The other day at clinic, my “pain contract” patient had an appointment (groan!!). Other docs will know what the words “chronic pain patient” entails! I will describe my patient, who I believe is somewhat stereotypical of chronic pain patients everywhere! Joan has an ‘idiopathic’ condition that has caused chronic pain for years. Idiopathic meaning that so far there is no medical evidence or reason for the pain. The original diagnosis was made elsewhere and old records have not been obtained yet. Joan requires daily pain medications to function, and guess what she's “allergic” to just about every pain medication out there (meaning she’s tried them all and none of them work to control the pain). I researched the condition and all possible treatments and went over the list of therapies with Joan. Most of the things on my list had already been tried, and… big surprise, did not work! These types of patients can be extremely trying, and also take a significant amount of time.
Patients who require long term narcotics for pain control sign a “pain contract”. Basically it says that the patient agrees to
1.visit only ONE doctor (me) for their pain control needs
2.fill their narcotic prescriptions at only ONE pharmacy
3.take only the drugs prescribed and take them as prescribed
4.take a drug test at each monthly visit (to ensure that the drug prescribed and only the drug prescribed is present)
So my chronic pain patients only see me and they see me at least once a month, which I guess means that we get to know one another more. Which in this case translated to me getting on Joan's Christmas list!
At the appointment the other day, Joan actually looked pretty good, and was in a good mood. Despite this fact, she still reported that the latest medication we tried did not work, and so we are now trying the last long acting narcotic on my list, and hoping for the best! Afterwards I was in with another patient and I heard a knock on the door. It was my ‘difficult-chronic-pain-patient’ who handed me a gift card and wished me Merry Christmas!! The gift is a big deal when you consider my patient population. It was unexpected, but the gesture was much appreciated!
I’m sure there will be other Christmas cards or gifts for “the doctor” as I progress in my career. We’ll see if they can beat my free meal at Jack-in-the-Box from the patient I least expected to give me a Christmas present!
Sunday, December 23, 2007
Sunday, December 16, 2007
Working in the Prison Unit
There is a special unit in my hospital for prisoners, complete with an officer for every inmate, a special code to get in (that most of the doctors don’t even know), and each patient cuffed to the bed at the ankles. When I arrive I try to knock on the door for one of the officers to let me in. The door is of course extra thick, so if my knock goes unheard I have to resort to waving my hands, hoping they’ll notice me through the small glass window. One of the officers then gets up, annoyed that my arrival has interrupted their focus on the crossword puzzle and types the code to let me in. I always check my name badge as the officer approaches to make sure that it’s visible, as if to say “See, I’m a doctor here, I’m not wearing the white coat to trick you into letting me in, I really do have a patient to see.” The hallway that opens into the patient rooms is lined with officers. The prisoners don’t get the prettiest or newest unit in the hospital and space is always an issue. From the patients to officers to doctors, nurses and staff it seems like everyone is cramped for space. I don’t know what the area was used for before it was the prisoners unit, but the layout is horrible, there isn’t much of a nurses station at all, each room has 3-4 beds and one small counter top with computer, sink, and patient charts, and there are passageways between the rooms that you have to turn sideways to get through.
The officers are very helpful and respectful for the most part, with the occasional one who obviously hates his job. The prisoners come in all types. Lots of them are very normal and respectable looking and you wonder what happened to them. I almost never know what they are in jail or prison for, nor do I ever want to. It’s completely irrelevant to my job. Of course I ask the same questions to prisoners that I ask non-prisoner such as IV drug use and sexual history, but no specifics on criminal activity! I’ve had a couple of patients tell me without being asked, but it wasn’t a big deal (I guess, in part, because they were not big crimes).
I had one patient where I heard all about his criminal background – mostly because a printout of the newspaper article reporting his sentence was actually in his medical chart! I don’t know how it got there or why, I should have ripped it out and thrown it away so as not to taint anyone else’s opinion of this individual. I must say it made the patient encounter different, and slightly awkward for me. This particular case was confounded by the fact that the crime was related to medicine. I guess the relation to the medical world made the story interesting and somewhat of a personal insult to us. In the end the patient was still a patient that required evaluation and treatment just like the patients on the newly remodeled 8th floor with private rooms, wood floors and flat screen TVs.
The officers are very helpful and respectful for the most part, with the occasional one who obviously hates his job. The prisoners come in all types. Lots of them are very normal and respectable looking and you wonder what happened to them. I almost never know what they are in jail or prison for, nor do I ever want to. It’s completely irrelevant to my job. Of course I ask the same questions to prisoners that I ask non-prisoner such as IV drug use and sexual history, but no specifics on criminal activity! I’ve had a couple of patients tell me without being asked, but it wasn’t a big deal (I guess, in part, because they were not big crimes).
