Wayfaring MD

I am a family medicine resident who likes to highlight the hilarious in medicine as I write about patients, medical school, residency, medical missions, and whatever else strikes my fancy.



Disclaimer:
HIPAA is for reals, folks. All of my "patient stories" have been changed to protect patient privacy. I will change any or all identifiers, including age, location, race/ethnicity, sex, medical history, and quotes. Also, I am an anonymous internet person. Why should you trust an anonymous internet person to give you medical advice? Don't ask me, ask your doctor!
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Pap smears are like pedicures. The people who do them don’t care how weird you look.
 LD, fellow resident
Can you explain to me the relationship between doctors and insurance companies and hospitals. Like say you had your own practice, do you have to buy-in to what patients you can take based on what insurance company you're affiliated with?
wayfaringmd wayfaringmd Said:

So when you go into private practice, most doctors will accept the most common commercial insurance plans in the area and then will limit the percentage of Medicare, Medicaid, and self pay patients they accept into their practice. They will accept more than one commercial insurance plan. Doctors aren’t really “affiliated” with insurance companies. We just choose which ones we want to deal with and try to get payments from.

There are also practices called Federally Qualified Health Centers (FQHCs) which basically have a deal with the government to take a high percentage of Medicaid / Medicare patients in exchange for slightly higher reimbursements from ‘caid and ‘care. That’s an over simplification, but it’s the gist of it.

Hospitals (public hospitals anyway) will take whatever payment source you have. 

Wayfaring: Do you take any other medicines besides the two you brought with you tonight?

Translator: **Russian Russ Rushy Russian**

Patient: **All the Russian**

Translator: Yes, he takes one in the morning and one at night. 

Wayfaring: Yes, I know he takes this medicine in the morning and at night. I’m asking if he takes any other medicines that he did not bring with him today.

Translator: Oh I see. **Russes**

Patient: **Russes back**

Translator: Yes, he takes it two times a day. 

Wayfaring: Ugh, yes, I understand this. How else do I ask this? Am I missing something here? Ok, it says in his history that he has diabetes and high blood pressure. Does he take any medicines for these problems, because he didn’t bring any with him today. 

Translator: **Long, flowing Russing**

Patient: **Short, snappy Russing**

Translator: Yes, he has high blood pressure. Today it is 174/90.

Wayfaring: Ugh! Yes, I know this. I told you he had high blood pressure. The question is: Does he take medicine for this?

Translator: Yes, he has high blood pressure.

Wayfaring: You know what, I give up. We’re going to restart the meds on his home list. Please ask him to have a family member bring in any other meds he may or may not take. 

CHART: 

Allergies: Sweet potatoes.

Reaction: Jugular venous distention.

Attending (with a sly smile): Anyone care to tell us about a common side effect of clarithromycin?

Resident: The way you’re smiling I’m going to say it has something to do with penises. 

Attending: NO! Metallic taste!

Resident: O.M.G. I just said penis to my attending!

 

Toddler: ****SCREAMS BLOODY MURDER****

Mommy: **struggles to get all the baby crap together and leave the office**

Douchebag Baby Daddy: **plays game on his cell phone while he sits in the corner**

Mommy: You see me struggling here with her and you just gonna sit there and play a video game? Will you please take her so we can go?

Douchebag Baby Daddy: **sucks teeth** but it ain’t even my turn to deal with her!

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I went to see the patient in the ED and he was laying with his mouth open and there was a fly buzzing around his mouth. I thought, “oh s***, he dead.”

Intern during morning rounds

Office Manager: We have a problem. The average third year resident here has 20-25 diabetic patients.

Wayfaring: I know I’ve got more than that. All I do is flipping diabetes check ups. Can a girl get a simple knee injection or stuffy nose once in a while?!

Office Manager: You have 37 diabetics. 37. We need to do something about this.

Wayfaring: It’s actually closer to 40. There are a few diet-controlled ones that don’t pop up when you search the computer system. Anyway, what have I been saying at diabetes management conference every quarter?! I have too many! Every time I get a new patient, I’m like

Office Manager: I know, I know. So we’re going to reassign 8-10 of your patients to the new interns to even things out a bit. 

Wayfaring

Office Manager: And you get to decide which ones! 

Wayfaring: 

Office Manager: And just between us, if you wanna slip in a non-diabetic or two onto the list that you wanna get rid of, I’ll look the other way. 

