everything i need to know, i learned in prison

I finished a two month rotation at a prison in rural northern Florida recently. And since i left, there has been a part of me that actually misses working in a prison health care facility. Yes its true, things didn't always run smoothly, sometime people were rude, it took FOREVER to get simple tasks done. But in the end, its what i expected. Unlike working in a top state of the art health care facility, where being treated like crap is not as expected. In prison, your expectations of other people's behavior, including those of the patients (inmates) are different. In the prison, as a doctor my word means something, my opinion means something, and there is no web MD for inmates to browse during their free time. There are no families to delay you getting your work done, and there is no need to be spending extra time dealing with family drama, instead you can actually focus on patient care - where it belongs, and social workers can deal with the family issues. So as stated earlier, in the prison the expectations are lower, but everybody has their role, and the boundaries are more clearly defined. And if you want someone to clarify their position, there are always prison guards eager to 'inform' others of their roles.


Here are some good tips I learned in prison:

1. patients lie! especially when they are 'falsely' convicted felons
2. you got nothing but time, while in prison
- if only they could take that kind of mental energy used to manipulate others for selfish gain, imagine the possibilities, productivity and ingenuity. Anyone that can make a weapon from soap, or devise complicated methods for smuggling contraband - should put his brain to better use
3. patients didn't become inmates for attending church
- at least in prison i know they are dangerous guys, in the real world - they walk around just like everyone else. they don't have 'murderer, rapist or child molester' stamped on their foreheads.
4. don't be shocked by any irrational behavior (ie self harm, swallowing of strange objects) - they like the attention
5. if you want to get something done, there is always someone around to "take care of it"
(ie - you want your patient to be compliant or stop refusing medical care - let other inmates know of your disapproval with his current behavior, the next day you will be amazed at his attitude adjustment)
6. the faster you can learn who to trust, the easier the job
7. trust no one but yourself
8. be grateful everyday you get to walk out the front gates



All in all - my two months were great. I met some nice people, learned a lot of medicine, practiced a lot of procedures and helped people who never had access to health care get treated. Its unfortunate, but here are people who actually have told me - they intentionally broke parole so they would be able to have access to HIV medication, chemotherapy or even surgery.

There is something to be said for not providing - productive members of society with universal health care, while making it a against the constitution (8th amendment) to not provide criminals with health care....

we treat our criminals better than our poor in this country....i am going to be interested to see how things change in the next few years.

HHS regulation

This is just another moment where i can use the internet to hopefully increase awareness regarding a proposed HHS regulation that will have far reaching effects if passed. The regulation will broaden the already present 'conscience clause' to include institutions and those not directly involved with the procedure deemed morally objectionable. This would mean in simple terms that the person who would clean the intruments after an abortion or sterilization technique could not be fired based on his objection to the procedure and can legally not do his job, because he/ she feels morally against the procedure. The new proposal also includes language that is quite vague and open to interpretation. We only have until sept 25 to post comments on the new regulation, so if you have a moment i highly suggest that you go online, take a look at the propsed amendment and post a comment. Since administrative agencies are appointed by the executive branch of government (non elected positions) we have the ability to let them know how we (the people) feel about the changes. These do not go before the legislation, and do not require the same type of voting process to be enacted. This is very important for the future of women's health. Please take a few minutes if you can.

here are some links to help you out.

http://www.regulations.gov/fdmspublic/component/main?main=DocumentDetail&d=HHS-OS-2008-0011-0001

you can view the proposal and follow the instructions to make comments

a moment of reflection....PALIN

Ever since i heard about the pick for VP, the name evokes an emotional response - and its not one of those warm and happy feelings. This simple decision, the pick for VP on the republican ticket simply put, gives me nightmares and panic attacks. At first glance, it seems that the McCain is trying to do the smart thing by placing a women to take the 'would be Hillary' votes - but that concept sickens me. Palin is the antithesis to everything Hillary stands for, thinking that women will vote for someone based on the fact she has a vagina is a personal insult to my intelligence and the intelligence of women everywhere. If you believe in what Palin stands for than there is no way you would have voted for Hillary, unless you vote based on gender alone. Joe Biden is more aligned with Hillary politics, and has a record of fighting for woman's rights, unlike Palin - who wants to see us without personal rights.

