where's the beef?
Do you think cardiologists invest in the beef industry? If they do, do you think it would be a conflict of interest and an ethical quandry? After all, isn't it a little like an infectious disease physician investing in bioweaponry? (Although, I suppose, lots of people like eating beef. I don't think anyone likes having anthrax.)
In any case, the beef industry has invented the mother of all fingerfoods: cheeseburger fries. (Would I be indicted for treason if I called them cheeseburger french fries?)
I'd call it instant angina. Golden-breaded, deep-fried coronary artery disease, made your way. (We love to see you grab you chest. Get me some nitro, stat!)
Can I just get a port installed into my thigh so that every time I have an angioplasty done, it won't have to be so traumatic?
And people wonder why Americans are so fat.
08:40 · permalink · add a comment
Sat, 20 Sep 2003 toppro re nata
Wow. For all this time I never knew what PRN really meant. What is sad is that I even worked in a pharmacy for a time. I learned very early in life, however, that it translates into "as needed." Anyway, so in Latin it's pro re nata, literally "for a thing that has arisen" (In case you really care, this is essentially the same nata that you find in such Latin/Greek neologisms such as neonatal (newborn), prenatal, postnatal, and perinatal—thanks to my OBGYN rotation, I don't really have an effing clue what any of these things really mean. I always thought of nata as "born," which makes sense, I guess. Arisen, born, etc., etc,. Actually, that word fragment is all over the place. There's innate, Nativity, native, even nation. OK, enough linguistics.)
I stumbled upon this on contraindications and love songs, which I mentioned before.
And then I think about how medical short-hand has infiltrated my and my friends' vocabularies (me and a were actually discussing this), even when we are discussing non-medical things. Phrases like "not very specific" instead of "it could mean anything," "plus-or-minus" instead of "so-so" or "give-or-take" (although, interestingly, you would say mas o menos in Spanish), "not indicated" instead of "we shouldn't do that," "not very high-yield" instead of "waste of time." We will actually say things like "Don't do that! You're going to give me an MI!" instead of saying heart attack. Or "Let me sleep! I'm status-post shelf exam, for God's sake." The worst is this: "Man, I need to raise my GCS a few points" instead of saying "I really need to wake up and pay attention." Man, are we nerds.
Of course, there's always the pseudo-medical terminology. For example, FOS (full of stool, or, more to the point, full of shit), which is frequently bandied about on the wards both literally and figuratively.
And then there's the informal jargon. Like "retic'ing" for "producing reticulocytes," "polys" for polymorphic mononuclear cells, "tap" for any act of sticking a huge needle into any body cavity (commanly referring to lumbar puncture or sometimes thoracocentesis or arthrocentesis) "Spiking a temperature" for an abrupt increase in temperature (usually designated as 2 degrees Fahrenheit over baseline), "streeting" for sending a patient out of the ER, "turfing" for pawning a patient off onto another service (this one courtesy of House of God), "pull some water out" or "make him pee" for giving someone Lasix, "vitamin H" for Haldol, "vitamin V" for Valium, "everyone is tucked in for the night" for that (rare) blessed moment that the intern's dirty work is all done, and he/she can maybe sleep half-an-hour before rounds start. Oh, there's "banana bag" for the thiamine, folate, and glucose mix they infuse alcoholics with. Oh, and while they sound facetious, the following (perhaps insensitive) words actually have technical meaning. "Loopy" means altered mental status most likely due to medication/illicit substances, which is different from "crazy," which means someone has an axis I diagnosis. Then there's "not all there" for someone suffering from dementia.
OK, my GCS is definitely dipping. I'm rambling on and on about absolutely nothing. I should probably get some sleep.
00:00 · permalink · 2 comments
Thu, 18 Sep 2003 topcel phones in the ICU
So this study (linked on Slashdot) proves that cel phones provide contaminable surfaces for various bacteria to colonize, providing a medium from which healthcare workers' hands can transfer said bacteria to a patient, causing multiple-drug-resistant nosocomial infection.
Big news. This would also apply to the pen I use, the chart I write in, the stethoscope I use to listen to your chest and abdomen, the bedsheets, the bed, that plastic wristband that they force you to wear when you're an in-patient, the catheter sticking in your urethra, the TV remote they give you, your dinner tray, your skin, my skin, all our skins, etc., etc.
(Read my comment on Slashdot)
Even if we all obeyed universal precautions, I'm pretty sure we wouldn't be able to stop all nosocomial infections from killing ICU patients, but proper handwashing (at least 15 seconds under the faucet with rigorous friction between surfaces) would cut it down a lot.
In the hospital I worked in last, vanc (as in vancomycin) was considered a 4-letter word, so we shouldn't mess around with antibiotics, either. All we'll end up doing is growing a bigger, better bug.
Anyway, I thought that, at least in older hospitals, the ban against cel phones was because it theoretically interfered with telemetry (which may or may not be bunk. I haven't figured it out yet. I'm not about to turn on my phone in the unit just to see if the rhythm strips go haywire.) Since a lot of unit patients are on telemetry, we couldn't bring our cel phones in there anyway. The real motivation, though, I'm sure, is to keep visitors from jabbering away non-stop while people are busy dying in the adjacent room.
10:15 · permalink · add a comment
Mon, 15 Sep 2003 topcalcium channel blockers
A condensation of "Pharmacology of the CCB" by Robert W Piepho.
STANDARD DISCLAIMER: DO NOT USE ANYTHING ON MY WEBSITE TO TRY TO PRACTICE MEDICINE, BECAUSE YOU WILL BE SORRY AND YOU MIGHT POSSIBLY KILL PEOPLE. ALL I DID WAS GOOGLE THE TOPIC AND READ THE FIRST THING THAT POPPED UP. YOU HAVE BEEN WARNED. I CAN'T BE HELD RESPONSIBLE!
