Stick it to Me!

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“Take a deep breath and let it out….. Ok, again….” I was leaning over patient’s bed listening to her chest. Done with the back, I moved to the front. The poor woman looked truly miserable. Her gray hair frizzed about her head in a silver halo of sorts. I felt awful for her. “Again. Good…. One last time…” 

There was a terrible rattling and wheezing, worse in the left lower lobe consistent with her X-ray. I gave myself an imaginary congratulatory high five for my superior diagnostic exam skills.

At that moment, as I was pulling away, she coughed a deep hacking wet cough that shook her entire body. I watched in slow motion as the biggest yellow loogie I had ever seen flew from her mouth toward my left shoulder. I tried to move out of the way but I was too slow. 

So much for Matrix ninja moves…

Splat! 

Right on my white clinic coat.

Sputum from a truly bad pneumonia smells awful but add in the hyperactive pregnancy sniffer and it turns into a very potent stink bomb. I started gagging. I had never actually vomited from a smell before but I had also never been pregnant before. I could feel breakfast rising rapidly in my esophagus.

Generally, puking on a patient while on rounds is frowned upon, pregnant or not, so I dashed out of the room and down the hall while I tore off the soiled clinic coat. I was in a hurry but I was careful not to dislodge the gooey glob of mucus, or so I thought, leaving the whole mess in the floor in the hallway. I was choking back the bilious vomit, a cold sweat broke out on my face and hands. I flew to the bathroom and retched in there. 

So much for breakfast.

I flushed the toilet and turned to the sink to wash my hands when a strand of damp hair slapped against my cheek and stuck there. I reached up to pull it away.

Eeeeew. Puke in my hair!

Only, it wasn’t puke. 

And that is my worst body fluid experience of my career thus far. I have been peed on, pooped on, and puked on. I have been squirted with blood and pus and semen (do NOT ask). But nothing, nothing has ever compared to getting sputum in my hair while pregnant. Thank you Domesticated Momster for asking the question that made me relive that…. I can still smell it.

Complications

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Katie (Do you have a blog?) asked several questions yesterday. I am going to break them into two parts. 

Was medical school worth the sacrifice of time and money and life?

If I had not gone to medical school, I would have never seen the world. Sure, there are people who have travelled more extensively but really what I have seen and done boggles my mind. There was a point during my senior year of high school where I realized my dreams were just dreams and not likely to come true, that I needed to adjust my expectations for reality. With a lot of blood, sweat, and tears (literally and figuratively) by golly my dreams did indeed come true.

Still, there are days where I think about what an amazing body I would have if I had time to work out and get my nails done. On the other hand, I would not be able to afford a housekeeper so that time would never materialize, would it? Adjusting my dreams for reality…

Without those awful years of training, I would have remained a terribly shy, frightened, introvert who never found her voice. Was it worth it? Yes, without a question. Was it fun? 

Oh, hell no. 

Can you have a life while in med school and residency? What about now?

Depends on what you mean by life. I loved medical school for the most part. Sure, it was hard. But it was fairly easy in the grand scheme of things. Residency is what really beats you down. Still, you have a heart beat most days so you indeed meet the criteria for “life”. There are opportunities for socializing from time to time and sometimes you are caught up enough on sleep that you actually feel like going out. 

Private practice is much better. Generally speaking, there is quite a bit more free time provided you are not blogging…

What do you think of a thing circulating on Facebook that says 66% of doctors are recommending careers as nurse practitioners?

I don’t Facebook but I am not aware of any physicians that would suggest becoming NP’s instead. Maybe they are out there, but I certainly don’t know them. 

Why?

NP’s get dumped on. They get the practice hours that the doctors don’t want like weekends, evenings and nights. They get assigned the most unpleasant patients that no one else wants to deal with. They are paid quite a bit less while their “supervising” physician pockets the excess (NPs and doctors generally bill the patients the same $). They are also not given much respect.

Now for something a bit lighter:

Check out Ye Olde Foole’s blog for some excellent medical poetry. I particularly like this one, entitled Interns.

It’s All An Act…

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“It is better to know some of the questions, than all of the answers.” – James Thurber

In medical school the first thing you want to do is look smart. 

