why health care cost so much....

In continuing a story about Larry (see previous post) I thought I'd give a little more information about his 4 night stay with us in the hospital. He is a 40 something year old obese male with congestive heart failure (CHF), acute renal failure, and a possible GI bleed. Our work up for the GI bleed on day 1 was to do a fecal occult (checking to see if his stool had blood). On day two we got the results---it was positive. So we scheduled a barium enema for the next day. That night Larry needed to drink about 4 liters of "go lytely" which washes your whole system out. I spoke to the RN to see when he should start, they suggested 5pm. So I wrote the order to start at 5pm and then for him to be NPO (ie nothing in the mouth) after midnight---standard orders before this procedure. Well on day 3, I went to visit my friend Larry to discover he had only finished half of his go lytely. Why ? you might ask. Apparently he was sleeping at 5pm and the RN didn't want to wake him. He started the 4 L at 8pm and wasn't able to finish it before midnight---at which point the RN made him NPO. This means no barium enema for Larry. Frustrated, we kept him NPO that day and had him finish the go lytely and rescheduled for day 4. On day 4 he he was ready to go, but we get a call from radiology saying he is too big to even fit in the CT machine. No barium enema for Larry ever. What do we do? We discharge him and tell him to follow up with his outpatient physician.

Gotta love our health system.

taboo

The Health Insurance Portability & Accountability Act or HIPAA was established in order regulate group health plans so they do not accept or deny patients based on their genetics, medical history, etc. It does allow group health plans to refuse pre-existing conditions under certain measures. This stinks for the patient. But the main way it affects doctors, nurses, medical students is the privacy act--which basically means: do not discuss patient information in the elevator, the cafeteria or the hallways. SHHH!!! So how do we get around it, you ask??? By practicing our Taboo skills!

Taboo--one of my favorite board games--helps us master our talking about the patient without actually saying the patients name. For example if we need to "run the list"* in the cafeteria, we just start with the first patient as "the guy who suctions all his breakfast out of his mouth." We immediately know its Bill** on the 4th floor. Or if we need to jump ahead to "the guy who can't fit into the CT machine" we all know we're discussing Larry**, and we can proceed in a timely matter, while filling our guts with awful cafeteria food.

I am so glad I've had younger siblings who were into board games, otherwise I may not be good at avoiding HIPAA violations as I am today.

* running the list is probably one of the most important things you do in a day. and trust me, we do it probably 2 or 3 times per day. its when you discuss patient by patient what else you need to do before you can escape from the hospital.
** you thought you caught me! But I'm too clever---this name is made up to protect the real suctioner and large man.

Deflated

I am deflated. I dont even know if thats a word, but I'm using it. My 31 year old female pt, the one who had nausea and vomiting for 2 months along with a growing liver and jaundice, has sadden me. She came in to the ED (emergency department) last week complaining of seeing yellow. With no past medical history, she denied any blood in her vomit, denied taking any vitamins, denied IV drug use, and said she rarely drank alcohol. She denied this everyday for a week. (I like to triple check) So we started working her up for hepatitis and cholecystitis.

Everything came back negative. I mean everything. She had a CT, MRI, HIDA scan, MRCP which just showed a fatty liver. We ran almost every autoimmune liver disease possible. Finally we had no choice but to take a liver biopsy (which was pretty cool---it was a transjugular IR bioposy). What were the results you ask? Alcoholic hepatitis.

At first I thought they mixed up the patient's results. But my resident said it was definite. I couldn't believe it. I had forgotten the first House, MD rule: "Everybody lies." or "I dont ask why patients lie, I just assume they do." When confronted, she said "Oh I am just so glad it was something as simple as that." She must have known the whole time. Or she is in incredible denial. Either way I was deflated. If I can't trust my patient then what is our purpose?

The beginings of medicine

So I'm currently in week 2 of a 12 week process, or what we call medicine rotation. I am following 3 patients, we're currently on call Q 5, meaning every 5 nights we're on overnight call, and my residents are fantastic--they teach, they're friendly, and I wouldn't mind hanging out with them outside of the hospital. But when people ask me "how was your day?" a response hasn't really jumped out at me. I guess I'm just sort of blah. I feel like I am going through the motions. I'm not bored at work. I am tired. My patients are interesting. I enjoy figuring out what is wrong with them. But then...well...I am kind of over it. So living every day is just a way to get to the next. It sounds terrible. Like I'm having a horrible time, which is definitely not the case--I have been laughing all the time at work, but I think I need something else to spark the situation. It hasn't happened yet.

paging the resident

its a ritual that occurs with each new rotation. we get a packet of information. we're told what is expected of us. and how often we will be spending the night at the hospital each week. they explain what is mandatory and what we can skip. and then we get a pager number and we're instructed to page our resident to meet up with our teams. We walk in a herd to the nearest phone and line up, single file. Each one of us takes a turn, dialing the 4 digit number and the rush of anxiety builds as we await for the return call. Will we look like a fool and be asked a thousand pimp questions today? Will we be scutted around the hospital? Or get lucky and leave early? What will really be asked of us? Will we get along with our team? Will lunch be involved at any point? Where is the nearest bathroom? Its these questions that plague our minds during the paging of the resident. Luckily the anxiety only builds for a few minutes, until they call back, we introduce ourselves over the phone (they either sound happy, indifferent, or bothered) and they tell us where they are and we leave the line of med students to join our teams.