The three types: phenylalkylamines, benzothiazepines, and 1,4-dihydropyridines.
The three prototypes, respectively: verapamil, diltiazem, nifedipine
In order of vasodilatory effect on coronary and peripheral vasculature, from greatest to least: nifedipine, verapamil, diltiazem
Negative inotropic effects, from greatest to least: verapamil, nifedipine, diltiazem
Negative chronotropic effects: verapamil affects AV conduction more (PR interval will increase), diltiazem affects SA conduction more (rate will decrease) Nifedipine has very little negative chronotropic effect.
20:06 · permalink · add a comment
Sun, 14 Sep 2003 topshift work
apparently the trend is for people to go into fields of medicine that do shift work, 8 to 12 hours a day, 5 or 4 days a week, where you don't have to take your work home with you, which would be ridiculous and sad if it were 30 years ago. but thanks to particular trends, both good and bad (maximum work week allowances on one hand, and the miserable reimbursement rates of hmos leading to the separation of inpatient and outpatient services on the other), opportunities abound. you don't have to consign yourself to the narcolepsy-inducing, dark chambers of radiology, the mind-numbing boredom of anesthesiology, the dead and frozen corpses and innumerable microscopic specimens of pathology, or the maddening mayhem of the emergency room.
as i said, particularly in california, the trend seems to be to try to separate inpatient and outpatient services. thus the creation of two fields: ambulatory medicine, and hospital medicine. the ambulatory care physician is basically a general internist who only sees people in clinic. (basically, in some respects, a crippled family practicioner who has no training seeing children or women. although, in reality, most ambulatory care physicians are indistinguishable from family practicioners.) the hospitalist only takes care of admitted patients (although it is possible to moonlight, i suppose. you are basically the house doctor, and it sounds a little bit like a permanent residency program, except that, like i said, it's shift work.) gone are the days where a physician was expected to see his inpatients in the morning, go into the clinic, maybe assist with a surgery or two, then finish writing notes/dictating at the hospital if he has to (and usually, he did.) but admitting privileges to hospitals are harder to come by, and harder to maintain, often because of the high cost of malpractice insurance,and the fact that many hospitals are owned by corporations who are much more interested in keeping their stockholders happy than anything else. some hmos will not reimburse you reasonably if you admit your patient, leaving you with no rational recourse but to refer them to a hospitalist.
then there is critical care medicine. this can be somewhat similar to shift work, in the sense that when you're not on call, you don't have anything to do. it's not like you have to follow up on unit patients in clinic (although, since most critical care physicians have another specialty, like pulmonology, or anesthesia, they sometimes do have clinics)
and, similar in many respects to radiology, except, since there is a therapeutic component to it, you actually see outpatients and maybe even admit. nuclear medicine is a very lucrative field as well, although there is a lot of overlap with radiology, cardiology, and radiation oncology, and there are a lot of turf battles to be fought still. and you do take call, although, thanks to the miracle of technology, you can often do your work at home. (after all, there are very few things that would need to be done stat.)
so, there are more options, and there is always a lot of flexibility. more than most fields, the amount of money you make generally correlates to how much you work. this is especially true of shift work, since, typically, you get paid by the hour. in contrast, with the traditional fee-for-service system, since most reimbursements are handled by an intermediate party, be it hmo, private insurance, the state, or the federal government, and they control the fee schedule and decide what they think is reasonable to pay you, a lot of times, the amount of work you put in does not very well correlate to how much you get paid.
not that you should be doing this for the money. (because if you are, well, you're an idiot. you would've made a million dollars in the time it takes to finish medical school and residency if you'd gone to business school instead.)
while continuity of care is definitely sacrificed, there is a lot to be said for reasonable work hours. i mean, it has been proven by studies that health care professionals who are tired and sleepy increase morbidity and mortality. it's one thing to be concerned about your patients and wanting to know how they're doing, and another thing to be doing work for free and being told by someone who has no medical training at all (insurance claim people, management, and all the other suits) that whatever you've been doing can't be reimbursed because they don't think it was medically necessary, and even if it was, you should've referred them and gone through the proper channels instead of trying to do it yourself.
that said, i think anyone who is going into a field that does shift work simply for the lifestyle will be unpleasantly surprised. i know that a lot of people are attracted to emergency medicine (and to a lesser extent, hospital medicine and critical care medicine) because, in theory, you do your shift, you sign out, and they don't bother you until you're back on shift. in practice though, especially if you value your medical license, sometimes things you signed out will go horribly wrong, and because you're the one who did the intake, they may very well call you in the middle of the night to see if you have more insight as to why the guy you signed out as perfectly stable, ready to go home, is all of the sudden crashing. and, realistically, the only way you learn anything is if you follow patients. i know a lot of good er physicians who will sometimes go up to the floors or at least call to check on someone they sent up for an admit. sometimes not even for purely educational purposes, but because they actually care what happened. same thing with good radiologists—i met one who actually goes to morning report to see what happened to patients whose films she read. observing the clinical course is often times the only way to learn whether the decisions you made were right or wrong. without this kind of feedback, how can you possibly improve? and, if anything, you have to keep up, because the field changes so fast. we're talking job security here. use it or lose it.
that said, every field has their good points and their really bad points. you might think that ambulatory medicine is pretty cake, for example, but in this hmo-riddled system we operate in, it's a serious pain in the ass to be a primary care physician. what really sucks is that half the time you're fighting over administrative problems (billing, admit privileges, formularies, eligibility) instead of practicing medicine. i don't think you can write off anyone, regardless of their field, as inherently lazy or less relevant to the practice of medicine. each specialty has its place, and they are all integral to the delivery of health care. at least in the urban centers of the nation, there is really no need to practice cowboy medicine, doing appendectomies with one hand, delivering babies with the other, and trying to write a script for medication with your right foot. the system is in place not to make your life as a physician easier (although it can do that), but to insure that your patient gets the best care possible, and a lot of times, you alone are not going to cut it.
in the end, we are human beings, and, as a wise attending once told me, if you're not taking care of yourself physically, mentally, emotionally, then how the hell can you expect to take care of anybody else? your no good to anybody if you're not sane, and sometimes the price of sanity is cutting down on the amount you're working, making less money, and knowing when you can't hack it and it's time to refer.
