Repost: Hey Paesan!

 

Some time ago, I had a day that was one of those days that makes you really glad your are off today. I swear to god, I had Uncle Jr from the Sopranos as one of my patients, except that my Uncle Jr was in his very elderly and about 95% deaf. The guy was still sharp as a tack, but just…..really….really…. hard of hearing. While a patient in the ED, overall, he was just fine. Now you know how people who are hard of hearing tend to talk louder since they can’t actually hear their own voice? Imagine hearing a patient shouting this the from across the ED

“OH JESUS, JESUS HELP, I KNOW I”M DYING, THIS IS IT, THE LAST FAREWELL, I DON”T WANT TO DIE!.”

The guy is totally fine mind you. So I go see him. And I have to shout back at him, damn near the top of my lungs to get him to hear me. Patient privacy is out the window and in this case as the whole ED is listening.

Me: SIR, YOU ARE NOT GOING TO DIE

UJr: WHADDYA MEAN I’M NOT GOING TO DIE? I KNOW IT, I JUST KNOW IT”

Me: NOT TODAY SIR.

UJr: I”M NOT GOING TO DIE? OH HEY, THAT’S GREAT NEWS! GREAT NEWS!  HEY, ARE YOU ITALLIAN? YOU LOOK LIKE A GOOD ITALIAN BOY (keep in mind I am pasty and white with freckles)

Me: WELL SIR, I”M HALF ITALIAN!

UJr: I KNEW IT, I JUST KNEW IT. THANK YOU JESUS! I KNEW THEY’D FIND A GOOD PAESAN TO TAKE CARE OF ME. DO YOU HAVE ANY FRESH TOMATOES I COULD HAVE? I COULD KILL FOR SOME FRESH TOMATOES. OH THANK GOD THERE IS A GOOD PAESAN HERE TO TAKE CARE OF ME

I was hereby referred to as the paesan by the patient for the rest of his time in the ED. 3 hours later, we finally got him on his way home. But not before he shouted a few other gems…

UJr: “HEY PEASAN, I”M GONNA TAKE GOOD CARE OF YOU. WHAT’S YOUR ADDRESS? I”M GOING TO SEND YOU A BIG CHECK WHEN I GET HOME”

Ujr: “NURSE, BRING ME SOME DINNER

Female Nurse: “I’l bring you something to eat soon”

UJr: “I SAID TO BRING ME MY DINNER, RIGHT NOW”

Through and through, the guy was old school Italian and kept us laughing all afternoon long.


It ain’t all bad

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Okay, fine, maybe peds is not 100% bad. When you examine a kid, and he crawls across the bed and into your lap and starts trying to auscultate himself with your stethoscope, huge grin on his face,  maybe that part is okay.

 


Due Dilligence

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Being at the children’s hospital for the past few weeks, especially coming off a month of vacation, has been absolute torture. Just…give…me…one…sick…patient! PLEASE! I know that sounds horrible to ask for, but when there are 5 residents covering 13 rooms, and it’s yet another kid with fever, but running around the room like a tornado, it feels like pulling teeth one agonizing patient at a time. The challenge here, and the thing that scares me a little, is that 95% of these kids are totally, absolutely, no doubt about it fine.  But some of these other little buggers, there may be some little thing, some little harbinger of impending doom, that if you don’t pick it up, these kids might not do so well. And that’s really no different than adult medicine when you think about it, but still, they are kids, and no one wants to do harm to a 1 year old. So the challenge has been to stay sharp, to do due diligence on each kiddo, get them all undressed, look em’ over from head to toe. Ask all the questions, to each patient, each time, even though, the majority of these kids can be discharged from the doorway.

So last night, I was seeing a 4 year old, mom brought her in for cough and congestion and some dry skin on the face. Clear as day, the kids got a simple URI, but I got the kid undressed anyways, just to make sure she wasn’t retracting or anything like that. And when I did, I noticed two 4cm marks on her forearm.

“Sweetie, what happened to your arm?”

“My mom hit me with a belt!” (all smilely when she said it too). And of course mom is sitting right there. Mom openly admitted to it, giving the reason that she has six kids, lost her cool one day, it only happened once, she feels horrible, and has enrolled in parenting class.  Fine. Still gotta fill out my paperwork and call child services.

