Happy Doctor's Day!

-

I overheard a nurse in the cafeteria today... 

"Doctor's Day? Pfft....like they need their own day!" 

Really? You get a whole flipping week! We get a breakfast and lunch a year as appreciation for what we do...and the rest of the year we get to deal with people like you on occasion....deal with it. 

Note: most of the nurses I interact with on a daily basis are AWESOME, and I got love for my nursing peeps. Then there are those others that hate me because I am a doctor. That's it. No offense, but suck it up.

It's a Virus...

Over the past 8.5 months, I've seen a very wide variety of patients in my clinic, in the ER, and as inpatients in the hospital. Most people I see have legitimate complaints....I would like to preface this by saying that I appreciate people who come to my clinic for any complaint - I don't care how trivial, how minor, or how silly some people may think it is, your quick visit to my clinic is one less person clogging up the ER and getting admitted for trivial, minor and silly things.

So the the lesson here is viruses...

1. Runny nose, headache, body aches, sore throat, cough, fatigue...etc, etc, etc.... If you are not coughing up bloody, green sputum, your fever is less than 102.6F (~39C), you don't have chest pain when breathing, and you can swallow, chances are you have a virus. No, I will not give you a z-pack. Like it or not, I will tell you to drink lots of fluids, get lots of rest, take lots of vitamin C, and let this resolve on it's own. Also, if you have a sore throat and a cough, and I see no pus in there, then it's not strep (sure there are exceptions, but if a strep test is negative and everything else points to NOT strep, please believe me.)

2. Nausea, vomiting, diarrhea, headache....etc, etc, etc.... If you are not having excessive vomiting or diarrhea (think less than 5 episodes per day), you can keep down some fluids, your mouth is moist, and you don't have a fever, chances are you have a virus. Now viral illnesses can leave you dehydrated (especially kids), so by all means, come see me and I can give you something for the nausea and diarrhea so that you can keep some of these fluids in your body. But no, I will not give you antibiotics. I will not order a stat endoscopy/colonoscopy. These studies aren't for acute viral illness, nor will they give me any more answers as to what you have. Like it or not, I will tell you to drink lots of fluids, get lots of rest, take an antiemetic/antidiarrheal, and let this resolve on it's own. 

I was taught once that viral infections will often show up with people complaining about all sorts of things - runny nose, sore throat, cough, headache, body aches, fatigue, dizziness, nausea, etc. And bacterial infections will likely have them coming in with only one or two complaints (usually the second one being fever) - sore throat, sinus pain, painful lump/abscess, pain with peeing. The exceptions could include (ie. there are others) pneumonias (which will have cough, chest pain, shortness of breath, often WITH cold symptons), or some bacterial GI bug (nausea, vomiting, diarrhea that is often bloody, severe abdominal pain, really high fevers, severe dehydration.) If your fever is high (>102.6F/39C), the symptoms are worsening rather than getting better after a couple of days, or if they last longer than the normal 10-14 days without letting up at all, then yes, you may have a bacterial infection. Again, these are all general rules, and by no means am I saying that any of this is concrete. That being said, I know a virus when I see one. 

The moral of the story really is this - if you come to me with complaints that you think is some raging bacterial infection, and I am 99.9% sure it's something viral, please do not insist that you need antibiotics. I usually will not give them to you...period. Fluids, rest, ibuprofen...that's what you'll get from me. No offense to those who 'do their research,' but your 20 minutes on wikipedia and webmd do not beat out my almost 10 years of training (and by no mean am I badmouthing wiki here....love it....I owe much of my degree to it really!) I don't tell you how to do your job, so please don't make demands of me and tell me how to do mine. You come to me for my expertise, so please respect it, and if you don't like it, then you can ask for a second opinion.  

