mdrambles:

The other day I saw a 4-year-old boy with some mild gastroenteritis symptoms and poor oral intake for about 12 hours. He was otherwise well, but we checked a urinalysis on him because he described some vague discomfort with voiding.

The urine came back positive for a surprisingly high amount of ketones, but otherwise no concern for infection. This can be pretty common in these young kiddos who haven’t eaten much in several hours, but I had to check a blood sugar to ensure he wasn’t this ketotic because of hypoglycemia.

Unfortunately, one of my nursing colleagues had gone in to attempt to get a point-of-care blood glucose but this little man was feisty and after she did the skin prick he was able to turn the room upside-down getting away from the glucometer, so she wasn’t able to get the sample. When she told me this, I went in with her so we could get the sample together.

When I walked in, little man was immediately highly suspicious.

“What are you gonna do?” he asked, eyes narrowed.

“I am going to talk to your mom a bit, kiddo.”

I discussed the urine findings with his mom, and the rationale for checking the blood glucose. Mom was completely understanding, but looked reasonably nervous about trying to prick her little guy again.

I turned to my patient and said, “Okay my friend, I know you haven’t been feeling well for a while, so there is a test we need to do to make sure you are safe and healthy.”

At the word “test”, he immediately started screaming and crying. “I don’t wanna! I don’t wanna!”

I sat in front of him and said, “My friend, I promise I would not do this test if we did not need to.”

He sniffled and nodded but was still trying to climb behind his mom.

“So I have a couple of questions for you.”

“Like what?” he asked, peeking out behind his mom’s shoulder.

“Okay, first question: do you like popsicles?”

He gave me a “meh” face and a shrug.

“Alright, do you like… ice cream?”

“Yeah!” he said, interest piqued. He clambered out from behind his mom.

“I like ice cream too!”

“So… if I do this test I get ice cream after?”

I chuckled and looked at his mom, who was laughing and nodding. “Yeah, buddy, we can definitely have ice cream after.”

He looked a little more open to the suggestion.

“So my friend, we have this special ice cream spray that feels like ice cream!”

“Really?”

“Yeah, can we show you?”

So we brought out the spray, but he also saw the glucometer and started losing it. We showed him what the spray looked like by spraying on his mom’s hand, but he was still crying.

“No, no! I don’t want it. I don’t want the test!”

I met his eyes. “My friend, I know you don’t want the test, but we need to keep you safe and healthy. But it’s your body, so I want you to choose, okay? You can get the mosquito bite [i.e. the lancet], or you can have the ice cream spray. Which one do you choose?” (I learned this protip from my child life colleagues during residency: you give the kids choice of how they want the test or procedure, but not whether they want the test/procedure done. It helps give them control and autonomy while also doing what’s in their best interest when they are developmentally unable to consent.)

“No! I don’t want either. I don’t want any of them!”

“I know, buddy, but we need you to pick so we can take care of you.”

He cried and sniffled for another few seconds, until finally he conceded.

“Okay, I want the ice cream spray.”

I nodded at my nursing colleague, who grabbed everything for the test. He still recoiled at the sight of the glucometer, so we positioned his ID band and let him press the scan button, which he actually kind of enjoyed (haha kids love buttons). Then I held his hands out, like he was going to receive scoops of ice cream in his palms.

“I’m going to help you hold your hands for the ice cream spray, okay? I want you to close your eyes and think of your favourite flavour.”

“I like chocolate,” he said, obediently closing his eyes tight. His mom covered his eyes with her hands.

“Me too!” I told him as I held his fingers extended for the nurse. She swabbed him with ethanol. “Keep thinking about your favourite flavour.”

“I like chocolate,” he said, sounding a bit more anxious. 

“You’re doing great buddy, keep thinking about chocolate! Say it faster!”

“I like chocolate! I LIKE CHOCOLATE!” he repeated over and over as we sprayed his fingers.

“ACK! That’s cold!”

“I know, that’s the ice cream spray! Still gotta think about your chocolate ice cream, bud!”

“I LIKE CHOCOLATE!” he repeated again as the nurse lanced his finger. He squealed and tried to retract his hand but I held it steady while the nurse collected the sample.