22:09 · permalink · add a comment
Wed, 10 Sep 2003 tophope
What we sell ("sell" is such a dirty word, but that's what we do)— what we sell is hope. Lately, I've had my fair share of being a consumer of health care, and have come to appreciate what exactly it is that we provide. The idea that, no, you (the patient) are not crazy, and that you really do have something wrong with you, but the good news is that we can fix it. And if we can't fix it, then we can make it at least easier to live with. Whatever it is, at least we can try something.
This is actually most apparent in psychiatry. While you may actually be crazy, at least you're not delusional about being crazy. (Crazy being—in my definition, my own private word usage—any axis I diagnosis.) Nowhere is this more important than in depression. You are not a lazy, worthless bastard whining over the most minor thing. There really is something wrong with you that can be fixed.
And often times, in depression, while the solutions are often quite simple, they are nearly impossible to discover on one's own. (Such is life, I suppose.) Often times, while your cure is within your own reach, you might need someone to direct your grasp.
But even when things are looking grim, you aren't dead yet.
I think one of the things horribly wrong with American culture is that we are needlessly fearful of death. This makes no sense if so many people really profess to believing in the afterlife. The problem is that we tend to pathologize death, that death is something awful and wrong.
But it isn't. It's part of the deal. The Circle of Life, and all that jazz.
The thing is, if you stop and think about it, none of us know exactly how much time we've got. Now wouldn't it be a good idea to make whatever time we have remaining be the best it could possibly be?
Even in the darkest hour, there can always be something to hope for. Even if you can't be cured, you can still live out the rest of your days with dignity, functioning to the fullest of your abilities, as free from pain and suffering as much as possible, free to act, free to choose.
To paraphrase a Tagalog phrase, as long as you're breathing, there's still hope.
19:40 · permalink · add a comment
top2 out of 2
I hit my second LP [lumbar puncture] today, the so-called "champagne tap" according to S. I never realized how difficult it was to not get blood in a spinal tap. (Just goes to show how much better I do when I don't stop to think about things.) I have been a lucky bastard. (Why am I such a pessimist? I can't help but think I'm going to miss my third one. I bet you it'll be right after I brag about hitting my first two ever LPs.) My attending half-jokingly wondered if I might not go into pediatric oncology. The PICU resident and the PICU nurse were mildly impressed.
I wasn't as triumphant as with my first one, though, because I was shaky as hell. Remind me never to drink a honker cup of coffee before I do an LP. I didn't get it on my first try either, but got it after 20 more of ketamine, and a redirect.
Still, I got it, and I'm pretty happy.
Mon, 08 Sep 2003 topA New Axis I Disorder?
I found this on William Gibson's blog. (Yes. William Gibson of Neuromancer fame.) Acquired Situational Narcissism. I especially like the solipsistic delusions. The world isn't real, so it can't hurt you. How much do you want to bet that the treatment is SSRIs, and if they fail that, ECT?
23:54 · permalink · add a comment
Sun, 07 Sep 2003 topbeginnings
OK, I'm having major problems figuring out the direction my life should go. Right now, I'm deciding between internal medicine, pediatrics, and internal medicine/pediatrics. I can't seem to articulate in a coherent fashion why I want to any of these things. Which makes trying to write a personal statement a living hell.
My strategy thus far is to just write. Write down all sorts of crap, all sorts of looney tunes, stupid crap, all sorts of neurotic and possibly completely insane crap. And then maybe I can just whittle it all down, and sanitize it.
I was never good at presenting my best face to the world. I'm violently ill with having to jump hoops to get to where I want to go. I just want to be real about all this, be authentic, but I just feel like my "realism" will get misinterpreted as cynicism and anti-social behavior.
But here we go.
How did I get into this medicine business in the first place? Truth be known, a harder question to answer would be, how could I have avoided going into medicine. Because of the culture I grew up in, my extended family has always been omnipresent, meaning that I grew up with four members of my family in health care, with this number eventually swelling to six, not counting myself. My father is a physician, my mother is nurse.
I have wispy anecdotes from my childhood, which my relatives keep repeating to me like some catechism. Like when I was two years old, my father was studying for the boards. He would read aloud his notes into a tape recorder, and you can hear me babbling in the background. Who knows what sort of effect this had on my subconscious. My mother worked at a hospital which was two blocks away from the house I grew up in. And then there were the fractious times when they couldn't get a baby sitter for me, and sometimes I would have to tag along to the hospital, or the clinic. And there were all sorts of medical paraphanelia lying around all the time. I remember as a small child being fascinated by the PDR, because of the colorful pages of medication. Then in third grade, I remember my father leaving a copy of Dubin's Rapid Interpretation of EKGs, which taught me how to count rhythms and recognize very basic waveforms. I would spend hours copying tracings of things like sinus rhythm with PVCs, or atrial fibrillation, with only a small inkling of what they meant. (Though I suppose it's proof that Dubin is easy enough for a child to read.) And I also became obsessed the anatomy of the heart, meticulously rendering the four chambers and the great vessels on paper. Instead of drawing heart symbols, I would try to be anatomically correct.
In high school, I ended up doing volunteer work on a medical/surgical floor, and once, in cardiac care unit. My fellow volunteers and I were allowed to observe a patient in the middle of a CABG from a distance. We also inadvertantly witnessed a code blue, which the patient didn't survive.