Now please don't think I am insensitive to parents out there - I'm really not. No, I do not have kids, but that doesn't mean I can't understand how concerned you are about your sick child. I am concerned too, which is why I am not giving them medication that they do not need. It could make them sicker! Is that what you want? I respect that people worry, but don't assume that just cause I don't know you or your child that I don't care about you...I do. I have devoted my life to helping make people that I do not know better (you and your kids included), and your arguing with me and demanding things just frustrates me, and puts me in a bad mood all day. It doesn't make me change how I am going to treat you. 

Cardiology

 -stemi-

Quote of the Day...From Hubbs

Me: "What are you up to?"

Hubbs: "Looking at the internet."

Me: "What are you looking at on the internet?"

Hubbs: "Things"

-Nice....I married a teenager ;-) Love you love!

Coding is the Bane of my Existence!

 -pure-ridonculousness-

 

So a huge part of medicine that you don't see (and you barely know exists until your finally a resident and your life is consumed by it) is coding and billing. Blech...I cringe at the thought. There's this whole ridiculous set of codes that we have to use (now the ICD-9, but come later this year, the ICD-10....a whole new set....again, blech!) We have to sift through about 80,000 codes now, and the new ICD set will have (gasp) over 140,000 diagnoses. Kill me now!! I am forever frustrated with the ICD-9, not being able to find codes for things I need that are common diagnoses, and the fact that there exists all sorts of ridiculous codes that I imagine aren't all that common at all.....For example - 

I had a patient who came in complaining of dizziness....not vertigo, but just a little bit of dizziness. I went through a review of systems with her and believe me when I tell you nothing else was wrong. Her physical exam was completely benign too! Now, what I thought was the problem is besides the point here....I wanted to work up her symptom, so I tried to code her for dizziness....no such luck. I could diagnose her 780.4 - Dizziness and Giddiness, but the woman wasn't giddy!

Now I just checked with the ICD-10 (save me now), and sure enough, still no way to code someone with just dizziness. There are, however, three different codes regarding being 'struck' by a turtle...

W5922XA Struck by a turtle, initial encounter

W5922XD Struck by a turtle, subsequent encounter

W5922XS Struck by a turtle, sequelae

So just picture having to use W5922XD - "Hey doc...look, I know you said for me to avoid them, but I'll be darned: I got hit in the head with a turtle again!!" Seriously? This they have a code for, but dizziness? Oh no! And that's not the only frequent complaint that can't be found...

Fibromyalgia: has to be coded as myalgia/myositis NOS. Personally, I think it's pretty specified...in the people that I believe actually have this condition (didn't believe in it at all at first, with so many of my 'fibromyalgia' patients having a million other things wrong with them... in every system of the body.... at age 30. Then I had a couple of patients who I really believed. That being said, I don't trust a diagnosis who's mainstay of treatment is exercise and sleep.) Now at least they have fixed their mistake with this new ICD-10 coming out, and there is in fact a code for this...M79.7

Back Pain: From what I understand, this is the most common complaint in doctors offices across the country (and likely in Canadia too). Back pain...seems simple, no? Well again, welcome to the ridiculousness that is the ICD-9: you can use 724.2 Lumbago (low back pain...most common sure, but definitely not all-encompassing), 724.5: Back Ache (but what if it doesn't ache? What if it's actual pain?), and the closest thing that you can use if someone has non-lower back pain (not ache) is 338: Pain. Luckily the ICD-10 really cleared things up for us - M54.9: Dorsalgia, unspecified.

Viral Gastroenteritis (likely the most COMMON cause of GE): there's a few ways to diagnose this one....separately as Gastritis and Enteritis, Viral syndrome NOS, but not just gastroenteritis. It has to be toxic, or radiation, or with colitis. Who comes up with this? The same people who watch slapstick movies apparently, cause look what's in the ICD-10 -

W22.02XA walked into lamppost, initial encounter
W22.02XD walked into lamppost, subsequent encounter

Really? People coming in reporting multiple lamppost-related injuries get two codes? Really?!

Or how about this addition to any sort of trauma/injury/illness diagnosis...

