Friday, December 31, 2010

The next moment

Looking in amazement at scores of New Year's resolutions, I realize that each moment of life is a chance to resolve to do better. Why do we wait until the calender rolls over to a new year? Why not constantly resolve to be kinder, fitter, smarter on a moment by moment basis?

With that in mind, I am going to be blogging from a new place in 2011. I am no longer "the local MD." I am a hospitalist. For the most part, I take care of those patients who have no physician. These patients have fallen through the cracks, usually of society first and the health care system second. Many are homeless, several are addicted to one substance or another, some are in this country illegally.

So, a new blog, possibly a new address, and yes, it is about to be a new year but where medicine, and life really, are concerned, I believe the goal is always the same: To do better. I tell my residents it is why we call it "practicing medicine." We may be perfect for a moment but in the next there is a new problem and a new challenge.

To the challenge of 01/01/11 00:01.
The next momentSocialTwist Tell-a-Friend

Tuesday, November 2, 2010

Sports and politics

I dressed in black this morning. At first I thought this was in mourning for my favorite baseball team, beaten in the World Series last night by a superior team. Then I realized it is election day. Oh, don't get me wrong. I have waited for this day for months. I cast my ballot weeks ago when early voting opened. I can't wait for all the yard signs to disappear and the negative ads to be gone from television and radio. Yet, in a moment of reality this morning, I realize that, just like the baseball game last night, this election cycle is another lost opportunity.

Going back to baseball, I liked the San Francisco Giants. I rooted for them against Atlanta and the Philles. They were the National League team I wanted to see in the World Series. I was surprised at myself when I began to feel something akin to hate in game 1. However, I think I can like them again, those young, quirky pitchers, that awesome catcher, who I don't think shaves every day, and a bunch of ol' guys who already have World Series rings from by gone eras on other teams. As I pulled on my black shirt, I realized they are just like my team in that they had hope and heart and they wanted to win. Really it was just the bounce of a ball back in San Francisco that gave them the momentum to do just that.

The change, the anger, rage really, that is sweeping this country is much different from fan excitement in sports. I have listened carefully to Mr. Boehner, who in all likelihood will be the next speaker of the House, for the past two years. He has been on a mission to discredit everything the current administration has tried to do. It is clear that Mr. Boehner cares about one thing - winning. If gridlocking Congress will accomplish that goal, then by all means, he and his colleagues were happy to do it.

Just as my Rangers made some errors, the other side carries some responsibility for their plight at the end of this day. From where I sit as the local MD, government has done little to help any of us through this quagmire that is the healthcare system. Yet, I am hear to tell you that our emergency rooms cannot continue to be the front line for care for what are ever increasing scores of uninsured people. It is an impossible task and it is also bad business and bad medicine.
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Saturday, October 30, 2010


I am pretty sure what ever you choose to call my generation, officially known as the "baby boomers," the "me generation" would be a better fit. I see this everywhere. Many of us drive big, gas guzzling cars, live in homes with enough square footage to graze cattle, and believe that the current government is trying to take all of this away from us by taxing us to death. So, this election cycle, I have chosen to sit it out so to speak.

Oh, I voted. Yes, I was at the polls the first week of early voting with my choices for the least worst candidates in many cases and in some, those candidates who I think will preform rather well. I have "Had Enough" and in my state that pretty much means I have had enough of the Me generation politicians who have been in power since I was in college. In my opinion our current governor has used his near decade in office to ruin our public schools, get almost everyone their own personal handgun, and make billions for his friends. Again, mostly this has happened because my generation was too busy making money to worry about where the state, country, or world was headed.

Back to my participation in this election. I put my yard signs out months ago, which only served to alienate me further from my neighbors. Oh yes, and I have a sticker on my car. I know this is risky, since many of the supporters of my candidate's opponent carry concealed weapons. I am just careful not to cut anyone off on my drive to work. I have been lucky so far. If my candidate does happen to win, I will pull that sticker off the day after the election.

As I said before I voted, but I did not remind my friends to vote. They are all voting for the other guy. I know this because we have rather in depth conversations about what might change the current course of our state, this country and especially our profession.

I still believe the health care plan is a start. I am well aware of the fact that medical insurance has increased by 10% this year. Remember, I am self employed and I buy my own. I will continue to drive my old car, which gets better than thirty miles to a gallon. I could have a new hybrid for what I paid in medical insurance and health care costs this year for myself and my family. The truth is medical care costs money and no one took one the biggest cost which are the insurance companies themselves into consideration in constructing the latest legislation. Why, the politicians needed the financial support of the insurance companies to get re-elected. Their CEOs and the CEO of the hospital where I work will still make at least 7 figures. They are part of the "me generation" too.

