Recently in Medical Category

Sometimes I look inside my head and see a violent, stormy ocean of ideas such that I need a life jacket in order to stay afloat and to make some kind of sense of things so as not to unleash fragmented bits of unfettered emotion onto the world. Other times, there are nothing but sand dunes as far as the eye can see; even the rare oasis quickly drained before it can quench anyone's intellectual thirst. After staring off into space for about 10 minutes, realizing that I am clearly in a state of mind more closely resembling the latter, I came upon this article: Mary-Kate Olsen Wants Immunity in Heath Ledger Case. What was more interesting to me than whether or not Mary-Kate is going to cooperate was the following quote, "Investigators have interviewed Ledger's doctors and found prescriptions for every drug so far except Oxycodone and Vicodin, two powerful and often-abused painkillers..." So, is it malpractice if a patient overdoses on a drug that I prescribe? Any real attempt to answer this question would require far more brainpower than the wasteland inside my head is going to provide me with. What's your answer?

Housestaff members of the MICU team at University Hospital are slowly beginning to rebuild in the wake of attending physician, Marshall. Pulmonary and critical care specialist, Hugo Marshall, who reached an unprecedented level five on the malignancy scale, caused general devastation to University Hospital MICU service leaving behind broken dreams, flooded hopes and dashed egos. As no such attending had struck University Hospital since 1977, the residents and medical students in his path found their emotional infrastructure was not sound enough to withstand the torrents of sarcasm and belittlement that characterized Dr. Marshall's two weeks on service.
"It was horrible," recall internal medicine intern Amelia Cruz and family practice resident Michael Silverberg. "We lost everything - our confidence, our desire to learn, even our will to live. It's going to take months to rebuild our sense of worth and to start functioning effectively as doctors again."
Attending physician Marshall could not be reached for comment, but forecasters predict he will continue to move eastward across the hospital where he will strike the pulmonary clinic sometime early next week. Many housestaff in the area have no means of evacuation and have been sighted employing strategies such as barricading the call room doors and laying stronger emotional foundations.

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.

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.