I just finished Night Float. It was crap. It turns out taking care of people with the lights out -- though much like taking care of people with the lights on -- is much less rewarding. I should have seen this coming considering the omens. Within the first five minutes of the first shift my intern lost an eye to the tarp covering the scrub stacks. He was only briefly incapacitated and was left only with a small bruise on his eyeball, but for a short moment I was torn between resuscitation and calling to find his back up.
Anyways, Night Float. Six times the number of supervisors with none of the actual supervision. Plus medicine consults, plus 72-hour consults, plus out of hospital transfers, plus morning report, plus an endless cycle of freetriplescore.com commercials on late night TV. Add to all those new responsibilities a generous supply of next day second guessing and general orneriness from the primary teams, and myeh. Truthfully, I would of rather been kicked in the junk. Now we'd have to haggle over the details, but nevertheless, do it again, kick me in the junk.
The hours themselves weren't that bad mind you; I actually slept rather well. Similarly not knowing what meal to eat at any particular time of day was disorienting but three breakfasts in a row never hurt anyone. My interns were both by and large good, solid citizens, and work load wise we truthfully got off relatively light. It was just the nature of the job, of being subject to a multitude of divergent interests leading to an inability to sufficiently satisfy any which made Night Float a lonely, thankless task. I suppose it developed character, but only if paranoia is a character trait.
It's done and over now, though. May we never do it again.
Monday, September 28, 2009
Thursday, September 10, 2009
Exit 25
This past month I earned my Geriatrician Merit Badge. In order to do so I had to start five campfires, diagnose ten cases of dementia, and administer twenty-five Exit 25 interviews. Thankfully the second and third tasks are related as it turns out there is no better way to diagnose dementia then to disorient the elderly and there is no better way to disorient the elderly than the Exit 25 exam.
Although the most recognized and often feared aspects of dementia tend to circle around the increasingly noticeable memory loss that slowly penetrates the minds of the afflicted, this is not the truly incapacitating aspect of dementia and the scare is only superficial. Memory loss makes life inconvenient and tends to sap away from us much of what makes us unique individuals, but it by itself does not lead to the helplessness commonly seen in demented patients. If you or I are forgetful we simplify tasks, standardize routines, write down lists and so on. There are a variety of ways to compensate and people are adaptive animals if nothing else. What truly makes dementia a terrible disease is its effects on executive function: our ability to plan and act. Without this there is no ability to adapt and, as the disease progresses, there is no ability to lead a normal life. Young children often have wonderful memories, it's the poorly developed frontal lobes which make them act as young, dependent children. And so that's why the Exit 25 interview was developed.
The Exit 25 is a series of twenty-five questions designed in a variety of ways to primarily test a patient's executive function and cognition. And it does this -- it seems -- primarily by disorienting and making as uncomfortable as possible the target of the interview. Although some parts are fairly standard consisting of the "remember these 3 objects" and "repeat these phrases," many are not. They range from tests of primitive reflexes and learned behavior by pushing and prodding on the patients' hands and arms in a variety of manners (and also tapping on their lips) while continuously telling them to "just relax", to asking them to stick out their tongue and say "ahh" for an uncomfortably long period of time, to a series of complex hand maneuvers that I still have not quite completely mastered myself. The best parts, however, are the ones I can rarely do without laughing.
The first is simple enough. Complete part 19 and then suddenly and without warning clap closely and loudly by the patient. If they do nothing but eye you curiously then they're in the clear. If they look about or motion uncertainly that's one point on the dementia scale. And if they clap back at you, a phenomenon called echopraxia, then it may be time to take the credit cards and car keys.
In a similar vein, the best portion of the test also consists of an abrupt, awkward transition from regular questioning. Part 10 is followed by a three second silent stare into the eyes of the interviewee followed by a polite and matter of fact "thank you." If the patient responds with a questions like, for example, "what the hell are you doing?" then they're good. If they again get anxious and flustered that's one point against them. And if they say, "you're welcome," well it may be time for a death panel consultation. My favorite response to date has been a panicked, "is this part of the test?! Is this part of the test?!" with simultaneous darting of the eyes to every part of the room.
In all seriousness the Exit 25 interview seems to be a consistently effective tool for screening and monitoring dementia, and will likely be an increasingly important one as it is more extensively used. Unfortunately I always feel bad doing it on my patients. It also takes a good twenty minutes to complete the whole bloody thing. Considering the main measure seems to be confusion and disorder, I almost feel as if yelling and shaking a gnarled stick at the elderly for a minute could have much the same sensitivity and specificity at a fraction of the cost in time. It's a shame I won't be going into geriatrics; I could have revolutionized the practice.