Where is this going? To solve these very real problems, someone will have to give up something. Honestly, I don't think it will be the "me generation" and I am afraid we have not raised our children and grandchildren to do this either. I think those who have immigrated here will likely be the ones willing to work hard for less and find ways to make change happen.
ChangeSocialTwist Tell-a-Friend

Thursday, September 23, 2010

As you shop for health insurance

In honor of the new health care policy beginning to take effect, I thought I would write a few lines to help those who may now find themselves in the market to purchase health insurance.

One of the first things you will learn is they charge by the pound. After your age, the next questions ask will be height and weight. The skinner you are, up to a point, the cheaper your insurance will be if all other items are equal. It pays to get and stay in shape, not only for your health but also for your pocket book.

If you use tobacco in any form, that is going to cost you too. You will be paying for this pleasure not just in the form of taxes on nicotine containing products, but your health insurance premiums will take a definite jump. Most companies require that you be tobacco free for two years to get a savings.

If you are under the age of nineteen, insurance companies can no longer deny you coverage if you have a pre-existing condition. What the insurance company can do is charge you a higher premium for coverage. That seems to be a recurrening theme: Increasing insurance premiums.

Under the new law, in case you haven't figured it out, by the year 2014 you will be compelled to purchase insurance if you cannot get it through your job or a social service agency (Medicare or Medicaid). However, when you purchase an individual policy it is going to cost you a lot more money than it would have previously. The average premiums will take a 20 to 40 percent jump. This is to cover the cost of manditory preventative care.

Who are the big winners in the new health care policy? I believe it is obvious. The industry with the biggest lobby in Washington and also probably your state capitol: Insurance companies.
As you shop for health insuranceSocialTwist Tell-a-Friend

Tuesday, August 31, 2010

Take the money and run

I called my health insurance carrier because I received a letter stating I was eligible to continue my health care coverage on an individual policy when my COBRA terminates in 2 months. It was mailed to my home address in Great Big State. With hope I called to initiate this conversion. After giving my name, social security number, and home address, I was told "you are not eligible."

"Well, then why does the letter say that I am eligible?" I replied.

"I don't know but you live in Big State. Any one who lives there is not eligible." said the voice on the other end of the line.

"Well your company mailed me this letter, to my home address in Big State. Did someone at your company think I did not live in Big State, I mean, I have been receiving bills and making payments from this address for the last 16 months?" I asked.

"I don't know about that but you are not eligible, I don't care what the letter you have says."

Who do I believe? The person who mailed the letter or the one on the telephone. I can tell you this, after searching for health insurance for over a year, there is not an honest person out there associated with an insurance company. The insurance industry holds are the cards and the Affortable Health Care Act dealt them a sweet hand. While health care is now becoming a requirement, I am not sure it is something the middle class will be able to afford.

Until this country is ready to do something about the insurance industry who has the largest lobby in both Washington DC and your local state house, they will continue to take our money and work hard not to pay for care.
Take the money and runSocialTwist Tell-a-Friend

Monday, August 23, 2010

Changing the world

Since it is Monday and the beginning of a new school year for many, I am thinking about the impact each of us has on the world. When I was younger, middle school and high school, my greatest desire was to make some world changing discovery. A cure for a deadly disease or an invention to ease human suffering was my goal.

With time and age, by about my second year of college, I realized these types of discoveries where a combination of brilliance and luck. Since I possessed neither in large quantities, I settled down to the slow, grinding task of preparing myself for medical school. In another couple of years, I realized that some combination of brilliance and luck were required for medical school admission also. Since I was short on the first, I would have to say it was the second of those two commodities which landed me in that now Well-Known Medical College of the south.

Getting back to change, it seems it comes in one of two forms. Change is either slow and insidious, something we are not able to appreciate in our life time. A physical example of this is the Grand Canyon. Or change is cataclysmic, the death of the dinosaurs (and many other forms of life) in a short span of time.

In the last 18 months, I have learned I am not going to have any type of meteoric change on the health care system, even in Major Metropolitan City. Hopefully, however, I am making some type of difference in the landscape, at least where the lives of my patients and colleagues are concerned.
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Wednesday, August 18, 2010

American medical care

Two months ago I saw a woman who was employed and has insurance, both medical and disability through her employer. I am not implying I never see patients like this any more but this woman was not really ill enough to be in the hospital. She and her husband moved to a community south of the Metropolis 6 months ago from another state. For reasons I will not go into her that community does not have women's services at their hospital.

She woke up on a Saturday morning with some mild pain which increased over the day. Having no physician to call, she went to the local emergency room. With no gynecologist to refer to, the ER physician got out his protocol book and began ordering tests. Pregnancy test was negative, white blood count was normal, ag. ain she really was not sick, but the next step was a sonogram.