Having this woman, Palin - take a position that is literally a heart beat away from the presidency frightens me more than 4 more years of Bush. Did you watch her ABC interview?? After watching the interview i am not sure she is qualified to be in national politics - she should stick to alaska (pop 900,000).

feel free to watch the interview and judge for yourself.
Palin interview 1/4
palin interview 2/4
Palin interview 3/4
Palin interview 4/4

here are some of the reasons she frightens me:
- doesnt believe in evolution (she believes in creationism, and thinks this is what needs to be taught in schools) - i guess this means we have no responsibility in furthering the species, god will take of it, sounds a lot like someone who has been president for the past 8 years..
- doesnt believe in abortion even in cases of rape and incest - this is more radical than most republicans who at least want women who have been victimized the right to not have the child born out of hate.
- clearly doesnt believe in teaching the youth about comprehensive sex education, and strongly believes abstinence education works - has she seen her daughter lately??? great work!
- HAS NO, i repeat NO foreign policy experience or knowledge - did you watch the video??
- would be an embarrasement representing our country to foriegn heads of state...yikes! i hope the rest of the world doesnt think all women in the US are like her..
- is a proud member of the NRA, enjoys hunting (has been trying for years to have polar bears taken off the endangered list so she could hunt them)
- thinks oil is the best form of energy and wants to drill in the alaskan wilderness
- IS CURRENTLY being investigating for abuse of power (sounds familar too!)
- remember the 'bridge to nowhere' - seems like someone is a 'flip flopper' on that issue. Evidence she says what she needs to, to get elected. (also sounds familiar)

clearly i think everyone has the right to vote for the candidate they think will do the BEST job. So if you think you Palin is a qualified VP and possibly president (McCain is not getting any younger) then go ahead and vote for the ticket. But if past performance is a sign of future performance, than take a look at her track record. The issues she stands for, and think about what type of person makes those decisions and thinks that way.....do you want that to represent us as a country??? do you really think that it will be any different than the current administration??

I actually think it will be worse than the current administration. Just remember the roles that government plays....taxes are decided by legislation, appointments are made by the executive branch (including appointments to the judicial branch, and other administraive agencies)

well i guess that includes my two cents for the day. If you do nothing else today. Please watch the ABC interview...also if you disagree with me and are in favor of the candidate, please let me know why, i am curious.

prison break

Well, i am about to complete my second week working in a prison. I really never thought i would be able to type those words. And unlike my two roommates, i have acclimated well, and even - shudder- started to enjoy myself. The work is interesting, challenging and starting to be rewarding. The two men, or boys, i live with seem to approach ever task with a negative attitude and horrible outlook. Besides being irritating to me, they have started to rub the nurses and staff at the hospital wrong too, so people are not willing to help them out, causing them to get more frustrated, and thus the cycle continues. Today in particular i thought about two proverbs that seem to fit the situation quite nice,

1. you catch more flies with honeythan with vinegar
2. when life hands you a bag of lemons make lemonade

i have started to ignore the horrible comments my roomates make, the constand disregard for those that work and live in the area on a more permanent basis - instead, i decided to just make the most of the two months i have here to learn something. Holy crap! it works :) I walk in smile, say good morning, made an effort to learn the security guards names, the nurses and the other key players (scheduling secretary, radiology techs, transcriptionist and the outpatient clinic nurses) - all this takes very little effort, but the payoff is amazing and already showing results.

For instance, i work in a government institution - the department of corrections, which is currently running with a 13 million dollar deficit (sound familar, like a microcosm of CMS???) basically all this means, is paperwork and lots of it. you want something done, you need to fill out a specific form, have it approved, signed by the correct people and placed in the hands of the correct people to have done, whatever it is you want done. On top of that, certain tests or doctors are only in the prison on certain days. If you want an MRI better have it mon or fri. If you want it read by the radiologist check the schedule to see who is working that can read that MRI. You want your inmate (patient) to see a cardiologist, fill out a form, include all justifying documents, have it approved, signed and give it to the floor secretary who will send it to the scheduling secretary who then faxes it to the medical center to hopefully get scheduled....yep it sounds complicated, and there is a LOT of paperwork.