Hell, that all any of us want no matter what our walk in life, right?

How to accomplish this while surrounded by 100-150 other brilliant academic and social high acheivers? This is the delimma. 

My strategy was this:

Only ask second or third order questions and ask them only if you already know the answer. Even more importantly, know when to keep your mouth shut.

Here is the scenario:

You are a third year medical student assisting the most bad-ass vascular surgeon in the hospital during an abdominal aortic dissection repair. This guy is scary. He has kicked other students out of the OR for simply looking at him the wrong way through their face shields. You have to be on the top of your game.

The Prep:

You knew this was coming because you checked the surgery list before you left the night before, read all of the scheduled patients’ charts, and stayed up half the night reading up on everything in text books.

Over coffee on your hour long drive in the next morning before the butt crack of dawn (enough caffeine to stay awake but not so much that your hands shake… it is a fine line) you plan out and memorize your questions.

Act One:

As you are holding retractors, trying to keep the small intestine from sneaking over toward the clamps and bovies, you ask, “So this fellow had a 7.5cm aneurysm. That puts his annual risk of rupture at about 20-40%, right?” You don’t look the surgeon in the eye, though. Never move your eyes from the operating field….

“Yes…” Is his gruff, muffled response. He knows the game you are playing and can appreciate it for what it is.

He then starts to pimp you on the anatomy and you ace it. Thank you, Netter’s Atlas of Human Anatomy…

Act Two:

“Oh, shit!” 

You can see the aorta is dissintegrating in his hands. 

The scrub nurse stands up a bit straighter while the resident surgeon standing next to you kicks your ankle hard, shooting you a warning look as beads of sweat form on his brow. Your own heart is pounding.

Act Three:

The next several hours are tense. You don’t say a word. Your arms are killing you from hold the retractors so hard for so long but you don’t dare let go or even intimate by body language that you are in pain or tired. 

All of those extra questions you carefully planned out? You don’t use them. Instead, you keep your mouth shut because you know that at a time of crisis the last thing anyone needs is a showboating med student trying to make a good impression.

The Grande Finale:

The graft requires two re-sews. You are dangerously close to the renal arteries….

Somehow, though, it holds. No leaks. Everyone stands back and watches for a few minutes just to be sure.

Instruments and sponges are counted.

As a reward, you get to practice sutures. 

“Nice knots,” Dr. Bad-ass says as he looks over your shoulder after scrubbing out. The resident will handle it from here. “I am doing a bypass tomorrow. You are welcome to come hold a retractor.”

Yes!

Curtain Call:

It is well after 8PM when you finally get to your car only to find that you have a flat tire. You blink the tears from your weary eyes and swallow down the lump in your throat as you get out the car jack and tire iron and set to work. 

The universe has a perverse sense of humor.

As you are screwing on the final lug nut the OR scrub nurse drives past, rolls down his window, and offers to help. You decline, smiling to yourself as he drives off. You now have a witness that you, a girl, sat in the dark parking lot and changed your own flat tire.

Tomorrow you will be legend.

My Request:

Questions. I want to know what you want to hear about from me. What do your inquiring minds want to know?!?!??? Silly questions? Thought provoking ones? I don’t care… Bring them on! 

Just don’t try to ask the anonymous doctor for medical advice. And NO, you cannot send me a picture of that rash you have “down there.”

Aperture…

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The photo circulating around the internet, that one of the doctor crouched down outside reportedly weighed down by the grief of losing a patient… 

I swear I have seen that photo somewhere before. Years ago. Maybe it is just because I relate. Maybe I saw something like it involving another physician. Dunno.

I am glad that this is out there but to be honest it has bothered me on some level that it took a photo to get people to talk about doctors caring.

Yes, we do feel.

Sure, you don’t see that as a patient. In a crisis you don’t want your doctor breaking down, overcome with emotion. We push it back, bury it. We have to so we can do our job.

Then afterwards, we have guilt. We weren’t good enough. What right do we have to something so selfish as our own grief? That was not our family member. 

And so we go on. And on. And on.

Our families don’t understand. 

Our friends do not understand. 

