Intake

Based on several new patient encounters over the last few weeks, I’m making an intake form for all new patients requesting narcotics.  It will look something like this:

1.   Are you taking cocaine right now?

2.   No? Good. Okay.

3.   Why have you fired your last 3 doctors or been fired from their practice?

4.   Are you expecting narcotics today, as in, right now?

5.   Because I am not going to give them to you without a little more information.

6.   What exactly is your pain?

7.   What, besides Vicodin, are you doing for your pain?

8.   Ok, what, besides medications, are you doing for your pain?

9.   Are you taking methamphetamine right now?

10. No? Good. Okay.

11. Are you willing to submit to a drug test?

12. Why aren’t you able to pee today?

13. If you had to choose among the Percocet, the Xanax, and the Soma you currently want to take all at once, which would you pick?

14a. Is it cool if I call your previous doctor before our next visit?

14b. Please list the names of the doctors you have received prescriptions from in the last 2 months:

1)_________________________

2)_________________________

3)_________________________

4)_________________________

5)_________________________

6)_________________________

15. Many people seem to have nicknames for their medications. What do you like to call your pain pills? (e.g. oxies, vikes, etc.)

16. After leaving jail last month and having been off narcotics for a year, why did you then immediately resume taking 8 oxycodone 30’s a day? Are you sure you’re taking them? Because you do not appear to be dead.

17. In the past month, how many times has your cat knocked your Vicodin into the toilet? (0-5) (5-10) (>10)

18. In the past month, how many times has your cat knocked your Ciprofloxacin into the toilet? (For statistical purposes only)

It will be printed on pleasing pink paper with a marbled background and smell like candy canes.  I’m super excited.

When I Hate My Job

Potter

“He looks like he’s ready to go to the disco,” K said, impressed. It’s been a while (never) since I went to a disco, but I had to agree. Wide collar, sparkly shirt, perfect hair.

Attentive, focused, by his wife’s side. It won’t be long now.

She’s a day shy of 35 weeks, but her body decided to have the baby today. I don’t have records, because it is the weekend and apparently we live in medieval times. Or 1975. It’s never really clear in the middle of the night.

She says it was a normal pregnancy, and she seems like she knows.

To be safe, I checked with Swiss. Sometimes we have these folks deliver in the city. She thinks we can manage here tonight, and she’ll be there.

It takes a while but it’s her first baby. An epidural helps her relax. Finally it’s time to push. Slowly the baby’s head comes down. Slower than I’d expect. An hour and a half into the pushing we’re getting close. She is quiet, focused. He is always by her side.

Swiss comes into the room, checks the warmer. We’re ready.

The baby’s head delivers. But then he’s stuck. I apply extra pressure. K and another nurse pull back her legs and help roll the shoulder forward from above the pubic bone.

Except the shoulder is already under. I can see both shoulders, they’re out. But baby still won’t come.

I don’t get it. This is not in any book. All the maneuvers I ever learned had to do with getting the shoulders out, but they’re out, and the baby’s still stuck. What is stuck? Is there another kid in there? An omphalocele?

Swiss is watching me.

I bring the head anteriorally. No movement. I try some sort of Wood’s screw, if you can call it that with the shoulders already out. I think about cutting an episiotomy. Finally I loop a finger under each armpit and slowly and firmly pull out. There’s belly, belly, and more belly.

The child is before me. A huge abdomen, 40cm in circumference, floppy. Little flipper feet. Tiny chest. Blue. No tone.

Swiss freaks out. I hand her the child as quickly as I can cut the cord. She starts to resuscitate, then moves the whole operation out to the nursery.

It’s quiet again, panic in their faces now.

I have no idea what just happened. I tell them it looks like their baby was born with some problems.

They’re terrified, and want to know what is happening. I duck into the nursery, where about 18 people are trying to intubate the child. A neocode has been called.

I go back in and tell them what I know.