The same thing happens for medications that are not formulary, or if you want a patient on certain antibiotics or pain medications. Forms, approvals and multiple people before it happens. If you are reading this i think you can figure out where understanding where and how to grease the wheels can benefit your patient.....and being a jerk to everyone is NOT the way to get anything done quickly, esp because most things that are quick, are still not quick by the standards we are used to in the private hospital settings....but here is how i managed to get around this....

for instance today, i have an inmate with a large list of problems, some urgent and others more chronic. But overall he is not doing well, and there have been moments where i wish Dr House would show up and help me diagnosis this patient. But i am trying to do the next best thing, i am advocating for him and his health. He needed to see a neurologist, it is taking too long to get an appointment....so i walked down to scheduling and asked who is the person to talk to re scheduling. I then asked what i need to fill out to have my patient moved to the appointments for tomorrow....she told me, i did it. He was seen. The MRI i had shot last week still had not been read. I waited in radiology for the radiologist to show up, had the film in my hand, and asked him to go over it with me. Had him dictate, asked the transcritionist to transcribe it - then walked it over the appointment with the neurologist. He then recommended that he see an ENT ASAP. I started to fill out the paperwork, went back to scheduling to find out when the next day the ENT is here...its tomorrow, ok. What do i need to do to get him on the list. I got her copies of the consult, the MRI report and my phsyical exam from that day. DONE. he is seeing the ENT tomorrow.

Later in the day i was dealing with another patient, and it turns out one of my forms had not been signed by the correct physician to have the approval. The scheduling secretary came up to the floor (almost unheard of) found me, and told me she is going to track down the medical director for me to have him sign it. Amazing. She really could have simply said the request was denied and than i would have to start all over again and the next week, my patient would have gotten worse....as she has done for the other people who are not nice to her.

the boys constantly want to know how my patients labs, consults and radiology is scheduled, completed and read - while they are still sitting around with their thumbs in their butts. I try to tell them to just be nice to people. Instead, one of my roomates, tries to tell me, "the way things get done is by talking to people like they are stupid, and pointing out their mistakes." Sometimes i wonder if people can hear themselves speak....

i have found that my days go back quickly, there is always something to be done, something to follow up with - or someone to chat with for a few minutes today who will be able to help me out tomorrow. Truly amazing and simple lessons to be learned. I have learned and seen a lot of amazing medicine, but the life lessons of dealing with people is by far the greatest acheivement so far.

i will upload pics when i have some faster internet...if you have facebook you can check them out - they are already posted!

how do i seem to attract the psych cases.....

well, so far this rotation has definitely been able to live up to the reports from previous students...the pathology is AMAZING and i have been told i will learn a lot during the two months and be more than prepared to deal with most situations i will encounter during my intern year....

it seems i am already getting that experience even on my 3rd day. Each day we get a new patient, so if we can transfer, or discharge the patient we will have less patients to see the next day. My counterparts ended Friday afternoon with 1 each, i on the other hand have 3. I spent four hours on the phone trying to 'turf' one of my patients unsuccessfully. Let me give you a quick recap about the patient (inmate)..

it all started on thursday when my attending looked with a smirk in my direction, and mentioned he has a great case for me - a chronic swallower!

yep thats right, you read that correctly - he gave me an inmate that swallows foreign bodies, and will sometimes require surgery to remove the items. He has been doing this for the past 40 years and knows a lot about the medical system and the correctional system (he is serving what is effectively a life sentence - 165 years without parole). I refused to give him pain medications, so he can have tylenol and motrin. He swallowed 6-7 metal objects 5 days ago, has not passed any gas or had a bowel movement since that time. I can visualize them on XRAY. In the past he has had 78 abdominal surgeries for similar episodes and the surgeon that normally operates on him is in italy for the next two weeks. The partner refuses to take him, and told me to manage him until he gets worse, there are no other surgeons willing to take the case. The inmate gets frustrated because i am not providing him with medical care so he swallows a spring loaded object and shoves a spring into his abdomen so its protruding about 2inches from the skin (and is about 5 inches into the abdominal cavity). Of course he does this at 4pm on a friday. Seriously.... why does this happen when i am trying to leave for the weekend?!?!

i removed the object, gave him some pain medication that in reality is more of a placebo than a narcotic, started to feed him with the idea of pushing some of the objects along and adding some bowel prep for fun....if he wants to be difficult, two can play that game. I also had all the furniture removed from his room and left him wit a blanket, mattress on the floor and a shroud to wear. I am hoping he doesnt find any more objects to swallow over the weekend and i have arranged to have him transferred to another facility monday for a scope to try and remove some of the objects.....

my other cases just make me feel like House. They are a constellation of symptoms without a clear cut diagnosis because of the multiple underlying diseases....

this is def going to be an interesting two months....

not to mention i live in a trailer and florida is gearing up for a major hurricane to strike next week...i hope i will be ok and not have to evacuate....stay tuned to hurricane Ike, it is going to get interesting.

Day 1

Today we had the orientation....all day....government organizations have one thing in common, paperwork, and lots of it.