Wayfaring: 

Patient: So are you just doing family medicine or are you going to do something special?

Wayfaring

Well I think Family Medicine IS pretty special, so I’m sticking with it!

Rheumatologist (in patient’s room): Solid answer! 

Rheumatologist (out of patient’s room): Ugh, I can’t stand those comments. Little does she know that you family medicine residents know WAY more medicine than I ever will. All I have to know is one tiny corner of the world. How do you guys do it?

Specialist attending: Ugh, I’m exhausted from yesterday. I saw a total of 14 patients! That’s the busiest day I’ve had in weeks.

Wayfaring: Really? image

I thought the morning was pretty slow. I saw 9 patients in just 3 hours yesterday afternoon and it wasn’t bad. 

Specialist: WHAT?! How many patients do you guys see in a half day?

Wayfaring: I think the limit for 3rd years is 12 or 15 in a half day. 

Specialist: Whoa! How do you guys do it?! I only have to deal with one problem and you guys have to deal with multiple problems in each visit! How can you see 20-30 patients a day? 

Wayfaring: image

Um, and out in practice it’s more like 30-40.

Specialist: When do you do your notes?!

Wayfaring: In between patients and at home and after work. 

Specialist: You guys amaze me. That’s too much work. I can barely manage work and a baby and I only work 4 days a week.

Wayfaring: Well that’s why they pay us…the little bucks. 

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Asker Anonymous Asks:
Are you or any of your colleagues considering concierge care? What's your opinion on that and is it going to die down due to the ACA?
wayfaringmd wayfaringmd Said:

I actually do have a friend who graduated a few years ago who is considering starting their own concierge practice. There is some confusion with the term “concierge practice”, because it makes it sound like those doctors are catering to rich people. Some of those practices do operate that way. But the one that my friend is starting is basically just a cash pay business for people of all walks of life.

They will offer a cash price for walk-in visits, and will also offer a monthly membership fee for individuals, families, and small businesses. My friend lives in a very poor area of the country, where most people do not have insurance. So this design of a practice would actually be helpful in a place like that. It would actually be cheaper for families to pay her membership fee then it would be for them to buy insurance. Of course this membership is only going to cover outpatient costs and not inpatient costs, so there’s a tradeoff there.

I really don’t think any of us really know what is going to happen with the ACA. We’ll just have to wait and see. 

Asker Anonymous Asks:
Can you be a doctor still if you developed depression and BPD in med school? I'm scared to get help in case I'm kicked out...
wayfaringmd wayfaringmd Said:

Yes. 

Your diagnosis is technically your business alone. But if your school notices that your work is being affected by your illness, they may ask you to take some time off to get better before you start back. 

Please get help. NOT getting help will do much more damage to your schoolwork and career than actually getting help. 

Asker Anonymous Asks:
Can I go to my family doctor and ask to get a rabies vaccine? I know the universal "back off or die" signs most animals give out, but I still wanna be safe. I keep my Tetanus up to date but i've never heard anything about rabies for people. And is there an minimum age on it? ( And plus It'd feel nice being the person to go help something that's injured somewhere and being able the scream IT'S OKAY IM VACCINATED)
wayfaringmd wayfaringmd Said:

Before I get to the meat of your question, let me say this: being vaccinated doesn’t necessarily confer 100% protection against a virus. Immunity can wane after vaccination, which is why boosters are sometimes recommended, or your body may not build up appropriate immunity to a virus. Just because you are vaccinated doesn’t mean you should take unnecessary risks of exposure to ANY virus. For example, healthcare workers are generally vaccinated against Hepatitis B, but we still wear gloves and other protective equipment when blood exposure is possible. We still wear masks around flu patients, even when we’ve had the flu shot. 

So don’t go out there thinking you’re untouchable! Be safe!

Now back to your question: 

Actually, the rabies vaccine is not recommended for most people because the chances of the average person being exposed to rabies are fairly low, and human-human transmission of rabies is exceedingly rare.

There are 2 types of rabies protection. One is pre-exposure “active” immunization, where the traditional type vaccine is given and the body builds immunity to it over time (and after several booster shots). The other is post-exposure “passive” immunization in which a person who has been exposed is administered rabies immunoglobulin (aka the stuff your body makes to fight off viruses, just in a synthetic form) to help protect against active rabies infection.

