Sunday, December 13, 2009

Our Great Society

Don't get me wrong. I am usually as liberal as they come. I admire LBJ. I have visited his library no less than six times. Medicare, social security, civil rights, and all the other legislation from the mid-sixties are programs I believe in but...

I pause when the father of the baby I just delivered tells me this is his ninth child. How is this possible? Three babies with each of three women. Or I receive a 16 year old girl pregnant with her third child from a nearby psychiatric hospital. She was admitted there when she expressed her suicidal thoughts to another obstetrician. All three of her babies are the product of rape. The second child is dead. This child's father is 33 years old and thankfully in jail.

There is decay in this Great Society. Our cultures of greed, power, and lust* are eating away at the heart of our nation, killing our children. Not my children, you say. Think. How will your children cope with all those born in such circumstances as I have described?

Our Great SocietySocialTwist Tell-a-Friend

Thursday, November 26, 2009

Next patient, please

One of my patients tonight is an immature 19 years old. In fact, I am shocked at her immaturity, though it is something I frequently see in teenage mothers. I met her in the mists of a seizure caused by eclampsia, a condition which strikes pregnant women. She has two risk factors: She is young and this is her first pregnancy.

While 19 is older than most first time mothers I encounter in this population for which I provide medical care, I believe her sexual experience began at a much younger age. Why do I think this? For starters she has 4 sexually transmitted diseases. Five if you count her pregnancy. These diseases are herpes, syphilis, gonorrhea, and HIV. Yes, HIV at nineteen. I suspect she has been working as a prostitute. She is not a run away. Both her mother and an older sister have been to the hospital to see her. The records from the county hospital show her mother accompanied her to the prenatal visits she made there.

It is hard for me to imagine what kind of life has been handed to this young woman. The facts I learned as spent most of the morning trying to fill in the gaps social work and CPS left were shocking. The stories from family members differ. "She been livin' with a relative in another state." "The baby daddy 's in jail." I can't help but think she needed multiple sexual partners to contract all these diseases and the variety of explanations from the family seem to confirm my suspicion about prostitution. Though nineteen is old enough for her to be living on her own, it seems she has been on her own for some time.

Yet I am at a loss as to what to do. Child protective services came to make sure the baby would have care. Social work has little to offer. She will leave the hospital with her mother. I am not at all sure she will continue the medications she needs to prevent her from developing full blown AIDS. I can not think to much more about the situation. She is scheduled for discharge in just a few hours and I need to move on the other, more pressing problems today.
Next patient, pleaseSocialTwist Tell-a-Friend

Friday, November 20, 2009

Evidenced based medicine

Evidenced based medicine is the terminology physicians use when we talk about medical practice which is based on studies large enough to have statistical significance. If you are not a physician it is difficult to understand how much of medical practice is based on dogma. This makes one of the best things about medicine one of the worst things about medicine, a patient's trust in their own individual physician.

Several years ago when remodeling our house the electrician gave us an estimate based on the plans which were drawn for the remodeling project. The demolition crew came and went. The electrician returned. He carefully went through the wiring again, ask to meet with me and my husband, and gave us the bad news. Wiring uncovered in the tear out was not code. It had probably been done by the previous owner and was in fact, a fire hazard. If we wanted him to do the wiring he would have to increase his bid by 20%.

My husband had a fit and was ready to fire the guy on the spot. I one the other hand reasoned the following: This man has a license. The city is going to inspect his work. We don't want to have a fire. I am going to trust him. I told my husband if he was that upset by the price increase we would get a second opinion from another licensed electrician. We went ahead, finished the remodeling project and twenty-five years later, everything in that kitchen is working fine.

Standing there with the electrician that day, I remember thinking, "I don't know electricity. I know medicine. I can trust this guy or I can get someone else I trust but I am never going to know electricity. Someone, hopefully an electrician, is going to give me the correct information."
(Also understand we did not yet own a personal computer nor was the Internet a household word so maybe my position was made a bit simpler by these two facts.)

Ever since that incident, I have hoped my patients trust me as much as I trusted that electrician. Over the years my patients have brought me newspaper articles, magazine clippings, and yes, websites to view. I have been given books, DVDs and tapes from the lay press. One patient offered to pay me to watch a thirty minute video about natural hormonal replacement therapy in hopes I would write the prescriptions she desired.

Through it all, I have tried to stay abreast of both what The New York Times and The New England Journal print along with Cosmopolitan, Glamour, and O. In these later years, I have even given in to watching television advertising by the pharmaceutical industry to try and hear what my patients seem to hear and believe will make their lives better.

So you can imagine I have been all eyes and ears these past several days as the new recommendations for breast and cervical cancer screening are released. I sat down this morning to write Diane Ream and the editor of my local paper but instead chose to put my thoughts down here.

First, both the Preventative Services Task Force and the American College of Obstetricians and Gynecologist are made up of excellent physicians much more knowledgeable than I about statistical analysis and evidenced based medicine. It is true, many of them have not spent their lives as I have holding patients hands and advising individuals on health care decisions. But these women and men did look at the evidence. They did not sit around as we practioners often do speaking only of their individual experiences. That is the kind of stuff which led to the dogma that every woman should begin hormonal therapy at menopause.

Second, I have two patients I can name, one now dead, which were low risk for breast cancer and normal routine screening mammograms DELAYED the diagnosis of their breast cancer. At the risk of being long, I will tell you the story of one of them.

At forty Barbara did what most obedient, health conscience, American women do. She had her baseline screening mammogram. It was totally normal. Three months later she felt a lump. She surmised it was normal since her mammogram had been. Just a function of the normal monthly ebb and flow of her hormones, she told me later. She forgot about it. Until nine months later when I felt it on her yearly examination. Not only could I feel that lump but I could feel a lump under her arm, the early metastasis of her disease. A disease that did not show up on her mammogram even on retrospective inspection by multiple radiologists (the case has been through several attorneys and expert witnesses.) She delayed seeking care because of a routine mammogram which was negative. Today, despite aggressive treatment, she is dead of her disease. I often wonder, what if she would have come in when she first felt the lump, which was solid and would have been biopsied regardless of mammogram findings, would she be alive today? She had no family history. She was in a low risk group. I can't help but believe that screening mammography contributed to her death by giving her a false sense of security.

This is a long piece incorporating many of the thoughts I have developed over the last twenty seven years of practicing medicine. The practice of medicine is not an easy task which is probably one of the reasons I was drawn to it in the first place. I believe the recommendation from these two groups have much merit (and a good bit of wiggle room.) American medicine has long been in love with and dependent on technology. Prehaps the best to come of these recommendations (besides an increase in the sale of newspapers) will be some serious discussion between women and their physicians.
Evidenced based medicineSocialTwist Tell-a-Friend

Thursday, November 19, 2009


I sat at the labor room desk staring at the form. DOB 4/18/96. Thirteen. 13. Any way I looked at it Morgan Whitney Nabors* is thirteen years old. And this is her second pregnancy. The first ended in a miscarriage but still, she had been pregnant before. I searched the form for other clues. The responsible party was Olive May Warren, a medical assistant, and her employer was blank. Emergency notification listed Arthur Warren. All the telephone numbers and social security numbers were filled in.

I imagined this mother sitting in the emergency room filling out the form. How long had she know her daughter was pregnant? Who is the father of the baby? They have not yet applied for Medicaid. Who is the father of this baby? Why hadn't she gotten her daughter contraception after the miscarriage? Who is the father of the baby? Which baby? What is going on here? Who is the father of the baby? How does a thirteen year old begin having sex? Who is the father of the baby?

I have a headache from the swirling questions. Some of the nurses have told me I just don't understand the culture. Which culture? I have lived right here in this city for the last 27 years. I understand motherhood. I have raised children. I don't understand how a thirteen year old gets pregnant. Who is the father of the baby? Here I go. I am about to dive into this with CPS and social work right behind me. Who is the father of the baby? I am sure the first answer I will get to this questions is "her thirteen year old boyfriend."

There seems to be a sea of inertia in which we are swimming. Despite my strong strokes to stop these teen pregnancies, they are coming faster and younger, with the resources of prevention occasional life preserves usually just out of reach. And who is this baby's father? I will probably never know.

*all names are changed
ThirteenSocialTwist Tell-a-Friend

Tuesday, November 10, 2009

The future

I stand very quietly watching the tiny form wiggle his toes, the whole foot not much larger than my thumb. "No name yet," the nurse informs me as she adjusts the ventalator. She is reading my mind, "We are coming down on the ventolator settings. He is doing better."

I always go up to the NICU or neonatal intensive care unit to see the babies I have delivered. Many make it through to the step down unit, grow to be 5 or more pounds and go home. As with this baby, I always wonder what kind of home that will be.

I know this baby's mother better than most. She was in the hospital 5 weeks before he was born. Her drug screen was positive and after a few days of "drying out" she ask me to terminate the pregnancy. When I told her this was not only against hospital policy but at her stage in gestation, it was illegal as well, she refused all subsequent care and left against medical advice.

She returned via ambulance, again in a drug induced stupor, and I delivered this two pound baby boy on the stretcher just inside the doors to labor and delivery. At delivery I thought he was dead but the NICU team was there and revived him. Now we are here. He is two days old and getting stronger.

