July 2008 Archives

The patient had already been intubated when I saw her in the ER, so I wasn't able to get much history. The story was basically - asthma exaccerbation, can't breathe, intubated.
We extubated her this morning. Great! My opportunity to find out her story and get a better handle on this patient.

"So, tell me, what were you doing before you came into the hospital?"
"I was at my boyfriend's house. We were watching a movie about this guy, who takes out your eyeballs and eats them!"
"Oh, wow. Ok. Then what happened?"
"Then, it turned out that he was really an alien from outerspace. But he was just disguised as a human. And he wasn't really eating the eyeballs, but just collecting them for experiments!"
"I see. But what was it that brought you to the hospital?"
"An ambulance."
"And the ambulance came because..?"
"Oh, my boyfriend knew something was wrong, so he called 911."

This is a theme I've been meaning to bring up on this blog for a long time but haven't gotten around to it until now: is there anyone else out there but me who feels that there is something drastically wrong with the way medicine is taught on the floors? Don't get me wrong, some attendings are fantastic. But there are some who continue to rigidly adhere to the attitude that they are somehow teaching us by not giving us the answer.

"Dr. Pulous, how many days of treatment would you give for a patient with this type of pneumonia?"
"Why don't you look it up and tell me?"

"Dr. Song, in what situations do you give bicarb to an acidotic patient?"
"That's a great question. What do you think?"

Yes, I am an adult learner and I am perfectly capable of looking up the information myself. But, since I happen to be in the presence of someone who knows the answer and whose job it is - at least on paper - to teach me thing about medicine, I just thought maybe you might be gracious enough to share some of that information with me.

One attending's reasoning behind not giving us the answers was, "If I tell you the answer, you won't remember." Well, Jesus Christ! That may be true. But, if you don't tell me the answer, I'm sure as hell not going to remember!

Where did this warped concept of what it means to teach come from? In any other teaching situation, information is supposed to flow downhill - from the people who are more knowledgeable to those who are less knowledgeable. Many readers of this blog will be familiar with the adage - If an attending asks you a question and you don't know the answer, a great response is "I don't know, but I'll look it up. To all learners in the medical community, I now propose a coup. If someone in a teaching position asks you a question and you don't know the answer, do NOT offer to look it up. Stand firm at the gates. There is knowledge is that brain; he can only hold onto it for so long. Hold your patients hostage, if you have to. You're the one writing orders, after all. Make your teachers understand that they can either tell you how to properly take care of your patients, or allow your patients to be subject to your guesses at how to take care of them. Medical learners unite, and we shall overcome!

Now that I have your attention, let me start by saying that restricting access to contraception is precisely what the new federal policy proposed by the Bush administration does not do. By defining emergency contraception and IUD's as "abortion," what the administration wants you and your grandmother to think they're doing is restricting access to abortion services. Please explain to your grandmother that they are doing no such thing. It's nothing more than a political gimmick to energize the right wing, conservative Christian base. What this new policy would actually do is to restrict federal funding for hospitals that refuse to hire personnel who refuse to provide abortion services. Sound confusing? In other words, this means is that if you're a hospital who receives any federal funds, you cannot discriminate against health care providers who refuse to provide abortion services (abortion being defined as noted previously). But, there are already federal laws prohibiting such discrimination in place! The only additional requirement that this new rule imposes is to force these hospitals (if they want to keep their funding) to certify in writing that they are in compliance with federal laws already in place. It is a proposal that is very carefully crafted to do NOTHING!

The aftermath has played out in the fashion of a Shakespearean farce. Rather than ignoring this proposed nonregulation, the democrats have seized on it as an opportunity to lash back - calling it "...A dangerous assault on women's health."

Nobody is more in favor of providing contraception and family planning services than I am. But please, let's make sure the battles we fight are meaningful ones. A federal ban on partial birth abortion, for example, could potentially have the effect of seriously limiting the medical options available to a woman for managing complications during the second trimester of her pregnancy. This current proposal does not mess with the legality of abortion, or birth control or with the laws that are currently in place in 14 states guaranteeing women who are in need access to emergency contraception. It may keep one or two reactionary pharmacists from losing their jobs and will certainly generate extra paperwork but, in the grand scheme of things, I think us progressives can live with that.

First mages ever captured of an ovulation in progress! Read more here.

Does race make a difference or does it not make a difference?
I remember a time, a simpler time, long ago, when the common wisdom was that the solution to the problem of racism was to achieve a color-blind society - a society in which a person's skin color made no more difference to anyone than the color of his eyes. We seem to have lost our way at some point, deciding that we, as a society, believe that race does make a difference. As another example of this fact, the AMA has recently apologized for racial disparities in the provision of health care in this country.

