Rants from the Crib

An Ob/Gyn gone mad

Archive for the tag “medicine”

Take Your Vitamins

Most of you are familiar, I believe, with the concept of vitamins. They are compounds that are essential (or at least damn useful) to the physical well-being and development of the organism taking them. Many of us take vitamins. Some take them religiously. They have been seen as possible cure-alls for almost everything. My husband superstitiously takes magadoses of Vitamin C whenever he feels like he is getting sick, which I think is a crock, but it probably won’t hurt him. The problem is, when I feel like I might be getting sick, he tries to foist them upon me too, and he becomes indignant when I refuse to take them. My dad, in the past, has dabbled with mega-doses of various vitamins and minerals. Usually when you take hyperdoses of vitamins, your body takes out what it needs, and dumps the rest into the toilet, wasting your investment

I will stand on my Doctor Soapbox for a moment, and remind my gentle readers that it is actually dangerous to take excessive doses of the ADEK vitamins (a mnemnotic for vitamins A, D, E, and K), which are the fat soluble vitamins, and they can actually hurt you in excess. It has been discovered that Vitamin E, taken in dosages higher than recommended, can cause heart problems.

Among other things, excessive vitamin A can cause birth defects in a fetus who is conceived when Mom is on megadoses. The acne medicine Accutane is actually a form of extremely high-dose Vitamin A, and they medically recommend abortion if you become pregnant while taking it – it often results in babies born without brains, which, needless to say, is an extremely undesirable outcome. Physicians are required not to prescribe Accutane for a female of childbearing age unless it is verified that she is on a reliable form of birth control. Accutane has been linked to suicide in some users. I don’t like Accutane. It is nasty stuff.

Then there are “medical vitamins”. These are not actually vitamins, but are very useful medications. Anything we medical types jokingly call “Vitamin” is usually a drug that gives immediate results, typically for a patient who is anxious, in need of immediate intervention, or a pain in the ass.

Vitamin K is a good one. There is an anesthetic drug out there called ketamine. Some of you may know of it. It was initially used as a veterinary anesthetic, because when they tested it on humans, it caused pretty intense hallucinations. It is seeing more widespread use now in people. My specialty uses it frequently to boost pain control in an awake patient who is having some discomfort during her c-section with a poorly functioning epidural. This results in the patient saying some pretty darn amusing things. I was actually given it during my c-section, because I had a hot spot in my epidural and was in a lot of pain. I watched the anesthesiologist squeeze something into my IV really fast and then I was out. When I awoke a few minutes later, the pain was gone, but all I could see were blue brains. Fortunately, I am not easily rattled and pretty much realized they had just dosed me with ketamine. The blue brains turned into blue triangles, and then I realized it was just the blue surgical drape that was placed over me. I couldn’t remember what I was doing for a minute. “Oh,” I thought, “I’m having a baby. Is it a normal delivery? No. It’s a c-section. What’s a c-section?” We also use it to quickly sedate uncooperative patients who need to undergo anesthesia. We hit them with something called a ketamine dart, usually in a sneak attack on the shoulder. Most typically this is used for patients who are unable to understand or cooperate, or who may be outright combative. I have a fairly large group of patients in a state facility who need annual pelvic and breast exams, but they may be violent or scared and unable to be awake for them. They are brought in, given a ketamine dart, and then their IV is placed after they are asleep. In one particularly funny episode, we were sedating a large and dangerous mentally handicapped female patient who struck fear and respect into everyone she came into contact with. She is missing one eye, and legend has it that she is so mean, she removed it herself. At any rate, she bites, spits, and hits anyone who comes near her, and she packs a mean wallop. Our anesthesiologist danced around her like a prizefighter, trying to sneak up on the side of the missing eye to administer the ketamine dart. She caught sight of him anyway, and administered a massive blow before he could duck away. She was finally successfully sedated, but not without a lot of expletives from the nurses and the anesthesiologist. Ketamine is also a street drug, prized for both its general anesthetic and its hallucinatory properties. On the street it is known as Special K.