From the mother's previous hospitalization I know there are two other children. One in the custody of her mother, the other her sister. The patient asked to have her tubes tied and if it were up to me that would already be done. I have no illusions of rehabiliation. Sterilization is at least part of the solution. I am just wondering about this baby, with feet the size of my thumb. Who will care for him? What does his future hold?

How many more like him are in this city, state, country? Where does it stop? I fear we will run out of resources sooner than we will run out of babies with feet smaller than my thumb.
The futureSocialTwist Tell-a-Friend

Sunday, November 8, 2009

My office

With my change in positions several people have ask, "Where is your office?"

The short answer and probably the most truthful is, "I don't have one."

Oh, I have an eight by eleven foot call room complete with bed, desk, and chair. I have grow so tired of this space in the last 6 months that I now only go there to sleep. I share a conference room, complete with two computers, monitors for all the beds in labor and delivery, and cable TV with any other obstetrician who happens to have a patient in labor. There is a common workspace I use in labor and delivery, again with monitors and computers to scan what is happening in each room or access medical records. Similar accommodations exist for my use in the emergency department.

Yet, it dawned on me one morning last week, as I slogged around a park south of my home, that my office is there also. On my non-call days, when I am not chained to the hospital by my contract which states I will be physically present to care for any obstetrical or gynecologic emergency, I head for this park. It has a one mile dirt trail, beautiful oak and pecan trees, a creek bed, and several grassy areas. Set back from the roadway, the sounds are birds, squirrels, and the rustle of the leaves.

The peace of this place passes any understanding. I can feel very beaten down when I arrive but I leave refreshed, physically spent, and believing I can make it at least one more day. And, lest you doubt, it is my office, my beeper is strapped to my side and my cell phone is in my pocket. Some days I spend more than one of the five miles I attempt to traverse talking with a young doctor about how to care for a patient. My counterpart, the person who is now captive in the hospital, will have to be the physical presence when one is needed. I am fine with talking for a few minutes as I sweat and struggle to make it around the trail again or as I simply sit and admire what a fine piece of work the interior designer of this space has done.

My officeSocialTwist Tell-a-Friend

Friday, October 30, 2009

The flu

I once heard from a patient, "You know you have the flu when your hair hurts." Well my hair hurts today, not because I have the flu but it certainly seems as if everyone else does.

I received my flu shot for the common seasonal flu over a month ago. Now city officials say all the current flu circulating is the swine variety. This is a problem since there is no vaccine. The hospital asked for 7,000 doses. They received less than 700. Pregnant employees in the emergency room and women's and children's services were the first to be vaccinated. Other pregnant employees will be next.

Flu is a dangerous disease in pregnancy. It can lead to pneumonia and hypoxia, a fancy word for too little oxygen. As you can imagine, too little oxygen is not good for mother or baby. We have had several mothers and mothers to be in the intensive care unit. So far we have not had a maternal death but we have come very close - twice.

I try not to think about getting the flu and I must admit, I am more afraid for my sons than for myself. The young seem to be very vulnerable to this virus. One patient who was in the ICU for two weeks is the same age as my oldest. He is not pregnant but he has an underlying medical condition. I will not hestitate to give him an antiviral should he or anyone in our household comes down with the swine flu.
The fluSocialTwist Tell-a-Friend

Monday, October 26, 2009

Another world

Here I sit in front of the computer screen. It seems I must have been transported to this location on an alien space craft. I could swear I drove here in my Honda but it has been such a weird twenty four hours that now I am not sure. My shift began with a woman from another city dictating her care to the nurses. Carrying a preterm infant, she is here as a transfer patient for the maternal fetal medicine service. In addition to her problems with this pregnancy she is bipolar and moving into a full blown manic episode.

In the room next door, a patient is withdrawing from cocaine. She swears she hasn't had any cocaine in months but it some how got into her urine on the drug screen. She is in labor, probably due to the effect of the cocaine on her placenta. Her baby is doing alright and is full term, so my hope is she will be able to deliver vaginally.

Next, a call comes from the emergency room. A cashier from the local WalMart arrives short of breath. After a complete work up is preformed, the only abnormality which can be found is her hemoglobin of 2. Normal is 12. Even though she is not having her menstrual period and doesn't complain of heavy menstrual periods, it is decided this must be a gynecology problem.

So it goes, on to the woman with the abdominal wall abscess from poor hygiene, the parolee with pelvic inflammatory disease, and the teenager pregnant with her third baby. I have been doing this for several months now and yet, I still feel as if I am in a foreign country, if not on another planet. The people I see are not like the people I when I am elsewhere. The language I speak here is somehow different. This worries me. I am not sure I want to go back to my old life in private practice but I wonder when this will feel like a place that I belong.
Another worldSocialTwist Tell-a-Friend

Saturday, October 24, 2009

Day of hopelessness

I am just past my worst day yet. The crowning blow came on my way home. A call from one of the neonatologist informed me that a baby I delivered at midnight had just died. This past 24 + hours has left me with no faith in medicine, humanity or any shred of hope that God exists.

It began with a 41 year old diabetic found unresponsive and hypothermic by her 7 year old daughter. In a coma from a combination of her adrenal crisis, diabetes, and a pneumonia, she was brought to the emergency room by ambulance. We did an emergency C section for a 3 pound 11 oz baby who is doing better than her mother.

Next I had a 19 year old having her third baby. This one has gastrochesis. The bowels are outside the abdomen. The first surgery was last night after he was delivered. It will take at least one more to get the intestines back in. The mother, as I said is 19. She has a one year old and a two and a half year old at home.

The baby that died was the second child of a 34 year old who is married to a software engineer. They have a two and 1/2 year old at home. The baby weighed almost 3 pounds but has no lungs due to loss of amniotic fluid at twenty weeks of pregnancy. I would sleep but every time I close my eyes I see that baby's feet sticking out of the patient's vagina as I am making the decision to do an emergency C-section. Because the feet were in the vagina and she had a uterine fibroid, I had to make an incision in the top of her uterus. This will complicate any future pregnancies.

All this was interspersed with my usual steady stream of pregnant women with no prenatal care, several normal deliveries, and trips to the emergency room. I have one woman who is living in the hospital because she has lost her job and health insurance due to her placenta previa. Her two year old is living with her sister. I don't know what they will all do after the baby comes. There are thirty beds at Major Medical Center with can be filled with the same type of situations at any given time. The hospital gets them on emergency medicaid and gets paid. Yet, we (the country) have not solved the real problem.

The problems are so much deeper than that. These problems of family, death, sex, and using one another will not be solved by Congress in some sweeping reform bill. I wonder if we have what it takes find solutions individually and collectively. Some days I hope that we do but today has not been one of those days.
Day of hopelessnessSocialTwist Tell-a-Friend

Thursday, October 22, 2009

Playing by the rules

In the emergency room yesterday discussing contraception with a 17 year old who had just had a miscarriage:

Doctor: "Were you and your boyfriend using anything for contraception?"

Patient: "We're Catholic and our church doesn't allow us to use contraception."

Doctor: "Oh, you two are married?"

Patient: "Well, no! I am only 17!"

Doctor: "So, when did your church start letting you have sex before marriage?"

Playing by the rulesSocialTwist Tell-a-Friend

Sunday, October 18, 2009

My crystal ball

Well, here I am. Back for more work at the big medical center. When I was last here, 2 days ago, I admitted and operated on a patient who came in through the emergency room. Both the emergency room physician and the radiologist who preformed the sonogram felt she had a twisted ovary. I agreed. Her symptoms, the signs on her physical exam, and the sonogram were compatible with this diagnosis.

Problem is this was not the problem. The problem was a large fibroid which had outgrown the blood supply. Painful yes, but not as much of a medical emergency as a twisted ovary. Also the solution to the problem of the necrosing fibroid had to be solved with a hysterectomy due to the location. This resulted in a longer and more difficult procedure than the one I would have used for an ovarian torsion.

The patient is past the age of normal child bearing. She even had a tubal ligation with her last child some fifteen years ago. The problem is she has a government funded health insurance which requires a thirty day consent for hysterectomy. Even with this knowledge, to cover all the possibilities, I discussed hysterectomy as an emergency procedure and ask her to sign a consent form for this in the emergency room.

Carefully reviewing my documentation, I worry this case will be refused payment by the third party payers. Even though I know I preformed the correct procedure for this patient, I am bothered because this will be a mark against me with the hospital administration. The hospital will not be paid for any of the care of this patient. It is the same with tubal ligation in pregnant patients. Even if the woman has had twelve children at home, the consent form must be signed thirty days in advance.

So, I find I not only need a crystal ball to aid in diagnosis but a magic wand. The magic wand would come in handy for situations such as the above. I could make the treatment fit the payers criteria rather than just doing what the patient needs.
My crystal ballSocialTwist Tell-a-Friend

Sunday, October 11, 2009

Falling through the cracks

In private practice I was always worried a patient would, as we say, "fall through the cracks." The cracks are spaces in the health care system where patients, especially those with few resources, get lost to follow up and go months or years without care. They finally reappear in an emergency room in crisis.

In my new position, most of my patients have fallen through the cracks. Examples I have come in contact with just today are:

O who had a fibroid uterus so large it was obstruction her intestinal tract. While she has government supplied health insurance due to her mental disability, she fell through the cracks because she is schizophrenic. The county system gives her medication for her schizophrenia. She can manage with her son's help to get to the Mental Health and Mental Retardation office for her medication checks but she tells me the paper work for the primary care doctor is too difficult for her to fill out.

