Island Medicine, Part 2

Of course it wasn't all work while we were in St. Lucia. Our group managed to stay at a resort for 2 nights/3 days to relax.

One night, we went to dinner at an old sugarcane plantation called Balenbouche (French for bullet-in-mouth--apparently named for a duel that took place that didn't end well for someone!). The grounds were very pretty, and there was a small, black sand beach on the property.

Old still:

Black sand beach:

Same spot, minutes later:

We stayed at the Almond Smuggler's Cove Resort, which is on the north part of the island. It was three days of eating, which made up for all of the peanut butter and frozen lamb neck at the cafeteria during the weeks before!

The Brig Unicorn (apparently was in "The Pirates of the Caribbean"):

One of many lounging spots:

There are two prominent peaks in St. Lucia. Gros Piton is the taller of the two, but the climb is slightly easier (very steep, but you don't need ropes to pull yourself up). Petit Piton is not quite as high, but is a much more difficult trail.

View of Gros Piton from the bottom:

This hermit crab was found halfway up the mountain trail!

View of Petit Piton:

Strange-looking breadfruit tree:

It was a great two weeks. Unlike my experiences in a rural hospital in Alaska, here I felt like I was able to do more for people because although we had less medications to treat people with, we had access to surgeons. It was more what I think practicing medicine was like 20-30 years ago rather than just being a pit stop hospital, where pretty much everything and anything is flown out for a higher level of care. As for the vacation aspect, I would have liked more time to explore the island and to have gotten in some scuba diving, but it just didn't work out. The island itself is pretty small- something like less than 20 x 20 miles, so I don't know that I'll be returning.

Island Medicine, Part 1

Our residency program has been sending senior residents down to St. Lucia for several years now. We volunteer in an Emergency Department at a small hospital there and in exchange, they provide us with food and housing. It's a different experience than back home. Resources are limited, and patients must pay for service and medicines up front. Patients pay a fee before they are even seen in the Emergency Department, and then they get billed for any medications dispensed, or supplies used, like gauze and suturing materials. If x-rays are ordered, they have to pay for them before they will be taken and blood tests are paid for before they are drawn.

This was our drug supply cabinet. It was organized by shelf. The third shelf was mostly empty, and was our only cache of antibiotics to work with.

Unfortunately, most of our antibiotic supply was this:

If you look closely, you'll notice that it's expired.

The Emergency Department itself was fairly small, and is one of the only air-conditioned areas in the hospital. There were four curtained off rooms. The big pink chair is the asthma chair, and standing next to it is a large oxygen tank.

The system seems to work well. Most of the patients are in and out fairly quickly. I put on splints, reduced a dislocated shoulder, and did a fair amount of suturing. What we could fix, we fixed, and unfortunately the mortality rate seems to be fairly high. The hospital has a fair amount of specialists- (pediatrics, obstetrics, orthopedics, general surgery) but there's not a whole lot that they can do for things like strokes or heart attacks. I saw one child with chicken pox-- which I haven't actually seen at all during my residency because of the vaccine. Another of my patients had lost a leg due to leprosy.

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There is only one certified paramedic on the island, and unfortunately he was not on any of the ambulances that brought me patients. The ambulances seem to function more like the old hearse system. They are minivans with equipment inside, but for some reason, other than arriving with oxygen, nothing seems to get done for the patients. IVs are not started, medicines are not administered, and sometimes you may not even get a set of vital signs.

My patient with the dislocated shoulder was transfered from a clinic and had gotten nothing for pain. He apparently bit his first ambulance attendant, so they dropped him back off at the clinic and took their attendant to a different hospital for a tetanus injection before returning back to pick him up and bring him in.

Two of my patients were brought in pulseless and apneic (not breathing) and neither one of them had CPR being performed as they arrived. When I asked one of the ambulance dudes why they weren't doing anything, he said that the patient had already had a minute of CPR by a bystander when they arrived, and it didn't help, so he didn't think the patient needed CPR or ventilation apparently! So our codes were pretty futile, but we attempted anyway. There was only one ventilator in the hospital, and it was occupied by some guy with a head injury, so intubation would have meant riding in the ambulance with the patient to a hospital over an hour away and bagging the whole time.

