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.

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....

EtAOK: Journal Impact

So for you fans out there of my ramblings, you may have noticed I don't drink. I've actually blogged before about it. Multiple times.

Anyway, the other day I was driving to an interview somewhere and heard a radio ad that reminded me of the whole issue. They were selling a supplement that was "red wine extract pills with no alcohol." So it obviously peaked my interest as knowing what it is in red wine that isn't in vodka is obviously what gives red wine its FDA/AMA stamp of approval over, say, moonshine.

Now I call this update journal impact because I'm all too aware of what journal impact factor is and what it means. So if I were to, hypothethetically of course, cite a study published by FASEB (that's the Federation of American Societies for Experimental Biology) I already know that it doesn't carry the same weight as something in, for example, The New England Journal of Medicine.

That said, the FASEB came out just recently and talked about what exactly it is in red wine that makes the difference. Turns out it's "polyphenols". There's a decent summary you can read about it here. After being tortured through organic chemistry anything with the word "phenol" in it just sounds dangerous, but apparently there's an exception to every rule. You can now buy polyphenol supplements on eBay (not that I am in any way, shape, or form endorsing this product. I personally think most supplements are garbage even more overpriced than the proven pharmaceuticals they "replace" - all without that pesky FDA who is always trying to stamp out American ingenuity).

One thing that's helped me support the belief that alcohol is heart unhealthy is the fact that the mormon population overall has a lower rate of heart disease compared to non-mormon countparts. In the off chance you're reading this and aren't mormon and don't know anything about mormonism, mormons are pretty well known for their abstinence from, among other things, alcohol.

Well, it turns out that it's the abstinence from one of those other things that seems to play one of the biggest factors. While I know that Deseret News is also not exactly a high impact journal, the story actually was broken across the AP wire and showed up on most credible news sites today (i.e. MSNBC, CBC, The London Free Press, etc). The study showed that fasting may actually be more cardioprotective than all that other stuff. Traditionally the first Sunday of every month is "Fast Sunday" worldwide in the LDS church. On fast Sunday, those whose health permits abstain from a meal or two and are encouraged to donate the money saved from not eating those meals to the Church's Fast Offering fund, which is specifically used to to provide welfare to the poor. While the study certainl by no means proves that fasting is cardioprotective, it certainly is suggestive.

But I still think alcohol is not good for the heart.

Questions: The Interview Process Part 2

If you know anything about me, you know I'm in the middle of interviewing all over the place for residency.

I'm not even half way done, but I don't think I can stand to hear one more person ask me, "Do you have any questions?" Because if I say no, then I look disinterested. And if I say yes and repeat the same question I just asked three other people at whatever place I am that day and then I look like a zombie totally zoned out as I hear the same answer repeated almost verbatim back to me.

Maybe I need to cancel some of these prelim/transitionals when most of the schools I applied to provide their own.

Watching Football with the Folks

I've waited to post this to wait for the relative excitement to die down. I was back home for the Thanksgiving holiday and my parents' home was filled with relatives. Two in particular are complete and utter BYU football fanatics. Having attended BYU, I understand. I do think it's a little ironic considering the fact that neither went to BYU, and neither did any of their children. In fact, one graduated from the hated rivals - the University of Utah. I digress. Anyway, so Thanksgiving was nice. And then came the Saturday after. The TV had to be dibbed days in advance for this game and the DVR was set to record "The Mountain" - the crappy station that broadcasts nothing but Mountain West athletics. BYU was playing the University of Utah.

There is a long tradition of heated games between the two. For example, last year the game came down to the final play. BYU trailed by 4 with time enough for one final play. You can see the rest below.

So after taking it to them in their own house, the Utes were particularly set on taking the W this year. That and the winner of the game actually stood to take the conference title for the year. It was a big game this year. Like Kansas v. Mizzou big. And I was interested in the outcome so I had to watch, despite my better judgement.