I’m not trying to say, oh look how great my H&P is, rather, just how easy this would be to miss. I’ve been really trying to do my H&P’s the same for most everyone, adults and kids, regardless of what the complaint is, same set of basic questions, same basic physical exam maneuvers, and then focus and expand based on the complaint, just to make it habit, so when it’s 4 am and I’m dragging my feet, habit will kick in and make me check these things that I might not bother to otherwise, as was the case with this kid.


(plus, the set of questions I ask, hits 10 systems on the ROS, two per system, so that way I’m not actually committing medical billing fraud when I document my level 5 chart! Bonus!)


Aww Snap

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So I don’t mind if another doctor or nurse disagrees with something I order, or the way I am doing something. That said, there is a proper way that you let a person know that you disagree with them. Usually, it involves being discreet, polite and generally non confrontational about it. Let’s review an example of how NOT to do it…

The patient is a young, non sexually active female presenting with RLQ pain, who was found to have a hemorrhagic cysts on imaging. From across the far side of the ED, where the admitting resident is doing her paperwork.

Admitting Resident: (at loud volume for all to hear). Are you taking care of this patient in bed 12?

Me: Yeah, I’m just signing out the patient now, what can I do for you?

AR: I don’t see on the chart where you documented your pelvic exam (how classy of you to point that out!)

Me: That’s because I didn’t do one

AR: What do you mean you didn’t do one? Why not?

Me: (now getting annoyed, I’m happy to talk about if you think she should have one, but don’t shout it across the ED). Because the patient didn’t need one.

AR: Her urine  shows 5-10 white cells which means she might have PID.

Me: Well, as I DID document on the chart, she’s never had sex, which makes that theory impossible, and she has a finding on CT which perfectly explains her urine.

AR: I really think you should do one, as she could have PID.

Me: She’s never had sex, and I’m not about to make my gianormous fingers her first experience.

Me: Fine, well, I’ll just have to do it upstairs then since your are failing to do a thorough assessment here.

(Really? We going to play the passive aggressive game? Okay fine, the ED attending is sitting two feet away, who also happens to be the chief of the department)

Me: Dr. X, the girl in room 12, the medicine team is curious as to why we didn’t do a pelvic exam. She’s never had intercourse, but the medicine team feels her 5-10 white cells on urine dip are indicative of PID, despite that she has no malodorous discharge, dysuria, bleeding or frequency. Do you want me to do an exam on her before she goes up?

Dr. X: She’s never had sex?

Me: She’s denies it up and down

Dr. X: (Turning to the medicine team). We don’t do pelvics in this ED on children who have not had intercourse. What you’re suggesting can be considered sexual assault and battery, so if you’d like to assault your patient, you can do it outside of my department.


Booya! (Fist bumps were had by ED residents all around.)

So that whole situation could have easily been avoided. The medicine resident could have been like “hey, can I ask you something about this patient’s chart?” Which would have piqued my interest, I would have walked over, we could have talked about it, discussed why or why not, I wouldn’t have had to throw her under the chairman’s bus wheels, the nurses wouldn’t have had to comment what a you know what she was when she left, and all would have been well.   Just sayin’.


ER JEDI 2013-03-01 02:33:20

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I think that one of the best things we do in the ICU is when we allow people to die with some degree of peace and respect. We recently had a Cambodian patient, on life support, with no hope of recovery. Discussions were started with family about withdrawal of care. And while they were in support of the idea, their concern was that he somehow had to die at home, and not on a Tuesday.  I understand the dying at home part, but I was never clear on what it would be bad for him to be allowed to pass on a Tuesday. It had something to do with his Buddhist religion, but I was never informed of the specific reason. I would have asked all the monks that where there in their orange robes, but none of them spoke English. So when Wednesday morning rolled around, the monks and family gathered in the room, the ambulance crew showed up. We loaded him onto the stretcher and literally pulled the breathing tube out as he rolled out the ICU doors. Medics were instructed to NOT check a pulse, NOT check for breathing, not to do anything other than get him home as quickly as possible. And, under no circumstances, where they to come back to the hospital. It was the best thing we did in terms of patient care all month.