Liar liar, pants on… Oh wait, nevermind.

During my Internal Medicine rotation, I had a patient who was picked up by EMS after he fell down and couldn’t get back up. He was pretty bruised and incoherent, so the ER people went through his bags and found discharge papers from a different hospital in New York, dated 2 days prior. The point of discharge papers from the hospital is to summarize why the patient was hospitalized, what was done (test, imaging, surgeries), what was found, and medications that the patient has to continue taking (and for how long). The patient gets a copy of their discharge summary and is supposed to bring it to their primary care doctor. (There are, of course, plenty of patients who don’t have the means to have primary care doctors or who have to use the ER as their primary care doctor, but that is a rant for another time.) The listing of the “admitting diagnosis” is generally listed in order of importance, and can contain other existing medical conditions. For example, if a patient came in for a heart attack, but also had pre-existing hypertension and then was found to have early type II diabetes mellitus and high cholesterol, all of those would be listed in the discharge summary after the diagnosis of a heart attack. My point is, other medical professionals (oooh, I just got a tiny thrill when I realized I am part of that group) read the discharge papers and depend on them as a succinct and honest summary of what happened.

So anyway, we read the discharge summary from the other hospital, and the leading diagnoses were “ethanol intoxication” and “mechanical fall,” which is just a fancy way of saying he was drunk and fell down. Well, that would explain the falling down and incoherence, right? It would be consistent with his liver function enzyme tests, which basically said that he had alcoholic liver disease and some liver failure. Because alcohol withdrawal can cause seizures, the ER is pretty aggressive about medicating any signs of alcohol withdrawal. So, they started this guy on a higher dose of medications, but it meant that he was even more out of it, and more incoherent. After a lot of time, we finally figured out what he was trying to say, which was that he was visiting New York from Scotland, and was trying to get in touch with old friends and family members he hadn’t seen in a long time. Further, he didn’t know where they were, or where he had been in the 2 days between when he was discharged from the other hospital and when he was brought to our hospital. Some of the details that he gave sounded pretty incredible, like how he used to be a musician in a band, and in the British Royal Navy after that as a longshoreman, and that he hadn’t seen these family members in over 30 years, and that he was friends with some kind of famous people. We asked if he had had any alcohol to drink, and he said no. But, given the discharge papers and his liver enzyme profile, we were kind of like, “Yeah, right,” and kept medicating like he would go into alcohol withdrawal.

A few days of treatment later, we tapered him off the medications and his speech cleared up. Once it cleared up, the patient was really able to give more details about where he’d been while in the US, and then gave us phone numbers so that we could check out his story with friends and family in Scotland. He also swore that he hadn’t had alcohol in two years, but did say that he used to drink “a lot,” which, in Scottish terms, must mean a LOT a lot. Anyway, I also called the other New York hospital and got in touch with the physician whose name was signed at the bottom of all the discharge papers. When I got him on the phone, I asked about the course of the hospital stay. The last question I wanted to ask was if the patient had actually come in with “ethanol intoxication” as the cause of his falls. And the physician was like, “Um. No.” I said, “Oh, really?” And he said, “Actually, we did a urine toxicology screen, and he was clean for everything; no alcohol, no drugs.” Understand that the discharge summary is not written until the day the patient leaves the hospital. So I said, “Well, then why did you write that the primary diagnosis was ethanol intoxication?,” which came out a bit rude, but I think a fair question, given that he flat-out said that they’d written a diagnosis that the patient didn’t have, and which also led us think that the patient had been lying to us for days.

We also finally got in touch with the patient’s friends, who told us the patient’s stage name from his days in the band. And lo, Google search turned up plenty of proof, including photos and interviews and discographies of the band. So, in the end, here was the tally:
1. Patient says he was in a band: true.
2. Patient says he hasn’t had anything to drink: true.
3. Patient says he is in town to see family and friends he has not seen in years: also true.
4. Patient says he is childhood friends with semi-famous actor: true, and they were raised in the same town.
5. Patient says he was a longshoreman: well, I stopped checking facts at this point, because he was up 4 points to our 0 points, and there was no way we were going to make up this deficit.

Anyway, the moral of this story is, people might lie about the little things, but I think they don’t tend to make up hugely untrue stories about who they are, and what they’ve been doing for the last 2 weeks. Maybe this way, I won’t get jaded about how “all patients lie” and will listen to their stories, no matter how outlandish the stories seem. But then again, my next rotation is in psychiatry, so perhaps not for this next set of patients who say they are Batman or psychically connected to Oprah.

