"i would rather have my patient smoke pot all day then be an alcoholic. pot should be legal, not alcohol. when was the last time you saw a THC overdose come into the ER..." -intern

"We should gang-ascultate him with our stethoscopes."-Cardiology attending (regarding a patient with severe AS)
-Lisa via facebook

"stump pump" -our new OMM treatment....

drug seeking....

every morning we get to the hospital at 6am and whoever is there first prints out copies of the current patient list. then, we sit down and divide out the new patients admitted overnight and keep the remaining ones we have already. today, we had 5 new patients so we all kept the patients we had been seeing and then picked new ones to see, write progress notes on, and follow up on. today, i picked a 37yo F named Brandi [not real name but similar]. i thought her case looked interesting because her CC was abdominal pain and hematemesis [vomiting blood]. i thought it would be a change in the cases i had seen in the past so i said i would take her. after us 3 students divided up the patients, one of our interns [Dez] walked in and we went over who was covering each patient. amongst our conversation went:

 “who is taking Brandi?” -Dez

“i am” -me

“hahaha, well good luck because apparently she is a complete handful and is pretty much just drug seeking. i didnt want to take her because i can’t say no so im making A [other intern] take care of her” -Dez

“wonderful” -me

I went up and read the patients chart and the nurses were already talking about this her. she was requesting specific amounts of medication and was very attentive to when she was getting her next dose. she was also making demands of how much and what else to give her because ‘she knew what worked for her pain.’ granted, she has had a couple different spinal surgeries because of accidents and had nasopharyngeal cancer, so shes not completely pain free, but everyone knew the story was a little seedy. especially because she had been vomiting blood “for 3 days, and vomited twice in the ER” but no one has actually witness this...

My other intern [we’ll call him ‘young persian doctor from brooklyn who is obviously from brooklyn’] was my intern on the case. he knew exactly what this lady was up to and knew exactly how to get her on his side and sweet talk her. his mission= get her out of the hospital as fast as we can to free up a bed for a real patient. i tried to give this lady some credit and since i am a medical student and not completely jaded yet, i went in with an open mind and tried to listen as though she really had a problem.

 i went into the room and spoke with her and immediately she started crying. she was not rude at all, just very talkative. she was very ‘opioid educated’ as she called herself, since she had been on pain killers for at least a decade. we [all the docs] were sure she was just constipated from opiod use and her abdominal pain was due to a ‘back-up’ and she just didnt want to hear this. she really thought something was wrong. and when i looked at her stomach, i agreed that this could be something more. her stomach looked very distended and firm,like she was pregnant [and she was not an obese lady]. so, i asked her a plethora of questions and decided she may have some kind of ulcer, colon inflammation, etc. She insisted on getting a GI consult and i actually agreed. 

when i told the intern he laughed at me. he had already called for a GI consult, mostly to cover his ass because you cant ignore this even though she may be making it up. he laughed because he thought i believed her, which i could of did. so, we discussed it with our attending and we got a GI consult. i was hoping they would order an EGD and sure enough, later that afternoon we heard the consult ordered a abd CT and an EGD. 

the abd CT was done in the afternoon and it was clear. “no acute changes or pathology.”  “you still think there is something actually wrong with this patient?” -brooklyn asked

“maybe.....” -me

i went up to tell her the results and she just cried more because now she had no idea why she had this pain. then she asked me for a neuro consult for her headaches and a pain management specialist for her pain. at this point, i stopped feeling sorry for this lady. while she talked, i had to force myself to not blow her off and be rude because there was a chance there really was something wrong. but it was very hard to take her seriously when in between questions, she kept saying how much she needs her dilaudid, ativan and benadryl cocktail. 

i am keeping faith that she may really been in a lot of pain and that tomorrow the EGD shows something. but, i wont be suprised if it doesnt. she admits that she had a pain pill addiction but says that she ‘doesnt abuse pills because she really needs them.’ partially, this is our [healthcare’s] fault because during all her post op and chemo we pumped her so full of drugs that she probably got addicted, but then again, not all of us constantly pop pills for the pain we feel. everyone has some sort of pain somewhere, it may be chronic or acute, but not all of us need a norco or vicodin everyday to deal with it. 

i really hope im wrong on this one.