“You’re doing so good buddy, the ice cream spray will melt off soon. What flavour are you gonna get?”

“Chocolate,” he said again. “I’m gonna get chocolate.”

We placed a band-aid and let him go. He seemed surprised.

“You’re all done, my friend!”

“Oh…” he said, looking at his hands. “You know… that really did feel like holding ice cream.”

The nurse laughed as she put everything away–glucose was normal.

“Buddy, you did SUCH a good job. I think you deserve a treat now, what do you think?” 

He nodded enthusiastically.

“Let’s see what kind of treat to get you, okay?”

He nodded again. I told him, “Let me check your ears–there are clues in there for what kind of toy you might like!”

I looked. “Well this ear is a little waxy… it means you must like squishy things!”

“Yeah!”

“And this ear… wow, it’s fuzzy! Do you like soft fuzzy things?” 

“Yeah!”

“Hm… let’s check your tummy to find out what kind of soft fuzzy toy. Your tummy feels pretty squishy… do you like stuffies?”

“Yes! I really like stuffies!!”

I finished the rest of my exam and told the little man we’d grab him a freezie to keep up his PO intake and also grab him a treat from our treasure box (a stuffie, of course). As I was about to head out to grab these things, he said, “Actually… I would be happy with just one treat. I don’t need both.”

I smiled. “Well my friend, that is very thoughtful of you wanting to make sure we have enough treats for all our little friends here, but I promise we can get you both and still have enough treats for everyone, okay?”

Predictably, this little man ate his freezie in record time and he really loved the teddy bear we grabbed him from the Child Life stash. After they were officially discharged, my little friend’s mom stopped me as I was about to head out of the room.

“I just want to thank you,” she said. “Your bedside manner went such a long way for him today. He has to get blood tests done at least every year for his [other unrelated condition], and I think the ice cream spray is going to make such a huge difference for him in making the tests less traumatic.”

“Thank you,” I said, a little flustered. “I’m really glad we could make this better for him in some way!”

“No, really. You were a game changer for him today.”

—–

Little things can go a long way. If you can… be a game-changer for your patient. They might not realize it, and you may not realize it… but doing what you can to make things better makes all the difference. Anything we can do to provide the best care for our patients will always be worth it.

There is a wealth of wisdom here, on the psychology of kids and parents, on the ways a thoughtful quick-thinking physician can shepherd everyone through a difficult moment.

themedicalstate:

“Never memorize something that you can look up.”

— Albert Einstein (via mednerds)

Was gonna memorize this, but…. reblog.

wayfaringmd:

Patient’s family member: Dr. Wayfaring, I noticed that you didn’t wear gloves when you touched that rash. Why is that?

Originally posted by naiivesoul

Wayfaring: *on the defensive a little* Uh, well, I just washed my hands like I do in every room, and the rash isn’t infectious and there’s no open wound on me or the rash, so I’m not super concerned about cooties here. 

Family Member: But it looks gross. Touching gross things doesn’t bother you?

Wayfaring: I don’t think it’s gross. I know what it is and I know it’s not contagious and I’m not going to make it worse by touching it. 

Family Member: Well I like it. Doctors don’t touch their patients enough these days. 

I’ve actually removed my gloves during rash exams a couple times, to display my confidence in my non-contagious diagnosis (sunburn, bandaid reaction, etc) to a doubting patient.

That’s the closest I’ll ever get to throwing down the gauntlet, probs.

Originally posted by various-cartoon-awesomeness

Cranquis: (talking loudly through an N-95 mask to parents of little kid)

Lil’ Kid: Excuse me?

Cranquis: Yes?

Lil’ Kid: You need to take a deep breath.

Cranquis: Huh?

Parent: Oh, uh, sorry – we’ve taught him to take a deep breath to calm down when he’s getting upset, so now he says that to anyone who is talking loudly.

Cranquis: Hey, thanks, little pal – wanna take a deep breath with me?

(He did, and I did, and everyone felt a little happier)

tastefullyoffensive:

20 Times Anti-Vaxxers Got Owned By People On The Internet

Elderly patient wearing a DC comics facemask: Nice scrubs, doc!

