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.
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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.
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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.
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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