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??)

 

15: Bizarre

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.

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Songs for the Recession

October 1, 2011

Some might remember that the “Recession Sessions” got a plug on Freakonomics earlier this year. It left me thinking that times of struggle are a common and popular theme in music, and a soundtrack for a recession could be an interesting compilation project.

Last year, one of the radio hits was “I need a dollar” by Aloe Blacc

I need a dollar dollar, a dollar is what I need
Well I need a dollar dollar, a dollar is what I need
 And I said I need dollar dollar, a dollar is what I need
And if I share with you my story would you share your dollar with me

Bad times are comin and I reap what I don’t sow
 Well let me tell you somthin all that glitters ain’t gold
 It’s been a long old trouble long old troublesome road
And I’m looking for somebody come and help me carry this load

I had a job but the boss man let me go

He said: I’m sorry but I won’t be needing your help no more
I said: Please mister boss man I need this job more than you know
But he gave me my last paycheck and he sent me on out the door

I’d never heard of this next band until recently: they’re singing about the Irish recession although the title could be mistaken for other things.

The Script – For the First Time

She’s all laid up in bed with a broken heart
While I’m drinking jack all alone in my local bar
And we don’t know how
How we got into this mad situation
Only doing things out of frustration

Trying to make it work but man these times are hard

She needs me now but I can’t seem to find the time
I’ve got a new job now on the unemployment line
And we don’t know how
How we got into this mess
Is it god’s test?
Someone help us ’cause we’re doing our best

Trying to make it work but man these times are hard

But we’re gonna start by drinking old cheap bottles of wine
Sit talking up all night
Saying things we haven’t for a while
A while, yeah
We’re smiling but we’re close to tears
Even after all these years
We just now got the feeling that we’re meeting for the first time

She’s in line at the DOLE*
With her head held high
While I just lost my job but
Didn’t lose my pride

But we both know how
How we’re gonna make it work when it hurts
When you pick yourself up
You get kicked to the dirt

Trying to make it work but
Man these times are hard

Still around the UK, Lily Allen gives  snapshot of credit woes and obtaining a mortgage in one verse.

Lily Allen – Everything’s Just Money

Oh Jesus Christ almighty,
Do I feel alright? No not slightly,
I wanna get a flat I know I can’t afford it,
It’s just the bureaucrats who won’t give me a mortgage,
Well it’s very funny cos I got your fucking money,
And I’m never gonna get it just because of my bad credit
Oh well I guess I mustn’t grumble,
I suppose that’s just the way the cookie crumbles.

Now looking at the Beatles… some of the lyrics are still relevant today.

Beatles – You Never Give Me Your Money

You never give me your money
You only give me your funny paper
And in the middle of negotiations
You break down

I never give you my number
I only give you my situation
And in the middle of investigation
I break down

Out of college, money spent
See no future, pay no rent
All the money’s gone, nowhere to go
Any jobber got the sack
Monday morning, turning back
Yellow lorry slow, nowhere to go
But oh, that magic feeling, nowhere to go
Oh, that magic feeling, nowhere to go
Nowhere to go

One of my favourites is Low Budget by the Kinks.

Cheap is small and not too steep 
But best of all cheap is cheap 
Circumstance has forced my hand 
To be a cut price person in a low budget land 
Times are hard but we’ll all survive 
I just got to learn to economize 

I’m on a low budget 
I’m on a low budget 
I’m not cheap, you understand 
I’m just a cut price person in a low budget land 
Excuse my shoes they don’t quite fit 
They’re a special offer and they hurt me a bit 
Even my trousers are giving me pain 
They were reduced in a sale so I shouldn’t complain 
They squeeze me so tight so I can’t take no more 
They’re size 28 but I take 34 

 

The Boss is back to his best with something a bit more positive than the above:

Bruce Springsteen – We Take Care of Our Own

And finally, a bit of black humour if business gets so bad people start jumping…

Weathergirls – It’s Raining Men

Thursday Fragments

July 15, 2011

The other day I found myself having a chat with a colleague Z – she was supposed to be at a lecture by videoconference but as luck would have it the technology had broken down.  After being partially productive and demonstrating the ANKI powered question bank (http://wp.me/sklAI-anki) and musing on whether to give it away for free (like the legendary Kaveh exam notes on the ANZAPT website) or charge for the resource and turn it into a profitable business venture (like Rege’s CTF Course) [I suppose that depends on what actually drives me…], it quickly turned to entertaining irrelevancies.

There was some musing on her behalf whether an annual income of $100,000 was enough for a couple [Yes] because “I don’t think my boyfriend will ever get a job. He’s an arty sort who just does his own thing,” a discussion on whether media and social pressure to buy a house was overwhelming and if it was a good thing [Yes, No at the current time] and how real estate statistics (http://bit.ly/nFT4n9) were at least as dodgy as pharmaceutical company funded drug studies.  Somehow this developed into an entertaining discussion followed regarding observations about half Asian kids being either extremely intelligent or the polar opposite) and how this essentially seemed to depend on which parent was Asian and mandatory referrals to the Tiger mum Amy Tan and the High Expectation Asian Father meme (http://chzb.gr/bxyYYe), which I had never heard of prior.

Very (un)productive afternoon… 🙂

Today is the first day of June.  I was driving home, and “Ironic” by Alanis was playing on the radio, “It’s the good advice that you didn’t take…”

Driving long distances gives one a lot of time to think, and thinking about good advice that I should have taken but didn’t, the first is advice given to me by a friend who is now deceased.  “Don’t date someone early on in medical school, it’ll be years of pain if it doesn’t work out.”  Probably should’ve listened to that one, although in hindsight I didn’t know about Schizoid personality disorder at the time.