When the sonogram was done by the technician, who was called in from home, she informed the ER physician that the radiologist would read it on Monday. The sonogram did, however, show something abnormal in the region of the right ovary. Hearing this the ER physician called the ER physician at my hospital. The result was the transfer of this woman, by ambulance, 45 miles to the hospital where I was on-call. No one told me about the patient until she arrived in the emergency room at my hospital 5 hours later. By this time it is 1 AM on Sunday morning.

Seeing the patient, reviewing her laboratory values and her sonogram, I explained to her that she had a hemorrhagic corpus luteum cyst or a blood clot on her ovary from ovulation, which had grown slightly larger than normal, probably causing the pain she had the day before but had now resolved. Her blood counts had been repeated by the ER doctor at my hospital. He needed to have something to do and bill for, right. These tests were all stable and now she was pain free.

Her husband was there. He had followed the ambulance to be with her. Following my exam and review of all that had been done, both were relieved to find out it was nothing serious. They packed up and went home. I gave her a follow up appointment in my post op clinic the next week to make sure she was feeling OK along with the names of several gynecologist who have practices in the area.

When I saw this woman 4 days later, she was doing great. She had an appointment in a couple of weeks with her new gynecologist AND she had four or five pages of paper work for me to fill out to get the ER visits and the ambulance ride paid for. I did my best.

And why am I bringing this story up now. Well, at the time I thought about how pointless all this was. Her pain resolved with a little bit of time and not much else but she got several thousand dollars worth of tests. I am now really irritated because I am still filling out paper work for the expensive items: sonogram and ambulance ride while I have little hope of being paid for my part in her care.
American medical careSocialTwist Tell-a-Friend

Tuesday, August 17, 2010


As I have alluded to before, most physicians do not practice medicine because we love people and hate money. After endless years of training, we spend countless hours working for the best possible outcomes for our patients because we crave approval. First we sought the approval of our parents, then our teachers, and now it is the approval of our patients. "Thank you!" sincerely spoken goes along way with most of us. A note or a card will likely be kept in a special place for years.

Perhaps you can imagine how devastating it is to have a patient who is dissatisfied. Three days ago I took a young woman to surgery after she had a Cesarean section at another hospital. On arrival to our emergency room she was hemorrhaging internally as well as vaginally and also out of her abdominal skin incision. Only her first baby, I was afraid I would have to do a hysterectomy to save her life.

Now that we are three days out from this crisis and the patient is getting better, with the aid of surgery, blood transfusions, and IV antibiotics, I am more optimistic. And, I was hoping for a grateful patient. Alas, she is tired, sore, and angry. Some of this is to be expected. The father of the baby is miles away, driving his truck. Her family consists of an 18 year old male cousin, who tells me he needs to learn about babies because his girlfriend is pregnant. He has been sleeping in her room because the hospital requires a responsible party be present to care for the baby.

Continuing to do the best that I can to provide good medical care, I am reminding myself that healing of my patient is reward enough.
RewardSocialTwist Tell-a-Friend

Saturday, August 7, 2010

"I can't...."

My mother use to say, "I can't never could do anything." She was correct. I hate those words. I cringe when they come out of my children's mouths. You will see from this post that I am very adverse to speaking them myself and I don't even like the thought to rattle around in my own head. Lately I seem to hear "I can't" everywhere.

This morning "I can't walk down the hall!" came out of the mouth of a young patient with a wound infection. I do have some sympathy for this woman. She has a chronic disease and she has had a difficult pregnancy. Three difficult pregnancies to be exact. Yet, she refuses to do almost anything to help herself and I am beginning to feel that she will never be well enough to go home. She needs to be up moving to prevent blood clots and pneumonia.

"I can't never could do anything" is connected to my comments about entitlement programs and how they create entitled people. The unemployment rate is very high but it seems most of my clientele are trying not to work. We are in a state where it seems rather simple to qualify for Medicaid coverage, yet no one wants to make the effort to walk 2 blocks and turn in the paper work.

There are two clinics with in three blocks which will provide services for Medicaid recipients, but you have to have a photo ID and a Medicaid card. (The photo ID is because several individuals have been caught using the same card.) I realize this all takes time and a small amount of money for bus fare.

"I can't..." are not words heard in conjunction with "get my nails done" or "pay the cell phone bill."
"I can't...."SocialTwist Tell-a-Friend

Friday, August 6, 2010

Something new

Little surprises me. I was not surprised when I walked down the hallway to a patient's room and three police were standing in the hall way. I was not surprised when I heard a patient screaming and protesting his inocence. I was not surprised when the nurse told me this particular patient was caught going into other patient's rooms uninvited and stealing money and belongings.

