Dodging work, one inappropriate consult at a time

Life on PCLS (psychiatry consult liaison service) at NNMC (National Naval Medical Center, known in the Army Medical Corps as "Navy" and in most of the world as "Bethesda") is very slow. It's been a week, and we've had a total of three patients, for three interns. One of them, my patient, had a history of depression and anxiety and had been admitted to the hospital four times in three months with abdominal pain, that the medicine and surgery teams had completely worked up and couldn't find a medical cause for. So they consulted us to see if there was a psych component to her complaints. I chatted with her for about an hour, presented to my attending, and we recommending increasing her anti-depressant (she was on a pretty low dose) and following with a psychiatrist after discharge. Done and done. One of the other two patients that we had was just as simple, and the third, the only one we were seeing for more than a day, was a retired Marine colonel with chronic pain (from combat wounds), who had been taking a lot of narcotic pain meds and self-medicating with alcohol. He pretty much admitted himself for detox, and we had been making recommendations for detox/withdrawal and following with him until he could get into an actual rehab program.

So, what do we do the rest of the time? Well, a lot of sitting around the intern room at NNMC and being made fun of by the surgery interns, who were actually doing work (and we mock them in return for having to do work), and dodging inappropriate consults. We've actually only had two of those: one from a surgery resident who had a patient coming into clinic. The patient had a pretty complicated post-operative course, with a lot of chronic pain issues, and had a lot of anger, so the resident wanted someone to come by to the outpatient clinic and talk with her. Well, we don't see outpatients (just inpatients and in the ER), and besides, how would you feel if you came in for your post-op appointment and saw a psych intern sitting there wanting to talk to you? So we told her that if there was nothing acute (suicidal or homicidal ideation, etc), that she should talk to the patient and find out if she wanted to talk to mental health profession, and if so, put in a referral for her to see a psychiatrist/psychologist as an outpatient.

The other one, and I felt sorry for the intern for this, because I could tell it wasn't her idea, was on an ICU patient in a coma, who had a family who was being difficult to the ICU nurses and docs. Patient relations and social work was already on board, but the attending "wanted to cover all the bases". So I asked what the PCLS issue was, and the intern said, "Well, there's some question about whether or not they can make decisions for the patient." I asked if they wanted capacity evaluations for the family, and the intern said no, that's not what they wanted. So I told her that I didn't think it was something for us to be involved in (especially since they already had patient relations and social work involved already), but that I'd talk to my attending about it and get back to her. Well, my attending laughed and said that we don't see the families of patients, no matter how much they're annoying the primary team. I did apologize to the intern when I told her we weren't going to see family, and explained that I don't want her to think we're dodging work (especially since we weren't doing any), but that it really wasn't an appropriate consult. She thanked me, and that was that.

In all, I went from working ten + hours a day, six days a week (plus being on call) for two months, and now I work about six hours a day and get weekends and evenings off. It's weird, and I'm trying to get used to having down time again. I've been running more, and since NNMC has a pool on base, have been swimming a couple of miles a couple times a week. Life is good.

End of Ward 75, beginning of psych, and a new coin

I was on call in Ward 75 on Sunday, for the last time in block 2 (I'll be back there in block 6). It was a really, really quiet call (which is a very good thing), and I actually got sleep, but we did have a bit of excitement. Right after the med student returned with dinner (we one out to grab us food every time we're on call), we were all sitting around eating and checking things on the computer, and suddenly he jumped out of his chair and said, "Hello, sir!" Just my luck--I had just taken a rather large bite of food. I turned to see who he was talking to (thinking it was our attending), and saw Lieutenant General Schoomaker, the Surgeon General of the United States Army (ie, my boss, after the President and Chief of Staff), standing in our team room. He was walking around the hospital on a Sunday evening, just getting a feel for the place and a reminder of what really happens in Army medicine, at the very bottom of all the decisions he makes. So he stayed and talked for a bit, joked about college football (he went to Michigan; I was wearing an OSU tee-shirt), and traded internship stories. He was an intern before the 80 hour work week (obviously), but still recorded his hours, just out of curiosity. There was one week that he worked 158 hours. He still doesn't know how he did it. Then he gave us coins (above), and resumed his wandering of the hospital.

