August 3, 2012
Today I was asked how I do my job and put up with all the BS. “Laugh often,” was all I could think of.
A selection of some of the odd things I’ve come across in the last 6 months back in the hospital system.
1: First day
After reviewing an agitated patient, I suggested that the treating team prescribed olanzapine oral or intramuscularly PRN. The medical reg asked about olanzapine intravenously (IV). I advised against this, given the propensity to cause cardiac arrest and also for the fact that it’s never actually done anywhere. When I reviewed the patient again the next day, he had been charted for Olanzapine… IV.
Fortunately, not given.
It was going to be a long 6 months.
2: Worst referral ever
An Obstetrics registrar called me up and said: “patient patient suicide suicide.”
Then he hung up.
I was reminded me of a med reg I worked with some time ago who once called the family of a patient and shouted “code blue code blue” at them. Also inappropriate, also utilising a 4 word phrase of only 2 words – and also a former O&G registrar – the similarities are… disturbing.
Apparently first registrar had previously made single word phone referrals (“bone”) to orthopaedics – which was apparently acceptable.
3: Already on one!
A surgical patient who had been in hospital for a month was referred “a patient who looks depressed, ?need to start antidepressant”
The patient was already written up for one, but had been only given once during his entire admission. He said, ‘the treating team stopped giving it to me, I don’t know why.’
The treating team didn’t know either!
They were also unaware drug in question was an antidepressant…
4: Anorexia Nervosa 1
A girl with anorexia nervosa weighing 35kg, hypotensive, with severe bradycardia and a Body Mass Index of 12 was sent home by the Emergency Department. Apparently they thought she was ok to go home. Whoops.
5: Check the damn ECG
Referral: 80 y.o woman with query psychosis. No psychiatric history, delirium excluded as all medical causes excluded.
On review, psychiatrist finds NSTEMI and trigeminy on admission ECG.
Expression on medical team’s face… priceless.
6: Bad drug chart 1
A patient was admitted following alcohol withdrawal. He was prescribed diazepam 20mg 4 hourly for a week (120mg/day), this was reduced to 20mg daily for 3 days, then it was all ceased. Unfortunately this patient went from a an alcohol delirium to a benzo withdrawal delirium.
A week later I was asked by a med reg to wean a patient off benzodiazepenes, because they didn’t know how to do it. I believed them.
7: Bad drug chart 2
In a 4 hour period, a 95 year old demented woman was given a total of 15mg Midazolam IM, 15mg Olanzapine IM 4mg Haloperidol IM… and a 10mg Temazepam to help her “sleep”.
Not a combination I would give to a healthy 20 year old, let alone some in her mid 90s.
8: Accidental pneumonia
A bed bound patient from a nursing home was admitted with a delirium. On review, I recommended that both regular and PRN diazepam be ceased. This didn’t happen, the medication continued to be given in large quantities and a few days later, the patient had developed aspiration pneumonia. Winner.
9: Another inappropriate referrals
Received a faxed referral: “Pt Admitted for sudden onset headache, nausea, vomiting, fever, photophobia. Is now agitated and confused. Was well this morning according to family. Requesting psychiatric input for diagnostic clarification.”
Referrer: “We think this patient needs a psychiatric admission…”
Me (incredulous): “You are kidding. Have you got done a Lumbar Puncture?”
Referrer: “Umm… no. We’ll get back to you.”
She had viral encephalitis. They never got back to me.
10: LOL referral
Faxed referral: “Plz treat pt to so he doesn’t keep bouncing back with panic attacks”
Note from the file: “Patient has a history of COPD, cancer with lung mets. Oxygen sats dropped to 70% at home, patient was cyanotic when ambulance arrived.”
Panic attacks don’t drop your sats to 70.
11: “Patient not eating ?depressed”
When I saw this patient, he was was physically unable to reach his food tray. Or his call buzzer – strategically placed, I imagine. No surprises he wasn’t eating. Then I was asked why a food chart was necessary “because he wasn’t eating.”
12: Bad Dreams
Referral note: “Patient anxious, having vivid dreams, nightmares”
The patient actually described a delirium, brought on by alprazolam prescribed by the treating team.
13: “The Surgery Went Fine”
“Please review Mrs X 90 years old, because she is lacking motivation post op and ?depressed. The surgery went fine.”
She had undergone major abdominal surgery: splenectomy, pancreatactomy, and partial bowel resection. Patient had died the day before the referral was made… WTF.