I was surprised when police reported they had searched the patient-suspect and found $150 in his colostomy bag. Any of you who have been patients know there are no pockets in those gowns. I guess this guy thought he had a place where no one would look. Fortunately, the police were smarted than he thought.
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Tuesday, August 3, 2010

"You know it is a bad day when...

I believed it would be a good day. It was certainly too hot to do anything outside. With temperatures soaring into the triple digits, the rates of preterm labor soared also. Not to mention the rates of unassigned term patients who made it into my hospital in labor. So it was busy when I arrived. My feet were not off the ambulance dock before another five patients were added to the labor board.

The first was from an outlying community. No prenatal care. The baby's head measured thirty-six weeks and his femurs (leg bones) measured twenty-five. I only had a few minutes to contemplate the cause because she was in active labor, completely dilated and a double footling breech. In doing an emergency C-section we found a baby with almost no lung tissue who died 2 hours after birth. Maybe that is how I was suppose to know the flavor of the day. I was only 2 hours into my twenty-four hour shift.

The other deliveries were more routine. Two couples who were probably actually married to each other. Neither spoke much English but both had their emergency Medicaid paper work. Perhaps if I could learn more Spanish I could open a clinic for these people. We could swap outpatient services for prenatal care.

In this scenario, my grass would be cut, my house cleaned, and I would have a good solid roof over my head. The government actually pays for the delivery. This would all go well until all the John Kyl supporters figure out how to take these undocumented workers children's citizenship away. Then none of us will have our grass cut, our houses cleaned, or a stable roof over our heads. (And no, I did not see Senator Kyl making this statement on TV. I simply read about it the next day in the newspaper.)

One twenty year old I was delivering had three other children in the waiting room. Her mother had the eleven month old at home. A bright spot in the afternoon was the woman who begged us to transfer her to the county hospital. The ambulance would not take her there because it was 15 minutes further. Her car wouldn't start so her mother could not drive her. But she was only in early labor and she knew she would get her tubal at the county hospital because she had signed the paper work well in advance. This was to be her fourth C-section.

As the labor rooms emptied of deliveries and the day slowed, the emergency room got busy for me. I saw a woman miscarrying. No one, not she, her husband, her brother-in-law, or their three year old son, spoke English. This is less of a problem for me this year than last. Maybe I am learning some Spanish. I also am on a first name basis with most of the translators. I always use the translators for the surgery consent forms.

Three more admissions from the ER and I know who is having the worst day of their lives. It is not me. Not by a long shot. It is now 3 AM. In trauma room one, a family is surrounding the stretcher with a body on a ventilator. They are being told this 18 year old boy, their son and brother, will not survive. He stole a car. He was chased and he crashed. He is now likely brain dead. Oh, it will take another twenty-four hours for this to play out. With more neurological testing, organ donation, and the like. As I stare into the room from where I am writing admission orders for yet another gynecology patient, I feel a bit of their pain. Any "bad" in the rest of my day pale in comparison.
"You know it is a bad day when...SocialTwist Tell-a-Friend

Saturday, July 31, 2010

Summer resolution

July is leaving and I am exhausted. I don't know whether it is the heat, the new interns, working an extra day and a half this month, or the combination of these things. My computer is down just as I am getting a new lecture together. I have continuing medical education to finish. And oh, it has been 7 months since my last vacation. Since I still consider this job a vacation from my previous one, that really doesn't seem to be the problem. Anyway, it is obvious I have had trouble getting motivated to write anything here.

There are several issues I would like to address. One is how entitlement (Medicare and Medicaid) programs have created a group of entitled people. Heck, all Americans feel entitled or at least most of us think our health care should be paid for by someone else. Another issue is how the big business of medicine can control access to hospital services in a community. It happens with not for profits just as it does with the big for profit hospitals. A third issue is all the maneuvering to make bigger profits under the new health care laws. For years I have wondered how much better health care in this country would be if doctors (nurses, pharmacists, etc) just thought about the best way to take care of a patient. This is why I am so attracted to a single payer system.

I also have a bunch of stories. People who have touched me as I have gone through the past 19 months. These families are trying to do the best they can with what they have. In case no one else has noticed the economy is still pretty crummy. Most of the people I see who are trying to deal with it are under employed. They are working but not up to the level of their skill. A lot was said about education this week and I hope those in my kids' generation were paying attention.

So, on to August. I am going to walk, jog whatever I can stand in the heat that is. The heat will be here until October and just like practicing medicine in a changing enviroment it is something I to which I can adapt. Here is to a better job of getting words on the computer screen in August.
Summer resolutionSocialTwist Tell-a-Friend

Wednesday, July 7, 2010

Needed: New technology

Back in the late '60s, when I was in middle school, I could be found in front of the TV almost every Friday night watching William Shatner and Lenord Nimoy cruise the galaxies. I could tell you warp speed in light years per second or some such terminology because I had calculated it. Yes, I wanted to travel in outer space. To go where no person had gone before. Tonight, however, I am simply wishing for a bit for the Star Trek technology we can put to good use here on planet Earth.