Cranquis wearing a Batman scrub top: Thanks! Nice mask.

Patient: Is that… a Batman logo on your t-shirt underneath?

Cranquis (looks down, sees Batman t-shirt logo poking over neckline of scrub top): Uh… maybe?

Patient: You and I are going to get along just fine, doc.

mdrambles:

On one of the last days of my anaesthesia rotation this year, we had a 10-year-old kiddo with quadriplegic cerebral palsy and lots of anxiety. He was a super intelligent, pleasant kid, who was understandably very scared of getting an IV–he was known to be a relatively “difficult poke”, so most of the IVs he had in his life required multiple attempts. For his history and current conditions, we felt a total intravenous anaesthetic (TIVA) would benefit him, but unfortunately we were not able to get the IV in on the first attempt. He became extremely stressed and we negotiated one more attempt for him to hopefully spare him from previous side effects he’d experienced with the inhaled anaesthetics, but unfortunately that attempt was also unsuccessful. 

We were quick to reassure him that there would be no third attempt while he was awake, and the entire time we got him prepared for his inhalational induction he was apologizing for getting upset.

“I’m so sorry that I was so upset,” he said. “I know you were just trying to do what was best for me, and that you just want to take care of me. But I really, really hate needles, and I know when I get stressed out my veins are even harder to find, and that really sucks.”

“It really does, buddy,” I told him. “But I want you to know it was not your fault for getting upset! You are always, always allowed to get upset. The most important thing is that you were so incredibly brave–even though you were stressed and upset, you did your very best to let us take care of you. Unfortunately today your veins didn’t cooperate with us, but you didn’t do anything wrong. You don’t have to be sorry for feeling the way you feel.”

“Okay,” he said. “Okay, well, I’m sorry for shouting. I didn’t need to shout, even if I was upset.”

“You know what, my friend? Sometimes we just gotta shout it out. You’re right, we shouldn’t shout at people because it can hurt their feelings. But I promise no one’s feelings were hurt today, we were just sad that you were upset by the needles. That’s why we said two tries only, right?”

“Right.”

He sniffled a bit and wiped at his face. I let him pick a scent for his mask (we use a drop or so of essential oil inside the face mask so it smells like oranges or strawberries or watermelon–it’s actually kind of neat!).

“Are you ready to go to sleep now?”

“Yeah. I know you guys will take care of me.”

—–

That day, I learned a lot about patient-centred care from this little gentleman. I also learned a lot about emotional regulation and how our emotions can affect others when we externalize or internalize them. I learned how our emotions can be recognized and how we can take responsibility for our emotion-driven actions, and how we can still prioritize kindness even when we’re upset and overwhelmed.

No matter how much experience or education we may have, we will always have something to learn. My favourite teachers are usually my patients. Even if the lessons they have to teach me may be a little hard to swallow at times, they teach with such purity and general adorableness that these are lessons for my heart and soul as much as they are for my brain.

Thank you to all of my little (and okay, fine, sometimes not-so-little, when they’re adolescents and taller than I am…) teachers <3

This kind of attitude towards your patients is absolutely vital to maintaining joy in your practice.

flyonthewallmedstudent:

On Compassion.

Vague title. But basically, beware of your innate biases as much as possible towards any population.

Because they always threaten to blind you to the medical and social issues of your patients vital to their care.

It’s also important for your own professional progression as a provider.

Don’t write things like “smells of alcohol”
Or “evidently drunk.” Don’t be persuaded by handovers or triage notes that say the same. I fell into that trap as an intern and nearly missed a grotesque fracture.

We rather stumbled on a patient in Child Pugh C cirrhosis the other day, or really bad liver failure. The jaundice and confusion was noted on the multiple ED presentations they had over the past few weeks. No one had done even a blood test. The notes were along the lines of ‘frequent presentations under the influence" or “ETOH +++” etc. or “counselling provided on ETOH cessation.” No medical or gastroenterology team was ever consulted.

We finally got a referral (which we on-referred to gastro) when the patient fractured a rib from falling over.

Try to have some compassion. Even if it’s a homeless bum.

