#screaming internally

icoulddthisallday:

sometimes while reading fanfiction it becomes obvious that the author has forgotten that 2012 is almost ten years ago and that technology was actually very different then. then I have a crisis about 2012 being long enough ago that some fanfic authors need to do research to have historical accuracy. 

We had an admission last night, left leg cellulitis. Only came to stepdown because he had a tracheostomy 20 years ago and required a vent at night.

A soft admit but they don’t usually do any kind of vent management on the floor. Fair enough.

So I accept, read the chart and the ED notes. Guy shows up (and manages to be as much of a flagrant racist asshole as one can while barely being able to make sounds), my intern goes in and asks him about his ventilator and the settings.

Guy goes “I don’t use a ventilator.”

Intern (an ED rotator) googles “Bivona vent” which is what was documented and communicated to us on report as the ventilator.

This is a Bivona vent:

Literally just a flexible tube that keeps the trach from collapsing while you sleep.

This guy had literally no other stepdown needs besides “vent dependence at night.” We put his ass on the transfer board to the floor without bothering to staff the patient.

What probably happened is the patient either mentioned it once in the ED or someone picked it up in the chart, and because he’s such a colossal asshole no one wanted to go back in the room and clarify this with him.

[Also, good on my intern for standing up for our nurses/patient care techs.]

“The patient in room 35 told me there’s like, nothing there. Completely blind [at baseline].

Which is interesting because he went on to tell me about how he plays baseball in a rec league.”

We had a crazy snowstorm on Monday and the clinic was still open. I took one look at the roads and decided all my in-person visits would be converted to telemed, which our front desk was able to do for me.

I posted about it in a physician group on facebook.

Most people were supportive and said it was a good call for me and my patients. But someone chimed in that I can’t make that decision and I have to call my program director to make sure it’s okay, and reiterated this after I said there wasn’t time for that because people were already trying to drive in (the alternative would be to cancel my visits or hand them off to the one resident that was able to get there). She was very insistent, and then went on to say “well I know you struggle with executive dysfunction” (my ADHD is not a kept secret). Still not sure what that has to do with any of this, though…

After a brief back-and-forth I decided to just let it hang like the onion fart that it was, and by the time the day was over moderators had reached out to let me know she was being a shithead and had removed her comments. It wouldn’t have been such a big deal but this group was specifically geared at people who are burned out, and often this is from administrative bullshit so it was uniquely offensive.

Ironically, I later remembered I had run the idea by my chief in the morning but honestly that’s beside the point.

I had a patient for hospital follow-up where I clearly had missed the point. I read the discharge summary and went down the rabbit hole of a high renin and severe hypokalemia. All the while slipping past the part where there were two weeks of preceding nausea/vomiting that needed an etiology.

Next thing you know, I’m looking up stuff in front of them and so is my attending. The intern who did the discharge was also around. My attending was the one who eventually was like wait… what the hell are you talking about she was vomiting a lot, of course she was hypokalemic with weird renin. I’m not sure why the extra work-up was initiated, either.

I think everyone had brain fog this afternoon, I know I did.

Anyway, despite all of that, the patient still insisted I become their PCP (even after I said I was graduating in six months). I guess it was the willingness to check into things and be transparent?

I’m getting a how-not-to crash course in managing academic inpatient teams this week.

Let me preface this by saying everyone is super nice.

But the workflow is totally fucked.

Teaching is important, and keeping tabs on people is important. But there’s a certain point where you’re doing too much of it and break the efficiency of your unit. If your senior AND interns are staying hours past their shift end for multiple days something isn’t right, and it isn’t them. I feel like I don’t even have time to run the list with my interns (because I’m running around trying to put out fires by myself), and thus I don’t even know how I can help them out.

I mean, look, when you’re out in practice you do things how you prefer. But when you’re leading a team you have to consider a lot more than the clinical part. It’s only September, interns need time to learn the process and seniors need time to help them. If you don’t, you’ll find that discharges are delayed, consults are late, and patient care ishindereddespite any effort you’re pouring into clinical decision-making.

My request to delay teaching this afternoon was effectively denied, and when the attending asked how they could help we had no idea because no one had enough time to review all their tasks. I need to help the interns prioritize but I can’t do that when I’m running around putting out fires by myself. I ended up signing out to the night senior directly… I was short call.

I am going to ask that we table round and stick to new/sick/interesting patients as a team tomorrow, as I’d suggested at the beginning of the week when I was asked. Not sure how that’ll turn out but I’m down an intern tomorrow so something has to give.