The only people who are recommended to get PRE-exposure prophylaxis are: 

  • rabies research workers*
  • people who make rabies vaccines and are around the live virus*
  • people who frequently handle bats*
  • cave workers*
  • animal control and wildlife workers** 
  • veterinarians and staff**
  • travellers***

*: requires primary series and boosters if titers are low

**:Requires primary series without boosters if working in an area where rabies is uncommon to rare. If living in rabies enzootic area, they require titers and boosters as well.

***: only required if traveling to a rabies enzootic area with reasonable risk of exposure and limited access to rabies immunoglobulin.

If you don’t fit one of those categories, then you’re like the vast majority of us who will only get a shot if an angry animal bites us. Also, if you do get bitten, go to an ER. Your family doctor will likely not have rabies vaccines, as they are given pretty infrequently and are costly to keep around.

Sources: cdc.gov, uptodate.com

1930: Checkout. I am warned about Mr. CCU. I admitted him last night with a massive, un-stentable MI that took out his entire right ventricle. Tonight he is intubated and is on 2 pressors, and his BP is still 70s/40s. Keep a close eye on him, they say. Wear a gown and mask if you code him. C. Diff. AIDS. Hepatitis.

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1945: I am warned about Mr. ICU. He came in after a major overdose and continued to endorse suicidal ideation with a plan. He’s medically stable, but mentally unwell.

2000: Checkout over. Peruse the computer and look over everyone’s vitals and labs. Not a big census, but a sick one.

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2020: Head up to check in on Mr. CCU. Oh by the way, his potassium is 6 and his creatinine has tripled. Dialysis just got started. BP 80/60. Ask dialysis tech not to take off any extra fluid.

2040: Check on Mrs. Recently-stepped down from ICU. She’s fluid overloaded. A spot of Lasix for you, my dear.

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2100: CCU: “Will you check on Mr. CCU’s pupils? They seem to be fixed and dilated.” Crap. Pupils as big as saucers. Scleral edema. No doll’s eyes. Guess the brainstem is gone. He’s not breathing over the vent anymore either. Great. No reflexes. Not stable enough for brain imaging. Let’s call the family. Oh there is no family. Emergency contact is a friend with a disconnected phone number. Still a full code. Write a note.

2120: Intern and I make a nest in CCU. Preparing for a long night ahead. We got iPads, reading materials, pagers, and beverages. Better order Chinese for me and the intern and the CCU nurse. 

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2130: Chinese already delivered, piping hot. How do they do that? The restaurant is 5 minutes from here!

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2200: CCU smells like egg rolls. Peruse the ER census to find my least favorite patient’s name on the list. She has been there 4 times since she was discharged from the hospital 5 days ago. Awaiting a call from the ER to admit her.

2230: Dialysis over. He got albumin and more fluid during dialysis. BP still 80/60. At least it’s holding steady. Going up and down on the pressors. Write a note.

2330: Things seem to be stabilizing. Change of strategy: retreat to the call room. Wow, no calls for admissions yet? I’m shocked. Let me refresh my knowledge of pressors.

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0002: ER: “Mrs. Supratentorial is here again and says she can’t breathe. All her labs are black. Her physical exam, x ray, and EKG are normal. I wanted to send her home but she’s refusing to leave. Will you guys come talk to her?”

0004: Send intern into the fire with Mrs. Supratentorial. If she is not sick, send her home! Do not admit her, I say. Make her leave, I say. She can follow up in clinic in 8 hours. 

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0101: Haven’t heard from intern. “You still in ER?” “Just sent Mrs. Supratentorial home. Just finishing up the documentation now.” “You’re a freaking rockstar.” I trot back to CCU. One more check and then maybe I’ll try for a nap.

0110: Mr. CCU’s belly is bruised and firm now. He’s bleeding freely from the mouth and rectum. BP 70s/40s. Glad cards didn’t put him on heparin. Let’s get coags, not that it really matters at this point. Write another note.

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0130: Paged by intern: Mr. ICU trying to leave AMA. What do I do?

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0135: Chatting with Mr. ICU. Nothing is wrong with me, he says. I was just kidding when I said I was going to kill myself, he says. Those 50 pills I took are no indication of my current mental state, he says. And why are you trying to trick me by changing your clothes and putting on a wig? I know you’re all the same person that keeps coming in here. I’m not crazy, he says. I’m leaving.