And our colleagues are too busy or too burdened themselves to share our load…

It’s what we signed up for, though. We knew it wasn’t going to be easy. So we might indulge, give ourselves a minute or two out in the cool night air, or maybe not. We shake it off and keep going and pray that it does not take our soul in the end.

I hear from people here and in my real life how generally awful doctors are, how I must be so unique. I don’t believe it. I am not special. There are so many out there who care, who give their lives to this profession. 

We all have different personalities. Patients have different personalities. Diversity is good. Some like a touchy-feely emotional doctor. Some like the reticent, to the point type. Maybe they want something somewhere in between. I have been both cussed out and complimented for being so “perky”. No single person can be all things to all people. 

Are we all perfect? No. Do we have bad days? Yes. I certainly do from time to time. Are there bad doctors? Sure. Do good doctors do bad things? Absolutely. We would all be fools to think otherwise.

So in the end, what am I trying to say? Our humanity makes us vulnerable to imperfection even as people are searching for our perfection. Keep your heart and mind open. Look for the light instead of the dark. It is there, I promise.

The Bait and Switch

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“So, now that I am on Medicare, the managed care company sent a PA to my house. They told me I needed to be on a generic cholesterol medication.” He frowned disapprovingly at me, like I had done something wrong.

Oh, really, now?

“Did you tell them that you have tried all of the generic cholesterol medications and they either did not adequately treat your cholesterol or they caused body aches or other side effects that prevented you from tolerating it?”

“You know, to be honest they didn’t even ask…” He absently scratched his scalp with an index finger. His face relaxed.

It’s Ok, I get it. I know what they are trying to do when they are sending people into new enrollees’ homes to “review” their health….

The company wants to spend less, so they tell patients that they need to change their meds to generics. Except that I only use generics whenever possible. I don’t use the expensive brand name meds unless we absolutely have to. 

And maybe I am being too sensitive or reading too much into it by feeling the insurance company is trying to undermine my rapport with the patient by having them question my clinical judgement but that is sure what it feels like. I worked hard for that rapport and unlike those company people, I really don’t have any ulterior motives at play here.

Too many cooks spoiled the broth…

This trend is popping up all over the place, even with private insurance. They pick the patients they are spending the most on and have a nurse call them once or twice a month. 

“We see from your biometric screening that you are morbidly obese. Why won’t you loose weight?”

As a patient if you have your doctor talk to you about your weight at an office visit and then a few days later some stranger, a case manager, calls out of the blue to talk about your weight, don’t you feel like your doctor ratted on you? 

I didn’t. I promise.

Weight isn’t like tobacco smoking. You cannot simply harass someone into getting skinny, but they sure as hell are going to try because that is the perceived root of all problems right now. 

Skinny people cost less.

The elderly are increasingly becoming targets. I can think of certain instances where patients needed a case manager, someone to help them use their benefits, navigate the system, make it to appointments, help with medications or checking vital signs. But those people never seem to get that kind of help.

A few months ago an elderly couple grinned widely at me during their tandem appointment. They were clearly excited. Each appointment for the past ten years they have brought me a detailed list of their daily blood pressures for the months since their last visit. This time, however, they had brought no such paper.

“Doc, a lady from the insurance company came out to the house and gave us a blood pressure monitor. She told us to check our blood pressure with it once a week. It is supposed to send that reading to you! Technology is just great nowadays.”

“Uh, those numbers aren’t going to me.”

“What?” They looked at each other and then at me, confused. “We thought…”

“They are probably going to the insurance company. Did they tell you what they were going to do with that information?”

“Well, no. No they didn’t. You didn’t tell them to send it over?”

“No, I’m sorry. I did not. I had no idea they were going to do that.”

What’s worse is that they were given the wrong blood pressure guidelines by the nurse practitioner that dropped off the monitor. You don’t tell an 80 year old to keep their blood pressure under 120/80. You just don’t. Guidelines indicate under 150/90 is the correct target for these patients as lowering further increases the risk of falls. And yet she told both of them that their blood pressure was too high and that they needed to discuss changing their medication with their doctor. 

But we are helping people, improving the quality of their care!