In college, for the first time doubting whether I would actually go into medicine, I went on a medical mission to the Philippines, in the province of Romblon, helping physicians with dispensing medications, learning how to take vitals, and observing surgeries. I also volunteered with a free clinic, which first introduced me to the importance of the social dimension of medicine, and how much of what we do is more than just pushing medications and doing procedures. And after graduating, still unsure about what I wanted to do, I worked for a time at a pharmacy, and then in a family practicioner's office, doing administrative duties, but nonetheless appreciating my exposure to the day-to-day details.
Eventually, I decided to pursue a masters degree in Applied Physiology, hoping that this would finally make me decide what I wanted to do, especially since I would take classes with first-year medical students.
Truth be told, things didn't really click until I started seeing patients. While I had interviewed patients in the free clinic, it was more about social history, and inquiring about basic daily activities. In 2nd year, the clinical learning was slow and halting, as were introduced to clinical medicine by shadowing an attending, and maybe doing a few interviews and examinations. But by the time that 3rd year began, I started feeling more sure. I remember the first patient I ever saw, on my surgery rotation. By chance, I ended up following her for the entire general surgery half of my rotation, from the initial ER consult, through her admission for acute pancreatitis, to discharge, then to her laparoscopic cholecystectomy, to her step-down unit stay because of bleeding complications, and then to her first follow up in clinic.
I went on to my family practice rotation. The first patient I interviewed ended up needing to be admitted. While in surgery, I eventually learned the routine of doing very tight, focused histories and physicals, family medicine often made me dizzy with the vast expanse of knowledge I felt I needed to know in order to even ask the right questions. Emergency medicine was similar, except that the pace was even more frenetic. I was allowed to perform a few procedures: ABGs, an I+D, sewing up a facial laceration. I was allowed to help with an LP, and with a thoracocentesis. But it wasn't until I got into the swing of my internal medicine rotation that I really felt that I had something of a grip on things.
My internal medicine rotation was easily the most challenging part of my third year. I grew a lot, both emotionally and intellectually, and learned a lot of skills, thus gaining confidence. My particular site was one of the few affiliated with my school that required us to take overnight call, and we would generally stay for the entire 36 hours. The teams were small, consisting of a senior resident, an intern, and two students. Everyone had their tasks to fulfill, and they trained us so that they could rely on us to do a lot of the leg work: doing the initial evaluation on admission and writing admit orders, pulling up lab values, making sure labs were drawn and sent, sometimes making sure our patients were taken to their imaging studies, even to the point of wheeling them down ourselves. Following up on consults, getting unofficial reads on imaging studies, calling outside hospitals for more information. We even did things like put in Dobhoffs and sump pumps. By the end of the rotation, the nurses sometimes wouldn't even bother calling the intern. They would just snag us and we'd be able to accurately tell them what our residents meant by their orders, and they'd even have us put in feeding tubes, or talk to a patient to calm him down.
While the remainder of third year was still quite challenging, none of the other rotations sparked my interest and passion quite the same way. But what caught my attention in pediatrics was because I was one of the few on the rotation who was exposed to the various subspecialties. I had a brief, though eventful, time in endocrinology, allergy and immunology, hematology and oncology, child protective services, adolescent and young adult medicine, and cardiology. This is what made me realize that I might want to specialize.
Initially, I had thought about doing primary care, and while I haven't yet ruled that out completely, I realized that there was something about specializing that truly appealed to me. I think it is somewhat ironic that this bit of advice was given to me by my family medicine attending: the thing about specialists is that they are truly experts in their field. In primary care, you have to know just enough about almost everything. In a specialty, you can dig deep within your discipline, uncovering things that few others know. Sometimes, when a patient is referred to you, you may very well be one among a very select few who can figure out what to do. And another reason why this appealed to me is that you often times have to be very creative in your treatment plans. While many times, some referrals are almost knee-jerk reflexes: patients with intractable diabetes go to endocrinologists, people with rashes to dermatologists, patients who are s/p MI go to cardiologists, etc., etc., sometimes patients end up in your office because no one else knows what to do. And sometimes all the textbook ideas have been tried, and have failed, so you've got to build from first principles, and tailor the treatment to the particular circumstances of your patient, physiologically speaking, and often, socially speaking as well.
While I would say that I've had a strong pull to both learning practical skills (explaining why I had such a difficult time ruling out family medicine) and to deep study, the idea of being able to delve into the hidden secrets of a particular discipline is very appealing. My OBGYN attending was surprised at the amount of detail I uncovered in my presentation on a relatively esoteric topic assigned to me: gestational trophoblastic neoplasia. This feedback further reinforced my feeling that the option to specialize might be a fulfilling path.
And while there are similarities to pediatrics and internal medicine, as pediatricians are wont to say, children aren't just small adults. I think the thing that appeals to me in pediatrics is that a lot of what you learn is supremely practical. A large number of your patients aren't really sick, you just have to educate their parents as to what is normal and what requires immediate attention. It's amazing how little formal knowledge any of us have with regards to raising kids, and yet, clearly it must be, on some level, an instinctual thing. What we can provide is the scientific justification for what we already do, and streamline the task of raising a child. I was greatly impressed with the fact that preventive measures alone were capable of drawing down the ranking of infection as the cause of pediatric mortality within the space of a century.
And finally, my pediatric hematology/oncology attending brought up an interesting idea that I had never really pondered before. Because of the amazing advances in medical sciences, conditions and diseases that were invariably fatal even as recently as 20 years ago are now controllable, if not outrightly correctable. So children who would often not survive infancy in the past, are suddenly growing into adulthood, and sometimes internists are confronted by somewhat unfamiliar circumstances. Such as the adult who had surgery to correct a cyanotic heart disease. Or survivors of leukemia, who, while in remission are clinically indistinguishable from other adults, their pediatric history will continue to be relevant for the rest of their lives. Having simultaneous training in pediatrics might be an edge in these particular cases.
So this is what I've got so far. I don't know what else to write about.