I had one patient where I heard all about his criminal background – mostly because a printout of the newspaper article reporting his sentence was actually in his medical chart! I don’t know how it got there or why, I should have ripped it out and thrown it away so as not to taint anyone else’s opinion of this individual. I must say it made the patient encounter different, and slightly awkward for me. This particular case was confounded by the fact that the crime was related to medicine. I guess the relation to the medical world made the story interesting and somewhat of a personal insult to us. In the end the patient was still a patient that required evaluation and treatment just like the patients on the newly remodeled 8th floor with private rooms, wood floors and flat screen TVs.
Friday, December 14, 2007
Stress
Yesterday was a particularly stressfully call day for several reasons. The two that I will mention are that I only slept from 5am to 5:30am and during post call rounds I looked and felt incredibly stupid. On my post call morning I presented two of my new patients to my attending, only to be shot down by what seemed like never ending questions that I did not know the answers to. Mind you this is in front of my whole team of other residents who knew some of the answers, but of course I was the one being asked so they kept quiet or mumbled things under their breath too soft for me to understand. I had done mostly everything right (my patients were being appropriately cared for) but I did know the specific reasons why we’re doing certain things, what do we do next, what is going on specifically and why, what tests will prove this and what would we have done if things were different. When I haven’t slept the answer is “I don’t care! I just want to go home and go to bed!”
I went home feeling pretty stressed, but resolved to do some extra studying on my next day off. As much as I do want to have kids I felt so grateful at that moment when I finally laid down that I do not have any children. I feel guilty enough that my husband does not get the attention he deserves, and as I understand, children require even more attention than husbands!! I think my current situation, one husband and no kids, is best for my mental health during intern year. I don’t know how I could handle intern year if I were single; I very much need the support from my husband. And, as great as I hear having kids can be, I know some added stress comes along with that and I’ve got enough stress for the time being.
I went home feeling pretty stressed, but resolved to do some extra studying on my next day off. As much as I do want to have kids I felt so grateful at that moment when I finally laid down that I do not have any children. I feel guilty enough that my husband does not get the attention he deserves, and as I understand, children require even more attention than husbands!! I think my current situation, one husband and no kids, is best for my mental health during intern year. I don’t know how I could handle intern year if I were single; I very much need the support from my husband. And, as great as I hear having kids can be, I know some added stress comes along with that and I’ve got enough stress for the time being.
Tuesday, December 11, 2007
Remember Mathnet?
Before I continue to publish stories about my hospital expierences, I feel the need to state that "the names are made up but the problems are real!"
Which happens to be my favorite quote from Mathnet, the detective show where they use math to solve the mystery! It was a show within the show Square One on PBS. Ah, good 'ol Kate Monday and George Frankly. The full quot is as follows: "The story you're about to see is a fib, but it's short. The names are made up but the problems are real." My stories are not always short... nor are they "a fib" per se... but you get the picture.
So... except for any stories about pregnant ladies, which by it self inplies that the patient is a female of reproductive age, I purposfully will not include or will change any and all details about my patients including but limited to: name, gender, age, ethnicity, language, and circumstances. So basically the stories are "made up" but believe me "the problems are real!"
Which happens to be my favorite quote from Mathnet, the detective show where they use math to solve the mystery! It was a show within the show Square One on PBS. Ah, good 'ol Kate Monday and George Frankly. The full quot is as follows: "The story you're about to see is a fib, but it's short. The names are made up but the problems are real." My stories are not always short... nor are they "a fib" per se... but you get the picture.
So... except for any stories about pregnant ladies, which by it self inplies that the patient is a female of reproductive age, I purposfully will not include or will change any and all details about my patients including but limited to: name, gender, age, ethnicity, language, and circumstances. So basically the stories are "made up" but believe me "the problems are real!"
Saturday, December 8, 2007
Good thing they’re unconscious... mostly
On my surgery rotation we take Trauma Call! This means we carry a Trauma Pager. When the trauma pager goes off there is a text page to read that is an encrypted message like “level I 25 M GSW Abd SBP <90 GCS 8 EMS 3 min out, trauma 5”
What that means, is that a 25 year old man was shot in the belly and even though the ambulance is still 3 minuets away, you better get down to bed 5 in the trauma bay because this guy is unstable.
