Saturday, November 29, 2008

On course

"I find the great thing in this world not so much where we stand, as in what direction we are moving -- we must sail sometimes with the wind and some times against it -- but we must sail, and not drift, nor lie at anchor." -Oliver Wendell Holmes, Jr.

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Friday, November 28, 2008


All Supreme Court decisions aside I am loathed to use the above word. I hate it. I think it is vulgar and repulsive. Yet recently I find it popping into my mind with uncomfortable frequency. When does this happen? Let me give you an example.

Mikaela, the barely twenty year old mother whose baby I delivered in her final year of high school was in my office recently. Her live in boyfriend of the past two months came with her to the appointment. I am always a bit curious when a sexual partner comes with the patient to a gynecologic visit but over the years I have become increasingly comfortable talking with couples regardless of race, gender or their choice of sexual practices

Today the subject is a vaginal discharge. This particular patient has had a positive cervical culture for chlamydia twice since she has been under my care. The first time was at her initial prenatal exam in her pregnancy. She was then eighteen and she came to that visit alone. I asked her to bring her boyfriend with her to the next visit. Just as I had explained to Mikaela, I told that boyfriend chlamydia was a sexually transmitted disease. That it could cause a serious pelvic infection in her and blind their baby. It could even cause an infection in his reproductive system that could result in a great deal of pain and render him sterile. I instructed the two of them, just as I had instructed her when she was alone, that they were not to have sex again until they were sure that he too was free of this disease and that it was always best for him to use a condom to prevent the trasmission of this and other sexually transmitted diseases.

At this point the boyfriend seemed repentant, admitting that he had sexual relations with someone else and that he almost never used condoms. They were expensive. I gave him a hand full from a box that I keep in my samples closet. He also promised to go straight to the health department for treatment and screening for other sexually transmitted diseases, just as Mikaela had done in my office.

That was the first scenario with Mikaela. It was repeated six months after her baby was born when she had moved back home with her mother, who was now caring for the baby so she could work and go to school part-time. She and one of her college classmates began dating and she again contracted chlamydia. During her pregnancy and following it, I had several documented discussions with Mikaela about both contraception and prevention of sexually transmitted diseases.

As, I said, those occasions were two sexual partners ago and I recognized this man as someone new and I had introduced myself as I came into the room. Following the exam and genital cultures for bacteria, I again began to write out a prescription for the appropriate antibiotics, asking this new man if he was having any symptoms. When he answered, very politely I might add, "No ma'am!" I again explained the need for protection from sexually transmitted diseases as well as pregnancy.

Mikaela got an inquisitive look on her face as she said, "Now what did you say caused problem again?" Only the extreme patience I have developed over many years of practicing medicine and parenting kept me from replying, "F**king!"
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Wednesday, November 26, 2008

The list of "ists"

Twenty three years ago when I finished my residency and made the decision to go into private practice most obstetricians did the majority of their own patients' deliveries. While there were groups of two, three or four obstetricians, most of the time these guys (and yes, they were mostly men) were on call 24/7 at least where obstetrics was concerned.

Now I am a dinosaur sitting in labor and delivery on a night I am not on call, waiting for a worried patient to deliver. There are "laborist" and the one here tonight would have already done a C-section on my patient. Laborist are OB-Gyn physicians that take call staying in the hospital for 12 to 24 hour shifts being paid both an hourly rate and for the services they provide.

As a matter of fact there is now a list of "ists." Hospitalists see the patients who are admitted to the hospital so that the internist or the family physician can spend the entire day in their offices seeing patients. The intensivists see those patients in the hospital who are in an intensive care unit or (ICU) setting. Intensivist have specialized training in cardiology or pulmonary medicine since the heart and the lungs are critical organs to care for when the patient is that ill. Neonatologist see very sick infants caring for them in the hospital when they need care the pediatricians are not specialized enough to provide.

Focusing on this list takes me back to my original post, the local medical doctor, or LMD as we use to call them when I was in medical school. The LMD was someone who knew you well. He not only knew your lab values and what the CT scan shows but who your spouse or significant other is and maybe even the fact that you have both. The LMD is not a technician, working a shift, providing a product called "health care". She is someone who cares about your health.

What could be more important when you are ill enough (and it takes much more to make you that sick today) to be in the hospital? The rational however is that this "ists", with their special skills and twenty-four hour attention to hospital care, will save money managing care and getting you out of the hospital sooner. I am yet to be convinced but I am not here to argue the point.

And by the way, my patient just delivered a health eight pound little girl without a C-section. That is something we can all feel very happy about, even at 3 o'clock in the morning.
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Saturday, November 22, 2008


There are events that are so clear in my memory it seems they happened yesterday. Forty five years ago today is an example. I was in the third grade. The school I attended was new and the public address system did not work well. A crackly, unintelligible announcement was made and our teacher sent Lesli Andrews to the Principal's office to find out exactly what had been said.

