Sun - July 6, 2008

Uh-oh



Used to be that when someone said that the government was beaming voices into their head, you could count on the fact that the person making the claim was crazy.

But oh, no, the government just had to go out and develop technology so that they can beam the voices directly into your head.

It's pretty scary when the people you had counted on being crazy turn out to be right. Of course, for my right wing friends, that is what seems to be happening with climate change. All those scientists they had dismissed as crazy are turning out to be right.

Posted at 07:28 PM    

Sun - April 8, 2007

Internet-Assisted Self Diagnosis



This is an example of what can happen.

Posted at 08:03 AM    

Mon - January 23, 2006

The Death Of Colorful Charting



Colorful charting is dead.

When I was a medical student at the Medical College of Virginia (Class of 1980), the medical record included some editorial comments. One man was admitted to hospital with yet another severe complication of alcohol abuse. The admission note started, "This 46 year old connoisseur of the grape was found down on Broad Street ..." . Another fellow who had been living a rough life on the streets was described as "A 37 year old man with multiple gladiator wounds."

Back in those days, the only people who would see such clever writing were the generations of house-staff to come, as they provided care for those patients at some later date. Now, charts are reviewed by Quality Assurance Departments, Professional Review Organizations, third party payers, the government, and the ubiquitous plaintiff attorneys.

There is nothing like seeing your chart note blown up to poster size on an easel in front of the jury to curb your inclination to be a smart-ass.

So, medicine continues to evolve. My grandmother was head nurse in pediatrics at a Washington, D.C. hospital. We used to marvel at the photographs of her and the other nurses on the hospital lawn, with the babies from the hospital nursery spread around them. That would be unthinkable today. Now some of the practices from my training are equally unthinkable. It would be interesting to sit and predict which practices in 2006 will be unthinkable in 25 years.

Posted at 10:24 AM    

Thu - November 3, 2005

Cue The Twilight Zone Theme



I was in the interdisciplinary team meeting at the SNF today. Social Work and Nursing passed along the information that the elderly lady in Room 17-B was from a family of clairvoyants. Her daughter had confided in the staff that "my mother sees dead people."

This family then carried on a conversation with the staff that left the staff convinced that the family was describing a patient who had died in that same bed 2 weeks earlier. Some of the staff found this very impressive indeed.

My interest in the family talents had only two facets, however. First, I wanted to make sure that this seeing of dead people was a phenomenon of long standing, rather than something which called for an evaluation of new neurologic pathology. Second, I asked: did they do lottery numbers?

Posted at 09:52 PM    

Mon - October 31, 2005

Doctor, Be Reasonable



It is 1992. I am a geriatrician and internist, taking night call for my group with five other internists.

The phone rings at 1:00 am. The answering service has a call from one of my associate's patients.

I call the patient, a relatively young man, we'll call him Tito. Tito is complaining of pain in his neck. I start trying to put the picture in focus.

"So how long have you been having this pain?"

"Oh, about three years."

I pause, resisting the temptation to ask why a problem of three years duration warrants a phone call at 1:00 am.

"Is it worse or different than what you are used to?"

"No."

I pause again.

"Over the last three years, what have you been doing to control this pain?"

"I take Tylenol."

"So Tylenol isn't controlling the pain tonight?"

"I'm out."

I realize it is a good thing that this is not a face to face encounter, as I would probably throttle this guy at this point.

"My suggestion to you is that you go to 7-11 and get some more Tylenol."

He responds, his voice incredulous:

"You want me to get out of bed?"

This story could end right there, but the next exchange did get us into one of the famous doctor-patient cliches.

"What advice were you hoping to get that did not involve getting out of bed?"

Tito huffed, "You're the doctor."

Posted at 11:13 AM    

Wed - October 26, 2005

I Just Take Orders



I have written about this story before, but was reminded of it by an item I saw on the web. I am telling the story again, with the link to the story that reminded me of it at the end.

---------------

It is 1978. I am a third year medical student, doing a rotation on the inpatient psychiatry ward at the McGuire V.A. Hospital, in Richmond, Virginia.

I've been given the outline for how to take a history. Start by getting the patient's name, age and birth-date, and occupation. Then get the other information, the history of present illness, past medical history, all that sort of thing. I am sent in to take the history from a patient newly admitted to the psych ward.

I go in and introduce myself to the man, and sit down with him to start. "What's your name?"

"I am John The Baptist."

Umm, ... right. OK. I plunge ahead. "What is your date of birth?"

"I have been on earth since time began."