Or there is D. She was going to a Medicaid clinic run by a doctor who doesn't have privileges at any local hospital. When D's bag of waters broke prematurely, she called her doctor but no one ever called her back. That was three days before she came into the emergency room with an infection from the premature rupture of membranes. And just so those of you out there who are thinking, "We don't understand why she didn't go to the hospital right away!" know, I thought of that too. When I asked her, she explained she has had two babies and two miscarriages at the county hospital. I don't think she was treated very well on any of those hospital visits.

Now there is B. I am waiting on the OR to call me. She has an ectopic pregnancy. She had a positive pregnancy test two weeks ago. She has a job and a three year old son. She was trying to figure out whether she qualified for Medicaid since her employer doesn't provide health insurance. I am hopefully we will be able to do an minimally invasive procedure and get her back to work in a week or two since she and the three year old depend on this job, which she is afraid she will lose. In this economy you can understand.

The cracks are scary. Most of my friends cannot imagine they would every fall through them. I believe the cracks are a hazard for those of us who make a good living, as well as those who live on the edge of a crack economically. We are all just one serious illness, just one disability away from a crack. A crack which all but the richest could fall through.
Falling through the cracksSocialTwist Tell-a-Friend

Monday, October 5, 2009

Down time

If my book ever gets written it will be like this. I have my feet up waiting for a case to go to the operating room.

Maya Angelo has a quote I read recently which goes something like, "Never whine. Whining only lets the bullies know who you are." Reading this has given me new resolve to figure life out. Which you would think I would have done by now. After all I have been at this more than half a century. But then maybe I have spent too much time whining.

Taking this job I believed I could make better use of the down time. Yet, in over 4 months I have not gotten the hang of it. I have yet to sleep on the mornings when I am on call. This is the best time in my twenty four hour shift to do so but I am either simply not tired, as today, or I have too much left over stuff to do. I have written lecture notes and articles. I catch up on odds and ends. Anything I can do from a laptop computer and the telephone, I will do in those quieter hours of the morning.

Before I know it, the downtime is gone. I am in the ER or doing a C-section or some other procedure with one of the first year residents. Surgery with them takes twice as long as it would for me to do it myself. I remind myself this is normal and make a mental note to buy some support hose.

Well, it is time to go upstairs to the OR but this is what I should be doing with the down time.
Down timeSocialTwist Tell-a-Friend

Friday, October 2, 2009

The gift of life

Tonight I can either read or write. While I my body is screaming, "Lie down and open the book!" my mind is whispering, "please, tell this story."

It is about this lady from the emergency room. She makes me think of the woman in the Bible. That one who touched Jesus' robe and he knew, yet the risk this woman took was coming to the emergency room. She almost passed out at work. Bleeding for three years, she has been afraid to go to the doctor. At least that is the story I got when her daughter translated for me. Her blood count or hematocrit is 21%. Normal is 40%. She is not bleeding much now and the transfusion is running into her arm. Two units of packed red blood cells. The gift of life. There are T-shirts all over my house with this slogan on it.

Yet, the blood is not going to be the gift of life for this woman. She needs more extensive medical care which could have prevented such a precarious situation in the first place. I guess when you are in this country illegally, working a minimum wage job, all ways afraid of being deported, daring to get medical care is a bit like trying to touch God. Hopefully her story will work out as well as it did for the woman two thousand years ago.
The gift of lifeSocialTwist Tell-a-Friend

Thursday, October 1, 2009

Why health care reform?

Every time I pull open the door to the stairwell leading to the Emergency Department I am forced to smile at one of the retired CEO's of my institution.

"He's there in the hospital?" you exclaim.

"No, nothing like that," is my reply. "He and his wife have larger than life portraits in the hallway. I pull the door open and I have to face them before I can descend the stairs. Anyone waiting for the elevator sees them. Well dressed and glowing, they pose for the artist. They are currently living in a very up scale neighborhood of this city. That is of course when they are not in their other home in another state. This gentleman made a sizable fortune from the business of health care."

"What is wrong with that?" you ask. "This is America."

"Ah yes. America indeed." I muse. "America is the place where a hospital can be a not for profit, gather in large donations, charge patients, and the government. This is 'A great humanitarian hospital.' Make no mistake. We do good work here. And I have made a good living doing it. Yet, in all the years I have been in practice, my total salary (all 24 years of it) has not come close to what this man made from this hospital system in ONE year."

"Amazing," you say.

"No, America. And it is why America needs health care reform."
Why health care reform?SocialTwist Tell-a-Friend

Monday, September 28, 2009

"In an emergency, take you own pulse first."*

There is nothing quite like waking up to an emergency, especially when it is not.

After a day of ectopic pregnancies, patients sick with the flu, and routine deliveries that belonged to the county hospital but managed to find their way to our labor rooms, my head was on the pillow and my mind just thinking about REM sleep when the phone rang.

"They're taking the patient in room 4 for a stat!" The next sound is the dial tone.

Instantly the light is on, my feet are in my shoes, and the cap and mask at the bedside are in my hand as I run out the door. I imagine this is a bit like a fire fighter going down the pole, propelled by an adrenaline rush into the unknown. My mind is foggy trying to remember the patient in room 4. I am not in charge of this patient's care but I try to keep a mental list of each patient in the 18 labor rooms. If something happens I could end up taking care of any of the patients in the labor area until her physician arrives.

"They are in OR 2!" the intern yells as I run down the hall way.

I get to OR 2 and no one is there. Well, maybe it was a dream.

I turn around to exit the OR suite as the double doors fly open. A large Hispanic woman is on the stretcher surrounded by people pushing her into the room. I ask everyone to stop.

"What is happening?" I demand. My pulse rate has maxed out at what feels like 200 beats per minute but I manage to keep my voice level.

"The nurse could not find heart tones." the second year resident pants. "I put the sonogram on and the heart rate is sixty so we came back here. I called a stat C-section."

Taking the monitor from the nurse I locate the fetal heart tones, introduce myself to the patient staring up at me, eyes wide. Covering her up a bit, I introduce myself, then ask the nurses "Where is anesthesia?" No way to do a C-section without anesthesia. (Well there is but that is another post.)

"Right here, I was just called," the anesthesiologist enters the room.

The fetal heart tracing is looking rather normal and the lady, though quite large, has a small fundal height. "Please tell me about this patient," I ask the second year resident as the upper level resident enters the room.

"She is here for high blood pressure. She is 26 weeks and breech. She may be having a placental abruption." The fetal heart tracing still appears normal for a 26 week baby. (40 weeks is term.) Nothing has been below 120 beats per minute.

I have noticed a faint scar just above her pubic bone. "How many pregnancies, deliveries, and C-sections?" I ask.

"Three pregnancies, two C-sections," is the reply. There are ten people in the room in addition to the patient. One person is translating and I realized the patient speaks no English. I thought I was sacred. She must be losing her mind with fear.

"Well, the fetal heart tracing looks OK now." I say to the second year resident. Let's get the sonogram machine and look again at the baby. Then to the special care nursery team, "I don't think we are going to do an emergency C-section. We'll call you if we decide we need to deliver this baby."

The scan looks normal. The biophysical profile is a perfect 8 out of 8. I explain to the patient through the translator that her baby is doing fine. There must have been a variable deceleration in the heart rate that is common for preterm babies.

Taking the patient back to her labor room to continue her monitoring and medication for her extremely high blood pressures, I read her chart. She does not have preeclampsia which would be treated by delivery. Apparently she has chronic hypertension and has not been taking her medication so she was admitted to the hospital tonight for blood pressure control.

A few minutes later I am sitting in the resident area writing my note about the earlier events. This is a chance for the second year resident and I to talk. I begin, "The good thing about being a second year resident is you don't really have to make any big decisions. The first thing you should do, IN THE LABOR ROOM," I emphasize this to hopefully save another false alarm with this resident, "before you move the patient."

Continuing, I explain, "call you upper level, call anesthesia, tell them to open the C-section room, but don't move until you have everyone there." I wait a few minutes to let that sink in. "It would be bad enough to lose a premature baby, but it would be much worse to lose a mother, especially one who has two children."

We sit quietly for a minute. I am remembering how difficult it is to be the second year resident. I was my most difficult year of residency. I even had a maternal death. Yet, what I said is true. The beauty of residency is there is always someone to call. In two years, nine months and three days, this young resident will be in practice. Then the decision will be all hers. Hopefully we will have her ready. Tonight was a step in that direction.

*quote from one of my attending physicians 28 years ago
"In an emergency, take you own pulse first."*SocialTwist Tell-a-Friend

Sunday, September 27, 2009

I dunno

To the 16 year old in labor: "Have you ever been pregnant before?"

"Yeah, I had a baby last year."

"When last year?"

"August." A pause. "I think it was August."

"How much did your baby weigh?"


"Is the baby doing alright?"


"Doesn't the baby live with you?"


"Why doesn't the baby live with you?"

"I gave her to my mamma."

"Don't you live with your mother?"


"Well, if you live with your mother and the baby lives with your mother, why don't you know how she is doing?"

"Well, that baby don't live with my mamma no more."

"Why doesn't your baby live with your mother any more?"

"She gave the baby to my grandma."
I dunnoSocialTwist Tell-a-Friend

Tuesday, September 22, 2009

The 4th floor

I frequently take a short cut path through the 4th floor. It is a medicine unit where a number of very sick patients from the emergency department wait for a room to open up the specialty area where they will receive treatment. I can usually save 5 minutes of waiting for an elevator because the stairwell on this floor is not locked as it is on the obstetrical floors.

