The On-Call Diaries / Blog

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fiatslug said:
Nine more lifetime residency calls. Full load of outpatients from 8am-1pm. I heart residency, I heart residency...
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Now that you mention it, I myself have only 10 more months of lifetime calls, which equates to about 30 total. The farther the year goes on, the less I'm involved....
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23:42. The inpt unit got a call from an entitled-sounding woman asking where we're located, so she can bring her "friend" in. A couple of hrs later, a 22 yo CM shows up in the ER, on a five-day, 2 pint per bender, after a grand total of 48 sober hours post-d/c from his 2nd 28 day rehab program in 4 months. I knock on the door to pt's room in the ED--coitus interuptus (canus, if you must know):eek: :eek: :eek: ! The woman looks vaguely familiar, but I confess I didn't take a really long look. The nurse kicks her out--as she leaves, she yells at the security guard "don't you remember me?"

Go about my interview with the pt--"I'm hella serious this time" about detox. Ah... right. Give him the abbreviated version of my loser lecture and finish up the admit paperwork. Then I look at his facesheet and notice the name of his "emergency contact"--no wonder she looked familiar! She's admitted to us ~q2 months for EtOH detox! I've admitted her myself at least 3 times. I remember her in part b/c she's such a pathetic, narcissistic frequent flier, and partly b/c we have the exact same birthday--my low functioning Doppelganger.

Ah, they are good stories from the ER... only 6 more nights after this to collect them!:love:
 
hrm, i'm not on call - but i never had a moment to breathe/eat/sleep when on call so far, so i can only sum up now that i'm not on call - can you say: 3 peri-rectal abscesses admitted in 3 days? all male... no, I don't know how they got them.
 
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no gloves, no body fluids. Two things I love about psych! "I'd love to do a rectal, but it would harm the therapeutic alliance."
 
fiatslug said:
23:42. The inpt unit got a call from an entitled-sounding woman asking where we're located, so she can bring her "friend" in. A couple of hrs later, a 22 yo CM shows up in the ER, on a five-day, 2 pint per bender, after a grand total of 48 sober hours post-d/c from his 2nd 28 day rehab program in 4 months. I knock on the door to pt's room in the ED--coitus interuptus (canus, if you must know):eek: :eek: :eek: ! The woman looks vaguely familiar, but I confess I didn't take a really long look. The nurse kicks her out--as she leaves, she yells at the security guard "don't you remember me?"

Go about my interview with the pt--"I'm hella serious this time" about detox. Ah... right. Give him the abbreviated version of my loser lecture and finish up the admit paperwork. Then I look at his facesheet and notice the name of his "emergency contact"--no wonder she looked familiar! She's admitted to us ~q2 months for EtOH detox! I've admitted her myself at least 3 times. I remember her in part b/c she's such a pathetic, narcissistic frequent flier, and partly b/c we have the exact same birthday--my low functioning Doppelganger.

Ah, they are good stories from the ER... only 6 more nights after this to collect them!:love:
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Good story...I know how you feel with these characters. Semi often, our patients wind up living together as pathological roomates, both romantic and non, after discharge.

If it makes you feel better, I had no pages or consults last night.
A new record.

Ah...life as a third year is "hella" good. My first year, however, ran around with an axis II vomiter all night on the floor.
:laugh:
 
Even though i am not in psych, I can relate with "Samsonite sign".

As an intern, we'd call it the "positive parking sign".

Now I am in a field with no call, and surprisingly, miss those days sometimes.
 
We have a further refinement on the Samsonite sign, when the contents of the luggage includes pink fuzzy slippers, you are looking at Borderline PD as the Axis II diagnosis.

MBK2003
 
MBK2003 said:
We have a further refinement on the Samsonite sign, when the contents of the luggage includes pink fuzzy slippers, you are looking at Borderline PD as the Axis II diagnosis.

MBK2003
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One morning at 2am, I got called to the ER to assess a woman in her young 20s who had BPD and bipolar. I was not used to covering nights, so I thought I might be hallucinating in my sleep-deprived state when I walked in and saw her sitting there hugging a 24" tall stuffed Eeyore whose front leg was splinted and wrapped up.

Unfortunately, it was real. My patient had hit a door during an intense emotional episode, so they thought she may have broken her hand and brought in the materials to stabilize it. When the xrays came back negative, apparently she convinced the ER staff that it would really be a shame to waste all of that good gauze.......
 
