Lingering residue from tobacco smoke which clings to upholstery, clothing and the skin releases cancer-causing agents, work in PNAS journal shows.

Berkeley scientists in the US ran lab tests and found “substantial levels” of toxins on smoke-exposed material.

They say while banishing smokers to outdoors cuts second-hand smoke, residues will follow them back inside and this “third-hand smoke” may harm.

via BBC News – ‘Third-hand smoke’ could damage health.

The war on smokers continues.  I am against smoking, but don’t get this ‘they’re endangering everyone around them’ approach.

Breaking news: life is dangerous.

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Welcome to Grand Rounds for February 9th. How are you? Sitting here, finalizing the posts, I am stricken by my utter inability to say anything nearly as entertaining as Dr. Rob did last week. I mean, I don’t have a single llama picture to offer you! I’m very disappointed in myself.

via edwinleap.com | Grand Rounds is up!.

No llamas?  Oh, well.  It’s still good.

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I am going to state something that is completely obvious to most primary care physicians:  I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance.  If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit.  This is totally obvious to me, and I suspect to most primary care physicians.  A huge part of our overhead comes from the fact that we are dealing with insurance.  A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge.  As  it stands, the percentage of my collections that goes to overhead is between 50 and 60% (depending on the month).  A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing, and documenting.  If I dropped insurance and charged a fixed amount, I could:

1. Cut my billing staff nearly to zero (someone would still have to do bookkeeping).
2. Increase my payment per visit, which would allow me to see less patients per day.
3. Document for the sake of patient care, and not for the sake of getting paid.
4. Add extra services like email access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid?  Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me.  There are several reasons why this is possible for insured patients:

• Insured patients generally have the option of filing for their own insurance (there are some that still don’t allow this, but that number is dwindling with the decrease of HMO’s)
• Insured patients could choose to just pay me cash if they choose

Can’t Medicare/Medicaid patients do this?  No, for several reasons:

• If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files.
• If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered).  So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud.
• If I drop M/M, I cannot sign up for it again for 3 years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still?  Why would I continue to make my life so difficult?  Two words: duty and calling.  I view my seeing M/M patients as a social responsibility (especially Medicare).  These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income.  So far.

Plus, I just like to take care of the elderly and the poor.  My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need.  If I dropped M/M I would reject the calling for personal gain, which is something I can’t do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care.  The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system.  I am personally willing to continue on this course as long as (it doesn’t get too much worse) but I have complete sympathy for PCP’s who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP’s.  PCP’s keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital.  The system is just holding on with the PCP’s we have; decreasing that number would be devastating and perhaps fatal to the system.  It’s a very bad sign when the best business model for PCP’s is to do something that, if done by all PCP’s, would wreck the system.  Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors!  They have to earn less money!  They have to actually have a conscience!  What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle, and live by my conscience.  At this time, most PCP’s accepting M/M are doing the same.  But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish.  Pushing down M/M payments for PCP’s will make a bad situation worse.

That’s bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

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Remember the old saying, “Don’t put anything in your ear except your elbow”?  You can’t do it!  In other words, don’t stick stuff in there - technically not even Q-tips. Although if you are really careful and don’t go in very far, they are usually OK.

Anyway, I had a guy who was using a Q-tip like that - but I guess was a little too enthusiastic about it. The cotton swab tip broke off and got stuck in his external ear canal. This is not the end of the world but he decided on an aggressive approach for its retrieval. He straightened out the a paper clip and JAMMED IT IN THERE to try and snare the cotton. You can see a bad ending here…..

Well, guess what? Laceration of ear canal and perforation of his tympanic membrane. Dude, follow what your momma told ya!!!!!!

Tokyo, Japan (CNN) — A body was found in the landing gear bay of an airplane that arrived at Tokyo's Narita Airport Sunday, the airport announced.

The dead man was not carrying a passport or personal belongings, airport police said.

via Body found in plane’s landing gear bay in Japan – CNN.com.

JFK to Narita.  Someone was able not just to approach this aricraft without appropriate ID, but was able to climb into the landing gear bay (under the wing structure, next to the fuel tanks) and hide there.

FWIW, stowing away in a wheel well is a bad way to die.  If you’re not crushed to death by the landing gear coming up (it’s hydraulic, powered to lift a couple of tons against high airspeeds, there’s not any ‘extra’ room in the wheel well*), there’s not enough oxygen to survive at cruising altitude, even if it were heated, which it’s not.  So, don’t try it.

Now, substitute the word bomb for body.  Someones’ security isn’t good enough.  By far.

*Dad was an airline mechanic; back in the Good Old Days, kids could go to work with their dads and watch their dads work on them (and occasionally I got to empty out ash trays and arrange seat belts).  I learned a lot from that.

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If you downed one too many while watching the Super Bowl, here's at least one reason to hold your head high: Drinking beer can be good for your health.

But seriously, a new analysis of 100 commercial beers shows the hoppy beverage is a significant source of dietary silicon, a key ingredient for bone health.

via Beer May Be Good For Your Bones | LiveScience.

Beer.  Wonder and medicine, in a convenient serving size.  (Also, silicon).

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Report a bad doctor to the authorities, go to jail? It might really happen for Anne Mitchell, RN in Winkler County, Texas : Respectful Insolence.

He’s been on this from the beginning.  Good news: one of the nurses was dismissed; bad news, the other is on trial.

Atrocious.

My grandparents lived in Winkler County (Kermit), and are gone now.  I think they’re spinning in their graves over this.

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Adding fuel to the fire is the fact that the doctor has been reprimanded by both the hospital ( he had been reprimanded on several occasions for improprieties in writing prescriptions and performing surgery and had agreed to make changes) and the Texas Department of State Health Services for some questionable actions including “suturing a rubber tip to a patient’s crushed finger for protection” (which in my opinion might actually not be a bad idea in the short term). Also, the physician appears to have a unique friendly relationship with the local sheriff Robert L. Roberts Jr (who the hell names their kid Robert if their last name is Roberts?) since he reportedly saved the sheriff after he had suffered a heart attack. Who knows how far this would have gone if they were not buds?

Anyway, I personally think this is some serious stuff. On one hand, it is obviously libel for a nurse to write inflammatory anonymous letters about a physician JUST to destroy his or her career but of I believe it is also a nurse’s (as well as other staff) ethical and official duty to report physicians for dangerous behaviour that puts patients’ safety in jeopardy.

15% off MedMan
scrubs with code “erman”

As an engineering piece ( and without having used it ) it looks terrific.

But, I usually buy a new can shortly after I lose the straw. How will their sales do with this unlosable straw gadget?

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Washington (CNN) — All U.S. military health facilities around the world will now carry the emergency contraception pill known as Plan B One-Step, according to a new Department of Defense policy.

The decision to carry the pill, often referred to as the morning-after pill, was based on a recommendation by the Pentagon's Pharmacy and Therapeutics Committee, an advisory panel made up of medical professionals from the military services, Pentagon officials said Friday.

Many military hospitals already carry the pill, but the new action means it will become a standard part of every medical facility's stock of drugs, including those on bases in Iraq and Afghanistan, the officials said.

via Military increases availability of morning-after pill – CNN.com.

Mostly right, I’d say.  I do wish it was OTC (for installations large enough to have a store of some sort) and not force women into Medical for it (it’s OTC in the US), but it’s better than not having it.

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Patient: “Great!”

Patient’s Husband: “Doc, can’t you keep her for a few days, she is driving me NUTS!”

Trying to avoid a painfully long wait in the ER?

One local hospital system is publicly sharing the current average wait time to see a doctor at all its emergency departments.

Akron General Health System recently began advertising up-to-the-minute wait times for its emergency rooms on billboards throughout town.

Six digital billboards in Akron are automatically updated every 20 minutes to show current average wait times to see a doctor …

The average times are computer generated, based on current patient information from the health systems’ electronic medical records…

via Ohio.com – Akron General puts ER wait times on billboards, Internet.

I think this isn’t terrible, as long as there’s some education that a) these are average times and that b) if you have a real emergency you go to the head of the line.

Oddly, I think this is different than the (currently boutique) practice of scheduling an appointment at an ED over the internet.  I think if you have the time to schedule your emergency, you don’t have one.  So, get a doctor and go there.

Bring on the ‘average wait times’, but make sure the same display is visible in the waiting room!

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And, I don’t care.  Yes, he mispronounced a word I think he should have known, or asked about.  He didn’t, and that’s just one of many things I wish he’d done differently.  Who cares.

He did recognize the service of this corpsman (pronounced cor-man), and to me that’s what matters.

Thank you Navy Corpsmen: what you do matters, and you’re appreciated.

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We’re wondering when the insanity will end. My co-chief has determined that if she leaves the admitting pager on her desk rather than holstered in its clip that it goes off less often. We’re going to repeat the experiment next week with me to check inter-rater reliability. We are in the throes of respiratory illness season; we are damning ourselves for not buying more stock in the company that makes albuterol.

Today was our first rank order list meeting. For the uninitiated, in order to become employed as a resident here in the US, you need to enter The Match. If you want to know the dirty details about how it works, go here. In short, med students apply for residencies and residencies select applicants to interview. Once the interviews are done, applicants rank their programs from most favorable to least. The residencies do likewise. The match attempts to be an impartial way at matching the best applicant to the best program. There was a lawsuit contesting the legality of the match a few years back but was subsequently dismissed.

Anyway, if you want to complete your training, you need to enter the match. Match Day is always the third Thursday in March. Sometimes it coincides with St. Patrick’s Day but almost always coincides with the start of March Madness. I spent my Match Day with my butt parked on a barstool watching basketball.

We now have the long and arduous task of reviewing all the applicants we interviewed and ranking them. We interviewed about six or seven applicants at a time twice a week for ten weeks. That’s a lot of files to review.

We holed ourselves away this morning for a few hours to get the party started. I brought bagels and we dug in.

At one point I looked up and looked around the table and thought at how absurd and surreal this was. I was sitting among the program director, the two assistant program directors, our education administrator, the general pediatrics division chief, and the most senior pediatrician in our department, who is also a former department chairman. This truly is the Inner Circle.

How is it that four years ago I was a file on the table and now I’m sitting at the table?

I spent so long trying to get in and now that I’m in, I’m starting to look out.

Where I am right now is a very good place to be.

Moment of Burrito:

I am mad at congress.

I don’t care if they are Democrats or Republicans, I am sick of healthcare being treated as a political football.  How much more of a crisis do we need before we actually start working on a solution?  Why does each party have to sit on its side of the aisle shooting spitballs at the other?  Each side has its pet issues that are tied to contributors, supporters, and lobbyists.  Each side will work to see the other side fail even if the other side is right.  Each side seems unable to do anything unless there is political value in it.  Power is more important than service, and power is a short-term project.

The real problem is that congress is thinking of short-term political gain while sabotaging the long-term.  It’s like the publicly traded company that works to maximize quarterly profits even if it damages the corporation in the long run.  Our society thinks in the short not in the long, and our congressmen are doing so in a way that harms all of us.

I thought of this while I was in the shower this morning.  I am not sure if it is the shampoo, but I have thoughts about blog posts while I’m in the shower.  I was getting filled with righteous rage about the stupidity of congress and how they mimic corporate America in short-sightedness.

Then I realized something: I do the same thing in my personal life.  I am trying to eat better and exercise, but that brownie in the break room looks awfully tempting.  A little indulgence now won’t hurt in the long-run, will it?  I start playing that damned Bejeweled game on Facebook instead of working around the house.  It’s only one night, and I am stressed-out about stuff.

Perhaps it’s the soap that gets me thinking this way.

Living my life making decisions based on my immediate feelings is the same stupidity that infects congress.  I indulge for personal gain in the short-term and let tomorrow’s crisis build.  I have had people younger than me have heart attacks and die; do I really want my last night on earth be spent playing Bejeweled?  Worse yet, if I survive and keep acting in this way, do I really want the measure of my life be how many brownies I eat or what my high score is on a game?  It’s not that I don’t realize I should spend my days better; it’s just human nature that thinks in the now in ways that harm the future.

Then I thought about my patients: they do the same thing.  My patients who are overweight, smokers, alcoholics, non-compliant, in bad relationships, neglecting their children, or hating others because of superficial differences – they are not all that different from me.  They are not different from congress.  They are living in the now because humans do that.  Humans overcharge their credit cards to the point that they can’t even afford the monthly payments.  Humans buy cars with money they don’t have just to get the warm feeling of having a new toy, and the joy of making others jealous.