Today, I finally realized the short cut is not worth it. I take this path to save time. However, for the fourth time in as many weeks I have run into a former patient with a relative in the hospital. I stop to talk and spend more time than I had hoped to save. Today it was a woman about my age there with her husband. From our previous conversations I knew he had been diagnosed with cancer some time ago. She is there, very anxious, and I am a friendly face.

I sit with her for a while and listen to what has happened with her husband. I remember how very difficult it is to wait with a loved one. I have had family and friends in the same situation forever grateful to see a friendly face in the swarm of medical personnel.

Perhaps there is a purpose besides time saved when I take this "short cut." I believe I will continue. That is at least on the days I have the time.
The 4th floorSocialTwist Tell-a-Friend

Sunday, September 20, 2009

Sometimes the best teacher ...

How much have you learned from those not given the title of teacher? Here is a story from my third year of medical school that reminds me how much I have learned from those we tend to think of as the supporting cast.

I was on my second full night of call in the obstetrical unit at the county hospital. Well Known College of Medicine staffed a large hospital primarily devoted to obstetrics in the poorest ward of Largest City, Texas. In the single month of my obstetrical rotation I delivered forty babies assisted only by the Licensed Vocational Nursing staff.

As medical students we joked that it was "see one, do one, teach one. " The chief resident would show you how to do a delivery. Next one of the third or fourth year residents would watch you do a delivery. You were checked off as a "delivery doctor." At that point you were on your own. The only condition was any repair of an episiotomy or laceration had to be inspected by an upper level (third or fourth year) resident. Legend had it a new third year student had once sown a vagina shut. I thought this unlikely and worried more about unrecognized third and fourth degree lacerations, the improper repair of which could leave a woman incontinent for life.

One reason that Friday night in October is so clear in my mind is it was the woman's first baby. It was also my first solo delivery. I had to cut a small episiotomy which I meticulously repaired but all senior residents were in the OB chief resident's call room. The most important thing about that particular night: It was the night the world learned Sue Ellen shot JR in the television series "Dallas."

At any rate this story is not about what the residents were doing. It is about a group of my real heroes in that chapter of medical school, the LVN's. I was convinced the LVNs knew more obstetrics than many of the attending staff. For the most part, the attending staff were just too busy to be bothered because they were putting together the next edition of a textbook.

Checked off by the resident from my last delivery, I took the patient to the recovery room and finished the paperwork in her chart. Out in the hall I heard a nurse call "delivery doctor!" Finished with one delivery, I rushed to help push the stretcher back to a delivery room for another.

No sooner than we had the woman on the delivery table and in the stirrups than I could see the baby's head crowning. I pulled on my gloves and helped the head out of the vagina. Immediately I realized there was not just one or two, but three loops of cord so tight around the baby's neck I could not reduce it over the baby's head nor could I delivery the baby.

Seeing the panic in my face, one of the LVN's picked up two Kelley clamps, and clamped all three of the loops of cord together. "Cut here, doc!" she commanded. I did just what she said. The cord fell away and the baby almost delivered itself into my waiting hands.

After placing the baby on the mother's abdomen, I looked up at the nurse. "You're gonna be alright, doc!" she exclaimed.

I thanked her and we both went back to work. Whenever I have a tight nuchal cord which needs to be cut rather than reduced over the baby's head, I think of that LVN working nights in a hospital full of medical students and residents. I doubt I was the only one who learned such a valuable lesson from her.
Sometimes the best teacher ...SocialTwist Tell-a-Friend

Thursday, September 17, 2009

Degrees of sadness

Yesterday an old friend from my private practice days asked, "What is the saddest thing you have seen while doing this job?"

My answer was, "A fifteen year old lying on as stretcher in the ER with a dead baby between her legs." I went on to explain what made this even worse for me was the fact the young woman was not upset. She acted as if for her this was a daily occurrence.

When I inquired who brought her to the emergency room, I was told, "An ambulance."

The girl told me she called the ambulance when her contractions became so painful she couldn't stand them any longer. This was necessary because she lived with her grandmother who was wheelchair bound and did not drive. The baby was dead when she delivered him shortly before her arrival. From looking at the baby, I suspected he died even before labor began.

I then ask if I could speak with her grandmother.

"She ain't here." Was the curt reply.

"Could I call and talk with her on the telephone?" I asked.

"Well, I guess you could, 'cept we got no phone at home." With this she opened her palm to show me the cell phone she was clutching. She had used to it to call the ambulance. In fact she seemed more worried about what her grandmother would say (or do) when she was caught with the cell phone, than she was about the fact she had just delivered and her baby was dead.

I did talk with the grandmother, the girl, and the social worker later that day. Hopefully things are better now. I don't know. I think about her every time I am on call and at times when I am not.

Sad, however, has reached a new level today.

Today my mental portrait of sad is a beautiful, 8 pound 4 ounce baby boy who came out screaming last night. He is now struggling to withdraw from the narcotics his mother has been taking throughout her pregnancy.
Degrees of sadnessSocialTwist Tell-a-Friend

Wednesday, September 16, 2009

An oxymoron

Safe sex.

Today many people feel this should be our focus of attention when it comes to talking about sex with those who have it, might have it, or have had it. I disagree. There is nothing 'safe' about sex. Here is a capsule of my morning and the case in point.

In one room is a nineteen year old pushing out her third child. She does not even look at the baby. Her three year old sleeps on the pull out couch. The one year old is home with the grandmother. The new baby is screaming, a sign of good health in a newborn, but I can't help thinking this child has more to scream about than most. How will she ever get the emotional support she needs to grow and develop, get an education, develop skills which will keep her from ending up right back here as the mother in a few years?

Next door is a thirty five year old 23 weeks and 6 days into her first pregnancy. Her cervix is too short to hold the baby in and her bag of water broke spontaneously last night making delivery likely in the next twenty four hours. The cause of this situation is likely the human papilloma virus (HPV) which infected her cervix years earlier growing abnormal precancerous cells. These cells had to be remove not once but twice in the last ten years. Now with a shortened cervix her first pregnancy will produce a premature infant who will weigh just about a pound at birth. The card I am required to wear with my name badge says that in our nursery her baby has a 76% chance of survival. Of those babies which survive, 67% of will be neurologically normal. In other words, her chance of a normal baby are just over 50%.

The rest of the patients? One is having a baby with a severe heart defect which will require surgery shortly after birth , one has a baby with trisomy 21, and a third, already delivered, has dangerously high blood pressure caused by her pregnancy.

So, I propose we stop using the term "safe sex." There is no such thing. We should instead speak of responsible sex while helping those who will, are, and have had sex learn to deal financially and physically as well as mentally and emotionally with the consequences.
An oxymoronSocialTwist Tell-a-Friend

Tuesday, September 8, 2009

Air and light

Back in the mid to late '70's when I was working on my biology degree, the conventional wisdom was living things need food, water, and sunlight for growth. I realize things have changed somewhat. Food is now grown under artificial light in nutrient replenished fluids producing amazing crops. Yet, I cannot help my belief of the need for natural light and warmth from the sun, a slight breeze on the skin, and fresh air for the lungs. It seems these are necessities for human well being.

One big problem with shift work is it can rob people of the natural diurnal variation. With that comes the lack of what I believe are essential nutrients, fresh air and sunlight. Bright fluorescent bulbs burn 24/7. The hospital air is a standard issue: cold and filtered. Chilled to about sixty eight degrees and pushed through laminar flow filters to decrease infection. So what is a body to do?

Here is a solution. The hospital complex now spans about four blocks. I am suppose to stay on one of those for my shift. I know of no rule that states when things are slow I cannot walk around that block. I do. And I do this at least four times in a twenty-four hour period. Occasionally more. Routinely I try for mid morning, early and late afternoon and once in the evening. I can even cut the diagonal which is the quickest way from the front door of labor and delivery to the ambulance bay of the emergency department. At times this is necessary. On the walk back, if there is not another emergency in labor and delivery I can stop at the prayer garden which is just off this path.

None of these routes are a walk in the woods. Many of the vistas include views of local skyscrapers which depending on the light can be picturesque. There are homeless or near homeless people on every corner. A number of times I am ask directions by visitors who are lost. However trees, flowers, and patches of grass dot this area. And the fountains! Believe me, no relgiously affiliated hospital has ever been build without fountains. There are six here at last count, smelling a bit like swimming pools but adding soothing sound of moving water to the venue.

A bit at a time I am figuring this out. After several months I am still sleeping mostly at night. I have not eaten fast food. I am writing and reading more. Now I have this habit of getting some air and sunshine.

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Monday, September 7, 2009

In case you didn't know

Just so you know what we are dealing with here is an excerpt from the Dallas Morning News today.

AUSTIN – Texas, a leader in teen pregnancy and the state where more teens give birth to subsequent children than in any other, maintains one of the most restrictive policies in the nation for minors to obtain prescription birth control.
Not even young parents in Texas can get birth control without their own parents' permission at nearly a third of the family planning clinics on contract with the state health department.
While most privately and publicly funded clinics in North Texas prescribe contraceptives without insisting that parents be notified, all 10 school-based clinics run by Parkland Health & Hospital System in Dallas must have a parent's signed consent. One in Carrollton-Farmers Branch, at the school district's insistence, can't prescribe any birth control.