Stuffed animals are also pathognomonic for Axis II, usually cluster B traits or full-blown disorder....

See?

JMA%20w%20Stuffed%20Animals.jpg
 
Sazi is that you in the middle, you old dog you????? Call, huh, what is that?? Actually I have spent years on call both in training and for hospitals, and plan to never do it again. I am on staff at several hospitals both as active and consulting staff, but leave call to the newbies.:D
 
Speaking of food on-call. I'd have to say that tuna and ham sandwiches have gotten me out of about 30-40 hours of writing by not having to do admissions.
:idea:
 
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Let's all have a moment of respect and adoration for the ER ham sandwich...the, the sultan of sleep, the arbiter of ambivalence, the purveyor of persuasion, the distributor of discharges....the ER ham sandwich:

We love you.

ham-sandwich.jpg
 
fiatslug said:
is this about bad breath deterring consults? ;)
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We see some sorry folks in the ER...the politically correct term is something like "malodorous male with no permanent address."

How many times have you had actual difficulty standing in the same room with a patient due to difficulty breathing from the odor?

I've had it of course on medicine with the infamous expected patients and their pseudomonas infections, but twice in my memory that I actually had a mild gag reflex, which I thought I had lost during med school anatomy.

And don't tell me to breathe through my mouth...I'm not letting that stuff into my oropharynx. Yes I know the anatomy leads to the same place, but I like to think that my nose filters some of the funk out.
 
Speaking of food, is it kosher to accept homemade cookies from a patient in contact isolation? I suspect not, but they were tasty. Mmmm, yummy yummy mrsa...
 
MBK2003 said:
We have a further refinement on the Samsonite sign, when the contents of the luggage includes pink fuzzy slippers, you are looking at Borderline PD as the Axis II diagnosis.

MBK2003
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Don't forget the positive teddy bear sign!
 
I had a pretty stable crisis patient bring me a lasagne after our therapy session once--people feel compelled to feed pregnant women!--I told her I'd have it for lunch, then got rid of it (even though it looked much better than the cafeteria crap on hand!). If I were a better therapist, I would have said something along the lines of, "I wonder why you feel like you need to bring me something to eat," but I haven't mastered letting go of politeness yet in dynamic work!
 
Had an interesting, this-is-why-you-always-CYA-&-call-attending-back-up-if-uncertain call last night. At 7 pm, I get a call to the TICU, about a female pt in her 40s with a significant cardiac hx (MI--'99, NSTEMI--'01, s/p cardiac stent placement x1 several years ago, with 2 new stents place earlier this week after presenting to ED with CP) who was admitted after d/c from new stent placement with AMS and memory loss. Initial CT was negative, medicine wanted to repeat, pt wanted to leave AMA. Our CL team had seen her about an hour before and noted some PI & STM loss but didn't put her on a hold. I was consulted by the cross cover intern, who knew very little about the case, poor guy. The hospitalist & cardiologist had ok'd her going AMA if we were ok with it. I talked to her, impressive STM deficits and mild paranoia/orientation problems, and quite agitated, though talking clearly, knows the president, serial 7s intact, etc. MMSE 25/30 w/recall & orientation (month/day) deficits. EKG shows QTC of 555, quite prolonged, and pt is getting more & more agitated, able to verbalize understanding of risks/benefits to leaving, etc. Neuro was concerned that she had an evolving stroke and wanted the repeat the CT. Talked to the CL attd'g who saw her earlier, he was ok with her signing out AMA (she had cards f/u arranged). So we sent her out.

Get a call at 1 am--she's back in the ED, doesn't remember signing out AMA, still confused with STM deficits. She consented to repeat CT and it showed a L occipital stroke, and her neuro exam showed some visual field cuts (no change in MMSE, clock drawing intact). She couldn't remember from moment to moment that she'd had a stroke, though she had been told over & over what the scan showed. Again wanted to leave. I called my attending again, put her on a hold for GD, wrote for Haldol (on a monitored bed only, after ok'd by cards) & Ativan (but use Haldol preferentially) IV q1hr prn. Interestingly, her mom was really upset about the hold, and wanted to take her daughter home--"she's not a criminal!" "she's not crazy!" Almost as difficult to explain the 5150 (CA's 72 hr hold) to mom as it was to the patient.

