Patient Confidentiality

Back when I was in residency, I had an HIV positive patient whose wife was unaware of his HIV status (apparently he didn't find out until AFTER they got married), and he refused to let anyone tell her. He'd tell his doctors that he was going to, but then never would. He would never want to answer any of our questions as long as his wife was in the room, even if it was for something non-HIV related, like how his chest pain was doing. To be fair, he took his HAART faithfully and his viral load was undetectable, but even as an intern the hypocrisy of the situation was not lost on me. He was one of the patients that no attending in the hospital wanted to accept just because he was an ass (that must be true only of teaching hospitals because in the real world we usually aren't supposed to refuse patients), and I wonder if his wife ever found out.

I'm now caring for another HIV patient whose parents don't know about his status. He'd developed a bad case of PCP, but before intubation he made it clear that his parents were not to know that he had HIV. I've seen his father fervently praying over him and wonder what sin he committed to acquire AIDS (most likely premarital sex with an infected male/female, given his age), and wonder how unforgiveable that truly would be to his parents.  I don't know what to say when his parents ask why he's not getting better and why his pneumonia just isn't going away. Can't exactly say, "Well, Mr. ___, your son doesn't really have much of an immune system because his CD4 count is one of the lowest I've ever seen in my career." Can't be judgmental when the guy's so sick, but I wonder what the end point is. If he should die, do I let his diagnosis go with him to the grave? The Tarasoff ruling allows us to break the shackles of confidentiality when there is intended harm towards another, but what am I supposed to say if this guy ends up dying and his mother asks why? The things we deal every day...

Fullmetal in the hospital

A few days ago while I was working in the ER, I was borrowing a nurse's computer to print out a patient's vitals when I spotted the name "Edward Elric" on the list of patients in that part of the ER. Almost immediately I burst out laughing. For anyone not familiar with anime, Edward Elric is the main character of a well known anime series called Fullmetal Alchemist. I've never seen FMA myself, but I've been to enough conventions to recognize the characters, not to mention I've seen Ed's voice actor Vic Mignogna at multiple cons and he's made no secret of the fact that Ed was one of his favorite characters to ever voice. I know the basic plot of the story, how Ed and his brother Al used alchemy to attempt to resurrect their dead mother, and in the process Ed lost an arm and leg and Al's soul got trapped in a suit of armor. I also know that there are a lot of themes in the series, i.e. the bond between brothers and how dangerous it is to play God with other's lives. One of these days I'll have to watch FMA, but for now, all that mattered was that there was someone calling himself Edward Elric in the ER, and apparently I was the only one who knew that name was a fake.

I saw "hallucinations" as the chief complaint, so it was entirely possible that this guy was psychotic and really did believe himself to be Edward Elric. However, he wasn't my patient and I wasn't about to violate any HIPAA laws by reading up on his file. So I did the next best thing and snagged one of the ER docs, telling him that the name "Edward Elric" was a fake one and that the ER social worker was going to have to try harder to learn his real identity. I even pulled up Ed's picture on my phone and showed it to him to prove that I wasn't crazy either. The ER doc laughed, saying that his patient didn't resemble Ed at all. He was also amused that it was thanks to my "inner nerd" that all this came to light. What can I say, it's not everyday that anime and medicine come together in my workplace. I later texted Kyle, a voice actor I befriended who'd also worked on FMA, to say that "Edward Elric" showed up in in the hospital (without going into too much detail); he thought that was pretty funny.

"Edward" was in the ER for at least 3 days waiting for a bed at a psych hospital, though by the second day, some of the ER docs had looked up FMA to learn about the real Edward Elric. "I heard you're the one who found out it wasn't his real name," said another doc. And apparently the ER docs were still talking about it over the weekend (I got those 2 days off) and my partners heard about it, too. I'm guessing he finally made it to a psych hospital; hopefully he'll get the help he needs and not fall into more delusions of grandeur.

Studer Training

Several months ago, my colleagues and I attended a mandatory meeting with a coach from the Studer Group, a group of physicians that educates other physicians about how to improve patient satisfaction and outcomes. It was four hours of teaching us how to demonstrate empathy toward our patients, ways of going "above and beyond" i.e. sitting down when talking to a patient, touching the patients, communicating, etc. Most of my colleagues thought it was a bunch of baloney; as for me, this was nothing that our med school hadn't already emphasized back in the day. I do try to sit down with my patients whenever I get the chance, I listen to their concerns, and I'm not afraid to lay a hand on their shoulder when they're crying. This I attribute to my med school training, not to the Studer Group.

Imagine my surprise (and dismay) today when the chief medical officer of the hospital poked his head into the physician's dictation room where I was writing my notes and asked if I had time to spare for him and a Studer coach (the same coach from above) to shadow me while I talk to my patients. I haven't had anyone shadow me since I was a med student, and I was sorry to say I couldn't recall much from the Studer training session. The CMO, Studer coach, and I saw 4 patients together: an osteomyelitis case, a chest pain, an A-flutter s/p ablation, and a new ESRD pt. I chose these patients b/c they were pretty straightforward and I had a pretty good relationship with them so the coach could see me at my best. The coach seemed pretty interested in where I trained, and asked where I thought my strengths were. I told him that I take time to listen to my patients, and that I make an effort to develop a relationship or rapport with them while they are under my care. I even gave some props to TCOM by saying our old motto, "Treat the patient, not the disease."