Over the years, as I have practiced medicine, it occurred to me that what DeForrest Kelley was doing with that hand held scanning device he held over his patients was reading the patient's chip. The patients in the future will be so lucky, as will their physicians, because in the future patients will have their entire medical record on a micro chip. Just like dogs and cats have now have a micro chip to help find their owners.

This space age technology is necessary because many patients cannot remember any pertinent facts about their care. And the EMR (electronic medical record) with universal access is too far off. Take the patient I have right now in labor and delivery. She is 19. She told me she had a miscarriage in December 2009. December, the month of a major holiday. I figured she could remember. When I was able to find a record of this, the miscarriage was in October.

Even worse, this patient tells me her due date is August 6, 2010. You can see why the miscarriage was important. Those two facts do not fit together. But her baby only measures a little over 2 pounds. She says this due date is from a sonogram done when she was four months pregnant but she cannot remember the month in which this sonogram was done. Her mother says it was April. She had a second sonogram last month but the mother and daughter argued about where last month was May or June. I am tired but I am pretty sure it is now July and last month was June.

You can see why I need records. The girl is hypertensive, her baby is small, and she is somewhere between 28 and 35 weeks. If she is indeed thirty five weeks, with her hypertension and the growth restriction of this baby delivery is the appropriate treatment. If she is only 28 weeks, then the baby is so premature, waiting is a safer approach. This all began after 5 pm so the clinic where these sonograms were done is closed.

Do you see why we need a medical chip. I know, the government will use it to control use. That is what the older patients tell me about electronic medical records. Well, if you can't control your self, and you are pregnant, the a little government control may be in order, at least if you want me to stay up all night and worry about your baby.
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Monday, July 5, 2010

The full circle

Almost anyone who knows me knows that I went to college to teach English and coach tennis. Those were the two areas of high school where I was moderately successful. I say this because in a high school class of 720 students there are some very high achievers. Fifteen of us grew up to be physicians. There is a least one federal court judge, several lower level judges, and about a dozen attorneys. Many of my classmates are teachers at various levels. In fact 82% of us finished at least 4 years of college and earned a degree. This is from a public high school in the western part of the state. College was expected and most of us found a way to go.

I did not begin my college career believing I had what it takes to get into, let alone finish medical school, so I just thought I would teach. Teaching looked like a good life and I had plenty of role models after 12 years of elementary through high school education. Yet, when I switched majors, earned a degree in biology with a minor in chemistry, applied to medical school and was rejected, I was shocked at what a difficult job teaching high school chemistry happened to be.

For just over 9 months, I read and re-read the chemistry text books. I organized class notes, prepared lectures, made pre-lab quizzes, and graded papers. Even more challenging, I dealt with the behavior of students who were 4 to 6 years younger than myself. "How did the world go downhill in such a short period of time," I often wondered. When I was a student we were never like these students. Or were we? I do vaguely remember the reason I had such a keen interest in college chemistry was because I learned none in high school. Was it me or was it the teacher?

At any rate, just before Christmas of that fateful year as a high school chemistry teacher, when I learned I had been accepted in to medical school, I wept. I cried not for the fact that on my second try I had been admitted into this elite institution to study for a different profession. I cried because the first 4 and one half months of teaching had exhausted me. Now realizing I would not have to continue teaching high school chemistry, I thought I could make it through the rest of the school year.

With this background, you can imagine my chagrin when I receive the residency program's teaching award for this past year. While I was overwhelmed at the thought that twenty residents voted to give this award to me, I was truly overcome when I received a standing ovation from the guests at the graduation dinner. The icing on the cake of this honor was having one of the just graduated residents tell me, "You were just the right amount of hands on and let me do it myself. I felt like I was doing it my way but you know what I was doing and you were close enough that I could call you if I got into trouble."

The past year, removed some thirty-three years from my first year teaching experience, has been an incredible joy. What I have gained from working with and teaching these young physicians as they move toward their goal of becoming obstetrician-gynecologists has more than compensated for anything I lost leaving my private practice. I feel as if I have come the full circle, arriving at a place much like the one where I began. And I realize that having traveled here, the journey has made me appreciate it so much more.
The full circleSocialTwist Tell-a-Friend

Friday, July 2, 2010

A story

Yesterday, while I was wondering around the grocery store in a post call stupor, my pager went off. Every patient I had seen on morning rounds was stable but there were a new group of residents on duty, so I quickly dialed an unfamiliar number.