They definitely didn't prepare me for this in the interviewing course. Maybe things will settle down if I just stick to the game plan. "What do you do for a living."

"I was sent to found the New Jerusalem."

That was it. Rookie that I was, I couldn't seem to have a conversation with him on my terms, so I pitched in my hand and talked with him on his terms. "Where is the New Jerusalem going to be?"

He didn't hesitate. "Kansas City."

Incredulous, I asked, "Kansas City??"

He got defensive. "Look, I just take orders."

He had me there.

I was reminded of this story today as I read about a number of people who believe the New Jerusalem is going to be in Jackson County, Missouri . I wonder if John is with them.

Posted at 11:51 PM    

Mon - October 24, 2005

Pimping Your Colleagues



This is someone else's story. This happened at Providence Medical Center in Portland, about fifteen or twenty years ago.

The man, in his late 60's, was admitted to the ICU with a delirium. His brain was seriously malfunctioning, and no one could figure out why.

CT scans showed no sign of stroke, tumor, trauma, or increased pressure. Lumbar puncture showed no sign of meningitis. Blood tests showed no sign of chemical imbalance, infection, or organ failure. Toxicology screens showed no evidence of alcohol or drugs of abuse. EEG showed no signs of seizures. His health had been good previously, his doctor had him on no medications. Baffled, the platoon of doctors asked a psychiatrist to see the patient, to see if this was some bizarre mental health problem.

His concerned next door neighbor came to visit and see how he was doing. The psychiatrist was there, doing his consultation on this curious case of mental dysfunction. He struck up a conversation with the neighbor. No, the patient didn't drink, he exercised regularly, he ate a prudent diet. Then the shrink asked her, "He doesn't take any medications, does he?"

She paused, her face guarded, and finally replied, "No medications have been prescribed for him."

Sensing that this answer left something unsaid, the doc pressed. Reluctantly, she said,"Well, a couple of weeks ago, his ankles started to swell. I gave him some of the medicine the doctor gave me when my ankles started to swell. One at a time didn't do much, so he started taking a couple at a time." Turned out that the medication she had shared with her friend was her digoxin.

The psychiatrist told the squadron of internists and specialists, "Check a digoxin level," and left without further explanation. They shrugged, but having nothing better to do, ordered the test. They were amazed by the shrink's diagnostic acumen when the digoxin level came back very high. They administered digoxin -binding antibodies, and the patient quickly recovered.

The psychiatrist never did tell them how he cracked the case. He left it to the patient to explain where that digoxin came from.



Posted at 11:22 PM    

Sun - October 23, 2005

Language Of The 1970's



1978, 3rd year of medical school, Medical College of Virginia.

I was observing a vascular surgery procedure, a big operation to try to tap into an artery in the armpit, and tunnel a bypass down to the arteries to the legs to keep them alive. These vascular surgery procedures are like trying to fix the plumbing with the water running, except with higher stakes. The patient had terrible blood vessels, so none of the connections were going well -- they would get tented, or the blood vessel would tear.

We were 14 hours (!) into the operation when the surgery resident looked over at the attending, the professor in charge of the operation, and commented, "You know, we're getting down to stems and seeds here."



Posted at 10:09 PM    

Thu - October 20, 2005

Medical School Performance Art



The Asshole Bingo cards were done by a small cabal of troublemakers and performance artists. The same ones organized the class for one particular lecturer. This guy, a famous psychiatrist, would ostentatiously light and smoke a cigar while giving his lecture. We lined the front row with women, and distributed cigars to all the participating men. Fifteen minutes into the lecture, the women began crossing and uncrossing their legs in unison, sort of a ripple across the front row like "The Wave." One minute after that, the participating men lit up their cigars.

At that point, he told us he didn't want to lose our attention, so he told us the story of how he lost his government funding by killing an elephant with LSD. At that time, the government had a lot of interests in knowing more about potential uses for LSD. This guy made a grievous error in calculating the dose of LSD to give the elephant. He gave a dose based on the body weight of the animal, rather than the brain weight of the animal. Putting an elephant through a bad LSD trip, circulatory collapse, and death turned out to be the end of his grant. He left the Medical College of Virginia soon after that, but returned every year as a visiting lecturer.

By the end of the story, we had forgotten all about the cigars and the chorus line.

Posted at 11:27 PM    

Tue - October 18, 2005

Asshole Bingo



When I was in medical school, for the first two years our entire class attended lectures together, in a large lecture hall. We used the seating preferences as a psychological test: the flamers lined the front, the zeros lined the back, and the obsessive-compulsives lined the sides.

