Four days ago I got a new patient, a 58 year old alcoholic who presented to the ED complaining of worsening abdominal swelling, spontaneous bruising, and low urine output. On admission his creatinine was 7.7, BUN > 110, INR 3.3, and bilirubin of 13. He had full blown hepatorenal syndrome (HRS); in the words of the gastroenterologist, he was "sick as $hit." The nephrologist and gastroenterologist both did not think he was a candidate for dialysis due to the extent of his liver failure, which meant he would not survive this hospitalization.
When I asked the patient if he understood how he sick he was, he stated matter-of-factly, "I'm going to die." I spoke to him about hospice, and he asked if I would write the important points down because "I know I'll probably forget soon." Even then, as the ammonia built up in his system, he knew that there would come a time where he would not be able to make decisions for himself, and he told us who he wanted us to contact (a female friend who was caring for his cat) if something happened. He had two brothers, but they were estranged due to his alcoholism and poor life choices. He told me he wanted to go home to get his affairs in order and take care of his cat, and I said I'd ask the hospice people to come speak to him about it later that afternoon.
The hospice people never showed, and when I saw him the next morning (yesterday), he was a completely different person. He had become completely encephalopathic, moaning and restless, unaware of anything around him, no longer in any position to make any decisions for himself. His friend was at his bedside and very tearful, but she took solace in the fact that he had listed her as his go-to person, which spoke of his trust in her. She wanted to make him DNR (rightfully so), which the nephrologist and I both agreed with. The nephrologist estimated that he had less than 24 hours left to live, and she was right. He passed away at 3:00 a.m. this morning.
Later in the day I got a text from one of my partners regarding a new admission: "aspirated on grass." That's one chief complaint that I never heard of before. It was really an interesting story; my patient was on a riding lawn mower clearing brush in a park when a branch suddenly flew through the air and smacked him in the nose and mouth. He had not worn a face mask that day, and afterwards he had persistent cough, shortness of breath, and right chest tightness. His chest X-ray was negative, but his CT chest showed that debris had completely occluded his right bronchus. The pulmonologist on call was out enjoying a bike ride when he got called to the hospital, but he got very excited when he saw the CT. It would definitely have made a great case study. We'll see how the patient does.
Thursday, May 30, 2013
Tuesday, May 28, 2013
You again?!
Almost 5 years ago when I was doing my sub-I at Brack, I had this borderline, noncompliant diabetic patient who was a total jerk through and through. Although I'd forgotten his name, I remembered him well b/c my resident made me see him everyday. Back then he had kept coming back to the hospital with lower extremity cellulitis because he didn't take his antibiotics. I remembered how he kept refusing the MRI that we ordered for him to rule out osteomyelitis, how he threw things at the wall and cursed at nurses, how angry he was because we put him on a diabetic diet, and how his room reeked whenever we went into his room b/c he wouldn't bathe and sometimes wet the bed intentionally so that he could accuse the nurses of neglect. He was only 29 years old at the time, and I thought it was a shame that he wouldn't take care of himself.
During my rounds today, I spotted him in the hall talking to one of the nurses. He saw me, too, and at that point I was 90% sure it was him. How many young overweight guys with a BKA in a wheelchair are there in Austin? Then I heard his voice, and I was absolutely certain it was him. There was not a single day at Brack where he didn't find something to gripe about, and as he complained to the nurse about his doctor, I recognized his voice for sure. I later looked him up; it seems that in the years since I last saw him, he'd gotten an ostomy from an abdominal wall infection, and currently he wanted to fire his doctor for not giving him Dilaudid. Apparently the plan is to discharge him from the hospital tomorrow; hopefully he goes back to Brack because there's no way in hell I want to take care of him ever again. Hopefully he doesn't remember me; I'm sure he's seen lots of doctors and med students come and go since he probably goes hospital shopping. Sad that some people never change.