Oh. I know. I'll probably dig into how molecular biology is revolutionizing the practice of medicine, and how my undergrad major, and my masters degree are therefore quite relevant.
toplife, liberty, and the pursuit of happiness
Another counterpoint to Incidental Findings (Saturday, 2003.09.06 at 10:30am— scroll down or search the archives.) Now, granted, I have my biases. I am a liberal, bordering on being a communist, so you can filter my rantings with the appropriate stereotypes.
But the thing is, I really take the Declaration of Independence, the Constituion, and the Bill of Rights at face value. I do believe that all men (and women) ought to be considered equal before the law. I absolutely believe that the only reason government exists is to protect individuals' rights to life, liberty, and the pursuit of happiness.
You cannot exercise these rights if you are dying of miliary TB out on the streets, unable to access appropriate health care.
Maybe it's ridiculous, but I take Count Rugen's trite comment in "The Princess Bride" seriously. "If you haven't got your health, you haven't got anything."
From a libertarian front, sure, it would make sense to deny people health care if it didn't affect other people, on the grounds that others shouldn't have to foot the bill. But, if you understand anything about the discipline of public health, this is so not true. For example, there is the problem of rampant hepatitis C in the prison system. And believe me, if a homeless person in skid row has multi-drug resistant tuberculosis, it's only a matter of time until some rich CEO who's office is downtown is gonna get infected. You can't let this kind of things spread just because you don't want to foot the bill. It would be like refusing to pay taxes to pay for fire departments because your house isn't burning down. Well, how do you know your house won't get struck by lightning some day?
I don't think I even have to push the altruistic angle here. It just makes sense on a practical level. Are you really going to let people wander around with infectious disease just because they don't have health insurance and can't pay for their INH? This just doesn't seem prudent on a personal level.
But back to the philosophical concerns. Like it or not, health is the absolute basis of any rights. Without a guarantee of health, nothing in the documents that founded our nation can make any sense. If you are dying, especially if this had been completely preventable had it been caught early enough, you clearly are being denied your right to life. If you can't pick yourself up from the ground because of severe weakness, you do not have liberty. If you are incapacitated, how can you possibly pursue happiness?
But the injustice in our current system is not even as simple as that. If you are truly poor, and unemployed, you can usually apply for Medicaid. There are plenty of people on this program established by the Social Security Act of 1965. If you are homeless, the county hospitals will take care of you, because this is the reason they exist, and, like I outlined above, we as a society cannot afford to let people walk around with active tuberculosis. This would impinge on the rights of everyone. And hospitals that accept state and federal money (i.e., Medicaid and Medicare) are beholden to accept indigents. It's one of the conditions of how they get their money. So, in truth, it is not the ultra-poor who are getting denied health care.
What is ridiculous is that people who work 9-to-5 jobs, often jobs that no one else wants to take, have no realistic way to pay for an office visit. They obviously can't get Medicaid, but they can't afford insurance either. So what the hell?
You don't know how many people I have seen who let their medical condition deteriorate to the point where they have to get picked up by an ambulance and sent to county, worked up in the ER, admitted, and then have to have a million dollar workup done on them. When, if they had been seen by a primary care physician two years ago, if only they had insurance, their condition could've been caught and treated very simply, without a massive workup, on the cheap. It would be one thing if our country was completely cutthroat and had no safety net whatsoever, but like it or not, we do foot the bill for county hospitals. And seriously, does it really make sense to have to do a million dollar workup on all these people who can't afford medical insurance when we could just catch them and give them a $5 immunization? This is the whole reason why the discipline of family medicine and preventive health exist. It really saves money. This is why the HMOs are pushing it so hard.
I honestly don't understand how people in health care can deny the necessity of universal health care. It would honestly make our lives so much easier. How many times have you been in a private hospital, where you've had to make a decision based, not solely on medical need (and you can never deny medical need, because even if their insurance doesn't cover it and you let a patient die, you will get sued, and you will lose) but also based on their insurance plan. How frustrating is that, when you could get the patient discharged with this somewhat expensive treatment that the insurance won't approve, so instead you have to transfer the patient to county, and county has to keep the patient in the hospital for extra days, and guess who eats the cost? That's right, the taxpayers. Because you cannot discharge someone onto the street if they don't have the same faculties they had before they came in. You have to, at the minimum, make sure they can eat and sleep, defecate and urinate on their own. And usually it's more than that. You have to make sure they can pursue their activities of daily living. If they used to be able to walk, they have to leave ambulatory. If they didn't need oxygen before they came in, you really can't send them out still on oxygen. (Just from a practical standpoint, you've got to realize that all these things cost money.) And like it or not, even if you completely ignored the Hippocratic Oath, the law demands that you perform these services on penalty of getting sued for malpractice.
Seriously, though. Instead of doing the right thing medically and pawning the patient off to county so that we the taxpayers end up paying, wouldn't it be better if it could be guaranteed that your institution would actually get paid for taking care of the problem? So you don't have to get the ambulance to transport them to county, the docs at county don't have to waste their time and resources readmitting the patient and redoing all the labs, and the patient doesn't have to say an interminable number of days.
I find it obscene that, technologically, we are probably the most advanced in terms of medicine, but overall, because of our obtuse social policies founded on a lot of demagougery and outright falsehoods, we rank near the bottom of all industrial nations. There is something depressingly futile about this. What's the point of all these neat flash-bang modalities if you can't take care of something as simple as TB?
The analogies given in Incidental Findings are somewhat flawed anyway. In fact, most municipalities do consider transportation a right. Hence, buses and subways. It's not free, but it has to be reasonable. (Because, honestly, freedom isn't free, but it has to be accesible to everyone. This is why, despite inflation, the L costs $1.50. If it were left to the free market, this price would be much more ridiculous than that. This is why things like bus-rider unions exist, to make sure that transportation remains affordable to the underserved. And, according to most court cases, reproduction is a right, in the sense that you can't take away this capability from anyone who has it. Forced sterility was outlawed almost a century ago in this country. It's another thing if they are sterile because of some unfortunate reason, like Turner Syndrome, or some other form of ovarian dysgenesis. This cannot even be fixed by the most advanced medical science at this time anyway. But if someone lost their uterus because of shoddy medical care, then I think they have a case.