Y92146 swimming pool of prison as the place of occurrence of the external cause

Really?! REALLY?! I mean putting the ridiculousness aside that there are swimming pools in prisons, how much stuff goes on in there that there's a whole diagnostic modifier for it? Actually wait...I've seen Oz....I take that back. 

V91.07XA burn due to water-skis on fire 

Darwin Awards....thought that would be enough said, till I found this one...

 V9027XD Drowning and submersion due to falling or jumping from burning water-skis, subsequent encounter

Implying that you have previously survived an episode of drowning after jumping off of burning water skis, and then you did it again? That alone would leave said person open to a whole slew of other codes on top of the subsequent drowning one...

F73: Profound Intellectual Disabilities

V40.0: Problems with Learning

(and likely) 303.0: Acute Alcohol Intoxication

E845.9 accident involving spacecraft injuring other person

E928.0 effects of weightlessness in spacecraft

Now I don't argue the fact that there are people in this world (likely only astronauts though) who suffer from these problems, but do you mean to tell me there are more of them then there are people with fibromyalgia? Or gastroenteritis? Or dizziness? Preposterous. 

I'm tired from all this ranting. Bottom line, coding sucks. And what sucks about that? We don't get paid unless we code. I have decided that when my loans are paid off and I am out of residency, I will (when I can afford it) hire someone to follow me around and just do all of my coding for me. Money well spent if you ask me! I'm just lucky in the meantime that I'm surrounded by nurses, fellow residents, faculty and others who are far more proficient in this art than I. 

I am left thinking of coding suffering from the following diagnoses myself...

R45.4: Irritability and Anger 

Z73.0: Burn-Out

797: Senility w/o psychosis

To finish things off, here are a few more that I think are either ridiculous, funny, or just way too weird to beat out those missing common diagnoses. Pleasant evening all!

• 787.03 Vomiting alone - This is just sad...cause it's always more fun to vomit with friends ;-)
• 704.3 variations in hair color - Look out punk-rockers and emo kids....we have a code for you!
• R46.1 bizarre personal appearance - See the above comment. Definitely should be used a lot more than I'm sure it is.
• R46.0 very low level of personal hygiene - I have no issue with this one...it's more common than you (or the people this affects) think
• E905.4 bite by venomous centipede - We had those living in the dorms in Grenada! One got into bed with Mel one night...
• E922.5 Accident caused by paintball gun - That's what you get for voluntarily letting yourself get shot at!
• E923.0 Accident by fireworks explosion - I feel sorry for the professional people this happens to, but am suspicious that this code will get used more for drunk idiots on July 1/4 trying to 'have our own light show!'
• S1087XA: Other superficial bite of other specified part of neck, initial encounter - So there's even a code for a hickey...
• S30867A: Insect bite (nonvenomous) of anus, initial encounter - Initial encounter?  Implying subsequent encounters exist somewhere?
• G4482: headache associated with sexual activity - Bummer :-(
• Z9989: Dependence on other enabling machines and devices - A diagnosis fit for so many trips to Vegas
• Y92250: injured in an art gallery - Watch out for those rogue artist-types who get all hopped up on Starbucks and then cause mass destruction in the gallery
• T7501XD: shock due to being struck by lightning, subsequent encounter - And you thought your luck was bad?

Note: for anyone who cares, the codes above are from ICD-9 and ICD-10....yes they are mixed up, and it's purely for entertainment purposes, not because of my lack to know the difference.