During my rounds today, I spotted him in the hall talking to one of the nurses. He saw me, too, and at that point I was 90% sure it was him. How many young overweight guys with a BKA in a wheelchair are there in Austin? Then I heard his voice, and I was absolutely certain it was him. There was not a single day at Brack where he didn't find something to gripe about, and as he complained to the nurse about his doctor, I recognized his voice for sure. I later looked him up; it seems that in the years since I last saw him, he'd gotten an ostomy from an abdominal wall infection, and currently he wanted to fire his doctor for not giving him Dilaudid. Apparently the plan is to discharge him from the hospital tomorrow; hopefully he goes back to Brack because there's no way in hell I want to take care of him ever again. Hopefully he doesn't remember me; I'm sure he's seen lots of doctors and med students come and go since he probably goes hospital shopping. Sad that some people never change.
Saturday, May 25, 2013
Discrimination among doctors
The other day I mentioned to one of my colleagues that a UT student recently emailed me asking me for advice on getting into medical school when her GPA (which she did not reveal) was "not very high." His response: "Apply to DO schools?"
I could not believe he said that, but then again, I don't think he knew I was a DO. Unless we ask each other or volunteer the information, I have no idea where my colleagues went to medical school or residency. And unless someone really looks at my ID or white coat, no one knows I'm a DO and not an MD. In the past 3-4 years I've been a doctor, I've never encountered any discrimination against DOs (or maybe I was just lucky). The hospital where I did my residency was a melting pot of US grads, DOs, and foreign grads; there were about 8 DOs in my class, and some of our attendings were DOs as well. There was no discrimination. We didn't care where we'd trained or what initials were after our names; we were colleagues first and foremost. I think there was one time I asked a friend why he went to med school in the Caribbean. His response: "I can't believe you're even asking me that." Which is true. Why did it matter? At any rate, he's doing an endocrinology fellowship, and my other friends who went to Caribbean schools are currently doing fellowships in nephrology, cardiology, and ID. As for other DOs in my class, they matched into fellowships in cards, heme/onc, nephrology, and GI. Actually I think I'm the only DO who didn't match fellowship in my year, but that doesn't make me more of a failure. I'm making a very good living right now, and I'm well liked and well respected in my hospital by doctors, nurses, and patients alike. To me, that is success.
Later I mentioned the other guy's comment to one of my partners (about 20 years older than me), thinking he'd be a more supportive since the two of us work well together and have a good relationship. His response: "Why did you even apply to DO school?" Apparently back in his day my alma mater was sending letters to prospective med students inviting them to come there to study medicine, which gave him the impression that no one wanted to go there and they were desperate for students. Of course it's different now; our school has a good reputation for primary care and is fairly well known so there's no shortage of applicants. My partner then went on to express his astonishment that one of our favorite cardiologists (the only other DO in the hospital that I know of) matched into cardiology and became successful, as though DOs were only meant to do primary care and nothing else. His attitude reminded me exactly of my dad, who tried to convince me eight years ago to give up my spot at TCOM and reapply for MD schools because he didn't want me to be a DO. He'd heard from a MD neurologist that DOs had no respect in the medical profession and that people would always look down on them, and he didn't want that for me. Apparently when I made my rank list, he didn't think I'd actually match at a DO school so he didn't say a word, and he was very unsupportive when I told him I intended to keep my spot. Nasty words were hurled and we had a huge falling out afterwards; I had to escape to Taiwan for the summer to get away before I could speak to him in a civil manner again. I even recall looking at apartment brochures because there was no way I was going to move back home (even though school was 20 min away), but my mom talked me into it by promising me lots of privacy. Of course, this happened a long time ago and my parents couldn't be more proud of me now, but I can never forget the hell they put me through following Match Day, just because they wanted me to be an MD and not a DO.
The conversation I had with my partner, however, dragged up all those unpleasant memories again, and now I'm pissed and angry at him. Why should I have to justify why I was not an MD? Why was he asking me why I even applied to DO school in the first place, eight years after the fact? Back when I was debating whether to keep my spot or reapply the following year, an adviser at UT asked me this question when I told her my dilemma: "Do you want to be a MD, or do you want to be a physician?" The answer was obvious: I wanted to be a physician. And now that I've become what I set out to be eight years ago, I had hoped that my being a DO would not make a difference in how people saw me. And now it seems my own father was right all along. I just wish my partner would have kept it to himself and not thrown it in my face.