It was a very defensive game with both teams struggling. The 4th quarter started at a score of 9-3 BYU. And in fits of passion, I can still hear one person yelling "Get 'im! GET 'IM" as we watched the Utah quaterback scramble away from poorly excecuted tackles. The other of this dynamic duo spent most of the time talking about how much BYU was going to miss their missed field goals and TD opportunities. All I could think was, "Duh". It was kind of like when John Madden says things like, "You know, the team that gets into the endzone the most is going to win." Real men of genius.

And then Utah scores a touchdown. 10-9. Less than 2 minutes to go. In comes another family member who starts trying to lead high-school-esque chearleader cheers. I'm practically boiling over to tell them all, "You know that they can't hear you, right?" or "You know I passed first grade math a long time ago, right?"

BYU has the ball and then after a bit of poor playing it's fourth and long. Like 20 something yards long. And the pull out a 40 yard pass to keep themselves in the game. And then it happens. What annoys me the most about the BYU uber-fan dynamic duo is the way they talk about the officiating. If their team loses, it was always the officials fault for making calls that weren't really there or missing crucial penalties that would have saved BYU. During this particular game, there were a few questionable no-calls for pass interference and personal fouls that went both ways actually. But on this particular drive all the flags came out. After completing the impossible on fourth and twenty, BYU went on to have a both a pass interference and personal foul call go their way. The thing is, on replay they both looked pretty identical to stuff BYU had gotten away with earlier. In fact the BYU no-calls in some ways looked worse. And after getting over 30 yards extra from questionable calls, BYU was able to ram home a rushing touchdown followed by a two point conversion to win the game. Despite their poor clock management. I digress again.

Anyway, it's pretty clear to me that Utah should've won the game, but didn't. And I'm a BYU fan. But if you bring up the questionable calls to the dynamic duo, they argue tooth and nail that the calls were fair throughout the game. Of course - the Lord's team won. (For those of you not immersed in Utah culture, some on the more extreme side of the religious scale feel that BYU is "the Lord's University" therefore making BYU football, "the Lord's team." See picture at top of page. And who's that kid tackling Jesus?)

So I guess the point of this post is two-fold. 1 - I hate watching football with certain family members because the endless stream of inane commentary. 2 - BYU should've lost the game but managed to win with lop-sided penalties in their favor. Sorry Emma G*.

Some People: The Interview Process

I've been interviewing for residency positions over the past month all over my home state. I've met quite a few individuals on the trail, and all I can say is "Some People!"

Interviews for residency are interesting. You are there obviously bowing before the altar trying to get a job from these people - although they can't officially offer you anything outside "the match". And they are trying just as hard to sell themselves to you. I consider myself lucky in that this year anesthesia programs are doing quite a bit to woo their applicants. Most are paying for hotels the night before. Most are providing us with extravagant dinners or lunches at fancy restaraunts. Several hand out SWAG bags when you leave. I've gotten pens, t-shirts, coffee mugs (they did their research on that one, huh?), snacks, and the obligatory school folder.

Each morning there is an introductory power point slide show (if the chairman/director is tech savy enough to figure out how to power up the projector and computer) that shows off their program. One program, which notably lacked the fancy dinner/lunch and SWAG, spent most of their presentation talking about unbuilt hospitals that they are pouring money into and how great their program is going to be. Others go on and on about their benefits, which frankly is what I want out of them, while others spend the hour showing you pictures of the town and of their residents out partying together at "journal club". Then you go off to interview.

Interviews so far have ranged from 2 to 6 interviewers for about 30 minutes each. When there's just two, you pray that you get someone high up on the chain of command while with 6 you die just trying to come up with original questions to ask each interviewer and to continue to look interested as they sell their program to you by giving you the same information the last 5 have.

