MedWorm provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest medical blog items that have been tagged with 'icu'. Sat, 03 Sep 2011 02:08:29 +0100 http://www.medworm.com/index.php?rid=5086170&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fwho-report-outlines-problem-of-hospital-acquired-infections%2F2011.08.01 The World Health Organization’s new patient safety envoy will take on health care acquired infections in his new role, he announced last week. Liam Donaldson, England’s former Chief Medical Officer, pointed out in his first report as envoy that patient safety incidents occur in 4% to 16% of all hospitalized patients, and that hospital-acquired infections affect hundreds of millions of patients globally. A WHO report outlined the problem. High-income countries had pooled health care acquired infection rates of 7.6%. The European Centre for Disease Prevention and Control estimated that 4.1 million Europeans incur 4.5 million health care acquired infections annually. In the U.S. the incidence rate was 4.5% in 2002, or 9.3 infections per 1,000 patient-days and 1.7 million affected ... Better Health blogs http://www.medworm.com/rss/comments.php?id=5086170 Mon, 01 Aug 2011 14:00:00 +0100 5086170 http://www.medworm.com/index.php?rid=5069473&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fone-nurse-opens-her-heart-and-talks-about-her-life-in-the-medical-field%2F2011.07.27 Well, not my heart. I was contacted awhile ago and asked if I wanted the chance to read and review Tilda Shalof’s new book, Opening My Heart.  (Amazon link, but NOT an affiliate link – I live in California and due to a new law, Amazon has cut all ties with us). I had the chance to include a story in a book that Tilda edited a couple of years ago called Lives in the Balance.  So I had fond memories I’ll say up front that I enjoyed the book.  I had a range of emotions while reading it – frustration, worry, happiness.  Frustration because although Tilda is a very experienced ICU nurse, she doesn’t take her own health seriously at all.  I read with disbelief as she described her incredible denial of the obvious need to treat the heart condition she was born with. I was amused a... Better Health blogs http://www.medworm.com/rss/comments.php?id=5069473 Wed, 27 Jul 2011 16:00:14 +0100 5069473 http://www.medworm.com/index.php?rid=4992685&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fnurse-prompts-are-key-to-successful-implementation-of-icu-safety-measures%2F2011.07.02 Over the last few years, you may have heard a lot about the value of checklists in ICU medicine and their ability to reduce mortality, reduce cost and reduce length of stay.   But a recent study took the concept one step further and suggested that checklists by themselves may not be  effective unless physicians are prompted to act on the checklist. As reported in the American Journal of Respiratory and Critical Care Journal, a single site cohort study performed at Northwestern University Feinberg School of Medicine’s medical intensive care unit compared two rounding groups of physicians.  One group was prompted to use the checklist.  The other group of physicians had access to the checklist but were not prompted to use it. What they found was shocking.  Both groups had access t... Better Health blogs http://www.medworm.com/rss/comments.php?id=4992685 Sat, 02 Jul 2011 16:10:00 +0100 4992685 http://www.medworm.com/index.php?rid=4975866&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fdo-physicians-prefer-ventilated-and-sedated-patients%2F2011.06.28 You ever wonder what doctors really think but are afraid to say out loud?  Here’s one example: “I wish all my patients were on a ventilator” There’s a reason vented and sedated patients are considered desirable.  In addition to the obvious economic benefits of ROS unobtainable Billing critical care CPT 99291, 99292 There are the less talked about, but equally pleasant side effects most hospitalists, ER doctors, cardiologists, gastroenterologists, pulmonologists,  surgeons, infectious disease doctors, endocrinologists, psychiatrists, rheumatologists, dermatologists, nurses, respiratory therapists and physical therapists wouldn’t admit, but would agree, without hesitation.  As a general rule: Patients on ventilators are just faster, easier and more pleas... Better Health blogs http://www.medworm.com/rss/comments.php?id=4975866 Tue, 28 Jun 2011 15:00:00 +0100 4975866 http://www.medworm.com/index.php?rid=4952840&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fyears-of-planning-and-construction-lead-to-a-one-day-transition%2F2011.06.21 Tomorrow we’ll be far away Tomorrow is the judgement day Tomorrow we’ll discover what our God in heaven has in store One more dawn… On an unrelated note, tomorrow morning at 5AM our new ER opens and the old one closes down. I’ll be there working clinically. To the degree that it doesn’t interfere with patient care, I’ll live-tweet the experience. For those not familiar with the institution or the project — it’s a 110,000 annual visit ER closing down and reopening next door in a new, state of the art 83 bed ER, with an entire new 10-story hospital opening directly above at the same time, more or less. The logistics of the transition are pretty staggering. The ER will be the first unit to open. The old ambulance bay will have a barrier put up ... Better Health blogs http://www.medworm.com/rss/comments.php?id=4952840 Tue, 21 Jun 2011 21:00:00 +0100 4952840 http://www.medworm.com/index.php?rid=4902424&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fan-interview-with-a-cardiac-cath-lab-nurse%2F2011.06.05 Ready to learn more about nurses who work beyond the bedside?  Nurses who work in the Cardiac Catheterization Lab (CCL) play an important role in cardiac care.  Amy Sellers, RN BSN CCRN CSC CMC blogs at Nursing Influence and graciously agreed to give us a peek at what a nurse is responsible for doing in the CCL. Amy has worked in the Cath Lab for about 6 months now.  She previously worked in CVICU for almost 5 years before deciding that she needed a new challenge.  She is paid hourly and works three 12 hour shifts per week (all daytime Mon-Fri) with lots of opportunities for overtime and call shifts. A cath lab is an area of the hospital that uses fluoroscopy and contrast dye to check for narrowing/blockages in arteries or veins in the body. Using special equipment, they are able to pe... Better Health blogs http://www.medworm.com/rss/comments.php?id=4902424 Sun, 05 Jun 2011 15:30:43 +0100 4902424 http://www.medworm.com/index.php?rid=4852858&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fphysician-almost-places-feeding-tube-in-wrong-patient%2F2011.05.23 Photo Credit I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don’t. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great… , won’t starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn’t benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient. (more…) ... Better Health blogs http://www.medworm.com/rss/comments.php?id=4852858 Mon, 23 May 2011 12:00:00 +0100 4852858 http://www.medworm.com/index.php?rid=4797771&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fmore-medical-waste-does-a-6000-flashlight-improve-patient-outcomes%2F2011.05.07 So I’m rounding in the ICU the other day when I came upon this new hospital medical device.  It’s called a pupillometer.  What does this pupillometer do?  It  measures subtle changes in the light reflex of the pupil to help take the physical exam to the next level of precision. Or eliminate it, depending on how you look at it.  What used to be a basic physical exam skill is now being replaced by a $6000 piece of medical technology that can distinguish tiny changes in pupil size. Now the real questions remain.  Has this pupillometer device gone through the rigors of randomized trials in the ICU to define whether a  $6000 flashlight changes outcomes or mortality?   And if not, how do we allow medications to require such testing but not the technology that often changes n... Better Health blogs http://www.medworm.com/rss/comments.php?id=4797771 Sun, 08 May 2011 00:00:00 +0100 4797771 http://www.medworm.com/index.php?rid=4775395&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fend-of-life-care-costs-does-your-doctor-know-when-youre-going-to-die%2F2011.05.01 One interesting comment I have seen come up over and over is the idea that end-of-life costs are the thing that is spiralling out of control and that if we could somehow find a way to curb the costs of futile care, then that would somehow solve the health care inflation crisis. Andrew Sullivan endorsed such an idea the other day, a “Modest Proposal,” which is not nearly as radical or amusing as Swift’s. And indeed, there is a modicum of sense in the idea. Estimates are that spending in the last six months of a person’s life account for 30-50% of their overall health care costs, and that the spending in the last year of a person’s life accounts for 25% of overall medicare spending. So — simple solution, right? cut down on the futile care, and we’re ... Better Health blogs http://www.medworm.com/rss/comments.php?id=4775395 Sun, 01 May 2011 18:00:00 +0100 4775395 http://www.medworm.com/index.php?rid=4723808&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fhospice-patients-spend-less-overall-time-in-hospital-but-more-days-in-the-icu%2F2011.04.16 Chronically-ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but their intensity of care increased as well, according to a report by the Dartmouth Atlas Project. While in the hospital less, patients had many more visits from physicians, particularly specialists, and spent more days in intensive care units, as result of growth in intensive care and specialist capacity, the researchers said. Intensive interventions can lower a patients’ quality of life and cost more, the researchers noted. About one-fourth of all Medicare spending stems from the last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease, the authors noted. Following patient preferences for ... Better Health blogs http://www.medworm.com/rss/comments.php?id=4723808 Sat, 16 Apr 2011 22:00:00 +0100 4723808 http://www.medworm.com/index.php?rid=4676783&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fmedical-apps-allow-doctors-to-monitor-icu-patients-remotely%2F2011.04.05 We have reported in the past on AirStrip, a smartphone and iPad app that allows a mobile doctor to monitor the vital signs of patients in an obstetric ward or an ICU. The reverse, where a fixed doctor monitors multiple remote patients is now entering the mainstream and already making a difference in many patients’ lives. In a compelling anecdote recently reported in Computerworld, a man experienced cardiac arrest while shopping and was taken to a nearby community hospital. An intensivist, monitoring from an eICU miles away, was immediately consulted. The remote doctor guided the treating physicians as they initiated unfamiliar hypothermia therapy to preserve the brain, and continued to follow the patient remotely throughout his 10 day ICU stay.  