Friday, April 18, 2008


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.

Wednesday, April 9, 2008


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.