Let's Talk About Death

We were talking about code status last night, and how it's really terrible that families get forced to make decisions about life or death. I know it's not a cheerful Thanksgiving Day topic, but as usual it tied in to some patients I treated whose families made them "full code" at 90 years old with advanced dementia, diabetes, heart disease, emphysema, strokes, etc (and usually all of the above). It's too late at that point to ask the patient what they want, so we rely on the families to help us. Unfortunately, I think it's human nature for families to balk at this, or to balk at withdrawal of care discussions when the loved one got intubated and is now in a persistent vegetative state on the ventilator. Who wants to be the one who "killed" Grandma? Isn't that how we would feel, if we make the decision to pull the tube, or the patient is crashing and doctors ask "should we intubate, or let her go?" (Not in those words, but you get my drift).

How much simpler if patients told us in advance what they wanted?

Having already had this discussion last night, I was surprised to see the One Slide blog rally going on today, and decided to jump on the bandwagon. Go check out their website to learn more, and then have the discussion with someone. They call it "Engage With Grace". It's easy. We fear death so much in America that we forget that life has a 100% mortality rate. Death is not always the worst thing that could happen to us. Tell someone what you want done to you when you can no longer decide for yourself. And then listen to your family when they tell you the same thing. Then, it's no longer your decision--it's the patient's decision, which is where it belongs.

I Had No Idea...

That I am a Cool Nerd. Who knew?

Grand Rounds

Today over at Dr. Deb's blog. Check it out!

New DSM Diagnosis

Post Night-Float Call-Induced Delirium (may also be known as Post-Call Delirium)

Symptom Criteria:

a) disturbance of consciousness--manifested by inability to pay attention during rounds, falling asleep during rounds or morning report (or while driving home), inability to speak coherently while presenting patients, etc

b) a change in cognition or the development of a perceptual disturbance--manifested by forgetting what one was saying in mid-sentence, forgetting to print a copy of one's H&P prior to presenting the patient, not being able to answer simple questions on rounds, delusions of nursing staff conspiring to page q3 minutes while patient is trying to sleep, etc.

c) the disturbance occurs solely on the morning and afternoon after a night of call or night float

d) the disturbance is not better accounted for by an underlying dementia, substance (must rule out caffeine intoxication), or general medical condition

Etiology: directly related to the quantity, frequency, and quality of pages received overnight during the call or float shift. Direct correlation between repeat pages for Vicodin in a patient with "knee injury" that is not addressed in primary team's notes (and primary team d/c'ed the Vicodin) or pages to give detailed prognostic information to a family member after normal hours when the primary team had several discussions with them during the day, and the severity of the patient's symptoms.

Prognosis: good. Encourage night/day orientation (give patient bright light in the day and full darkness at night), re-orient them frequently ("You're presenting Ms. X, remember?"), withhold further caffeination, encourage proper nutrition (donuts and leftover pizza don't count), TURN OFF THEIR PAGER AND ALERT OTHER SERVICES THAT THE PERSON IS NO LONGER RESPONSIBLE FOR EVERY MEDICAL PATIENT IN THE HOSPITAL AS OF 0700, ensure that the patient makes it home safely and does not fall asleep while driving, and encourage a refreshing post-call nap.

I'll be submitting my findings to the DSM-V committee soon.

Addendum: This cracked me up: "It may also be associated with post-call dysphoric disorder, as manifested by irritability and the irrational belief that everything "sucks"."--thanks Midwife With a Knife!

Intern Learning

At various points in medical training, you go through brief intense phases where you must acquire new knowledge at a tremendous rate. (I would say this is a "steep learning curve", but according to Wikipedia, this is the wrong way to use this phrase. Who knew?) Once you start clinical rotations, usually in the third year, you are constantly getting knocked off balance. In medical school, I rotated in 4 different hospitals and at least 6 different clinics in two years. At the start of every rotation, there's a new place to learn, new medical language (especially on OB), new medical record systems, etc. Every time you start to get into a routine and get comfortable, it's time to move on.

It's just like this as an intern, only even more dramatic, if possible. The first few days of a new rotation are, in technical terminology, guaranteed to suck hardcore.

It's November, and I'm on my 5th rotation, my 3rd hospital, my 3rd electronic medical records system, and my 4th new service. Even though I've been to this hospital before, every unit and service are different, so I'm relearning all the procedures of daily medical business, like how to arrange for discharges (on my last service, we met weekly; on this one, we meet daily). The call schedule is different and complex, with day call, night call, short call, and a ghost team that I don't fully understand. Every day, I have to try to attend morning report at 8 and noon conference (the benefit here is free food), but some days it's grand rounds here and some days it's grand rounds there and others it's simple noon conference in room X.

I have a small book of various call schedules, specialty schedules, and enough phone numbers to make a yellow pages. It takes me 3-4 minutes to find the phone numbers I need every time I want to make a call.

I had two med students over the weekend helping me out (and they're quite good), and today we acquired two more, plus a co-intern, and a new upper level, and an attending I'd never met before, so I'm thanking JCAHO or whomever that we all wear nametags or I wouldn't know who anyone is.

On Saturday, I inherited 7 patients, which is more than I've managed at one time as an intern. One had been in the hospital for 5 months when I picked her up.

Add to this the complexity of actually learning the medicine I'm supposed to learn this month. When my upper level says "replace his K" I usually go "okay, how?" Potassium comes in multiple oral and IV forms and can be administered slow or fast or even hanging upside down for all I know. As a med student, you generally don't learn medication dosing, because you're too busy learning the medicines themselves. Now, I'm trying to learn the dosing, in addition to remembering which calcium channel blocker is a dihydropyridine and which tricyclic antidepressants have the least anticholinergic side effects. Thank god for the PDA (or in my case, the smartphone) that contains the free Epocrates and gives me a starting point to say "should we start metoprolol 50 BID?" (Of course, the answer to most of my dosage offerings is "no, let's start x dose instead", which often seems to be more a matter of personal preference than anything. Or maybe I'm just always wrong.)

I spend half my day (it seems) just looking up the acronyms and abbreviations, because in every place they're different. One service used "HLD" for hyperlipidemia, this one uses "HLP". "MDS" is myelodysplastic syndrome, "SSS" is sick sinus syndrome, "AVR" is aortic valve replacement, and "FUBAR" is how I have felt these past three days. Thank god for Google.

I fully expect that by next week, I'll have my groove down. I'll fly through my notes and know how to replace basic electrolytes and remember the intricacies of acid/base metabolism and how to read an EKG. I'll know the names of the nurses (or at least the main ones) and the social workers (and of course, my team). I'll know my patients backwards and forwards and have their discharge plans in mind shortly after admission (always subject to change, of course). Seven patients will seem like nothing at all (and I'm sure I'll have more soon, as we admit q4).

Those first few days always suck, though. Welcome to internal medicine!