Trust Me, I'm a Doctor

It's actually true now.

AI

In keeping with this month's tradition of posts entitled with abreviations (with a grand total of 2 now), I give you AI.

Not artificial intelligence. That might actually be useful in medicine. Like really awesome PDA's. No, AI in medicine means "Acting Intern". That's what I am this month. I think it should also stand for "Absolutely Inept". Because that's how you feel when the nurses page you for something. Not because you don't know what to do all the time (that's only like half to 3/4's of the time). It's because even if you do know what to do, your answer can only be, "We should probably do xxxxx, but I can't give you an order. Let me talk to the resident and they'll take care of it."

As an acting intern, I'm supposed to be doing all the work that interns do. Except there's billing and medicolegal implications involved, so everything I do has to be duplicated anyway by a resident. So it makes me redundant. And out-of-the-loop when things happen and people go to where they can get orders instead of to me.

The nice thing, however, is that since my upper level resident has to duplicate everything I do she tends to not give me a lot to do. I only take up to 2 patients on call and tend to be last in line every time to get patients. That means if the service doesn't cap, I get only 1 patient on call. This is glorious because it frees up all sorts of time to do other important things. Like watch every single episode of Arrested Development.

The third year medical students on my team are all taking their internal medicine shelf exam this week. And they are all blaming me for their decreased study time because I told them about Hulu.

AMA

I've considering posting about this multiple times over the past two years. AMA. It stands for a lot of things. Like acquired member assets, or Academy of Model Aeronautics. It's actually also a word that means "metabolic waste products and toxins that have accumulated in body and mind and which obstruct the healthy functioning of mind and body". On a related topic, it also stands for the American Medical Association.

But even more importantly, it stands for against medical advice. It's a phrase that means you took off from the hospital without being discharged. It generally conotates that you absolutely don't agree with your doctor and would rather be billed for all services since no insurance company will pay for a hospital stay that ends in a patient going AMA.

I knew going AMA existed before coming to medical school, but have been interested in its multiple faces since being on the wards. My first encounter with it was with a patient who came in for an organ transplant. If all goes well, they spend a bit of time in the ICU followed by about a week in a regular floor room. One patient during my first month had one of these kind of transplants. Everything was great and he was getting close to being discharged. To encourage this, we encouraged him to get up and walk around, as doing so has been shown to decrease length of hospital stay for most patients. Well, this patient interpreted that "going for a walk" meant leaving the hospital and strolling around, IV pole in tow, down the park across the street. The nurses caught on after about 4 or 5 hours that the patient was gone and not in the hospital anymore, so they started filling out the AMA paperwork. When the patient finally returned to find an empty room, they were clearly angry that the hospital would do that when they were just trying to do what the doctors had asked.

While amusing, other times its less so. Like the patient that showed up with **automatic admission** complaint earlier this week. They knew all sorts of details and used medical jargon in a bit of a peculiar way, sometimes seeming to feign not really knowing the right word, but then in the end getting it out anyway. Lots of patients show up and say they're in pain and sometime in the past that one that starts with a "D" helped. They then look in the corner and go "hmmmm" and then say, "Oh yeah! Demerol. 100mg in my IV." This patient was one of those. They also are ALWAYS allergic to a lot of stuff. Because if you're allergic to ibuprofen, morphine, vicodin, etc, etc, etc (add pain meds here) then you know that they can't give it to you. If you're allergic to everything but *drug of choice* then that's the only one they can give you.

Anyway, so this patient shows up following this pattern, but to a new high. They supplied medical record type information saying they'd been in the hospital recently for the same thing. Except when we called said hospital, they'd never heard of this patient. The patient also wasn't just allergic to all the other medicines, they were also allergic to the workup for **automatic admission**. No iodine. Not even xenon.

Seeing through the ploy, the patient was given no narcotic pain meds. Period. They were restricted to their room in the ED, and not allowed to leave the unit. And within a few hours, the patient demanded the AMA form. By name.

I've previously witnessed such things as punitive exams (like DRE's) and procedures (like colonoscopies) that aren't exactly necessary, but justifiable. They're done to discourage frequent flying of that particular hospital's ER. If you do enough mean stuff to a patient, they won't come back.