And the whole time you pray you don't have a situation like I had at the aforementioned school-who-sells-you-unbuilt-hospitals. I walk into the interviewers office which happens to be noticably bare of any decoration. That's a red flag that whoever this is is new to the faculty and can't tell you much or not very involved with the main faculty. Turns out this interviewer was the later. The interview starts and I notice right away that this interviewer also doesn't say much. And then the fun starts. They asked me about my step 1 score. It by no means is anything that would blow you out of the water, but it is one I'm proud of and feel like was an accomplishment. They specifically ask what I did to study for it. I tell them all about the 3 week course I took and how it helped and they start writing down details on a sticky note and then put it in their pocket. Weird. Finally they give me something to grasp at and tell me their daughter is about to take her step and they just wondered what kind of courses were available to help. Fine - I think. Then I made a big mistake. I asked what their daughter was going into. The answer was she wants to go into XX-non-anesthesia-program. Without any further interaction on my part I then get a story about how this interviewers spouse was a high up faculty for this speciality at a near by hospital and then died of cancer 4 months ago. And then the interviewers eyes started welling up with tears. Not exactly what I signed up for.

Anyway, usually while part of the interviewees are interviewing, the other half are off in a room trying to make stifled conversation. Some people are great and are people I wouldn't mind working with in the future. And some, especially those who come from big name schools, act very guarded. They ask probing questions of you and offer very little information in return. They like to hear all about every other school and even go as far to ask where you want to end up, but when you ask them in return you get a quiet, "I don't really want to talk about it." Cut throat gunners! One girl I interviewed with today was just that person. She tried very hard not to divulge any iformation even about where she had applied. What's worse is this was at her home institution so she knew all the residents and faculty well so was off gossiping with them and even had the gall to take over on part of the tour of the facilities. She was very snooty about this particular school and inferred that no other school in the state was good enough for her. I hate cut throat gunners. Fortunately none of the other residents in that program came off that way, but she seriously drove me up the wall. Some people!

Note to Self [update 1]

No "disco dancing" while intubating. Or putting in lines or anything else. Especially if I ever have the opportunity to be using an extremely high powered drill that CUTS BONE while cutting bones in the face. Read more here: http://www.msnbc.msn.com/id/21599495.

The real issue here is what do/should doctors and other health professionals do if (read WHEN) they screw up. Clearly not do what this guy did. I'd write more about it, but it's late.

[update 1]: I fixed the broken link, in case any of the 3 people who read this actually wanted to read the stem article.

P = MD

Today we ate lunch with one of the pharmacy students and a pharmacist. While eating, the pharmacist said, "There are people who were in my class I just thought shouldn't be pharmacists. Do you see the same thing in medical school?"

Sadly you do. Medical education is interesting. The admissions criteria are difficult. There are lots of hoops to jump through. You have to look good on paper and in person. You have to weigh competing offers or pray that you are at the top of the wait list. But once you are in, you are in. Atrition from medical school, at least my medical school, is remarkably low. I can think of only one person who has actually been kicked out. I can think of at least 5-10 others who probably should be kicked out. But doing so is a death sentence to a career in medicine. After acquiring so much debt to get through school, it seems like the school bends over backwards to get you through to the end.

Some people pick fights with ancillary staff. Some people let their egos supercede their training. Some people just don't have what it takes to survive effectively in the system. Some people are just plain not mature enough to handle hearing the proper terms for certain anatomic regions without giggling. Somehow all of them become doctors.

Every now then urban legends crop up about so-and-so who did such-and-such on the wards. Hearing those things second hand through the grapevine make them hard to believe, but almost all gossip and rumor are seated in at least a little peice of truth. And what's even more incredible is the fact that almost universally everyone seems to have a story about one person they rotated with that did something so incredibly stupid that you wonder how that person ever got into medical school. What's funnier is that sometimes the entire class knows how that yahoo got into medical school. It's so prevalent it just leaves you wondering - was there ever a day that it was me who gave someone else something to talk about? I know when I hear stories about people, or witness it for myself, I don't really have the guts to bring it up to their face (i.e. coumadin anyone?). Am I the gunner that just makes people look bad without knowing it (you couldn't tell from my non-AOAness)? I'm that guy who left all the scut work for someone else to do? I'm I the class idiot who doesn't see what everyone else on the team sees?

I try to not be any of those things, but sometimes you just have to wonder. Am I?