We learned about the facility and how we function on a daily basis...

some of the fun facts we learned today -

-- always have your personal body alarm on you, even though it doesnt really work
-- if you feel threatened, knock a phone of the hook and help will come
-- do not bring any electronic items into the prison (it is now a 3rd degree felony)
this includes: cell phones, PDA's, flashdrives, cameras etc
-- do not wear blue scrubs - the inmates where blue
-- come in tomorrow at 7:30am for patient assignments.

more updates and pictures to follow

Operation Trailer Trash.....

Its been a long time since i have posted anything, mostly because i didnt have much to say. Or i was busy...either way - here is the recap of the past few months...

i finished 3rd year in june started 4th year in july after a 10 day vacation (spent moving home to detroit from florida and studying for boards....not much of a vaca really). The next two months were spent trying to impress potential residency programs, so i will not be posting about those - just know, i DEFINATELY want to do surgery, that has been made cyrstal clear the past two months. Now onto the next phase....

I have just moved into a double-wide trailer, i will be rooming with two married men (also 4th year med students and classmates of mine) where we will live and work together as the medical team at North Florida Reception Center. If it seems like a reality show, its not - its my reality.... i will be posting pictures of the facility later this week (we have very slow internet)

Here is how my introduction to life as TT (trailer trash) started... I pulled into the main entrance of the prison in an attempt to find the 'main control room' so i can pick up my key. After pulling into the wrong gate and being redirected by a guy with a machine gun, i found the control room. I placed my ID against the glass and behind the steel bars while i introduced myself, the guards seemed confused - probably because of my appearance (wearing yoga pants, an old navy shirt and my hair is a disaster after driving for the past 8 hours without a break) They find my key and slide it through the bars, i take the sealed envelope and leave the building. I then start the process of finding my trailer - known as the 3rd trailer on the left.

there are no street signs or roads, just what appears to be a solid field of concrete. I see a row of trailers in the distance and have to assume that is my new residence. I count to three, park take a second to allow my surroundings to set in, and get out to walk to my door. I try the key secretly hoping that it wont work, but it turns and i walk into, *sigh* my trailer home for the next two months. Its actaully quite nice on the inside, we have satelite dish tv, a 40" in the living room, brand new appliances and mosdest size bedrooms. The only DVD on the shelf is "escape from alcatraz" - feel free to laugh, i did.

I unpacked and inflated my airbed - then decided to try and find food for dinner. According to my GPS - everything is about 15 miles away, but i managed to find a CVS with some lean cuisines. Agenda for tomorrow is finding grocery store.

Right now i am waiting for my roomates to arrive - yes, the two married men. (also be on the look for pictures), in the meantime i am relaxing on the couch watching the premiere of 'gossip girl' - just realized we dont get BRAVO (ugh no project runway...this totally sucks, but at least i will be able to watch the 2hour premiere of 90210!!)

cell service is shaddy - but texting seems to work.
GPS - unable to locate the trailer address
8343 SW 155th rd Box #3
Lake Butler, FL 32054

**in case you want to send something***

looking forward to not working weekends and making some trips to tampa, gainesville, orlando and miami...at least there is something to look forward to

i start working tomorrow at 8am - have no idea what to expect but will definately be posting and letting you all know what happens as operation trailer/jailhouse continues:)

One flew over the last rotation...

I know i have been neglecting my blog posts, and truthfully there is no good reason or excuse. Updating my blog is my method of decompressing from my days on clinical rotations, since i dont live in a cave, i am not antisocial and generally enjoy talking. So normally when i come home from a long day my roommate and i cook dinner and debrief from our day. We are both on clinical rotations, at different institutions and we enjoy sharing cases with one another, 'pimping' each other on topics discussed during the day and having time to gossip and swap stories/ drama from the other hospital. usually by the time i have completed this evening ritual there is nothing left for me to say, and i dont have anything to share with the world through my blog. In recent days, people have approached me asking to update. In my amends to them, i decided to be more proactive with the updates, since most are not present at my dinner table and miss out on the debrief firsthand, i will try and give the highlights. From now on my blog with the 'sports center' of my day.

I have not posted anything from my time in the psych hospital, where i spent my 4wks of February. Oddly enough it was the most exciting event filled rotation i have been on to date, so you would have thought there would be much to talk about it....but by the end of the day, when i got home i was happy to be home and away from the crazy patients i dealt with on a regular basis.