It doesn’t justify stupidity, but it does explain it.  I feel righteous anger toward congress because I see the result of their inaction.  I see the harm caused to people by a dysfunctional system.  My paycheck is affected by it.  Congress can’t resist the brownies; they can’t stop playing Bejeweled.  Congress can’t stop smoking, or stop spending money on credit cards.

So how do we fight this battle that is all too human?  How do we get congress to act in a way that’s best for us, not them?  How do we get ourselves to spend time with the kids, not the blog?  How do I get my patients with heart disease to stop smoking?

I don’t know.  I had to get out of the shower.

Photo Credit

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In ironic coincidence with the 50th anniversary of the Woolworth lunch counter sit - in down in Greensboro, NC (the counter and stools are part of the Smithsonian now), I had a patient who staged his own sit - in, albeit under less noble circumstances. He marched into a local diner and plopped himself down at the lunch counter and demanded to be served. He was refused. He then broke into loud protest and the police were called. When they arrived he was passed out face-down on the counter, retching and sinking up the place. See, this place had a segregation policy. They would not serve drunks who slobbered all over the counter and yelled curses at other customers. Personally I am in favour of such policies.

When I got him, he was in full protest mode. I served him myself. With a delicious cocktail of Haldol and Ativan!

Grand Rounds from Doctor Rob.  Fun!

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Another emergency department closes under financial pressures. Deaconess Hospital, near the University of Cincinnati, lost $13 million in 2008. Financial numbers for 2009 were not disclosed, but it reportedly had multiple staff layoffs last year. Deaconess stopped providing emergency services effective January 11, 2010 and is converting the emergency department to an urgent care center.

Hospitals in Canada are restructuring and turning their emergency departments into 24 hour urgent care centers. Now patients with emergencies must travel much further to obtain emergency care and are dying in transit. Ontario’s Premier Dalton McGuinty stated that “the stark reality [is] that the government cannot afford the best health care in every single community.”
Government appointed “Local Health Integration Networks” decide how health care dollars are spent, but their government-appointed boards do not have the expertise or the tools to do their jobs.
The “fast care, free care, quality care - pick any two” paradigm may be changing.

What advice would economist Uwe Reinhardt give to President Obama about health care reform? “Talk to the people, not the academics.” Creating a health bill that doesn’t suck ass would probably help, too.

New Jersey is facing a shortage of 2,800 physicians in the next 10 years.

North Carolina is making cuts to Medicaid services, but is still more than $250 million over budget. So it plans more cuts to health care services. On the chopping block now … funding for about 3000 people who require personal care assistance providers to help them perform their activities of daily living (such as dressing, eating, going to the bathroom and getting out of a chair) — who are predicted to “completely lose those services.”
“We’re trying to … pay [only] for the services that are clinically appropriate,” said the state Health and Human Services Secretary. Currently, personal health care services cost the state about $750 per month. If those services were cut and a patient instead needed to be placed in a nursing home, it would cost the state $3000 per month.
Wise choice?
Then again, how many home-bound patients are likely to vote?

I like performance cars. Especially sports cars and vintage muscle and European cars. My current car is somewhat of a hot-rod (2009 Pontiac G8 GXP with a 6sp manual) and I have a Big Block 71 Camaro for summer weekends. Thus, I tend to be a little heavy on the accelerator pedal. Now, I am not a speed demon by any stretch (I got that out of my system when I was in high school and college - routinely burning rubber in my Camaro and taking it up to speeds unsafe for the crappy tires it rode on), but when there is not a lot of traffic (ie at night when I finish my 4pm-1am shift and on weekends), it is hard for me to obey posted speed limits. I mean, come on. No one is on the road and I am supposed to plod along at 25 mph? Not possible.

So thus I have done my best to schmooze with the local men and women in blue. Well, the locals where I work where grey but you get my point. That means treating them fast in the ER when they come in - even with relatively trivial complaints. That means being extra nice to them in general - after all they do have a damn hard job. Getting a bunch of PBA cards does not hurt either (just make sure you know the name of the cop who gave you the card - it makes a difference when you have to flash it).

Let me tell you, it has paid off. Literally. I have now avoided about 6 or 7 tickets in the last 4 years. Mostly for cheap speeding of 10-15mph over the posted limit in the middle of the night. Once for an illegal right hand turn. And once, most amazingly, when I was in a nearby big city, I accidentally ran a red light (I was trolling for a parking spot and did not have my eyes on the lights like the idiot I am) and the guy let me off due to my PBA cards and by being respectful. A few time they commented that they liked my car and asked how fast it runs a quarter!

Once, when I was a resident, I was speeding to work (I was seriously hauling ass since I was late) and got pulled over. The place where I did my training was the big local trauma centre where all the seriously injured cops were take. When the guy saw my ID, he told me hurry up and get to work - just keep it below 90!

Now, I do not advocate exceeding the speed limit or driving recklessly but hey, be nice to the police, it can pay off!

It happens every year.

I try to get a little shut-eye, but then these guys in hats come around and yank me out of bed.  They proceed to parade me around a huge throng of people (most of whom are not wearing hats), obsessing about the presence or absence of stratus clouds.

What a strange group of people.  I seem to be the center of attention for the day, though, and that’s not all bad.  It’s my day on February 2nd, and nobody has ever taken that from me.

Until this year.

Let me back up a little.  My name is Phil, and I am a woodchuck who lives in western Pennsylvania.  Yeah, I know I was supposed to say “groundhog,” but I like throwing people off.  I am also called a whistle pig and a ground beaver, so it could be worse.  I personally prefer the woodchuck thing because I like the “how much wood could a wood chuck chuck…” poem.  Shouldn’t I be able to decide what I am called?  What’s wrong with “Woodchuck Day?”  It beats “Whistle Pig Day,” doesn’t it?

Sorry, that subject gets me emotional.  I live in a town known as Punxsutawney, which is an Delaware Indian (or Native American – see, it’s not so bad to have more than one name!) word meaning “town of sandflies.”  I can vouch for the appropriateness of that name.  It’s not much of a town otherwise; which is why I suppose they go around in hats and pester me each year.  What else is there to do?

There are a lot of llamas in our town too.  I think that’s why Dr. Rob came in the 1st place.

But this year we’ve been invaded!  Turns out that there is a whole other group of strange people who get all excited on a regular basis, and this year they invaded Punxsutawney!  They are lead by a guy named Steve, and for all the doting they do on him you’d think that this was “Whistle Steve Day!”  He took the much-anticipated day of my emerging and turned it into a way to show off a new thing he made; I forget what it’s called…something beginning with an “i,” I think.

So you see, I have be relegated to second-fiddle, which doesn’t suit me well.  That’s why I took Dr. Rob up on the offer to give my particular woodchuckian perspective on medical blog posts.  Plus, I thought he said “Ground Rounds,” and it seemed up my alley.  Ah well, you can’t blame me for wanting to get out of Punxsutawney as quickly as I could.  I’ll show you other pics of the day in Pennsylvania to prove it.  This guy is crazy!

Everyone thought last year’s stunt by the llama was crazy, but that was nothing compared to this year!

Since Dr. Rob inexplicably got a gazillion submissions, I am grouping them.  It makes things easier to digest.

Group 1: My Faves

Some of the posts stood out from the rest.  This is not to say the rest weren’t great, but certain posts just resonate with a large North American rodent.  I’m not sure if that’s good or bad.

The first on the list of Faves is a Post from the blog named Nourish: Living, Laughing, Whining (great name) which tells about Jacqueline du Pre’, a woman who played the cello but lost her ability due to Multiple Sclerosis.  Marie Cooper, the author of the post identifies with her in the pain of facing a horrible illness. Like the pain I feel facing Steve.

The next is from Dr. Charles, who writes about being a doctor and going to a patient’s funeral. Dr. Rob says Charles expressed the emotion perfectly.  Dr. Charles is a good writer.

The third of my faves is from Dr. Robert Centor, who’s a smart dude (so I am told).  He discusses the reason nobody is choosing primary care: it’s not because of what people say about it, it’s the job itself.  I think he is basically saying that primary care should suck less.  Dr. Rob agrees.

My final fave is from a psychologist named Will Meek.  He explains the difference between remembering and reliving hard things. Why do I like this so much?  First off, I have a lot of trauma to deal with, getting lifted out of bed every year (the whistle-pig side of me is quite sentimental, you know).  Second, there was a guy once who relived Groundhog’s day a bunch of times.  He should have read this post.

See!  He took over!  At least he wore a hat, though.  Even the llama wore a hat.

Group 2: What Docs Do

I get a skewed view of doctoring by just talking to Dr. Rob (he’s a skewed kind of guy), so reading posts about docs being docs was quite enlightening.

The Happy Hospitalist taught me what the difference between a hospitalist and an intensivist.  If there’s a Happy Hospitalist, is there an Idiosyncratic Intensivist?  I am sure there are lots of them.

Dr. D taught me how doctors diagnose the weird stuff.  It turns out you don’t have to be mean and abrasive (like that doc on TV) to be able to make “good catches”!  Who’d have thought?

Lockup Doc talked about how some doctors make you feel at ease, while others make you feel like you are a nuisance put on their schedule to give them justification to abuse illegal drugs (kind of like that mean and abrasive doc on TV).  The interesting thing here is that Lockup Doc takes care of prisoners!

Why do people need a thorough physical exam before getting surgery?  Dr. DJ (sounds like a rapper) talks about how people hide stuff that can hurt them later, necessitating a thorough physical exam.  He wonders if that is unique to India.  Dr. Rob says that it’s definitely not.

Kent Bottles…no, that’s his name…I am not saying he bottles things.  He might bottle things, but that is not relevant.  Dr. B talks about how some smarty-pants surgeon is telling everyone to use checklists all the time. Dr. B thinks that this guy may be right, but there needs to be room for imagination and deviating from the checklists.  I find that it’s very important to have creativity as a woodchuck.

Group 3: Yowza!

Some posts made me say “yowza!”  That’s woodchuck for “wow, what a controversial topic covered in the blog post.”

Dr. Wes talks about the healthcare legislation that has stalled in congress.  The amazing thing about this post is that the comments section is about 5 times as long as the post itself.  Great discussion, but Dr. Rob confessed that his Adderal ran out before he got to the end of the comments.

A blogger named Phil (good name!) on the Behaviorism and Mental Health Blog says that Schizophrenia is not a disease!  Dr. Rob was impressed by his bold stance that is definitely against the mainstream, and the way Phil put forth some solid points.  I was impressed by his name.

Mary Clark has a chip on her shoulder.  I think it’s a Pringles, but I can’t tell for sure.  LOL ROFL – That was a bit of woodchuck humor.  Anyway, Mary is very frustrated about two people who got surgery who clearly would have chosen otherwise.  Not all docs (or woodchucks) disagree with Mary.

Toni Brayer wonders about how doctors and hospitals get rated.  How can this information be useful to patients?  She says it can’t.  Of course, she’s from California, so you have to expect that kind of thing.  She probably got sick on some tofu or sushi.  (More woodchuck humor)

I have to admit, I was a little star-struck when I saw the iPad for the first time.

Group 4: Taking Care

What’s the best way to take care of people’s health?  There were some good posts on that topic.  If only they’d cover the best way to avoid guys named Steve.

Metformin for Type 1 Diabetics?  Amy Tenderich at Diabetes Mine once thought the idea ridiculous.  But then after looking into it more, there are definitely times it’s a good idea.  Who’d have thought of such a thing?  I am probably the only woodchuck with that knowledge.  Thanks, Amy!

What’s best, low carb or low fat diets?  The blog On The Wards discusses the research on the subject.  It turns out that they are the same.  I am glad about that.  Some woodchucks eat bugs and other yucky stuff, but I stick to the veggies to maintain my chuckish figure.

Bruce Siegel, who writes at the Robert Wood Johnson blog talks about some people from Minnesota who are working together to improve the quality of care.  He has the quote of the day:

You could dismiss this as another example of “Minnesota care”—where all the clinics are strong, the doctors are good-looking and the scores are above average. But Minnesota is only a harbinger of things to come in other parts of the country as the movement for high-value health care continues to pick up steam—with an extra boost coming soon (we hope) from the quality-related provisions of the national health care reform bill.

Group 5: Hah!

Some posts were either funny, or they were unexpected.  I usually like unexpected things, but Steve and his disciples are making me rethink this whole issue.

My first “hah” came when I read the post by Dear Dr. Ramona Bates on her blog, Suture for a Living. It turns out that there’s a surgery to make a navel!  I guess people would look funny without one.  Rumor has it that Dr. Bates learned the procedure at the Navel Academy.

Step aside Scoobie and Astro, the new dog darling is Ruppy – a genetically-engineered dog that fluoresces!  Jamie Newman at the ACP Hospitalist blog uses Ruppy, who’s a combination of beagle and sea anemone genes, as evidence that very different things can work together.  Pretty clever!