A Scramblers Tale

So it was just about a year ago now that I was in Queens, tequila shots poised, checking the match results on my phone....a friend and I had gotten off of work early so we wouldn't have to check our results at the hospital. I wasn't worried about matching...I thought I had a sure thing set up. So on our way to the little cantina where we decided that we would check our results (s/p tequila shots and a margarita or two), we went to a church so my friend could light a candle. I also tried to light one, but it wouldn't light. Neither would the second or the third ones that I tried. I eventually gave up, half laughing at the situation, thinking that maybe it was cause I was a Jew, trying to light a candle in a catholic church. My friend joked that maybe it was a sign.....maybe he was right. We got to the cantina, where we were told they didn't open until noon; we told them what the day was, and about the email we would receive at noon, and they let us sit....and even bought us a round of shots. A few minutes later, we were on our phone's ready to check our emails....and then....

-oh-shit-

To say that I was devastated doesn't quite put into words how I felt. I hadn't matched?! Are you F*&$ing KIDDING me?! I felt numb, and started crying. Then one by one I started getting texts and phone calls from friends - "I matched!!", "All good!!", and "How'd it go?" I didn't want to reply. I didn't want to face what had happened. Then my parents called, all the way from New Zealand where they were on vacation - "Tell me good news and tell me that you matched!!!!" yelled my dad when I picked up the phone. I couldn't say anything. I just cried and blubbered into the phone. 

I spent the next few hours collecting myself, sobering up to the reality of the situation (both literally and figuratively), and making my way home from Queens to Manhattan. I spent my evening putting together a resume, a cover letter, and calling around to beg friends to take the day off to help me scramble. I am lucky that I have great friends - 8 of them took off work and sat with me at a Brooklyn apartment faxing, emailing and calling around all day....we applied to over 500 positions in all specialties (all the positions available), and this was after the great ERAS crash of 2011. We were getting nothing, and the spots were getting to be fewer and fewer with every update on the web browser. 

And then....

Then I got a call from Dr. B, my current program director. It was loud in our room, so I didn't hear what the program was, or what specialty I was interviewing for, but I had heard his name. I scribbled it down on a piece of paper and handed it to Layne, asking her to figure out who I was talking to. In the meantime, I went into one of the bedrooms, and started my phone interview (note: not an easy task when you have no idea what specialty you're interviewing for). We chatted about school, and what I wanted out of a career in medicine. Within a few minutes he was making fun of my Canadian accent, and then he pulled in several residents and some faculty to chat with me too. We ended up talking for almost an hour and then he said to me...

"So let me put you on hold for a minute so I can see what everyone's thinking....never mind; nods all around. The position is yours if you want it."

I didn't know what to say. I had a job. It was in Fort Wayne. And Hubbs was in Phoenix....for 2 more years. I asked them for some time to talk to him about things, and they said they couldn't hold the position for long, but would love to have me. I got off the phone and after a quick pep talk from Gia (essentially "you have to take it.") and a quick chat with Hubbs (essentially "you have to take it"), I called back the program and accepted the position. And then I cried. Two more years away from my man?! Could I do it? Did I have a choice? No. But I had a job. I had to thank my lucky stars for that.

Flash forward to now....here I am at the program I scrambled into, and I'm happier than I think I could have been had I matched to any of the places I ranked (or any of the places I interviewed at and was too stupid to rank). Not matching was very really the best thing that ever happened to me....I couldn't see it at the time, but I wouldn't change a flipping thing if I could go back....well, maybe I would have actually applied to this program and saved myself all the tears ;-) The icing on the cake to all this was that in February last year, I saw a psychic, just to see how things were panning out....I told her nothing about who I was or what I did. She told me I was almost a doctor, told me I would have a successful career, and she told me that in mid-March there would be some "big goings-on" that would leave me "devastated and broken." Then she told me that one year later I would look back and say that "it was the best thing that ever could have happened to you." She was right. Kicker of it all too was that she told me I was going to end up "near Chicago....near Detroit....I can't quite figure out what city you'll be moving to next year, but it's somewhere in the mid-west." I brushed her off, thinking to myself "okay crazy lady....I didn't even apply to anywhere in the mid-west." Joke's on me I guess!