Background: the hospital i worked at is a state psychiatric hospital, that mostly has involuntary commitments with some voluntary. I had the pleasure of working on the male aggressive unit, with the convicted rapists, murderers, felons of other types, and basically the worst males in the hospital. We had a full unit of 40 patients, some of which had been there for the last 15 years. Most were not going to be getting out anytime soon either...the diagnosis ranged, but all had a major psychotic disturbance, schizophrenia or schizo affective disorder with concomitant personality disorders, overlying substance use disorders, and a variety of the normal and common medical conditions.

responsibilities: During the course of the month, i also had the pleasure of working with another student which always made the day more fun! We divided the patients in half and each managed and took responsibility for 20patients. For these patients we had to write monthly progress notes, interview and conduct assessments, write update notes for any incidents that occurred, reasons for medication changes, prepare court briefings for the attending to testify at hearings (for the involuntary court commitments of the patients), obtain consent for psychotropic medications and write orders and monitor medications adjustments.

daily schedule;
Arrive to the hospital and enter key code to obtain my keys, walk to the unit and unlock/lock the door, meet in the Dr office for morning report from the head nurse (no nurse ratchet here!). This is when we would get all the updates on who didnt take there meds, got into a fight, had an outbreak or difficulty overnight, or wet the bed. (we had a lot of people with psychogenic polydipsia, meaning their brain told them they were thirsty all the time, and these guys would have the water shut off to their rooms, but would drink from the toilet at night or sneak drinks during the day and wet the bed at night, we had to monitor their sodium level and watch for seizures). after report we would give a list of patients to the techs so they could bring them to the team meeting room. We could then ask questions and talk to the patients in a more controlled environment. Some days we had team meetings, with case workers, social workers, the patient, the social worker, recovery specialist, psychiatrist, med students, head nurse. (this would drive me CRAZY!!! seriously, hide the knives, because team meetings made me want to hurt people...)



I really enjoyed talking with the patients, mostly because i could ask them any question i wanted, and would get a response. Normally in the clinic you can ask patients a variety of questions, but here any question is fair game.....I would like to provide you with the highlights from the month...

"what super powers do you have?"
"are the voices fighting today?"
"are the voices male or female? what are they saying?"
"how much money did you win in the lotto?"
"did the zombie come and visit you last night?"
"why did you hit_____ in the face?"
"why did you take your clothes off and run down the hall?"
"what type of experiments are the Russians performing?"
"so you say there is a serial killer loose in the unit, and is hiding bodies in bags in the cafeteria..."
"why do you think we are trying to kill you with Zocor?"
"why do you tie a string around your penis? how come you put rub the semen on your face?"
"what are the names of your 53 kids?"


basically, i could ask a single question, and from there just try and follow the thoughts, usually it was pretty interesting to see what they would say. I enjoyed assessing the delusions, but at the same time its also amazing to watch some of the patients start to get better, as the medications are adjusted, you can actually see a difference in the mood, affect, tone and their delusions. One of my patients on discharge said to me, "Dr stephanie, i dont have delusions anymore!" but he had severe tardive dyskinesia (abnormal movements of the jaw, tongue and spoke with a lisp). Watching a few of my patients leave the hospital is bitter sweet. If on their medication they are pleasant and not threatening, but i have read their charts and i know why they came into the hospital in the first place, so its only a matter of time before they stop taking their medications and have another relapse and develop their psychotic symptoms all over again.

The single largest problem with the psychiatric population is compliance (or adherence) to the medication regimen. The patients do not like taking their meds and then they start to decompensate and definitely will not start taking their meds on their own...basically the only solution is to create more depot injections of psychotropics that last for weeks to months at a time, and have them come in to have shots of their meds, or if they can develop some form of an implantable that would release slowly overtime.....clearly there is room for progress. Historically the mentally ill have been forgotten, and i am guessing with the current trend in health care costs, the chronically mentally ill will continue to be forgotten.

Another interesting case i had, we decided to stop the depakote on one of my bipolar patients, and within 3 days of not taking his medications had slipped into a manic state, where he would rap and preach about black power and white hatred, and started to form a gang with the other black patients to gang up on the doctors and nurses. He also filed "habius corpus" for being held against his will, called the local newstation to report that he had been mistreated by the staff. Basically went a little nuts, even his appearance changed. It was remarkable to see the change in his demeanor in just a few days with no medication, esp because he was not on a large dose. He refused to take medications at this point and we had to forcibly give some injections, after which he started to cooperate and take his medications by mouth. Most of the patients didnt like to take their meds, and would hide them in their cheeks, spit them out, require them to be smashed and put into apple sauce or pudding or they were placed on Intramuscular injections of their medications. because these patients were court ordered to be here, we had the right to force them to take their medications.