In this case, the patient had resorted to heavy drinking after significant losses (personal and financial) in the pandemic. The tone of most of their presentations written up by their providers implied each felt the patient was some sort of a lost cause. You just miss so much if you fall into that trap.

modernathenamd:

wayfaringmd:

hawthorn-and-ivy:

Just for context for those of you not in medicine, the average time to get in with endocrinology from time referral is completed to appointment is basically 8-12 weeks or longer, unless the endocrinologist thinks you’re dying in the hospital basically. Endocrinology and rheumatology are hands down the hardest specialties to get someone into, and it turns out not feeling good and being in pain are not the triage criteria for dying. 

I had a patient fire me as their PCP today essentially because I cannot force endocrinology to see someone. They’re leaving to “find an office that can process referrals and refills more efficiently” (refills noted because I didn’t fill a script within 4.5 hours of receiving a request) and then had the audacity to ask for immediate refills and referrals right afterwards. 

Low key wish I could watch them discover that minimum it’s going to take 2 weeks to get established with a new PCP (most recent stats suggest this is more like 18 days) and then find out that endocrinology still takes 8-20 weeks to get into, all the while also having to realize that actually all PCP offices have a policy on how long it takes to respond to a refill request, and that it doesn’t actually matter how many times a medication is sent to the pharmacy if the pharmacy has the med on back order. 

smh. Like, I get that patients don’t understand how the utterly convoluted and terrible USA system works, but when I am explaining that I actually have no control over an endocrinologists schedule, asking for me to somehow put an appointment in to a clinic I don’t work at in a system I don’t work in or have access to is basically asking me to use a magic wand.  

For more perspective: in the small town I’m in its more like 3-6 months to see endocrinology. I did manage to get someone in with thyroid storm in 6 weeks which means I manage them in the meantime 👎🏼. I have another patient with multiple endocrine gland failure (thyroid, parathyroid, type 1 DM, gonads) and we did get them in to endo in about 3 months. Rheum is just as bad or worse. They’re 9-12 months out for new patients near me. So I usually do most of the rheum work up and start what meds I can but I can’t start them on fancy biologics. It sucks. Neuro is available fairly quickly but there are maybe 2 good ones near us who who’ll actually put forth an effort to search for a diagnosis on patients with weird symptoms. My patient with autoimmune encephalitis (yep, don’t see that 🦓 everyday) was told it would be 3 months before they could be seen. It took multiple calls and 80+ pages of faxed records proving the diagnosis before they’d see the patient earlier.

Also for folks to realize: most specialists haven’t reviewed your records before they see you. The doctors often have no say in when you are scheduled and don’t see the referral info in advance of the visit. Someone who may not even have clinical experience is usually in charge of scheduling you. So if you have a weird/acute/severe issue that requires quick attention, it often takes a phone call direct from your PCP to the specialist or their assistant to get you seen in a timely manner. Example: cardiology scheduled my patient’s stress test 6 weeks out because the referral was from GI (patient insisted it was reflux when I told them it was angina. GI agreed it was angina). I called and got the test moved up to 3 days out. Patient had coronary artery bypass surgery 2 days after the test. They likely didn’t have 6 weeks to wait. So if you feel like your wait is too long, you can ask your PCP to intervene, but if they tell you it still won’t happen any faster or that there are sicker patients in line ahead of you who can’t be postponed, believe them and back off.

Regarding speed of referrals and scheduling, non-med folks also need to understand that under-staffing is an issue everywhere, and it’s not necessarily one we can fix quickly. My office is down 2 people right now, which means our 3 MAs are all doing the work of 1.5 people now. We are hospital owned so we only get the staff the hospital says we can have, so we may or may not get a fill-in person some days to help. For privately owned offices, it often means big money and time to hire and train new folks. It can’t be fixed quickly. And medical staff get sick just like regular people do. If your doctor has a massive kidney stone and has to have lithotripsy, as my partner did once, then your refills might be a tad late. Give them some grace. You don’t know what’s going on behind the scenes, and I assure you that nobody is sitting around playing games and checking TikTok during work hours in a medical office. If your stuff doesn’t get done, it usually means someone else had more pressing issues than you did.