The spoof article in BMJ about evidence based medicine and parachutes made a lot of people (and woodchucks) say “hah!”  Not so for Jacqueline at Laika’s Medlib Blog.  She thinks that rejecting EBM is equivalent to rejecting science as a basis to medicine.  She’s right about that; I just hope she doesn’t bash the article on Ruppy.  She does have a picture of a dog using a parachute, so I’m optimistic for Ruppy.

From “Down Under” comes a post by Chris Nickson in the blog Life in the Fast Lane. He talks about a real mean dude who comes into the ER, goes to the ICU, and gets a rude surprise.  It’s not a funny “hah” at the end, but perhaps there’s a bit of justice in it.

Steve looked pretty smug when he found out I already own an iPhone.  I swear, I was borrowing it from the llama!

Group 6: Huh?

Understand this: I am a rodent.  My brain is not real large.  So there were some posts that made my brain complain to me.  Dr. Rob assured me that they were great posts, and that the smart people will get a lot out of them.  I wonder how Dr. Rob knows about smart people.

The first one is from David Williams on the Health Business Blog.  He interviews two real smart dudes who made software that improves the process of case-reviews. It seems like they are on to something good, because you can’t fix something if you don’t know where it’s broken.

The second “Huh?” was an article on the Health Care Law Blog by Robert Coffield, who is a Lawyer!  Does that surprise you?  Dr. Rob thinks some lawyers specialize in “huh?”.  But Mr. Coffield isn’t one of them, and he actually points to some really good resources for getting an idea about IT laws for different states.

Group 7: Feeling Better

Whew!  There are lots of submissions to cover!  My paws are starting to ache.  If only I had a tablet with a touch screen….  Well, the point of medicine is generally to make people feel better.  Here are some good posts on that subject.

The first one comes from the blog How to Cope with Pain.  I was interested in this because Steve is being a real pain to me.  Anyway, the article is about how values affect how people deal with pain.  Good stuff.  Useful.

Steve (no, not that Steve) over at the Funky Heart blog talks about being an adult survivor of childhood heart disease.  He sees how just his existence is an encouragement to parents of kids with heart disease.  Very true stuff.

Being sick is lousy, but a lot of times it’s harder on the people taking care of the sick person.  Barbara at In Sickness and in Health asks the question: Caregivers, do you tell your ill partners about your stress? Tough question.  I’ve already told you all about my stress (named Steve).

Group 8: Dumb Stuff

I was surprised to find out that Dr. Rob doesn’t have the corner on the “Dumb Stuff” market.  There’s enough dumb stuff to go around, and bloggers like to tell about it.

Dr. Val (who gets my vote for empress) writes on the Better Health blog about her experience getting licensed in Maryland and California.  Maryland took no time flat, while California is still working on it over 500 days later!  Perhaps they are all sick on tofu or sushi.  For a state that needs doctors, making it hard for Val is very dumb.

The ACP Internist blog brings up a very surprising fact: many medical students don’t have a clue when it comes to electronic medical records. Considering how hard they are being pushed, that’s a dumb thing to be happening.  Just ask Steve, a computer is your friend!

Scott Marshall is a Chaplain who has a bone to pick with Sanjay Gupta.  It’s not that Sanjay has fancy gig at CNN, and not that he has a cool sounding name.  It’s that in his book he compromises as a doctor for the sake of being a journalist. Scott says the book is a good read, but it could lead people to make dumb conclusions.  Scott’s no dummy.

I finally got my paws on the iPad, and what does Steve do?  Whoa, don’t drop the goods, buddy!

Group 9: Following Rules

Rules are there for a reason.  There is often a good way to do things that should be followed.  Other times there are just dumb rules that should be changed.  Steve certainly ignored all the rules in my fair town today.

Fee for service medicine is just the way we do things.  Is that right or wrong?  Lots of people want to change it.  Michael Kirsch at the MD Whistleblower blog muses about the pros and cons of FFS.  Interesting stuff, and he has a new spin on the idea of  ”putting an end to tonsillectomies.” Read it; it’s more woodchuck humor.

Dr. Ed Pullen’s blog has an article about taking medication correctly.  It’s not therapeutic to just want to take your medication, you have to actually take it.  He gives some good rules patients can follow to do it better.  It’s hard for me to remember to take medications during hibernation.

If you are in the hospital, the last thing you want is to go right back.  It’s kind of like Punxsutawney.  Amy over at the Health AGEnda blog writes a post with a link to a guide to prevent readmission.

Group 10: Reader Beware

Some posts are for mature audiences only.  No, they don’t have any gratuitous sex like they do on Animal Planet; they are just…well…I guess you should read them yourself to understand.  Maybe you should ask your mom first.

Elizabeth over at Life. Not Terribly Ordinary justifies the name of her blog, giving a recount of a very busy day.  It’s a great view into the very busy life of an academic doctor.  It also uses some words that would have had my mother washing my mouth out with dirt.

The Inside Surgery blog takes on a big controversy: the use of acupuncture for battlefield medicine.  It’s not a real graphic article (aside from gratuitously poking people with needles) and it uses no cuss words, but I suspect there will be some fonts a flying in the comment section.

Nobody ever accused Patient Anonymous for being subtle and reserved.  That’s pretty obvious when you read her post So, Is This What Medical School feels Like? Brace yourself for some strong words and stronger emotion.  I hope she doesn’t ever run into my mother.

Group 11: That iThing

OK, I confess: I am turning into a fan-hog of the new iPad.  Steve has this magnetic appeal that makes me want to go out and buy something I never thought I needed.  Even Dr. Rob uses a Mac!  I don’t really know what I’d use it for, but I still want to buy 50 of them.  Predictably, the Medical blogs had things to say on the matter.

Dr. Anonymous (who is, ironically, well-known) is the first to jump on the iPad bandwagon.  But wait!  He takes issue with the assertion that it’s a perfect device for healthcare.  Couldn’t cool aps be written for it?  Sure, but it’s not about the aps, its about the hardware.  Dr. A doesn’t think the iPad has what it takes for medicine.  Say it ain’t so, Steve!

Finally, Peggy over at The Blog That Ate Manhattan chimes in about the iPad.  Being an OB/GYN she first scolds everyone for snickering at the name.  I know for a fact that Dr. Rob snickered a lot – saying that the virus scan should be called the iPap.  Shame on Dr. Rob!  Anyway, the post analyzes the claim that the iPad is perfect for healthcare.  She too is mystified at where exactly it would be used.  But she should give up on trying to get Dr. Rob to grow up.  It will never happen.

Conclusion

It’s been a pleasure to get out of my hole and away from the hullabaloo in Punxsutawney.  You medical bloggers are bright folks and the world should pay more attention to you.  I read more common sense this week than I have heard in my entire life from Washington DC.

Pathetic Dr. Rob is now a fan-boy.  HE TOOK MY IPAD!!
I’m going to have to bite him (if the llama doesn’t get to him first).

Addendum:

After the deadline, I got an email from Paul Auerbach From Healthline.  I add this on because of the importance of the topic:

I just returned late last night from two weeks of medical relief work in Haiti, so apologize for the late submission. Please consider the following posts, which are a series of what we experienced, for submission for this week’s Grand Rounds. I realize that it would be highly unusual to list so many posts, but I offer it nonetheless. If you read them, you will understand.

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-22.html

http://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-thursday-january-21.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-23.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-24.htm

lhttp://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-january-25-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-26-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/from-haiti-january-27-2010.html

http://www.healthline.com/blogs/outdoor_health/2010/01/haiti-january-28-2010.html

Thanks for the opportunity!  Next week GR is hosted by Edwin Leap.

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I’ve been thinking: the surgery in-training exam is really like a recitation of legends, orally recounted histories, not too closely related to facts, that define our community.

The test runs through a long series of stories, which are so familiar to surgeons and surgeons-in-training, that we only have to mention a few words of the story, to have the whole thing immediately recognized and understood.

These are some of the legends: gallbladder cancer, incidentally discovered after lap chole, invading through the lamina propria (snap answer: resect a surrounding rim of normal liver tissue); projectile vomiting in a 4wk old male (pyloric stenosis, hypokalemic hypochloremic metabolic alkalosis); medullary thyroid cancer (MEN 2; check for pheochromocytoma before resecting); knee pain and blue toes in a 50-yr old smoker (popliteal aneurysm; resect and bypass, and check for a contralateral aneurysm and AAA); mesenteric thickening after total colectomy for FAP (desmoid tumor; chemo only, no surgery).

That isn’t even English, and it certainly bears little relationship to what we actually see and do; but those are the legends that we all recognize. In that light, the ABSITE is an exercise in intergenerational transfer of epic tales. . . like the Iliad and Beowulf and Hansel and Gretel. . . That’s my explanation for the high incidence of rare diseases, the lack of correlation between what we practice in real life, and the right answer on the test, and the way the residents go around for a week afterward trading key words and comparing answers. This is our oral tradition.

I generally say that I went into Emergency Medicine because I like my medicine exciting. I will take someone coding over a URI any day. However, there are times when I don’t want exciting. Mostly at the end of the shift. You are in wind-down mode for most of the last hour and it pains you to go get overly involved in any case. You want to tidy up your existing cases and get everyone dispositioned.

Alas, my last night shift had too much excitement at the end. 20 minutes before the end the RN’s grabbed me to see an elderly man “bleeding really bad”. Great. From where?
His scalp. They weren’t lying. This guy had fallen in his bedroom and smashed his head into the corner of a metal dresser top. Ouch. It was bleeding like nobody’s business. The dressings were soaked and when I took one off, I almost got spurted in the face with an arterial pumper. And the guy was not even on Coumadin!

I spent the better part of the next 45 minutes clamping, ligating, and cauterising the bleeding. I had two nurses helping me with two different suctions. I had two techs holding the guy still. My white coat sleeves were all blood-covered and the room looked like the inside of a slaughter-house. It was a very messy, unsterile procedure but finally I had the two biggest bleeders tied off, the small ones cauterised, and sutured the galea and subcutaneous layers. I stapled the skin closed and called it a night. His Hgb dropped from 11.9 to 9. Yeesh. Be more careful dude!!

Then the really crappy part came. I had to disposition four other people who of course had all their CT results and labs back just as I was about to sign out (cuz I am a nice guy and don’t like to sign out crap to my relief). Some days you just bend over and take it like a prisoner.

Grand Rounds is a big event, and I have gathered together a star-studded line-up.  Do not submit any more posts, however, or you will be forced to go onto Dr. Phil to explain why you are such a dead-beat.  You don’t want that.

Obviously, with such a gathering, you don’t want to miss it.

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The deadline for grand rounds submissions is on Sunday at Noon EST.  EST stands for “Eastern Standard Time,” not “Estimated” or “Extra Submission Time” or “Even Steve Trounces.”

iSuggest you get things in as quickly as possible.

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I was talking to a fellow physician about a mutual patient.  I had information  that would help him in their care and he was taking the unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a thought: “I could email you those documents much easier.  Do you have an email address?”

Silence.

After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email.  The palms sweat, the speech stumbles, and the awkwardness is thick in the air.  It’s as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult.  There is a culture of fear in our healthcare system; it’s a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger.  Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them.  They see it as a collar on their neck that they only wear because others are stronger than them.

It’s the only reason I can see for the resistance of a transforming technology.  It’s the only way to explain how they would favor a non-system that hurts their patients over a system that can improve their care immensely.  After all, what good is it to embrace a technology – no matter how good – if it will take away their ability to practice medicine?  ”It’s good for you!” they hear from politicians and academics, but they see it as a poison pill.

What gives me cause to use such strong words?  Surely it’s not that bad! It is, and what makes me so sure of it is the very high cost of their resistance.  The cost of this fear is huge, and so the fear itself must be bigger for a healer to accept that cost.  What is the cost?

Frustration

We see our patients without information.  The call from the specialist I described at the start of this post was a truly rare event.  Most of my consultants don’t expect to get information from me, and I expect to work without their input.  All of this has happened despite my repeated attempts to improve our system.

• I have offered to send our referrals with attached appropriate documents.  I can do this very efficiently using email.
• I have tried to send labs, x-rays, and other information to specialists when I felt they couldn’t do their job well without them.
• I have requested that they stop mailing their information to me, instead faxing them to our server.
• I have offered our hospitalist physicians after-hours access to our records for our patients.

Ironically, the only physician who has embraced my offer is an ENT at our local teaching hospital who specializes in parathyroid surgery.  I shoot him an informal email when I have a suspect calcium level and within the day I get a response.  In exchange, he gets consults with a full set of labs and can practice with greater efficiency.  He also sends me quick notes on my patients when he sees them, asking me questions to fill any gaps.