This sort of thing isn’t going away. It is only going to get bigger, more invasive. I will be placed in a more defensive position than I already am as insurance companies and managed care try to reduce costs further. 

Quite frankly, I don’t even know what to do about it at this point… Can it be a good thing? Sure, if we are able to work together somehow.

Rejection

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“Doc, his MRI was rejected. You have to do a peer to peer.”

Damn.

I hate that.

My staff had already spent half an hour getting the forms filled out and records sent over to the insurance company for the prior authorization, not to mention the time it had taken between the patient and the imaging center getting the thing scheduled in the first place.

I dialed the number and endured the automated phone tree. Finally I got a representative who informed me the phone call may be recorded for “quality assurance purposes.” Sure. Whatever.

I had to spend ten minutes telling the rep all sorts of things that they already knew. Why? Just because.

Then I was transferred to another rep and repeated the process.

“Hold while I get the doctor for you…”

Ten minutes later…

“Has he done a trial of NSAIDS?”

“Yes.”

“Does he have any documented neurological deficits?”

“Well, no…”

“Has he demonstrated treatment failure after a round of physical therapy?”

“Yes! He had physical therapy two years ago and it did not help his pain.”

“Yeahhhh…. See, he is going to have to have done physical therapy in the past six months.”

“What?”

“Physical therapy. It has to have been in the past six months.”

“What the hell? He has had cervical radiculopathy requiring two daily medications in order to function and after two years of this constant pain you are going to deny him an MRI? That is just plain stupid.”

The man had not been able to afford the MRI two years ago after he had gotten finished paying for the physical therapy.

“I know. But it isn’t my rule.”

“Fine. I will relay this information to the patient.” I made sure to relay my displeasure through the tone of my voice.

At least this guy was cordial. The last one I had to talk to was a real prick. It would be helpful if the rules were the same across the board but they aren’t. 

Time Travel

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I was curious. How many of you had time travel fantasies as kids? 

Once upon a time, I stood in the center of old Fort Parker and closed my eyes tight, both hands balled up into tight fists. My life was miserable and I wanted an escape route. If faith the size of a mustard seed could move mountains, well I could surely believe hard enough to travel back to the mid 1850’s.

To be honest, I was too young and naive to have thought it through. The civil war was coming. Texas without air conditioning? Shoot me. I would also need an everlasting supply of red hair dye, deoderant, razors, tampons, and birth control. Toothpaste. Can’t forget the toothpaste. 

“What are you doing?!?!! Keep up!”

Fortunately, wishing (even if you wish very hard with every fiber of your being) is not the same as faith and so I never had to regret my decision…

So….. Am I the only one who ever did this? If you did, too, why? What time would you travel back to?

Heavenly Bodies

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“Look now.” He stepped away for the telescope and gestured that it was my turn. “Do you see the craters?”

My brothers were off playing in one of the dark corners of the backyard. I pulled my sweater tighter as I leaned in, holding my breath.

There it was.

The moon. 

Like in the books at the library, all of the glorious details were right there. All of the sleepiness that had been folding its arms around me faded away in the excitement of the moment.

“Be careful. Don’t put you eye on the eyepiece.”

I looked again.  

An hour later I was looking at the red spot on Jupiter. Some of the moons were even visible.

At some point in the night I saw Saturn’s rings.

All told, my actual viewing time was under 20 minutes (It was a challenge to line up tiny bodies of light in a large telescope…), but those 20 minutes were some of the most profound of my life. They have stuck with me, vividly, for the past 30 years. Other memories fade. This one does not.

I asked my father to pull it out again on multiple occasions but he never did. I could not understand that. Why buy this thing of you did not intend to use it? What was the point of that? 

It was a huge Celestron 8in schmidt-cassegrain telescope with a bright orange case, and it had a motor that kept it moving with the Earth’s rotation. We might not have had enough to eat sometimes, but by golly we had a giant telescope packed away in a trunk somewhere and knowing that made me feel special. Who else had seen these things in their own backyard observatory? No one that I knew.

Three weeks ago, my father gave me the telescope. Last night the clouds finally rolled away and I was able to let my son see the moon through it for the first time.

The moon hasn’t changed a bit.