Good thing is, no management changed--neuro essentially still recommended Plavix/ASA, which she'd already been on. I probably shoulda put her on a hold eariler--but we didn't then (and one could argue still don't, by a strict reading of the law) have cause to hold her, GD meaning "unable to provide food, clothing, or shelter"--these were not her issues. Hmmm... gonna be thinking about this one a lot!
 
Sounds like a tough call. Those are difficult consults...we're generally told to, after a thorough evaluation, err on the side of the patient, since holding against their will is a stronger violation of rights. Not that a jury would care.

We've all been there, but an evolving stroke can be a scary thing. Sounds like you covered your bases reasonably well, and most importantly, called the attending.

I had a case a few months ago where a guy was in CHF decompensation and had endocarditis. He was expected to go downhill soon, though he was remarkable clear at the time he wanted to sign out. By the time I had made it to the CCU, he had put his clothes on, and was being held by security pending my eval. He was uncooperative and physically tried to push past me, then told me that he rebuked me in the name of Allah, and would strike me with his cane if I did not move out of the way.

Long story short, I wound up letting him go. People are allowed to be stupid as long as they know that what they're doing is stupid.
 
Grrr... same pt, 3 days later: her 72 hr hold expired today. When she's lucid, which is apparently infrequently, she tells anyone who will listen, "if I talk about wanting to leave, I want you to have security stop me." The CL resident pages me about this--I run into him & say, you know, security has no authority to stop this pt unless she's on a hold. He goes back to put her on a hold again--the family fights him on it (!!! gd family!!!), he calls the attending, who essentially knuckles under and says "have them call the on call resident if she wants to leave AMA." What is the f*&%#g point of that? :mad: :mad: :mad:

This brings up again my frustration with the involuntary hold. GD (in CA, at least) means unable to provide for food, clothing or shelter. She has a place to go and family who are not about to throw her out into the street (no, instead they'll bring her back to the damn ED 2 hrs later, and I'll get paged AGAIN). You can't use DTS for people who are going to make stupid or deliriously-informed decisions about their medical care, even if it will be ultimately harmful. There's the "2 physician rule," which states 2 docs can document that they agree a patient can't make decisions regarding their care because of cognitive impairment, but that's really only if there's eminent risk of serious M&M, right? She's not likely to die if she goes AMA. She's just likely to re-present to the ED and ruin any hope of peace for me. :rolleyes:

Maybe I should call the CL attending at home when I get paged...
 
fiatslug said:
Grrr... same pt, 3 days later: her 72 hr hold expired today. When she's lucid, which is apparently infrequently, she tells anyone who will listen, "if I talk about wanting to leave, I want you to have security stop me." The CL resident pages me about this--I run into him & say, you know, security has no authority to stop this pt unless she's on a hold. He goes back to put her on a hold again--the family fights him on it (!!! gd family!!!), he calls the attending, who essentially knuckles under and says "have them call the on call resident if she wants to leave AMA." What is the f*&%#g point of that? :mad: :mad: :mad:
...
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F- the family. Unless they're the proxy, and your assessment finds her GD or DTS, she has to stay.

Unless I'm not getting the story correctly...it sounds like the family member who shows up on the inpatient floor, furious, demanding to "sign out" their mother/daughter/sister, etc.
 
At what point do you just get sick of being treated like s***? I'm not there for 5 minutes again this morning, and a decompensating psychotic lady throws her breakfast tray at an antisocial, adaptive sociopath that the attending insisted we admit over the weekend. He goes into a rage and attacks her by starting a running charge, which I have to stop by grabbing him; he tries to start attacking me and so I must respond by throwing him to the floor. She's railing on in the corner about the apparent link she sees between her bowl of frosted flakes and her daughter being raped. The sociopath gets up and starts screaming at me...with his disgusting breakfast flying out of his mouth into my face, which is starting to make me enraged. He goes to make another attack at me/the other patient, when I have to constrain him again until help arrives. Some said I should have let him beat on her until backup arrived. I just can't see myself letting that happen. Didn't seem right.

Unfortunately, this happened at around 8 am, when the shifts are changing and we're short staffed for a few minutes depending....

Of course, when the action is over, the attending comes conveniently waltzing over asking "if everything's ok, and I should medicate the patient."

No S*** Sherlock. I'll get right on it !

2 weeks and counting of inpatient left.
 