Cost

The total lack of communication results in huge cost to our system.  It’s not that the communication tools are not there, it’s that they just are not used anywhere near where they should.  Examples?

• A woman came to my office recently after being hospitalized.  I never was notified of her hospitalization, only finding out when she came for a “hospital follow-up” visit.  While in the hospital, she was found to be anemic and so had a workup for this condition.  This workup included a full consult by a hematologist and a gastroenterologist.  If my records had been looked at, they would have noticed that I did a workup 6 months earlier for her anemia.
• Specialists not accepting email copies of the labs I run usually end up repeating the tests.  For specialists like rheumatology – where the diagnosis is largely made on the basis of those labs – this elevates the cost by several thousands of dollars.
• I have had patients rebuffed by consultants who “didn’t know why I sent them.”  Nobody calls, and nobody accepts email.  I could send them whatever information they need in a matter of minutes if they would accept email.  Heck, they could even text me if they wanted.

The real cost, of course, is to the patient.  The Hippocratic oath says we should “first do no harm” as physicians.  Yet our non-system of communication does just that, and even kills people.

So why would presumably smart people reject a technology that could improve care, reduce cost, and reduce frustration?  Did any of them order gifts from Amazon?  Do any of them bank online?  I am sure they do, and they do so because it makes things easier and more convenient.   So why does that ease and convenience not apply in medicine, which is far more broken than shopping or banking ever was?  It’s not fear of technology.

To be honest, I don’t really know.  My best guess is that it is the overwhelming sense of pessimism most doctors feel about their profession.  Docs are second-guessed by lawyers, patients, TV shows, insurance companies, and the government.  The fate of medicine is not in the hands of doctors, it is in the hands of politicians, corporate executives, and malpractice attorneys.  It seems to me that the only way to avoid more scrutiny and to hang on to some control is to hold tightly to what we’ve got: our information.  Once that information is on computers it is far more accessible by others, and this is a bad thing if the goal is to retain full control.

So are docs just power hungry, wanting total control because of their inflated egos?  Some are, but most are not.  Even the most technologically-minded of us, however, have an increasing unease about the intrusion of others on our ability to do our job.  I don’t want to be thinking about attorneys when I am prescribing medications.  I don’t want to withhold information important from the chart because I know patients will be reading it.  I don’t want to be forced to include a lengthy justification of a procedure in my notes to make the insurance company happy.  As it stands, it sometimes feels like anything we include in our records “can and will be used against us.”

If someone like me, a physician who embraces technology, feels increasingly penned in by the increasing number of people peering at what I do, it is very understandable that other physicians reject technology outright.  They’ll quit before they give up their independence.

Is it stupid?  In some ways it is.  It certainly is a rejection of the centrality of what’s good for the patient.  But our system can’t afford to alienate physicians at this time.  If technology is going to be pushed, there needs to be a reassurance that this won’t be used against them.  I am frustrated at the lack of  acceptance of technology, but even more frustrated at a system that is hostile that forces docs into this foxhole.

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I had to calm one of the medical students down the other day. We were in a crowded elevator, and he was carrying on the conversation we’d started before getting on, about what he’d liked about the surgery rotation so far.

“I got to see a craniotomy the other night on call,” he exclaimed. “They let me touch the brain! It was kind of squishy.”

In the middle of the elevator. Full of visitors.

So you wanted more “Ask Dr. Rob.”  Next you are going to be asking for a colonoscopy.

Well, I guess I can do it.  It has been a long time since I have done one of these.  I thought I was being merciful.  Whatever.

Here’s a question from a moderately fictional person named Mike:

Dr. Rob:

What’s the deal with physics?  I heard that you have to take physics class to get into medical school.  As a doctor, do you ever use physics?

Sincerely,

Moderately Fictional Mike.

Wow, what a coincidence!  That’s the question I would have chosen had I written it myself!  What’s the chance of that?

To answer your question: yes, I do use physics quite a bit.  It’s a good thing, because my dad is a physicist.  This is a physical world we live in, with irresistible forces impersonally shoving us around without getting permission.  My father never told me about this dark side of the forces.

Force #1: Gravity

The first example of these forces at work is the ingrown toenail.  Toenails ingrow for one reason: they can’t grow out.  Instead of sticking out the front of the toe like any self-respecting toenail would do, they grow into the toe.  Why do they do this?  What causes some toenails to grow in while the others behave respectably?

Gravity.

Ever since Sir Isaac Newton suffered a head injury, gravity was felt to be related to the mass of an object.  The bigger the object, the bigger the gravity.  But then came Albert Einstein, and the trouble began.  Einstein’s theory of general relativity put forth the idea that gravity wasn’t even a force, but instead a curvature of the spacetime continuum.  Wikipedia explains:

Einstein discovered the field equations of general relativity, which relate the presence of matter and the curvature of spacetime and are named after him. The Einstein field equations are a set of 10 simultaneous, non-linear, differential equations. The solutions of the field equations are the components of the metric tensor of spacetime. A metric tensor describes a geometry of spacetime. The geodesic paths for a spacetime are calculated from the metric tensor.

Confused?  Yeah, well so is everyone else including the toes. What started out with a simple equation in Newtonian Physics:

became 10 simultaneous, nonlinear, differential equations! Yuck!!

Despite his lifelong battle with fruit, Newton remained
a gentle soul.

To get back at Einstein, the toes decided to take advantage of these changes.  Using a loophole in this new law, they increased the local gravity in his big toes, pulling the nail down into the flesh part, giving Albert the first ingrown nail in recorded history.  In foot-wracking pain, Einstein tried to recant his theory, but the damage was done.  This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

• People step on them – scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
• Heavy objects are kicked – careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

Why do these things happen?  Gravity.  Thanks a lot, Albert!

Einstein, on the other hand, was left embittered by
his chronic foot pain

Force #2: Opposing Forces

Following his head injury, Sir Isaac Newton (yeah, him again) decided to take the law into his own hands.   The result of this was the creation of Newton’s Laws of Motion.  His design was to prevent future fruit-related head injuries, and he was largely successful (except for one unfortunate Kumquat encounter).

Kumquats can be dangerous

Newton clearly had a lot more sense than Einstein, and he kept his toenails happier as well.  Take it from me: always keep your toenails happy.  The three laws that Newton made were about moving objects, the most famous of which was the 2nd law, with the formula:

Translated: Force = Mass x Acceleration.  This is a great formula because it is so simple (as opposed to Einstein’s ten differential equations), but sadly, it doesn’t apply in the doctor’s office.  The third law (the law of reciprocal actions) however, applies very nicely:

Which translates: “any force that is applied to object 1 due to the action of object 2 is automatically accompanied by a force applied to object 2 due to the action of object 1.” (1)

The application in medicine is not in the clinical realm, but in the interaction between doctors and nurses.  Since both doctors and nurses are important cogs in the machine of medicine, they commonly have significant effects on each other.  Believe it or not, they don’t always agree.  I am sorry if I shattered anyone’s image of a blissful cooperation and camaraderie.  That is true most of the time (if by “most” you mean “almost never”).   The Law of Medical Opposing Forces goes like this:

Any force that is applied on a nurse by a doctor is automatically accompanied by an opposing force applied by the nurse on the doctor.

The best example goes something like this:

Nurse: Doctor, Mr. Tucker’s wife wants to talk to you about the side effects of all of the 29 medications you prescribed.  I told her you were on the floor, so she’s expecting you

Doctor: Fine, nurse, I’ll do that.  Let me first write these three orders for enemas and the order to discontinue the sedative for the screaming lady in room 244.

Nurse: That’s nice.  Did I tell you that the Mr. Wafter has a large abscess that started draining?  I left it alone after explaining to him that you are an expert at wounds like that.  His roommate had to be moved, though, because he couldn’t take the smell.

Doctor: Wonderful.  I forgot to mention that I can’t discharge Mr. Whiner or Mrs. Screamer today.  I just want to wait another day to make sure they are stable.

Nurse: I’ll be sure to have the night shift nurses call you hourly through the night to give you updates.

These two children are in training.
This picture was taken before the hand-to-hand combat

This is a very important law to understand, especially for doctors in their residency.  Most residents assume that they are in charge since they have those letters after their name, but what they don’t realize is that they are weak forces.  Nearly all forces exerted by a resident on a nurse are met with much stronger opposing forces.

There are other opposing forces in healthcare, including surgical vs medical doctors, doctors and nurses vs hospital administrators, members of congress vs. people who don’t get money from drug companies, and insurance companies against anyone trying to get money from them.  Anyone dealing with healthcare needs to understand this very important law of physics.

Conclusion

I am just scratching the surface (which, of course, involves the force of friction), but the spacetime continuum is putting force on me.  But the bottom line (x-axis) is that physics is at the center of the medical universe.

Here’s to you, Dad.  May the force be with you.

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Emerging on February 2.

Llary says that you should submit your blog posts to grand rounds.  Llary also says that Dr. Rob really stinks at photoshop.  It’s a good thing you don’t need to photoshop to be a doctor or all of his patients would be in extreme danger.

Llary thinks they might be in danger anyway.

Obey Llary.  The email address is llamas.are.grand.rounds@gmail.com.

Deadline is January 31 at noon EST.
————————
Addendum: Several people have sent me the full articles. Grand Rounds is a summary of the best of the medical blogosphere. I read and link to your posts, giving summaries. Following those links gives traffic to your site (which is another big advantage). Submitting to GR is one of the ways this blog became widely known.

No related posts.

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I went to my first Tweetup last night. Apparently I surprised a few people with the news of my move to the Left Coast. I was replying to this tweet because at the end of the day, beer > coffee. Apparently sarcasm (or at the very least, my sarcasm) doesn’t travel well in 140 characters or less. I’m not moving to Tacoma and I hope to make it to future Tweetups right here in central New York.

From time to time I like to post a “day in the life”. Today is a very good day for one of those.