The article goes on to say that one city in Texas, which is not Houston or San Antonio, has the highest rate in the nation of teens having their second and third child while still teenagers. Old enough to have a child but not old enough to legally obtain birth control. Texas wisdom at it's finest.
In case you didn't knowSocialTwist Tell-a-Friend

Sunday, September 6, 2009

Sunday's child?

At times I have serious doubts about whether anyone reads this blog. At other times I feel afraid to say how I feel or divulge too much. Today, while I do care, I think those of you who might read this and contemplate going into medicine need to know some days are, as a former resident classmate of mine would describe, "Just the pits!"

It really began last night. One of the doc's in my group had a death in the family and called to ask if I would take his call on Tuesday so he could go to the funeral. He had tried to call others but no one is in town except those of us on call. I had something really important planned for Tuesday but it wasn't as big as a funeral, so I ended up telling him I would do it.

With that mind set I came to work only to be confronted with a sick patient in the emergency department. She needs some treatment and then surgery tomorrow which I will have to do on a holiday weekend when things are slower than normal. To make things even worse, she is mentally ill. After a conversation with her and then with the family, I had to take a walk around the block to make sure I was thinking straight.

Next, I was confronted with a belligerent family. There seem to be several on this holiday weekend where the hospital is overflowing and understaffed.

So that is how this Sunday has gone.

Enough of this self pity. It is time to get back to work.
Sunday's child?SocialTwist Tell-a-Friend

Sunday, August 30, 2009

Special day

Twenty years ago at 3:17 PM this afternoon a blessing of unbelievable proportion arrived. My eldest child was born. After a mere 27 hours of labor he arrived by Cesarian section, looking wide eyed and wary of this big world. His place in my life is always one of welcome. It is like a cool breeze on an August morning in Texas. The promise even better things to come.

These two decades have passed at warp speed for me especially where N's life is concerned. Parenting, though at times tough, is a position I love. I believe both of us would admit I have not always done it well. My role as a mother has given me a perspective on this life and beyond I could not have gotten anywhere else. I am most grateful for this role.

Yet, more than my role as a mother, I am grateful for this person, who he is, and who he is becoming. His big brown eyes still look at the world warily but often with excitement and awe. It is always a pleasure when our conversations gives me a new view and this is often.

Birthdays are special days for those who own them either by entering the world on that particular day or by being apart of that entrance.
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Thursday, August 27, 2009

On leaving private practice

For many years I believed the private practice of medicine was what I was meant to do. I had great difficulty leaving. Now almost three months after leaving my office for the final time, sitting here in the artifical light of labor and delivery for twenty-four hours at a time, reading this quote is a fitting summary of the past year.

"You can take from every experience what it has to offer you. And you cannot be defeated if you just keep taking one breath followed by another. " Oprah Winfrey

Still here, still breathing.
On leaving private practiceSocialTwist Tell-a-Friend

Tuesday, August 25, 2009

Deposition Day

I had the privilege of being deposed today. I am not a party to the lawsuit - yet. My goal today was not to be. I am not sure I made it. Time will tell. It goes without saying that it was a difficult day.
Deposition DaySocialTwist Tell-a-Friend

Sunday, August 23, 2009

Capitalism or socialism

I am not in the habit of copying an other's material but this excerpt from Fox News is too good to pass up:

Democrats, realizing the success of the President's "Cash For Clunkers" rebate program, have revamped a major portion of their National Health Care Plan.
President Obama, Speaker Pelosi, and Sen. Reed are expected to make this major announcement at a joint news conference later this week. It's called... "CASH FOR CODGERS" and it works like this: Couples wishing to access health care funds in order to pay for the delivery of a child will be required to turn in one old person.
The amount the government grants them will be fixed according to a sliding scale. Older and more prescription dependent codgers will garner the highest amounts. Special "Bonuses" will be paid for those submitting codgers in targeted groups, such as smokers, alcohol drinkers, persons 10 pounds over their government prescribed weight, and any member of the Republican Party. Smaller bonuses will be given for codgers who consume beef, soda, fried foods, potato chips, lattes, whole milk, dairy products, bacon, Brussels sprouts, or Girl Scout Cookies.
All codgers will be rendered totally useless via toxic injection. This will insure that they are not secretly resold or their body parts harvested to keep other codgers in repair.

All of this speaks to the broader issue which is now being debated in our country. I keep asking myself why it is not socialism to bailout banks, insurance companies, automobile manufacturers, and brokerage firms but it is socialism to offer government subsidized health care? The answer must have something to do with the recipients of the government monies. If they are rich the government is preserving capitalism. If the recipients are poor or struggling middle class it is socialism.
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Friday, August 21, 2009

"Denial ...

"Denial gets you no where." The first time I heard that phase I had just transected a patient's ureter (tube from the kidney to the bladder) in an effort to stop her exsangunation. For those not in medicine, transected means cut in two. Exsangination is, well, simply bleeding that will kill you. All the blood in the body is moving outside the circulatory system rapidly. Usually the patient's heart is beating about 180 times per minute, which is only slightly faster than the doctor's. Neither patient nor physician can sustain this kind of stress for very long.

"Denial gets you no where" has become a motto of sorts. I try see things as they are not as I hoped they would be. I don't expect events to occur as I would like without an effort on my part to effect a positive outcome. My eyes are wide open and in my new position it is a good thing.

An average day is going to contain at least one case of syphilis, one cocaine positive drug screen, and a multitude of teen pregnancies. It is also very likely someone will be bleeding enough to need a blood transfusion. If we (this job is a team effort) are lucky no one will die, everyone will getting treated appropriately, and we will move on to the next day with at least some optimism intact.
"Denial ...SocialTwist Tell-a-Friend

Sunday, August 16, 2009

Dr. Seuss didn't tell me

The street is hot.

The ER is not.

The result for me:

More patients to see.

Yet, I recall

It will soon be fall.

Cooler days, football
Will clear the halls.

A break will be great.

'Cause a similar fate

In winter I will find

As temperatures decline.
Dr. Seuss didn't tell meSocialTwist Tell-a-Friend

Tuesday, August 4, 2009


Names are interesting. Some patients spend months searching for the perfect one. Others choose the name of a beloved parent, grandparent, a favorite aunt, uncle or sibling. Then there are those who have to have the most original name they can imagine.

Today I have two new ones. Definitely the most original I have ever seen.

"Ra-a" pronounced "ra dash a" and "La-a" pronounced "la dash a."

The 17 year old mother told me, "The dash don't be silent."

This may be just the thing to end standardized testing. Either that or there will have to be a new bubble for the "-" to be included.
TwinsSocialTwist Tell-a-Friend

Monday, August 3, 2009

Cost or compliance?

August is here.

It is early yet but so far one third of my deliveries this month have syphilis. Syphilis is cheap to diagnose and treat. All these are new cases. The state mandates testing at least three times in pregnancy and I have been able to get records on patient showing negative test results with in the past year.

It is, however, a difficult job to make sure these women are adequately treated since follow is required and most of them do not return unless they are sick or get pregnant again. It is even more difficult to get their sexual partners treated. That is where the health department comes in. Babies have to stay for 10 days of intravenous antibiotics.

The greatest obstacle in any health care system is patient compliance. If the patient will not take the medicine, follow the treatment plan, return for re-evaluation, even the best attempts at treatment are futile.

So, while the rest of the country is debating the cost of health care, those of us providing health care know compliance is key. We also know compliance is not always tied to cost.
Cost or compliance?SocialTwist Tell-a-Friend

Wednesday, July 29, 2009

Night in the ED

The smell is still with me.


An 80 year old woman

brought in by her daughters.

She wanted to die in Mexico.

Her daughters wanted her here.

The daughters won.

Now I will share their nightmare.
Night in the EDSocialTwist Tell-a-Friend

Tuesday, July 28, 2009

When (not) to call the doctor

Knowing when to call the doctor is important inside the hospital as well as out.

One night as newly minted third year resident I received a call from one of the floor nurses at about three AM. The beauty of the third year was the fact that call meant you were expected to get some sleep. "Doctor!" the nurse exclaimed, "the patient in 722 is complaining of itching."

"Really? Well please tell me more about the patient in 722." I asked since I had no idea who the patient was.

"She is a 45 year old who had a vaginal hysterectomy yesterday." The nurse told me. "What are you going to prescribe for her itching," she demanded.

"What medications is she taking? Does she have any allergies?" I was still trying to figure this out.

"She is only taking tylenol for pain." The nurse stated.

As I tried to drag as much history out of the nurse as possible minutes ticked by. I felt that I might as well get up and go up stairs to see the patient. "Well, does she have a rash?" I finally ask.

"I don't know," replied the nurse.

"You don't Know?" I ask. "Why don't you know?"

"Well, you see the patient was so sleepy she ask me not to turn the light on. She was worried turning the light on would wake her up too much."

(No, I didn't say what you know I was thinking.)
When (not) to call the doctorSocialTwist Tell-a-Friend

Monday, July 27, 2009

More (writing) next month...I hope

It seems I need to hurry and get something on this page before the end of July. July 2009 will be a record month for me. I have seen more blood, sexually transmitted diseases, drug screens positive for cocaine, and dead babies this July than in any previous month of my career. I am hoping not to break more records anytime soon.