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During our two weeks, the Carifta Games were going on. The Carifta Games are kind of like a Caribbean Olympics for athletes ages 14-20. Several of the athletes eventually go on to compete in the Olympics. The group of residents prior to ours had helped develop a mass-casualty plan for the event with the hospital, and we were there to staff the medical stations. The actual spectator turnout seemed to be a lot less than what was originally anticipated, and the weather was mild. Something like 200 patients were seen over 3 days, but most of it was minor cuts, twisted ankles, nausea, or "Can you just check my blood pressure?" type complaints. I spent most of my day there watching the races and long jump competition.

These stands were in the sun, so they were largely empty. The one behind me probably held a couple thousand people.

If I remember the uniforms right, these two young ladies were from Barbados.

The Jamaican athletes were clobbering all of the other teams, just like in Beijing.

Our favorite thing to do after work in the evening (unfortunately it was dark by 6:30!) was to sit around drinking and playing cards. The hospital sold cases of Piton (local beer) at a discount. If I worked the evening shift, the day was spent hopping on buses and getting myself down to the nearest beach, where the wind was apparently perfect for kite surfing and windsurfing. It was also a great spot to pull up a towel in the shade and relax before work.

My favorite reading spot:

Hiatufied

--Ok, so maybe that isn't a real word. What I had intended to be a month-long hiatus stretched a little longer than planned. It has been a busy few weeks, but I think I am ready to return to work and to writing, perhaps with a better attitude.

Sort of a Day Off

I had today off, but it wasn't very relaxing. My realtor met with me and did a walk-through of the house. I have a few more things to finish up and then a lot of de-cluttering to do. My plan is similar to what I do when my parents come to visit. I just throw a bunch of crap in boxes and shove it in the attic. I'll post some before/after pictures soon.


It snowed again today. Just a little bit of flurries, but it made me glad that the other day when we had "unusually warm weather" I slapped a fresh coat of paint on the deck outside to cover up all of the peeling spots. I would have liked my realtor to have been a little more optimistic today, but I guess I'll just have to see how it goes. I still think the house will show better in May when everything's green and blooming, but I would like to at least get people looking at it now.


Last night's shift was really busy. I typically average around two patients an hour, but I was at almost three per hour, and that was even with precepting an intern, which slows me up a little. I got so backlogged on dictations that I was there two hours past my shift discharging patients, slapping together splints, and stabbing at pockets of pus in the hallway and I still had to go in for an hour of catch-up work today.


The rest of the time was spent running errands... picking up empty boxes, grocery shopping, buying a shop vac to vacuum up all the cobwebs and spiders that have been breeding in the basement the past 3 years, etc.


Next week I head off on my "international medicine" rotation. Two weeks of sun, and working with limited resources. It sounds like fun... especially the nearby beach and hiking part. I can hardly wait. I'm really looking forward to lounging and reading a book in the sun.

The Steamer

In my line of work, it is important to get along with one's coworkers. Doing shift-work means that we don't stay until the patient is dispositioned. Often a patient gets seen and examined, labs and imaging studies are ordered, and then their care is transferred over to the new doctor when it is time for the original provider to go home. In regards to patient care, this can be the most dangerous time for the patient as the incoming doc typically doesn't have time to fully re-evaluate the patient.

As you can imagine, everyone has their own level of comfort in decision making. After you get to know the other doctors in the group, you can typically figure out who is going to have more patients to sign-out because they tend to order more tests than everyone else, who is going to do very minimal work-ups, and who is going to intentionally order a CT scan fifteen minutes before the end of their shift so that they don't have to make the decision about what to do about the patient during their time in the department.

Like every other job, it's frustrating to get additional work handed over to you by people who seem to be determined to get by doing the bare minimum. It also stinks to come in to a full waiting room and patients who have been in rooms for hours, not seen by anyone, and the previous staff heads home seemingly carefree on-time.

At my place, we've come to refer to bad sign-outs as steamers, because the messes left behind are reminiscent of steaming piles of... well, you get it. Sometimes it's unintentional, but sometimes someone who's billed as "stable" suddenly deteriorates after shift change and it seems to be more a factor of a shoddy exam or workup because someone was in too much of a hurry. Extreme examples of this would be the patient signed out as "possible pneumonia" ending up needing a pelvic exam because their "rib pain" turns out to actually be belly pain, or in one really bad example, a "stable" patient coding in the CT scanner.

After being in a hospital for a while, you get to know how your night's going to start depending on who the previous shift was, and steamers definitely happen at both the attending and the resident level. I think that all of us ultimately want to do right by our patients and co-workers, but when there are so many interruptions in care throughout the shift, it becomes easily to get distracted, especially by the thought of it being past time to go home. It does get old after a while, and I can't imagine what it's like to be in the same place, taking bad sign-outs from the same co-workers over and over, year after year. While the names and faces will be changing out in a few months when I leave, I am sure the situation will be the same.