Like it or not, we already foot the bill for the health care of the ultra-poor and indigent. This is strictly on practical grounds, in that we don't want multi-drug resistant TB to spread all over the place. It's not like bacteria can tell when they're crossing socioeconomic lines. So wouldn't it be better if our coverage made sense? Instead of, as is often case, screwing the middle class, can't we have a more logical system? Because, believe me, if corporations could get away with it, they would let people just die, even if their cause of death were completely preventable. (Seriously, how much more beneficial to society is a healthy adult who can work, then one taking up a bed in the county hospital who is unsalvageable because they waited too long to be cured?) But, unfortunately, we, as health care professionals, can't just let people die, even if that's what we wanted. It's a Catch-22. If we force the corporation to eat the cost because the insurance won't cover it and the patient can't afford to pay, no matter how many times we send the collection agency to their door, like it or not, you'll probably eventually lose your job. But if you just discharge the patient without appropriate care, believe you me, an opportunistic malpractice lawyer can't wait to present you with a lawsuit. And you will lose. Because "insurance wouldn't cover it" won't pass muster with the judge.
In any case, what's so wrong about guaranteeing basic health care? It's not like we'd just abandon all reason and say that everyone deserves botox injections and liposuction. Like it has been throughout all history, it will always be based on triage and the rationing of resources.
Realistically, the only people who would get massively screwed if the health care system were nationalized are the insurance companies. The corporations wouldn't care, because instead of paying private insurance (something that was in fact legislated, that corporations owe their employees health insurance), they would just pay the government. If we are earning a paycheck, we are already paying for Medicaid and Medicare (and because of the broken way our system operates, tons of this money is completely being squandered, taking care of unsalvageable people with wholly preventable conditions, had they been caught early enough) so what's a few dollars more to take care of everyone. Think about it. The more healthy people, the more people working, the more people paying taxes, the less our individual tax burdens would be.
People talk about horrendous lines, horrific waits for getting appointments with their doctors in countries with socialized medicine, but isn't it that way already? Does it really matter if you have private insurance? You still have to wait a million years to see your PCP. The only way you'll be seen on the spot is if you fork out cash, and like it or not, not many of us can actually afford the $3000 that a CT scan costs. So we have all the problems of socialized medicine and none of the benefits. The other thing is that people always think of pure socialization, where the government runs the show. We could simply change it to how Canada operates, with single-payer coverage. Instead of getting reimbursed by multiple private payers, you would just get a single check from the government. Like Medicare and Medicaid, you'd obviously have to meet certain requirements (thanks to very few unethical individuals who are cheating the system by filing false claims) But you have to do that anyway for an insurance company to approve your contract. Note that this in no way stops the ultra-rich from going to Mayo Clinic and slamming down cold hard cash for their botox injections.
Don't get me wrong. In the short term, it will cost. But in the long term, it will pay for itself.
02:30 · permalink · add a comment
topdepression and inspiration
Before you consign me to being a heartless bastard (although I may very well be), read this. Right now I'm doing a Pediatric Hematology and Oncology rotation. The attendings are really nice, they take the time to teach me stuff, and I've seen a lot of interesting things. Hell, I even got to do an LP and push some methotrexate into some kid's spinal fluid.
There are, obviously, a lot of depressing things about this rotation. Sure, it's not as bad as the Internal Medicine Hematology and Oncology service, where everyone there is basically just one transfer away from Pathology, but, at the same time, the intensity of emotion is a lot worse on Peds. Not that I don't have any compassion for these folk, but when you see a guy who has smoked 5 packs a day for 60 years dying of lung cancer, you honestly can't feel that bad. More often than not, they've accepted their lot in life. "I've had my good times, I've lived a full life, I made the decisions that got me to where I am today." That sort of shit. Obviously, a 10 year old with stage 4 neuroblastoma can't really say the same. The prognosis is absolutely dismal. You still try though. I think you still try because they're kids, even if the hope is thinner than a thread, you've got to try.
The thing that really gets to me is that, despite the fact that they're only 10 years old, they do accept their lot in life. They take their chemo without complaint. They don't have any problems with having no hair. And when they're not vomiting their guts out, they play, just like normal children. They laugh and smile. Adults who are dying of pancreatic cancer don't really laugh or smile.
If these kids can take it, there's no way I should be complaining about the minor mishaps occurring in my life. (As a psychiatry resident once told my friend when she was having a really bad day, at least you don't have lymphoma. Long story.)
So on one hand, it's really depressing. While most of these kids have ALL [acute lymphoblastic leukemia] and the cure rate is something like 90%, some of them have really terminal problems. Like stage 4 neuroblastoma. And I know that chances are they won't be around before I finish my residency. But, well, they seem to understand that time is precious, that you gotta do what you gotta do, even if it involves puking your guts out for a week or so. Even if it means getting stabbed in the arms every day. Even if they have to stick a needle deep into your back. Because it might earn you an extra year or two or three. Sometimes maybe a decade.
This is where I come to despise people who seek security in their lives. There is no security. You could drive to work one day and get killed in a traffic accident. Your doctor could diagnose you with metastatic melanoma. Some lunatic might fly an airplane into your office building. You could get shot for no good reason.
There is no security in this life. I think it's something we just have to accept. No matter what religion you believe in, despite everything you do, some day you will die. This is the immutable law of the universe.
While it's depressing as hell, these kids also inspire me. If they can take the horrible cards that life has dealt them, then I should be able to suck it up. Because all you can do is play the cards you're given. You can't expect to get a royal flush all the time, but you can play them to the best of your ability.