Anasazi23 said:
F- the family. Unless they're the proxy, and your assessment finds her GD or DTS, she has to stay.
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That's what I'm talking about! I think they successfully browbeat the CL resident into calling the attending. When I put her on a hold on Friday, I had to have the "I'm not asking you about this, I'm telling you what is going to happen" conversation with her mom.

Anasazi23 said:
Unless I'm not getting the story correctly...it sounds like the family member who shows up on the inpatient floor, furious, demanding to "sign out" their mother/daughter/sister, etc.
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Now this is the weird & completely frustrating thing. The family totally wants her to be treated for the stroke, to stay in the hospital, etc. Their issue, as I understand it, from an incredibly frustrating conversation with her incredibly concrete mom, is that she's not a "psych patient." :rolleyes: They don't want her to go AMA, they're just opposed to the one tool that we can use to prevent it!

And just checked the orders--the intern (for unclear reasons) d/c'd the Ativan/Haldol. So her only prn is freakin' Tylenol! I'm about to remedy that...
 
Anasazi23 said:
At what point do you just get sick of being treated like s***? I'm not there for 5 minutes again this morning, and a decompensating psychotic lady throws her breakfast tray at an antisocial, adaptive sociopath that the attending insisted we admit over the weekend. He goes into a rage and attacks her by starting a running charge, which I have to stop by grabbing him; he tries to start attacking me and so I must respond by throwing him to the floor. She's railing on in the corner about the apparent link she sees between her bowl of frosted flakes and her daughter being raped. The sociopath gets up and starts screaming at me...with his disgusting breakfast flying out of his mouth into my face, which is starting to make me enraged. He goes to make another attack at me/the other patient, when I have to constrain him again until help arrives. Some said I should have let him beat on her until backup arrived. I just can't see myself letting that happen. Didn't seem right.

Unfortunately, this happened at around 8 am, when the shifts are changing and we're short staffed for a few minutes depending....

Of course, when the action is over, the attending comes conveniently waltzing over asking "if everything's ok, and I should medicate the patient."

No S*** Sherlock. I'll get right on it !

2 weeks and counting of inpatient left.
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That's a truly sucky experience. We're under a lot of pressure to admit any clear & obvious piece of crap intake from outside facilities--people we would absolutely decline if we evaluated them ourselves in our ED--because a full unit is a profitable unit! So we're picking up these obvious dumps, clearly antisocial & malingering--so frustrating. Most of them have been placed on a 5150 by uttering the magic "I'm suicidal!" phrase at an outside ED without psychiatric staff on call. Our attendings are at least on board with how sh*tty these pts are--the pressure to admit once the "wallet biopsy" is positive (ie, pt is insured) is coming from higher up.

I hope you weren't hurt! Weren't these attendings ever residents, for gawd's sake? Hang in there--only 2 more weeks. BTW, I can't believe they make you cover for vacationing interns on your admin inpt rotation--thank god we don't have to do that as 3s or 4s.
 
My my aren't we all fruitful as of late! great stories and pics!

quick question to the experienced here - what psych specialty is most medicine heavy? And, how could you go about achieving it without doing a med/psych program?

And about this being the call board: Can I post my oncall blogs from moonlighting? I don't have medicine call until next summer :p
 
00:42.

I think I'm having some kind of call-Stockholm-syndrome thing going on... but as my lifetime call countdown continues (2 more after tonight), I think I'm actually going to miss call. This year, there's been something about the combination of feeling like clinically I know what the hell I'm doing more than 50% of the time, some really interesting cases (including tonight--51 yo Cantonese F w/no psych hx with one month of AH & PI, with HA--CT neg, no hx trauma, labs unremarkable, FHx pos for bipolar in the brother, negative for dementia, MMSE (w/interpreter) 18/28... diagnostic puzzle! Will get neuro referral & f/u with me next week in clinic... started on Risperdal 1 mg qhs after d/w my attending), and the somewhat sadistic but entirely ego-syntonic us vs them camaraderie with the ED docs & staff... I enjoy the acuity.

Having said that, I'm officially in the 3rd trimester as of today, passed my GTT, and the crappy call bed does not easily accomodate my ever-expanding belly! So I won't miss it too much. ;)

g'nite.
 
IT IS DONE!!!