Going to court was the other highlight of the rotation, and preparing my attending for the cross examination was fun! since we (as the students) knew the most about our patients, we had to brief him on the patients that were being presented at the hearing. Supply him with dates of incidents, medication changes, and basically supply the judge with the specific reasons why they should not be discharged at this time, and why they require continued hospitalization. The defense attorney did his job well, and gave some great cross examinations were i began to think theses patients my have a shot of getting out...until the judge would allow the patient to speak on his own behalf...then they would place the nail in their own coffin. Here is my favorite testimony....

'I am in my right mind, i am fully aware of my situation. The Russians are experimenting on me with methamphetamine, and have possessed the bodies of my family members in order to gain access to my mind and uncover the secrets that i posses. If you continue to keep me here the Russians will kill me because they are no longer to experiment while the doctor has my cholesterol so low.'

yep i know....crazy. truly crazy. those are the only words.

then there were the days, were i actually feared for my own personal safety, the day one of the convicted rapist decided to remove his clothes at the nurse station, state very loudly that he needs physical sex, points at me and yells, "you stupid bitch, you stole my money" This is a guy who already has been restricted to the unit for days and days for fighting and sometimes spends the majority of his day in time out or seclusion for inappropriately touching the female staff, attempted to rape one of the female nurses who subsequently had been let go. This is a patient that is definitely not to be trusted, and has the potential to snap. he has anti personality disorder and doesnt care about his actions and has no sense of consequence. while at the same time has more rights as a psych patient than i do as a medical student because they are protected under Florida statue (similar to children and the elderly) so if we get hit or assaulted in any way we are not allowed by law to fight back. This is completely unfair! We are trying to transfer the patient to a forensic unit where he is in a prison setting and the guards have guns. All we have are some big black guys, and the ability to tell him in a stern voice to please stop and go back to your room. Which if you have ever tried talking to a man in an active psychotic state, who is angry...talking is not going to do a damn thing...we need meds and we need them in dart guns.

Haldol 10mg Ativan 2mg darts! that is what we need....if they can combine those into one injection and then be able to put them in a dart gun that will inject upon penetration!! ahhh the future!!

Well i guess that basically sums up the month i had in psych....everyday was an adventure, there was never a dull moment, and there are plenty of stories....i think my unit was more exciting than jack nicholson in one flew over the cookoos nest, but hey i probably have a small bias.....

next up.....a month of veterinary medicine!!! yep you guessed it i start a 1month rotation at the children's hospital......yay kids!! (apply sarcasm here)

DNR, DNI..where do we draw the line?? DNT?

Ok i understand most people have no idea what the title of this post is all about, just one year ago I had the same perplexed confused look upon my face. This post will explain a the title and go into more of what I have been experiencing the past few weeks on my rotation. Currently I am completing a medicine rotation in the Intensive Care Unit, during my surgery rotation I had one month in the SICU (surgical ICU) and now i am in the CCU/MICU and on the code blue team. At the start I envisioned learning medicine and the care of the critically ill patient, fortunately I have learned so much more, focusing more on the ethical medical decision making, how to address family in times of critical illness and how to effectively manage all aspects of patient care.

A little background, i currently work in a 'closed unit' - this means that all patients in the intensive care unit are cared for by an intensivist, not their regular PCP. All orders and care is over seen by one doctor, who is board certified in critical care.

First learning point - not all hospitals have closed units with 24hr intensivist on duty to manage critically ill patients. According the Critical Care Medicine (journal) in order to achieve a better outcome for patients in a critical care setting the management should be overseen by a single doctor who is trained in the management of critical care.

That seems like a stupid obvious point, but one that is just starting to catch on throughout the country. Recall back to High School or even college when you had to work on group projects, or function on a team. Didn't everything run smoother when there is a single leader? project manager? chief? The idea of too many cooks in the kitchen, actually makes sense and applies to medicine. So many times the continuity of care is fumbled by too many doctors taking care of a patient without a central communication. I am only a 3rd year medical student, and have been in a hospital setting for 7 months, so i know i have a lot to learn. But has the 3rd medical student, I am generally the person who reads the CHART, the WHOLE CHART, including all recent orders for the previous 24hours. Countless times i have seen orders reversed, overlooked, recommendations by specialist ignored or contradicted. Most of the doctors taking care of the patient never speak to one another....even a medical student can see the possible problems here..every patient needs a captain, a quarterback, a single person that manages all the specialist. This is supposed to be the hospitalist/ internist or primary care doctor, but when it comes to the critically ill, I would want an intensivist looking after me.