01:17 · permalink · add a comment
Fri, 05 Sep 2003 topmore scatology
Always remind your patients NOT TO STICK THINGS INTO THEIR RECTUMS. Man destroys his perineum with a firecracker.
23:09 · permalink · add a comment
topit doesn't mean you can't
Riffing off of an entry from Incidental Findings: (Scroll down or check out the archives for the entry dated September 5, 2003 at 12:45am. No permalinks. Whatcha gonna do.)
Now, I imagine that a lot of my mental health problems arise from the fact that I grew up in an Asian household, completely inured in the health care profession. My father is a physician. My mother is a nurse. My aunt is a nurse. My godmother is a nurse. My second-degree cousin is a nurse. The wife of my first cousin once-removed, through both of my maternal grandparents (don't ask!) is a nurse. Hell. My brother has suddenly decided to go into nursing. And, though not as obvious, another of my second-degree cousins used to program software that kept track of the immunizations of children in Los Angeles. The aforementioned first cousin once-removed, while being an electrical engineer, works at a hospital. There is no escape. (Both from health care, and my extended family. But I digress.)
So, given this background, I tend to look at things from a very warped perspective. You could call it cynical and jaded. But it's more complicated than that. At least I like to think so. I think that it is telling that during my first year in med school, I only really hung out with other sons of Asian physicians. There is a particular madness that only we can understand, perhaps.
As another piece of background: my dad is an incredibly cynical bastard. What makes this insanely funny is that it seems like most of his patients actually like him anyway.
Switching gears, before I get caught up in tangents, the thing is, it's one thing to feel guilty about something you truly, truly screwed up. Like completely missing an intracranial hemorrhage on a hemophiliac because you didn't get a good history nor did you even do a neuro exam. Or cutting the cystic artery instead of the cystic duct even though the attending asked you to make sure you got the right structure at least 20 times. Or heparinizing a guy who you didn't realize had esophageal varices (again, because you didn't take a good history nor did you actually try to palpate his scarred-down liver) and letting him drop 4 grams of hemoglobin before he finally asks you about why he's been throwing up blood for the past couple of days. Worse, consigning a patient to psychiatry because of the nonsensical weakness and paresthesia pattern they present to you (it's got to be functional, right? Conversion disorder?) only to realize after morning report that she did in fact have a subarachnoid hemorrhage.
I mean, most of these mistakes (and, you know what, despite all of the bitching and whining, only a very small fraction of these actually go to trial) are big mistakes. Bordering on negligence. And while you can make these kind of mistakes even when you think you're doing the right thing, none of these things are immediately fatal. You can fix things. I mean, things might still go south for your patient eventually, but, I don't know, cynical bastard that I may be, you figure, after all, if someone ends up in the hospital, it's probably not because they are a healthy person to begin with. You tried. You made an honest mistake. You're human. Most of the time you can fix what you screwed up. And, frankly, the times that you can't, it doesn't matter anyway, because, you know what, when it's your time to go, it's your time to go. (And, seriously, Samuel Shem got it right. Gomers never die. At least never all of the sudden. It usually takes a month or so, and then you really have to be trying to kill them.)
There are mistakes that you are going to make that you can't help, because you will be sleep-deprived, because the conditions in the ER will be suboptimal, because the stars are aligned wrong, because God hates you. Like dropping someone's lung while slinging in a subclavian central line. Or getting a trillion RBCs in the CSF because you hit a dural vein. Or stabbing yourself with a needle. And then the little things, like mixing up your patient's histories, addressing people by the wrong names. You'll feel foolish, and maybe a little ashamed. But, truth be known, it happens to everyone. This is what my ER attending told me after I had stabbed myself with a used scapel, and I told him how stupid I felt. He replied that, well, it's bound to happen. Everyone stabs themself at some point. My senior resident on medicine admitted to me: everyone drops a lung eventually when sticking in a subclavian line. Even attendings who have been practicing for decades will find themselves sleepless for a night, because in hindsight they will realize what they could've done to make the patient's outcome better, but their support system of colleagues will prevail, and remind them that 1) they're only human 2) that probably was the best decision you could've made at the time given the information you had because 3) hindsight is always 20/20 and 4) more than half the time, blind luck will take care of you, because, if it's not your patient's time to go, it's not your patient's time to go.
(As an aside, have you—I mean, if you're a health care professional— have you ever noticed that it's only the people who seem remarkably healthy who all of the sudden wind up dead the next day? The really sick, truly dying people always seem to surprise me and linger on, forever and ever. Anyway.)
Anyway, the point of my blather is this: there is no use in flaggelating yourself for things that you are not sure you might have caused. Because, there will be plenty of things you can flaggelate yourself for that you know you caused. And, unless your action or inaction seriously changed a patient's outcome (like they would've lived for another 60 years if you didn't screw up), chances are, it doesn't really matter. Because if a 75-year old is going to die from an MI, they are going to die from an MI, regardless of whether you put in the thrombolytics half a second too late or not.
Then again, maybe this is the luxury of internal medicine. Half of the time, whatever you're doing is palliative because it's an incurable condition anyway, the other half, your patient isn't really sick and just needs to chill for a few days (under watchful eyes, of course). So I think it's hard to screw up in these kind of conditions, which often differ markedly from the OR or the ER, where things can be a lot more precipitous.
This is what struck me as the essence of internal medicine: To take a code blue [cardiac arrest] as an analogy, my senior resident always reminded me not to be afraid of breaking someone's ribs while doing chest compressions. Because if someone has coded, they are, for all intents and purposes, dead. And you can't really make the situation of a dead person all that much worse. And if you miraculously bring them back, well, my senior thinks that broken ribs are a small price to pay for resurrection.
