Tuesday, July 11, 2006

 

Footnote

I thought I'd take this opportunity to explain the origin of my blog's title and web address. None of my readers have asked about this, although I'm sure this is mostly due to deference and a wish not to disturb a great mind with meddlesome questions. I'll capitulate, nonetheless. The term "over the mountain" refers to the general direction of the state hospital, which is where we send our patients when we can't make them better during the two week maximum stay that most insurance companies will allow at our acute care facility. This being the South (with a capital "S"), the state mental institution is actually separated from our hospital by a giant mountain that you cannot go around. You must go over it. Rumor has it that there is actually a nuclear bunker hollowed out of this mountain, although I've never actually seen any evidence of this. Few people actually refer to the state hospital as being "over the mountain" anymore. The progenitor of this phrase is now retired - a celebrated psychoanalyst who formerly conducted LSD-based experiments on psychiatry residents during the 1960's, and who was fond of speaking in cryptic psychobabble. One memorable morning rounds found a young borderline patient curled up in a ball with her head at the foot of the bed. The aging psychiatrist turned to a fresh-faced medical student and queried in his thick Austrian accent, "Do you recognize this position?" As the student stammered to reply, he declared with great gusto, "It is the breech position!" He then asked the patient when her last period was and what she had dreamed of the night before, and in a flash of light she was cured of her personality disorder. The next patient, a disorganized young schizophrenic was not so lucky, and after a brief series of questions, the attending turned to his head resident and said simply, "Send him over the mountain."

The blog's title, "That Incident at the Clubhouse" is a reference to the downfall of many schizophrenic patients who find their way back onto the acute ward. The clubhouse is the name of the local community center where schizophrenics go for the day and learn basic life skills to enhance their assimilation back into society. It seems, however, that there is an almost daily incident of epic proportions that lands someone back in the hospital. This leads to frequent explanations from local counselors to the tune of, "Johnny was doing really well until that incident at the clubhouse. Now he's been off his clozapine for 2 weeks, hasn't showered in five days and thinks the devil is after him again."

Thursday, July 06, 2006

 

Sorry Seems To Be The Hardest Word

My career as a doctor is starting off in the ER. I was originally slated to begin in the MICU, which would have been a terrifying experience for everyone involved (just imagine me, after ten weeks of nothing but drinking and reading The New Yorker suddenly in charge of managing the sickest patients in the hospital, most of whom are requiring electricity to aid their breathing). Thankfully, at the last minute, the gods smiled on me in the form of ACGME regulations and I got switched to the emergency room. (I'll now be in the MICU during December, and, according to the call schedule, will predictably be on call all day and night on Christmas.) Although my ER rotation thus far has been incredibly informative and an excellent way to start the year, I should offer some apologies.

First, I apologize to everyone I saw on my very first day who required a prescription of some sort. How was I to realize that the generic prescription pads I had been issued by the pharmacy required some means of identifying myself as a doctor besides my completely illegible signature followed by the letters "MD"? I suddenly became cognizant of this at 3am that night, two hours after my shift ended. This explained the odd feeling I had that day every time I wrote a prescription, as if I knew something was not quite legal about the process, but couldn't articulate where the flaw in my design might be. I especially apologize to the man with excruciating testicular pain of unknown origin for whom I prescribed a three-day supply of Vicodin until he could follow-up with his PCP. I guess what doesn't kill you only makes your stronger, huh?

Secondly, I want to apologize to the 68 year old woman who came in with a swollen left cheek, and who I tried to convince that she must have just slept on her face wrong. In fact, she had an enormous dental abscess, the presence of which I should have been clued into given her horrendous dentition and the pus filled pocket emanating from her gum line. Instead, I asked her 15 times if she was sure she didn't fall down before going to bed the night before and then basically decided that she was probably mildly demented and/or intoxicated and didn't remember what happened. For some reason, I was also convinced that this all had something to do with a pointy nightstand. I apologize also for failing to use a tongue depressor during my initial mouth exam and instead just kind of poking around with my finger. That's disgusting. Seriously, though, shouldn't a dentist be seeing this patient? The attending asked me which number tooth was involved. Teeth have numbers?! When did we learn this? Was it before or after the sketchy dental resident started hitting on the first year females?

Perhaps the largest apology I owe is to the numerous people I have rectalized over the past two weeks. You know who you are. Even more deserving of my guilt are those I had to perform multiple rectal exams on because of errors I made in the initial process. To the woman with a history of gastric ulcer who presented with melena, I'm sorry I didn't go deep enough the first time. To the nursing home paraplegic patient with colitis, I'm sorry that I accidentally smeared the sample on the wrong side of the guaiac card. To the young man with a Dieulafoy's ulcer, I'm sorry I failed to realize that there were no cards in the room until after I performed the exam. And to myself, I'm sorry that I took off my glove prematurely after my very first exam, and was holding the guaiac card in my bare hands asking an attending to confirm the negative result before he pointed out to me that I should wash my hands twenty times over. Again, that's disgusting. Additionally, I apologize for the fact that I can never remain completely silent during a rectal exam and instead either make an incredibly awkward comment ("This is why I became a doctor" or "This is less fun for me than it is for you") or make oochy-ouchy noises reminiscent of everyone's favorite gynecological surgeon.

