Insulin is OTC

It was a surprise to me to learn today that one does not need a prescription to buy insulin (as well as insulin syringes) in a pharmacy, except for newer formulations like Lantus. One of the antepartum patients on the floor today has been self-medicating herself with regular insulin for a few years without seeing a doctor, and if it wasn't because she decided to come to the hospital to check if her pregnancy is "ok" (she has no insurance and said she doesn't qualify for Medi-Cal), no one would have told her that this is a problem.

Insulin can be some pretty lethal stuff and I think the fact that you can get it over-the-counter is scary. You could overdose yourself or someone with insulin and kill the person. Sure you could overdose someone with a bottle of Tylenol or by just taking someone's insulin vials, but the fact that there is no regulation regarding the sale of insulin is awry. Regular insulin acts in minutes, whereas the prescription-only Lantus insulin is long-acting and relatively less lethal when overdosed. In comparison, most sleeping pills are available by prescriptions only. On the other side of the scale, inadequate control of diabetes due to lack to a doctor's guidence can be dangerous to the patient (and in the above case, her unborn child) as well.

This page shows that most states do not need a prescription for insulin and syringes.

Preeclamptic Patient on My Watch

Last night ICU refused to admit one of my OB patients - the patient has just delivered her baby via emergency section due to extremely elevated BP. Her BP went down to normal after the operation but the attending felt that the patient still has high risk of having eclampsia. ICU said her BP readings do not warrant a bed there. Then the attending said the postpartum nurses will freak out if the patient has an eclampsia attack because they wouldn't know how to react. The patient ended up staying in the postpartum floor and that's when I started to worry - do I know what to do if the patient throws me a seizure attack? That's when I went back to my call room and started reading up.

Sure enough, nothing happened to the patient overnight. Well, at least I forced myself to study :)

Progress Notes

I did 23 progress notes last night. Do I even know most of these patients? Did they know who they were talking to when I woke them up at four o'clock in the morning?

Speculum Exam

Speculum examination is without a doubt one of the most embarrassing and stressful procedures for patients. The same can be said to the inexperienced health provider (Ahem~) who performs the procedure; moreover, when it's not done right, it can only make a patient even more stressful. I have the "pleasure" the other day to supervise a medical student to do one - my mind was thinking "run!" when I got the assignment - I have barely done enough to do it on my own, let alone teaching a student. As nervous as I am (as well as the student), I walked into the room and handed the speculum to the student. Then I handed over a glass of water as said, "here, use water as lubricant." The nurse who's standing next to us immediately stopped us and told us that there we use jelly instead of water. That's when I realized that it was the patient's darn drinking water container that I was holding!

I laughed it off and continued on. The rest of the procedure went well actually, and I was surprised that I was actually able to show the student a few techniques from the little that I know. One of the most important things I've learnt that I was trying to tell the student is the need to communicate with the patient well during the ordeal - tell the patient exactly what you are doing before each step helps the patient to relax, and at the same time the provider will feel more comfortable.

See one, do one, teach one. So the adage goes.

"Hot" Work in the ICU

OB Attending to MICU Resident: Boy, your hard work in the ICU is keeping you hot huh?
MICU Resident: What do you mean?
OB Attending: Your hair's all wet...
OB Resident: I think that's his hair gel!
MICU Resident: ... [embarrassed]

Grey's Anatomy

I have to admit that I enjoyed watching Grey's Anatomy after the first 2 episodes. I have been avoiding the show since the beginning, knowing that it's an overly-dramatized show that is not realistic and all (who does 48-hr calls anymore? And where are the Meredith and Izzie in my class?). I found the interactions between characters interesting, and I can actually relate when they sit in the dimmed corridor complaining about intern lives. My life is nowhere as stressful as them of course. I know the show becomes even more dramatic in later episodes so... but I'm sure Katherine Heigl's presence will keep me watching. I am sure...

Another medical drama I like a lot is none other than House, M.D. It's a much more realistic show and I can actually learn something from it. And Hugh Laurie from the Blackadder fame as Dr. House? He is great.

AMA

I was on day call today and got my first experience of a patient who wanted to leave the hospital against medical advice - or AMA as we call it. I can't blame the patient but there are times when I just don't really understand what a patient wants. The patient, who has just delivered a baby through c-section 3 days ago, has an uterine rupture and high blood pressure reading that warrants a full 96-hour stay. She has a complicated social history - positive drug screen, no prenatal care, and G10P4504 prior to this delivery which means she had 5 prior miscarriages. Her newborn did not live beyond the first 24-hour and I was told by the nurse that when the baby was sent to the NICU she didn't spend any time there. After the baby passed away, she would cry in her room in the Postpartum area and constantly complained about pain from her c-section incision. As her bed is in an area surrounded by newborns, we offered to switch her to another room on a different floor but she refused. Then she would complain about how we don't understand how emotionally painful is it for her to hear babies crying all day long. All the nurses there wanted me to send her home so they became ecstatic knowing that she wanted to leave AMA. I had to explain to her all the risks of leaving the hospital early and have her signed a form saying that she understands.

"What about her meds?" I asked the charge nurse.
"You don't give them any meds home if they are leaving the hospital this way."
"What? Really? But her BP is still high despite the BP meds!"
"Don't worry - you are free of any liability after she signed the AMA form - she'll come back if she's sick enough. And definitely no pain meds."

But that's not the point!! I ended up writing a prescription for her BP meds (which I later found out that I did the right thing) and told her to come back in a week for staple removal. I hope she got the part about coming back. She was then taken away by a guy who's at least 10 years younger than her.

"What do you mean he's not her son?" I asked the nurse.
"That's her partner, kiddo."
"Oookie."

Talk about complicated social history.

"Thank you doctor; you're a very good man."

What's more rewarding than being told by a patient that you are a good doctor?

I was in my clinic the other afternoon and saw this new patient. He doesn't speak English, but his sister was helping with the interpretation. He's a typical case of someone who needs multiple visits to the clinic to get things straight - a male in his 40s with sub-optimal health care due to insurance issues, with history of insulin-dependent diabetes, high cholesterol, hypertension, as well as a chronic lower back pain that is the main reason for his visit today. I took the time to learn more about the pain and explained to him the management plan. I told him that it will probably take some time to fine-tune his meds, since besides the back pain we'll need to address his other problems too after checking his lab work. A quick neuro exam revealed that his diabetes is not too well-controlled either as he's showing signs of peripherial neuropathy.

As they walked out of the patient room, his sister said to me, "thank you doctor; you're a very good man and we'll see you again next month." As I always say, that extra mile you take to learn and talk to your patients' problems shows that you care about them and often times this is the most important thing they need. Of course, as an intern I have the luxury of seeing only 3 patients in the afternoon instead of the typically 12-16 for a typical family physician; when you have only 15 minutes for a patient it's not easy to try to address his problems all at once.

"Here's the motivation," I told the medical student standing next to me who smiled at me after hearing the lady's remark.

A Quiet Night in the Call Room

It's 2:20 am. I have just finished seeing all my patients (16 of them tonight, which isn't too bad) and my progress notes are half done. It's a surprisingly quiet night - I only got called twice for some minor things. But shhh~ touch wood... just keep this to myself because someone up above may listen!

I have a sudden crave for hot scrambled eggs for some reason. I think I still have some eggs at home; i know what I'll be having this morning before I go to bed.