I remarked one day while rounding "If we could get some doxycycline (antibiotic to treat gonorrhea and chlamydia) in the water supply along with an oral contraceptive and do something about this cocaine, I could happily be without a job."

The residents are great, as is the nursing staff. They are up close and personal with all this stuff even more than I am. For instance, last Friday night while I was on the phone explaining to the operating room why I needed to do an emergency surgery on a lady with no blood pressure, the resident was in the room holding the patient's hand.

So, while this sounds like complaining, I am trying to make some observations. The final observation is: I am exhausted. This is truly only one month in. I have been trying to stay on a reasonable schedule. I am not sleeping in the day unless I can't help it. I want to be awake at home when I am there with my family. I am trying to exercise. I just can't on the days I am at the hospital for twenty-four hours. Tonight I had ice cream for dinner which wiped out the Lean Cuisine and fruit I had for lunch but I felt I needed it.

I have worked 184 hours this month. I have thirty-two hours to go.

And yes, I know I should not be counting.
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Tuesday, June 30, 2009

The gift of July

Every year, July brings with it a new beginning. Brand new, fresh faced, eager, and probably terrified new doctors and nurses dot the hospital. With them these newly minted professional bring a wealth of knowledge and some experience from their respective professional schools. Most importantly though they bring with them the gift of enthusiasm.

For these new professionals medicine is fresh and exciting. Yes, it takes longer to do everything. From the initial history taken from the simplest patient to surgical procedures that almost double in length I will be watching every move that each one makes. Though most aspects of hospital practice slow for a few months as these young women and men acclimate to their new roles, I don't care.

Even the residents who have been here for a year or more are moving up a step. They are more alert, eager, excited. This enthusiasm for medicine serves to invigorate all of us. This all comes at just the time when we need it.

So in those moments when I am watching every move, count the number of throws in each knot and making sure they are square, questioning each and every finding, asking for that complete differential diagnosis, checking the lab tests myself, I will also take some time to enjoy working here. The privilege that surpases that of practicing medicine is the privilege of sharing the experiences of others who are new to learning to practice medicine.
The gift of JulySocialTwist Tell-a-Friend

Saturday, June 20, 2009


On a trip to the emergency room yesterday I caught this glimpse of the problem.

The young woman I saw was a renal dialysis patient transferred from an outlying suburb due to left sided pain and severe anemia. Gynecology was consulted immediately based on the results of a CT scan done at the other hospital.

I will admit, I looked through all the lab tests and read the CT scan report before I spoke to the patient. She even had a battery of blood work ordered by the physician who accepted her transfer. He had not seen her yet either.

She was a 24 year old woman with systemic lupus erythematous. This is a debilitating disease that can affect every organ but usually goes straight for the kidneys. She was currently on dialysis, a whole bunch of blood pressure medicine and the anticoagulant Coumadin. She was married and yes, she was sexually active, using condoms for contraception. She and her husband had a four year old son and she had a miscarriage 2 years ago when all her problems with the lupus began.

After talking with her, I took her blood pressure and pulse both sitting and lying. They did not change very much. She did not "tilt," a term used when the blood pressure decreased and the pulse rate increased as the patient sat up. This was a good sign.

My first problem came when I ask the nurse if a pregnancy test had been done since I could not find one in any of the lab work from either hospital. "Well get me some urine and I'll order one," what the terse reply.

"She doesn't make urine. She is a dialysis patient." I calmly told her. "There is all that blood work. If you will show me how to enter the order into the computer I will call the lab and ask them to run it on the blood they already have."

"Well, hasn't she had a hysterectomy or something?" The nurse frowned at me. I could tell I was too much trouble.

"No. She is still menstruating. She has a four year old and a miscarriage two years ago." I waited patiently. "After you do that I will need some help with an exam."

"Why do want to do an exam? She already had a CT scan."

I could have said something like "well, I am a doctor and I am writing up this history and physical exam." I didn't. I got all the things I needed and when into the room.

In the room the patient told me that no one had examined her at the other hospital. As a matter of fact she had not had a pelvic exam since her miscarriage. I was busy setting everything up. When we were ready the nurse said, "I haven't ever seen this before. What do I do?"

"Just stand there," I replied as I positioned and draped the patient. Five minutes later I was done. Helping the patient, I thanked the nurse.

The patient was not very tender. Her blood count was low. Her pregnancy test was negative. All the fluid on her CT scan was probably blood from a ruptured ovarian cyst. Because she is on the Coumadin to prevent her blood from clotting, bleeding was far more likely than in most people. I explained to her that we would need to watch her blood count closely but it had been stable all day while the transfer was taking place so she probably would not need surgery.

As I was leaving the ER, I thanked the staff for their help. There were three techs and an RN. Each had a computer console where they could look minute by minute at everything that was going on in each of the patient rooms. Pulse, blood pressure, EKG tracing, oxygen saturation and all of the laboratory tests right there at your finger tips. Modern medicine.

Still, there is nothing like seeing, talking to and examining the patient.
"duh"SocialTwist Tell-a-Friend

Sunday, June 14, 2009

The loco MD

Today I am considering a change in the title of this blog. Loco MD seems more fitting. Recently I left the security of a well respected group to practice as an obstetrical hospitalist. Every day I have at least one second thought. This morning it came as I was delivering a 17 year old patient. The "baby daddy" was there very curious about all that was taking place. I was equally curious about how he was keeping his pants from falling down. The pants were riding about 4 inches below his waist to allow more than adequate exposer of his underwear.

Two days ago my second thought occurred as I dealt with a patient laboring after she had taken PCP. I had forgotten about the vertical nistagmus. The patients eyes oscillate up and down very rapidly. I know of no other instance when this happens. Patients on PCP can also be quite agitated which is understandable if your eyes are jerking up and down about a hundred times per minute. Have you have seen that commercial with the fried egg - "your brain on drugs"? Believe it!

I also spend way too much time thinking about who is taking care of those toddlers left at home. One of my standard questions after I find out the ages of previously delivered children is "who is taking care of them." "My mom" is a common response. In a short time I have concluded there is a large group of children being raised by their grandmothers. I am hoping the grandmothers do a better job the second time around.

I have also become way too familiar with filling out and signing death certificates. These dead certificates are for babies who died before their mothers came to the hospital. Many times the delivery of their dead baby is all the care these women get for their pregnancy. Drugs are frequently involved.

I came to this job through a series of events that have happened over the past two years. I could be seeing patients in a high profile wellness clinic in the wealthiest part of the city. That job was my second choice. At the time I believed it was too tame. I still do.

I write these things to say that I was not as well prepare for this job as I thought. Still it is what I wanted. And still it is work worth doing.
The loco MDSocialTwist Tell-a-Friend

Wednesday, June 3, 2009


Every profession has it's own vocabulary. The vocabulary of medicine is notorious for it's complexity. "Inspection of the malar area revealed a patch of vitaligo next to a maculopapular rash that the patient states is puritic." Translation: "This patient has an area on her cheek that has both lost it's pigment and a rash that is visiable, palpable and itches." Dysuria means it hurts when you pee, excuse me urinate. A cholecystectomy is the removal of a patients gall bladder as opposed to a cystotomy which is making an incision in a cyst, even that big cyst that all of us have, the urinary bladder.

Today puzzling over what it is that physicians do, I realized that I went to school for four years to learn all these words. Then I spent another four years learning how to use them with other physicians while also learning to translate them back into a language patients can understand. Now that I am in practice, to get paid I have to use an entirely new language: Current Procedural Terminology or CPT for short.

CPT codes are numbers that insurance companies use to determine payment. The reimbursement I receive for a patient visit is based on the number of questions I ask, the number of body parts I examine and the time I spend explaining the diagnosis and treatment to the patient. All of this must be properly matched with a numerical code that is put into the computer and sent to the insurance company in order to receive payment. No one is ever told in medical school that the system is run this way. Why would anyone spend all that time learning a complicated language only to then learn some sort of Morse Code system so that the insurance company will pay you?

As I write this, I realize that in the practice of medicine I now use three languages. There is the language I speak to the patients. It is much the same that I use with friends and family. This language is English, hopefully as plain and simple as I can make it so that the patient I am caring for will understand what I believe is happening to them and what my plans are for treating this condition.

My second language is the one I use with other physicians and the health care team. I love this language. I have spent years learning it. I enjoy reading medical journals, talking with colleagues and attending conferences where it is used. The preciseness of this language is helpful in the diagnosis and treatment of patients.

This third language I consider a necessary evil. Without it I will not get paid. I am not proud of the fact that I know a 99213 is a specific level of office service or that V25.1 is the code for contraception counseling. These are facts that seem to clutter my brain. They do not make me a better physician or even a nicer person. Knowing this language only allows me to succeed at billing for my services.
VocabularySocialTwist Tell-a-Friend

Sunday, May 17, 2009

Inside out

The political cartoon of the day features a patient lying in a hospital bed labeled "US Heath Care System." Equipment packs the room preventing the nurse and the masked and gloved surgeon, labeled "Obama," from touching the patient. The nurse questions, "Where do we start?"

The letters section contains comments from a physician decrying the criticism of a retired multimillionaire hospital administrator and a taxpayer who points out all pay the price of the uninsured using hospital emergency rooms as their sole access.