Et-AOK revisited [update 1]

Those of you who have been reading my blog since its previous address may remember my EtAOK post. Without reposting it, a quick summary is that despite its many ill effects and the huge cost it creates within society, alcohol (a.k.a. EtOH) is consistently and preferentially ignored throughout medical education. I like to therefore call it Et-AOK because despite the huge medical burden it places on society, since most doctors seem to enjoy drinking more than the average individual it is passed off as being totally OK, or EtAOK.

We all know smoking is bad. It causes cancer of many kinds. It causes significant decrease in lung function. It causes birth defects. It even carries a surgeon general's warning that using the product will cause these problems.

Alcohol can cause cancer, specifically hepatocellular cancer and stomach cancer. Alcohol can cause you to die from just about any organ system failing. Alcohol is the #1 cause in America of birth defects. Nobody seems to care.

Not only does alcohol cause all these things, it also causes a lot of trauma. You might remember my ER rotation posts "Life Lessons" and "Chief Complaint". A lot of those people also came in with pretty notably elevated blood alcohol levels. Anyway, the whole reason for me revisiting this post is I spotted this article in the news today. You might notice a few things about this guy. Like his use of a mixture of "stupid stuff" right before inserting the snake in his mouth. A poisonous western diamond back rattlesnake. Into his mouth. Because it was a "nice snake". Not that this one case report among many would change the fact that in medical school you will hear more about "the beneficial effects of drinking one glass of red wine daily" than anything other consequence of drinking alcohol.

Oh yeah, and this case is double awesome because it's anesthesia related because his tongue was so swollen as to totally occlude his airway requiring an emegency trach.

[update 1]: Who could ask for such luck in a single day?! Not just one story of inibriated madness, but two. This one is the story of a 54 year old drunk man who got in trouble with the law for throwing an onion at his 27 year old wife. I'm sure there's more than one story of "night's I can't remember" in that family. Your first clue might be that when the man was his wife's age she was but an embryo.

It's Broken

American health care. It's an entirely broken system.

While I don't necessarily believe in socialized medicine, what we have doesn't work. And it will only get worse. A major problem in health care is non-payment. Hospitals and doctors have horrible collection rates. Some collect as low as in the neighborhood of 20%. What that does, however, is forces costs to climb in an attempt to cover the cost of those who don't pay. A single dose of aspirin, which costs cents over the counter, can cost several dollars if you get it in the hospital. The ramification of this is that as people don't pay, everything will cost more, which will create more non-payment. Simple economics says cost will climb until the supply and demand curves intersect, the problem is that the demand/usage doesn't change despite the increasing cost.

So as costs climb, so does cost to insurance companies, which in turn creates higher cost of health insurance. Health insurance, however, does experience normal economic pressure and demand does drop with increasing cost. So fewer people will be insured every year as fewer and fewer can afford it. Which will create more non-payment. Which will raise the cost of health care. Which will decrease the number of insureds. Lather, rinse, repeat. Fortunately, I don't think it'll get to the point that health care ceases to exist, because at that point even politicians would be affected.

Beyond that, there is a huge amount of waste in the system today. Administrative costs of health care in America are astronomically higher than they are in other countries. For example, in the billing department of hospitals there is a full time staff of many people to keep up with the paperwork of billing each seperate insurance company or private payor. Each company has their own forms and documentation that has to be filled out in their own particular manner in order for them to even consider paying the claim. Across the border to the north, it takes one person to do all the billing for an entire hospital. Because it is standardized. One form. One location. What if America were to mandate that all health insurance companies accept one single form, like the Medicaid form? It would certainly cut out some administrative cost.

What if health insurance were an industry that was mandatorily non-profit and could not be traded on the stock market - so that health insurance companies would be responsible towards patients instead of stock holders?

What if health insurance were a mandatory benefit all companies with >15 employees had to include (not just offer, but include) for all employees (not just full time, but ALL)?

What if congressman and senators had to get their own private insurance and were not given free care?