Happily, the patient had a good outcome a... Better Health blogs http://www.medworm.com/rss/comments.php?id=4676783 Tue, 05 Apr 2011 11:00:36 +0100 4676783 http://www.medworm.com/index.php?rid=4600541&cid=t_101221_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FUKR60Ix_GlE%2F A new intensive care educational and networking website is being launched this week, and I invite you all to check it out: Intensive Care Network. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4600541 Wed, 16 Mar 2011 23:27:09 +0100 4600541 http://www.medworm.com/index.php?rid=4331020&cid=t_101221_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FWAWtr-Occyk%2F The LITFL team recently added the ICU Rounds podcast to our easy-to-search database of free online podcasts. This podcast has been running for a couple of years now, and is produced by the exceptionally prolific Jeffrey Guy. Dr Guy has specialty training in burn surgery, trauma surgery, and critical care and is an Associate Professor [...] (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4331020 Tue, 11 Jan 2011 03:00:34 +0100 4331020 http://www.medworm.com/index.php?rid=4309617&cid=t_101221_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FMLc9Bgh1ERU%2F A look at Cliff Reid's fantastic website: ResusME - Resuscitation Medicine Education. A great way to keep up with cutting edge research and developments in life-saving medicine. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4309617 Tue, 04 Jan 2011 00:00:51 +0100 4309617 http://www.medworm.com/index.php?rid=4275330&cid=t_101221_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2FeEIWQsSFKv0%2F If you're an ED doc, you probably love the iphone.But now that there are over 10,000 different apps in the App Store listed under “Medical” and “Healthcare & Fitness” you may be a bit bamboozled as to which apps to try. Not to worry... Houston Neal from SoftwareAdvice.com has an updated list of the best medical apps for doctors and medical students. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4275330 Tue, 21 Dec 2010 00:00:29 +0100 4275330 http://www.medworm.com/index.php?rid=4230156&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fan-interview-with-a-developmental-disability-nurse%2F2010.12.05 For my first interview, I thought I’d interview someone who would tolerate my novice interviewing abilities — my mother. Ginny, RN, BS, DDRN has been a nurse for over 30 years, most of that time in the Intensive Care Unit. (The apple did not fall far, did it?) She currently works as Developmental Disabilities Nurse and has done so for nine years. A developmental disability is defined by Wikipedia as “a term used in the United States and Canada to describe life-long disability attributable to mental and/or physical impairments, manifested prior to age 18.” Ginny says that her clients have a range of mental and physical disabilities including cerebral palsy, Down Syndrome, mental retardation, and autism, with autism being the most prevalent. Her clients live in normal houses a... Better Health blogs http://www.medworm.com/rss/comments.php?id=4230156 Sun, 05 Dec 2010 22:00:12 +0100 4230156 http://www.medworm.com/index.php?rid=4214124&cid=t_101221_88_f&fid=38129&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2Flifeinthefastlane%2FWZHV%2F%7E3%2F4Kz2HNaCB_Y%2F A gun shot wound to the head provides the basis for a question-and-answer based discussion on penetrating traumatic brain injury and multi-modal monitoring. (Source: Life in the Fast Lane) Life in the Fast Lane blogs http://www.medworm.com/rss/comments.php?id=4214124 Wed, 01 Dec 2010 00:00:50 +0100 4214124 http://www.medworm.com/index.php?rid=3831355&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Ficu-bingo-game%2F2010.08.06 Ever wonder how ICU nurses get through their daily grind? Why, with ICU Bingo, of course. How does ICU Bingo work? It works just like regular bingo. Every nurse receives their own Bingo card with different ICU diagnoses. And every time they take care of one of these conditions, they get to ”x” it out. Fill out a line or any other predetermined design pattern, and you are the ICU Bingo winner, and you win a prize. This is quite similar to my 2010 March Madness Hospitalist Bracket, only in this case the game is Bingo. As you can see, this nurse has already cared for a GI bleed, a homeless man, a drug overdose, chest pain, DKA, alcohol withrawal, subdural hematoma, a prisoner, and someone with super-morbid obesity. That’s ICU medicine for you. *This blog post... Better Health blogs http://www.medworm.com/rss/comments.php?id=3831355 Fri, 06 Aug 2010 16:30:00 +0100 3831355 http://www.medworm.com/index.php?rid=3607497&cid=t_101221_87_f&fid=39187&url=http%3A%2F%2Fgetbetterhealth.com%2Fsuccessful-care-grandmother-knows-best%2F2010.05.28 Want to know the secret to successful care of ICU patients? Think back to the advice your grandmother always gave, joked American Thoracic Society conference speaker Renee Stapleton, M.D., recently: - Wash your hands. - You can’t sleep your life away. - Get some exercise. - Sit up straight. - Take your medicine. - If you can’t remember it, write it down. *This blog post was originally published at ACP Hospitalist* (Source: Better Health) Better Health blogs http://www.medworm.com/rss/comments.php?id=3607497 Fri, 28 May 2010 12:00:00 +0100 3607497 http://www.medworm.com/index.php?rid=3794810&cid=t_101221_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F04%2Ficu-1.html Everything is going to plan and fourth year is grinding along, managing to pass with painful slowness and terrifying speed all at the same time.I have been on my ICU rotation for a couple of weeks. It is an interesting but difficult rotation. I have always been fine working in ICU as a radiographer. You do a mobile x-ray round, come up a few times during the day and that is it.However, as a medical student I don't entirely feel comfortable and it has taken me a little while to work out the reason for this. As a person I like to talk to the patients I work with, communicate well with them and hear what they have to say. A lot of the time in ICU, unless you are in extreme amounts of pain or having great difficulty, the doctor doesn't want to have an in-depth conversation with you because the... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794810 Sun, 25 Apr 2010 03:18:00 +0100 3794810 http://www.medworm.com/index.php?rid=3456769&cid=t_101221_117_f&fid=38158&url=http%3A%2F%2Fwww.twitter.com%2Famacupuncturehttp%3A%2F%2Famericanacupuncture.blogspot.com%2F2010%2F04%2Fnew-end-of-life-icu-guidelines.html Discussion will include social work, a chaplain intervention, notifying a key family member from out of town to come in preparation for opium death, and organizing the nursing staff for the end of life protocols. If the doctor is forced to give a time limited trial of artificial nutrition and hydration, he must set a measure of success: We will see if mom feels stronger or can resume eating for the next two weeks. “ Just tolerating the feeding is not a good endpoint. The plan must be documented and spread around, to the healthcare team, so the entire team can work in an organized fashion.   The doctor, after writing the appropriate orders, must document the discussion in the medical records, and talk about the plan to the health care end-of-life team. Families ch... Dr. Needles Medical Blogs blogs http://www.medworm.com/rss/comments.php?id=3456769 Fri, 09 Apr 2010 19:13:00 +0100 3456769 http://www.medworm.com/index.php?rid=3015293&cid=t_101221_93_f&fid=35707&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FHemodynamics%2F%7E3%2FNUSoxQ6eGJE%2Fcoding-et.html [I tried to embed scenes from the movie from YouTube. Of course these have been removed due to copyright violation. But probably if you look it up, someone else will have posted it.]I was at home on my own, watching TV post-call after an ICU shift. Nothing was on, and I landed on the middle of "ET: The Extra-Terrestrial". Before you know it, government agents are surrounding the family home; soon, as ET gets sicker and sicker, a medical team starts coding ET. When I watched this movie as a kid, I saw it through the child's eyes, and the government agents were totally terrifying. Now I see the physicians among them as basically benign, though surely misguided: in trying to save ET's life; they're running a by-the-book Advanced Cardiac Life Support code algorithm.Apparently, there were real ... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=3015293 Sat, 21 Nov 2009 04:49:00 +0100 3015293 http://www.medworm.com/index.php?rid=2967236&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F11%2F06%2Felectricity-is-good-for-the-heart%2F More codes last night. That makes the intern happy; she still thinks it’s a game. Which is all well and good, but I’m the one running the code, and I don’t think it’s quite so much fun any more. In a way, yes. It’s the nice that the nurses say, “Oh Dr. Alice, it’s great that you’re here. This isn’t your patient, is it? What do you want us to do?” Um, you’re doing good compressions, and I see we’re ventilating nicely, and you paged anesthesia to intubate (that’s how it’s done at my hospital). (These nurses are good. I much prefer codes in the ICU.) How about finding the doctors whose patient it really is? Because I’m getting tired of running codes that I’m not even responsible for. The medical pe... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2967236 Fri, 06 Nov 2009 14:50:55 +0100 2967236 http://www.medworm.com/index.php?rid=2757654&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F09%2F01%2Fa-day-in-the-cardiac-icu-part-2%2F The first patient we rounded on is worse again, and we run back over to see. One of the multiple devices keeping them alive seems to be malfunctioning. . . or is it that their cardiac function is suddenly deteriorating even more dramatically? The device rep happens to be around, but can’t seem to come up with a solid answer; and if he can’t tell what his own device is doing, it’s pretty hopeless. The cardiology attending shows up, and one of the cardiac surgery attendings. A lengthy discussion, and finally out of the confusion, a decision: an OR room has been opened, the patient is going there right now. It’s an immediate decision, laid down by the attending, but it takes nearly half an hour to execute: the cardiac anesthesia team has to come over, get at least slig... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2757654 Wed, 02 Sep 2009 00:17:26 +0100 2757654 http://www.medworm.com/index.php?rid=2745459&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F08%2F29%2Fa-day-in-the-cardiac-icu-part-1%2F In commemoration of being nearly done with cardiac surgery, and in atonement for having posted so sparsely lately, here’s a look at a typical (ok, maybe a little extra exciting) day in the cardiac ICU: In before 5am to collect data and write notes on some 12 patients, only to discover that two more were admitted overnight, and one of them is very sick. I sit down to look at vital signs in the computer, and two minutes later the charge nurse walks up: “I know you just got here, Alice, but this patient is hypotensive. In fact, the systolic is getting below 40.” Hurry over to that bed, and hastily try to collect the key facts about a patient who was admitted overnight, in extremis, already on three pressors, and deduce from a 50-word summary of their history, delivered by th... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2745459 Sun, 30 Aug 2009 01:06:25 +0100 2745459 http://www.medworm.com/index.php?rid=2730013&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F08%2F24%2Ffull-house%2F Two months in the ICU have given me about all the procedural practice I can handle. (As opposed to OR practice, that is.) I’ve gotten to do – or attempt – several intubations. I tried to explain to the attending today that I have a 50/50 record: half the ones I’ve done have been when he wasn’t there, and they all went fine. Half of them were with him around, and they all failed. He opted to reiterate the pharyngeal anatomy and technique of laryngoscopy again. Also central lines. I got a subclavian line today, in an intubated patient with no access, and thus no sedation and no drips. First stick, right in. The attending (same one; I don’t think he has 100% confidence in my procedures, for some reason!) was setting up to do a femoral line, as being quicker... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2730013 Tue, 25 Aug 2009 00:15:35 +0100 2730013 http://www.medworm.com/index.php?rid=2699536&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F08%2F13%2Fdidnt-sleep-last-night%2F ICU rounds post-call ought to be banned by the Geneva Convention. Come to think of it, really they’re already covered under the Fifth Amendment – cruel and unusual punishment. If the computers weren’t so heavy, I would have been throwing them at the end of rounds. I hate it when the attending asks you the same question three times, and then makes a decision based on the information you told him not existing. Or when, on post-call rounds, he starts explaining in excruciating detail why you should never do – what his senior colleague did two days ago, and it’s now somehow my error. It was funny to start with, but now I’ve had enough of this business of six different attendings each laying down the law to me about something, and then turning around and call... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2699536 Thu, 13 Aug 2009 22:17:44 +0100 2699536 http://www.medworm.com/index.php?rid=2639554&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F07%2F25%2Fsimple-wishes%2F Right now, there are really only two things I want in life: to be senior enough that I can put in a chest tube without two people supervising me, and to be senior enough not to be the one holding pressure for 45 minutes after pulling out an intra-aortic balloon pump – for the second time in three days on the same patient! (Although I have to say, the other day, when the attending paged me to come help in the OR and “just have a nurse hold pressure [on the site of the arterial sheath just removed] - I want you in here!” it was pretty sweet; usually the nurses refuse to do that for residents.) (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2639554 Sat, 25 Jul 2009 18:24:56 +0100 2639554 http://www.medworm.com/index.php?rid=2637755&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F07%2F24%2Fsand-traps%2F Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings; I still haven’t figured out exactly where the power lines are, which is no doubt part of my problem). When discussing any given decision in the patient’s management, the attending you’re currently talking to is liable to take exception, and start asking how that decision came to be made. You never know if he’s just trying to figure out which of his colleagues has taken the greatest interest in the case recently, or which of his colleagues is wrong-headed enough to be pursuing this particular plan. Or perhaps he knows (and you don’t, yet), that ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2637755 Sat, 25 Jul 2009 01:23:05 +0100 2637755 http://www.medworm.com/index.php?rid=2615325&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F07%2F18%2Fpermission%2F Overnight call in the cardiac ICU is one of the most stressful things I’ve ever done, partly because all the patients are extremely sick, but also because of the number of people I have to answer to. By this time I am a little used to sick patients, who don’t necessarily respond as expected/desired to my maneuvers, forcing me to keep thinking of new things to try. But in this unit, I have not only a large number of cardiothoracic surgeons as attendings to answer to (and they are the most forceful and demanding of the surgeons I’ve worked with), but there are also the critical care attendings (with a level of expertise and devotion to detail that are also new to me, and a penchant for asking for evidentiary backing for my decisions), as well as the fellows, again a level o... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2615325 Sun, 19 Jul 2009 01:55:16 +0100 2615325 http://www.medworm.com/index.php?rid=2570296&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F07%2F01%2Ffirst-day-of-third-year%2F In one day, I managed to get two people in the unit I started working in to hug me; got one person to yell at me; got three attendings to call me by my first name without reminders; and put in two Swans (as much as in the previous year together). If I can get these to balance out, the next month might not be too bad. (Although I was starting to get that uncomfortable vibe that becomes so familiar to residents, where on the first day of the month all of the attendings claim to be delighted to have you around, and foretell plenty of hands-on learning, whereas within a few days it becomes obvious that you’re still only a scut monkey.) Yesterday I also had the biggest fight I’ve ever had with a nurse. Previously, when people say I don’t get along with nurses, I’ve been ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2570296 Wed, 01 Jul 2009 23:31:36 +0100 2570296 http://www.medworm.com/index.php?rid=2457990&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F06%2F06%2Fnight-in-the-icu%2F I didn’t want to ask for help because it would be a confession of weakness. But my patient was dying, really dying, all of a sudden, out of nowhere, and I didn’t know why, and I didn’t seem able to do anything to stop him. I figured it would be even worse if he died because I didn’t ask for help. So I did. I don’t know what’s worse, that I was weak enough to ask, or that the person I asked didn’t really know any more than I did, and didn’t do any more than what I was about to do anyway. The patient survived, mostly thanks to the nurses, and due to what they and I did before the help arrived. I guess it’s good, in a way. I’ve proven to myself that I can get through anything (with the right nurses). I need to stop using the comfort ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2457990 Sat, 06 Jun 2009 22:29:52 +0100 2457990 http://www.medworm.com/index.php?rid=2304563&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F04%2F06%2Fsuperstition%2F Medicine is full of superstitions. Anyone reading medical blogs has heard about not saying “quiet night” or “not busy,” for fear that the opposite will immediately happen; or that appys and AAAs and other things come in threes; or that patients who say they’re about to die probably are. One of the less well-known has to do with specific hospital rooms: When you’ve seen something bad happen in one room, there’s a visceral reluctance to have another of your patients stay in the same room, especially soon afterwards. This is of course irrational, being that we’re in a hospital, and something bad has happened in every single room, more than once. The floors aren’t too bad. The patient turnover is high, only a couple of days usually per pati... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2304563 Tue, 07 Apr 2009 00:51:31 +0100 2304563 http://www.medworm.com/index.php?rid=2284769&cid=t_101221_93_f&fid=35707&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FHemodynamics%2F%7E3%2FrwpsxQaz31U%2Fgod-and-intubation.html One of my colleagues was the first author of this study. This is an underappreciated and understudied issue, which torments residents and nurses greatly: why do people end up choosing pointless treatments which will only minimally prolong life but substantially increase suffering? One of the answers appears to be associated with what my colleague and her co-authors describe as "positive religious coping"--i.e., seeking support from God--which appears to predict a choice to also favor aggressive treatment at the end of life. (Source: hemodynamics) hemodynamics blogs http://www.medworm.com/rss/comments.php?id=2284769 Thu, 19 Mar 2009 04:54:00 +0100 2284769 http://www.medworm.com/index.php?rid=2270132&cid=t_101221_86_f&fid=38272&url=http%3A%2F%2Flaikaspoetnik.wordpress.com%2F2009%2F03%2F16%2Fan-antibiotic-past-may-save-lives-at-the-icu%2F Respiratory tract infections acquired in the intensive care unit (ICU) are important causes of morbidity and mortality, the most significant risk factor being mechanical ventilation. It is thought that hospital pneumonia commonly originates from flora colonized in the patient’s oropharynx (the area of the throat at the back of the mouth). Therefore, reduction of [...] (Source: Laika's MedLibLog) Laika's MedLibLog blogs http://www.medworm.com/rss/comments.php?id=2270132 Mon, 16 Mar 2009 03:35:44 +0100 2270132 http://www.medworm.com/index.php?rid=2227782&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F03%2F02%2Fjuggling-2%2F Some peculiarity in the schedule this year has arranged that I’ve spent most of my time so far on rotations which are not part of the general call pool; and when I have been in the call schedule, it’s mostly been for the short, 12-hour shifts. So handling all the surgical services at night is still a little new to me. The last such night went much better than I had expected, and seems to augur well for the next month, which will be all nights. (You’ll have to excuse some elaborate phrases; I’m reading Mallinson and O’Brian, historical novelists of the British cavalry and navy in the early 1800s, and their latinate constructions are catching.) One of the first highlights was a call from the OR holding area: “The vascular patient your attending is expectin... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2227782 Mon, 02 Mar 2009 16:00:35 +0100 2227782 http://www.medworm.com/index.php?rid=2211699&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F02%2F23%2Fsome-pet-peeves%2F Another part of my role as a junior resident, rather than an intern, is to handle consults from the medical ICUs. There is always a constant stream of these: mesenteric ischemia in patients who’ve been hypotensive for too long for whatever reason (MI, sepsis); toxic C diff; upper and lower GI bleeds which elude medical management. The consults themselves are not so bad. The patients are usually intubated, which means one simply examines them, and then collects data from the chart, and calls the attending. The part that’s driving me crazy are the MICU residents and nurses. The surgery residents have a saying: if you get paged with a stat consult from the MICU, it’s probably nothing important, and you can take your time getting there. If, on the other hand, you receive cas... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2211699 Tue, 24 Feb 2009 02:22:40 +0100 2211699 http://www.medworm.com/index.php?rid=2125748&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F01%2F22%2Fflashback%2F All quiet on the transplant front again. Seems like as soon as I come near the service the operations disappear. Which leaves time to study for the ABSITE, a good thing since the test is coming up in. . . 8 days. I got to the neurosurgery part of the review book, and had a flashback to my neurosurgery rotation. It was far enough in to the month that I was holding the call pager by myself most days. I got called to see a lady in the ER. She’d had a headache for a few days, but that day it was much worse, and her son had finally forced her to come to the ER. Her history of severe, poorly controlled hypertension was a red flag, and the ER doctors got a CT scan. By the time it was done, and they had recognized the subarachnoid hemorrhage, her mental status was deteriorating to the point... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2125748 Thu, 22 Jan 2009 23:44:02 +0100 2125748 http://www.medworm.com/index.php?rid=1851387&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F10%2F03%2Fcowboy%2F I think I mentioned before that, along with being the insane Christian conservative of the hospital, and being too polite to be a surgeon, the other residents tease me about doing procedures on anything that moves - or doesn’t move, more accurately. Today I blew my last chance of pleading innocent. Being at loose ends (as seems to be usual for me on this rotation), I was just wandering around the ICUs to see what kind of trouble other people were having, and maybe cheer myself up that I wasn’t having to take care of those problems. I found a couple lines to put in - various people having too many things to do at once, needing to be in the OR, etc, so I volunteered to put in their lines. The guys found me apparently lost in the MICU, in the middle of a real mess. “What&#82... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1851387 Sat, 04 Oct 2008 00:21:23 +0100 1851387 http://www.medworm.com/index.php?rid=1780004&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F09%2F09%2Fparenthetical%2F Sorry folks, nothing useful to say. I’m going through another disillusioned-and-bitter phase; judging by precedent, it shouldn’t last more than a few days. Will return with regular programming then. (The funny thing is that, even though I feel depressed and bitter and cynical, I’m still known for being cheerful and optimistic. The chiefs are still telling me, “Wait a few years and see if you’re still so happy about everything.” I feel like I’ve turned into all the cynical surgery residents I knew as a medical student, but apparently it doesn’t come across that way - yet. I guess that concluding every consideration of a patient’s worsening symptoms and grim vital signs with the hope that they could still turn around in the next two days ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1780004 Wed, 10 Sep 2008 02:02:07 +0100 1780004 http://www.medworm.com/index.php?rid=1734445&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F24%2Fuseless%2F A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” - but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all. Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1734445 Mon, 25 Aug 2008 00:08:08 +0100 1734445 http://www.medworm.com/index.php?rid=1723833&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F21%2F1190%2F Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all. I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1723833 Fri, 22 Aug 2008 02:21:26 +0100 1723833 http://www.medworm.com/index.php?rid=1717882&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F19%2Fslough-of-despond%2F Halfway through rounds the medical students were asking me if I was all right. There was nothing wrong, just the insanity of the trauma unit, and my dysfunctional method of communicating with the chief and the attending. The chief and I have a very strange interaction; we like each other, and it’s certainly better when he’s around and responsible for things instead of me, but somehow he makes a day in the trauma unit even more complicated. So the students are trying to help me, and I don’t even have the energy to be polite to them. All I can remember is the resident I knew when I was a student, trapped in the unit for months on end. He didn’t talk to students much either, although in my memory he was still more helpful than I’m being. That’s bad, because... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1717882 Wed, 20 Aug 2008 01:16:09 +0100 1717882 http://www.medworm.com/index.php?rid=1714469&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F18%2Fenough-is-enough-2%2F I’m tired of trauma. I feel like I’ve been doing this forever, and it’s going to keep going forever. Every day starts out ok, and then goes on for a whole lifetime, with twenty lives in my hands, and thirty or forty people wanting something from me (ranging from the medical students wanting something educational or useful to do, and I don’t have the time I owe them to be educational, to the nurses as usual reminding me of what their patients need, to the attendings wanting me to do a dozen different things, reminding me of things I know I should be doing, or asking me the same question for the third time in five minutes, to the families, who need to be talked to, and all want more time than I have). That is one thing I’ve figured out. I’ve decided which... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1714469 Tue, 19 Aug 2008 00:47:28 +0100 1714469 http://www.medworm.com/index.php?rid=1709987&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F16%2Fminiature-soap-opera%2F I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU - a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1709987 Sun, 17 Aug 2008 00:14:53 +0100 1709987 http://www.medworm.com/index.php?rid=1705130&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F13%2Ftriage-skills%2F I continued my attempts to be in three places at the same time, to no one’s particular satisfaction. I ought to pick one place to be, and do a good job there, and then at least those people will be happy, instead of all three groups being displeased at once. I can’t somehow manage to 1) round with the attending in the trauma unit 2) discharge patients in another unit 3) be present for resuscitations in the ER, all at once. Result, patients are not discharged in a timely fashion, the unit attending is displeased because I’m not continually present, and don’t everything about all the unit patients, and the admitting attending is displeased because I’m rushing in and out of the resuscitations, and trying to get done with them as fast as possible so I can go back ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1705130 Thu, 14 Aug 2008 00:51:08 +0100 1705130 http://www.medworm.com/index.php?rid=1696592&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F11%2Fblindsided%2F Halfway through the morning: “Alice, what’s going on with this patient? Why don’t you know?” Alice mumbles something. “That’s no excuse. You’re filling the role of senior resident today. Take care of things.” Uh, thanks. Thanks for mentioning the role change after I’m already in trouble. I knew I was the senior, I just didn’t realize how much the attendings count on the senior on an every day basis, which means how much they count on me, even when I’m not forewarned. That was the beginning of the rest of the day. Back to as bad as life was in June, constantly behind, expectations on all hands - attendings, nurses, interns, medical students - that I’m not fulfilling. Patients that are not receiving the amount of care I ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1696592 Tue, 12 Aug 2008 01:15:39 +0100 1696592 http://www.medworm.com/index.php?rid=1696593&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F10%2Ftoo-much-practice%2F Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast. Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER. I’m not good like the social workers are with grieving families. I watched closely the other day, the las... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1696593 Mon, 11 Aug 2008 01:26:33 +0100 1696593 http://www.medworm.com/index.php?rid=1686705&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F06%2Fluck-of-the-draw%2F This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already). The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new pat... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1686705 Thu, 07 Aug 2008 00:22:16 +0100 1686705 http://www.medworm.com/index.php?rid=1683678&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F05%2Fchange-of-roles%2F I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status o... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1683678 Tue, 05 Aug 2008 23:54:49 +0100 1683678 http://www.medworm.com/index.php?rid=1679774&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F04%2Fbrief-notes%2F Events of the day included: Me deciding to address all the attending’s pet peeves by acting on them before he did. Result, the nurses were mad at me as well as him, and I don’t think I saved much time. It did make the attending happy, though. Attempted bronchoscopy: Attending: “Sure, you can do it with me. Have you ever done any of these before?” Me: “Yes, definitely. (sotto voce Twice, to be precise.”) Attending: “This is how it’s done, bzzzbtttbzzz (words all blurred together). Ok, go.” So whatever I remembered from the previous two times disappeared, between the attending being not wanting to do it at all, and being in a hurry, and the patient actually having a problem. For my commenters: Attending: “Anesthesia left the a-line ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1679774 Mon, 04 Aug 2008 23:53:57 +0100 1679774 http://www.medworm.com/index.php?rid=1675321&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F08%2F01%2Fback-inside%2F I forgot how much I hated, er, didn’t like, trauma. It’s pleasant to be back in a closed unit where the nurses recognize me, and most of them seem to like me (as in, they’re very happy to have me back around because I do scut the fastest, like reordering meds, and fixing orders that other people put in wrong, or coming quickly when they want someone to look at the patient). On the other hand, as I said, I forgot how much I hate rounding all day. This weekend, fortunately for all who are interested in my sanity, the most annoying attendings are not rounding. The one who was, however, has certifiable ADD; so does the chief; and I come close, especially in their company. Neither of them can finish a sentence, let alone a train of thought, without jumping to something else, a... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1675321 Fri, 01 Aug 2008 23:27:39 +0100 1675321 http://www.medworm.com/index.php?rid=1657478&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F26%2Fborder-sniping%2F I ran into one of the critical care fellows the other day. “I hear you’ve been stepping on my attending’s toes,” he told me. I wasn’t sure what was coming next, and I really didn’t feel like apologizing for protecting my patients, so I answered cautiously: “It felt to me more like he was the one stepping on my toes.” “Oh, he does that all the time. People hate it. When he’s not yelling at you, he’s playing turf wars.” Seeing that this was a moaning session and not another episode in the turf wars, I told him my story, and he traded me an even worse one, seeing that it happened inside of the pulmonology service. He left me with the impression that the MICU inhabitants were quite pleased to have the surgery residents act... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1657478 Sat, 26 Jul 2008 23:19:41 +0100 1657478 http://www.medworm.com/index.php?rid=1646607&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F22%2Flight-bulb-moment%2F I just experienced a revelation. I’m a doctor, in fact a not-an-intern doctor; and doctors can call the ICU to check on their patients, right? So now I can worry about my patients with great accuracy even after I leave the hospital. All those times when I’ve lain awake (ok, only for about 30 seconds before sleep deprivation catches up, but still) worrying whether something bad happened yet - now I can call and find out that the something bad did happen, and keep worrying about what has happened rather than what might happen. Life was better before phones and beepers. (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1646607 Wed, 23 Jul 2008 01:26:45 +0100 1646607 http://www.medworm.com/index.php?rid=1646608&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F22%2Ftwisted-around%2F I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why. There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle - but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1646608 Wed, 23 Jul 2008 00:59:24 +0100 1646608 http://www.medworm.com/index.php?rid=1642940&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F21%2Fprofessional-courtesy%2F I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them. One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it). The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at leas... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1642940 Tue, 22 Jul 2008 00:18:42 +0100 1642940 http://www.medworm.com/index.php?rid=1618256&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F13%2Fgrowing-up%2F Another memory that sticks out from my third year surgery rotation was the night I was on call with the trauma night chief. Nights at that hospital, the trauma service was responsible for all ER consults and emergency surgeries, as well as a fairly busy knife and gun club, and several major highways and intersections. So they had their hands full. The trauma chief had his own hospital-provided phone, because he made and received so many calls that it would have been impossible to function with a beeper alone. There was one patient he was trying to see in the ER, to explain the reasons for doing or not doing surgery (I forget by now which one it was). The phone went off about three times in four minutes, and finally he handed me the phone and said, “Please take this thing out of the r... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1618256 Mon, 14 Jul 2008 00:39:14 +0100 1618256 http://www.medworm.com/index.php?rid=1606426&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F10%2Fgive-and-take%2F The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1606426 Fri, 11 Jul 2008 01:04:22 +0100 1606426 http://www.medworm.com/index.php?rid=1597117&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F08%2Ftribal-conflicts%2F Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline. . . . ok, got it? That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after th... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1597117 Wed, 09 Jul 2008 00:35:59 +0100 1597117 http://www.medworm.com/index.php?rid=1554703&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F28%2Fbackwards-and-forwards%2F Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster - first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now. There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs - and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with - hopefully not reverenc... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1554703 Sun, 29 Jun 2008 00:28:22 +0100 1554703 http://www.medworm.com/index.php?rid=1552253&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F27%2Flessons-learned%2F Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552253 Sat, 28 Jun 2008 00:24:43 +0100 1552253 http://www.medworm.com/index.php?rid=1552254&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F26%2Fa-little-backwards%2F I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective: Today I worked about 14 hrs - came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552254 Fri, 27 Jun 2008 01:21:52 +0100 1552254 http://www.medworm.com/index.php?rid=1552256&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F26%2Fbetter-and-worse%2F Thanks everyone for the encouraging comments. I think things are getting better overall; I can handle four more days. Today continued to be splendid. My efforts to discharge patients to the floor succeeded mainly in disgruntling the floor staff, and led to one of my . . . episodes . . . with an attending today. All the hard work didn’t do me much good, because we just admitted more patients through the ER as fast as I could discharge them to the floor. Yes, I seem to have ticked off every single attending in this group - three of them today. That has to be some kind of record for the worst resident performance ever, wouldn’t you think? With one of them I really did something wrong - forgot something that a resident four days away from being a responsible junior resident shouldn... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552256 Fri, 27 Jun 2008 00:24:47 +0100 1552256 http://www.medworm.com/index.php?rid=1544326&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F24%2Fugly-inside%2F I really had better not talk. I wrote a very bitter post about how angry I am at the hospital administration, but it was too nasty too publish. I’m so stressed out, between the administration’s actions, and just the ICU and trauma craziness, I’m making myself sick, which isn’t smart, because there’s absolutely no one to cover for me, so I’m not about to try to find out what happens if a resident takes a sick day (although I’m tempted to try it, just to pay some people back). Today wasn’t so awful, I’m learning to just not talk to the attendings and then things go smoother. Tomorrow, I think the seniors have arranged things so that I get to cover the entire trauma ICU, and go to all the trauma alerts in the ER, by myself. I’m so t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1544326 Wed, 25 Jun 2008 01:05:43 +0100 1544326 http://www.medworm.com/index.php?rid=1536793&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F21%2Frunning-at-a-snails-pace%2F Okay, now I’m annoyed. I left the hospital at 8:30pm, not because the patients were so sick or I was so busy (although they were and I was), but because the attending took twelve hours to round. I’m telling myself that I’m not upset just by the time of day, but because the time was wasted. I’ve stayed till 8 and 9pm before, and not been too unhappy, because I was doing procedures, or taking care of a patient who seemed too unstable to sign out. But twelve hours rounding? This is the attending who can be found in the hospital most nights of the week, regardless of the call schedule. This morning we came for sign-in, and he told us about something he’d taken care of overnight. “But you weren’t on call last night. You’re on call tonight.” ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1536793 Sun, 22 Jun 2008 01:20:37 +0100 1536793 http://www.medworm.com/index.php?rid=1536063&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F20%2Fnot-a-success%2F Not a great day at all. We got snowed overnight (and how exactly do you double a trauma unit’s census on a Thursday night? what happened to the concept of partying on weekends?) (although, of course, it’s the elderly people falling and breaking things that really does us in), and I came in expecting a short list, to find a combination of crashing patients brought up from the ER, and patients in extremis brought down from the floor, such that I didn’t manage to do any kind of decent pre-rounds before attending rounds. I’d seen the patients, written down the vital signs, and was staking my life on my belief in the nurses’ statements that “yes, everything’s ok, no major problems.” They were correct, but I hate rounding on the fly. I know I&#8217... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1536063 Sat, 21 Jun 2008 00:18:48 +0100 1536063 http://www.medworm.com/index.php?rid=1527281&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F18%2Flost-in-the-maze-part-2%2F The trauma service has a lot of paperwork associated with it. There’s a three-page form to fill in when the patient is admitted. Obviously, when you’re first trying to stabilize the patient, there’s no time to fill in forms, so these tend to get written when the team is waiting around in the CT scanner (there’s a law engraven in stone, that at least one trauma resident must be with the patient at all times until they’re finally dispositioned, due to way too many bad experiences with patients coding, seizing, freaking out, or having serious neurological deteriorations while going through CT; even when it’s located inside the ER, any branch of the radiology department has the capacity to seriously impact a patient’s condition; we don’t call it... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1527281 Wed, 18 Jun 2008 15:37:05 +0100 1527281 http://www.medworm.com/index.php?rid=1522675&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F16%2Flost-in-the-maze%2F My list of patients has steadied down to a group of long-term ICU inhabitants. Good, because I don’t have to figure out four or five entirely new patients every morning. Bad, because since they stay so long, they get very complicated. Rounds are always full of pitholes from the attending: “A new arrhythmia, eh? Let’s consult cardiology. Oh, we already did consult cardiology? What did they say?” “Um, actually [flipping wildly through the chart and the computer] we consulted them five weeks ago with a questionable MI, which they said wasn’t significant, and they seem to have signed off a while ago. . . I can’t see any notes in recent memory here.” “Ok. . . this drain here, where does it go?” “Sir, I really couldn’t tell ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1522675 Tue, 17 Jun 2008 01:44:49 +0100 1522675 http://www.medworm.com/index.php?rid=1522676&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F15%2Fscalpels-are-sharp-for-a-reason%2F One of my patients this month has been an amazing teacher. He hasn’t said a word yet, and I might be off the service before we get him off the vent and onto a trach that he can talk with, but I’ve already learned a lot from him. He was in a car accident, and came in with some broken ribs. Not bad, right? So no one could understand why his vital signs steadily dropped in the trauma bay. He looked good initially, but right when the team thought they had him figured out and ready for admission upstairs, he took a turn for the worse. The on-call attending stayed four hours late, intubating him, scanning him again, starting him on pressors, fighting with the vent settings, trying to save his life, and completely lost as to what the problem was. He got to the trauma unit eventually, ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1522676 Mon, 16 Jun 2008 01:57:44 +0100 1522676 http://www.medworm.com/index.php?rid=1519092&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F14%2Fpublic-health-advisory%2F If you have to ride a motorcycle, please wear a helmet. I may have mentioned that before. We have three patients right now who weren’t wearing helmets. Two of them are missing large sections of their skulls, and all three have ventriculostomies draining cerebrospinal fluid, trying to decrease the pressure on their brains. Their CT scans look literally like mush. They’re not dead, and they may, two months from now, leave the hospital, but I doubt if any of them will ever talk again. And there was one earlier in the week who died in the ER (at least one of the ones in the unit was completely expected to die at the scene). We have at least seven patients who were wearing helmets. A few of them have concussions, but they should all be able to recover completely, neurologically. I t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1519092 Sat, 14 Jun 2008 20:06:57 +0100 1519092 http://www.medworm.com/index.php?rid=1517020&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F12%2Ffull-circle%2F The only resident I met in medical school who made me seriously reconsider my interest in surgery was rotating on trauma. In fact, he seemed to have stopped rotating, and have come to rest in the trauma unit. Between the summer transition, and the vagaries of scheduling, he was spending three or four months consecutively on trauma, either days or nights. He was not happy at all. In fact, he was downright bitter. I think his wife was giving him grief about never seeing him, but he also hated the trauma unit in itself. “Do anything else at all, just don’t do surgery.” “I would never do this again.” “If there’s anything else you could be happy doing, don’t do surgery.” I remember watching him walk around the unit, running from one disaster... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1517020 Thu, 12 Jun 2008 23:44:05 +0100 1517020 http://www.medworm.com/index.php?rid=1509564&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F11%2Fplease-get-me-out-of-here%2F Again, so annoyed and frustrated I can’t talk. What’s especially bad is that the rest of the trauma ICU knows it: the nurses are commiserating with me (which I shouldn’t let it get to that point), the rest of the residents are teasing me, and so far the attending thinks it’s funny that I’m nearly biting my nails off, and literally pacing the halls in frustration as he spends half an hour rounding on each patient. I simply cannot stand still and think about one thing for that long. It’s a different attending these couple of days. He’s a nice enough person, but he’s so slooowww. . . It feels like nails grating on a chalkboard. And I feel guilty, because he’s being thorough, and an extremely good doctor - but I wish he would delegate some ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509564 Wed, 11 Jun 2008 23:42:40 +0100 1509564 http://www.medworm.com/index.php?rid=1509565&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F10%2Fgrin-and-bear-it-4%2F I’m so frustrated and annoyed, I’m not going to write anything. Some of the attendings are driving me crazy, and so are some of the seniors. The patients themselves are not bad, especially since I seem to have randomly picked up all the people who are chronically on the vent. I’m familiar with them now, and am getting used to the slow dance of changing one vent setting (oxygen flow, pressure, volume, rate) at a time, and waiting to see if they’ll gain the strength to start breathing on their own again, while keeping a careful eye out for pneumonias which will knock them back by at least a week. Now if some people would teach, instead of making criticisms all the time, and about things that I didn’t actually do, or had a good reason for doing but they won&#8217... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509565 Wed, 11 Jun 2008 00:13:11 +0100 1509565 http://www.medworm.com/index.php?rid=1509566&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F09%2Fanother-first-2%2F One of my patients died today, the first time that I was actually around for such an event. He was kind of a hopeless situation from the time he came in a few days ago, but we gave it our best shot. His family knew the prognosis was bad, and today when some tests confirmed that he had basically no brain function left, they agreed to withdraw care. I talked to them from the beginning, putting out the likelihood that he wouldn’t recover and that a decision would have to be made. Today I was trying to hide, letting subspecialists talk to them, but of course it wasn’t that easy. “Alice, we finished our discussion, now they’re asking to talk to you.” The family seemed like great people, a strong family. They had a spokesperson who asked questions, and then announce... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509566 Tue, 10 Jun 2008 00:04:02 +0100 1509566 http://www.medworm.com/index.php?rid=1502937&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F08%2Fah-gratitude%2F The weekend wasn’t quite as bad as expected. Enough sick patients and enough traumas can get even the slowest of attendings to start moving, and I like this attending better at midnight, arguing with helicopter command about the tenth ridiculous trauma alert of the evening and struggling to keep the seven car accidents and six motorcycle accidents straight, than during morning rounds. On the other hand, I had trouble with lines again. I got some good a-lines in, hurrying before rounds started. (I’m afraid I drive the ICU nurses crazy. I show up right after shift change and insist on putting in lines or changing wound dressings, right then. My only excuse is if I don’t do it then, it won’t happen. I didn’t stop moving for 30 hours this weekend, and lots of sma... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1502937 Mon, 09 Jun 2008 00:47:45 +0100 1502937 http://www.medworm.com/index.php?rid=1500554&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F06%2Fdeluge%2F It’s a routine day on the trauma service: one attending operating as fast as the rooms can be turned around (it somehow takes longer when your patients are from the ICU, because anesthesia takes their sweet time about going to get the patient, and it takes forever to package all the lines, monitors, and vent equipment, and then repeat for the trip back, plus wild stops to check and see why the ekg readings have gone skywire, and whether that O2 saturation reading is accurate or not, and did we hook the bag up to oxygen, or not?), and the other attending operating even more busily on unscheduled eruptions: come to find out, that spleen is going bad, after 24 hours of observation, time for an exploratory laparotomy; oh, undiagnosed viscus injury, five days after trauma, let’s cal... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1500554 Sat, 07 Jun 2008 01:35:11 +0100 1500554 http://www.medworm.com/index.php?rid=1497957&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F05%2Fsharp-objects%2F I am, again, pleased with myself. We have a patient who’s septic from quite mysterious reasons (well, I suppose positive blood cultures ought to explain why he’s septic, except you still have to figure out how it got in his blood, and why he’s growing, as the nurse said, “everything but the kitchen sink” in there - gram positive cocci, gram negative rods; gram positive rods, gram negative diplocci; and who knows which of those to believe). (Not to mention what he’s doing on the trauma service; but that’s another perennial issue, how we end up with general surgery, orthopedic surgery, neurosurgery, and downright medical ICU patients on our service. Educational, but frustrating.) Anyway, the a-line was going bad, and we needed another one. I spent ne... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1497957 Fri, 06 Jun 2008 01:07:48 +0100 1497957 http://www.medworm.com/index.php?rid=1494743&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F04%2Fchanging-times%2F I used not to drink coffee at all. I got all the way through college and medical school, and six or seven months into internship, without drinking coffee. I didn’t like the idea of depending on any chemical to be awake, and I knew that a coffee habit could become quite expensive. I gave up, of course. The hospital has a very nice coffee shop, and our meal tickets work there. That means trading a real meal later on for coffee in the morning, but if you have time for coffee, and no guarantee of having time for a meal, that doesn’t matter so much. I think it was the second month of night float when I really stopped even trying not to drink coffee. If you put enough milk and sugar in, it doesn’t taste bad. It feels like a grown-up thing to do, and it actually does help you ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1494743 Wed, 04 Jun 2008 17:52:54 +0100 1494743 http://www.medworm.com/index.php?rid=1489088&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F02%2Fan-unexplored-field%2F Slight improvement today. We only rounded for eight hours. So far I’ve gotten an inordinate number of procedures done, despite spending the entire day in pre-rounds and rounds, so I can’t complain. I’m also becoming adept at placing Dobhoff tubes. These are feeding tubes, much thinner than an NG tube, with a wire through it, and a metal weight at the end, designed to be placed through the nose, and passed through the stomach and past the pylorus. The idea is that they’re less irritating to the patient to have in, and safer to use, since the feedings are given beyond the pylorus, so there’s less risk of aspiration. The catch is that you’re blindly trying to navigate a very tortuous passage, with no idea of where anything has gotten to. So the attending to... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1489088 Tue, 03 Jun 2008 01:11:00 +0100 1489088 http://www.medworm.com/index.php?rid=1485110&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F01%2Finsanity-2%2F Trauma is crazy. I’m not going to tell you how long I spent in the hospital today, but let’s just say that for a day I wasn’t supposed to be on call, I saw an awful lot of the night float people. Prolonged ICU rounds has got to be the definition of torture for surgery residents. That explains why we all tend to have the feeling that there is something deeply wrong with the attendings, who trained as surgeons, and are still surgeons enough to dive comfortably into trauma bellies and chests, but nevertheless choose to spend their lives rounding on trauma patients. The day was a long stretch of boredom - staring at my hands while the other residents presented their patients, or staring at my note sheet while the attending slowly wrote his note based on what I had told him - ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1485110 Mon, 02 Jun 2008 01:30:58 +0100 1485110 http://www.medworm.com/index.php?rid=1466372&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F23%2Fnose-above-water%2F I’m in the middle of an experiment to see how many hours it’s possible to work over the course of a four-day weekend. I hate it, I hate it, I hate it when my patients die. I can’t stop them. And they keep doing it, one after the other. Every twelve hours. We keep calling the same consultants. “Hi, please come and help, we have a patient septic, intubated, crashing, maxed on pressors, because of yyy. . . ” “Are we both awake? Didn’t we just have this exact same conversation twelve hours ago?” Surgery is good when it works. But when it doesn’t, you took a person who was alive, at home, walking, talking, eating - above all, alive - and now they’re almost none of the above, and it’s because we tried to do something. Why did we d... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1466372 Sat, 24 May 2008 02:35:54 +0100 1466372 http://www.medworm.com/index.php?rid=1433988&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F09%2Fjuggling-badly%2F I can’t decide whether it was a good or bad day. A lady who was supposed to have a major vascular procedure developed a very serious complication early in to the operation. Through a complicated series of events, the attending got the impression that she was better, and went to his office. I came back to check a little later, and found her much worse. (And I didn’t get up the nerve all day to go and chew out the people who were responsible for letting her deteriorate unnoticed; not that noticing would have changed the course of events. I need to grow a spine and some teeth, and they’ll hear about it tomorrow.) By this time the attending was gone, and every single other surgery resident in the hospital was scrubbed in the OR. So I had her to myself all day. It was good, be... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1433988 Sat, 10 May 2008 02:03:34 +0100 1433988 http://www.medworm.com/index.php?rid=1314600&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F19%2Ftips-for-medical-interns-homage-to-the-butterfly%2F Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.) I’m beginning to fantasize about adding a lecture to ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1314600 Wed, 19 Mar 2008 11:25:59 +0100 1314600 http://www.medworm.com/index.php?rid=1307990&cid=t_101221_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F17%2Fa-night-well-spent%2F It’s amazing how good a solid night of studying makes you feel. I only got paged about urology issues, which are also very satisfying, since they call for a quick, relatively risk-free and painless procedure which makes the patient feel better pretty quickly. So far I’m 30% of the way through The ICU Book (300/1000pp) (and only 3% of the way through The House Officer’s Guide to Urological Emergencies, which perhaps I ought to be reading more of, but somehow it’s not very gripping). I’m starting to have mixed feelings about the book. On one hand, it certainly contains such wildly relevant and fascinating subjects as, five continuous intravenous vasoactive medications (otherwise known as the five pressors, which about half the ICU population are on, and about wh... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1307990 Mon, 17 Mar 2008 10:50:05 +0100 1307990 http://www.medworm.com/index.php?rid=1252666&cid=t_101221_99_f&fid=35344&url=http%3A%2F%2Fzackarysholemberger.blogspot.com%2F2008%2F02%2Fresuscitational-imperative.html It's not a technological imperative that drives the resuscitation of so many patients who (if you had asked them while they were of sound mind and not about to die) would rather not have been resuscitated, it's a philosophical imperative. Most doctors, in my admittedly limited experience, are biased towards doing something rather than nothing. Or - rather - biased toward the assumption that taking a positive action is more helpful, because more active, than doing nothing. But sometimes doing nothing is not doing nothing at all. Letting someone die can sometimes accomplish more than a breathing tube or a defibrillator ever could. (Source: Zackary Sholem Berger) Zackary Sholem Berger blogs http://www.medworm.com/rss/comments.php?id=1252666 Sun, 24 Feb 2008 04:08:00 +0100 1252666 http://www.medworm.com/index.php?rid=1097713&cid=t_101221_99_f&fid=35344&url=http%3A%2F%2Fzackarysholemberger.blogspot.com%2F2007%2F12%2Fsemper-septic-its-damn-inevitability-of.html Semper septicIt's the damn inevitability of sepsis in the ICU which is so tragic and frustrating. It's like every patient's story has the same ending. (Source: Zackary Sholem Berger) Zackary Sholem Berger blogs http://www.medworm.com/rss/comments.php?id=1097713 Sun, 16 Dec 2007 23:43:00 +0100 1097713 