"Pathology, Erin speaking," said the chipper voice at the other end. When I identified myself saying I had been paged, she replied, "Yes, Dr. P wants to speak with you."

A very formal Dr. P now on the other end of the line says, "Do you remember a woman you saw in the emergency room on the 28th, M.C.?"

I could remember no such person. "Did she have a D and C or an ectopic?" I asked.

"I can't tell," Dr. P answered. "All I have on the pathology slip is products of conception."

"I know I did NOT admit her to the hospital. What night was this again?" I have been on call 3 of the last seven days. Actually, it has been 4 of the last nine so everything has run together. The name is Hispanic and one night the theme was 'I am very sick and I do not speak English.'

We determined she was in the emergency room on the 28th but never seen by me or one of the OB-Gyn residents. The patient was given my name to follow up but I had yet to have a call from her. Not necessarily a bad thing since it had only been three days but I had to get to a computer and see what phone numbers I could find for this lady who might have a molar pregnancy.

A molar pregnancy is where no fetus develops and only placental tissue grows. This tissue can even spread to other organs such as the lungs and the brain. Patients can get very sick, bleed a great deal, even die if they don't receive appropriate treatment including at times chemotherapy.

Later, at home, I get on my computer and find the patient information. Reading through the emergency physician's notes I see where he saw her and referred her to me. Looking at her patient information I see that she does not have a social security number. She is an undocumented alien.

There is a home number, a work number, and a husband's name and work number. I call the home number first. A man answers. Identifying myself I ask to speak to the patient. He hangs up. Not, "Sorry, you have the wrong number." Just click.

When I can the work number and ask for the woman, I am told I can only leave a message, which I do. Finally calling the husband's work number I speak to him. He understands English but tells me he is not allowed to talk at work and hangs up.

Sure enough, the woman leaves a message on my voice mail from the cell phone of a co-worker who speaks English. I am able to call back and talk with her and make arrangements for the woman to be seen. Is this a HIPAA (Health Insurance Portability and Accountability Act) violation? I doubt it but I worry a bit that I have divulged all this information over the phone to a total stranger.

I am also very upset that the emergency room seems to take no responsibility for the follow up. I understand the task of follow up is over whelming. Even in private practice, where patient want their test results and call daily until the results return, people fall through the cracks. Here I feel as if I am sitting on something bigger than the Grand Canyon with very few resources.

I don't know what the answers are to health care access or to people who are in this country illegally. I do know where these two issues intersect it is extremely difficult to get anything done.
A storySocialTwist Tell-a-Friend

Thursday, July 1, 2010

"Happy new year!"

These were the words of the recovery room nurse as I put the finishing touches on orders for a post operative patient at 00:05 or 5 minutes past midnight this morning. Looking at the clock, I sighed, "Well, it is July 1st." Her come back was "Happy new year!"

Yes, it is the first day of the post graduate training year. There are brand new interns, who are also known as first years, signifying their PGY 1 or post graduate training year 1 status. A quote from my past when the PGY 1 designation was just beginning is "They can call us anything they want, we are still working our butts off." This is true. I just did not know it would get worse my second year. I also did not realize the terror I some times felt when I was on call late at night was nothing like the terror I some times feel now when I realize I am truly IT. Yes, I have colleagues I can consult but the responsibility is all mine.

So, at 07:00 there they were in front of the board, new interns. The old interns were now PGY 2s or second years. They sounded as if they had learned a great deal in the last 365 days. The computer was down for an extended period of time and the electronic medical record was a mess as a result but we muddled through the change of shift and as I left an intern was recording the first set of orders which would be signed with a MD following her name.
"Happy new year!"SocialTwist Tell-a-Friend

Saturday, June 26, 2010

I am here because...

It is 6 AM on Saturday morning. My feet feel like two stumps as I stand on them in the operating room. In this fog of fatigue I am wondering why I am here.

Literally, I am here because this woman is doing her best to bleed to death. By her best, I mean she has now lost close to two liters of blood. One and one half of those liters could still be circulating in her blood stream if she had listened to me ten hours ago. She presented to the emergency room holding her 14 week fetus that she passed at home around supper time yesterday. I was in the operating room and the intern on call retrieved a large piece of placenta from her cervix and managed to slow the bleeding. Medication decreased the flow of blood to a trickle.

As I arrived in her ER cubicle, she declared, "I am not having a D and C!" She proceeded to tell me that she had retained placenta with the baby before last and she was "treated very badly." She adamantly refused to have a surgical procedure to suction out the remaining placental tissue which had not passed. I sympathized and let her talk on. "I don't want blood because of AIDS. If you put me to sleep, you will sterilize me. You think I am a bad mother because I don't have custody of my six children." This last statement she volunteered when I ask her who was caring for the baby born less than a year ago.