Later on I’ll actually write a cohesive post about how I think teams are supposed to run when I get my brain cells back

yesterday was a NICE day in clinic

a patient I was reluctant to pick up on my panel (a situation I complained about on tumblr as my attending basically hoisted her on me as a patient we poached from FM) took some basic measures and dropped her A1c from 11% to 7% in the course of about 6-7 months. like all she did was cut way down on the regular soda/sweets. she looks better and is mentating much better than when I saw her initially. super motivated, I’m not sure what I did differently though. but I gave said attending the opportunity to gloat in her head when I let her know how this turned out.

I had a random add-on phone visit yesterday for a guy who is on chronic opiates. is currently being bridged to pain management but the earliest visit they gave is like a month from now. saw his PCP a month ago who continued it but only wrote for two weeks worth (there are pretty tight limits on length of opiate prescriptions here). it would have been easy to say “well I can’t really write opiates for someone I’ve never seen” but he’s established in our system and I think his PCP was on vacation or something. next visit with that PCP was also in a month. so I made up a pain plan with the patient on the fly where I’ll be refilling his opiates contingent on him checking in with me once a week, until he sees his PCP/pain management.

patients I see as add-on urgent visits continue to request me as their PCP, even under the caveat that I’m graduating next year. can’t peg down exactly what it is but I think I’m doing something right. and the entire day ran seamlessly.

also, not sponsored but doximity faxing has made my clinic life SO MUCH EASIER.

aw cmon man not again

https://www.strokejournal.org/article/S1052-3057(20)30805-3/fulltext

Development of Internal Carotid Artery Dissection During Masturbation

Sexual intercourse is known as one of the daily activities triggering spontaneous cervicocephalic artery dissection (sCAD), however, it has been unclear if masturbation can trigger the development of sCAD. Herein, we report a case of sCAD in association with masturbation. A 51-year-old right-handed man developed subarachnoid hemorrhage during masturbation. The dissection of the left internal carotid artery was evident on the 9th hospital day. Finally, he was treated with stenting and coiling and discharged with a good prognosis.

h/t to The Misfits podcast (which is not at all medicine related) for putting this interesting case report on my radar

now to decide how I use this case to formally contribute to my scholarly activity ^_^

pleasedotheneedful:

“You can call my primary doctor, he’ll clear all this up. He’s my personal doctor, he’s a good friend of mine.”

I’ve known this guy since I was an intern. Very self-sufficient with some chronic medical issues. Works as a freelance trucker, switched contracts and the new company has an outside corporation handling their occupational health. The new occ health folks decided he needs a new set of CDL clearance forms despite his previous ones being up to date, and a sleep study.

The funny thing is, even though they think he needs the sleep study they insist that I order it. This guy meets physical criteria for OSA screening but has never, ever had a symptom related to it. So like… you’re a doctor too, right? If you think he has sleep apnea, why don’t you order the study?

I was immediately suspicious when I found out who the occ health company was–let’s just say they also own a nationwide chain of urgent cares.

Anyway, what he said was correct: for this guy, I will handle his forms and order the sleep study, with an extra page in the return fax expressing my concerns about how they handled this.

“Regarding the sleep apnea, this was marked once in the patient’s chart by anesthesia in the post-op setting, and this was due to him meeting screening criteria by age, sex, and BMI. However, there are no witnessed or self-reported symptoms of OSA currently or in the past including excessive daytime somnolence, unrefreshing sleep, or frequent waking during sleep. Furthermore, the patient has been in his current line of work for most of his life without any apparent safety concerns. Thus, I do not believe he requires a sleep study nor do I have prior sleep study results to attach. However, I did order the study in order to facilitate his return to work.”

-Attached to a letter I faxed back with the forms.

I also had to report on a UA with trace blood/protein that was collected during concerns of STI/UTI. They asked me if he was on dialysis, I was like what the fuck lmao his renal function is FINE. There’s not even CKD

“You can call my primary doctor, he’ll clear all this up. He’s my personal doctor, he’s a good friend of mine.”

I’ve known this guy since I was an intern. Very self-sufficient with some chronic medical issues. Works as a freelance trucker, switched contracts and the new company has an outside corporation handling their occupational health. The new occ health folks decided he needs a new set of CDL clearance forms despite his previous ones being up to date, and a sleep study.

The funny thing is, even though they think he needs the sleep study they insist that I order it. This guy meets physical criteria for OSA screening but has never, ever had a symptom related to it. So like… you’re a doctor too, right? If you think he has sleep apnea, why don’t you order the study?

I was immediately suspicious when I found out who the occ health company was–let’s just say they also own a nationwide chain of urgent cares.

Anyway, what he said was correct: for this guy, I will handle his forms and order the sleep study, with an extra page in the return fax expressing my concerns about how they handled this.