Vitamin A is Ativan, which is a drug in the same class as valium and it works great on addled little old ladies who are in the hospital and causing a fuss. Typically the anxious patients are placed on this medication, or others in its class, as outpatients, to calm nervousness and the bad habit of calling the office daily with imaginary problems.

Vitamin H is Haldol, which is less commonly used, but extremely useful in the case of a violent or psychotic patient as it is a rapid acting antipsychotic and has an almost immediate sedating effect. We will frequently call for “a butt full of Haldol” for an out-of-control patient, because they aren’t going to cooperate with any pills given them, and pills wouldn’t act fast enough anyway. The key is to, well, corral them enough to pin them down and administer the aforementioned Haldol Butt Shot.

Vitamin V, or Versed, is also an antianxiety drug that is extremely potent. It is used for situations where a patient needs to remain conscious but sedated for a procedure, and combined with a good pain med, it keeps them calm and comfortable. Vitamin V is used routinely in the OR holding area, where the patients waiting for their surgery are almost certainly anxious, whether they seem so or not. Versed also has a powerful amnestic effect – that is to say, once you are given it, you will almost certainly not remember what transpires in the next few hours. This is handy, because the patients will not remember the ride back to the cold OR, the positioning on the table or preliminary and potentially frightening discussions about instruments or other such. Best of all, should a patient have an extremely rare consciousness experience under general anesthetia, which I understand is terrifying, they will probably not remember it. Having been given Versed myself, I can testify that the stuff is AWESOME.

Watching a patient being given Versed is a wonderful thing to see. At the bedside, in preop holding, your patient is trying to hold it together but it is obvious that they are tense and aprehensive. After your preop chat, where you address any final questions or concerns, it is nice to be able to then say to the patient, “Anesthesia is going to be coming in a couple of minutes, and they will be giving you the equivalent of at least 3 margueritas in your IV. Once you get that stuff, you will be grinning and telling me that you’re so psyched, you’re having surgery!” They look at you skeptically, and you hang around because it is so merciful and fun to see that stuff kick in. When anesthesia arrives with the syringe of Versed, you tell the patient, “Here come your margueritas!” They will eye their arm apprehensively and watch as the needle pushes the medicine into the IV. Then, about 30 seconds later, you can see them visibly relax, and almost sink into the bed. A lot of times they will look at you out of stoned eyes and slur, “Thish shtuff is AWESOME! I’m having Shurgery! YAY!” Gives me a kick every time! And a lot of times, they will tell you some REALLY funny things. One patient, after her Vitamin V, became convinced that the handsome CRNA was a doctor whom she needed to seduce and make her sugar daddy immediately. She pinched his ass repeatedly, making him yelp and jump every time he tried to check her vital signs. She kept offering him fascinating sexual favors, some of which are only available online, and he was so embarassed that he turned bright red, which was hysterical because he is normally an obnoxious and non-embarassable person.

My husband has a very funny history with Versed. After we married, for the first several years, he seemed to need a surgery almost every year, usually in November. For his first ever surgery, I accompanied him to the holding area because I am a doctor and I can. I also had some concerns. My husband, in his right mind, is a blabbermouth who cannot keep a secret even if he really means to, and has very little internal filter regarding whether something might be inappropriate to say. He has mortified me on numerous occasions. Rarely, I have seen him drunk, and am surprised he has not been arrested (or at least had the shit beat out of him) for some of the things he says. He loves women and doesn’t have any problems with discrimination against women, near as I can tell, but what he thinks is subtle sexual innuendo, out of his mouth, can be freaking AWFUL. No filter. Then he brightly looks around and says, “Oopsie! Was that my out loud voice?” I maintain that it is his out loud OINK.

At any rate, I had concerns about his behavior under the influence of Versed. It was entirely possible that he would began to disseminate details of our intimate personal lives, or the last awesome video he saw on YouTube, all of which would render me humiliated and my colleagues confused as to what kind of person would marry someone this awful. So I was there to police him, at least until he was wheeled back to the OR. Well, Vitamin V knocked him on his ass. I somehow kept him on track until they wheeled him back, but I am still worried about what he may have said on arrival to the operating room. The problem is, it may have been embarassing enough that my colleagues would not report it to me. I will never know.