I have to wonder, do they really understand what they've done? A perfectly analogous situation would be if the justice department were to apologize for the disparity between the number of blacks and whites on death row. Can you imagine the public outcry if that happened? I mean, we already knew that there way more blacks were convicted of murder but we didn't realize that you guys were preferentially convicting them on purpose! Why were you doing that? And if that's what you're doing, don't apologize, just stop doing it!

Likewise, the AMA's apology amounts to an admission of racism. They have apparently been intentionally giving inferior care to their African American patients. Again, rather than apologize, why not simply stop doing it? The answer, of course, is that they really aren't responsible. With rare exceptions (the Tuskegee experiment, comes to mind) you won't find any doctor who makes it part of his practice to provide one level of care to members of one race and another level of care to another race. Nor are any such health care policies in place, nor has the AMA issued any such guidelines. Are there disparities in the levels of care that blacks and whites receive in this country? Absolutely, there are! Just as there are huge disparities in income, level of education, crime etc. But for the AMA to say, "Yeah, sorry. These disparities exist because we fucked up. We've been giving shitty care to blacks while giving excellent care to whites, " is obviously ludicrous. If this were the case then the solution, as I have said, would be simple - STOP DOING IT! But, even though the AMA has apologized for these disparities, I'm pretty confident they will persist - at least for the short term. Which means that either a) the AMA was never responsible for these disparities in health care to begin with or b) they were responsible, but are going to choose to go on providing disparate care based on their patient's race.

We need to put aside this issue once and for all. The simple existence of racial disparity would not be a problem if race made no more difference to people than hair or eye color. Can you imagine anyone studying whether blue-eyed people received the same level of health care as brown-eyed people? If there are systematic ways in which our society is treating whites differently from blacks the solution is to seek out these injustices and to fight them. But the simple existence of these disparities does not necessarily point to any such injustice. And, if we are serious about achieving a color-blind society, the question of racial disparity is one that we need to stop asking.

Nothing forces you to come face to face with your own inadequacies quite like medical school and residency. I certainly have my share and there are many posts in store in which I plan to reveal my failures, shortcomings and flat out disasters. By contrast, there are two particular areas in which I have always excelled. Namely, maintaining objectivity and withstanding the various sights and smells of blood, pus, feces, urine etc. Except when it comes to the male genital tract.

While on call last week, I received the following page: "Mr. Gephardt has pulled out his foley; there's blood everywhere. You should probably come see." The nurse's words were calm and measured - as if she'd seen this a thousand times before. She seemed almost apologetic at having to wake me for something so trivial. I walked over to Mr. Gephardt's room. There was, indeed, blood everywere. The nurse didn't need to say another word as the blood splashes on the floor told whole story. The story began with Mr. Gephardt pulling out his foley while still in bed, walking over to the bathroom to urinate blood, walking from the bathroom to the nursing station (with no clothes on, mind you, and still dripping blood) and back to his bed after being chased there by the nurse from whom I had received the page. And the most relaxed person in the room was Mr. Gephardt himself.

"Mr. Gephardt, you pulled out your foley." I tried to sound as matter-of-fact as possible.
"No, it just sort of fell out."
"Did it hurt?"
"Yeah, it hurt!"
"Does it hurt now?"
"No."
He wasn't actively bleeding anymore. So, I went back to the call room, arriving just as my vision was about to turn completely black and just in time to pass out on the bed rather than on the hard tiled floor.

When there is blood coming from the female genital tract, I've never had an issue. During my former life as an OBGYN, I used to handle buckets of it! When it's coming from the male genital tract, I need to put my head between my knees and take some smelling salts. I could never have been a urologist.

For those of you unfamiliar with the concept of a foley catheter, this illustration should help you understand what I'm talking about.

I made quite the startling diagnosis in clinic today. The patient was brought in by her mother with complaint of a fever 2 days earlier. She had also had some diarrhea but otherwise no complaints and no significant past medical history. Sound like a straight forward case of gastroenteritis, right? WRONG.
On physical exam, I could tell immediately that something about this patient was grossly abnormal. She stood 36in in stature at most, weighed 38lbs and appeared to be a stage I on the Tanner scale of sexual development. Her language and intellectual capacity also appeared to be markedly underdeveloped as she mostly appeared to understand what I was saying, but didn't speak throughout the whole encounter and was uncooperative during the physical exam.
Before going to present to my attending, I scoured the medical literature for what might cause the bizarre confluence of findings. And then, like a blot of lightening, it all made sense and I was able to confidently give the patient a diagnosis of...child!

Before today, I hadn't seen a pediatric patient since my first medical school rotation - now going on four years ago! It kind of throws you. If someone had brought in their cockatiel into the clinic for an evaluation, I'd have been just about equally flustered. To be fair, I actually had seen one or two pediatric patients during my tenure as an OB resident, mostly either for injury related to sexual abuse or to remove a foreign body. Those cases are kind of different though. OB's don't have to medically manage the patient. To us, she's just a minature vagina that has some strange creature attached to it.