24 calls in 11 weeks. I will never ever take call again as a resident. It's both too sweet for words and weirdly anti-climactic, as it seems so many milestones in medicine have been. The only time I was appropriately giddy when something horrible was over was the day I walked out of SFGH after the most malignant rotation of my life--inpatient Neuro (seriously, surgery was much, much better--with better hrs. Left home at 4 am to round on an essentially comatose post-stroke service. Only to repeat rounds again with the most antisocial chief resident EVER, then to repeat rounds AGAIN with a terrifically narcissistic attending). I think I skipped to my car that day.

Brought in brownies as a thank you for the ER folks--it was really fun working with them for the most part, even with a few dopey consults and some Cluster B-dispo issues thrown in.

My last ER patient was, of course, a recently homeless, antisocial malingerer. I've taken the approach of going to the bedside with these clearly-don't-need-admission folks and saying, "hey, there's just no psych beds in the city tonight (which is true most of the time), and we can't keep you on the guerney in the hallway. How else can I help you?" Then housing referral, +/- the ER ham sandwich;) , and they're on their way.

Busy until midnight (preventing me from going to the annual Kaiser recruitment dinner...:( ...bitter slug!). Had to do a little mop-up work from a pt the day ED covering-intern referred for inpt transfer to "detox off sleep meds." Unsurprisingly, SW was unable to place him (no criteria for hold, and... hello... acuity??) and I had to deal with getting him out. Didn't get any calls after midnight, but still couldn't sleep on that crappy call bed (of course, having a big gravid belly doesn't make sleep easier no matter what the surface).

Vacation begins in 3 1/2 hrs. We're off to Vermont, Maine & New Hampshire for 2 weeks to leaf-peep and meet w/CAP fellowship directors. I miss the East Coast! Vacation... now that makes me giddy.
 
Wow...congratulations. You've earned it.

You won't realize the wonderfulness of not having call until a few weeks go by most likely.

Remember studying non-stop in med school...then being suddenly done?
It took a few weeks for it to sink in for me. I walked around like a caged tiger, not having any pressing test to study for. It was weird and disconcerting at first. Then wonderfuly blissful later.

Again, congrats. Enjoy vacation!
 
I, on the other hand, have 9 more months of call.
:(

Last night I was on.

28 y.o. Chinese woman, found lying in the street. Admitted for "syncopal episode." ER can't get much out of her, and she's crying.

She wasn't properly evaluated and I notice bruises on her shoulders. She's in a bad relationship with a married man 20 years older than her.

Not strong enough to admit.

The next beauty was a 32 year old female with cc: "I need my Klonopin refilled." Gave a sob story about skin cancer, being fired, dumped, etc. Told her no. She then proceeded to page/call the:
1. Nursing supervisor
2. Patient advocate
3. Chief of the ER
4. Legal services
5. The chief medical resident (who has no jurisdiction over us).

They all know me, and basically told her to move on. She went to another local hospital, who called me. She completely changed her story, but it still boiled down to her wanting Klonopin.
:oops:

Third case was a sad story. 18 year old AA female, in foster care since 7yo. Mom's schizophrenic, dad's out of the picture. Long and short of it, she's prodromal schizo herself, and having so-called "delusional mood." The real deal. Probably didn't meet full criteria, but I took pity, and wanted her adjusted to help her out. I'd rather admit a case like that any day, than the other trash that malingers their way in to get a bed.
 
Anasazi23 said:
I, on the other hand, have 9 more months of call.
:(

...
Probably didn't meet full criteria, but I took pity, and wanted her adjusted to help her out. I'd rather admit a case like that any day, than the other trash that malingers their way in to get a bed.
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:thumbup: On one hand I'm sorry for you, but damn, Sazi, I'm GLAD you're out there on the front lines doing this stuff. (Guess it's how I feel about our kids in Iraq, too....:( )
 
OldPsychDoc said:
:thumbup: On one hand I'm sorry for you, but damn, Sazi, I'm GLAD you're out there on the front lines doing this stuff. (Guess it's how I feel about our kids in Iraq, too....:( )
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Thanks for the props, OPD. I had my first year working with me. Trying to pass along some of why we went into the field. She seemed to get it, which made me happy.
:idea:
 
bump.....

i love this thread.
 
Get a page from the ER: "The guy "got upset at a movie at his residence...I need psych clearance for him to return."

I show up with my intern. The guy is psychotic from across the room. Very weathered-looking, in his 50's. As soon as I ask his story, he becomes beligerent, hostile, and is drooling.

Had to make a decision to walk out and medicate, or hang in and try to see what was happening. Very glad I did the latter.

