r/medicine

Incoming a patient with massive lower GIB. Hypotensive. HH dropped several units. GI won't do a colo since pt is unprepped. CT angio positive for active bleed. I call IR:

IR: We need the patient to be stable before we do a visceral angiogram/embolization

< Patient gets rapidly transfused blood, is stabilized; good BP. I call IR back >

IR: The patient looks stable now. In that case go ahead and prep for colo; they no longer meet criteria for urgent angiogram

I'm not criticizing IR here but just wanted to see if I'm missing something? Patient met criteria for an angiogram because they're too unstable to undergo prep. I stabilize the patient per IR request but now they're too stable to meet criteria?

Crosspost from /r/Psychiatry.

Some patients with BPD make conditional threats that they will commit suicide if you do not admit them (or extend their admission). I send a lot of these people home.

Some of them do try to commit suicide and end up on a medical or surgical ward. The direction I tend to give is that they should be stabilised and sent home rather than to the psych ward, especially if the act was because a previous admission wasn't extended. IMO this makes it abundantly clear admission is not benefiting them if they are continuing to present like this despite a recent stay, my feeling is there is probably some iatrogenic harm there as there would not have been an extinction burst at the point of discharge if there had never been an admission, and I certainly do not want to reinforce behaviour that high-lethality suicide attempts are tickets to previously-declined admissions.

However, what do we do if a patient attempts to leave while being medically stabilised, and demonstrates capacity to do this? They are aware they are being stabilised, that they are unwell, and that the risks of leaving include death.

I've seen two schools of thought from attendings.

One is that we should not allow people to commit suicide, and that having BPD impacts capacity. However, I would argue that many people are allowed to deny lifesaving treatment in ways which essentially amount to suicide, and that there are clearly disordered personality-driven processes contributing to these in some people, e.g. I am going to leave before being treated for my MI because I am annoyed that someone else was seen before me. We still allow them to leave.

I find myself aligning more with the second school of thought which is that leaving is a stupid decision, but it is their stupid decision and they are free to make it - thus this should be handled along the DAMA pathway, they should not be detained, and they should be allowed to leave with thorough safety netting and return instructions (and a signature on the DAMA paperwork). If we detain them, often I see that they are detained until stabilisation, are sent home, and then promptly end up in hospital again with another suicide attempt. Conversely when it becomes clear you will not detain them they tend to stop threatening to leave (or come back if they have already left).

What are your thoughts on this? Keen for some discussion.

I was reading a case -- Medina v. Hochberg, 987 N.E.2d 1206 (Mass. 2013) -- that held that a medical professional other than a mental health professional owes no duty to third persons to warn her patient of the risks of dangerous driving associated with an underlying medical condition.

A google search resulted that forty-four U.S. states do not have laws that mandate physicians to report or warn state motor vehicle authorities about patients with epilepsy.

I thought that most states would mandate reporting (since physicians have a duty to warn others of their patients' contagious diseases) but I'm surprised by the findings.

I'm a hospital nurse. I got sick recently with an infection I've never had before. I've taken care of many pts with this infection. It was interesting to be on the other side. I'll be changing my nursing practice based on what I've experienced.

(I apologize for being vague/not expounding more - this is a very recent development, and I don't want to provide too many details and risk someone connecting the dots to my account.)

October is the best month to be a pediatrician.

-PGY-22

RANT/

4yo patient new to me. CP, doesn't walk. Still in diapers. Markedly delayed/intellectually disabled (BTW, I wish they'd update the ICD-10s/IMOs because "mental retardation" is an outmoded term and it's still the one I have to use on the problem list).

NOBODY at her prior practice had thought to order a PT referral. NOBODY at her prior practice had prescribed a wheelchair, walker, or stroller. NOBODY had done an OT referral. NOBODY had offered to prescribe diapers. I was honestly appalled.

By the end of the visit, her mom was looking at me like I was some sort of saint as I put in referral after referral after referral and DME orders. As for me, I just got more and more horrified through the whole visit. This mom is ready to cry tears of joy because I did what I consider to be the bare minimum of my job. But really what happened is that someone had dropped the ball really badly and her mom had just accepted that as par for the course.

I don't get it. You don't do Pediatrics for prestige, money, or power (if you did, someone really failed at giving you career advice). There is one reason to do this job and that's because you care about kids. So why are you doing this if you're going to suck at it?

/rant

-PGY-22

my entire urgent care shift consisted of being asked for antibiotics. I saw 40 patients today. even had mom bring her 1 year old come with viral exanthem adamant that she needed antibiotics because her parents said so. then mom of a teen with mono asking for antibiotics. patients come complaining primary didn’t prescribe so now they are at urgent care. What’s your best line to comfort these moms and grandmoms

EDIT: coming from working with a very talented interventional cardiologist so my skin is irking…

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