Imagine for a minute that you are a trauma patient:
You are in a car accident. The paramedics show up, they put you on a rock hard plastic board on your back and strap you down tight so that you can’t move. They also put a neck brace on you. They rush you off to the hospital. You’re rolled into the trauma bay and transferred onto the bed, though still on the plastic backboard. While the paramedics tell your story to the doctor, half a dozen people rush towards you in yellow gowns and purple gloves. The two at the foot of the bed start pulling your shoes and socks off and cutting off all of your cloths, including underwear. Simultaneously two others are poking you with needles on both arms to draw blood and start IV lines to give you fluids; others are sticking plastic EKG leads on your chest, a blood pressure cuff on your arm, and a pulse/oxygen monitor on your finger. Someone pushes on your belly. At the head of the bed a doctor yells at you “Open your eyes”, “What’s your name?” “do you know where you are?” “what’s the last thing you remember?”. While this doctor is firing questions at you he also shines a bright light directly into your eyes, and then looks in your ears, nose, and mouth. Next the group tilts you to one side for some reason, and shortly thereafter someone is yelling “X-RAY!” and they tilt you to the side again. The whole time people are talking back and forth “what’s his blood pressure?” “Can you get me a Foley kit?” “Good breath sounds bilaterally” “Did you get a temperature?” “He has good pulses” “Is his chest x-ray up yet?” “Does this guy have any medical problems or allergies?”
Finally they unstrap you from the plastic board, tilt you to one side, remove the board, and push on each of the bones down your spine. “Tell us where it hurts?” they yell. Next someone yells “finger up your bottom” just before you feel it happening. They roll you back onto your back and a catheter is shoved into your bladder. Someone else is moving a sonogram probe across your belly. If the chest x-ray the doc just examined looks bad you may get a slice between two of your ribs and a tube stuck in your chest. From there it’s to the CT scanner, the ICU, or the OR depending on your condition. Hopefully not long after your arrival someone gave you some pain medications and sedatives… I would sure hate to be wide-awake for all of that!
Moral of the story: don’t talk on your cell phone while you drive!
What that means, is that a 25 year old man was shot in the belly and even though the ambulance is still 3 minuets away, you better get down to bed 5 in the trauma bay because this guy is unstable.
Imagine for a minute that you are a trauma patient:
You are in a car accident. The paramedics show up, they put you on a rock hard plastic board on your back and strap you down tight so that you can’t move. They also put a neck brace on you. They rush you off to the hospital. You’re rolled into the trauma bay and transferred onto the bed, though still on the plastic backboard. While the paramedics tell your story to the doctor, half a dozen people rush towards you in yellow gowns and purple gloves. The two at the foot of the bed start pulling your shoes and socks off and cutting off all of your cloths, including underwear. Simultaneously two others are poking you with needles on both arms to draw blood and start IV lines to give you fluids; others are sticking plastic EKG leads on your chest, a blood pressure cuff on your arm, and a pulse/oxygen monitor on your finger. Someone pushes on your belly. At the head of the bed a doctor yells at you “Open your eyes”, “What’s your name?” “do you know where you are?” “what’s the last thing you remember?”. While this doctor is firing questions at you he also shines a bright light directly into your eyes, and then looks in your ears, nose, and mouth. Next the group tilts you to one side for some reason, and shortly thereafter someone is yelling “X-RAY!” and they tilt you to the side again. The whole time people are talking back and forth “what’s his blood pressure?” “Can you get me a Foley kit?” “Good breath sounds bilaterally” “Did you get a temperature?” “He has good pulses” “Is his chest x-ray up yet?” “Does this guy have any medical problems or allergies?”
Finally they unstrap you from the plastic board, tilt you to one side, remove the board, and push on each of the bones down your spine. “Tell us where it hurts?” they yell. Next someone yells “finger up your bottom” just before you feel it happening. They roll you back onto your back and a catheter is shoved into your bladder. Someone else is moving a sonogram probe across your belly. If the chest x-ray the doc just examined looks bad you may get a slice between two of your ribs and a tube stuck in your chest. From there it’s to the CT scanner, the ICU, or the OR depending on your condition. Hopefully not long after your arrival someone gave you some pain medications and sedatives… I would sure hate to be wide-awake for all of that!
Moral of the story: don’t talk on your cell phone while you drive!
Wednesday, December 5, 2007
Good Times On Call
So the other night I was on call for the ICU. This means that I get called on any ICU patients with problems during the night, and I admit or transfer any new ICU patients.