Anyway. Life is suffering. (Damn you, Substance P!) Most people would rather suffer and then get well, than suffer and then go down the toilet, even if the suffering in the former far exceeds the suffering in the latter. So you can at least offer hope. Even if it's in the form of an NG tube. Or a lumbar puncture. Or a ridiculously painful, invasive procedure that opens up all the body cavities at the same time, and which will take a year to recover from post-operatively. "As long as it takes care of the problem, doc. I'll go for whatever you think is best. Anything is better than being sick all the time." (Scary shit, huh? Because you know and I know that it probably won't take care of the problem. But it should make things somewhat better. I suppose it gets really sticky when your patient doesn't want hope. There is nothing as unnerving as someone asking you to just let them die.)
Here's a cynical idea that I swear my dad taught me: the problem with medicine is that the problem we are attempting to solve is the fact that everybody dies, and you know what, this is the way things are supposed to be. People are supposed to die. So we aren't really solving anything. There are no grand gestures. We can only make things incrementally better. The difference between being sick and being not-so-sick. As small and possibly worthless as that seems, it's still worth something.
Attempting to be perfect in this field is suicidal. People will live and people will die, and they won't give a crap about how you feel about it.
And onto the idea of not taking care of people close to you: all in all I'm in agreement. I sometimes wonder how different my life would've been if I had actually had my own doctor, instead of having my dad always just treat me empirically for pneumonia with ceftriaxone every time I had URI symptoms and a fever. But, I think the idea of withdrawing from their care is misguided. I mean, these are people you care about, after all, right?
Me and N (who is finishing up PA school) got into this conversation, about how she was sort of convinced to move back home because there were a couple of medical emergencies in her family, and her fiancee pointed out to her that, wouldn't it be more comforting to actually be in the same city when something like this happens?
Well, yeah, in the sense that you are someone who cares, yeah, maybe it would be good. But as a health care professional, it would be completely worthless. Even if you were a cardiologist, and your uncle coded at the family party, it's not like you could cath[eterize] him right then and there. Even if you were a surgeon, if your kid got hit by a truck, it's not like you'd be able to cut him open out on the asphalt and do a Pringle [manuever] to stop his liver from spilling out all his blood. Times like this require the System.
As a health care professional, although yes, we should always be wary of trying to be the primary care provider for our loved ones, I think it is good to always act as an advocate. To be an unofficial consultant. To help your loved one weigh all the options, giving them the benefit of your training.
Because, like it or not, it makes a difference. We can't just be normal people. Whether or not we are the physician in charge, we will still be doctors, and that will always mean something, though I guess what exactly it will mean will always vary.
I actually don't mind when people bring me their medical problems. One, it helps me keep sharp in disciplines that I normally wouldn't think about. For example OBGYN. Or orthopedic surgery. Two, I automatically know it's not my problem to handle. I mean, I can give them slightly more informed advice, but it's not like I'm going to be doing the delivery, or the arthroscopic procedure. There is always that safety net. "Well, this is what I know about it, and you should be OK, but you really should ask your doctor."
I don't know. Maybe I've just gotten used to how medicine at a teaching institution is practiced. There is always someone who will save you from your mistakes. They might yell at you, but at least you will never be the final arbiter of life and death. And yet, this will always be true if you work in a large institution, or at least have good connections in the medical community that you work in. If you don't know the answer, someone else will, and as long as you can point your patient in the right direction, it should be OK. The only time this all falls apart is if you're practicing in the middle of nowhere, the only health care professional in a 200 mile radius. Or if you're out in the middle of the night on a dark lonely road, where you're the only one alert, awake, and oriented times three, and now you have to try and handle a massive trauma.
In short, don't go looking for trouble and try to take responsibility for things you have no control over. Trouble knows exactly where your office is. It'll make its appointment with you in due time. As Candide said in Voltaire's story, "We must tend our garden." There is a job we have to do, even if it seems futile and sucky, and even if no one cares whether we do it or not.
15:14 · permalink · add a comment
topmore messed up acronyms (dedicated to Dr. DRE)
I wonder how Dr. Dre would feel if he realized that DRE is often used as an acronym for the digital rectal exam, AKA the finger up the butt. And since I'm feeling scatalogical today, another acronym that you might hear that you won't find in textbooks is FOS (full of shit.) The most common LLQ [left lower quadrant] mass is impacted stool—make sure you think of this before you go spouting off about lymphomas or enormous diverticuli or even more enormous triple-As [abdominal aortic aneurysms]. Of course, FOS is a diagnosis that can be given not only to patients, but to residents and attendings and most importantly fellow medical students, often in a metaphoric sense.
04:36 · permalink · add a comment
Wed, 03 Sep 2003 topfirsts
I got to do my first LP [lumbar puncture—i.e. a spinal tap] today. Remarkably, I hit it (that is, after the patient was given 60 of ketamine so that he stopped jerking around.) It was pretty sweet.
Moments like these make me hope that I really want to do what I'm doing. (Although making a decision into what particularly field I want to go into is another story all together.)
I remember the first time I did an ABG [arterial blood gas, where you draw blood from the radial artery instead of from a vein] and hit it on my first try. And then that time I had to do one on a patient that was HIV and hepatitis C positive and got it. That was pretty cool too. And that time I sewed up a facial lac[eration] in the ER and the attending thought I had done a pretty decent job. Or when I was able to get a couple of sump pumps into patients' stomachs (with help from nurses, though) And even though I didn't like my OB/GYN rotation, it was really awesome when I got to first assist on a TL [tubal ligation] (with the scrub nurse's help)
This is in stark contrast to all those times I hung around uselessly in the ER, having no idea how to proceed with the the workup. Or that time I stabbed myself with a scalpel that had just been used to drain a pilonidal abscess in a patient's butt crack. Or all those Dobhoff [feeding tubes] that I failed to get down. Or all those C-sections where I would get yelled at.
I felt really good after doing the LP. And now to get stupid and sentimental. There's no one I can really tell to share my sense of satisfaction. Oh well. At least there's this blog.
20:22 · permalink · add a comment