14: Anorexia Nervosa 2
Case note entry querying a change in diagnosis from “anorexia nervosa” to “anorexia” because the patient is no longer anxious. (What the hell??)
Referral: “Patient has become angry, think she needs a psych review”
Patient had surgery cancelled 2 weeks ago, and would like an explanation why. Doesn’t know what’s going on or what’s going to happen bext. No entries in file from surgical team in during this period - I was reminded of a surgical fellow who used to tell students that you should never write in the notes so no one can sue you. He also used “impotent” and “incompetent” interchangeably.
July 5, 2012
Was recently forwarded this paper by a colleague. It is a fascinating read about the 2008 credit crisis which examines Klein’s formulation of manic defences and applies this to the broader corporate and government culture in the lead up to the events of 2008. Melanie Klein is known for her contributions to children psychiatry, in particular play therapy, object-relations theory, as well as her feuds with Anna Freud in the 1930s (Sigmund’s daughter and another prominent child psychotherapist).
A culture of mania: a psychoanalytic view of the incubation of the 2008 credit crisis (Stein, 2011)
“There are two contributions to theory. First, working with ideas from psychoanalysis and its application to social and organizational dynamics, the theoretical framework of a ‘culture of mania’ is formulated and developed. This culture is specified in terms of the four characteristics of denial, omnipotence, triumphalism and over-activity. Second, also drawing on psychoanalytic ideas, this article contributes a new notion of denial to the literature. While denial is usually taken to refer to the overlooking or ignoring of vulnerabilities and problems, the idea of ‘manic denial’ developed in this article refers to the concept that warning signs are indeed noted and observed, but that they serve not as warnings but as provocations to act manically in taking on more extreme risks.”
The full paper is available here, and well worth a look.
June 26, 2012
Hacked my Wii on the weekend!
As the console nears the end of it’s life cycle, I thought I’d set it up again and see what I’d missed out on: lots of cheap games available which if I recall has always been a rarity for Nintendo. Many years ago I’d installed the Homebrew Channel to play some 16bit classics, but since then the level of mods and hacks have increased significantly. Now hooked up to a USB Harddrive with a couple of backup games!
June 22, 2012
This week, I found myself having a chat with one of the new bosses. He was telling us how he had just purchased a house with his wife.
“Last year,” he said, “it was going for a million dollars.”
“This year, the real estate agents were telling me that nothing is moving, the top end is stagnant and they’re looking at fifteen percent drops. This particular house – sitting on the market for a good 9-10 months.”
“So let me tell you about this million dollar place: 600 sq m, inner eastern suburb, newly renovated, enough room so the relatives can visit and close to good private schools with transport links.”
“I got it for 700k.”
Me: “That isn’t 15%!”
“I know! I expect this sort of thing to happen more and more, but you’ll never hear about it in the news.”
Looking for holiday ideas (as ones does), and was flicking through the travel pages when I came across this article from March. Could this be the first part of Australia to go broke?
The picturesque Norfolk Island, which has been proudly self governing for more than three decades, has run out of money and been declared officially insolvent. An investigation by The Sun-Herald reveals that the government of the former penal colony-turned-tourist playground has been unable to pay its bills for almost a year. A collapse in the tourism industry is sending financial shockwaves across the island. Many homes, hotels and businesses are up for sale, islanders who are not eligible for Australian unemployment benefits are struggling to make ends meet and the island airline, Norfolk Air, has been grounded. A new report by the federal Department of Regional Australia shows that the federal government has pumped more than $37 million in emergency funding into the island economy to keep it afloat, more than $20,000 for each of the 1800 permanent residents.
Wow! It then goes on to discuss how the Norfolk Island residents don’t pay income tax to Australia and changes to the system may be made regarding land tax if they still want to receive funding.
Read more: here
It isn’t quite the man made Palm Jumeirah in the UAE – but I have been wanting to use this image for a while.
May 31, 2012
Today it was reported that Australian Health Minister Tanya Plibersek has refused to apologise for posters in her electorate office which label Opposition Leader Tony Abbott as racist, homophobic and sexist. The full article is here.
This is one of the offending posters:
The other poster has the caption, ‘Note to the Ladies: Make me a sandwich.’
Can’t let material like this go to waste!
For those wondering, the image is a screen cap from Arrested Development – hopefully we’ll see a new season next year.