Eat Your Greens

I was talking with my mother the other day and she was telling me about some new sort of lettuce-type plant that she was growing in her garden. She couldn't remember the name of it, me- something or other. Jokingly, I asked her if it was mescaline, which she thought it might be, but clearly that is not it. Although that would make it more interesting when the javelina raided her garden.

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As for working the overnight after St. Patrick's day, it wasn't too bad. I was expecting all sorts of drunks and injuries, but surprisingly, there wasn't a whole lot. We were busy all night long, and I had some very sick patients, and for some reason there were people who in the waiting room all night for little things like rashes and sore throats, but it wasn't the drunkfest I was expecting.

Silence

My attitude has been in the toilet lately. I'm not sure what did it: maybe working too much, maybe not taking the time to do anything fun/relaxing, or maybe I just need a change in pace. My vacation time is all used up, so that is not an option. Fortunately, I have an elective block coming up where I will be spending two weeks with some of my co-workers staffing a small emergency department in the Caribbean. Yes, there's work involved, but there's also a nearby beach, and plenty of sunshine.

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I deal with violence on a daily basis at work: shootings, stabbings, and plain old assaults. To be able to handle it, you have to be able to separate yourself emotionally from your patient. Too much time spent imagining the pain of a steak knife entering your gut doesn't do anyone a whole lot of good; sympathy and empathy don't mix. Desensitization is a much-needed coping skill.

Recently, all of us were shocked by the death of a co-worker. She was shot by her ex-husband in front of their children. He later shot himself during a standoff with police. Both of them were brought in to the ED, and I was extremely thankful that I wasn't there when either one happened. She was someone that I knew, although not personally. I can't imagine the pain that those who worked side by side with her over the years are dealing with it, especially those that were involved in her care.

As expected, it is taking some time for people to go back to working the way they were before. It is somehow quieter, and more orders seem to be falling through the cracks, but people are piecing themselves back together, and reforming that protective shell that keeps them going.

Sweetheart

Should I be creeped out that a teenage patient of mine called me "sweetheart" the other night? He's a manipulating emancipated teen that mainly comes in for med refills and to be fed a meal every now and then. I'm sure he has a lot of great relationships in his future.

Um, Spring?

Ok, so it's not my favorite sign that Spring is on its way, but last night as I was driving in to work, I caught an unmistakable whiff of skunk. Hey, I'll take it if that means we are almost done with this winter!

We got dumped on with snow again this week, but it has almost all melted away the past two days. I'm actually getting a good view of my lawn for the first time in months. The crocus are on their way, but nowhere near blooming yet.

There's Always One

It seems that no matter how small or large the workspace, there's always one: the wackadoo. You know who I'm talking about, that special guy or girl who is prone to sudden outbursts and unpredictability. Sometimes they mark themselves with crazy hair colors or head scarves (or both!), and sometimes it's a little less obvious than that.

I think that we have more than our alotted wackadoos at my workplace, but there is one in particular that stands out. You would think that if you were a doctor or a nurse, that perhaps you wouldn't call out sick for stupid things, but you would be wrong. It is annoying when people call out sick, but most people are very apologetic and just say they don't feel well, or whatever.

Well, this particular person at my workplace likes to invent crazy stories that really don't make any sense at all. Since I've known them, they've missed multiple days at work for deaths of cats, neighbors, had three separate cancer scares, and various bizarre diagnoses that never really get confirmed. The highlight last year was when she called out saying that she had fainted, fell down the stairs, and dislocated her jaw. Supposedly, she had to put it back in herself by punching herself in the face. (Jaw dislocations take a lot of force to reduce, and not only can you probably not hit yourself hard enough, but an uppercut is not the right direction of force.) It was a really busy day, so since her jaw was supposedly back in, we asked her to come in anyway, but then she said she had lost her vision-- yet she declined an ambulance. Oddly enough, she was back to her usual state of health the next morning.

Every now and then there seem to be flare-ups in Wackadoo-land, prompting another bizarre illness. The other day, it was "I'm vomiting so hard that it's coming out my ear." While I guess the pharyngotympanic tube does connect to the nasopharynx, it is blocked by the eardrum, and it seems pretty unlikely that you could retrograde vomit out your ear. Most people open their mouths when they vomit, so it doesn't seem possible to force it back in the other direction and you'd have to perforate your tympanic membrane in the process. Nose? Yes. Ear? No.