My point here is to encourage those friends of mine who did not match to never give up, and never feel like your fate is sealed until you seal it for yourself. It's the lowest of the low reading the words "We're sorry, you did not match to any position," but believe me when I tell you, that this is not necessarily the end to your story. I'm a believer that everything in life happens for a reason, and when bad things happen, that reason is usually revealed later. Stay strong, stay determined, and stay dedicated to what you have worked so hard to accomplish, and somehow things will work out.

Quote and pic of the Day

"We hadn't told you about it Stanley because we...we like to wait until kids are a little older to talk to them about things like condoms and ritualistic human sacrifice for harvest."  

- Randy Marsh

I heart Southpark

I had a lovely little afternoon doing a shoot of this little cutie. On her very best behavior, she was a perfect little model for me, tolerating lots of positions, outfit changes, and tummy time without any 'projectile' bodily functions. Always love shoots of los bebes :-)

 -I-wanna-eat-her-toes-

 

Nice to know that preggers have a sex life

Today was the last day of my OB rotation; last for my intern year too (it's bittersweet since I love me some babies). This afternoon I was practicing OB ultrasounds, we got a glimpse of Cletus (the fetus) kicking back and fanning his/her toes... Nice beer belly there Clet...

-chillin-like-a-villain-

**FYI - stop reading if you are easily grossed out by the discussion of normal bodily functions**

So I had a really interesting interaction in the NHC (OB) clinic today with a new patient....her and her husband/boyfriend/baby-daddy were there together, and Dad was really into the questions and learning all he could about pregnancy. As I'm going through her review of sytems, I'm asking about if she's having any vaginal bleeding or discharge...

"Yeah, I'm having some whiteish discharge" she replies. 

I go on to tell her that if it's white and odorless without any itching, pain or discomfort, that's likely just the normal discharge seen in pregnancy. Then I start telling her signs to look for if it's something abnormal...

"Green, yellow, or grey discharge, any foul odor, vaginal pain or discomfort, etc" I say. 

Then dad looks at me and says...

"So if it's colorless, odorless and tasteless, then it's normal discharge and won't do anything to us, right?"

Yeah.....that's fine. Extra protein wherever you can get it I guess. Then he jumped right into wanting to know "how much sex is too much sex?" Oh Friday, you can never come soon enough....

True love is spoon-feeding your wife jello when she has too much post-op pain to do it herself, and she's got a baby suckling on the teat..

A seemingly appropriate strip for hump-day if I do say so myself....aaaaaaaaaaaaand now s/p c-section...

-what-it-looks-like-when-a-baby-poops-during-labor-

And after Cervidil x 1, Prostin x 4, Pit x 8 hours, and 36 hours of labor, I reached in and pulled out this beautiful little guapita, complete with a cone head to put all other cone heads to shame... I love my job :-)

-Cephalopelvic Disproportion-

My Hippocratic Oath

I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher's sons, and to disciples bound by an indenture and oath according to the medical laws, and no others.

  

I do consider dear to me those who taught me this art -  Hubbs, Nealie Poo, Dr. Smith, Mel, The Baroney Pony, Noah, Goljan, Dr. Wolf, Dr. Sindler, Robbins, everyone I have worked with here in residency, and most importantly my Dad. You have all shared your goods with me and I'm the Doctor I am today thanks in part to all of you. I love where I am right now, in a program where all levels 'live in common' with each other... The support here has  been amazing (yay scrambling!!) I look forward to next year and our new class of interns (we got a few great DOs already), and that's not just because I like to be the boss ;-) 

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

Obviously. Now it's whether the patients will comply with these regimens that is really the big problem....maybe patients should be taking an oath themselves. Maybe I'll make patients do that when I have a private office -

Me: "Okay so we start with the oath...repeat after me. "I will follow the regimens that my doctor has prescribed for the good of me, according to more than ten years of education that it took for them to learn to make these decisions for me. My Doctor's judgement in the world of medicine should overrule my own with certain decisions to be made in treatment, though I am always encouraged to ask questions so that I might better the understanding of my diseases, rather than taking my medical opinions by what I heard from Jenny McCarthy or Fox News. If I do not like something about my treatment, I will bring this to the attention of my Doctor, and we will find a treatment that we can agree on through me being honest about my abilities to comply and the things that may stand in the way of my treatment. My Doctor takes an oath to never do harm to anyone, and I will trust that they have my best interest in mind. I will do this because I trust this doctor, and if I don't then I will find a new doctor without Doctor Shopping all over town.""