(All times EST.)
0030: Husband gets home from work. Talk for five minutes, fall asleep with the Australian Open on TV and John Isner taking Gael Monfils back to the middle ages with his massive serve.
0600: Alarm goes off.
0630: Finally drag my ass out of bed because I have things to accomplish before lecture at 8. It’s outpatient conference and we’re talking about how to break bad news. I teach communication skills to the medical students with a few other faculty members and there’s a session scheduled for today and therefore is a combined lecture. It’s kind of a big deal.
0710: Realize that I cannot pack a lunch in my lunch bag because my lunch bag is conveniently sitting on my desk at work. Oh, hell.
0715: Hop in the car to go to work. I used to listen to Mike & Mike on ESPN Radio but I always seem to be in the car during a 10-minute stretch of commercials. Try to increase IQ by listening to Morning Edition on NPR.
0725: God I love my short commute. Unlock my office, obtain coffee. Quickly check work e-mail and discover I have to precept in clinic all afternoon because one of the docs has a sick kid. This is one of the reasons I took this job. It’s far easier to get another attending to cover for you to precept residents and medical students in clinic than it is to cancel an afternoon of 30+ patients. I’ll have him pay me back next year…or in beer. His choice.
0728: Head upstairs to snag admitting pager and a bagel from the staff lounge.
0730: Find resident currently carrying the admitting pager. She’s in the room of a patient currently attempting to shit the bed, despite the interventions of the staff. Her mom is not helping matters at all and is belligerent and swearing at staff. Awesomesauce.
0735: Situation is SNAFU. Realize that I may have a SNAFU of an entirely different sort on my hands and head to the ER.
0745: Talk to another one of my residents who is finishing his overnight ER shift about this holy shit of a mess patient that he saw overnight. Even the admitting attending doesn’t know what’s going on (and this is NOT GOOD because the attending is one of the smartest people I’ve ever met). Chit chat about party tomorrow and poof! It’s time for lecture.
0800: Grab a seat with the attendings in lecture. It’s a packed house.
0810: Admitting pager chirps.
0812: After inhaling the last few bites of bagel, I return the call. There’s a kid up north who’s sick and I know I’m not getting the full story from this doctor despite my best efforts. I have beds (a miracle!) so I tell him to just send the kid with any x-rays/lab results/important paperwork he might have.
0814: Pager chirps again.
0814.1: Why yes Virginia, today is going to totally suck ass.
0815: Return second page. Another kid, another transfer. This kid isn’t acutely ill but needs the services of our hospital in order to figure out what the hell is wrong with him.
0817: Talk to our transfer center, have one of the nurses help arrange for a bed. Just about to hang up with him when he tells me I have another transfer.
0817.1: Seriously? What the fuck.
0818: Talk to another doc in another hospital about another transfer. Your sick children, bring them unto me and I will fix them.
0825: Joke with the nurse at the transfer center about how today has started. Not really laughing.
0830: Finally make it back into lecture I’m supposed to help moderate. The outpatient chief moves to the next case and puts me on the spot. He introduces the case by saying, “You are an attending and one of your patients is admitted to the PICU.” Muffled snerks are heard to my left and right. From the attendings. I tell them to shut up because I’m going to be one of them in five months.
0845: Lecture is over. Great discussion on how to break bad news. It’s something we don’t teach well and we don’t talk about it nearly as much as we should. Our PICU attendings are great at modeling what should be done but we need to do a better job of teaching the medical students about this kind of stuff.
0900: Break some bad news of my own to the hospitalist team senior – he’s got three admits.
0915: Decide there is no way I’m going to make it to my 10 o’clock meeting, especially if I’m out of the office all afternoon. I have a lecture to give Wednesday, party plans to shore up and a metric ton of e-mails to answer. Talk quickly to committee chair and promise I’ll be there next week.
1000: Experience a blinding flash of the obvious when I realize the schedule for the next three days is fucked. One of our interns is out sick and while normally we’d use the back up schedule to cover her shifts, we can’t because we changed the call schedule without changing the back up (we used a back up resident to switch a call with someone else). Call Jay, our education admin who also does the scheduling. Start swearing profusely. Prita, my co-chief, is laughing so hard she can’t read the schedule to figure out where we can fix things.
1015: Make some phone calls, arrange for a contingency plan. Commence second caffeine infusion of the day.
1045: Open power point for presentation Wednesday.
1046: Get paged by inpatient attending. He’s completely swamped (I wonder why! And yes, it’s all my fault) and wants me to come and do one of his admits for him. He hangs up before I can remind him I’m co-teaching at noon lecture and will be at clinic all afternoon. He’s in for a treat.
1100: Go and see the kid that I brought down from up north that I didn’t feel like I was getting a good story from on the phone. I was right. I didn’t. I ask the kid’s nurse if any outside records came with him and she shows me the run sheet from the ambulance. Yeah. That’s not what I wanted.
1115: Wow. This kid needs a serious workup. He’s been misdiagnosed with all sorts of random crap in the last three months. Decide to start with some basics (x-ray, basic labs) before deciding on any particular medications other than the ones he’s already on.
1130: Dictate admission note (I will be doing this for all my admits next year, might as well start now), place orders, get child life consult because this kid’s going to need an IV started and some swabs stuck up his nose. He’s already cranky and I can’t imagine any of this is going to help.
1145: Run to another floor to grab the hospitalist team senior and inpatient attending so I can tell them at the same time about this kid.
1148: Attending is in a room, dealing with the same patient he’s been dealing with for the last three hours. Create an on-the-spot interpretive dance routine to try and indicate to him that I, in fact, have better shit to do than to wait for him to come out of this room.
1150: I suck at interpretive dance.
1151: Head to the conference room around the corner and have a quick chat with the attending with whom I’m giving the conference. I tell her to present her bit first and I’ll be in as soon as I can.
1152: Attending has escaped from the patient room. I rattle off my history and physical exam findings, along with my assessment and plan. The senior resident’s head is spinning. I think he’s still trying to figure out how to spell the patient’s name.
1215: Try not to make a complete ass out of myself by coming into lecture late. Oh well.
1300: Presentation goes well; my co-teaching attending is happy.
1301: Realize that I haven’t eaten since 8 AM. This is a problem.
1302: Call clinic en route to my office to tell them I’ll be late. This is a recurring theme today.
1310: Provisions obtained. Start the walk of shame over to clinic.
1315: Inhale roast beef sandwich and caffeination #3. Start seeing patients with the residents.
1320: Become incredibly thankful for awesome residents. I like when I go into a room and I don’t have to do anything because the resident has already done it all – anticipatory guidance, disease education, medication information and the like. Pray that we get awesome residents in the match this year.
1600: How the hell is it four o’clock already?! And where are all those charts I need? I’ve probably seen ten kids and haven’t documented anything yet. Oh shit. I’m going to be here a while.
1700: Last patient going into a room now. Yay.
1730: Track down that last pesky chart. I still have to have an attending sign off on all my charts for billing purposes so I hand my stack over.
1800: Rooms are clear, charts are done. Time to boogie on home.
1820: Stop by Christmas Tree Shop to get thank you cards and candles. The thank you cards are for all the attendings that sponsored residents for tomorrow’s party. The candles are for the tables.
1840: Hit up Wegmans. Too damn tired to cook anything tonight. Sushi and salad it is!
1900: Home, twelve hours after I left. Pour a very large glass of cabernet sauvignon.

Despite the nonsense and the crazy and despite how much I might complain sometimes, I really do love my job. I love where I work. The staff is great, the attendings are awesome and supportive and I work among friends.

But I’m really glad I don’t have to carry the admitting pager next week.

Moment of Burrito:

“I thought you’d be over in Haiti,” a patient said when I walked into her room.

A pang of guilt hit me as I explained that I can’t leave work for long without risking not meeting payroll.  It’s a true fact about being in private practice: I am the commodity I sell, so my absence brings nearly all revenue to a halt.  Given the tight margins in primary care, that makes any day off be accompanied by the that hovering fact.

That sounds uncomfortably like rationalization.  Am I sitting comfortably here in America making excuses for my inaction?  A large part of me wants to help, but then there is my staff, my patients, my family – all of whom depend on me being at my job.  I feel tied by my responsibility and the needs here, but then I see the needs in places like Haiti, and it makes me ponder.  It makes me feel uneasy.

Maybe a conscience in this circumstance is OK.  Maybe it’s OK to feel powerless when I look at TV.  It’s fine that I am doing what I do now, and I need to be committed to first helping and serving those who are in front of me, but I shouldn’t ever forget that there is more.  We can help by sending money and prayers, but should always be looking for more we can do.  One of my greatest fears is that my comfort will turn into a sense of entitlement of the things I have gotten.  Pictures of Haiti remind me that much of what I have stems simply from the fact of where I was born.

So, my attention was piqued when I got the following email:

Dear Rob

International Medical Corps is a global, humanitarian, nonprofit organization, founded by volunteer doctors and nurses and dedicated to saving lives and relieving suffering through relief and development programs. Our emergency response team is in Haiti responding in force and I would like to ask for your help to get the word out to the readers of Musings of a Distractible Mind. There are still thousands of patients seeking treatment of which approximately 80% are in need of surgery and are running out of time – especially with the tremendous aftershocks still devastating this country. The team is treating crush injuries, trauma, substantial wound care, shock and other critical cases with the few available supplies – And they’re in it for the long haul.  I would love your help spreading the word by blogging or tweeting about IMC’s rescue efforts. We’ve put up a blogger friendly widget here on our site:

http://www.imcworldwide.org/haiti

With the widget it’s really easy to let your readers know that donating $10 to help the people of Haiti is as simple as sending a text message of the word “haiti” to 85944. If you have any questions just let me know and I will do my best to help you out. If you are able to post the widget or tweet, I would appreciate it if you could send me the link.

Thanks so much,

Ellie

Here is some information from their website:

International Medical Corps is a global, humanitarian, nonprofit organization dedicated to saving lives and relieving suffering through health care training and relief and development programs. Established in 1984 by volunteer doctors and nurses, International Medical Corps is a private, voluntary, nonpolitical, nonsectarian organization. Its mission is to improve the quality of life through health interventions and related activities that build local capacity in underserved communities worldwide. By offering training and health care to local populations and medical assistance to people at highest risk, and with the flexibility to respond rapidly to emergency situations, International Medical Corps rehabilitates devastated health care systems and helps bring them back to self-reliance.

International Medical Corps has gone on to provide life-saving care in more than 45 countries worldwide, responding to nearly every emergency in the last two decades. It deploys quickly in emergencies and then stays on to teach life-saving skills so that people locally can become self-reliant. Its training assures continuity and a new level of care for those impacted by conflict, tragedy and extreme poverty.

Over the years, International Medical Corps has responded to the world’s most devastating man-made and natural disasters, including famine in Somalia, ethnic cleansing in Bosnia, the Rwandan genocide, and atrocities against children in Sierra Leone. More recently, International Medical Corps was a first responder after the 2004 tsunami in southeast Asia, the 2005 earthquake in Pakistan, responded domestically following Hurricane Katrina, and is among the dwindling number of humanitarian agencies still working in Darfur and Iraq.

What I like about this is that this is a group of medical people providing relief.  These are people who can give care in the first person.

No organization is perfect, and no amount of giving on our part will fix the pain in Haiti.  But I think the medical blogging community should consider standing behind this organization.  If you have a blog, put the widget on your site.  Grab the one on the top of my sidebar.

And give what you can, but not to assuage your guilty conscience.  If your conscience is that easy to assuage, then you probably need to think a little more about your situation and that of these people.  It’s not wrong for us to have what we do, but it does give us a responsibility.

Everyone to whom much was given, of him much will be required (Luke 12:48)

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Short though it may be, this week is a busy one.

Meetings and clinic and admits (though we still have no beds) and lecture and prepping for two lectures and taking care of sick residents and I need hiking shoes for Arizona in March…

…breathe…

…and making sure everything’s set for Saturday’s party and what is that drilling noise in my ceiling and are they trying to drill into my brain and holy OMFG paperwork for insurance credentialing and lighting fires under lazy residents’ asses and when the hell am I going to Chicago and poster presentation and mandatory education…

I’ve perhaps gnawed off more than I can masticate at the moment. I’m cautiously reassuring myself that it will all get done in due time, even if that due time happens to be, oh, TOMORROW.

I’m happy, I’m healthy, my family and friends are well and all of my appendages are exactly where they’re supposed to be. I’m stressed but content, I’m busy but smiling, I laugh until my stomach hurts at least twice a day (doctor’s orders).

Big party on Saturday. The department used to host (ie. foot the bill for) a mid-winter party for residents and attendings. They dunked that idea a few years back for reasons that aren’t completely clear to me but whatever. If dunking it meant being able to hire me and afford me then I’m all for it. Anyway, it’s been up to the chiefs the last 3 years to organize this hot mess. I’ve been knee-deep in an Excel spreadsheet since the middle of November. I’ve managed to con a good chunk of the attendings into “sponsoring” a resident while also paying for themselves. I’ve got a bunch of fun attendings coming and 85% of my residents will be in attendance. This is a feat unto itself – trying to get all of them together is like herding cats. Underslept, non-e-mail-or-snail-mail-checking cats. I paid the caterer today and need to call and make sure the DJ is all set tomorrow. And then? I walk around with a glass of wine in my hand and cross my fingers on the other hand and hope to heaven everything goes ok.

I always said that I’d be a wedding planner if this “doctor” thing didn’t work out. I’d like to recant that statement. I’ll stick to being a doctor. It’s much easier.

Moment of Burrito:

(The above is from a post over at I am fuel, you are friends. If you like music and aren’t reading this blog, SHAME ON YOU.)

((Oh hai. I’ve updated this blog a bit – new theme, updated blog roll, and a disclaimer on the side because in five short months – HA! – I’ll be a Big Bad Attending.))

(((I’m not kidding about the Amazon thing. Not even a little.)))

Huh?

Am I early?  I heard there’s something big coming up soon.  So much talk about llamas – I demand equal time!

Hah!  At least Dr. Rob will work for a change.

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It’s kind of touching when patients and their families notice the hours we’re working.

The service I’m on right now is particularly opportune for this, since the attendings start operating so early, and demand such detailed knowledge of the patients by the residents, that the entire team (intern, resident, chief, couple medical students) has usually come through each patient’s room, severally and ensemble, by 6am every day. Which is certainly annoying, but also noticeable.

In the course of the day we’ll round with an attending. Then we all also come through around 5-6pm, as well as the intern multiple times in between. The people who aren’t completely asleep, or completely absorbed in the TV, can’t help noticing that we’re there around the clock. They also notice that the same small group of us is there virtually every day of the week. They’ll comment, after one of us has had a day off, that they’re glad we got to sleep in. (They didn’t, though, because someone else was in just as early. . .)

One patient has run the entire gamut of the service: preop admission to the floor, postop transfer to a monitored floor, and now in the ICU (don’t ask me why the downward progression; we wish we knew). The family has been so polite; asking the right questions, but also not pestering us when we give our best explanation, and admit that there are things we can’t explain. They’ve also been commenting on the amount of time we spend in the hospital. One of them asked me today if I’ll be off for the weekend, and I said no; he was interested and inquisitive, so I told him the 4 days/month rule; which sounds shocking, when you say it out loud to a person with a semi-normal life. We see it in contrast to the old rules (or non-rules) so to us it sounds good; but although I will, rarely, tell patients and families about 80 hours and 4 days, somehow the old rules seem like a secret that belongs inside the clan.