But what's always bothered me is what if they really are in pain? What if? There was another patient who left AMA this week that I felt bad about. They genuinely appeared to me to be in pain. And had several good reasons to be in pain. But also knew the names of a few pain meds that worked for them. But didn't get any. And left really upset. And part of me feels like they were just there for the pain meds, and part feels like we just did a bad job helping them.

Baby Story

Moved

Proud Daddy

Moved

Second Best

For those of you who know me, you know that I believe very strongly in my religion. That's why this post is called second best. Because if had to choose a back-up, this would be it. The Jedi Church. It's for real. The Jedi Church was officially estabilished in this, the year of our Lord 2008. It's no secret that they've been around for years - putting down "Jedi" as their religion on census bureau data for quite a while. But what's different now is that is officially recognized by the UK as a religion. Ned Flanders admitted in one episode of the Simpsons to "eating Kosher - just in case." Well, here's to the Force - just in case.

A quick survey of their site reveals that they "have no doctrine", and that their members are almost exclusively males between the age of 10 and 40 who live in the US and UK. Most are students, although quite a few work for the government. Which reveals a rather bleak future for the religion. How far could a religion go without women? Then again there's always this girl:



I guess it's like the Smurfs. They only needed one Smurfette to populate an entire village of mushrooms.

Not So Infrequent

I was just reading through the day's "Odd News" and found an article that raised my interest, possibly because it relates directly to my current situation. The story talks about a woman who was 36 weeks pregnant and started having labor pains. She went to the hospital, was told that it was false labor, and went home. Waiting for the false labor to pass, she rested at home until she just couldn't bear the false labor pains anymore. So she tried to get to the hospital again. Except she didn't make it very far. Only to her driveway, in fact.

The thing that struck me about this article is that it isn't exactly a rare event for a woman to go to the hospital and be told it's false labor and get sent home only deliver shortly thereafter. I remember a few such cases in the 3 weeks of inpatient OB that I did last year. That's 1 a week. Late in the residency calendar year. At the end of the residency calendar year, in fact. One woman came in and the resident checked her. He told her that she was only 2 cm dilated and her contractions weren't regular enough. So after protesting that she had a history of short labor she left. And then nearly had her baby at IHOP over pancakes. She made it back to the hospital and was crowning within 5 minutes of getting to triage.

I'm glad I'm not going into OB. It's becoming more and more of a regimented profession in a process that is highly variable. But that's a whole different story for another post....

Triage

One of the (many) perils of going to medical school is the whole concept of phone triage. That is, when someone calls you up and wants to know your medical advice for their current ailment.

The first time it happens it's almost universally so early into medical school that you have no idea what to actually say to the person. But you feel awesome that someone thought to call you. Medical school is interesting in that most people have little or no patient contact until the third year. So when you're a first year student, you can think of that one weird disease you just learned about in histo or micro, but really you don't even know what to ask next. Then you get to second year. Second year's classes are all about things that go wrong in the body. The "zebras". So when you get that call all you can think of is that rare African tribal disease that it "just might be." It never is. And of course along with second year comes the supressed hypocondria. Everytime you yourself have any symptom at all you think you have lupus or colon cancer or leishmaniasis. Never mind it's pretty unlikely. You probably have it.

Then you hit third year. Actual daily patient contact and real medicine. You start to learn the differential and actual effective history taking. That's also when "I don't know" becomes the only thing you can think of during that phone call. "Ummmm. I don't have Peds till next semester. Better call someone else." Then you finally get to fourth year. Blessed fourth year. You get to where you think you know everything. You've passed your step 1, 2, and 2CS. You've gotten boat loads of invitations to interview at residency programs. You've turned down interviews. And then you get that phone call. And all you can think is the absolute worst case scenario. "She says her neck hurts and she has a fever." "Oh my gosh - it's meningitis". "She says her stomach hurts when she eats fatty foods and now she's vomitting." "Oh man - I hope it's not cholangitis." And so your answer becomes the same for every single phone call. "Better take 'em to the ER. Just in case."

So if I've told you this year to go the ER and it turned out to be nothing, or if you called and all I could say was "Ummmm. I don't know", or if I told you that you have a rare African tribal disease that comes from eating human brains, I'm sorry. It's just the way of the med student.