Anyways, for the past 4 days i have been working the night shift, 7pm-7am. It def seems that if you are going to code, its going to be during that shift...basically my nights have been busy and a little on the crazy side...before continuing let me give some definitions to the title.
DNR - do not resuscitate
DNI - do not intubate
DNT - do not treat (not a realistic option)

If a patient does not have a DNR on file we are required to code the person, that means pump on their chest, breaking ribs, shocking the body, putting a tube down their throat and administering drugs...realistically we code people for (100-age)min. Ex: 80y/o man codes, we will work on him (coding) for 20min before the doctor will call it (pronounce death)

Over the last few nights there have been some interesting train wrecks that have come into the unit, some will hopefully leave and others are hear to stay. Some of them are interesting to say the least...

case #1: 61y/o female chronic hep B, end-stage HIV, and COPD. She arrived to the hosp 5 days earlier for COPD exacerbation, on admission tested positive for opiates, cocaine and THC. She had been admitted to the ICU on admission, and is ready to transfer out when the nurse calls to say she is having difficulty breathing, they want us to intubate her (ie keep her in the unit longer). She is on full contact precautions, including airborne, so it takes us a few extra minutes to put on gowns, masks, gloves before entering the room. Her pulse is elevated, breathing fast with a good blood pressure. My doctor asks me what indication for intubating the patient are present, after a quick listen, i reply with "none!" "Correct, this is an example of nurse panic! there is no reason to tube this woman, intubating this patient is futile and will not help her recover." the doctor decides to get a new urine drug screen, and it comes back positive for cocaine, meaning someone brought her drugs into the ICU and she took them while under the close watch of her nurse!! no wonder the nurse panicked and wanted the patient ventilated and sedated.

case #2: 81 y/o female came to hospital from nursing home facility 5 days s/p (status post) AAA repair with graft, with bilateral cold, pulseless lower extremities. It turns out while at the nursing facility the patient had been neglected and had developed a clot occluding all blood flow to her legs. Both of the legs were mottled and the feet where both black. These legs were both dead! they took her to the OR in an attempt to remove the clot and restore perfusion, completely unsuccessful. There was nothing left to do, amputation is not an option, the dr said she would need a hemicorpectomy (cutting her in half at the waist) and at 81 years with a list of complicating other conditions no other surgical options. The husband is crying in the hallway, there is no other family left, and its one of the hardest things to watch. The husband mentioned she was awake and walking 2 days prior and now she on a ventilator with two legs that are rotting. We convinced the husband to make her a DNR. She is going to die, and it will probably be tonight or tomorrow...that conversation is a difficult one to watch, i dont know how i am going to be able to tell a family, your father/brother/mother/sister is going to die...

case #3:
47 y/o male had been in and out emergency rooms for the last few months complaining of difficulty swallowing and burring in his chest. he had been told be the ER he had gastric reflux and to change his diet and try prilosec. no imaging studies ordered. came into the hospital on this occasion with new onset of cough, producing pink stained mucus. He got a CT of the chest, to reveal a mass the size of a grapefruit at the base of his esophagus, wrapping around the pulmonary arteries and into the left lung. He actually had stage 4 esophageal cancer. This is beyond surgical intervention. I watched my doctor tell his wife, and 3 kids (range from 7yr-25yr) that their father is going to die. The ventilator is keeping him alive, but the mass is surrounding major blood vessels that when infiltrated will cause him to bleed to death (meaning if we ever had to perform CPR the act of chest compressions may actually kill him).
Having a 7yr ask, "if the tube in his mouth is keeping him alive, can we keep it forever?"

heartbreaking. truly heartbreaking.

My doctor actually walked out and shed a single tear. A nurse said, "Dr B, you have a heart!"

she replied, "yes, but it normally pumps ice cold blood." then walked away.

I stood there in disbelief of the comment. My attending is an amazing doctor. She is triple board certified in general surgery, transplant surgery and critical care medicine. Has 2 kids, a husband and is one of the smartest people i have ever spoken with....it is possible to have it all!

anyways, i am going to leave the post for now....i will try and give another update this week when i am back on days, working nights is rough. I come home and sleep for 6 hours, wake up, shower eat and have to be back at work 4 hours later....

how come when you work early in the morning there seems to be more time to the day...this night shift is just crazy and messing with my clock...

peds...at least the kids are cute

The month of December i spent working in a Peds office, in theory it sounds like a chill vacation of a month, the hours are great 9-5 M-F and 9-12 every other sat. Fortunately for me i have learned what i do not like in medicine and working 9-5 is one of them, especially in a field like Peds. The best description of a pediatrician is a veterinarian. In Peds you cannot talk directly with the patient and have to spend a lot of time counseling the parents or dealing with screaming siblings, over bearing grandparents or new parents that think every fever and runny nose is a reason to see your doctor. The other part of the rotation particular difficult for me involved working with the ancillary staff, that at times could be more of hassle then assistance.