We would play a game called Asshole Bingo. We had some really obnoxious people in our class. The archetype was the woman who always sat on the front row. Dr. Richard Lower, one of the cardio-thoracic surgeons who trained Christian Barnaard, came to give us a lecture on heart transplants. He was in his introductory sentence when her hand went up. Perplexed that there was a question when he hadn't yet said anything of substance, he recognized her.

"Will there be any questions from this lecture on the exam?"

He said, "No, but ..." Before he could get out another word, she stood up, gathered her armful of books, and went out the door. He went to the door and called after her, "It really won't be that bad!" As he returned to the podium, the entire class murmured an apology.

We would take people like this, and put them on Asshole Bingo cards. On our cards, we would mark off the various subjects as they asked questions. At some point in the day, someone would ask a question, and the cry would go up from somewhere else in the room, "Bingo!" Usually, the subjects and the lecturers viewed these as random events not worthy of investigation.

I thought of this today when Wonkette posted her version of Indictment Bingo . This may be just as much fun.

Posted at 07:49 PM    

Thu - September 29, 2005

Opportunity Du Jour



Today's e-mail included this:

----------------


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Posted at 07:45 AM    

Mon - April 19, 2004

Psychiatry Training, Part 2



My friend and classmate, Daniel L. , writes in to remind me of another medical school psychiatry training story.

I was on the Emergency Psychiatry rotation. I was assigned to shadow one of the Psychiatry Residents. The resident I was assigned to that night was from the Phillipines. She was well read in psychiatry, but she was not well versed in American culture, and her ability to speak English was still limited.

We were called to the ER to see a patient who had slashed his wrists. Actually, they weren't slashed -- there were some half-hearted cuts. It turns out that he was on a police hold, for outstanding warrants.

He initially tried to talk to me instead of the resident. I nodded towards the resident. "You've gotta talk to her. I'm just a student."

He explained that he was despondent because he was going to have to return to prison, because of parole violations.

The resident got excited, and broke in with her limited English, in a sing-song cadence. "Why you not like jail?"

He appealed to me. "Is she for real, man?"

I was embarrassed and worried. It was embarrassing to be with a psych resident who wasn't grasping the full implications of the patient's story. I was worried that if the fellow kept talking to me instead of her, that her displeasure might have consequences for me. I nodded to her again. "You have to talk to her."

He looked at her with disgust. "They tried to rape me, man."

Her face broke out in a big smile. This, she understood. "Ah, so -- have you ever had the homosex?"

This was effectively the end of the interview. None of the heated statements after that were steps towards establishing a therapeutic relationship.

Posted at 06:08 PM    

Sun - April 18, 2004

Psychiatry Training



In medical school, the first two years were in the classroom. The third year is when the clinical experience starts.

I was assigned to do a psychiatry rotation at the Veterans Administration Hospital in Richmond, Virginia. In starting to get histories from patients, we had learned the procedure by rote. First, you took the Demographic information -- name, date of birth, occupation, that sort of thing. Then you took the History of the Present Illness, the Past Medical History, and so on.

I got my first patient assignment, and went in to do the interview. I went into the room and introduced myself to the patient, a middle-aged man with a round face and curly, unkempt dark hair and beard. I dutifully started down my checklist, notepad at the ready.

"Tell me your name?"

He didn't hesitate. "I am John the Baptist."

I blinked, and then blinked again. I had a premonition that the checklist was not going to serve me well.

"What is your date of birth?"

The immediate response, "I have been on Earth since time began."

This was vexing, as I wasn't sure what that date was, precisely. I was going down, but I stubbornly stuck to the checklist.

"What do you do for a living?"

"I am here to found the New Jerusalem."

This was my first experience with an oft-repeated scenario, the one where I haven't been taught what to do and I am on my own. We had been taught that we should not engage with a patient's delusional system, that we were their touchstone with reality. This did not serve me well when speaking with someone who didn't venture outside their delusional system. I took the plunge.

"Tell me about the New Jerusalem."

He started off with descriptions of it's purpose, and his role. I got curious.

"Where is the New Jerusalem going to be?

"Kansas City."

I was incredulous. "Kansas City?"

This implied criticism of the site choice made his eyes flash and then darken.

"Look, I just take orders."

He had me there.

Posted at 05:46 PM    

Wed - March 31, 2004

Web Site Housekeeping



I am subdividing the entries into more categories, but I want the old links to continue to work.

The category of Narrative Medicine will be for entries like:

"What Is My Father's Prognosis?"

DEA Regulations: Let Them Have Pain

Constantine's Lament

Posted at 06:07 PM    

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