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.

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… 🙂

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.

Friday 20/1/11 5.00 PM: Number of empty beds – 5

Saturday 22/1/11 9.00AM : Number of empty beds – 0

Dodged another bullet!

Delegating.

January 16, 2011

I was working at the ward the other day, and I happened to see the following written in the notes.

Plan: “Family meeting with the weekend on-call psychiatrist to discuss discharge.”

Now, the idea with having a family meeting is to discuss management, plans, discharge etc with a patient’s family by someone who knows what’s going on. The On-call doctor is someone who’s just covering for the day – not an appropriate person at all. It’s just a thought, but one would think that when one gets paid to make the big decisions, they don’t palm them off in such fashion. The shift leader couldn’t believe it, but it was marked in on the weekend whiteboard. Would’ve liked to be a fly on the wall the next day.

The bottom line…

October 2, 2008

…also on the topic of all things anal.

At today’s weekly meeting, the last of the student presentations described a patient who had abdominal pain secondary to perforated rectum of unknown cause, perhaps an ingested fishbone.  Then it was followed by the “Rectal Foreign Bodies”.  How about that!  Besides the usual joking around the topic, it actually did touch on important things like making sure it’s safe before a digital rectal exam in the case of sharp objects, and how plastic objects, eg. caps of shampoo bottles don’t show on an X-Ray and why you have to be careful even after you’ve fished out the offending object.  Then there was the one about the guy who swallowed a bag of fish hooks and got his finger caught on one…

Life’s little Mysteries

September 27, 2008

Have you ever wondered what happens to a foreign object after it’s removed from a patient’s rear cavity?  I mean, I hardly expect there to be a big box of lost property in the surgical department full of them.  You all might not have, and in fact I never did until the question was put to me.

“So where is the on call registrar, anyway?”
“I saw him downstaris in ED.  I think he’s removing a vibrator from a crazy old guy.”
“Yeah, that must have been what they were laughing about.  You’d think with all their years of experience they must have seen this sort of thing hundreds of times.  Should it still be funny?  They need to get over themselves.  Anyway, what do you reckon happens to it after it’s removed?”
“…” (Me, stunned silence)

Apparently, it gets cleaned and given back to them.

It was an instructive day on call.  I watched the Grand Final without interruption, and was called to insert a grand total of ZERO IV cannulations.  It was great, except I started to have symptoms of the beginning of tendonitis (secondary to Cave Story).  Have you played this game?  It’s an awesome NES styled 2D platformer in the Metroidvania style.  It has more charm and is less buggy than it’s compatriot freeware title Eternal Daughter, which is brutally unforgiving.

Anyway, the moral of the story is a dildo up the backside is timeless entertainment.