Which is strange, now that I write it down. Because people do expect their medical providers to be available 24/7 (or to have a thoroughly informed colleague covering), and yet on a personal level, they’re surprised by our lives.

At any rate; it’s nice to be thanked, every now and then.

Happy Delurking Day!

I know you’re out there reading. Why not go ahead and leave a comment to let me know who you are?

I’d be remiss if I didn’t advise you to send good thoughts (and money if you can) towards the relief effort in Haiti. These good people could use your help:

Partners in Health
Doctors Without Borders/MSF
Yele Haiti

Work was b-a-n-a-n-a-s today. I gave one of my residents 10 admissions between the hours of noon and 5. I ended up doing one for her and asking the other team’s senior to do another just so she wouldn’t have to sign out a lot of work. RSV season is in full swing and this year is definitely worse than last year. The PICU is brimming with bronchiolitics.

And if I had one of these in my office, I’d have to pre-pay it.

I’m going to try not to comment on this too frequently, as I get to operate more. But:

I had a case the other night. I did most of it myself. Being as objective as I can manage, I think I did not do it too badly, perhaps even very well at some points, but overall I was certainly slower than the attending doing it all himself would have been.

Now, a few days later, the patient is struggling through the post-op period. Nothing frankly technical (no vascular bleeding, or suture lines falling apart) – but I can’t stop going over the case again and again, trying to decide, definitely, whether if I had tied those knots faster, or run that suture line more adeptly, or not crossed that one tissue plane that we weren’t supposed to cross, would he be doing appreciably better now? Or was he just a sick man having a high-risk operation, and the current problems are no more than were bound to result anyway? Really, actually, I think I probably only added 15 minutes to a 4 hour case. But I operated on him; I cut on him – and now he’s sick. . .

This is scenario is replayed for every one of my patients who encounters what, last year, not operating, I would have regarded as a common and inevitable post-op complication; a bump in the road. But now, I touched the patient; I more than touched them; I was cutting things up; and now things are not perfect.

my fault – my fault – my fault

The last few months have seen me being allowed to operate far more than previously. My performance in the OR seems to consist of occasional stretches of competency, mixed in with a good many more episodes of apparently completely failing to grasp what I’m being told to do.

So I rather enjoyed the other day, when, after about six hours of operating with one particular attending, we came to a crucial and difficult step, deep in the abdomen, close to the aorta. She was just starting to try to explain the maneuver, when I had a sudden flash of insight, and, building on a couple of moves she’d been trying to teach me all day, completed the step, much faster than either of us had anticipated. She exclaimed, “Where did you learn to do that?” “You taught me, earlier today.”

That was fun. Wish I could do it more often. Usually it’s a much slower process, with the attending repeating, “[unspoken: as I've already told you five times in this case] don’t move your hand like that, do it like this.”

I admitted a patient from the ER one night over the holidays. The ER called with a CT scan showing diffuse pneumatosis, and the most obvious portal venous air I’ve seen so far. The patient himself looked far better than the scan, and was amazingly comfortable, considering that he had a heart rate of 140 and was already in acute renal failure. He was so comfortable that it was very difficult to persuade either my attending, or the patient, that he needed emergency surgery. (“Pain out of proportion to exam, Alice. You can’t tell me he has ischemic bowel and no pain.” I insisted, so we didn’t really lose any time, but it was a little disconcerting.)

As for the patient, that was the worst conversation I have ever had to have. Telling a family that someone died is easier. Telling a man who’s chatting happily that he’s almost certainly going to be dead within 24 hours is nearly impossible, either to find the words, or to convince the patient. I had to not only convince him that matters were this serious, but also discuss the option of surgery – his only chance of survival, but a very slim one, with a significant chance of a long ICU stay and major morbidities, if he did survive. (Some might say that with that CT scan, we shouldn’t operate. 1) You can see pneumatosis and portal venous air from a bad bowel obstruction, which can be salvageable. 2) He was relatively young, and with few comorbidities. We never did figure out what caused his ischemia.)

In between talking to him, I was calling the chief and the attending and the OR and the ICU, getting iv fluids and antibiotics running, and moving him to preop holding. Not much time. No sooner had I settled him in preop, with a nurse to watch, and the attending about to walk in, than the trauma pager started going off with multiple gunshot wounds, so I had to leave him. Three hours and several traumas later, I found him and the chief resident in the ICU. The operation had been completely unsuccessful; there was absolutely nothing to be done. His body was shutting down, and there was barely time to have the family at the bedside before he died.

I felt awful afterwards. Not just because it was the holidays, and we had lost a previously healthy man suddenly, but because I had spent half an hour talking to him about his death, and had never talked about what would happen to him after death. I had watched somebody dying, and had never even mentioned God or heaven or hell. Which meant that I did him exactly no good at all. He died, as I knew he would, and had to face eternity, and I hadn’t even mentioned it.

Yesterday one of the PACU nurses came up to me. (At night PACU and preop are staffed by the same nurses.) “Remember that man with the ischemic bowel who died? I went to the funeral home. I had to tell his family something he told me that night. He said, ‘I’m not worried about this, because I’m putting it in God’s hands. He took care of me when I had surgery 30 years ago, and he’s taking care of me now. If he wants me to live, I will; and if not, it’s all right. If I don’t make it through surgery, tell my family I’ll see them in heaven.’ ” I started crying in the middle of PACU. He’s safe, after all. I didn’t do anything I should have, but he knew better than me. Next time, I won’t make the same mistake.

(As for the nurse, I have a whole new respect for her, going out of her way to comfort not only the family, but also the other caregivers.)

My perspective on time in the hospital has certainly changed in the last two and a half years. I remember, even as recently as the end of my intern year, watching the clock intently as the end of a shift got closer, and being very antsy if something came up at the last minute to prevent me from leaving. I also used to spend a good deal of time pondering my days off for the month, and exactly when they fell, and how far apart they were.

I don’t pay as much attention to those specific times any more. I come in as early as I need to so that I can round on patients to my satisfaction. (To me, that means reviewing all the drips on ICU patients, reviewing and correcting all labs, and reviewing the most important consultants’ notes [for me, infectious diseases], before signing in with the team.) I stay as late as necessary to tuck my patients in for the night, and make sure that I’ve checked the intern’s orders from the day. If a case is running late, I expect to stay late with the chief, and don’t pay too much attention to the time. The work is becoming more important, and the time less important.

Which is actually less stressful. It’s almost more peaceful, not thinking so much about time of day. Of course, the corollary is that I’m so busy I scarcely look at the time except when I need to date a note, or in terms of figuring out how cases are running in the OR (usually not that important; our OR is so chronically slow and late, there’s always time to do another chore before the next case starts).

As for days off, after pulling a couple stretches of four weeks straight (between one month and another), working two or three weeks straight through isn’t such a big deal anymore. Four weeks, though – I was definitely getting pretty crazy by the end of those. That was more definitely dangerous for patients than working 30hrs straight.

You get acclimated to anything, I guess.

The Anesthesioboist inspired me.

Not tagging anyone out of principle (but this sounds like something up Kelly’s alley) so play along if you’re so inclined.

Please share:

* One book that changed your life.
* One book you have read more than once.
* One book you would want on a desert island.
* One book that made you laugh.
* One book that made you cry.
* One book you wish had been written.
* One book you wish had never been written.
* One book you are currently reading.
* One book you have been meaning to read.

* One book that changed your life: Me Talk Pretty One Day by David Sedaris. I read it on a flight back from Florida nine years ago and it changed the way I think about words and how they go together. It was sofaking awesome to read something that sounded (in the way it was written) like me. I’ve since read everything by Sedaris. He certainly has a way with words.

* One book you have read more than once: The Diary of Anne Frank. I’ve probably read it 20 times or more.

* One book you would want on a desert island: Isn’t there a Worst-Case Scenario book about that? Because if there is, I’d want that one.

* One book that made you laugh: The Hitchhiker’s Guide to the Galaxy by Douglas Adams. I have two books of the trilogy in five parts left to read.

* One book that made you cry: And the Band Played On by Randy Shilts. Every page is powerful.

* One book you wish had been written: A Female Pediatrician’s Guide to Getting a Job, Getting a Life, and Staying Sane Through it All. I’d definitely read that.

* One book you wish had never been written: The Good Earth by Pearl S. Buck. I was forced to read it in 9th grade English class. We had to write a “reaction diary” and while I think the teacher had intended it for use as a reflective instrument, I tended to use it as a venting instrument. Phrases like, “she’s pregnant again?!” and “who the heck would bind their feet?” come to mind. I’ve never fully recovered. I know there’s a bigger symbolism to be learned from this book but I was so pissed at how crappy it was I just didn’t get it. Maybe if I read it now I’d have a different perspective.

* One book you are currently reading: Lisey’s Story by Stephen King. It’s been in the pile forever and so far, I’m enjoying it. It’d be even better if I could just figure out what the hell a “bool” is.

* One book you have been meaning to read: Reading the OED: One Man, One Year, 21,730 Pages by Ammon Shea. It’s on my Amazon wish list.

Dear Beth,

It’s ok to be happy.

It’s ok to pat yourself on the back every now and then.

It’s perfectly ok to laugh at yourself.

But don’t forget the happy part.

Love,

Me

I’m out of books to read. I would go to the library but it’s so warm and toasty in my house and so…not…outside. Instead, I bring you this.

1. What did you do in 2009 that you’ve never done before?

I started running on a regular basis. I don’t know why I never did it before but it’s done wonders for my levels of stress.

2. Did you keep your new year’s resolutions, and will you make more for next year?

I don’t think I made any for last year. This year, I’ve resolved to be more involved in my community and to spend more of my money locally.

3. Did anyone close to you give birth?

Yes. Erin and Nick had Ella.

4. Did anyone close to you die?



My Uncle Bill passed away this summer.

5. What countries did you visit?

Alas, none.

6. What would you like to have in 2010 that you lacked in 2009?

A regular schedule.

7. What dates from 2009 will remain etched upon your memory, and why?

June 30: I finished residency. September 23: I helped move into the newest children’s hospital in the country. December 7: I passed the boards. December 8: I got a job.

8. What was your biggest achievement of the year?


I passed the boards. After 10 months of studying, I think that’s a pretty big accomplishment.

9. What was your biggest failure?

Not sticking to my guns enough.

10. Did you suffer illness or injury?

I got my first stomach bug in four years. I probably had an upper respiratory tract infection (I work with kids – it happens).

11. What was the best thing you bought?

Philosophy’s eye believe. My under eye circles have all but vanished.

12. Whose behavior merited celebration?

Barney Frank is my personal hero. He’s got serious cojones.

13. Whose behavior made you appalled and depressed?



The Republicans made me appalled and depressed. Otherwise, I have a few other people whose behavior made me disappointed in them.

14. Where did most of your money go?

Taxes (and it’s only going to get worse…). A new TV and couch for my family room that’s finally done.

15. What did you get really excited about?

Our new hospital. It’s beautiful and functional.

16. What song will always remind you of 2009?

“Daylight” by Matt and Kim.

17. Compared to this time last year, are you:


– happier or sadder? About the same.
– thinner or fatter? Thinner.
– richer or poorer? Richer, both financially and personally.

18. What do you wish you’d done more of?


Run. Eat better. Shop at the farmer’s market.

19. What do you wish you’d done less of?



Eat crappy food. Whined.

20. How did you spend Christmas?


I started the day by hanging out at work for a few hours, spending time with some special kids and their families and checking out all the stuff that Santa brought. Then my husband and I went to my parents’ house for dinner.

21. Did you fall in love in 2009?

I fell in love with my new couch. It is the b-o-m-b.

22. What was your favorite TV program?

The Office. Sportscenter.

23. Do you hate anyone now that you didn’t hate this time last year?



I don’t necessarily know if I hate anyone, just disappointed in them.

24. What was the best book you read?

When You Are Engulfed In Flames by David Sedaris, mostly because it’s one of the few non-work-books I read this year.

25. What was your greatest musical discovery?


Matt and Kim. I rediscovered The Tragically Hip.

26. What did you want and get?

I wanted and got a new bag for work. Mine is pretty trashed and I wanted something new and shiny for when I start my new job. Oh, and the new job is a Christmas present to myself.

27. What did you want and not get?

Hm. Can’t think of anything.

28. What was your favorite film of this year?

Ha. Like I had time to see anything in a theater.

29. What did you do on your birthday, and how old were you?

I turned 31. I worked. I had a cold too.