And finally, it would be great if some patients realized that in medicine, the customer is not always right and customer satisfaction is not always priority #1 (yeah yeah patient satisfaction surveys are a thing but your doctors mainly care about practicing good medicine). Put on your big kid panties and take some personal responsibility. Don’t get mad that it took 4 hours to respond to your call. You are not your doctor’s only patient. They can’t drop everything to send in your viagra because there might be someone having a heart attack in the office and that’s kind of more important to deal with. Remember that failure to plan on your part does not make for an emergency on my part. Keep track of your meds. Ask for refills at your appointment or call a few days before you run out so you have a buffer. Take your meds with you to appointments so they can be checked to avoid errors in prescribing. If you feel like you are waiting too long for an appointment, call first thing in the morning and ask to be worked in if there are cancellations. We are eager to fill empty spots. Take some initiative.

I second all of this. I have had patients yell at me about referrals and sometimes I can help, but mostly I can’t. Derm takes 3 months minimum, there is no such thing as an emergency in their book. Yesterday I got yelled at because a local chiropractor wasn’t answering the patient’s phone calls…. I never referred to that chiro, or any chiro. The patient set this up themselves. Or two days ago when someone sent a rambling message about how unhappy he was with his care through a GI doc at the competing hospital network- not because we’d referred him, but because their office wasn’t answering his repeated same-day messages fast enough.

Originally posted by 1starryeye

I rant about the customer-service direction medicine is being forced in every day. I have a patient who stopped taking all their meds (not due to cost or lack of access or lack of insurance, just because they didn’t want to take them) and then, understandably, their lab work reflected this very visibly. I had to complete paperwork for them, which now reflects this lab work that they caused themselves, and for the last 3 weeks we’ve gotten angry phone calls, portal messages saying we’ve ruined their life, and a 3 hour irate sit-in staged in my waiting room demanding that I change my documentation (ie LIE) which only ended when the police were called. Someone else said I was violating my Hippocratic oath if I didn’t refill a Med they’ve been out of for several months, when they haven’t come into the office for over two years and haven’t had labs for that Med in 4y- and it’s not a life-threatening Med if they don’t get it.

Sometimes I wish more people understood more about medicine. Other days I wish we weren’t moving towards such a customer-service based society. But every day I am just exhausted by people.

Just gonna print out this entire thread in 96-pt font and hang it on the waiting room wall.

wayfaringmd:

cranquis:

TSK: Believe what you want, I guess?

When the patient with hypoxemia and cough and covid exposure demands that you “repeat the covid test” because “it MUST have been a false positive”

When the 2nd covid test comes back positive too

When the same patient refuses to go to the ER from your Urgent Care because “I’ve had influenza, and covid is weaker than influenza”

When the patient gets admitted overnight for (gasp! [pun intended]) respiratory failure

There is something to be said for hypoxia brain tho. I’ve had a patient or two be fully conversational with an O2 in the upper 70s/low 80s and refuse hospitalization. In my opinion, if your sats are that low you probably aren’t competent to make medical decisions for yourself. After these patients were hospitalized anyway (yay for pushy spouses) and got better and went home they had no recollection of their behavior while hypoxic. I’d like to think that was the case with COVID deniers like Cranquis’ patient, but unfortunately it’s more likely that they’re just idiots.

Counterpoint: You can be BOTH low PO2 and low IQ

When the patient with hypoxemia and cough and covid exposure demands that you “repeat the covid test” because “it MUST have been a false positive”

When the 2nd covid test comes back positive too

When the same patient refuses to go to the ER from your Urgent Care because “I’ve had influenza, and covid is weaker than influenza”

When the patient gets admitted overnight for (gasp! [pun intended]) respiratory failure

wayfaringmd:

mymedlife:

dontf-ckwiththepancreas:

Sometimes, I wish Epic had an emoji feature just so that I could throw a much-deserved 🙄 or 😒 into a note every now and then.

Thank you for the interesting consult. 🙄

…except now patients can read their notes so mine are full of abbreviations and roundabout ways to express my skepticism or internal eye rolls.

“Patient is unconcerned about need for indicated Covid vaccination, secondary to reassurance from internet sources and social contacts” = 🤦