Common story: ran out of meds, bounced around from hospitals, non-compliant, but truly thought disordered, moderately paranoid, with a strange sort of pseudo-cotard's syndrome.

Says he's on prolixin dec...doesn't know last dose, when it was given, and can't remember his residence's name or phone number (more likely a psychotic process than a memory problem). He is uncooperative with cognitive exam.

When I ask if anything is bothering him physically, he says that his back itches a lot. He says he picks at his skin because it's itchy. I ask him to remove his shirt (another great "medically cleared" eval by the medical ER staff).

He has a 2x3.5cm melanoma on his right scapula. Irregular borders, various shades of color, bleeding, and somewhat ulcerated from his picking.

He received a punch biopsy this week. Turns out he's 3 weeks past his prolixin, and didn't show to his followup appt. for the next shot.
 
Doc Samson said in another thread how we're often the "consult of last resort." I find this to be absolutely true. It was exemplified last week while on call:

I trudge up to to the med/surg floor where we received a consult for "rule-out factitious disorder." I was at least impressed that they had come up with a semi-sophisticated diagnostic possibility. The details are the following in abbreviated format:
41 year old female; s/p bariatric surgery <1 year ago; went from nearly 400lbs to 220. Admitted to the surgical floor with complaints of gnawing abdominal pain. US negative for acute cholecyctitis (no gb wall thickening, some spitting up, no murphy's sign, etc). Initial CT abd unremarkable, done days ago.

The surgeons were under the opinion that she was med seeking, since the level of her discomfort was not commensurate with her clinical findings. Unbelievable, she has been taking 3-4 prns of dilaudid daily, on top of standing demerol for pain, with only fleeting effect. They wanted psych, I think to "write her off" as having a psychiatric issue, so that they could discharge her with a clear conscience.

My interview reveals no acute depression no major anxiety disorder, does not appear to me to be the med-seeking personality type, and the psychotic, simple phobia, malingering or otherwise personality disordered screens also largely negative.

At one point, they had put in a pediatric NG tube, since her lower esophagus is now directly connected to the antrum or thereabouts, which became clogged, so they simply removed it and kept pushing IVF.

So in short, I don't find her to be malingering, and do not find her factitious.
I asked the patient when her last BM was. She states almost a week ago.

I confirmed this with the nurses.

I checked the online rads reports. Turns out she had a KUB that morning. "Dilated colon with large stool collection. No contrast seen in the distal small intestine; no contrast seen in the distal bowel. Findings consistent with Severe bowel obstruction."

I called the surgical intern to tell him to start another NG tube and get the old disimpaction gloves ready.
:laugh:

Axis I: No diagnosis
Axis II: Deferred
Axis III: S/P bariatric surgery, HTN, SBO

Recommend to optimize pain control. Recommend non-opiate pain medication with discontinuation of meperidine to reduce possibility of sphincter of Oddi spasm.
Please reconsult psychiatry as necessary.

The funny part is that the surgical attending actually had the cajones to call me later and tell me that he looked at the x-ray himself later, and that it's most likely a prolonged ileus pattern, and not an obstruction per se. I nicely told him that regardless, I cannot make a psychiatric diagnosis on a patient for factitious disorder who has a documented SBO pattern on x-ray with no bowel movement in a week. I said that they really needed to take care of all possible causes for this woman's pain before they turf it to psychiatry, and that they haven't done that.

I mean, you know that radiologists are masters are not commiting to a diagnosis in their reports - understandably so. It is filled with tough calls, especially since they usually don't see the patient or have a cohesive history to go on. But this report was quite committed and left no room for interpretation.
 
wish I could say "unbelieveable" but... nice catch, Sazi! Esp funny that surgeons missed a BO, given that they are flatus-obsessed...
 
Thanks, but that's the weird thing. Not like I caught some zebra. I just asked the lady when the last BM was, and then checked the radio report. They would have caught it eventually, but the surgical interns are busy, and didn't get around to reading the report yet.

The messed up part is that they called psychiatry before doing the complete workup, which in this case they did, but it either didn't jibe with what they wanted it to be, or they haden't gotten around to piecing all the parts together. Oh well....
:)
 
Just thought I'd bump this up, as I'm on call again today, but wanted to shed some positive light.
:idea:

I'm a PGY-III now, and I'm officially back from writing notes that started at about 8:30am after signout. I've got a PGY-I working under me, and I have to say that life is much, much better as a third year. They handle virtually all of the scut, and I get to see patients with the psych intern, and teach.