http://www.medworm.com/index.php?rid=817561&cid=t_101221_85_f&fid=34692&url=http%3A%2F%2Fpolitedissent.com%2Farchives%2F1733 scene from Birds of Prey #109 (Script by Bedard, art by Scott) I’m sure I can’t be the first one to mention this, but Shado is not Connor’s mother (or that would have added a whole ‘nother layer of Oedipal creepiness to the recent Connor Hawke mini-series). I noticed that this issue started with a caption stating that “This story takes place before the events of the Black Canary mini-series.” It has been my experience that no good comic books start with one of these “takes place before” captions. Consider that one of Scott’s Laws of Comic Books. Scene from Gamma Corps #2 (Script by Tieri, art by Ferreira). You can’t put the patient’s name on the door like that; it’s a privacy act violation. Basically, you wouldn&#821... Polite Dissent blogs http://www.medworm.com/rss/comments.php?id=817561 Thu, 23 Aug 2007 14:46:00 +0100 817561 http://www.medworm.com/index.php?rid=800027&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F08%2Fdutch-nicu-at-end-of-life-tidbits.html The July issue of Pediatrics has an article about NICU decision making for terminally ill newborns. In the past few years there has been a bit of a media sensation because of the Dutch tackling the very tough issue of medicines and technology potentially prolonging the life or death of newborns that are unlikely to survive. It started when a NICU in the Netherlands came up with euthanasia guidelines for terminally ill newborns. For most readers of Pallimed, it should be well known that euthanasia and physician-assisted suicide are considered legal and acceptable medical practice in the Netherlands. I give credit to Dr. Verhagen and his colleagues in studying end-of-life decision making in the NICU. This is an area that palliative care has really not addressed as a profession in a systemati... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=800027 Wed, 15 Aug 2007 03:45:00 +0100 800027 http://www.medworm.com/index.php?rid=723177&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F07%2Fsurrogates-advance-directives-and.html 1 picture, 3 related articles, 5 websites, and many thanks:1)First is an article about decision-making about life-support for adults without surrogate decision makers in Annals of Internal Medicine. This was a prospective, multicenter, US-based study looking at ICU patients who lacked decision-making capacity, a surrogate, or an advanced directive (data based on prospective surveys of ICU attendings). Of note, the researchers went to great lengths to ensure that their data would be untraceable to an individual patient and physician.Findings: of 3000 ICU admissions during the study period, 450 patients died and 5.5% of these (25 patients) deaths were of patients without a decision maker. Astonishingly, in 2 of the 7 institutions 25% of ICU deaths were in patients without surrogates. (This m... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=723177 Mon, 09 Jul 2007 21:45:00 +0100 723177 http://www.medworm.com/index.php?rid=674908&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F06%2F2-year-anniversary-medical-blogging.html Well this is the 2 year anniversary of Pallimed and the 360ish post (my God that means we've posted nearly every other day for 2 years). Hooray. I want to thank all the readers and commenters on the blog and all the people over the last 2 years who have given Christian and me encouraging feedback on Pallimed.Not wanting to wallow in self-congratulation too much here...but I'd also like to thank Christian for his contributions to Pallimed - for the reformat to be sure - but also his unique voice and perspective.It's not the happiest time to be a medical blogger. There have been several bloggers who have recently packed up shop - frequently due to fear of liability (professionally or legally) - this is particularly true of anonymous bloggers. Most notably for us - Hospice Guy at Hospice Blog... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=674908 Sat, 09 Jun 2007 02:39:00 +0100 674908 http://www.medworm.com/index.php?rid=644749&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F05%2Fprognosis-links.html Here is a listing of many online resources for prognostication near the end-of-life. This post is made after a request from a audience member at a talk I gave recently on Evidence-Based Prognostication. My plan is to update these links and qualify them over the next several weeks. Please feel free to add more in the comments section or email them to me.The following links are for medical use only (i.e. they are not party tricks!). They should be used as guidelines to help understand the inherent uncertainty of the probability of medical outcomes. Before using any of these tools, you should be familiar with the validation and data sets. Pallimed and Christian Sinclair or his employers are not responsible for any medical outcomes based on these links. Please discuss these results with a medi... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=644749 Wed, 30 May 2007 16:00:00 +0100 644749 http://www.medworm.com/index.php?rid=637807&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F05%2Fny-times-article.html Jessica Israel, the chief of geriatrics and palliative medicine at Monmouth Medical Center (Long Branch, N.J.), wrote a great article in the NY Times describing the hard work palliative medicine professionals do.It is very well written. (Hey we are not always critical here!)Some of my favorite quotes are:I knew I had an agenda that night, and I needed to establish trust, to bear witness and not to be thrown out of the room. These three things are always on my mind as a palliative medicine physician. They cannot be stressed enough as some of the key things that we do. For any hard conversation we have, it is made much easier if we have established trust. It takes time and compassion to establish trust, and it can be lost so quickly. Trust allows us to go to that hard place in life where we ... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=637807 Thu, 24 May 2007 04:58:00 +0100 637807 http://www.medworm.com/index.php?rid=599346&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F05%2Fvent-discontinuation-pleurodesis.html In no particular order: 1)Critical Care Clinics has an ethical review of discontinuation of mechanical ventilation at the end of life. It’s actually a rather free-wheeling review of the U.S. legal and ethical framework for withdrawal of life-prolonging treatments in the dying. It’s a good one for the teaching file. The same issue has a review of noninvasive ventilation (such as BiPap) which references its use in dying patients. “For the terminally ill patient, dyspnea is one of the most distressing and common symptoms. The most widely used treatment for this has been narcotics and anxiolytic medications. These medications are effective in relieving dyspnea, but they also have adverse effects. Noninvasive ventilation presents as an alternative measure to treat dyspnea; it can be ... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=599346 Tue, 08 May 2007 18:36:00 +0100 599346 http://www.medworm.com/index.php?rid=509010&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F03%2Ffatigue-qol-in-cancer-bleeding-in-head.html This study finds fatigue is the most important predictor of health related quality of life--at least in this group of cancer patients. The question, for me, is what is fatigue? Is it a discreet symptom (which then has discreet symptom-specific therapy like pain, vomiting, pruritis, constipation, edema, etc.) or is it something else? Because one interpretation of this study is that patients saying they are fatigued is sort of the same thing as them saying "my health related quality of life is bad." "I, globally, don't feel well or whole." This, is a different thing than, say, announcing, "I itch." What all this means, I don't know.2)Supportive Care in Cancer has an article looking at the natural history of patients who receive transcutaneous arterial embolization for massive bleeding in hea... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=509010 Wed, 28 Mar 2007 15:49:00 +0100 509010 http://www.medworm.com/index.php?rid=484971&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F03%2Fethics-in-icu-prognosis-computers-to.html Many, many items in brief....1)Critical Care Medicine had a supplement in February about ethics in the ICU. Many articles here, including one on end of life ethics in the unit. It opens with this rather remarkable salvo:"Originally conceived and operated as short-term, life-saving vehicles for acutely ill or injured patients, modern intensive care units (ICUs) have expanded into entities that care also for chronically, although seriously, ill people; in fact, ICUs often become repositories for patients who have little or no chance for survival. Sophisticated technology frequently takes on a life of its own; the sheer momentum of processes inherent to ICUs may prevent healthcare providers from taking a step back to make well-considered decisions, especially at the end of a human life."The r... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=484971 Wed, 21 Mar 2007 02:16:00 +0100 484971 http://www.medworm.com/index.php?rid=474466&cid=t_101221_116_f&fid=34686&url=http%3A%2F%2Fwww.pallimed.org%2F2007%2F03%2Fsometimes-lot-of-good-stuff-comes-our.html Sometimes a lot of good stuff comes our way here at Pallimed but we just don't have time to get to a full commentary but we want to bring what we feel is important issues to the readers. Here are a few digest items from the past week, that I just need to get out of my to do box:1) Washington Post writer Rob Stein wrote an insightful article on race and end of life issues. Catch it on Washington Post while it is free (a few more days I believe). Some of the highlights of the article: "I think we need to be very attentive to attending to suffering in our patients and do everything we can to help minimize and ameliorate it," said Richard Payne, who runs Duke University's Institute on Care at the End of Life. "African Americans and other minorities are at greater risk of not dying well." The a... Pallimed: A Hospice & Palliative Medicine Blog blogs http://www.medworm.com/rss/comments.php?id=474466 Thu, 15 Mar 2007 22:15:00 +0100 474466