Ward Month 1 Complete (Part 2)

In just the first month of being an intern, I’ve already had the curtain lifted from my eyes in different situations.  I wanted to document my thoughts and memories about the “frequent fliers” of the resident service.

It’s 3:30 in the morning, my pager goes off, then my cellphone, the resident saying we have an admission in the ER.  But, not to worry, he’s a “frequent flyer” and we’ll have it done in no time.  The resident also tells me that, as an added bonus, I’m going to learn how to manage diabetic ketoacidosis (DKA).  So I get my stuff together and wander up to the ER, wondering how the resident knows that it will be a routine DKA admission without ever seeing the patient.

Little did I know, the 23 year old, Type I diabetic who is also a drug addict and alcoholic has had over 100 ER visits in his life.  He has no insurance so he always gets the stellar care of the resident service.   Reading old dictations, the story is almost the same as a month or two ago…drinking a gallon of whiskey a day, stopped taking insulin, in ER with messed up metabolism.  I dictate almost an exact replica of the last H&P, start some fluids and insulin, and wait for labs.  My resident and I talk about just how many interns this same patient has taught how to manage DKA insulin, fluids, and labs…and I get frustrated and depressed.  One guy, refusing to take his insulin, drinking, and lost in the world has a bill of probably over $50 million for ER visits, ICU admissions for DKA and insulin drip management, attempted inpatient alcohol treatments, and medications.

We managed to reverse his DKA over the course of a few hours in the ER, preventing the use of an ICU bed.  He denied any help with his alcohol use and we sent him on his way after a meal.  I would go on to take care of him about a week later in the ER, with the same problem again.  I wonder if every new intern will have a chance to learn to manage DKA with this “frequent flier?”

There are many other stories of the “frequent fliers” of Cottage, teaching interns to treat DKA, endocarditis, alcohol withdrawl, etc.  From my first month I can recall a few special patients.  There was the man with no colon and only some small intestine left who enjoys milk so much that he drinks 120 oz of it each day.  Nevermind that this causes his GI tract to flow like Niagara Falls into his ostomy bag, severely dehydrating him and pickling his body.  Best part is, he refuses to learn to change his ostomy bag or stop the milk because he just loves Cottage living so damn much!  I did learn to work up chronic diarrhea, and my “frequent flier” made a new friend…

Frequent fliers are the perfect example of the system’s reactive approach to healthcare.   The same problems are solved over and over again. However, what I’ve learned is that the reactive nature of healthcare in the US is not always the fault of the system, but it is what the patient population demands in many instances.  Until we find a way to motivate, alter behavior, and bend will, the healthcare system must react to the decisions, however harmful, of the patient’s we aim to treat.