Torchwood

I've been watching this new season of Torchwood. It's amazing. There are so many medical ethical issues that are being raised.

In a nut shell, people live forever so there are not enough resources to keep everyone in hospital. The sick are sent to what are essentially concentration camps. They are treated like things rather than human beings. It is a bit reminiscent of how we treat demented patients. They don't have rights and are spoken over rather than to.

Doctors' responsibilities are focused on dealing with placement of these "dead but not dead" patients.

I spent a large part of today's weekend rounds on politics. Moving patients between areas of the hospital, planning resources for patients to go to when they leave and continue to manage the health of patients who will never leave hospital. We sometimes find ourselves discussing the futility of certain treatments, choosing the course of treatment that is most cost effective. While we always consider what is best for the patient and act accordingly, it often feels that our conversations are centered on economics and politics rather than medicine.

According to the CanMeds roles, resource allocation is an important part of being a doc but it truly is my least favorite part.

I found myself today longing to just figure out a medical problem and make my patients healthier.


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Diabetes

We measure our diabetic patients' blood sugar using an average estimate called the HbA1c. We like to see this number at around 6 or lower but I often see it much higher.

When I watch a patient's A1c drop it gets me excited. I often proclaim it to be a high five moment. It's a big deal for the patient to make the changes that are needed for them to have their sugars under control.

It's particularly great when my patient is in their nineties and I'm making them give me a high five.

Well. Great for me anyway.


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A Foot Problem

This story is one from clerkship, one of my ER shifts. It a particularly busy shift. There were several codes, a few traumas and people generally having bad days everywhere.

As a result, the waiting time for less urgent cases was long - some eight hours. I met a patient who was triaged as “green” (not urgent) with a “foot problem”. He did not speak English. His friend spoke some English, but not much. I had a difficult time doing my normal history and physical. It was almost impossible to understand what his past medical history was, when he began to feel unwell or anything else we would normally ask a patient. The patient was perseverating about first his length of stay in the ER then his foot that was causing him problems with walking.

I was frustrated. So incredibly frustrated. I had to keep leaving to check in on my other patients and calm down enough that I could talk to him again. Eventually I realized that this guy was sick. I couldn’t tell if it was a neuro problem (?stroke, trauma, seizure) or a cardiac problem. Once I was able to figure this out - at least one or two hours after laying eyes on the patient - things went much quicker. He had an ECG, cardiac enzymes, blood work up, CT head, everything I could throw at him.

He was indeed unwell. He went for neurosurgery that night.

It’s a good ending - I saw him a month later and he was well, walking and doing his normal life.

This is a story about the system though.

The nurse who triaged my patient didn’t realise that this patient was as sick as he was and took the fact that the patient stated he had a foot problem at face value. They didn’t call a translator and probably wouldn’t have known the patient’s language or where to find a translator in the city.

The nurses who had this patient in their area didn’t check in on him. He was triaged green, he could wait. They had patients with active cardiac issues to tend to. They believed the green triage and had difficulty getting past the language barrier.

Without a proper translator I found the interview process for this patient difficult and annoying. I was focused on the annoyance rather than the illness of the patient. It wasn’t until I chose to go past the history to the physical that his illness became apparent.

Once his neurological deficits were apparent, the nurses were amazing in helping me get tests done quickly. Consults were called in, the patient was cared for.

10 hours after first presenting to the ED.

I was angry with myself and with the system that caused this patient to have such a terrible experience. I felt guilty for being so frustrated with the language barrier I had with this patient. I was scared that because of my ignorance my patient would have lasting deficits.

Rather than be angry with a triaging system that was doing what it could, I looked for practical solutions to the problem. With the immigration hub in town, we came up with a “health passport” for new Canadians. It contains basic info about the patient like their country of origin, mother tongue and how to get in touch with a translator. It would also contain their past medical history, medications and other important medical information that would help the ED physicians.

I left the community before I could see it put into place. I hope it’s being used with good benefit.

Kids say the darndest things

I have an adorable young family who comes into the office. Every time I see them I giggle because mom allows the kids to dress themselves. Sometimes I'm treating princesses other times race car drivers. They are a lot of fun.

Yesterday, Kiddo was in for a sore ear. Every time I tried to look, he'd swivel his head around to look at my stethoscope. Finally I just hung it around his neck so I could do the exam.

While I was telling Mom what I saw, Kiddo put the bell in the middle of my chest and said "ba bum ba bum ba bum". I asked him what noise my stomach made. He said "whooshy wishy woosh". I asked what noise his knee made. He said "sqeeeeeee". Then I went back to th exam but he clearly wasn't done. He said "what sound does you boob make?" put the bell on my breast and said, "woooo-uuu, woooo-uuu".

Mom quickly stuck out her elbow and asked what sound it made.

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My favorite plan for a patient yet;

More foreplay!!!



I should start to prescribe it more freely.


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Why do my patients wait until my preceptor goes away to decomponsate??

Why?? I love the learning I get to do when I'm on my own, but the terror of not knowing what to do plus the realization it's up to me to figure out how to keep the patients alive ... It's a lot for a new resident.

My next block is emergency medicine. It's less intense than family right? No? Dammit.


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Jam

I try to ask my in patients if there's something I can do for them before I leave. Sometimes it's a change to their bowel meds, others something goofy like get me out of here. It's a way for us
to get the little uncomfortable things fixed and sometimes have a giggle. I think it's good patient care. We are always running between patients and trying to get to clinic so the little things are easily missed.

This morning, after thinking very hard about it, one of my elderly patients waiting for placement replied "you know, I'd really like an extra jam for my toast. I love jam and one just isn't enough".

That patient is on a high calorie diet in an attempt to help him gain weight. The jam makes sense from my point of view.

I asked the head nurse if I could order it for him and she said no.

But, as I was leaving, she was on the phone with dietary making the request.

Things like that are good for patients, good for hospital staff. We are showing we care about individuals and by making my notes about the conversations we have and his request for jam, everyone who picks up the chart has a better idea of what kind of a person the patient is.

He's one who likes jam.


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When our rounds get canceled

Residents play Super Mario Yahtzee!!



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High tech problem...

Low tech solution.

There was a quick power outage in town yesterday. The computers mounted on the walls, very high up, shut down.

As I turned onto the floor, I saw a nurse on tip toes with a cane in hand trying to turn the computers back on.

Made me giggle.



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I hate cigarettes

I hate cigarettes. Hate the smoke they make, hate the stink they cause, hate how addictive they are and the diseases that they cause.

Every time I find out that a patient smokes, I ask them “What can I do today to help you quit smoking?”. It shows I care, that I think smoking is a really bad thing and is non confrontational.

Talking with a couple yesterday, I found out that they smoked. They were joking around that she had told her partner that if he continued to smoke with his Crohn’s disease. I told them that there was something to that since smoking causes damage to our smallest blood vessels like the ones in our retinas.

I then pointed to him and said, it’s the reason you guys get erectile dysfunction when you smoke.

Without missing a beat, he responded, "Ok, when I get erectile dysfunction, I'll get my eyes checked."

I almost fell off my chair I was laughing so hard. Not what I had in mind but really funny.

**unlike all my other stories, this is one that I've asked permission from my patient to share this story with you and was given verbal permission so this is a true, unadulterated story!**