While I have gotten use to people not taking my advice, this patient was particularly difficult to care for. Over the course of the next 8 hours I came to realize why she did not have custody of any of her living children and why she was afraid of sterilization. I am sure this option has been offered to her multiple times. I could never reason with her because I could not get two complete sentences out of my mouth before she began railing at me. We finally went to the operating room when she continued to bleed despite multiple medications and a repeat sonogram, done the way she insisted, which showed retained placental tissue.

She is now stable in the recovery room. She still has her uterus. She will be pregnant again, probably within six
months since her last child is less than a year old.

So I am here because....

Well, my answer this morning is, "I couldn't make a living as an investment banker."

I also know I wouldn't be any good at the law or half a dozen other jobs which would give me this kind of perspective. People fascinate me and I often feel privileged to have such a intimate view of their lives. I sound jaded this morning because simply put, I am tired. A couple of days off will cure this and I will be back for more.
I am here because...SocialTwist Tell-a-Friend

Friday, June 18, 2010

On to the next step

It is graduation day. That's right. All of the fourth year residents have finished their duties as resident physicians. There will be a dinner tonight. Tomorrow some of them will actually continue studying for their written board exams which will be given at the end of the month. Most will take a break of a month or two to move, getting settled before beginning jobs practicing medicine.

In the future there will be continuing education, the dreaded oral board exam in a couple of years, and recertification. Hopefully they will read regularly and continue to learn but the formal process of teaching is over. From here on out their patients will teach them more than they ever thought they would know. It is important that we remember that both as physicians and as patients. Education is endless, especially in medicine. This is why it is called practicing. As physicians, we will never know it all.
On to the next stepSocialTwist Tell-a-Friend

Thursday, June 10, 2010


If obtaining healthcare is difficult for America's citizens, imagine how it must be for those who are here from another country. Living in a border state, I knew I would be seeing patients who are in this country illegally. What I did not realize one year ago, is how many of these patients I would see, how sick most of them are, and the fact that their diversity is no different than that of other populations. Here are some examples:

Recently I delivered a premature infant to a couple who have been as attentive to this baby and their other two children as any parents I have ever seen. The baby is a little girl. Her brothers are 8 and 14 years old. Both parents were employed at the time labor began, the mom with a cleaning service, the dad in construction. The father of the baby apologizes every time he sees me that he is not present more but there are two days during the week where the pediatricians tell me he is always there with his family. Both of the brothers are clean, bright, and polite to everyone. Always well behaved, they seem to do as they are told and wait patiently for their parents to speak with the physicians.

A few nights ago I admitted a lady who is about my age. Her adult daughter was with her to translate. This woman does not speak any English but through the daughter I find out that she has been in two other hospitals in our city. I am sure one reason she has not received follow up for her medical condition is fear of deportation. I am also sure the reason she does not go back to her own country for treatment is the fact that she may not be able to re-enter this one. Her family is here and they are natural born citizens.

A 17 year old I have been seeing for two months delivered her baby a few days ago. He has a heart problem. The baby will need specialized treatment for sometime. This young mother is a candidate for Medicaid, as is the baby but it remains to be seen if they will get it. I have helped her fill out all the required paper work - twice. She has had minimal schooling. She is a citizen. Her parents are not. The father of the baby, who is 20, seems to be her support system. He has money to spend but no steady job. This concerns me. She needs contraception. The baby is going to need a great deal of care.

This is the very tip of an iceberg. I do not know how the social workers do this work. My work at least is interspersed with the working poor, many of whom get social services such as Medicaid and WIC. There are also the women who left their midwives to get pain medication during labor, and patients just like the ones I use to see in private practice. These women have health insurance, jobs, and families. They are simply at the big hospital due to complications with their pregnany or problems with their baby.
AliensSocialTwist Tell-a-Friend

Friday, June 4, 2010

Holiday weekend

It was a holiday weekend but the aftermath maybe nothing to celebrate.

This was my thought as I spend an hour with a young woman who was only a couple of weeks into her college summer internship. She was from another city and had come to the emergency room with several symptoms of sexually transmitted diseases. The worst of these symptoms were the ulcerations surrounding her vulva or the opening to the vagina.

"He seemed like a really nice guy." Maybe, but he must have had herpes because this young woman, who had not previously been sexually active, surely has it now.

"But I didn't see anything like this on him." I sat and explained to her how he could have been someone who sheds the virus asymptomatically. Occasionally these people don't even know they have herpes. It is also true that early in the course of an outbreak, before the blisters appear, virus is shed but there is no visible sign of a herpes infection.

