Monday morning: 84-year-old “T-Bone” car accident victim for a hospital follow up. He was admitted to the hospital for seven days with multiple rib fractures and a wrist fracture. A CT of the abdomen showed, in addition to the acute injuries, a dilated common bile duct with the radiologist report stating, “cannot rule out malignancy versus cholelithiasis [gallstones]”. We explain to him the possibilities, and that to determine this we would need to order an endoscopic retrograde cholangiopancreaticography, a procedure in which a scope is placed down the esophagus into the small intestine and injects contrast into the biliary system. “Doc, I was just in the hospital for a week, it took everything out of me. I dont have the strength to get another anesthesia procedure. I’ve had a good life.” We agree with him, and decide to monitor with blood work.
I am beginning to work on the worksheet that we must complete before the end of our six-week rotation. Having asked the three nurses to grab me if anyone needs shots, I get several intramuscular injections checked off by giving flu shots and quadracel vaccinations to children. I also need to perform five EKGs (electrocardiograms). I see a fit 38-year-old nurse who works in the Cardiac Care Unit (CCU) and has experienced feeling faint three times within the last month. Her nursing colleagues hooked her up to telemetry, which showed “an arrhythmia”. I hook up our clinic’s EKG machine’s leads to her, but nothing happens. The three nurses all come in to help troubleshoot. We cannot fix it so we decide to have her return in a few days.
Wednesday morning, Farmer Fiona and I head into the depths of the hospital for an afternoon with occupational medicine (“OccuMed”), a clinic that treats hospital employees for work-related issues. The 32-year-old physician trained with the military before leaving to work in civilian practice. The five patients on his schedule were all no-shows, so we got a 2.5-hour sales pitch regarding the great lifestyle of an OccuMed doctor: “We have no call, our day is like a dermatologist’s.”
His team is responsible for safety protocols at the hospital. He explains the airborne precaution protocol. “OSHA mandates a standardized nine-question questionnaire with any ‘Yes’ responses requiring a formal physical by occupational medicine. A few years ago we used a slightly different form, and we developed an in-house scoring system to determine need for a physical. Our system was actually more restrictive, requiring almost every employee to get a physical, plus we also do annual physicals on clinical workers. The higher-ups couldn’t understand why we needed to use the OSHA-approved form. What we were doing was actually illegal due to the paperwork discrepancy.” A big smile took over his face: “That’s the beauty of OccuMed. We understand the intersection between medicine, administration, and law. And it’s only getting more complex. We’re the only ones who can do this.”
Lanky Luke, Mischievous Mary, Geezer George, and I head to an impromptu Wednesday beers and burgers night. Geezer George describes the tension between the employee trying to get a work-related pay out and the OccuMed doctor working on behalf of the hospital trying to minimize the problem: “The doctor asked, ‘Could you please bend over and touch your toes.’ The patient responds, “I can’t, it hurts to move my back.’ ‘I know, but just try and touch your toes.’ ‘Okay,’ it’s going to hurt’ As he bends over and attempts to touch his toes, the physician comments, ‘So you can bend over.’ ‘Yes, but it hurts.’ He ended up getting disability.”
Luke recounts his week on inpatient pediatrics. He explains: “We admitted a six-month old with RSV [“respiratory syncytial virus,” a common illness at this age]. The baby presented to an outside emergency room where she was given an intraosseous catheter access [“IO”, a radical drill-through-the-bone procedure with significant risks that was unnecessary for this patient] and medevaced to our tertiary center. The baby was totally fine on arrival. Our attending admitted the patient overnight because the baby was helicoptered in and said ‘The patient has an IO so I guess we should use it.'” Samantha, the PA wife, recounted a similar experience: “We had a patient with chest pain — no troponin or EKG changes — medevaced to our hospital. My attending commented that he would never have been admitted if he’d come into the ED, but he was helicoptered in from six hours away. We let him stay the night under observation.”
Thursday: I spend 30 minutes talking with a fit 64-year-old who had bilateral total hip arthroplasties (replacements) over a decade earlier. After a tooth extraction, he was admitted for a 5-day ICU admission for sepsis in both of these artificial joints. He underwent two surgeries and a 50-day rehab stay. He is now doing a 3-week antibiotic holiday to confirm no infection before a revision. He is back home, but is not allowed any weight bearing on either leg.
The next clinic patient is a 35-year-old female, BMI 32, with a history of depression and polysubstance use disorder (alcohol, benzodiazepines, and cocaine) presenting as a new patient due to worsening shortness of breath. She explains she drinks a few beers on the weekend, but has been sober from other drugs for the past three years. She is also very upfront about being incarcerated for the past three years: “I was selling cocaine and meth.” My attending: “I always find it ironic when a drug user includes incarceration years as part of their sobriety time.” We order an echo, but strongly suspect she is drinking causing an alcohol-induced cardiomyopathy. We discontinue her seroquel, which might help her lose some weight, order an echo, and instruct her to stop drinking alcohol.
We are required to attend an Alcoholic Anonymous (“AA”) meeting as part of this rotation. Wildflower Willow and I select a Thursday evening meeting through the AA online portal (there are more than 10 within a 20-mile radius every night). The leader asks the 35 attendees if anyone new would like to introduce themselves. Older people tend to be sober and say “I am an alcoholic” while the members who are our age are more likely to be active users and say “I am alcoholic and an addict”. Willow: “I didn’t like it, it felt like we were sent to the zoo to learn from the freaks firsthand.”
Friday morning: “Medicine” grand rounds on gastrointestinal bleeding at the hospital, then head to the clinic around 9:00 am. I burn several actinic keratosis (“AK”, a common precancerous skin lesion) off with cryotherapy. Doctor Dunker lets me do two punch biopsies on a patient with numerous nevi (moles) on his back. I grab supplies, including local anesthesia, suture, drapes, needle driver, and forceps. The next step is to draw lidocaine and epinephrine into a syringe and inject to anesthetize the nevi sites until a “wheal” forms.
Doctor Dunker sees that I am comfortable getting the supplies, so he lets me do an excisional biopsy on a later patient whose previous punch biopsy pathology results showed a squamous cell carcinoma in situ, but with “positive margins” (i.e., the cylindrical punch biopsy did not remove the entire lesion). Steps: acquire supplies, prep the site with iodine, use a sterile marker to outline a 1cm margin around the lesion, incise with scalpel until reached subcutaneous fat, cut tissue with scissors, place into tissue container, suture wound close. Doctor Dunker: “Great job. Haven’t seen anyone hand-tie in quite awhile.” (As opposed to “instrument tying” using a forceps and needle driver.) This was my first time doing surgery on a conscious patient.
The last patient of the day: 47-year-old overweight female on birth control presenting for an annual wellness visit and mentions foot pain when walking. The ankle appears swollen and slightly inflamed. Although the patient does not report any worsening shortness of breath, our concern is she may have a deep venous thrombosis of the lower extremity (“DVT”, a clot in the leg, which can throw small chunks into circulation until they reach the lung). Alternatively, it could just be a sore muscle. Following the standard protocols, which are heavily biased toward defensive medicine, Doctor Dunker decides to send the patient to the ED. “Every doc will get burned by a PE [pulmonary embolism]. I wonder how many CTs it takes to diagnose one PE? How many CTs to save one life for a PE?” (After a no-doubt multi-thousand dollar bill to the insurance company, and a whopping deductible cost for this rare privately insured patient, the hospital determines that there is no DVT.)
Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night.
The rest of the book: http://fifthchance.com/MedicalSchool2020