After the surgery, my husband waxed lyrical about the amazing stuff they gave him on the way back to the OR. “I never understood how anybody could crave or be addicted to drugs, but I could sure see wanting more of THAT stuff!” He did remark, however, that he found it extremely disarming that he could remember nothing after the injection was given. That could be disturbing for a bona fide control freak, which he most certainly is. At any rate, despite that, he found the stuff quite enjoyable.

A year later, we were back in the holding area, getting ready for another surgery. My husband had told me that he was psyched, because he was looking forward to the Vitamin V, but that this time, he was DETERMINED not to forget events that followed its administration. I told him that was probably not possible. He insisted that his superior intellect would absolutely make memory of the event possible. I found this immensely reassuring, because, distracted by the work of recalling all events with his “superior intellect”, he would be unlikely to say anything inappropriate, because he would be focused on remembering everything around him. I also found this extremely amusing, because a fiendish plot was forming in my mind.

Prior to the administration of the Versed in the holding area, I pulled the CRNA, who is a friend of mine, aside. I explained to him the whole dislike of forgetfulness and loss of control thing, and about my husband’s determination to use his “superior intellect” to beat the amnesia. My friend, who is my friend because he catches onto things very quickly, smiled a sneaky Grinch-like smile at me. “I’m doubling the dose.” he told me. This did not concern me as it would not harm him – he was about to be put all the way to sleep. It would, however, be wicked funny as hell.

Sure enough, my friend loaded up enough Versed to drop a rhino and pushed it through my husband’s IV. He was WHACKED. I watched him ride back to the OR, pointing at objects on the way back to the operating room and slurring, “I’ll remember you DOOR and I’ll remember you WINNOW and I’ll remember you LADY and I’ll remember you DESK…”. Awesomesauce. Never laughed so damn hard in my whole life.

After the surgery, I asked him how his memory was. He was indignant, because somehow, the drug had overcome his superior intellect. He couldn’t understand it. Of course, at that point, the final stop in my plot arrived – I told him I had arranged to have him DOSED and he couldn’t have remembered his name if someone had asked for it at that point. He was downright incensed. And then he laughed. And laughed. Because he loves a good joke, even if it is on him.

So as a medical person, I must say, it is essential to remember your vitamins! And not just the ones that come in expensive bottles at the GNC…

Medical Coding Made Easy

Many of you may wonder, how is medical billing done?  How are your unique ailments translated into standardized format, to be recognized as payable by the insurance company?  Or, more likely, NOT recognized as payable to the insurance company.

The first coding category is ICD-10 code.  Translated into English, this category encompasses Shit That Is Wrong With You.  For example, gonorrhea is 098.0, which encompasses the following conditions and more:  acute gonorrhea, gonorrhea of the vagina, gonorrhea penis, gonococcal urethritis and acute Bartholin’s gland gonorrhea.  However, something slightly different (and you may be provided hours of entertainment trying to visualize how this was transmitted), gonococcal infection of eye is 098.4.  There are codes for every possible disease, illness, deformity, even one for High Risk Sexual Behavior.  I have this one memorized.  The digits in front of the decimal point usually delineate the main category of the disease, whereas the 2 digits after the decimal point delineate more specific details.  That fifth digit (the second one after the decimal point) is added only where extreme differentiation is required, say as in 607.83 (edema of penis) and 607.84 (impotence of organic origin).  In my opinion, many codes for Shit That Is Wrong With You have been excluded.  It would be very useful, for example, to have an ICD-10 code for Skank Ass Ho.  This would immediately trigger payment by insurance for things such as testing for STDs, multiple pregnancies, and chain smoking.  You could add a fourth digit, after the decimal point for Skank Ass Ho Who Lives In A Trailer Park, and a fifth digit to delineate Skank Ass Ho Who Lived In A Trailer Park But Got Thrown Out On Her Ass For Screwing The Guy In The Trailer Next Door.  See how useful this would be?  Also there could be one for Neurotic Middle Aged Woman, which would cover any number of ills, which I will not go into here for fear of being lynched.  Another highly useful code would be for PITA (which physicians all know stands for Pain In The Ass).  That code should cover all sorts of tests that the patient demands for ailments that he doesn’t really have, and allow higher billing, because the visit will be interminable because of all the whining and complaining.  The ICD-10 codes are changed almost annually, to numbers that are frequently completely different, by the Powers That Be,which are most likely owned by Big Insurance Companies.  The changing of the codes occurs in hopes that some hapless doctor will accidentally use last year’s code, which is now obsolete, and then they can weasel out of paying. 