And just to put things into perspective about how nice we have it now, in Block 2, I worked a total of 260.17 hours, which is 65.04 hours per week.

Well, I was supposed to start on PCLS (Psychiatry Consult Liaison Service) at National Naval Medical Center (better known as Bethesda) on Monday, but as I was post-call in Ward 75, I didn't start until today. It's going to be a really laid-back rotation, especially after MICU and Ward 75. We currently have three patients and three interns. I showed up at 0730 and left at 1600, and maybe worked two hours. The rest of the time, I sat around and twiddled my thumbs. Tomorrow, I'm bringing some fun reading, and after work, I'm going to Barnes and Noble and seeing if they have a USMLE Step 3 study book so I can pretend to study while I'm at work. It's going to be a good month.

Team lunches and winning the game

Yes, I know, it's been pretty much forever since I last wrote a post--sorry about that.

Life on Ward 75 has been, well, pretty much like purgatory. You just have to bid your time here until it's time to move onto something else. We've had a few interesting cases, but for the most part, all I do is pretend to be a social worker and get people discharged and back to their retirement homes/nursing homes/back to their units.

Since the rotation is almost over (just one more night of call!), we had a team lunch yesterday--the attending, resident, two interns, sub-intern, and two third year medical students--at a Thai place in Silver Spring. The food was quite good, as was the conversation; with the exception of my fellow intern occassionally treating me like I'm quite useless (despite the fact that I have twice discharged all of my patients, a feat he has yet to accomplish), we had a really good team. The two med students we currently have are quite sharp and work hard, but have good senses of humor (of course, they thought I was joking when I told them that I gave low passes on their evaluations...)

Anyway, today I started the day with two patients, one with a fairly simple pacemaker placement, and one who had been admitted with high fevers and chills after returning from three weeks in Africa (we thought it was malaria, but those tests came back negative; he got better on his own, and we still don't know what he had). Both got discharged today, so I had no patients--that's what we call "winning the game" (the game being treating patients; winning being discharging all of them before the next night on call). So I won the game, for the second call period in a row :) My sub-intern calls me a discharging machine. That's certainly true. And because I won the game on Friday, and we aren't on call again until Sunday, I get Saturday off :) This makes me happy.

Not taking 'no' for an answer

One of the jobs of preventive medicine physicians is to tell colonels and generals--pretty much, people who outrank you by quite a lot--that they can't do something because it's too dangerous/stupid/etc. In other words, prev med docs aren't typically easily intimidated and don't really take no for an answer eaily. I guess I'm getting an early start on that.

Yesterday I was the only doc on the team (except the attending, who doesn't really count); the resident and other intern were both out. So I was taking care of all the patients, which fortunately, was only four, as well as our two new third year medical students. Unfortunately, I didn't have time to do anything educational, as I was spending most of my morning running aorund trying to get a patient discharged to a rehab facility. The transport was scheduled to come at 1400; at 1310, the nurse told me that the facility wouldn't take him. He still had a bed, but there was something about not having enough therapists. They social worker didn't bother arguing with them, so I called them and essentially said that I don't care about their therapists--if he has a bed, he's going. They had me write an order saying that it was okay if he didn't get therapy until Thursday, which I gladly wrote, and he got out of there.

I'm currently working on taking this not taking no for an answer to get the internship director to say that it's okay for me to go to Peru during my research month. Stay tuned for more details.

Anyway, it's been two and a half weeks on ward 75, and the vast majority of what I've done in that time is stuff that they don't teach in med school--social work. Talking on the phone with rehab facilities, setting up follow-up appointments, etc. For as exhausting as the MICU was, at least I didn't have to deal with any of this stuff associated with discharging patients. When we were ready to get rid of a patient, we just called the on-call medicine team and had them take the patients to their service, and then they could deal with all this discharge stuff.

Okay, enough of that. I'm going to go back to enjoying my day off, and by 'enjoying my day off', I mean waiting for my eyes to return to normal after being dilated for my eye exam, and then heading back to Bethesda in about an hour for another doctor's appointment. Fun, fun.