Pt: "Uhhhh, not sure I want to make that oath."

Me: "Fired."

.....wouldn't it be nice if it could work that way though?

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

Of course I will never physically give someone a lethal drug....but that does not mean that I am against certain practices that are legal in other countries/states; I watched a heartbreaking documentary about a man who was dying of ALS (Lou Gehrig's disease). He traveled to Switzerland where he scheduled his suicide...while he was still physically capable to do so, this man sat with his wife by his side, having said his good-byes to those he loved, and tying up all his loose ends. He drank from a cup a liquid that would slowly and peacefully let him drift away to wherever, and he would be freed from the prison that his body was turning into. He did this holding his wife's hand and listening to his favorite music. Everyone in the world should be so lucky to have such a fabulous exit to their life, and so few get something even remotely as dignified. His disease was preventing him from living the life he loved and doing the things he liked to do. As it progressed, he would have reached a point where he was completely immobile, being fully present mentally, and having no control over any part of his body, including breathing. So he took control and decided how it was going to happen. I don't know if I could ever practice physician-assisted suicide, but I'm definitely not against it. 

Being too much of a hot topic, I'm not even going to get into the last part of the above statement.... I will say, however, that I would never give a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I definitely promise that I will not engage in anything that will divert me from making the very best recommendations to my patients. It's corny and it's not why I was driven towards this career (the puzzle was), but there is something satisfying about helping people. The happy moments in this job can be few and far between, and I look forward to working with people who I help get better.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

Well, I'm certainly not going to do any hip replacements or open-heart surgeries, but I hope to cut a few people....there's something really cool about cutting things open - abscesses (it's like popping the ultimate pimple...awesomeness!), uteri (who doesn't like anything involving the birth of a baby?), etc. I hope to get certified in some 'minor' surgeries and C-Sections (again, anything involving the birth of a baby!!) I gotta say though, that I way prefer sewing things up than cutting them open. And poking people....it's all in the name of helping people, so don't think I'm some kind of masochist or something. 

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

Very happily married , and I don't do doing ill - enough said :-)

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

 Anything my patient's tell me will remain anonymous. I might discuss the general story to colleagues, or perhaps say on a blog, but I'll never connect the dots so that anyone will know anything about a particular person with whom they are not participating in their health care. Couldn't keep everything people tell me secret, or else I'd have no funny stories to tell!

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.

 I will do everything I have said I will do, and I will love every minute of it. I remember being like 6 or 7, sitting in my Dad's office, looking at his nameplate from work, and telling him that I wanted to be Dr. T when I grew up, just like him....and here I am, with that nameplate hanging on my 'office'/sparebedroom door (yeah, I said my 'office'...it's where I put my clothes-dryer and pile mail that I don't feel like opening.) My whole life I have wanted to do this, and I would never do anything to compromise that. As far as being respected by all humanity in all times...sounds a little grandiose don't you think? I guess that just goes along with my hypomanic personality ;-)

Quote of the Day...

"Patient called in stating she is having an upset stomach with a burning-type sensation under her boobs." -EBH

One of my favorite moments in life to witness - a father meeting his son for the first time...

-Bromance-

No better way to start a Monday than with 9lbs 3oz of baby, and a second degree lac...

 -Hulk-Baby-

Quote and Pic of the Week

 "Sometimes I think I'm a hypochondriac. And sometimes I think I have cancer."           - Dr. J

 -2 hours; 2 soon-