What if we find a solution before the system collapses?

Omega Beta Gamma Pt. 2

I guess now I can give a more fair assessment of OB/Gyn rotation now that I've done almost a week of OB. OB isn't bad in and of itself. It's actually pretty easy considering most of the patients are generally pretty healthy.

My general day consists of doing morning rounds on post partum patients, going to checkout (worthless for students to be there), and then trying to stay on top of all the new patients coming in through triage and those who are delivering for the next 12 hours until evening board checkout (equally worthless for students to be there). After that I can go home. Lather, Rinse, Repeat x 10. It actually seems a lot like working in an ER with a very focused patient population.

There also is a lot of procedures to do. On gynecology, it was all procedures. On OB, it's less so, but still everyday there is stuff in the OR, deliveries, tubal ligations, etc. It keeps you on your toes and is active medicine. I hate passive management. For example, today was my first delivery. Probably because everyone in Houston delivered today and so we were a little shorthanded. I can't take all the credit though. The resident delivered the head (i.e. yelled "PUSH PUSH PUSH" at the patient until the head was out) and then had me jump in to pull out the rest. I probably would've delivered the head too, but the baby was DOP (direct occiput posterior). That means the baby came out looking up. It sounds good, but it's not because of the diameters involved. So this kid came out looking like a conehead (like most vaginal deliveries), but the cone was on his forehead.

Then, of course, I did the obligate medical student delivery of the placenta. They finally actually taught me what exactly I was doing, so now it makes more sense why you push on mom's belly while you pull it out.

Anyway, so that part hasn't been bad. What's been bad is that a lot of the female residents in this program are mean. They just don't like medical students. I thought that one I had on gyn was bad, but almost all of them on OB this month are that way.

For example, today when I got there at 0500 and began rounding on the patients I worked backwards from the direction the resident usually goes. Once I got to the resident, she got upset and told me "Work the other direction so we aren't just fighting over charts." She just assumed I had ignored what I'd been told the other day and had come late to rounds. I guess she figured out she had wrongfully yelled at me once she got to the other pods and saw notes on all the other patients.

Then after board checkout the residents (all girls on this OB team) just walked out of the room without saying a word to us. So we just went and tried to find stuff to do. I thought we were doing OK, but apparently one of the residents thought we weren't doing the right stuff and yelled at us. Usually the first step in getting people to do what you want is to ask them, not just assume they know and yell after it doesn't happen.

Then we have a bunch of stuff happen all at once with admitted patients. Cool stuff, like a velimentous implantation of the umbilical cord and stat c-sections. The problem was everytime something good happened, they would overhead page the other med student on the team (a girl) to come do them. The other problem was whenever something cool was about to happen suddenly there would be some kind of mind dumbing scut for me to suddenly have to do right then.

So, that's how the day goes almost all day long. I'm seeing all the patients in triage. I'm doing all the stupid paperwork. I'm spending all day trying to chase down the residents. The other (girl) medical student is spending all day doing procedures and scrubbing in cases (that I had been invited to scrub until they found out she wasn't doing anything). And then we get to board checkout at 5 pm. Finally the day was over. While doing checkout on a newly admited patient from triage (guess who the med student was who saw her) a question came up about her history. The attending asked and didn't get an answer, so finally I spoke up and answered the question. And got an evil eye death glare from one of the residents for having spoken during board checkout. Heaven forbid I attempt to make sure the patient gets good quality care instead of protecting the resident's ego. I mean it would be one thing if board checkout was 99% a ginormous gossip session about all the residents and attendings who are not currently present (note the sarcasm). So, once again put in my place for looking out for patient care. Like the time I mentioned chest pain and shortness of breath in a tachycardic women in triage, who had come with a different chief complaint, to the resident who went on to send the patient home at which point the patient called their clinic doctor who then had the patient direct admitted for chest pain. And then suddenly the residents threw a fit over how the patient had never complained of that to anyone and she shouldn't be being admitted.

I guess she didn't read very closely the MS3 note she copied almost verbatim.