The second category is the E Codes, which in English mean Bad Shit That Can Happen To You, basically from an external force.  These are numerous and extremely specific, such as Slipped On Deck Of Yacht While Walking In Swim Fins.  I believe this one actually exists, although I seldom have cause to use it.  The ones I use are usually tragic, things like Spousal Abuse, or Rape, Alleged.  You gotta love it.  Even medicine is biased against the sexual assault of women.  There is no Rape.  There is only Rape, Alleged.  I am totally surprised that they don’t have an E Code for:  Rape, But The Bitch Totally Had It Coming.  They have numerals that differentiate between Jumped and Was Pushed.  I shit you not.  There are some E Codes that would be extremely useful but do NOT exist, such as Had His Ass Kicked In A Bar Parking Lot After Talking Smack To Some Gangsta Guy.  Now THAT would be useful.

Then there are CPT codes, which translated into English are Shit That The Doctor Does To You, which covers most surgeries, treatments, and other medical interventions, or a badly needed bitch slapping.  We use these to cover Normal Spontaneous Vaginal Delivery, Primary Cesarean Section, Total Abdominal Hysterectomy, and Oopherectomy (removal of the ovaries), just to name a VERY few.  The insurance companies like to “bundle” these codes, which is to ensure that we are paid as little as possible.  For example, you are paid so much for just a Total Abdominal Hysterectomy.  If you remove the ovaries at the same time, these two codes are bundled, because they are frequently done together.  If you had removed only the ovaries, you would have been paid for that, but for both together, you just get paid the one reimbursement, usually the lower of the two costs.  They bundle some rather unlikely things, to make sure that we don’t get too big for our britches and do “unrelated” stuff.  Also, let’s say you do two procedures, with two different surgeons.  The specialist OB/Gyn does a hysterectomy, and a sub-specialist Urogynecologist does a bladder lift procedure, during the same surgical episode.  Typically only the sub-specialist is reimbursed, for both procedures, because they are considered capable of doing both, and sub-specialist outranks specialist.  I consider this outrageous, because it deters physicians from seeking specialized care for their patients, because if we bring in a sub-specialist, we don’t get paid for anything.  Thus, patients may be subjected to two different procedures at two different times, so that reimbursement will be given to both parties.  Now tell me how that optimizes patient care?

There is another coding system, for psychiatrists, which I believe is now DSM-4.  They change that up a lot, just like the CPT codes.  New diseases are added and removed with each revision.  For example, Female Hysteria was finally fortunately removed .  See?  We are making progress.  Psychiatrists code things on Axes (plural for Axis), in which one axis might be physical (like psychosis induced by lack of sleep), or biochemically induced bipolar disorder.  Another axis might be external, such as psychosis triggered by drug ingestion.  My friend, with a PhD in psychiatry insists that they should add a whole other axis, “The Axis of Evil.”  She also states they should be better reimbursed if it is invoked.

So let’s see how all this works.  A patient presents to the ER, bashed up and ranting and raving.  ICD-10 codes might be Acute Alcohol Intoxication, Chronic Alcoholism, Oppositional Defiant Disorder, Nausea and Vomiting and Opioid Addiction, Other.  E-codes might be assigned for Had His Ass Kicked In The Parking Lot Of A Bar After Antagonizing Some Dude Named Vinnie and Blunt Force Trauma To The Head, .  CPT codes for Shit The Doctor Did might include codes for Gastroesophageal Lavage (stomach pumping), four-point leather restraints, skin suturing, CT scan of the Head, and Adminstration Of A Rapid Paralytic Agent To Settle The Guy Down And Shut Him The Hell Up.  See how neatly that works?