All this, and a post-call day off tomorrow. It's really not a bad deal.

It took what seemed like a long time to get here though. Lots of frustration and feeling like you're constantly stepped on by the hospital and patients.

I imagine that being an attending is even better. You can almost see how someone would want to go into hospital psych if you didn't have to do all the scut and heavy lifting every day. You get to dedicate your brain's resources to thinking about patients and coming up with good treatment plans, rather than throwing something together that's relatively stable so that you can move on to the next project.

....just some thoughts
 
OK, so ICU calls:
58 year old morbidly obese >400lb man, with gram (-) sepsis, apnea on BIPAP, HTN, Dyslipidemia, uncontrolled DM II, s/p left foot ulcer debridement has been "paraoid."

Protonix 40 IV
Insulin drip 2-4 u/hr
Zosyn IV
Renally dosed lovenox (cr = 6.1)
Meperidine PRN x 1 dose
Morphine 1-6mg PRN x 4 doses in two days

Accuchecks running from 100-600, depending.

On exam, he is mostly intact, but some pertinent positives:
Year = 1906, able to perform calculations, otherwise oriented.
Some continuing mild paranoid features.
Drug/alcohol history negative
I don't feel like writing out a full MSE :rolleyes:

Received one 5mg IM dose of haldol yesterday.

Pretty straightforward. Just continuing to contribute to the thread, since I get requests to keep it up.

Haldol 1mg Q12h...relatively neuroleptically naive. Can always titrate up and it won't make the sugars much worse, if at all. I could have done a long winded consult about various antibiotic choices, talked about protonix, more detailed pain control, etc. I did a little.
 
Anasazi23 said:
Meperidine PRN x 1 dose
Click to expand...

Why? Is there ever a good reason to give demerol over another less-troublesome opioid? The OB service here uses it all the time and I don't know why...

Perhaps I'm just biased because as a med student I did a couple medicine rotations with a PharmD on our team whose personal mission in life was to stamp out meperidine...
 
Hurricane said:
Why? Is there ever a good reason to give demerol over another less-troublesome opioid? The OB service here uses it all the time and I don't know why...

Perhaps I'm just biased because as a med student I did a couple medicine rotations with a PharmD on our team whose personal mission in life was to stamp out meperidine...
Click to expand...

It's a crusade we should all take up.

You're simply right.
 
I actually get to add to this thread, I'm growin up Sazi!!!

Ok so its home call, but shut up, let me have my glory K?

5 minutes after leaving hosp: ring ring, hello? Hi Dr Poety? yes? Mr. XyZ that you just saw and ordered that sliding scale for.... me: yes? has a BS of 400 - shoudl I give him the sliding scale? ummm yes, tahts why I ordered it.


<BANGING HEAD OVER AND OVER AND OVER>

:p

yeah, I know, my story is lame BUT I COULD CONTRIBUTE I COULD CONTRIBUTE!!!
 
Anasazi23 said:
Home call, eh?

Hmph.

Think you're an attending already?

Welcome anyway...

:)
Click to expand...

you SOUND like my attending :laugh: He's like you are all SPOILED :smuggrin: but ya know, I really have time to learn which is nice :oops:
 
We take six calls a month at MCG. Weakling. :laugh:
 
I'm on neuro, and this morning we're sitting in rounds going over the new patients. We had this one guy admitted for seizures from the jail. The other intern that admitted him said he didn't think they were real seizures, but he had a history of real seizures and he was off his meds, so he got admitted to our epilepsy unit for video/EEG monitoring. He's from jail, so he's shackled to the bed with a police escort. The intern also mentoned that the patient asked to use the phone, get some food, get up and go to the bathroom, etc whenever he walked into the room. "I think he's going to run," he said.

So we're sitting in rounds, and we hear a commotion in the hallway. Then through the glass windows of the conference room, we see this shirtless tatooed guy in hopsital pajama bottoms with EEG leads on his head booking it down the hallway with 2 cops and a bunch of nurses in pursuit. But it was too late. He's long gone.

And because he's in the video/EEG unit, the daring escape is immortalized on tape. So tonight husband and I are kicked back watching Studio 60, then the news comes on, and what do I see?

http://www.nbc5i.com/news/10363121/detail.html#

Guess that intern was right.
 
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