30. What one thing would have made your year immeasurably more satisfying?

I wish I could have spent more time with family.

31. How would you describe your personal fashion concept in 2009?

Clogs. Khakis or scrubs.

32. What kept you sane?

Beer and Curriculum. My friend Sarah.

33. Which celebrity/public figure did you fancy the most?

Jon Stewart.

34. What political issue stirred you the most?



Health care reform. ‘Nuff said.

35. Who did you miss?

The 10 people I did residency with and the two chiefs from last year. I miss them horribly.

36. Who was the best new person you met?



Prita, my co-chief. She’s the opposite of me. It’s great.

37. Tell us a valuable life lesson you learned in 2009.

Think positively.

38. Quote a song lyric that sums up your year.

and in the daylight we can hitchhike to maine
i hope that someday i’ll see without these frames
and in the daylight i don’t pick up my phone
cause in the daylight anywhere feels like home

-”Daylight”, Matt & Kim

Steering back to safer, less political waters:

I’ve been having a peculiar experience lately. Of course I’ve grown inured to the embarrassment of concluding that a patient needs surgery, and making my case, and then being informed by the attending that I’m insane, there’s no such indication, and the patient is best left far outside the OR.

But recently, I’ve encountered the slightly more disconcerting phenomenon of being told by the chief resident that the patient doesn’t need surgery, adjusting my presentation when talking to the attending, and then being told by the attending that we should book the case for first thing in the morning. Depending on how much I caved to the chief, I then get reamed out by the attending, again, or I get credit for having made the call.

Last night was a succession of such cases. A large bowel obstruction, a variety that I haven’t seen a lot of, which people weren’t convinced was really obstructed, but the attending agreed with me. Ischemic bowel, which the intern and the ER doctor were trying to downplay as questionable, but I knew the CT was incredibly bad, and the patient’s vitals and appearance were subtly hinting at the outcome, which was that he died six hours later despite our best efforts (I can at least be glad that I didn’t waste time, and that I stuck to my interpretation enough to drag both the chief and the attending in much against their wills). A less obvious case of ischemia in a vascular patient, requiring intervention in the middle of the night. . .

Now that I’ve gotten to the seniority, and perhaps the reputation, that the attendings will usually, despite questioning me at length, book the case immediately just on my say-so (because surgeons can’t function without interrogating each other, and especially their junior members, regardless of how correct the plan is), I’m starting to encounter the weight of responsibility: I have the OR set up, the patient consented (often after being talked into it quite urgently; so that I would feel incredibly guilty if I had persuaded them so firmly, and was mistaken) and carried down to preop. Everything ready to go for a major operation, and all on my authority. I make time, no matter how much the ICU is calling me, to wait till the attending comes, so I can see what he thinks of the patient and the CT scan. I only ever once got the patient and the attending together in holding, and had the attending seriously consider cancelling. But I get very nervous at the idea that I, virtually by myself, am setting people up for big surgeries. . . what if I get it wrong?

Ah, 2009. You have been bitchy mistress and saucy minx all in one.

January: I did a hospitalist elective…and hated it. I didn’t realize it would be a harbinger of things to come. I ushered in the new president while eating Ramen noodles and drinking champagne. I am one classy broad.

February: I started running. I earned respect (and hatred) from my PICU nurse friends from all the codes I ran in the ER and the patients I sent them. Five codes in eight days, five extended PICU admits, and all of the patients lived. I did too much work running and not enough running running that month.

March: Went away on vacation for the first time in five years. I drank a lot of beer, ate a lot of seafood, walked everywhere (including the entire length of the Freedom Trail), and met up with awesome friends. I didn’t get the job for which I interviewed, but I got asked to do an extra year of residency – because I earned it. In a good way.

April: I survived night float, despite overwhelming crankiness. I used to not mind night float but I am beyond happy I never have to do it again.

May: I confirmed my black cloud status on one particularly craptacular night. I also made a pretty big decision about my future. I had yet to realize that life is what happens to you when you make other plans…

June: I blogged once. If I remember correctly, this whole month blew from multiple perspectives and I was happy for it to end. I finished my required residency training on June 30th. I have a certificate and everything.

July: I continued my tradition of posting only once a month. I said good-bye to friends (and to my Uncle Bill), moved into my office, got a sweet lamp, and started my chief year. I also celebrated my sixth wedding anniversary.

August: Apparently I only post once a month during the summer. Anyway, I celebrated the 10th anniversary of my 21st birthday. I also started attending Beer & Curriculum meetings. Curriculum is much easier to tackle when there’s beer involved.

September: I got my name (and article) in the paper. I also helped move a bunch of kids (and residents…and attendings) into the newest children’s hospital in the country.

October: I survived the boards. I don’t remember much else about October, probably because my short-term memory in the two weeks after I took the boards was pretty much shot.

November: I survived NaPhoBloPoMo. I came to yet another crossroads and had to decide which way to go. In the end, I had decided a long time ago but didn’t want to admit it.

December: I passed the boards. I had my first abstract accepted for a poster presentation at a meeting. And? I got a job.

Only three days remain in what ended up being one monumentally crazy-ass, nut-bag year. I’ve tried to think about what the next year will bring, as I make the quantum leap from resident physician to attending physician. While I don’t know the specifics, I do know it will be one hell of a ride.

Moment of Burrito:

I’ve been trying to avoid talking about health-care reform (or deform, if you want to be accurate) on here, because it makes me so angry that I’m virtually speechless. I’ve also stopped talking about politics with my liberal friends at work. I used to enjoy a friendly debate, but there’s nothing fun about the looming disaster.

I can’t not talk about this any more. I just opened a mass email to all the physicians at my hospital, informing us that, in addition to compazine (a very basic anti-nausea medicine; cheaper and more effective than zofran, and less sedating than phenergan; my go-to drug for post-op nausea) and some iv narcotics, and antibiotics, there is now a national shortage of propofol (the fast-acting sedative used to induce anesthesia for a general case, used as almost the sole agent for a conscious-sedation outpatient procedure, and relied on heavily to sedate ICU patients, because its very short duration of action means you can turn it off quickly to check for neuro status, and trials of vent weaning, and get it back on quickly if needed), and we are going to be using the European variant, whose key features are that people who are allergic to peanuts can’t have it, and it doesn’t have the same anti-microbial agents built in, meaning it’s more liable to acting as a culture tube for bacteria.

I can’t see any explanation for this sudden, simultaneous shortage of all kinds of basic drugs (which I have never seen before in my career; one at a time, maybe, and usually more rarely used drugs) than that pharmaceutical manufacturers are scared stiff of the antics in Congress, and are trying to cut their losses by not manufacturing surpluses when they can’t tell if they’ll get paid properly in the near future.

In other words, it’s starting to feel like a third-world country (or maybe just Europe) and they haven’t even settled on which gigantic, mysterious, debt-riddled, unworkable socialist plan they’re actually going to force down our throats. (Anyone else seeing this phenomenon too? Any less depressing explanations?)

60% disapproval rating across all polls, and it’s still full-steam ahead? Who still thinks Obama gives a rat’s — what the people really want?

Although I have to say, since a majority of the American people were idiots enough to vote for this traitor, after having heard him advertise his socialist agenda loud and clear for a year’s worth of campaigning, it’s their own fault that he’s now giving them exactly what he promised. (And I say traitor because I mean it, in the sense of someone who’s committed to the destruction of Constitutional government and the traditional American way of life, and perhaps even national security. Think KSM trial in New York.)

If any non-medical people are reading this, and if you’ve been wondering what the medical profession thinks of Obamacare, I have two remarks for you: the AMA does not represent us, and we haven’t been screaming simply because we’re too busy taking care of patients, and too despairing of being able to stop this railroad crash, to try to express our fear and disapproval. (And a minority of us are socialists, don’t ask me why.)

Guys, this is how freedom is lost: we’re celebrating Christmas, we’re not watching, and Obama and his socialist cronies in Congress are about to transfer 15% of the national economy to government control, after having already taken banking and finance. . . this is going down fast. I’m glad I got to at least see America as a free nation, although I guess I won’t get to spend much of my grown-up life in that country. . . If I wanted socialism and multiculturalism gone crazy, I would move to Europe. . .

Merry Christmas.

I talked to my father-in-law this weekend. He’s a pulmonologist who owns a private practice and does a fair amount of adult critical care in a local hospital. I had sent him my contracts for a job offer and I wanted him to review them. The contracts are fairly boilerplate and there’s really no points of negotiation, just of clarification. When we were done going through everything, he said to me, “I’m really happy you’re taking this job. You were meant for it. You belong in academics, not in private practice. You’ve worked hard and earned it. You were built for this job.”

For a job. Like, a real one.

I didn’t want to jinx anything before, but this was good thing #2 in the trifecta of good things that happened a couple of weeks back. Starting in July, I will be an assistant professor in the department of pediatrics at my hospital.

I was rather disillusioned when I didn’t get the hospitalist job last year but in fact, that was the best thing that ever happened to me. I was given the chance to re-evaluate what I want out of life and in fact, I want just that – a life. I was in school for a long time and then what will amount to four years of post-graduate training. I kept putting off Life for Career. I was even willing to sacrifice Career for Life.

I’ve thought about this a lot. Stressed, pondered, researched, not slept over it. I wanted to make sure I was taking it for the right reasons. I didn’t want this job because I’m comfortable where I am. I wanted this job because I would be good at it and that it was a right fit for my interests. I get to have both a great personal life and a professional one. I get to be mentored and supported to become the doctor I want to be. I get to continue to work with some great people – doctors, nurses, child life specialists – who want what I want. We want healthy children. We want better lives for them and their families. And we’ll do whatever it takes. These are My People. This is My Family.

Today marks the winter solstice. It is the darkest day of the year; the one with the least sunlight here in the Northern Hemisphere. I have worked and lived my darkest days.

It’s time for the light to shine.

It’s starting to dawn upon me that all the chiefs and attendings I’ve found very annoying or stressful have actually been teaching me a great deal. Most of them, because it was their personal demand for excellence and thoroughness which was irritating me; a very few, because their laziness was forcing me to take more responsibility for being the thorough member of the team.

Too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me.

But I recognize now that my regard for getting some degree of social history; my attention to looking at all the available imaging; my goal of knowing absolutely all the details of the medical history before calling the chief or attending; my thinking about electrolytes in the ICU; my thinking about DVT prevention – they all came from chiefs and attendings whom I found nearly intolerable at the time – because I wasn’t yet prepared to think that hard or that thoroughly about “only” a surgical patient.

Now if I can just think of that when I’m getting annoyed at someone. . . what is it that they’re teaching me?

I remark on the above, in order to avoid relating in detail how extremely annoyed I am at an ER resident and attending, who called us ten minutes before signout with a claim of appendicitis, on a college-aged female, without obtaining a white count, a pelvic exam, or a CT scan. I’ll grant that the CT scan is probably unnecessary. But they seriously seemed to expect us to book the patient for the OR without knowing any lab values, and without anyone having done a pelvic exam. (She had pain, but no peritonitis.) Please tell me if I’m mistaken, so I can stop being annoyed at them; but in the real world do ER physicians call surgical consultants without either a CT or a pelvic, on a young, sexually active female patient?

(I’m sure they’re teaching me how to be polite to frustrating referring physicians. . . like the PCPs whose first test for gallbladder disease is the HIDA scan. . . I haven’t quite learned it yet.)

Here's the most important piece of equipment in the hospital:

You got it, the ice machine. Just ask all those parched patients on Med-Surg which device they'd take with them to a deserted island.

Patient: I’m allergic to [lots of other things], and red and green dye.

Me: No problem, we won’t treat you with M&M’s.

I did a 36-month residency in pediatrics in order to be eligible to sit in a cold ballroom at a hotel and bubble in answers to 338 questions about all things pediatric on a scantron in order to be able to receive the designation of “board certified”.

I found out today that I passed the American Board of Pediatrics 2009 General Pediatrics Certifying Examination.

Yes, Virginia, it really was all worth it.

I mean the Pacific Ocean, and I mean in a good way:

This is why I need to make a greater effort to crawl out of the hospital more often, and remember why I moved all the way to Rural.