The next six hours I split between their bedside and the unfolding drama. More of “We’re not sure what this means, but this is what is happening and here is the plan.” Transport arrives but hangs out for a couple hours with Swiss to stabilize. More tubes, lines, xrays, consults, taps, needle thoracostomies. The lungs are too tiny. The belly too big. There’s a mass near the bladder and the kidneys are huge, maybe cystic? The oxygen is lower than expected.

Finally he’s ready to go to the city. I bring them over to see their son for the first real moments. I have to give them permission to touch him; the lines and tubes have a way of keeping folks away. A few minutes of the three of them, and then he has to go.

The next morning, at the University, he codes again. This time, he doesn’t make it.

They were on their way. But the first time they were able to hold him, he was already gone.

And why? Well, it was the Potter sequence, you see. He had posterior urethral valves, meaning the urine couldn’t leave the bladder and backed up. The pressure got high enough to blow a hole in a kidney, filling his abdomen with urine. Meanwhile, over weeks, he made virtually no pee, so the amniotic fluid was chronically low. Thus his legs never developed fully, and, more importantly, neither did his lungs. He died because he was born 5 weeks early with lungs that were 15 weeks early.

Yes. I understand. But why?

24

What a day.  Only 5 patients this morning, and it was all I could do. 2 OB’s needing NST/AFI’s. One of course presented at 39 weeks without any prenatal care from our group, with pre-existing hypertension on medications, and without any prenatal records. She’d like to be induced Friday, please, but she’s not sure when her due date is.

Next another patient with severe back/left belly pain. It’s not her pelvic organs, or her gallbladder; those were removed a while back.  It may be something around her kidney, like the liquid she had removed twice with a needle several years ago, now that she thinks of it.  I’m not sure, as I talk to her, that it isn’t actually from her heart. But I am sure that something is wrong with her. She can’t smile, or really move her face at all. Tears come early. She’s anxious, can’t sleep. Nothing is fun anymore. She’s guilty about everything. Energy is gone. She can’t concentrate.

She has lost 30 pounds over the past several months.

She thinks about driving off a cliff nearly every day.

She hasn’t seen a doctor in 7 years. I guess I’m it, then.

We do an EKG, and I examine her. I grab the therapist from her office to see if she can stop by. She does. We make a plan, and order labs and a follow-up appointment. Then she’s gone.

Later I stop by the therapist’s office to ask how the discussion went.  “She sure is depressed. Also, guess what she’s drinking every day?”

I brace myself for the inevitable unearthed alcoholism that the patient had denied previously. I’m wrong.

“24 cans of Pepsi. A day. 24 cans. I asked her three times to be sure.”

What?

Leafy stops by after clinic to catch me staring blankly at the 30 charts on my desk. We talk about the drama currently happening among the staff.

As we leave the building I tell her about the Pepsi. She acknowledges sometimes you just don’t know what to do. Today, her patient complained of being run over by a Studebaker. Which crushed his penis. And now he wants to have an erection.

“But I don’t even know what even will work?”

“Well, can I just have some Viagra?”

“Sure.”

While I'm At It...

Another dream:

Everyone else is in EMR (electronic medical record) training. It’s super awesome and there’s a pic in the staff newsletter of everyone jumping in the air with joy. I, instead, have to see patients outside next to a kiva fireplace near a pumpkin patch. All my patients have fibromyalgia. For lunch I have barely enough time to look for food, and all I can find is a small piece of stale bread.

WTF, brain?

Dreamy

Last night I was on call with a resident. She told me she had a dream in which she was evaluating a woman in OB triage when all of a sudden the patient’s baby came out without any warning.

Here is the sort of dream I have.

I am running through a maze of doors, under a dark sky with trees. Several rabid deer are chasing me. The doors are crumbling, so when I close them behind me the deer can still get through. Finally, a room seems safe, and there is a piñata. I stand next to it and it breaks open and millions of tiny chainsaws fall out.

The good news is neither of those things happened last night.