. The visits were just like any other pleasant house calls. I also worried that we might visit to find someone had already expired by the time we got there. But nope! Luckily everyone was alive. It was kind of a good day. Relatively speaking.
I thought that this would be incredibly uncomfortable. This is how I imagined it would go:
::knock, knock::
::front door opening::
Us: "Oh hey you! So you're still.... alive..."
Hospice patient: "Yeah."
Us: "You're not dead yet!"
Hospice patient: "Nope."
Us: "We really expected, you know after the last time... well this is a bit awkward then, isn't it? Can we... bring you some more morphine?"
Hospice patient: "Ah, no, I'm good."
Us: "Okay. Yeah. See you tomorrow then?"
Hospice patient: "Maybe."
But I was completely wrong. The visits were just like any other pleasant house calls. I also worried that we might visit to find someone had already expired by the time we got there. But nope! Luckily everyone was alive. It was kind of a good day. Relatively speaking.
Bikram Yoga (aka Hot, Nasty Yoga)
Bikram yoga: If you can't stand the heat, you probably have a better sense of self-preservation than I do.
To take full advantage of all the glorious free time on our ambulatory block, some of us interns have been getting together a few times a week. I've wanted to try bikram yoga (or "hot" yoga) for a while. So yesterday four of my co-interns and I went to a hot nasty yoga class.
Bikram yoga involves traditional poses and breathing exercise...done in a room heated to 105 degrees. Which is only 10 degrees warmer than your average summer day here, but whatever. If you've never done hot yoga before, let me take you through a virtual session:
First of all, it smells like unwashed, medieval ass. It smells like a mix of hot garbage and potent body odor with 50% humidity. It's like a face punch delivered by a multitude of unwashed socks. Alright. Then it's 105-107 degrees in a room with no air circulating and about 20 other dripping sweating people (so let's say 70% humidity. You can taste the humidity in the air, and it tastes like an unwashed mongol horde). Most of these are die-hard yoga ladies, aged late 20s through 40s, the kind who glare and loudly shush you if you laugh or fart during silent meditation time. Not that you have the kind of energy to do either of those things because it's 105 degrees.
Wait, because it gets better. Then there are the 3 old men in the back, dripping sweat, looking like they are actively having acute coronary syndromes. Jesus christ man- just because you spiked your hair and got a surfer tattoo only takes you back 60yrs in YOUR MIND, not in real life. My zenlike state of mind was frequently interrupted by the weird grunting noises they made, causing me to worry if they collapsed who was going to run the code.
The instructor is telling you to get into various poses that will "mobilize your pancreas", and encouraging you to rotate your torso even more, "take it to your edge," so that you can "massage your liver." At this point I giggled, and was shushed by a die-hard yoga lady. Throughout the class, the instructor tells all the new students not to worry if they feel nauseated, dizzy, headache, or otherwise ill, because that is the sensation of toxins leaving your body. It is coincidental that those are also the signs of dehydration and heat stroke. Anyway.
Did I achieve new yoga heights? Strengthen my core? Increase my flexibility? See my toes again? Eh, no. Good workout though. Overall, it was a very interesting experience, but not one that begs repeating.
To take full advantage of all the glorious free time on our ambulatory block, some of us interns have been getting together a few times a week. I've wanted to try bikram yoga (or "hot" yoga) for a while. So yesterday four of my co-interns and I went to a hot nasty yoga class.
Bikram yoga involves traditional poses and breathing exercise...done in a room heated to 105 degrees. Which is only 10 degrees warmer than your average summer day here, but whatever. If you've never done hot yoga before, let me take you through a virtual session:
First of all, it smells like unwashed, medieval ass. It smells like a mix of hot garbage and potent body odor with 50% humidity. It's like a face punch delivered by a multitude of unwashed socks. Alright. Then it's 105-107 degrees in a room with no air circulating and about 20 other dripping sweating people (so let's say 70% humidity. You can taste the humidity in the air, and it tastes like an unwashed mongol horde). Most of these are die-hard yoga ladies, aged late 20s through 40s, the kind who glare and loudly shush you if you laugh or fart during silent meditation time. Not that you have the kind of energy to do either of those things because it's 105 degrees.
Wait, because it gets better. Then there are the 3 old men in the back, dripping sweat, looking like they are actively having acute coronary syndromes. Jesus christ man- just because you spiked your hair and got a surfer tattoo only takes you back 60yrs in YOUR MIND, not in real life. My zenlike state of mind was frequently interrupted by the weird grunting noises they made, causing me to worry if they collapsed who was going to run the code.
The instructor is telling you to get into various poses that will "mobilize your pancreas", and encouraging you to rotate your torso even more, "take it to your edge," so that you can "massage your liver." At this point I giggled, and was shushed by a die-hard yoga lady. Throughout the class, the instructor tells all the new students not to worry if they feel nauseated, dizzy, headache, or otherwise ill, because that is the sensation of toxins leaving your body. It is coincidental that those are also the signs of dehydration and heat stroke. Anyway.
Did I achieve new yoga heights? Strengthen my core? Increase my flexibility? See my toes again? Eh, no. Good workout though. Overall, it was a very interesting experience, but not one that begs repeating.
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