Fortunately, most of the people at work don't seem to care about the initials following my name, and if someone does bring it up, I dare them to say I'm a horrible doctor. Because I know that I'm good at my job, and that's what matters at the end of the day.
I could not believe he said that, but then again, I don't think he knew I was a DO. Unless we ask each other or volunteer the information, I have no idea where my colleagues went to medical school or residency. And unless someone really looks at my ID or white coat, no one knows I'm a DO and not an MD. In the past 3-4 years I've been a doctor, I've never encountered any discrimination against DOs (or maybe I was just lucky). The hospital where I did my residency was a melting pot of US grads, DOs, and foreign grads; there were about 8 DOs in my class, and some of our attendings were DOs as well. There was no discrimination. We didn't care where we'd trained or what initials were after our names; we were colleagues first and foremost. I think there was one time I asked a friend why he went to med school in the Caribbean. His response: "I can't believe you're even asking me that." Which is true. Why did it matter? At any rate, he's doing an endocrinology fellowship, and my other friends who went to Caribbean schools are currently doing fellowships in nephrology, cardiology, and ID. As for other DOs in my class, they matched into fellowships in cards, heme/onc, nephrology, and GI. Actually I think I'm the only DO who didn't match fellowship in my year, but that doesn't make me more of a failure. I'm making a very good living right now, and I'm well liked and well respected in my hospital by doctors, nurses, and patients alike. To me, that is success.
Later I mentioned the other guy's comment to one of my partners (about 20 years older than me), thinking he'd be a more supportive since the two of us work well together and have a good relationship. His response: "Why did you even apply to DO school?" Apparently back in his day my alma mater was sending letters to prospective med students inviting them to come there to study medicine, which gave him the impression that no one wanted to go there and they were desperate for students. Of course it's different now; our school has a good reputation for primary care and is fairly well known so there's no shortage of applicants. My partner then went on to express his astonishment that one of our favorite cardiologists (the only other DO in the hospital that I know of) matched into cardiology and became successful, as though DOs were only meant to do primary care and nothing else. His attitude reminded me exactly of my dad, who tried to convince me eight years ago to give up my spot at TCOM and reapply for MD schools because he didn't want me to be a DO. He'd heard from a MD neurologist that DOs had no respect in the medical profession and that people would always look down on them, and he didn't want that for me. Apparently when I made my rank list, he didn't think I'd actually match at a DO school so he didn't say a word, and he was very unsupportive when I told him I intended to keep my spot. Nasty words were hurled and we had a huge falling out afterwards; I had to escape to Taiwan for the summer to get away before I could speak to him in a civil manner again. I even recall looking at apartment brochures because there was no way I was going to move back home (even though school was 20 min away), but my mom talked me into it by promising me lots of privacy. Of course, this happened a long time ago and my parents couldn't be more proud of me now, but I can never forget the hell they put me through following Match Day, just because they wanted me to be an MD and not a DO.
The conversation I had with my partner, however, dragged up all those unpleasant memories again, and now I'm pissed and angry at him. Why should I have to justify why I was not an MD? Why was he asking me why I even applied to DO school in the first place, eight years after the fact? Back when I was debating whether to keep my spot or reapply the following year, an adviser at UT asked me this question when I told her my dilemma: "Do you want to be a MD, or do you want to be a physician?" The answer was obvious: I wanted to be a physician. And now that I've become what I set out to be eight years ago, I had hoped that my being a DO would not make a difference in how people saw me. And now it seems my own father was right all along. I just wish my partner would have kept it to himself and not thrown it in my face.
Fortunately, most of the people at work don't seem to care about the initials following my name, and if someone does bring it up, I dare them to say I'm a horrible doctor. Because I know that I'm good at my job, and that's what matters at the end of the day.
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