sick people

Had to work again on Saturday at 6am. Came in, saw my patients, did a progress note, then went to check out labs and found out one of my patients has VRE [vancomycin resistant enterococci] on blood culture. I cant stop washing my hands now....

code blue this morning. patient was in the ICU. 64yo female dying from liver damage. her organs are failing...basically all from alcohol. i couldnt figure out what rhythm she had on the monitor so i asked the intern and she looked at it and was just as confused as i was. After, we spoke to the nurse taking care of her and i asked again, "what rhythm is she in? "nurse replied "she has been in everything. its a medication rhythm. shes basically dead." apparently they were waiting for the family to show up and her pulse was the result of vasopressors. her heart was bradycardic, then tachy, had random PVCs, then went randomly into lots of other rhythms. we left the code because she technically still was alive  but we expected to be there again shortly when she went into asystole inevitably [the second the drugs wear off her heart would stop]. she never coded again while i was in the hospital but i would assume she will die sometime today.

chicken scratch

part of my job every morning is to decipher the handwriting of attendings who have practiced medicine so long that they dont give a shift if anyone other then themselves cant read their handwriting. seriously, its like they do it just to fuck with everyone else. in internal med we get consults with all different specialties so each morning we look in the patient's chart and see what the consult suggests. without fail, every morning i have to get at least 1 other person to get a second opinion on what the note actually says.

2 down!

again, i went into the hospital at 6am on Monday and came out at noon on Tuesday. this was my 2nd 30 hour call and now i wont have any more for the rest of the rotations [2 more weeks.] It actually wasnt a bad night because i got a really interesting case to admit from the ER. this poor guy was having severe back pain, fever, chills and night sweats for 1 month. he had been to a couple docs who gave him pain meds and had even been to the ER to check it out. in the ER they did an X ray which came back normal so they sent him home. finally, he couldnt stand it anymore and he and his wife came back to the ER. we did lots of blood work and imaging on him and when the MRI came back, we saw that he had osteomyelitis in his spine! thats a pretty serious bone infection. he was in so much pain and i felt terrible for him. [side note, it might be TB--Pott's disease-- because he is from Mexico and has had a lot of exposure to TB. thats a pretty rare disease so to see one in my career is pretty cool.]

as i walked out of the ER, i stopped dead in my tracks walking out of the entrance. at the front lobby, i found my 2nd year resident speaking with 27 people [i counted] of all ages. she was talking in a serious voice about an ICU patient who they all came to see. turns out, they were here for their family meeting about wether they wanted to do surgery on their 91yo relative or too let her die peacefully. they were all waiting around and the resident had to tell them the meeting was tomorrow at 7:30am not tonight at 7:30pm. ouch. well, turns out they were all really nice about it but damn, thats a lotta pressure to talk to that many people at once about a patient she didnt know too much about [but acted her way out of that one.]

Tuesday morning, after ~5 hours of sleep, i presented my patient at morning report to all the students and interns. it was a good case. they i saw my patients, wrote my progress notes, rounded with my team, and got the hell outta there to get some sleep.

Dictations

this is the first rotation where we have to do dictations. since this hospital does not have electronic medical records, we have to call a phone service and dictate all of our admission H&Ps and it gets typed out by a service. i discovered on my 30 hour call tonight that its really hard to dictate a note when you have worked all freaking day and are falling asleep on the phone. im pretty sure the person that typed out my note thought i was a complete moron because i stutter and cant spell when im tired. just picture me trying to read and talk fast while trying to keep sense of what is going on with the patient. oops.

Mrs. G

2 code blues this morning.

Another eventful patient I have been following is Mrs.G. A 40-something-yo with no PMH who also has no health insurance and barely speaks English. Shes really sweet and has a very bad case of gallstone pancreatitis. well, this lil lady has been in the hospital for about a 5 days now and had a lap chole to remove her gallbladder. everyday i come in in the morning and say out loud "Mrs G is still here??" she should have gone home a long time ago but her laps just werent right and then surgery didnt want to sign off. after being on a constant drip of dilaudid for her entire hospital stay, I am convinced that we have gotten her addicted at this point. sending her home on vicodin will be interesting.

ps its Saturday December 31st and I had to come in to work at 6am for a half day. lame. at least we get new years day off.