My hypochrondriasis is incredibly prescient

Hey, remember when I told everybody that an insulinoma would explain my Insta-Bitch? Well, all that self-awareness made me actually pay attention to insulinoma as a disease, even though it is very rare. It paid off, though, because it was the answer on my exam last week! The question was a case presentation of a woman brought in by her friend, because the woman had been eating tons and gaining weight suddenly, acting generally irritated and anxious, and had a headache lasting weeks. I was reading it and not understanding what the question was trying to hint at, and thought, “Huh, that sounds like me when I’m hungry…. OH HEYYYY, insulinoma is an answer choice!” Very exciting. Good job, unfounded paranoia!

For the record, though, I did not see an insulinoma while on my Internal Medicine rotation. So really, the exam was not representative of my actual Internal Medicine rotation at a certain Manhattan hospital. Had the test been truly representative, the patient in the question would have been a 50-something-year-old male, probably homeless, with hypertension or high cholesterol or poorly-controlled diabetes (or all three), current or former smoker/drinker, coming in for shortness of breath or chest pain after drinking all weekend/doing cocaine/losing his medications (all things that happened). It’s like a really tedious and frustrating game of Mad Libs.

It’s the end of medicine!

[This post goes out to Grace, who I probably scared when I simply messaged her, "NO MORE MEDICINE, WOOHOO!" on gchat, and then disappeared. I later got a message from her that said, "WAIT, are you quitting med school?!" No, I am not. I think this story illustrates a growing difference in our vocabularies. Med school is tearing me apart from real life and real English!]

This past weekend was the end of my Internal Medicine rotation, which was my first rotation in 3rd year. If you’re thinking, “Wow, I didn’t realize she was on the same rotation since July; that seems really long,” you’d be right. It’s friggin’ long. Internal Medicine is a 10-week rotation in 3rd year, and it’s the longest rotation we do as students (3rd or 4th year). In fact, it used to be a 12-week rotation (meaning three whole months, ack), but this year, the school shortened the rotation to 10 weeks, because students in the past had asked to have extra time to explore other specialties as 3rd year students. Our choices were really wide-ranging and exciting, but instead of seeing something that I probably wouldn’t end up choosing as a career (ie, radiation oncology or dermatology or preventive medicine (I didn’t even know what this was when we were ranking our choices, but NOW I find out it would have meant working with the New York Department of Health on outbreak investigations(!) and Adolescent STD Education, maaaaan that would have been SO COOL dang it)), I decided to really take a look at a field I have been interested in since 1st year: I’m doing my elective in radiology! It’s funny because I came into med school thinking I could do anything except radiology because I didn’t think I would be able to stand sitting in a dark room all day. Imagine my surprise during 1st year when I realized I really liked looking at films, and was clearly a visual learner. Radiology keeps jumping in and out of my Short List of Possible Specialties (it has always lived on the Medium List), so much that I’ve now nicknamed it “The Siren Song of Radiology,” because while the specialty appeals to me so much, but the competitiveness of the field and the very real possibility of having to move to some really faraway place (such as a Dakota!) for residency makes it seem like a pipe dream. Anyway, we will see how the next 2 weeks go. One point for radiology: I don’t have to start until 9 AM every day! That seems luxuriously late, after 10 weeks of getting to the hospital before 7 AM.

In any case, when I say that I’m done with medicine, I don’t mean that I’m dropping out of medical school. Within the medical field, the word “medicine” has a very different meaning. To the New Me, “medicine” and “medical” mean having to do with Internal Medicine, internists, and basically anything that doesn’t have a procedure involved with it. Think pills, not scalpels.

Though I’m finished with the rotation, I have so many stories that I have been meaning to write about. (To blog about? That phrase just seems so wrong for me to be saying about myself. Would that make me a… blogger? Uh, I just threw up in my mouth a little at the idea.) I’m thinking that I’ll take advantage of these next 2 weeks of easy-peasy 9-to-5 working to catch up on storytelling. Here’s a good one to end with for today: at the end of each rotation, we have to fill out evaluations. One of the questions asked how many hours we worked per week, not counting the hours we stayed VOLUNTARILY (the word was in all caps). This was problematic because we are often told that we can leave, but it’s not like I’m going to take off at 2 PM simply because my interns don’t know what to do with me. Similarly, I have been on call and told that I could leave if I wanted to, even though technically we are supposed to stay for the duration of call. It’s a sticky situation because I don’t want to appear as though I don’t care, but I am sure that if I played it right, I could have been out of the hospital by 4 PM most weekdays (which is the absolute minimum we are expected to stay, as dictated by the school, not by our residents or interns). Does that mean that any time I’ve spent after 4 PM is considered “voluntary”? Of course not. But it wasn’t all against my will, either. I ended up splitting the difference and estimating that I spent 10 hours a day on non-call days plus 14 hours a day on call days, plus 6 hours on Saturdays, which came out to a rough estimate of 65 hours a week. 65. That is bananas, you guys. I will now proceed to scoff at anybody who complains about a 40-hour workweek (including the Old Me from 2004-2006).