Watching his face gave me more joy than what I had felt at seeing the moon for the first time myself. I didn’t know that was possible…

All in the Family…

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One of the aspects of being a physician that I have not explored much for you kind people is what it is like being the doctor in the family.

Health brings out the worst of those closest to you and even if you are now a doctor, it is still very hard for people who knew you back when you finger painted walls with poop to take you seriously. They want to. They really want to…

But they just can’t.

It all started early on in medical school when my brother called me all in a panic wanting to know if his girlfriend might be pregnant. Easy. Take a dang pregnancy test, I said. But somehow that was not a good enough answer. I was supposed to psychically calculate the likelihood of pregnancy and assign a risk ratio to a cost analysis of a pregnancy test on a student budget and then arrive at…. Hell, I don’t know what.

She wasn’t pregnant, in case you were curious.

Then other family members took to asking my thoughts on this and that. Just let me give you a piece of advice: never, ever ask a medical student for their thoughts on anything medical. They do not know enough to know that they know nothing and they are all floating around with big heads full of self importance. As such they can be quite dangerous. No one died because of me, thankfully. It will leave it at that.

Sometimes, family members want you to be their surrogate physician. Resist. Case in point, my father-in-law, who was a terrible diabetic and on the heart transplant list due to his congestive heart failure would always want me to check his blood pressure and comment on the treatment he was receiving. I spent hours and hours with him, educating him, or so I thought. Meanwhile, he would show up at the house with two dozen glazed donuts and a burger and fries from a fast food joint. Finally, one day, I had had enough. “I am not your doctor! You are on a list to get a HEART transplant and you won’t even take care of the rest of you. Your sugars are killing your kidneys and everything else that will be left behind. The sodium is going to land you in fluid overload again. When you start doing what you know you should do, I will be happy to check your blood pressure and blood sugar again. But for now it is just making me angry.” We did not speak for many months. He eventually took himself off the transplant list and went onto hospice.

My father hates doctors. Loathes them. In fact, he goes out of his way to do the exact opposite of what he is told. He and my mother stayed with me for a few terrible weeks after my mother’s knee replacement surgery because he had had another seizure and was not supposed to be driving for six months. I came home early one day to find him tooling through the neighborhood in their little red car. I could just see the headlines: “Five dead in horrific road accident after father of local physician seizes while driving….” When I confronted him about it, gently, he exploded and packed his stuff. He drove back to his own home in the little red car and never came back.

Last week, my mother in law set fire to the kitchen when she left the house with some eggs boiling on the stove. Firemen were called by the alarm company. I can tell you now, this is going to be messy.

Sometimes, I would like to NOT be the doctor…

√Čtude to Silence

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“Soon silence will have passed into legend. Man has turned his back on silence. Day after day he invents machines and devices that increase noise and distract humanity from the essence of life, contemplation, meditation.” – Jean Arp

How does silence affect you? Do you crave it? Find it difficult to bear? Why? Is it harder for you to come by now? What is your biggest obstacle? Do you actively try to avoid silence? Why?

I was asked to elaborate on my statement last week: 

“For the past week, while the kids were on spring break, I had the thirty minute commute to the clinic and back all by myself. I purposely kept the radio off which soon made me I realize how difficult it is to be alone with my thoughts. As my mind began traveling down a path I was not comfortable with I would absently reach for my phone, remember I was driving, then put it back down.”

The striking thing is I had not realized how unused to silence I had become. I am so accustomed now to filling up empty space with minutia at work or checking blog stats, writing posts, answering comments, email, perusing news sites… I had forgotten what it was like to have silence that was not meditation where I actively work to keep my mind free of the clutter. The other interesting thing is that in the midst of this constant distraction I am probably in a much better place than I have been in quite some time.

Where does my mind go when it is free to wander? 

To all of the mistakes I have ever made. 

To everything that has made me sad or angry or humiliated. 

To every love ever lost. 

My head fills with negative thoughts that tell me how ugly or stupid or selfish or unworthy I am. I worry and ruminate and tension builds until I want to cease functioning.

These thoughts serve no good purpose other than to distract me from going forward. So I am working on controlling the negative, forcing the issue of silence. Practicing. Retraining. 

Silence.