Internal Medicine
oracknows | December 9, 2015Et tu, Scientific American?
A few of you seem to know what will catch my attention and push my buttons, because over the past couple of days a few of you sent me an article published in Scientific America by an internal medicine resident named Allison Bond entitled Sometimes It's Okay to Give Patients a Treatment with No Proved Medical Benefits. Yes, a title like that is akin to waving the proverbial cape in front of a bull. Of course, I doubt that Bond herself came up with that title; editors usually come up with such titles. Still, the title is a fairly accurate summation of what is being…
signout | September 11, 2008While I slowly scrape together some original Signout blather on one of my favorite subjects, please to enjoy this terrific post by Dr. Rob about why much of the crap patients go through is not the fault of their providers. When you're done, read PalMD's interesting piece that follows up his first answer to "Would you do it all over again?" (See also the comments section in Orac's pointer.) Then, as a snack, go here for some outstanding fashion photography. After which you may enjoy this week's Change of Shift.
Also, my heart goes out to those memorializing loved ones lost on this day in 2001…
signout | June 3, 2008Let's say, for the sake of argument, that my first name is Trixie.
I spent most of my first year of residency introducing myself as "Trixie Signout, the junior resident on the team." I got called "nurse" a lot, then started introducing myself as "Dr. Trixie Signout." I wanted people to feel comfortable calling me by my first name, I said. I didn't want to seem classist, or superior.
Most of my patients ended up calling me "Doctor," anyway. During most of my intern year, it felt like a joke. But over the past half year or so, I've started to feel like that's really what I am. I finally feel…
signout | May 5, 2008A few months ago, a new patient walked into my clinic at four o'clock on a Friday afternoon. She was a fiftyish woman who had recently moved to the area from a different state. On the plane ride up, she had developed a fever and cough, and the day after arrival, had been admitted to the hospital with a huge, cavitating pneumonia. She was seeing me in follow up to her hospital stay.
Her hospital discharge, which I had skimmed earlier in the day, detailed an extensive past medical history including sarcoid disease and drug abuse. That afternoon, when I walked into the room where she waited for…
signout | October 29, 2007"Is anyone running this code?"
There were two residents in the room, one administering chest compressions, and one getting an arterial blood sample. Neither of them answered me; in response to my question, there was only the binging and bonging of various monitors ably detecting a dead man.
"OK, so, I guess I'm running this code."
Although I'd been looking forward to this moment for a long time, it was acutely uncomfortable in the way that being onstage in one's underpants might be. As fifteen people watched and waited for my decisions, I bumbled through the algorithms, alternately talking to…
signout | September 26, 2007There's sad news from the HIV prevention front: trials of an experimental vaccine against HIV have been suspended in the wake of an interim data analysis suggesting it's not really effective.
Per the NIH's press release, the vaccine hasn't been shown to alter either the predisposition to or course of HIV infection in human subjects. There's no mention of any harm to participants, and it's worth noting that the vaccine itself is formed of synthetically produced bits of HIV-like viral material incapable of causing actual HIV infection.
Vaccine development has long been one of the holy grails…
signout | September 25, 2007In the resident room at our hospital, we have a dry-erase board that plays an important role in resident education. On one side of the board, residents write the emergency department's (ED's) diagnoses of patients admitted to the medicine service. On the other side of the board, they write the actual diagnosis of each patient. Although some of the words in the below image of the board might be a little fuzzy, I promise you, many of them are hilarious:
I'm not gonna lie: most of the words on this board positively drip disdain. Fairly or not--and certainly, as is common in many institutions--…
signout | September 15, 2007I spent the afternoon today in the office of Dr. Leaky, a neurologist who takes care of people with movement disorders. One of the patients we saw was a man in his late fifties with amytrophic lateral sclerosis (ALS, otherwise known as Lou Gehrig's disease). ALS is a devastating illness that slowly drains muscle strength until a person is unable to feed themselves, bathe themselves, or even breathe for themselves. The course of the illness varies, but affected people usually die of respiratory failure within five years of the diagnosis.
This patient had been seeing Dr. Leaky for a year, ever…
signout | August 8, 2007Running a resident team on the general medicine wards is not a simple thing, especially at this time of year. The medical students are new to clinical work, and are painfully self-conscious. The interns are new to the hospital, and are scared of their own shadows. The upper-level residents are new to running teams, and are not completely sure what it means to be in charge.
That's not to say we don't understand our responsibilities. As one of those upper-levels, it is my job to set the team's priorities, which means I determine the order of rounding and delegate work to different members of…
signout | July 31, 2007We're not supposed to pick favorites among our patients, but I have one. We'll call her Brenda.