So where do we begin? With the only avenue open to each of us. Ourselves. The physician must take the time to get the results of the test done last week rather than simply ordering another one from the laboratory she owns. The health care administrator must stop ordering supplies exclusively from the company on whose board he sits. The politician must look at the big picture of affordable health care not the plan that will garner the most votes in the next elections.

And the patient? The patient wants everything done and wants it, well, yesterday! We are all patients. If we do not require health care at this moment we will in the future. You can bet on that. Where do we begin? Start eating better. Increase physical activity. Drink more water. Reduce stimulants (caffeine, sugar, electronic media) and depressants (alcohol). Get more fresh air. Don't smoke tobacco. Go to bed at a reasonable hour to get enough rest. These simple measure will not only reduce health care costs. Lifestyle changes such as these will decrease illness as well reducing the need for many of the costly advances now available.
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Saturday, May 2, 2009

A new norm

As I closed my eyes after the last twenty-four hour shift as an OB hospitalist the realization hit me concerning my new patient population. My final delivery of the night was one of a 16 year old having her first baby with her mother and her older sister in attendance. If she had delivered yesterday she would have been 15 when her first baby was born.

The baby weighed 4 pounds and 11 ounces. Small in size due to the fact that she was six weeks early, the early arrival was due to the fact that her mother and her aunt, her mother's older sister were smoking pot and doing lines of cocaine last night just before the bag of waters broke. The patient unabashedly told me this story which was confirmed by the urine drug screen.

This is the new norm for me. Teenage moms, positive drug screens, no fathers in the picture. No one employed, no insurance, the government attempting to pick up the tab.

Today social services have been notified. The patient and I have discussed and she has agreed to injectable contraception that will last for three months following discharge. Still I have the feeling that this entire screen will repeat itself in her life all too soon.

And what will happen to this baby. Born six weeks early, withdrawing from drugs to a single teenage mother living with her single grandmother. How will she ever have a chance?
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Tuesday, April 28, 2009


This morning I am up at the crack of dawn for the monthly quality assurance meeting. It is my favorite meeting of the month and I am not being facetious. I have been doing this for, let me see, almost sixteen years! There is more painless learning in this one hour than any other time of the month. The only time that it is painful is if one of my cases is being presented.

The physicians that serve on this committee receive no monetary compensation for what amounts to about six hours of work each month. The reward for serving on this committee is that a lot like medical school and residency, you find out what will get you in trouble second hand.

It works like this:

The hospital has a list of "quality indicators." Things such as excessive blood loss at a delivery or a surgery, the patient developing a complication, the baby developing a complication and so on. I believe you get the picture.

Now these things happen. And interestingly enough it is usually not the "quality indicator" that got the patient in trouble since everyone is doing everything they can to keep these things from happening.

No, what gets patients and ultimately doctors in trouble is some little, seemingly insignificant occurrence that no one noticed. Here too is the pay off for those of us on the committee.

I will give you an example. Early in my stint on this committee there was a Cesarean section patient who developed a fever. She received the correct antibiotic at delivery to protect her from infection. The doctor involved saw her when she developed the initial temperature spike and every spike after that for four days and then her appendix ruptured. She got peritonitis, an inflammation of the lining of the abdomen and had to undergo another surgery. This is when the appendicitis was diagnosed.

Now the chance of appendicitis after a C-section is probably less than one in a thousand patients but this whole thing happened to a very good physician that I respect a great deal. It also happens that I don't ever do a C-section without at least a glance at the appendix to make sure that it looks alright.

Every meeting is like that. Some great pearl of a pay off for those hours looking at charts, getting up early, wrestling with the issue of how to make the quality of medical care better for future patients.
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Monday, April 27, 2009

Finding a cure

If I could find a cure for one thing it would be uncertainty. It seems to be the disease that plagues humans the most, causes the greatest anxiety, renders much suffering. It is why much is made of living in this moment and not wondering and worrying about the next.
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Monday, April 20, 2009

"See one, do one, teach one"

Back at Famous College of Medicine when I was learning to delivery babies the motto of the OB department was "see one, do one, teach one." This was my experience in the first two days of the rotation. We arrived on a Friday and I was on call that night. Paired with another medical student one of the junior residents took us to a delivery room and carefully walked us through a delivery from positioning the patient, to putting on the gown and gloves, to the careful (and artful) act of holding the baby in our non dominant hand while we clamped and cut the cord with our dominant one.

Yes, I trained back in the days where the dads did not get to come to the delivery room. I also trained in a hospital so big and so busy that there was no room for a father in delivery. FID as I was to later learn in my residency program where fathers took a special class to earn a pass to the delivery room.

So, imagine that it is my second day on my medical school OB rotation. At this point in my career I have delivered five babies. I am just beginning to be comfortable with the process. Looking down the hallway I see a nurse pushing a stretcher from the triage area. One the stretcher is a woman with the largest abdomen that I have ever seen. "Delivery doctor! I need a delivery doctor!" the nurse calls.

Delivery doctor. That's me. I run after her and in to a delivery room trying my mask on as I run. After we get the woman over on to the delivery table I check her cervix and note that it is completely dilated.

"I gotta push doc!" the woman pants.

"Not yet!" I yell. "Let me get my gloves on." The art of gowning and gloving myself is as difficult as delivering the baby.

About the time my gloves are in place her bag of waters breaks and out comes a tiny four and a half pound baby. I suction the baby's nose and mouth, clamp and cut the cord and put the baby on the woman's abdomen just as she says, "There's another one coming."

"No, no," I say. "That is just the placenta."

"Doc, I have had babies before. Trust me. There is another baby coming."

At that moment I look down and see two tiny feet at the vaginal opening. It dawns on me why this woman's abdomen was so large and yet the baby I had just delivered was so small. She is pregnant with twins and the second one is breech.

"Get me a resident!" I yell. See on, do one, teach one did not extend to twin deliveries or breech deliveries either.

Again I ask the patient to please just breathe for a moment while I try to do the same myself. Suddenly through the door comes a resident I have never seen before. He looks at me and in a very self important voice says, "What have you got here?"

"Twins. The first one is delivered and this one is breech." I say stepping aside.

"Shit!" he screams. "I am a family practice resident and I have never delivered a breech baby." Then he yells, "Get a resident in here!" I guess he had done something that I had not which was read the chapter on Multiple Gestations in the textbook.

At this point the patient is no longer able to help herself and she pushes. I step up and delivery a small breech baby boy, who after I suck out his nose and mouth begins to scream his head off as if he knew how ill prepared these two doctors were for his arrival.

Now having read all the complications of both multiple gestations and having had more than one complicated breech extraction, I still marvel at how I managed to do a breech delivery before I ever even saw one.
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Sunday, April 19, 2009

The ability to cut

As a medical student I heard the surgical residents brag "the ability to cut is the ability to cure." While I enjoyed the way surgical patients tend to improve much faster than those receiving medical therapy I have also achieved a healthy respect for the risk of complications from surgery. I understand why patients wish to avoid surgery when possible. Yet there is a subset of patient that seem to enjoy having surgery.

Take this case of a woman who has been my patient for the last ten years. I have operated on her four times and delivered two children for she and her husband. I am not proud of the four operations. I feel that two of them were probably avoidable. It is difficult for me to explain especially to non-physicians how I came to do these two probably unnecessary surgeries but a clue comes from the last encounter I had with this woman.

The patient walked into my office looking the picture of health and stating that she never felt better four weeks following her latest surgery. Looking at her operative incision which is now well healed I said something like, "You look great and you seem to be doing great, too."

"Yes," P exclaimed, "I do feel great. I think this will last at least a couple of years.

"A couple of years? You shouldn't ever have to have surgery again!" I exclaimed.

"No, I am sure that I will get some adhesions [scar tissue in the abdominal cavity, a known complication of abdominal surgery in about 15% of patients], " was her quick reply.

"Well, " I said thoughtfully, "I think you have about an 85% chance of NOT getting them."

She frowned. She enjoyed her time in the hospital away from her children ages five years and 18 months. Enjoying time in the hospital as a patient is something that I fail to understand. It seems like a difficult way to get a vacation. Also from my experience on patient side of it surgery hurts. I don't mind confessing that I don't like needles and I really don't like tubes in places that I am not use to having them.

All this said, the patient is now "well" and no complications were encountered. At least not yet. This surgery was successful. I can and do feel good about that.

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Wednesday, April 15, 2009

What doesn't kill you

In the back of my mind is the quote, "What doesn't kill you will make you stronger." I believe I got that saying from one of the physicians with whom I have practiced for the last eight years. Given the past two years I am hoping that it is true.

This hope comes for two reasons. The first is that the past two years have almost killed me. I have never found the practice of medicine to be so difficult. As I have often alluded to the practice of medicine seems to be changing. Many patients seem to believe that medicine can do everything including make them beautiful, skinny, and happy and all at the same time. While I don't Check Spellingdisagree that ugliness, obesity and depression are diseases, they are not the only ones that I was taught to treat and no one taught me a therapy that would negate patient responsibility where their cure is concerned. Also while medicine has always been an art and a science it has now become big business as well with the physician patient relationship a mere by product rather than the center of this enterprise.

All that said, I am leaving private practice. At least for now. BEFORE it kills me. Practicing as an OB hospitalist will take its toll too but for few days each month. Once I catch my breath, who knows. A.J. Cronin, Robin Cook, J. Michael Crichton, Atul Gawande look out!
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Sunday, April 5, 2009

Work worth doing

I have often been asked if I keep track of all the babies that I have delivered. The answer is no. When I was a third year medical student in the largest county hospital obstetrical unit in the country I preformed forty deliveries by myself in just under four weeks. This may sound like bragging and I am. I also use that figure to illustrate that the motto of the obstetrical service "see one, do one, teach one" was not far from the truth.