The best part of geriatrics was not terrorizing the elderly; however, it was the absence of call and two day weekends. Beautiful. And the worst part, conversely, wasn't trying to then persuade demented people that they were in fact demented, but rather the senior citizen two handed handshake I now find habitual. For whatever reason I found myself clasping with both hands the single hand of patient and/or accompanying family member in a gratuitous gesture of friendship. They seemed to appreciate it well enough, but some of my colleagues not so much. Men weren't meant to double hand clasp the hands of other men, and many a muffled look of befuddlement has been exchanged between myself and another as a result. It is either a sign of my great empathy or my folie à deux that I have become more like the elderly in treating them. Or perhaps it's just two more points on the dementia scale.
Although the most recognized and often feared aspects of dementia tend to circle around the increasingly noticeable memory loss that slowly penetrates the minds of the afflicted, this is not the truly incapacitating aspect of dementia and the scare is only superficial. Memory loss makes life inconvenient and tends to sap away from us much of what makes us unique individuals, but it by itself does not lead to the helplessness commonly seen in demented patients. If you or I are forgetful we simplify tasks, standardize routines, write down lists and so on. There are a variety of ways to compensate and people are adaptive animals if nothing else. What truly makes dementia a terrible disease is its effects on executive function: our ability to plan and act. Without this there is no ability to adapt and, as the disease progresses, there is no ability to lead a normal life. Young children often have wonderful memories, it's the poorly developed frontal lobes which make them act as young, dependent children. And so that's why the Exit 25 interview was developed.
The Exit 25 is a series of twenty-five questions designed in a variety of ways to primarily test a patient's executive function and cognition. And it does this -- it seems -- primarily by disorienting and making as uncomfortable as possible the target of the interview. Although some parts are fairly standard consisting of the "remember these 3 objects" and "repeat these phrases," many are not. They range from tests of primitive reflexes and learned behavior by pushing and prodding on the patients' hands and arms in a variety of manners (and also tapping on their lips) while continuously telling them to "just relax", to asking them to stick out their tongue and say "ahh" for an uncomfortably long period of time, to a series of complex hand maneuvers that I still have not quite completely mastered myself. The best parts, however, are the ones I can rarely do without laughing.
The first is simple enough. Complete part 19 and then suddenly and without warning clap closely and loudly by the patient. If they do nothing but eye you curiously then they're in the clear. If they look about or motion uncertainly that's one point on the dementia scale. And if they clap back at you, a phenomenon called echopraxia, then it may be time to take the credit cards and car keys.
In a similar vein, the best portion of the test also consists of an abrupt, awkward transition from regular questioning. Part 10 is followed by a three second silent stare into the eyes of the interviewee followed by a polite and matter of fact "thank you." If the patient responds with a questions like, for example, "what the hell are you doing?" then they're good. If they again get anxious and flustered that's one point against them. And if they say, "you're welcome," well it may be time for a death panel consultation. My favorite response to date has been a panicked, "is this part of the test?! Is this part of the test?!" with simultaneous darting of the eyes to every part of the room.
In all seriousness the Exit 25 interview seems to be a consistently effective tool for screening and monitoring dementia, and will likely be an increasingly important one as it is more extensively used. Unfortunately I always feel bad doing it on my patients. It also takes a good twenty minutes to complete the whole bloody thing. Considering the main measure seems to be confusion and disorder, I almost feel as if yelling and shaking a gnarled stick at the elderly for a minute could have much the same sensitivity and specificity at a fraction of the cost in time. It's a shame I won't be going into geriatrics; I could have revolutionized the practice.
The best part of geriatrics was not terrorizing the elderly; however, it was the absence of call and two day weekends. Beautiful. And the worst part, conversely, wasn't trying to then persuade demented people that they were in fact demented, but rather the senior citizen two handed handshake I now find habitual. For whatever reason I found myself clasping with both hands the single hand of patient and/or accompanying family member in a gratuitous gesture of friendship. They seemed to appreciate it well enough, but some of my colleagues not so much. Men weren't meant to double hand clasp the hands of other men, and many a muffled look of befuddlement has been exchanged between myself and another as a result. It is either a sign of my great empathy or my folie à deux that I have become more like the elderly in treating them. Or perhaps it's just two more points on the dementia scale.
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