So we got a call from the ER for a patient who needed to be admitted to the ICU. He had suffered a stroke and was intubated by the ER doctor. He came to the ICU on the ventilator. I was filling out my admission orders and some paperwork for stroke patients, while the nurses were getting the patient situated. I came across a section that asked if the patient needed supplemental oxygen to breath. So I turn around and ask, "is the patient requiring any oxygen or is he breathing on room air?" The nurses paused and looked very confused... "he's on the ventilator" someone said. So yea, he was not breathing, the machine was breathing for him. I've felt pretty stupid in various situations this year, but I think that may be the worst so far. I replied that I'm allowed at least one stupid comment at 2AM and we had a good laugh.
So that's not a real mistake, just a moment where I was not thinking straight and asked a ridiculous question! Fortunately I have not made any real on call mistakes. (Though if I had I would not advertise that information to the world wide web!) I definitely have moments when I'm dead tired and it takes me twice as long to do things because my brain is just working a little more slowly. I think approaching patients the same way helps avoid potential problems, for example always asking if the patient has any allergies, or always looking at the date the x-ray was taken first. When I'm on call I try to sleep when I can, even if it's just for a half hour it helps. I do not use coffee or rock star or monster or red bull or full throttle, which I believe helps in the end. I would rather yawn occasionally than be artificially awake. Eating helps too, when you’re up for 30+ hours you require more calories.
Things are better now than in "the old days". In the old days residents worked over 100 hours per week and might stay at the hospital for days (hence the term resident). Now, by law, we cannot work more than an average of 80 hrs per week during the month. When on call, we cannot work more than 32 hours straight, and we must have a minimum 12 hours off before returning to work again. It is also required that we take an average of 2 days off in each two week block. It's still a lot of work, but it's do-able. Family practice is still way better than surgery! I definitely would not want to work this hard for the rest of my life, but it's only for a few years and supposedly the hard work will pay off in the end....
So we got a call from the ER for a patient who needed to be admitted to the ICU. He had suffered a stroke and was intubated by the ER doctor. He came to the ICU on the ventilator. I was filling out my admission orders and some paperwork for stroke patients, while the nurses were getting the patient situated. I came across a section that asked if the patient needed supplemental oxygen to breath. So I turn around and ask, "is the patient requiring any oxygen or is he breathing on room air?" The nurses paused and looked very confused... "he's on the ventilator" someone said. So yea, he was not breathing, the machine was breathing for him. I've felt pretty stupid in various situations this year, but I think that may be the worst so far. I replied that I'm allowed at least one stupid comment at 2AM and we had a good laugh.
So that's not a real mistake, just a moment where I was not thinking straight and asked a ridiculous question! Fortunately I have not made any real on call mistakes. (Though if I had I would not advertise that information to the world wide web!) I definitely have moments when I'm dead tired and it takes me twice as long to do things because my brain is just working a little more slowly. I think approaching patients the same way helps avoid potential problems, for example always asking if the patient has any allergies, or always looking at the date the x-ray was taken first. When I'm on call I try to sleep when I can, even if it's just for a half hour it helps. I do not use coffee or rock star or monster or red bull or full throttle, which I believe helps in the end. I would rather yawn occasionally than be artificially awake. Eating helps too, when you’re up for 30+ hours you require more calories.
Things are better now than in "the old days". In the old days residents worked over 100 hours per week and might stay at the hospital for days (hence the term resident). Now, by law, we cannot work more than an average of 80 hrs per week during the month. When on call, we cannot work more than 32 hours straight, and we must have a minimum 12 hours off before returning to work again. It is also required that we take an average of 2 days off in each two week block. It's still a lot of work, but it's do-able. Family practice is still way better than surgery! I definitely would not want to work this hard for the rest of my life, but it's only for a few years and supposedly the hard work will pay off in the end....
Tuesday, November 20, 2007
Continuity OB
So... as a family practice resident we have a requirement to have at least 10 continuity deliveries. This means I see the patient in the clinic for prenatal care, deliver her baby, and then see her after delivery in the clinic. The rough part is that babies come unexpectedly.
I've delivered over 40 babies, but I've only had two continuity deliveries so far... here are the stories:
Patient #1 arrives at 5am dilated to about 3cm, contracting every 5-10min. I am just finishing a 24 hr call shift, but stay in the hospital to follow this patient. I sleep in the call room and emerge every 3-4 hrs to check on her progress. Being a primagravida she progresses kinda slow, and we break her water and help things along with pitocin. So by 10pm or so she's complete and pushing! I help the nurse coach and wait anxiously to catch the baby... no such luck after two hours of pushing the baby is still at zero station. So I consult my OB colleagues and we decide a C-section is in order. At this point I've been in house for 44 hrs. As much as I did want to be there for the birth and assist with the C-section, I was not crazy enough to actually stay. I went home for a little more sleep before I had to return to the hospital for my regular duties in less than 5 hrs. The OB team did the C-section, which went fine and I took care of her the remainder of her hospital stay. I decided that with my next continuity delivery I would NOT live in the hospital to follow my patient through every step of labor, but would allow the nurses and doctors working in L&D to help and call me when it's time for the delivery part. I tried to implement this with my second continuity delivery, but it did not work quite right, as you can see below.