It's been several months since the space-time continuum was indelibly altered by Noo's critical illness and my decision to leave Gimbels. Whereas previously I was a bit of a chatterbox on this blog, I have to acknowledge a certain surly silence which has take the damn thing over ever since. I've never been good at change, and there's been nothing BUT change since July, and all I could do was surrender myself to it and see where it would take me. Most of the time I feel like one of those ordinary citizens in the movies who, through no fault of their own, wake up at the center of a David Lynch movie, apparently plunked there by Martians. A video montage of this movie might include scenes such as:

• Me, erupting into tears of rage the first week I worked at Macy's when one of the urologists tried to take my head off because of a perceived oversight on the part of one of the other hospitalists.
• Me, writing vengeful notes in a patient's chart, implicating the urologist for his failures of communication, personality and common decency. 
• Me, packing bags for a week at Nordstrom, including critically important home decor items to compensate for the dismal apartment Xpress Hospitalists has rented for us up in Extra Rural County.
• My late sweet cat on one of her better days after the neuropathy was diagnosed, raising her moist black nose to the last of the autumnal sun.
• Me, exploding into tears of frustration the second week I worked at Macy's, because all the doctors there are bitter and jaded and don't do the job they are capable of doing. Not that unsafe things are taking place at Macy's, but there is a general absence of excellence, the kind of Santell standard of professionalism I used to believe was the unwritten code of honor among doctors. And this depresses me.
• Me--too lazy to hang my new blackout curtains--deciding to drape a dark-green flannel fitted sheet over my old curtains instead. This effectively creates a darkroom effect in the guest bedroom where I sleep all day prior to night shift at Macy's.
• ICU Horror Night #1 at Macy's. Don't ask.
• The daily grey gloom of Pacific Northwest winter skies, against a savage rural coastline.
• Me, dissolving into tears of pure grief the third week I worked at Macy's, because I miss the people at Gimbels and I HATE THIS NEW JOB!
• Noo, jumping six feet in the air when I emerge from what has affectionately become known as "The Cave" every mid-afternoon when I'm scheduled at Macy's. With the sleep mask pushed up onto my forehead and trapped hair sticking straight up, I'm not a pretty sight.
• Me, inreasingly anxious every time I have to go up to Extra Rural to work at Nordstrom's, now packing FIVE BAGS: one for food items, one for clothing, one for bedding (the Xpress apartment has the worst pillows I've ever encountered), one for electronics (thank goodness for video iPods, that's all I have to say), and one for books because THERE IS NO BOOKSTORE IN EXTRA RURAL!
• ICU Horror Night #2 at Nordstrom's. One of these days I might write about this night, but I'm probably going to need several years of therapy first.
• Me, becoming resigned to the job at Macy's because at least I get to stay at home after work, instead of shacking up in the ugliest apartment in Extra Rural county.
• Me, succumbing to tears of despair the fourth week I worked at Macy's, because both my new jobs suck. This was also the week I stopped bawling in the bathroom and started crying in front of all the ER staff instead. I figured I might as well write orders if I was having a nervous breakdown.
• ICU Horror Night #3 at Macy's. One of the biggest scares I've ever had, a roller-coaster of emotions, a big save in the OR--and a good outcome. More therapy and several large cocktails are in order.
• Topsy-turvy me on my days off, either waking up at three in the afternoon ("Wha' happened?") or at two in the morning. On the latter occasion, I was so wide awake and ready to perform that I started roasting soup bones for stock before the rooster crowed. Poor Noo thought the house was on fire, and my cats--my remaining cats--were mystified.
• Smurf, my Extra-Rural colleague and roommate in the ugly apartment, putting up with my morning grump every day we're on the job.
• ICU Horror Night #4 at Nordstrom's. Another big scare, another OK outcome.

Which brings us almost up to date on the Adventures of Theresa Chan, Itinerant Rural Hospitalist. Wow.

A girl 18 weeks pregnant came in with something trivial.

Me: (During the pelvic exam) “Ok, everything looks normal.  Do you want to know if it’s a boy or a girl?”

A 19 year old guy about to get a shot was nervously flipping channels on the TV in the room.  He was too freaked out to notice what he stopped on.

Me: “Oh, so you’re a big Murder She Wrote fan?”

Hoo boy.

I've been quiet on the blog because I've been listening to myself. I realized that I've been putting solutions together for years which look good on paper but truly suck in practice. Flashing my middle finger at Gimbels and working at Nordstrom (a good job, btw, but...) seemed so reasonable at the time, but I hate being away from my home for a week at a time, and I hated missing my cat's final moments because I was on my way from 60 miles north. Not that working at Gimbels that day would have been a walk in the park, but I would have been there and I would have been able to hold her one last time. Thank goodness Noo was there. We raised this cat from a 4-week old kitten and she was like the warm pulse of our household. I don't expect everyone to understand this sentiment, but cat people will, and I honestly don't give a shit about any opposing opinions.

"Being there" is an emerging theme in my current reflections about doctoring, early middle age, the creative life, and What Comes Next. I'm going to try to get some of these reflections onto the blog but only episodically. I need to be quiet. I need to listen.

A woman came to the ER with one month of belly pain, a complaint I would normally find irritating.  Pain for a month hardly seems like an emergency, now does it?  Don’t you know emergency rooms are for emergencies?  (Of course everyone knows that ER’s are mostly for non-emergencies, yet ER staff love to conjure up mini-bafflement/outrage tizzies for particularly egregious complaints, I guess to allow for some form of masochistic release.)

But this lady was somewhat different than the typical something-wrong-x-1-month-er.  For one, I liked her almost immediately.  She was affable and seemed reasonable, two characteristics so rarely found in tandem amongst my patients, which conspired to melt through my inherent pessimistic frostiness over such a complaint.  As she augmented her description by sitting up and placing her hands over an unusual area to hurt, I was struck by a discreet moment of clairvoyance.  It was less a thought and more as if someone briefly took control of me, dimming the surrounding din then playing for me my pre-recorded voice inside my head, confident and clear so that I could not possibly miss the message, “something is horribly wrong with this woman.”

I was only allowed a second or two on this omnipotent perch, in the blink of an eye I was once again relegated to collecting data on associated symptoms and social history.  Though the premonition’s prospective weight was not that of its retrospective cousin, it was impressive enough that I found an excuse to scan without a second thought.  I wouldn’t have been shocked if it came back normal since time blunts and allows for second guessing.  Still, I was not surprised in the least to read of her now newly-diagnosed metastatic cancer within the CT report.

I made sure this nice woman was taken care of, then bumbled through the rest of my shift, ensconced in ambiguity, the dizziness probably just inner ear, the chest pain probably not cardiac, the headache probably just a migraine, the fever probably just a virus.

I don’t want to talk about vaccines and autism for the same reason I don’t feel like standing up and repeatedly smacking my head against the wall.  I would, however, like to pass along the following information about the H1N1 flu vaccine and mercury.

There are three different companies that make H1N1 (swine flu) flu shots.  Of those only one, Sanofi Pasteur, has a shot FDA approved for kids less than 4 years old.  Sanofi Pasteur makes three different H1N1 flu shots, one of which is FDA approved for kids older than 3, the other two are approved for kids all the way down to 6 months.

Of the 2 Sanofi Pasteur shots approved for kids older than 6 months:

-one is a 0.25 mL prefilled syringe (an individually packaged shot) which contains no mercury
-one is a 5.0 mL multidose vial (a bottle of vaccine that 10 shots can be drawn out of) which contains 25 micrograms of mercury per shot.

A mercury free H1N1 vaccine is out there for your kiddo if you are so inclined, don’t let any fear mongers tell you otherwise.

CDC website — scroll to the table near the bottom if you want to see for yourself

1. See next toddler with flu-like symptoms.

2. Try to figure out if the mom will only be satisfied by a flu test.

2a. If no, she just wants my opinion:
-It’s swine flu
-Discharge home
-Diagnosis: Swine flu, clinical
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

2b. If yes, I don’t care about your opinion I want a test go to 3.

3. Test for flu

3a. If negative:
-Good news!  It’s not swine flu!  It’s some other virus.
-Discharge home
-Diagnosis: Swine flu, test false negative
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

3b. If positive:
-Good news!  We know what’s wrong.  It’s swine flu.
-Discharge home
-Diagnosis: Swine flu, I mean it was proven by a test
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

4. Go to 1.

At least not literally.  Figuratively I’m still not sure.  I have some things I’d like to write about, but life can change and I’m just finding it harder and harder to come up with the chunks of time I need to post.  Hopefully it’s just a sabbatical.  Thank you all for your nice comments and concern.

Recently a reader asked me why I left rural practice, and I took this as a sign that my recent job-hopping has made me seem like one of them fancy-pants, highfalutin' cityfolk doctors who make such a stir on TV. At one time, I too believed a country doc stayed in one town for thirty years, delivering babies and burying octogenarians, until you finally drop dead in the office one day after seeing a clinic full of patients. Modern doctors seem to move from job to job, role to role, throughout their careers, as mobile as information technology supervisors, customer service representatives and hedge-fund managers, regardless of the demographic they serve.

Me: Now that you’re pregnant, you should stop smoking.

Patient: I’ve been smoking for 12 years, and I don’t plan on stopping now.

Me: (Pause) Wait, you’ve been smoking since 2nd grade?

I haven’t seen very many people die.  Instead it’s people who’ve already died and then are brought to the ER (usually still dead), or people who are about to die that we prop up long enough to die in the ICU, or people that die just a minute before I get to them in response to their code blue.  Of those that actually manage to die in the ER, most are lined and tubed and monitored so that their death is observed not on their person but rather in an aseptic collection of downward trending numbers oblivious to our resuscitative efforts.

But then I saw a 103 year old man who actually looked fine but turned out to be in complete heart block.  And then some time later his heart rate jumped from 40 to 190 and now he was in V-tach.  He still looked fine so I just stood somewhat mesmerized by his sine wave waiting for the nurse to come back with the amiodarone.

And then abruptly his sine wave became a flat line.  He had a Do Not Resuscitate order in the chart so I didn’t.  Instead I just watched him.  For a few long seconds his countenance seemed to defy his condition.  But then his eyes rolled back in his head, and his color began to change from pale to red to dusky blue.  His mouth kind of drew in on itself in a manner wholly unnatural with life.  I asked his son if he wanted to say goodbye and he did so I led him to the bedside and everyone else including myself out of his room.

But I continued to eavesdrop from the remote heart monitoring station.  And I saw a blip in his flat line, then another, and soon his heart was beating again, more normal than when he arrived.  I headed back to his room to find him eerily well appearing, as if the last few minutes had abruptly been erased.

Like I said, I haven’t seen very many people die.

The ambulance pulled up and two medics hopped out, which was unusual since I wasn’t at work.  From my kitchen window I had seen them drive past my house to the next door neighbor’s, a nice enough couple that I share a fence but little else with as they are more than twice my age.  I thought about going over to see if I could help, but other than being in the way I add nothing to a medic’s prehospital interventions, not to mention I was literally heading out the door for work and I figured I’d just see them there.

I saw him soon thereafter, and shook his hand, and told all his family the next time we get together let’s do it someplace besides the ER since that always lightens the mood with people you only kind of know.  As I started my assessment it soon became clear that he had something VERY BAD.  I ordered a series of tests to show the BAD and quantify how VERY, placing some calls to make sure they were done as soon as possible

A bystander might wonder how an ER can be so devoid of empathy, how we can be unaffected by and in fact make light of disease and suffering and death.  The reason is that it’s impersonal, that we interact with you but don’t know you, that the fact of the matter is unless something is particularly tragic some sort of an interpersonal connection is necessary to conjure up grief.  It’s the difference between reading an AP story of another soldier’s death, then watching a sit-down interview with his decimated wife and kids.

I’ve been cognizant of my emotional detachment for some time now, but never really appreciated its benefits until I worked without it.  I’ve taken care of friends and acquaintances before, but always for some relatively minor ailment.  But now here was my neighbor, and his VERY BAD findings.  No longer was I able to run the department expertly, only adequately, since I was spending far too much time perseverating on him.  He had a few different treatment options, his accompanying co-morbidities causing each choice to carry a substantial countering risk.  I second guessed myself far longer than I normally would, continually revisited and reupdated his family, and had a persistant underlying sense of unease and jitteriness — all because I had a small but legitimate fear that he would tip over some ill-defined physiologic precipice and die in front of me, his house becoming my permanent reminder of his family’s grief, my house turning into a monument of failure and shortcoming to his widow.

Finally he was gone from the ER, as stable as possible, and at least if something happened now I’d be off the hook for it.  As it was, he went on to make a full recovery.  He now credits me for saving his life, and while my emotional side is plenty willing to soak that up, my more insistant logical side knows his diagnosis couldn’t have been more obvious, that sometimes a patient’s fate is set, one way or the other, regardless of this or that treatment thrown at them, that as an ER doc it doesn’t feel like you’ve done anything extraordinary unless you, well, do something extraordinary — certainly not just see over some case that anyone, save for a complete hack, would be unable to bungle.

Still, I’m so glad you’re ok neighbor, for both you and for me.  Next time we get together let’s do it someplace besides the ER.