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0150: Intern informs me she has turned down an unassigned admission from the ED. This is not something we ever do. Technically we are open for another one. “Ain’t nobody got time for an admission when everyone’s trying to die and leave AMA on us,” she says. Agreed. We will take the next one.

0220: Involuntary commitment papers done. Geodon flowing. Patient resting quietly on the bed. Back to CCU for us.

0225: Everything kosher in the CCU? Pupils still blown. Belly getting harder. ABG says the bicarb is improving his acidosis just a smidge. Awaiting other labs. 

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0330: Mr. DKA’s potassium is 5.8. Mrs. Step-down + Lasix’s potassium is 2.7. Is the lab having issues with potassiums? Everyone was normal this afternoon. Someone give Mrs. Step-down some K. Recheck in the AM. Is it naptime yet?.

0500: Mr. CCU is maxed out on 2 pressors. BP 70/30. Now with a heart rate in the 40s. Here, have some atropine. Intern has already pushed more fluids. Let’s get as far as humanly possible away from our comfort zone and put on a third pressor. Sure, why not. Gotta keep him alive until the attending rounds in the AM.

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0510: Back to the CCU. 2 nurses, intern, and I are gowned in preparation for the inevitable code that is coming. His ABG is in the toilet. O2 sat in the 60s. Acidotic out the wazoo. Here’s another amp of bicarb. Potassium’s back up to 6, even after normalizing after last night’s dialysis. Still bleeding. Intern writes another note.

0520: Mr. ICU is awake again and just punched a nurse. Intern and security to the rescue with 2 point restraints.

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0545: Mr. CCU is tanking quickly. One epi in, and oh look, we have a blood pressure again for about 15 minutes. Now he’s in and out A-fib. Great.

0700: The slow-code continues. We’re on epi number 4 now. Coags are back. As suspected, he’s in DIC. Hemoglobin has dropped 4 points overnight. He’s out of platelets. This is futile. Brain gone, heart gone, lungs gone, liver gone, immune system gone, kidneys gone. Attending makes him DNR since there is no next of kin. Finally got in touch with his home health aide. She will go get the emergency contact friend and bring them here.

0720: Friend arrives and agrees that DNR is what he would have wanted. Excellent. No fighting. Give them some time alone with him.

0800: Inhaled breakfast and headed back to CCU. Day backup is there now, stopping the pressors.”You guys wrote a lot of notes last night, he says.” Yes we did.

0815: Potassiums have been jacked up in the lab all night. Everyone’s K is actually OK. Except Mr. CCU’s, of course.

0830: On-call intern is a no-show to rounds. He is pronouncing Mr. CCU.

Asker Anonymous Asks:
Hi Wayfaring! I work for an answering service and we answer for a lot of doctors. Sometimes we get calls for doctors who have pregnant patients where the message to pass on is "APGARS 8 & 9" or some other two numbers, after a baby is born. Do you know what this means?
wayfaringmd wayfaringmd Said:

I assume these docs are passing the message on so they can include the info in their dictations and delivery documentation. 

So the APGAR score is both an acronym and the name of the person who invented it. It’s a quick test used to assess an infant at 1 and 5 minutes after birth. The maximum score is 10. If the score is low at 5 minutes, it is usually repeated every 5 minutes until >7. 

It stands for:

  • Appearance: 0 points for blue or dusky color, 1 point for blue only on hands and feet (called acrocyanosis), and 2 points for pink all over.
  • Pulse: 0 points for absent, 1 point for <100, 2 points for >100.
  • Grimace: assess primitive reflexes. 0 points for no response to stimulation, 1 point for a grimace or feeble cry, 2 points for lusty crying or pulling away with stimulation
  • Activity: 0 points for none, 1 for flexed arms or legs, 2 points for flexed arms and legs that resist extension
  • Respiration: 0 points for not breathing, 1 for weak or irregular breaths, 2 points for lusty cry.

Of note, APGAR scores haven’t been shown to have any correlation with longer-term health outcomes in babies. It’s mainly used as an assessment a birth to direct initial resuscitation efforts (including giving oxygen, suctioning fluids from the mouth/nose, physical stimulation to raise the heart rate). A score of 10 is not common (and pretty unheard of in my hospital. I think the nurses are superstitious against giving 10s. Basically all babies that come out crying get an 8&9.) because most babies have some acrocyanosis that persists for hours after birth.