For the most part i saw healthy kids ranging in ages from newborns to 20yr, and in terms of sick kids here is my top ten complaints
1. cough
2. runny nose
3. fever
4. diarrhea
5. rash
6. rash
7. runny nose
8. constipation
9. reflux
10. runny nose, runny nose, runny nose

if you can get the hint, every kid came in complaining of cough with a runny nose, sometimes with fever and most of the time without fever...on a happy note, the doctors i worked with had great personality and a quirky sense of humor that kept the craziness of crying, screaming and vomiting kids to a tolerable level.

Unfortunately i seem to lack fun and exciting stories from my time on peds, most of what happened is very boring day to day stuff....here are some of my highlights-

Story: "parenting 101"
it was a Friday afternoon, the doctor left to attend a meeting and the medical assistant, receptionist and I were staying until 5pm to administer vaccines, return phone calls and follow up on labs. A mother calls at 2:45pm to ask if she can bring in her 12 year old son for some vaccines. Not being terribly busy, she had been told to come in as soon as she had the time. I am in the lab working on the computer and hear some screaming/ yelling from the front, its 3:02pm and a mother is becoming irate because she got there at 3pm for vaccines and she has to leave...the woman had literally been there for 2 minutes. I checked the computer for the vaccines her son needed, and started mixing the dilutants to prepare for administration. I am working on drawing up 4 different injections and preparing the tray, by 3:14pm i walk out to the front to call her son back, and all i hear is her yelling, "i have to go, i have 2 kids in the car, this is supposed to be a fast process all i need is some vaccines!"

at this point i happen to mention, "why did you leave 2 kids in the car?"

the mother freaks out and invokes the 'head motion' to proceed to yell, "how dare you tell me how to raise my kids!"

I think she obviously misunderstood my comment....basically i wanted to know why a mother would leave 2 kids in a car alone, in a parking lot at a pediatrician's office. The waiting room is kid friendly and the staff are willing to play with kids, that there is literally no reason to leave children unattended in a car.

clearly, it makes more sense to yell at me for inquiring about the location of her two other children....on the bright side, at least she is taking responsibility and vaccinating her children.


(I take issue with the parents who dont want to vaccinate their kids, if i hear one more parent tell me it causes autism i will scream! the medical literature actually states that there is no link!!! I should just get mad at CNN or MSNBC for bringing it up in the first place, just like 2 months ago when they had headlines about a NEW super bug, MRSA!! MRSA has been around for more than 10years, its not new and 50% of the population have already been colonized anyway)



Story: "what is the jugular?"
So the office has a medical assistant student, who is also a certified phlebotomist (ie the person who draws blood from a vein). While in the back, the office manager told a story about how they had to draw blood from a childs jugular. The MA looked confused and then asked,
"what is the jugular"
we all starred in disbelief, astonished by the comment, since its almost a term that is in normal vernacular. After we educated her about the major veins of the head, she asked, "oh, so its the carotid!" Again, stunned in complete disgust, trying to explain the difference between a vein and artery, something most junior high students understand, to a soon to be medical assistant.

I tried to look past this, she is still learning, maybe others dont pick up science concepts as quickly as others....but this girl is 21years old, has a 2 year old son and is studying to be a medical assistant, she has a lot on her plate and i tried to give her a break. Until her next comment...

while discussing travel, citizenship and passports, she asked, "do i need a passport to travel to Palestine?"

i responded, "a passport and a time machine back to 1947."

"why do i need a time machine??"

"Because Palestine has not existed since Israel declared its independence in 1948, then fought a war to secure itself as a state."

"What are you talking about? Palestine exists and dont you dare tell an Arab, that Palestine doesnt exist!"

"First, i think Arabs know that Palestine doesnt exist, its part of the reason for all the fighting in that region. Secondly, you need a passport to travel anywhere outside the US, not to get out necessarily but more importantly to get back into the country."

After this conversation, i decided to not take anything she states seriously, and to not discuss certain topics due to limited education on the subject.


Overall- my peds rotation went well, until the last day when i became super sick sleeping for almost 20hrs, and finishing a box of advil cold and sinus, a bottle of cough syrup and 2 boxes of tissues. Stinky petri dish kids carrying disease!!