Lesli returned bursting into the classroom with the words "President Kennedy has been shot!"

Miss Conklin, a brand new teacher, who knew everything, at least in her own opinion and in most of ours, shook her head, "No, no, Lesli. The President of the United States is a very important person. He travels with Secret Service men to guard him. There is no way someone could possibly shoot the President," she assured us.

No sooner were the words out of her mouth, than Mr. Bailey, the school Principal entered the room. Shaking his head, he looked at the floor rather than face us as he said, "Yes, President Kennedy has been shot and he is dead." By this time some of the older kids were in the hall crying. School was going to be dismissed early. We were to wait to be called to the office when our mothers arrived. I remember walking out into the bright sunlit afternoon, seeing the American flag at half mast and feeling that the world had changed a great deal in the few hours that I had been inside.

Since that time I have talked with my father about how he learned of the bombing of Pearl Harbor. He returned home from a Boy Scout camp out to hear the news. For him that day is also frozen in time. My sons seem to have the same type of recollection for the details of Tuesday morning September 11, 2001, another "day that will live in infamy." All of us had our sense of awareness heightened by the occurrence of seemingly impossible events.

Today, I have wondered what this day forty five years ago much have been like for the first lady. Jacqueline Kennedy arrived in Dallas as the wife of the most popular and powerful man in the world. She left a few hours later a widow, journeying home to tell her two young children that their father was dead.
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Sunday, November 9, 2008

The suture room

As a first year medical student my favorite Friday night activity was volunteering in the emergency room. A county hospital in a city of three million is busy anytime but on Friday night the "suture room" easily accommodated three or four medical students learning to repair lacerations. We were encouraged to sign up for a four hour shift immediately upon beginning medical school.

After sitting all day five days a week in a classroom listening to lectures, taking notes, and fighting back the fear that I would never know enough, the excitement of the emergency room along with the activity was therapeutic. A shift in the suture room made me remember why I had come to medical school.

That first night in the ER I change into the required clothing. The outfit, matching short sleeved, V necked top and baggy draw string pants looked like pajamas. Scrub suits as they are called were color coded to decrease bacterial contamination of the operating rooms. Green scrubs only could be worn in the OR but they were not to be worn any where else in the hospital. In the remaining parts of the hospital such as the emergency room everyone was suppose to be in white. There was a specific changing room for the students and residents. I quickly found a locker and changed into the suit.

Next I reported to the second year surgery resident who was in charge of the suture room. Patients came into the suture room from all over the ER. Anyone who had a laceration that did not need to be admitted to the hospital ended up there for repair. From the motorcyclist who was is shorts and a T shirt when he laid his bike down on the freeway to the two women who got into an argument at a restaurant and went after each other with steak knives, all of my patients had at least one cut and a story to go with it.

On that first evening I remember watching the surgery intern carefully clean a wound with betadine scrub before anesthetizing it with local anesthetic. He was very careful to explain to me the dosages that I could use and how not to inject directly into a vein. Next the cut must be probed for foreign bodies such as stones or glass. Then the wound could be sutured closed. This particular wound required three separate layers as the gash was deep, exposing muscle and even bone, when a drunken man fell out of the back of his friends pickup truck. Sobering up a bit the guy was very grateful for the care this young doctor provided. The laceration looked great as the final layer of sutures, all tiny blue nylon, went in to the skin pulling it together in a neat row. After applying a bandage and giving verbal and written instructions for care to the patient and his friend, the intern looked at me and said, "Next one's yours."

"What! I have only watched one repair." came my astonished reply.

"See one, do one, teach one! That is the motto here," came my young mentor's enthusiastic reply. About that time a teenager with bloody towel wrapped around his arm and filthy from head to toe walked into the room. "Here you go."

I was speechless. Not wanting to scare this poor kid by showing my inexperience I guided him to a table and stretched the arm out to take a look. Under the towel was a jagged wound, oozing blood with small pieces of rock embedded in the skin. "What happened?" I ask pulling on sterile gloves.

"I laid my dirt bike down as I turned off the highway," replied the young man dressed in a sleeveless t-shirt and cut off blue jeans. We were probably about the same age so I did not offer the advice that he should have been wearing more clothing. From experiences of my own I was sure that would come from a parent.

After getting the young man positioned comfortably on the exam table, I began to systematically clean the wound as I had been previously instructed. My mentor watch me carefully but allowed me to fill the syringe with lidocaine and injected carefully as I had been instructed. I had pulled the appropriate sutures on my own also under his careful watchful eye.

By the time I was finishing the final layer a man who looked like an older version of my patient showed up. "There you are!" he exclaimed, viewing the now also repaired laceration. He seemed glad to see his son but I also got the impression that this kind of reunion had occurred before. "What happened this time?"

After a brief explanation by my patient and following the admonishment that I withheld, the young man's father said, "Nice work doc. Thank you for taking such good care of my son."

Today, just as then, those words "Thank you," make me glad to have chosen this profession.
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