All his other advice has turned out to be pretty much spot on, although some of it can border on unrealistic or highly fantastic.  “If you find a girl who appreciates classic songs like this, marry her!”  And by classic songs, he was referring to tracks like this:

Probably a bit much to ask in this day and age of Rebecca Black and Autotune.  I’d probably settle for someone aware of the pop/upbeat Judy Collins version of the above video 🙂

That wasn’t the only ‘advice’.  Don’t date an international student. Definitely should’ve listened to that one, although it was strange that it came from an international student. I think the underlying rationale was that they’re just after your money, residency status etc and will leave you at the drop of the hat for someone with more earning potential. Funny how things have a way of working out.  Then again, it could be just me unintentionally extracting the stupid out of people – often on the first meeting.

For example:
“Hi, my name is…< >  I’m retarded.”
[It certainly sounds like it!]

OR

“This might sound weird, but is your father a dentist?”
[That’s a new one… different!]

OR

“Don’t you get orange flashes?  If someone I who likes is thinking about me, I get an orange flash.  Don’t you?”
[…]

But it isn’t always like that.  Some chance encounters leave a deeper impression.

“What did you tell me your name was?”
“I didn’t” and walked away (<- me being a jackass)

Then she came back later, apologized and introduced herself like nothing had happened at all.  Second chances don’t occur often.  It just goes to show that every now and then you meet someone kind, tolerant and genuinely interested.  Of course, it turns out that she was leaving for interstate and unlikely to ever return.   The fact that something completely unexpected occurred that day reminds me of a quote from Neil Gaiman’s “Sandman”

“Have you ever been in love? It makes you so vulnerable. It opens your chest and it opens up your heart and it means someone can get inside you and mess you up. You build up all these defenses. You build up a whole armor, for years, so nothing can hurt you, then one stupid person, no different from any other stupid person, wanders into your stupid life… You give them a piece of you. They didn’t ask for it. They did something dumb one day, like kiss you or smile at you, and then your life isn’t your own anymore.”

So know I have an email that’s will likely sit in my draft folder for a week while I think this through.  How does one reconnect with someone they haven’t seen in years?   Is it worth the anxiety, and potential pain of rejection and disappointment.  Or are good memories better left as memories?

Anki

February 23, 2011

Given my current job has plenty of downtime (half time in a department focused on service development/provision and the rest of the time in an Indigenous health centre where the bookings and attendance is fairly sporadic), I’ve found ample time for studying.

Although I can still back out, I’ve mentally committed to sitting the Written exams in August this year. There’s a few kinks to iron out in terms of booking leave and such, as well as a small matter of being interestate for my 10 year high school reunion and that all but clashes with the exam dates. Given I was quite looking forward to this event, it’s annoying that it’s been lumped together with a general annual reunion dinner instead of being in isolation – that would have made it later in the year. I’m not sure what I’ll do, but it’s certainly not the best preparation having to catch two rapid fire interstate flights prior to what is hopefully my last major set of written exams ever.

But I digress. In the last few weeks I have begun compiling the EMQs from a selection of mock papers into Anki software which I’ll comment on below. EMQ stands for Extended Matching Questions, kind of like a MCQ (multiple choice question) with about 10+ answers and 3-4 question stems referring to those answers. With recent exam format changes, the written SAQ (short answer question) section have been removed, leaving 140+ marks allocated to EMQs instead. Given that SAQs are a traditional favourite of mine, and MCQs are not, the fact that the first paper has been altered in this way is daunting.

Fortunately, I have recently stumbled upon Anki. The official website is here: http://ankisrs.net/
ANKI is Japanese for ‘memorising,’ and quite frankly is a revelation. In short, it’s flash card software and it’s something I wish I knew about a few years ago. One of the problems of just doing mock papers (of which I have 10 years worth!), is that you end up memorising patterns instead of information. Say a question has 4 parts has an answer key of A. C. D. G. and the first part begins with “John, a 33 Balinese male…” the next time I want to review those questions, I alreadly will know what the answer will be, making it a pointless exercise in subsequent exposures. By inputting the questions into Anki, the 4 parts can be mixed with countless other questions (400 currently!), breaking the memory link. Also, if the “John” card is appearing too often, I can edit the name, age or other clinical details on the fly.

There are other benefits I have noticed which I will outline in future blog posts.

Reminds me of a song I once heard.

I found my blog again!  Kind of glad I did.  Looking back the last post was in late 2008 – I think that was in the middle of my run of night shifts.  I guess it had its moments, but it’s funny how things always look better with hindsight. The years in between then and now can be summed up rather quickly.

2009 – now that was forgettable for all the wrong reasons – it started badly, it almost could have ended just as badly.  It was like a car crash where nothing is recognisable and nothing can be salvaged.  All in all, it’s a year I never want to revisit and I’d be glad to consign it to the scrapheap of memories.

In comparison, 2010 was a blast.  New challenges, new friends, and a new environment.  A change of scene can do wonders, and with that came a sense of hope, optimism, a reignition of passion, values and above all respect.  I actually feel a shiver down my spine thinking about it.

The challenges this year will be to keep the momentum going.  It’s been a good start so far.

The Three L’s

November 24, 2008

Contemplating the women that I’ve ever loved/liked/lusted over…

1. finance consultant, went interstate.
2. doctor, went interstate
3. doctor, went interstate
4. doctor, also going interstate…

Hmm, notice the similarities…

If I ever have to go interstate, it’s going to hard to pick where…