The fact that I'm now a doctor somehow causes everyone around me to assume that, if they have a problem and there is no other specific person who has the solution, I am the one to turn to. "Doctor, I've noticed my dog's farts smell a lot worse lately." "Doctor, I think my son might be gay. Can they do hypnosis for that?" "Doctor, I have a nearly uncontrollable urge to shout obscenities when I go to church." This is a priniciple I have been familiar with since childhood. The reason this knowledge did not deter me from going to medical school is that I believed, naively as it turns out, that medical school would actually prepare me to answer these questions. After all, there must be some reason people feel their doctor should have an opinion on whether or not they should let their child play violent video games. I figured, as many others do, that doctors must have access to some secret, ancient knowledge to which only a chosen few are allowed access. In fact, somewhere deep in my subconscious, I'm still hoping my program director will turn a wall-mounted oxygen dial in a particular sequence opening a hidden passage leading to a dark room deep below the hospital where he will gather all the interns, tell us to forget everything we learned in medical school as it was just to keep up appearances for the general public, and unlock a dusty, leather-bound book containing the real answers.

Clem Bronson, a 70 year old army vet from Oklahoma who wears cowboy boots, gray hair down to the shoulders, a thick bushy mustache and a face that appears to have been left out in the sun too long had been admitted two days earlier with a COPD exaccerbation. On the way to his room this morning, I was confronted by the respiratory therapist. "Mr. Bronson really made upset Rachel this morning." Tall, blond, 25 year-old Rachel was his nurse today.
"How so?"
"He was making comments about her legs and her butt. Rachel told him to stop, but he didn't. She was really upset."
And, the fact that I went to medical school and wear a white coat makes me qualified to deal with this situation how?

That morning on rounds, we decided to have a little chat with Mr. Bronson about his behavior. His response, "Yeah, I know she's upset. She'll git over it." Great. And in regal fashion, the men in white coats come charging forth in order to...have virtually no impact on the situation. If it happens again, plan B is to recruit the second large category of professionals one goes to when there's nobody else who is specifically qualified to deal with their problem - the police.

I'm currently on one of the hardest rotations our program offers. I had the day off the other day and I went to pick up my first paycheck. My program director happened to be there at the time.
"How's it going?" he asked, with a look of genuine concern.
"Oh, it's ok. I had eight patients on my first day, so that was a little rough. But everyone's really helpful and I'm getting the hang of things."
"Good, glad to hear it. We do our best but for some of these rotations, we seem to be just perpetually short on personnel. I appreciate you're sticking with it."
I almost forgot to pick up my paycheck as I was preoccupied with picking up my jaw off the floor. I'm still getting used to the idea of being in a residency program where the job that they ask you to do is actually reasonable and where your hard work is appreciated. Especially having come for a program where the job you are asked to do is not only unreasonable, but where you're expected to be grateful for the wonderful experience this unreasonable job is affording you. Let me try and give you and idea of the sharp diction between the two.

QUESTION	RESPONSE
	New Program	Old Program
Are there any more patients for me to see?	Nope, you've reached your cap!	There are 12 more, and you also need to cover the next three c-sections.
My mother died, I have to go to the funeral on Monday.	Ok, we'll have the jeopardy intern fill in for you.	Sorry, we need you to work on Monday. Can you have the funeral when you're on a lighter rotation?
I saw your patient, did the appropriate workup and she's all tucked away.	Great, thank you!	Why did you wait so long to tell me she was here!
Slouching forward, falling asleep in the computer lab	You look tired, why don't you go rest a couple of hours before your night shift starts?	Since you're not being very productive here, why don't you go help out on labor and delivery?

Oh, I'm sure I'm in for all kinds of long, crazy nights on call and run-ins with evil attendings over the next three years. But, so far I'm really feelin' it, here at my new home.

I had a few projects to work on tonight - none of which really panned out. The problem is that my beautiful new Gateway FX7026 (which has apparently already been discontinued as I can no longer find it anywhere on Gateway's website) is currently in the custody of DHL, en route to the Gateway mothership for some repair. In the meantime, I'm using my old 128MB of RAM Compaq which is broken in so many subtle ways that I want to stab it with a pitchfork. Therefore, I'm not going to be doing any structural work on my blog for a week or two. I will, however, continue to post daily or at least semi-daily.

The FX7026? He's fine - thanks for asking. His motherboard was just slightly misaligned. This, unfortunately, was making 5 of the 7 USB ports unusable. Otherwise, he's running great! I'll keep you updated on his condition. He should be getting discharged very soon!