I hope that this quick guide has helped you to a deeper understanding of the inner workings of the world of medicine.  If it does, I’ll send you a bill.  ICD-10:  Eyestrain, and Complete Incomprehension of Medical Procedures, E-Code:  Spending Too Much Time Reading Blog Posts, and CPT code:  Administration of basic information needed to comprehend the complexities of the medical world.  That’ll be $1,349.53, of which your insurance will cover $135.  Any further questions will cost you extra.

Things I Learned At Work

1.  If you carry keys in your pockets everyday, they will make holes in your clothes.  Most women don’t realize this, because they typically keep their keys in their purses, but I keep a set of mine in my work hoodie in case I need to get into the call room or the doctor’s lounge.  I have holes all in both pockets now and the keys poke through them embarassingly.  I guess I’d better get another hoodie, so I can make holes in it too.

2.  No one will replace the toilet paper, the pillow cases or the hand soap in the call room but you.  That’s right.  I have put more rolls of paper on the spool, bought more hand soap from Bath & Body Works and replaced the pillow cases on the call room bed more times than I can count.

3.  People will cheerfully take/use your stuff.  I am constantly running out of paper clips and people steal whole Post-It note pads off of my desk.  They also steal my pens.  Since we no longer get these free from the drug reps, replacing them becomes annoying.

4.  Dried yogurt looks exceptionally bad on scrubs.  Enough said.  It just does.  It looks disgusting.  I guess dried yogurt looks pretty bad on all clothes, when it gets right down to it.

5.  If you have an opportunity to put your scrubs on backwards, you will.  Especially if it is three o’clock in the morning and you are rushing to put them on.  Your patients and nurses will cheerfully point this out to you.

6.  You can persuade yourself that you do not have a weight problem if you wear scrubs all the time.  Scrubs are loose and forgiving, except for when they become tight and unforgiving and you have to go up a size.  Reality sinks in when you attempt to put on normal clothes at home, which doesn’t really happen all that often.  Especially when you know your clothes aren’t fitting well, you will tend to stick with the scrubs at all times in an attempt to lie to yourself.

7.  More babies are born at four AM than at any other time.  This is a cortisol and circadian rhythm thing, and the babies cannot be persuaded to help you out and be born at some other time.  Neither can the moms, who have no interest in waiting. 

8.  Your phone will always ring at the least convenient time.  Especially when you are at work and being bombarded with problems from six different directions and dealing with demanding patients.  Or especially when it is your husband, who ALWAYS calls at the worst possible time.  Like when you are peeing.  Or in a room with a patient.  Or doing a delivery.

9.  Your computer will always fail just after you have entered in about an hour’s worth of data.  Even if you hit save frequently.  Somehow the save button is rendered useless by the evil computer.  You will have to type everything in again.

10. You will never find your nurse when you need her.  She will always be in another room with another patient when you need her to bring you something, or when you need her to help you with a patient who is passing out.  No one will have any idea where she is. 

11. You will always be on call when there is an event that you want to attend.  Without fail.  If there is something fun going on on a weekend, you will always be on call on that weekend.  And if you try to plan something on a call day, something will always happen so that the activity is canceled.

12.  The elevator is always on the wrong floor.  And you will run into that problem patient, who, while they have you on the elevator, wants to ask you “just a few more questions”.  They even ride the staff elevators.

13. Your patients will always start early and end late on those days when you are already running behind.  Everyone shows up on the day where you’ve been stuck doing a c-section in the middle of clinic.  And they all want to wait to see you; no one wants to reschedule.  You will have a relentlessly heavy schedule on days where you have been in surgery all morning and are exhausted, are post call and are exhausted, or on days where just waking up in the morning requires more coping skills than you have.

14. The patient you have been strenuously avoiding throughout her entire pregnancy will find you and be in labor on your call day.  You will have to do a c-section alone on a three hundred pound woman.

15. Medical professions breed negativity.

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