Ahh Man, Who Dumped My Stuff?

Last week I diagnosed hypoaldosteronism all by my little old self. A turning point? Have I become a real doctor? Will I cure all disease?

The next day I dumped a glass of milk onto the kitchen floor when I tried to transfer a paper towel full of mini donuts into the same hand.

In other residency news: I have a friend who has a patient who regularly schedules appointments to see her in clinic only to talk at great length about nothing at all. Today I heard through the thin exam room walls, "... and then the preacher said, 'you are what you are because you want to be!' And I fell down and praised Jesus!" This went on at length for about 10 - 15 minutes until I heard the staff, who was apparently also in the room with my friend helping assess the gentleman, say matter of factly, "Sir. What exactly do you want us to do for you?" And the booming story continued.

Oh crazy people. What would internal medicine clinic be without you?

Driven to Drink

Another week of clinic and another week of working late secondary to patient problems in the head. This time it was anxiety and panic. An otherwise uneventful morning clinic was made a good 2 to 3 hours longer by the theatrical shenanigans of one young patient who, medically speaking, was freaking out. This manifested itself mostly through exaggerated breathing which was entirely unnecessary as even when we slapped him across the face with some Ativan and his respiratory rate dropped into the range where the rest of us typically like to breath he continued to have excellent oxygen saturation of his blood. Unfortunately, the fact that his oxygen sats and vital signs were pristine were of completely no relevance to him as he continued to complain of anxiety, shortness of breath, and so on. Why did he feel this way? Who the hell knows. He couldn't say. Why was he still complaining of shortness of breath when he clearly was not short of breath any longer? Beats me. He couldn't say. How was this at all in any way different from the panic attack he had had only two months before in the emergency room? *Shrug* He couldn't say. He just knew something was amiss.

Of course there wasn't. He was just having a panic attack and all this was both consistent with panic attacks in general and past panic attacks that he had himself experienced in the past. We'd done a thorough cardiac and neurological exam, even, probably unnecessarily, ordered an EKG and looked into the possibility of a pulmonary embolism of which he had no evidence for, and we found nothing. Unfortunately, I am not yet confident enough in my nascent physician skills to say, "hey, buddy, get out of my exam room already!" and so we gradually titrated his Ativan till clinic ended, my supervisor came in to take a peek, and we gave him the choice to go home or to go to the ER. Next time I think I'll try grabbing his shoulders, shake, and exclaim, "get a hold of yourself man!" Maybe I can get a clinical trial published out of this.

And so now I drink. Not alcohol so much -- I still generally don't care for that -- but I have taken up coffee. These long hours and frustrating patients mean drinking tea three times a day will not suffice. Who wants to drink that much tea? Certainly not me. The alternative caffeinated beverage list included coffee and soda, but as the idea of a cold Dr. Pepper at 0700 did not sound terribly appetizing I decided to turn to coffee. I had never really enjoyed coffee in the past, but it turns out with a couple creamers and a couple sugar packets most things taste better. Unfortunately it seems even the added caffeine boost of 16 oz of generic Wilford Hall coffee cannot sustain my attentiveness any longer than the actual drinking of the beverage itself which makes me think: maybe it's just the act of doing something during lecture which helps me stay awake? Maybe I just need to keep busy somehow instead of passively listening/staring/dozing off? Maybe I should try milkshakes? I'll stick with coffee and tea for now, but if things continue on it may be milkshake time. And after that? A fifth of jäger? A nice club soda?

Internal Medicine with a Minor in Psychology

My clinic doth run over.

Officially each office visit should take 45 minutes of my time. Recently, however, this has not been the case. Instead I will have three or four 50 minute appointments and one drawn out and draining 1 hour and 15 minute one. This is not because I am just that thorough and kind hearted. But rather because my patients all seem to have a touch of the crazy.

Sometimes it's fibromyalgia with the patient reporting pain here, here, and here. Some pain there radiating back to the first here and sometimes becoming the second here. And that place over there has two types of pain. Oh and my hair hurts.

Sometimes it's chronic fatigue syndrome. Or myalgic encephalomyelitis as my patients like to call it. Or yuppie flu as I like to call it. They aren't the actual patients, their sick relatives in need of custodial care are usually who the visit's for, but patients' families can just as often be as much part of the problem as part of the cure.

Then there's the standard old major depressive disorder. Patient wants to kill himself, doesn't want to talk to anyone about it, and doesn't want to leave the exam room. Of course he didn't come in for depression. No, you cannot get a medicine appointment for a psych complaint. Instead you gotta be sneaky crafty. Don't want to ruin the surprise.

And lastly there's the undiagnosed bipolar patient talking incessantly, not answering questions, and generally providing no relevant information about his ailments to do either of us any good. Feel free to leave before I return from consulting with the staff physician about your diagnosis. It's not like you came to the clinic for medical care because, actually, I am still not sure why you came to the clinic today.

All in all it makes clinic interesting and for me leaving the hospital at 1900 or 2000 at night. The immediate frustrations aside I do not mean to convey that I dislike psychiatric patients -- and two of the disorders aren't even psychology related really. Crazy people are people too after all. It is just that I don't have enough time to take care of all the problems which actually threaten life and limb let alone the hours extra needed to take care of the problems brought about by bad humors and forest gnomes. I am training to become an internal medicine physician but to date it seems my end expertise will be that of a psychologist / orthopedist who occasionally dabbles in the diabetes and the common cold.

***As a general disclaimer: though I in general like to try and be an honest guy, with all the rules these days and the rise of the HIPAA fascist state I must resort to vagueness, generalizations, and outright lies when it comes to recounting my patient stories. Don't want to breach any privacy here and I definitely don't want a summary execution without trial.***