I was talking with AG on the phone about it, and he said, "How come somebody just doesn't call 'Bullshit' on her?" To which my answer is, that it's typically easier to just work through the shift with one less person than have to deal with her antics and whining at work. At least she's creative, although it is annoying to those of us who just show up day after day and don't call out sick.

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Silk's comment on my last post made me realize I probably haven't mentioned my upcoming move. I'm graduating from residency this summer and have signed with a hospital just far enough away that I don't want to commute. It's not a position that I plan on keeping long-term, but one that will be more convenient for up until AG and I decide to relocate (hopefully somewhere warmer).

So, the house is going up on the market soon, and I'm scurrying to get a lot of things done beforehand. This week's project was painting my bedroom. There were several holes and cracks in the wall and a kind of half-ass faux finish done by the previous homeowners, so it needed to be done. Unfortunately, I didn't have somewhere convenient to stash the furniture in my room while I worked, so I resorted to shoving it around in Tetris-like fashion while I sanded, taped, and painted. I'm planning on contacting my realtor next week to come out and help me choose which projects to complete.

Housework

I celebrated Valentine's Day with a phone call from AG and we were able to exchange gifts in the mail. That morning a plumber came to the house and installed a brand new garbage disposal for me (I didn't trust myself around water AND electricity) as part of my getting-ready-to-put-the-house-up-for-sale project.


This weekend I worked a couple of shifts where we were actually overstaffed, so we all just kind of sat around. I am on the pediatric side right now, so I spent a good couple of hours sedating the Incredible Hulk the other night. He was a toddler in superhero pajamas who came in after having his 3rd seizure, so we went ahead and ran him through the MRI machine. The problem with MRI's is that they take FOREVER. A CT scan is pretty quick, but getting a small child to lie perfectly still for 30 minutes for an MRI is darn-near impossible.


This kiddo took dose after dose after dose of ketamine like a champ. He was really cute though, and came out of the machine all wide-eyed and yelling, "Whoa!" Luckily, there weren't any bad things like tumors on his scan.


Today I was off, so I spent the day finishing up painting along the stairwell, and started patching some holes and cracks in my bedroom. I really wish I had gotten this stuff done early for me to enjoy a freshly-painted house, but I think I should be able to get everything done in time, provided I can find a responsible contractor to do some cement work.

Wintry Mix

Yesterday it was 50 and sunny-- or so I'm told. I slept the day away after working the overnight shift. Today I'm off and it's now alternating between raining horizontally, frozen rain, and big wet flakes. Argh.

Avoidance

I haven't been doing much writing around here lately. Work in the PICU the past several weeks was somewhat monotonous. See the sick babies, write progress notes, round, check the babies labs, round again, blah, blah... in to work in the dark, home from work in the dark.

Sick babies depress me.

The unit was actually slow while I was there. Given the time of year, I had expected a lot of nasty respiratory illnesses, but most of our kids were post-op kids. Tiny runts on ventilators working with half a heart, or trying to breathe through little buds instead of lungs. Tubes in mouths, stomachs, chests, bladder catheters... little plastic octopi plugged into walls. And the beeping machines... yuck.

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On weekends I have been working at my other job. The extra money will be nice when it comes in, but it probably hasn't helped my attitude. Some days are good and I walk out of there confident and ready to start my upcoming new job, and some days are not so good. One of the other residents and I were on together the other day, and although I was in the room helping her for almost an entire hour, the patient ended up dying anyway. We have talked the case over and over since, and even though everyone has told us over and over that we did everything right, there's still that feeling of failure.

I don't know why I take it personally when patients die, but I do. If anything, we probably overworked the code-- shocking, giving every medication, and doing compressions so vigorously our joints hurt the next day. Obviously there will always be some that are too sick to save, but it just aggravates me when people die in front of me.

Up until that shift, I was thinking that I was ready to start doing single-coverage (working without another physician on in the department), but now I'm hesitant to do so. On the one hand, I think it will be a good while before I have a case that emotionally draining again. We were lucky in that both of us were able to devote our attention to the one patient, and because I was there, I was able to go back to seeing new patients and cleaning up the rest of the rooms while she spent the rest of the evening dealing with the family and other stuff. I can't imagine what the would have been like if I had been there by myself, especially as I soon got wrapped up in stabilizing a patient having a heart attack and getting him shipped out as quickly as possible. I haven't had the wonderful experience of having to run in between two or more unstable patients yet, and am not looking forward to it.