At the end of my medical school rotation in obstetrics I decided to stop counting deliveries. Each delivery is very special. I found that I enjoyed remembering them individually and not as the collective whole their sum would represent.

However, I do count in short intervals. I vividly remember the day I did six term vaginal deliveries when I myself was nine months pregnant pregnant. I hauled my big pregnant belly up and down the back stairs to my office that day just expecting to be in labor myself at any moment. I was even grumpy when I delivered a patient due two weeks hence as she and I had both anticipated that my baby would arrive before hers.

I remember the night that I did three surgeries in a row for ectopic pregnancies. Since things seem to arrive in threes I slept like a log after the final one was in the recovery room. It was three AM when I crawled into bed and I felt that there could not possibly be another patient with an ectopic pregnancy out there with my phone number. Fortunately there was not.

Today my record will be dead babies. Intrauterine fetal demise or IFDs as the residents call them. The first was just after 7 this morning. My hospitalist shift began at 7 and I arrived a bit early due to anxiety at what might await me. Sure enough there were two IFDs in labor and delivery when I arrived. I have never had two in one day before. Thinking about this and waiting for board checkout (the procedure for passing off the patients present to the new on call physician) I was called to the emergency room when another obstetrical patient who had just arrived and was delivering. Her baby was dead also.

I remember what I was told in medical school. "If it were easy, then anybody could be a doctor." This is true. The work here is hard not only physically but emotionally as well. These people make me realize how easy my life has been. And that hard work is worth doing.
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Wednesday, April 1, 2009

At what price?

Over a decade ago when my mother was hospitalized to have her lung cancer diagnosed I was somewhat chagrined to see the name of a 74 year old heart transplant patient listed in a room down the hall. The health information privacy act was not in effect yet and I happen to glance at this man's age, post operative diagnosis and profession as I walked past the nursing desk one day. My mother was six years younger, probably much more frail and had retired thirty eight years before when I was born. As America enters the debate over health care yet again, I think back to the questions that I had when I noticed that bit of information about a random patient in 1991.

You see, until the moment that I saw the patient's age, I believed that organ transplantation was offered only to those 60 years old and under. Well maybe, I thought, he was able to buy out of the system. That was only a fleeting idea as I noticed he was a retired minister. We were in a denominational, not of profit hospital so he probably had some influence. Again, no problem. Except that health care is a pie, even if it is one that America has tried to expand, someone paid all the expenses that went with the cost of the heart transplant surgery, recovery and on-going care.

My mother's condition was terminal. I have shared before that I had that realization the moment I saw her fingers some weeks before. Her palliative treatment also had a price tag. The radiation alone she received cost thirty five thousand dollars. All this was paid by a health policy that my father's former employer paid for as a part of my father's retirement benefits package.

Looking back I feel that the care my mother received was worth the cost. I believe it would have been worth the price if I had paid it out of my pocket, which I am not sure my parents would have allowed if this was the way our scenario played out. We had five months to prepare for her death. My mother had some good days and actually stopped her treatments when she determined they were more painful than she felt they were worth. Hospice, which Medicare covered, was extremely helpful in the last few weeks of her life and afterwards as my father began to deal with life without my mother.

Yet, I have always wondered about a heart transplant in a 74 year old. Perhaps if it were less of a mystery. Did the recipient believe it was worth it in terms of the suffering? What was his quality of life? How long did he live? What were his families thoughts. If I knew the answers to these questions I could better measure them against the 40% of children who did not receive immunizations in our county that year or the women who had to wait all day for each visit in their obstetrical care so they went to work instead unable to lose a day's paid to receive their "free" care.

I hate to be the bearer of such tidings. I venture to guess that all of us glancing at this blog can do the math. The toughest part of the health care debate will be the rationing of health care. Patients, physicians, hospitals, third party payers all need to get use to that fact and move on to making choices.
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Monday, March 23, 2009

Cost? depends on who's counting

Much in the business of medicine is made of the "cost effectiveness" of a treatment. A recent example is Gardicil, the new vaccine that provides immunity against four strains of the HPV or human papilloma virus. Two strains are responsible for about 70 % of cervical cancer and the other are responsible for about 90 % of genital warts.

I have heard many arguments against the vaccine. Some of them have been from mothers who tell me that their daughters will never have sex until they are wed. To them I simply ask if they can be that sure about their future son-in-law. A few of the arguments come from physicians who say that the number of cases of cervical cancer that will be prevented is not that great while the cost of the vaccine is tremendous. To those physicians, who I might add, are not gynecologist, I reply they must not be aware of all the time and money spent on the precancerous problems. Preventing even the agony and the fear that patients experience after being told that they have a virus that potentially could cause cancer seems worth the price.

Today I saw a 34 year old with cervical cancer. I also saw a 17 year old with genital warts. I can't help but believe that both of these could be prevented by proper education, safer sexual practices, and in the case of the 17 year old possibly by Gardicil.

One treatment that receives a great deal of advertising dollars are the medications for male erectile dysfunction. I have never heard any cost effectiveness discussions where these medications are concerned. Also much has been made of the safety of these medications as many of the patients who need them also have heart disease.

Conclusion: It is easy to see that the cost depends on who is doing the counting.
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Wednesday, March 18, 2009

Real time

Most of the posts in this blog have to do with things that have happened in the past. At 3:06 am or zero three hundred hours on this shift as an OB hospitalist, I am posting in real time. I can't sleep even though things are quiet at the moment because the housekeeping crew has decided tonight is the night that they will wax the floors in the on call area. I wonder if this happens on the same day every month? Maybe I can negotiate that day out of my contract.

This is a new phase in my career. I am going to be working as a hospitalist nine to twelve days a month. So far so good. There are several potential disasters but all is quiet. It is like being a resident again with no staff to back me up. I am also the staff physician for the resident clinic. I have done deliveries, staffed residents on their deliveries, taken care of many mundane health problem, seen one extremely interesting case unlike anything I have ever seen before, and the only problem is this noise induced insomnia. Well, that and I am still a bit nervous about what might happen.
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Friday, March 13, 2009

It's the truth

This story should come under a title like: How do you make this stuff up? The truth is I couldn't if I tried.

Phone call with the nurse, "I need to come in for some blood tests. I have been dieting and exercising and I just can't lose any weight." The nurse said there were sniffs and she felt the patient was about to cry.

I called the patient back. "What kind of blood work do you think you need? What kind of symptoms are you having," I ask.

"Well, I am having trouble with my hormones. I think they are out of balance because I can't loose weight, " my patient replies.

Trying harder to figure this out I continue, "Are your menstrual periods regular? Are you having any hot flashes or night sweats?"

"No," my patient continues slowly. "The worst thing is that I get dizzy when I eat cake and ice cream."

I am glad we were on the telephone.
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Thursday, February 12, 2009


Separated by about two hours on different continents two of the finest mind in history were born two hundred years ago today.

Abraham Lincoln (1809 - 1865) "Nearly all men can stand adversity, if you want to test a man's character give him power."

Charles Darwin (1809 - 1882 ) "It is not the strongest of the species that survives, nor the most intelligent, but the most responsive to change."
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Tuesday, February 10, 2009

Green eggs and surgery

With office surgery suddenly being the rage in my speciality, I have had to ask myself whether I will begin to do procedures currently done at an outpatient center in one of my exam rooms. Many reasons are cited by my colleagues for this change in practice. I believe I have heard most of them so here is the list:

"It is more convenient for the patient." (Some of these doctors practice in a fifteen story office building with basement garage parking. The surgery center is a single floor with a drive through for picking up the post operative patients.)

"Patients are more comfortable at their doctor's office where they are familiar with the staff." (But these doctors hire a company to come into their office one day per week to accomplish these procedures and when was the last time you were 'comfortable' in any doctor's office?)

"It will cost the patient less." (The co-payment if the patient has insurance is the same. The surgeon charges the same. The people who own the traveling surgery center bill also.)

Last but certainly not least is the one true reason that I suspect physicians are now doing office surgery: "I am making three times as much money doing the same procedure." For some reason, probably that insurance companies have not caught up to the billing procedures, the reimbursement for an in-office procedure is much higher. About three times as much in fact as the reimbursement for the same procedure in a surgery center.

Yes, endometrial ablations are being done in doctors offices to lessen or stop menstrual periods so that the surgeon can receive as much as three times what they could for doing the same procedure at an outpatient surgery center.

I had this exchange with a company representative for one of devices used:

LDM: "Well, I don't think I am ready to do these procedures in the office. What if I wanted to try your product at the surgery center?

Rep: "No problem! I have the equipment in the trunk of my car. Here's my card. Just call me and I will bring it over."

Thinking about this sparked the following in my mind:

The rep, let's call him Sam, is ready to help

"Where would you, could you do this?" I hear him yelp.

"It is all about patient safety can't you see.

"I took that oath saying primum non nocere*"

"But everyone is doing it this way," cries Sam with glee.

"That's what I told my mother but still she never let me."

Would I, could I do surgery anywhere?

Only if patient safety is optimal there!

*Latin for "first do no harm" in the Hippocratic oath
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