Patient #2, this story is even better.... She arrives around midnight, dilated to 4, contracting every 5 min. I'm 17 hrs into a 32 hr call shift. So I think, this is perfect, I'm already here, this is her second baby and so she'll surly deliver in the morning before I leave. Well, by 1pm she had not delivered yet... so I go home shower and go to bed! I had just about drifted off into a deep post call sleep when my pager went off at 2:55pm. "your patient is complete, hurry up and come if you want to deliver this baby!!" In my post-call daze I get dressed. I glance at the counter and decide that all I need is a pen, my pager and my stethoscope, I grab these three items and rush out the door! As soon as the door locks behind me I realize that my keys should have been on the list of necessary items... now not only am I lock out of my house but I cannot drive my car. Nor can I make a phone call because my cell phone is charging on the counter inside. I knock on my neighbor's door, and coincidently he's about ready to leave for work and offers to drop me off at the hospital. In route I get another page. Moments later I'm headed toward the labor and delivery floor. I rush in only to find out that it was a false alarm... the second page was to tell me never mind she's not ready. At this point my only option is to head back to the call room and try to sleep, which takes a little while but I fall asleep. The next page is the real thing and I make it just in time to catch the baby at 7pm. For being as sleep deprived as I was I did pretty good, the only think I forgot was to put on my shoe protectors and so I got blood on my sneakers.
Only 8 more to go!
I've delivered over 40 babies, but I've only had two continuity deliveries so far... here are the stories:
Patient #1 arrives at 5am dilated to about 3cm, contracting every 5-10min. I am just finishing a 24 hr call shift, but stay in the hospital to follow this patient. I sleep in the call room and emerge every 3-4 hrs to check on her progress. Being a primagravida she progresses kinda slow, and we break her water and help things along with pitocin. So by 10pm or so she's complete and pushing! I help the nurse coach and wait anxiously to catch the baby... no such luck after two hours of pushing the baby is still at zero station. So I consult my OB colleagues and we decide a C-section is in order. At this point I've been in house for 44 hrs. As much as I did want to be there for the birth and assist with the C-section, I was not crazy enough to actually stay. I went home for a little more sleep before I had to return to the hospital for my regular duties in less than 5 hrs. The OB team did the C-section, which went fine and I took care of her the remainder of her hospital stay. I decided that with my next continuity delivery I would NOT live in the hospital to follow my patient through every step of labor, but would allow the nurses and doctors working in L&D to help and call me when it's time for the delivery part. I tried to implement this with my second continuity delivery, but it did not work quite right, as you can see below.
Patient #2, this story is even better.... She arrives around midnight, dilated to 4, contracting every 5 min. I'm 17 hrs into a 32 hr call shift. So I think, this is perfect, I'm already here, this is her second baby and so she'll surly deliver in the morning before I leave. Well, by 1pm she had not delivered yet... so I go home shower and go to bed! I had just about drifted off into a deep post call sleep when my pager went off at 2:55pm. "your patient is complete, hurry up and come if you want to deliver this baby!!" In my post-call daze I get dressed. I glance at the counter and decide that all I need is a pen, my pager and my stethoscope, I grab these three items and rush out the door! As soon as the door locks behind me I realize that my keys should have been on the list of necessary items... now not only am I lock out of my house but I cannot drive my car. Nor can I make a phone call because my cell phone is charging on the counter inside. I knock on my neighbor's door, and coincidently he's about ready to leave for work and offers to drop me off at the hospital. In route I get another page. Moments later I'm headed toward the labor and delivery floor. I rush in only to find out that it was a false alarm... the second page was to tell me never mind she's not ready. At this point my only option is to head back to the call room and try to sleep, which takes a little while but I fall asleep. The next page is the real thing and I make it just in time to catch the baby at 7pm. For being as sleep deprived as I was I did pretty good, the only think I forgot was to put on my shoe protectors and so I got blood on my sneakers.
Only 8 more to go!
Saturday, November 10, 2007
my first post
Well... in just 3 cliks I've created my own Blog. I created an account so that I could post comments, and then I just happened to click on the "create your own blog now!!" button. So we'll see what I do with this. I have plenty of experiences to reflect on being a Family Practice intern at the county hospital, so perhap this will be a good medium for processing those expierences.
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