As for criticism, the coach said that I never once sat down while talking to my patients (the other chair was occupied and I didn't want to sit on the patients' beds), and he also commented that I rarely ever smiled. That's nothing new; I know my default facial expression is more of a frown than a smile. Still, I could see his point. One of the nephrologists at our hospital is extremely bubbly and friendly, and just seeing her makes me want to smile. Now I wonder what kind of disservice I've been giving my patients by not smiling when I walk through their door. And as for sitting down to talk to patients, they say sitting down gives patients the impression that our face-to-face time lasts longer than if we spoke with them while standing. That, thankfully, was one tidbit I remembered from the Studer training session, and the coach seemed pleased when I was able to recall it. Overall, he said I was doing pretty well, and that with a bit of tweaking, I can do even better.

Some of my partners wanted to hide when they heard that the Studer coach and CMO were walking around finding people to shadow, but I think everyone's going to get it eventually.

When the homeless can't help themselves

I don't think there's a single doctor in the US who has not had to care for the homeless population. A lot of them have multiple medical comorbidities and can't afford to take care of themselves properly on the street, or else spent whatever money they earn on drugs and alcohol. A lot of these people are regulars in our hospital. There's a 23 year old meth user with ESRD (due to malignant HTN) who never goes to dialysis and instead shows up at the hospital whenever his scrotum swells up (I wish I were joking about this chief complaint) or pruritis. He's so noncompliant that many nephrologists in the city want nothing to do with him; the ED docs don't even admit him every time he shows up anymore. Usually they check his labs and only admit him if his lytes require him to get dialyzed. Then there's a 21 year old type I diabetic who can't afford insulin (another meth user) and comes to the hospital at least once a month (on average) for DKA. When I was a new attending, I felt sorry for him and donated $5 so he could afford his insulin at Walmart. It didn't solve anything; he returned to the hospital the following month. I felt like a fool afterwards; he probably spent that money on meth.

Most recently I took care of a homeless guy with cellulitis who required an I&D of his foot. He was supposed to have gone home the day before, but had refused b/c he was homeless and was not able to receive wound care at the homeless shelter. More importantly (and irritatingly, to me), he said that if he was discharged from the hospital, then he was going to go straight to the nearby county hospital because in his own words, he did not feel safe walking and was afraid he would fall and hurt himself. Never mind that I saw him walking pretty well in his room and pulling his IV pole beside him to boot. I usually feel sorry for the homeless patients I care for, but he definitely wasn't even trying to make me sympathize with him. He was Spanish speaking only so I had the tech in the room to help me translate, and not once did he look directly at me; in addition, I didn't need to understand Spanish to know that he was being a total jerk. I asked if he could stay with his son, and he said no, b/c his ex-wife lives with his son. What was I supposed to do? Discharge him and have him run "crying" to the county hospital that foot hurts when he doesn't even need to be in a hospital anymore? That would certainly look bad for me and my hospital. I went and talked to our social worker about the situation, and she said that since he had Medicare/Medicaid, she'd try to get him into a SNF. "Do you think he'll agree to it?" she asked. Of course he would, if it meant he'd get fed three times a day and wouldn't be stuck outside in 100 degree weather.

Not surprisingly, the patient agreed to a SNF, and further requested (or demanded, who knows) that he go to a SNF where the staff spoke Spanish. If not for the fact that our hospital is big on patient satisfaction (they call patients 2-3 days after discharge for feedback on their stay), I don't see why he should be allowed to choose which SNF to go to. Fortunately there was such a SNF and he was discharged later that same day, but seriously...it doesn't take too much nowadays to become disillusioned with healthcare today.

The night from hell

I've been working nights for the past 4 days, and during my 2nd night, the ED was full of drunks and psych patients. One ED doc grumbled that he was tired of people calling him a "f***head;" a lot of people joked that maybe the supermoon was the reason why the ED was so full. Fortunately for me, drunks and psych patients don't need to be admitted unless they're medically unstable, so I only did 5 admissions that night. Even still, I had the feeling that I would pay for it much later.

