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Medical Axioms 🇺🇸

21 Apr, 18 tweets, 2 min read

You know those adult patients who get admitted “all the time” and “every resident knows them”?

I will tell you something you don’t know. 1/

Most of those “frequent fliers” weren’t born that way.* 2/

*I know, peds. I know...

When you’ve been around the same institution as long as I have, you learn the “natural history” of the “frequent flier.” 3/

It usually starts with a catastrophe. A major trauma. A single critical illness. Often with a loss of irreplaceable bunches of cells: neurons, cardiac myocytes, glomeruli. 4/

For this, many patients are innocent bystanders. And sometimes victims.

Remain compassionate. 5/

From there, there is usually a conspiracy of
- chronic infection
- medication side effects
- financial ruin and homelessness
- untreated addiction
- etc. etc. 6/

I know how this looks as a resident when you pick up the story in the middle. Same admission as last week.

You get the feeling this started 20 years ago and will end 20 years from now. 7/

Incorrect. 8/

You are witnessing the crescendo in the patient’s illness. Something that will usually end soon.*
9/

*a year or two at the most

What happens?

Some of these patients finally stabilize. Get housing and support and find a new balance point.

Great treatment for addiction and get better.

Get incarcerated.

Die. 10/

I’ve been around a public hospital in the US for 15+ years and I’ve seen maybe 20-30 of these patients who end up with 50+ admissions per year.
11/

Most of them are not around any more. 12/

Know when you care for these patients you are not witnessing their way of life.

More likely you are witnessing the end of their life. 13/

Or you are standing on top of a moment when you could change this pattern.

Do not lose hope.

The Evil Demons want you to lose hope. 14/

Instead try to figure out the linchpin from the cycle.

And remove it. 15/

All the while keep yourself observant. 16/

Patients admitted many times for the same thing often end up dying of something completely different. 17/

Try to avoid getting lulled into complacency. 18/18

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More from @medicalaxioms

Medical Axioms 🇺🇸

@medicalaxioms

21 Apr

The single most valuable question to ask any older homeless person:

Do you have any kids? 1/

The answer is often yes and the conversation that follows will destroy your preconceived notions and biases. 2/

People with all their worldly possessions in a backpack by the side of the bed will tell you a story. 3/

Read 14 tweets

Medical Axioms 🇺🇸

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14 Apr

One thing we don’t teach you in med school or residency is how to call in sick. 1/20

I will tell you an embarrassing story. 2/20

Twenty years ago, my then wife’s dad committed suicide on a Tuesday. 3/20

Read 20 tweets

Medical Axioms 🇺🇸

@medicalaxioms

12 Apr

At this time of year, your goal with residents is to get the to relax. 1/

Let them put easy things together.

Pneumonia with hepatitis and hyponatremia might be legionella. (It was). 2/

After 9 months, the interns are scared shitless of missing some tiny detail.

They miss the forest for the trees. Due to anxiety and hyper-vigilance. 3/

Read 18 tweets

Medical Axioms 🇺🇸

@medicalaxioms

12 Apr

We do patients a grave disservice by avoiding the term “alcoholic.”

There is no free widely available support group called “Alcohol Use Disorder 12 Step Sobriety Club that Protects your Personal and Professional Identity.”

It is malicious to convince someone repeatedly hospitalized for the ravages of addiction to alcohol that they don’t belong at free, widely available meetings of self-identified alcoholics.

Also while we are at it, if you think you know how 12 step programs work because you have been to a meeting you are dearly deceived.

Only step 1 and step 12 occur at meetings. The rest are done between 2 trusted friends in private.

Read 4 tweets

Medical Axioms 🇺🇸

@medicalaxioms

9 Apr

I round at the bedside and also do most of my teaching in the patient rooms drawing on the window with a dry erase marker.

I get A LOT of compliments from patients about
- showing them how we think about problems
- how smart the team member are

Patient like to see how hard we work to solve their problems and also how much of their story and details we keep in our heads each day.

I can only recall once in 10 years when a patient asked us not to teach and discuss in the room. It was last week!

He said, “Will you stop talking and fix my problem??”

A few days later we were drawing on his window and he said “Am I your favorite patient?”

I had to be honest that we teach and learn in every patient room just the same.

Read 7 tweets

Medical Axioms 🇺🇸

@medicalaxioms

9 Apr

I see a fair number of doctors every year because, you know, chronic illness.

About half the time, they have residents or students with them.

I enjoy being a part of their education and training because that also happens to be my job. 🤓🤓🤓 1/12

I also understand how things are made.

When I eat a salad, I know human beings cut those greens in a field. Food doesn’t walk to my store. It’s grown and harvested by people. Then washed, shipped & handled by others.

I respect the people involved in the things I consume. 2/12

The people that make and do and grow things for me to consume are human beings.

They are not printed in a factory and they aren’t grown in a lab. 3/12

Read 13 tweets

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