Brenda heard about our clinic through a friend of hers, a guy she used to smoke crack with. She'd been off drugs and booze for almost a year when she came to see me. Now that she was sober, she said, she realized she had "normal-people problems"--joint pain, high blood pressure, obesity--and needed a normal-person doctor. She had anything but a normal-person mouth, however, and from the moment I met her, said anything she wanted to, any time she wanted. She never held back the many, many things…
signout | July 4, 2007I've started my second year of residency with a rotation where I don't really function that differently from an intern. Our job descriptions are almost exactly the same: arrive stupid early, gather data on several sick people, round with our moody attending, and run around following up on details for the remainder of the day. The care of most of the patients on our ward is pretty specialized; under the fellow's supervision, I play at subspecialist-style management, but my actual decision-making is limited to basic inpatient medical issues.
Most of the time, I feel just like an intern.…
signout | April 9, 2007A couple of weeks ago, a study appeared in the New England Journal of Medicine showing that patients admitted to hospitals with heart attacks on weekends had higher mortality than similar patients admitted on weekdays. The investigators' analysis demonstrated that the main reason for this was a decreased rate of invasive intervention--namely, cardiac catheterization and angioplasty--on weekend admissions compared to weekday admissions.
This is perhaps not the surprise of the century: interventional cardiologists like their weekends off, just like normal people do. And although any hospital…
signout | March 18, 2007On Friday, I did something I never thought I'd have the guts to do: I looked a patient in the eye and told her I was not going to treat her pain. It was hard.
She had been admitted the previous day with nausea, vomiting, and epigastric pain. Although she had some marks of a drug seeker--she was rude and demanding, she had a long history of vague chronic pain syndromes, and she had a habit of switching doctors--her initial bloodwork showed an indisputably real and concerning abnormality. "Even crazy people get real disease," said my upper level resident, and we offered her the diagnostic…
signout | February 21, 2007A few weeks ago, I wrote about a woman I met in the intensive care unit after she was successfully resuscitated with ACLS. Serendipitously, she ended up on the medicine service I switched to shortly thereafter, and I've been taking care of her on the general medicine floors for a few weeks.
Today, on my way out of her room, I let on that I'd be switching services in a few days. "What?" she said. "You come back here." From her mouth poured forth a torrent of words, mostly good ones: "You're great, but you're a little rough around the edges. You're a go-getter. You know what needs to happen,…
signout | February 18, 2007I just talked to a regular reader of this humble blog, a good friend doing his residency in another institution. He brought up the code I mentioned here, and was appalled by the fact that procedures were still being done on a patient long after he'd died because the practitioners needed practice. "I've got some ethical issues with that," he said. "People donate their bodies to science so we can practice procedures on them. That's not what happened here."
I've got news, people. When you make yourself a full code in a hospital--namely, when you elect to have full cardiopulmonary resuscitation…
signout | February 11, 2007This morning, I was writing in a patient's chart on a general medicine ward when I felt the energy around me shift. Everyone seemed to suddenly be walking faster and talking louder--something was obviously wrong.
I overheard snippets of conversations swirl around me while disaster built: "patient is unresponsive," "don't know what to do." There was a team of doctors already in the room, and I didn't want to be intrusive. I just watched and listened from in front of my chart until I overheard a nurse say, "Maybe we should call a code."
When I got into the room, there were eight people crowded…
signout | February 7, 2007I'm always a little restless the night before a new rotation. Sunday night was no different, and I laid awake in my bed for longer than I'd hoped to, worrying about leaving behind the intensive care unit (the ICU) and switching to the general medicine floors.
At about six o'clock Monday morning, I walked into the room of a 91-year old guy admitted with antibiotic-related diarrhea. "How're you doing?" I asked. "Anyone I can get my hands on," he said, and cracked a little grin. Instantly, I was back.
What I worry about most prior to starting rotations is whether anything in the new place will…
signout | January 28, 2007Back in October, I admitted a patient to the general medicine service with a three-week history of abdominal pain and progressively yellowing eyes. She was a large, pleasant, quiet black woman who was almost always accompanied by her husband, a broad man with laughing eyes and a white beard who wore an old-fashioned train engineer's cap. Her history was suspicious for pancreatic cancer, as was the flurry of radiologic studies and biopsies that followed her admission.
On a Saturday morning shortly before I finished the rotation, I had a long conversation with the patient and her husband.…
signout | August 8, 2006It was bound to happen sooner or later: I finally broke someone.
Last Thursday, we admitted an 84-year old lady with bad disease of her kidneys and their vasculature. Her kidneys were too sick to make urine, making her a good candidate for hemodialysis. (In hemodialysis, a patient's blood is circulated through a big machine that sucks waste and excess fluid out of the blood-sort of an out-of-body kidney).
The goal on admission was to manage her acute issues, find her a slot for long-term dialysis as an outpatient, and send her home. Her most acute issue? Her very high blood pressure: she…
signout | August 1, 2006On Sunday, we admitted a new patient to my team, a young, kind of hip lady with an 8-month history of progressively worsening abdominal pain, fever, night sweats, and weight loss. All signs pointed to pancreatic cancer, which generally has a very poor prognosis. So it was a little confounding when the initial CT scan failed to show a pancreatic mass.
My team spent about an hour and a half discussing her differential diagnosis-the list of diagnoses she could possibly have-with two different attendings. It occurred to me at a certain point that I so badly wanted this woman not to have cancer…