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Things are starting to normalize around here. I have umpteen projects to do before I put my house on the market in the next few months, and kept myself busy this past weekend taping and painting the hallway along the stairs.

AG is safe and doing well, although frustrated by his minimal trips "outside the wire".

I did my taxes already, now I'm just stalling on paying them until April.

I'm back in the department starting tonight, so at least I'll be around my people more the next few weeks.

More Winter

Phil is now on my hit list. I don't want another six weeks of winter! On the plus side, it now doesn't get dark here until 5:30 pm, so spring must be on its way, although not fast enough!

Superbowl

Ate too much and didn't think about work. I thought that this commercial was the best.

The Greatest Gift

She was already dead when I came in to work. Blunt head trauma sustained during a common winter activity. Not breathing, and intubated on scene by paramedics. Despite two emergent neurosurgeries, there were no signs of improvement. The day before she had failed neurologic and apnea testing.

For some reason, the weekend team did not want to declare her brain dead the day before, so we waited, as a re-evaluation by neurosurgery had been promised. When I first examined the patient that morning, her family members were yelling at her nurse for not supporting their hopes that she would wake up. I just quietly listened to the patient, and did a quick neuro exam and let them be.

When we rounded as a team, the child's father told us that they were waiting for a miracle. He said that he believed in the Bible and there were cases where people had been brought back from the dead. He didn't believe that God would allow his daughter to survive the accident only to die now. My attending said that he believes in miracles, but that from his exam, the child was clinically brain dead. He apologized to her father, but said that in his opinion, their daughter did not survive the accident. He told them that they should talk to only the loved ones whose opinions they valued. They would have some decisions to make, including possible organ donation, if the child was confirmed brain dead by neurosurgery later as he suspected.

Neurosurgery finally came back to the bedside and the same tests from the day before were repeated. Again, there were no signs of brainstem functioning or breathing. Time of death was declared, and the family was given time to talk with their pastor and social workers.

It was an awkward situation for us to walk into that morning, having not met the family beforehand, but I think that my attending handled it pretty well. I believe in miracles, too. I would have also added that miracles and unexpected outcomes happen in spite of what we do. As a physician, there is nothing that I can do to stop one of God's miracles from happening. Some people recover in spite of showing up late in their disease, while others seek treatment immediately, get treated aggressively, and still die. Life is unpredictable. While I have not seen anyone declared brain dead recover, I have seen a patient recover from removal of life support when it was expected to be a terminal wean. Maybe that's how I rationalize dealing with my own values though, when sometimes families and powers of attorney make different decisions than what I would do. However, at the same time, I think that saying something like that also helps the family to move through their grief. To the family members, there is never going to be an acceptable time to remove life support. They will wait, day in and day out for weeks, and even months. It's horrible to watch families camp out in hospitals, losing sleep and sometimes risking their jobs to be at the bedside of a loved one non-stop, especially when there is not expected to be any recovery.

In the end, the patient's family decided to donate her organs. An organ transplant service was contacted, and they set out immediately looking for matches across the country. Things got a little hairy while we waited as the patient developed renal failure, had great swings in blood pressure and glucose levels, and lost the ability to concentrate her urine (likely due to pituitary infarction). It took about 36 hours of constant work to arrange, but three separate surgical teams were flown in and coordinated to harvest her heart, lungs, kidneys, pancreas, small intestine, corneas, bone, and skin. In the end, she helped about 50 people, a significant number of which were probably children.

I think that this child was part of a miracle, it just wasn't one for her family. It was amazing that she was able to help so many others, and that her family was able to make the decision to donate in spite of the shock of an unexpected death.

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For the last couple of weeks, "Grey's Anatomy" has been focused on a small boy needing organ donation. However, in their scenario, the surgeons are running all over the hospital testing critically ill patients to look for a match, and pressuring their family members to donate. In reality, this is prevented by the use of independent organ donation teams. Once we find a donor (typically emergency and ICU patients), the procurement team is contacted and they come in and run the show as far as looking for matches on the national database.

While it makes for good drama on TV, there are obvious ethical concerns about having the same doctor caring for a potential donor and a potential recipient. We can't randomly test people for matching a recipient without their knowledge, and have no control in regards to what order on a recipient list a patient is. So get it together, TV writers, that was just ridiculous-- I'm not running a chop shop here!