Finally, I apologize to the wonderfully warm and charming man who came in complaining of right upper quadrant pain at 9pm and to whom, at 3:30am, I had to break the news that he had a huge pancreatic mass with probable mets in his liver. I'm so sorry. You broke my heart and I broke yours. Good luck.

Wednesday, July 05, 2006

 

We Both Know That I'm Training To Be A Cage Fighter

In typical fashion, I've abandoned my blog after two posts. This is not for lack of ridiculous topics to write about. On the contrary, I have so much good material that I'm at a loss as to where to start and I fear that my post could turn into one of those marathon posts that seem hilarious at first but quickly degenerate into tedium, and you feel obligated to finish them because you know how much time I spent writing it, but really, you just couldn't care less anymore and you'd like to move on the other websites you haven't visited yet today, such as your 14 year old niece's myspace page and Tim Gunn's Project Runway blog. Perhaps, though, since I'm now facing five days off, I can write in short bursts about the hilarity of my life over the past few weeks.

We started out orientation for psychiatry with a day of CPI training. Most specialties are required to receive training in advanced life saving techniques. For residents who will be interacting with adult patients, this includes a two-day Advanced Cardiac Life Support class, which features a young instructor wearing a pink and purple vertically-striped technicolor dreamcoat and a diamond-studded crucifix around his middle finger who calls the ladies "Hun," and claims to have a "wife." (Were it not for his blatant, nonstop sexual harassment of the females in the group and his out of place references to Jesus during scenarios of pulseless electrical activity, I might have found him charming.) Pediatric residents have several variants of life-saving training, including PALS (Pediatric Advanced Life Saving), NALS (Neonatal Advanced Life Support), and the recently-added FALS, which the conservative-leaning AMA has now instituted to teach residents how to resuscitate the nonviable fetuses mercilessly murdered by the OB residents down the hall. For psychiatrists, though, all of this is largely irrelevant, as everyone knows that we don't actually care about saving lives and are just in it for the sweet leather chair and the possibility that LSD might someday be reinstituted as a psychomimetic and we would get first dibs. We are concerned, however, with the possibility that our patients will one day attack us or even attempt to kill us. (This is actually in many ways a complete falsehood. While psychiatric patients are slightly more likely to commit acts of violence, the base rate remains extremely low and most psychiatrists are never assaulted during their careers.) For residents, the chances of injury seem particularly high, as studies have demonstrated conclusively that patients are more likely to be violent once they realize that their doctors have absolutely no idea what they are doing and no business wearing a white coat. In light of all of this, psychiatry residents are required to receive training in CPI (I actually have absolutely no idea what this stands for, despite having attended a day long class. I was going to go get the brochure from my closet and look it up, but I decided that it would be a colossal waste of time. I'm pretty sure one of the words is "crisis.")

I had very definite visions of what CPI training would entail. To start with, I imagined the training space would in many resemble Rex Kwondo's dojo, and that the instructor would be wearing the requisite zoobas. I envisioned lots of blue and red mats arranged on the floor and I figured we would be given complimentary bandanas with the Japanese rising sun emblazoned on the front. I had glorious visions of finally learning how to execute a standing dropkick and an arm-drag-takedown. Needless to say, my dreams were crushed almost instantaneously. I arrived first, at 8am, to find a short 60ish woman with curly red hair wearing tan slacks and a pink blouse standing behind a podium attempting to launch her Powerpoint presentation. I find it a bit disconcerting that we've arrived at a moment in history where self-defense training is taught via Powerpoint. Once the remaining members of the intern class filed in, we were treated to a five-hour lecture on patient safety procedures, which featured a riveting video news program which was second only to that featured during Day 2 of ACLS. (On Day 2 of ACLS, during a video about acute stroke protocol, we were all stunned to find out that stroke victims frequently lose the ability to properly use articles and begin speaking with a vaguely offensive Japanese accent, as in the following dialogue: Daughter: Mom, what is the matter? MOM: I havin' stroookkee.) The CPI video did not include any racist impersonations, though it did make use of state-of-the-art stick-figure digital rendering to further demonstrate specific moves. Finally, after lunch, we were given the opportunity to practice on each other. I can safely say that if any of us gets attacked by a patient, we will most definitely get our asses kicked. Even something as simple as escaping from a wrist-lock was a monumental task for most of the trainees, and it's clear that we won't be fielding any winning intramural teams in the near future. I am in no way exempting myself from this criticism. I couldn't figure out how to escape from the hair grab and I don't even have hair. I did get bonus points for having "Excellent stance technique," which was a total accident as I wasn't paying attention when the instructor yelled freeze. Apparently you are supposed to stand with both hands at your side, palms flat, which everyone knows is by far the most awkward position to stand in and nobody could possibly last more than 10 seconds like that. (My preferred stance involves one hand in my back pocket and the other holding a gin-and-tonic, but the instructor said this was "a bad idea.") In the end, nobody died, and we all left feeling a little more terrified about our chosen profession.

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