Last night was my worst night call to date. I got 4 patients in the first 30 minutes, already a bad start, but I was able to triage them and see them in order of sickest to least sick. However, the admits kept coming, and after 3 hours I had 9 admits and was still at least four in the hole. The ED doc even asked to make sure I didn't have any sharp/hard objects in my hand before he gave me another admission. I was hoping there would be a time where I'd be able to catch up on my admissions and not be 2+ in the hole, but it never happened. I was in the hole all night, and as the admits kept coming, I'm sorry to say that I also became angrier and angrier. Usually I'm good at keeping my emotions at bay, but not last night. I was slamming charts on the table, dropping f-bombs when talking to the ED docs as they gave me yet another admission, and slightly rude to the floor RNs who called to say their patient needed a sleeping pill. By the end of my shift, they'd given me 16 admissions, of which I could only complete 15 because I didn't have time to see the 16th. I didn't finish dictating my h&p's until nearly 7 a.m., a whole hour after my shift ended. If I'd seen that 16th patient, who knew when I would have left the hospital. At any rate I was in a completely bitchy mood as I left the hospital, which I'm sure did not go unnoticed by my coworkers.

Went home, slept for 4-5 hours, then treated myself to a 60 minute massage (found a 20% off coupon in my inbox, decided to use it). There were a lot of knots in my lower back and neck (no surprises there; I've been waking up stiff for the past few days), but those got smoothed out by the therapist. It was just what I needed after 4 days of working nights; I feel better now =)

Prisoners

I recently had a patient get admitted for a-fib, and I learned that he'd been in a correctional facility (aka prison) for the past five years. I don't know what he did to earn such a sentence (and who knows how many years he has left), but he was one of the nicest patients I'd ever had the pleasure of caring for. A few nurses and I wondered what crime he had committed in the past that landed him in prison, and in a way, I don't want to know. I'd rather keep the memory of him telling me, "God bless you" when I told him he could go home, rather than learning that he did something heinous like assault another person or commit murder. That reminded me of another patient I admitted one night, and the "what-if's" still haunt me once in a while.

Last month when I was working nights, I admitted a 29-year old male with asthma exacerbation. He said that he had become short of breath while walking on the street; I remembered he was pleasant to talk to. The following night  I heard a "Code Purple" (code for "Aggressive patient or family member") overhead pointing to his room, and I wondered what could possibly be going on because I remembered him being a nice guy and unlikely to cause trouble. Usually I stay away from Code Purples; security usually deals with all that, and I didn't think much of it later. I found out later that he had gotten into an argument with his ex-wife who had come to visit him.

Later on, I looked the patient up to see how he fared after he was admitted. Then I got a huge surprise: the patient's mother had called the hospital saying that he had told her that he had knives in his room and that he was going to hurt himself and some of the nurses who kept coming into his room and "bothering" him. In fact, he had used a fake ID to get into the hospital; in reality, he was wanted by the police for assault (apparently tried to choke his ex-wife prior to coming to the hospital) and has a strong history of violence. He'd had a bag in the room with him that he'd refused to let the nurses handle; when security searched him at the social worker's insistence, they found a machete and another knife in the bag. He then began making threats and ranting that there was a hitman out to get him. The police was then called to take him to jail.

I was speaking to one of the nurses about this today, and she commented that she and another nurse had "been chatting with him" most of that day, and no one knew that he had a knife in his bag. What if he'd chosen to act on his paranoia? What if he pulled out that machete in the ER while my back was turned and sliced off my head? What if he stabbed the nurses instead and then proceeded to attack other people in the hospital? I imagine something like that would have made national news and brought up the issue of safety in hospitals. How the hell did the patient get a MACHETE into the hospital? I know we don't have metal detectors, but usually personal belongings are well documented prior to the patient leaving the ER. I hate to think about what could have happened if the patient's mother didn't call the hospital, what kind of terror he could have unleashed if he became any more unstable in the mind. We were very lucky.

Not Enough Time/Grass Aspiration

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.

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.

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.

Being Prepared

After the bombing at the Boston Marathon on 4/15/13, plus the explosion at West and the ricin envelopes in DC, it's become more obvious than ever that no place is truly safe. At lunch yesterday I asked one of the emergency medicine docs if Austin was prepared for mass casualties (it's no longer far-fetched to think that someone may drop a bomb in the middle of SXSW someday), and he said yes. Apparently they run mass casualty drills once a year, and he recalled that when Hurricane Katrina hit, many patients from coastal hospitals were evacuated to Austin. I forget how many people he was able to triage in ___ hours, but it was done. He also commented that if anyone really wanted to do serious damage to Austin, then the football stadium at UT on any home game day would a prime target. Thousands of defenseless people in one spot, they'd be sitting ducks. Whereas at SXSW, everyone was all spread out. And of course UT is always a target; wasn't there already a shooting there in the 60s?

There are many runners at my hospital (one of my partners ran the Boston marathon years ago), so the bombings have been a hot topic here. I know a guy who is a surgery resident at one of Harvard's teaching hospitals, and he commented that he's been treating some of the victims from the bombing. I don't dare ask for details, but I imagine it must be hard being on the front lines, seeing the damage the bombs caused to these patients, trying to fix them up. What can an internist do in such a situation? I once admitted a patient for chest pain after her house caught on fire and her husband died in the fire (back in Philly), but that seems tame compared to what's going on now.

I certainly hope that I'll never have to encounter an event with mass casualties in my lifetime, but if I do, I would be out there helping others, just as we were taught (and called) to do. It's our duty as physicians.