2008 Reading List

Continuing in my quest to read less and less each year:

The Kite Runner - Khaled Hosseini

This book was pretty engaging, an interesting account of the author's life in Afghanistan.

Animal, Vegetable, Miracle - Barbara Kingsolver

An account of a year's worth of sustaining a family by only buying locally, growing fruits/vegetables, and harvesting poultry. Is this really possible? Probably not for your average working family, although it did make me think more about supporting my local economy.

Bringing Down the House - Ben Mezrich

This one had been in my reading pile for a long time, but I had to read it before going to see "21". Still can't seem to win at poker.

I am America (And So Can You!) -Stephen Colbert

If 1,000 monkeys typing on 1,000 typewriters can randomly peck out "War and Peace", this is what 10 crackpots armed with macbooks and endless coffee can do. Ridiculously goofy.

Not So Funny When it Happened - Tim Cahill

I don't remember this one too well, but I think that it did make me smile.

Intern, A Doctor's Initiation - Sandeep Jauhar

My mother sent me this one. It's the story of one guy's progression through residency. He struggles to find balance between family life and work. A lot more sunny perspective than "House of God".

The World Without Us - Alan Weisman

If you suffer from insomnia, this one's for you. There were some interesting points along the way, but so slow and painful.

Into the Wild - Jon Krakauer

Haven't seen the movie. I read this soon after returning from Alaska. Kind of a bizarre story, and tragic to die so close to aid under the delusion of a wilderness adventure. Wondered if the guy wasn't an undiagnosed schizophrenic.

Love in the Time of Cholera - Gabriel Garcia Marquez

Joined a book club, read the book, then missed the meeting (oops). I have another book of his sitting on my shelf, but this one was kind of weird. I think I missed the romance behind the protagonist's delusion that if he could seduce one widow, he was fated to wait out the marriage of his one true love and get the girl in the end. Also, enemas? Not an intimacy to be shared between lovers! Ugh.

You Don't Know D _ _ _

The PICU is running at about half-capacity this week. As a result, we had the Inauguration coverage playing live on the television in Room 1. There were about a half a dozen of us clustered together in there at one point, when suddenly--

"Who's the guy in the wheelchair?" a lone voice questioned.

"That's Dick Cheney, he strained his back packing, or something." I said.

"Who's Dick Cheney?" she asked.

"Only the current Vice President, who's been in office for eight years." scoffed my attending.

"Dick Cheney, you know the guy who shot some guy in the face while he was out turkey hunting," a nurse chimed in. (Well, at least she was sort of right.)

"Oh yeah, that guy... Huh, I guess I've never seen him before," she said, defensively.

There was kind of a long, awkward pause and then people started guessing who Nancy Pelosi was. To their credit, they did recognize Steven Spielburg...

Brr

-11F is really just too silly to go outside.

New Low

The other day I confronted a woman who was seeking pain meds. The medical student saw her first and there were a few things during her presentation that just screamed that this lady was going to be trouble:

1. Abdominal pain x 1 year

2. Recent month-long admission with no diagnosis

3. Multiple abdominal surgeries

4. Allergic to morphine, "Only Dilaudid works"

5. "I need a PICC line, no one can ever get an IV on me."

At first I felt mildy guilty for being cynical, but as the case unfolded, it turned out she had lied to us during the interview. When I had asked if she could be pregnant, she said, "No." When I told her that she was, she said, "Oh yeah, the hospital yesterday said that, too." Her pain had been coming and going for about a year, so there wasn't anything to do emergently besides some basic labs and physical exam.


We got ready to discharge her and she asked for pain meds. As it turned out, she already had a prescription for narcotics from another hospital, but it wasn't very pregnancy-friendly. I don't like talking down to people, but in this case I told her that the only way I would give her a prescription for a pain medicine was if she gave me her other one to destroy. So we traded prescriptions. Let's just hope she doesn't call the other hospital up saying she "lost" their prescription. In the meantime, I've sent a nasty-gram to her primary physician. I will still probably end up with a letter from the Board of Health in a few months letting me know she got multiple prescriptions from different providers, but at least she left my department with a prescription for a safer drug.

Just before discharge, I looked her up in our computer system, and the only thing listed was a previous admission for what turned out to be pseudoseizures and there was a mention of "drug-seeking behavior". When we confronted her, she didn't deny seeking pain meds, but now I wonder if I didn't miss the real diagnosis.