Then we talked about oral sex. I am always amazed at how many young people do not even consider this sex at all. This woman did not. Regardless of whether she considers 'oral sex' sex, I explained to her that she could contract herpes from his lips and he could get it from hers. I also had to explain that I have seen gonorrhea of the throat and syphilitic chancers (the lesion of primary syphilis) in the mouth. Recently pathologist have been reporting human papilloma virus or HPV in biopsies of polyps in the mouth and throat.

A short time later, I overheard one of the nurses taking about how paranoid her 18 year old son is about sexually transmitted diseases. This is good. I wish someone had made this young woman paranoid. If so, perhaps she would have at least insisted that a condom be part of the celebration.
Holiday weekendSocialTwist Tell-a-Friend

Tuesday, June 1, 2010

Family doctor

I have often wondered what families who do not contain a "medical person" do for medical care. I am not referring to diagnosis and treatment. Please don't misunderstand. Everyone in my family has a physician. I am talking about the persistence and the proper vocabulary to make the person who answers the phone at the doctor's office understand the importance of the problem and the fact that you expect attention before the end of the decade.

I am reminded of the time my father had a 103 degree fever on a Sunday afternoon. Elderly and with multiple medical problems, I am sure this was a situation, the severity of which even the newest answering service attendant would understand and page the physician. Yet, due to the slow response my father had received on previous occasions, he refused to believe he could even talk with the doctor on a Sunday afternoon.

In fact, my father did not call even me. One of my cousins happened to drop by my parents home and called me to apprise me of the situation. When my father told me, "Well you can't just call a doctor on Sunday afternoon!" I ask him how many times he had been present when my beeper when off on Sunday afternoon, at night, during dinner, or a dozen other times that might be inconvenient. "That's different," he said. "You deliver babies."

True. I do deliver babies but when I was in private practice I got calls about everything. Patients use to call me about their husband's chest pain and their mother's fractured hip. Most of the time I tried to answer those questions just like I do with my our family members, "Have you talked to the doctor taking care of this problem?"
Family doctorSocialTwist Tell-a-Friend

Thursday, May 27, 2010


The nurses named the baby "Jezebel." I hope her mom, even with her limited English will give her a name today. Yesterday, the mom, brought to the hospital by an ambulance, was too sick to name her. Growth restricted by her mother's hypertension, "Jezebel" only weighs 5 pounds even though she is full term. Her mother had been on medications for the high blood pressure but felt these medications were not working so she did not go back to the clinic for more. I am hoping in three days with my limited Spanish and the translator, I can help her understand.

Mom has many reasons to stay healthy. A single mother with two other children to feed, clothe, and get to school every day (one is elementary age, the other middle school), Jezebel's mom was working cleaning houses until she got sick with feet and hands too swollen to work and a terrible headache. I am just happy someone called the ambulance before a stroke or a seizure occurred. I also feel pretty good about the fact that Jezebel's blood gases and Apgar scores at birth were good. Now, I only have to worry about how to convince mom that her blood pressure is a problem even when she is not pregnant. How do I know? I appears she has the early signs of kidney disease probably secondary to her long standing, untreated high blood pressure.

I am remembering I live in that great land where we pay for care if you are in renal failure and need dialysis but we don't cover patients who are not pregnant with hypertension that could cause renal failure. At least not yet. I hope, as a country we are at least getting there.
JezebelSocialTwist Tell-a-Friend

Sunday, May 23, 2010


subspecialist - def. In medicine, someone who makes more money by doing less work.
SUBspecialistSocialTwist Tell-a-Friend

Monday, May 17, 2010

The babies

While most of my stories end with the birth of the baby, when I was in private practice, I always enjoyed seeing my patients' children grow. Because of this, I cannot resist visits to the neonatal intensive care unit (NICU) to see the babies. Occasionally one will celebrate a 1st birthday there. Usually the stint is much shorter. After graduating to intermediate care and "rooming in" with the parents over night to allow the parents to adjust to the machines such as the apnea and bradycardia monitor which checks heart rate and breathing, these kids will go home.

This morning, however, I am thinking about Megan. This is not her real name but she is a real baby. Born in early January, she weighed slightly more than a pound. She is now almost six pounds and her mother is now 18. Megan's mother rarely visits I am told. Megan is very fussy and the non-pediatrician that I am, I thought this was due to inattention. I ask to hold Megan and I noticed she gets quiet for a few seconds but then she is fussy again. The respiratory therapist explained the fussiness is due to air hunger. That is right, even with oxygen on, Megan struggles to breath. She is off the ventalator in an effort to get her stable enough to move to intermediate care.

For those of you out there who have had the opportunity to sit with someone afflicted with emphysema, air hunger is what makes these adults so restless. Every nerve connected to respiration is firing, pushing the muscle cells that control respiration to work harder and faster. When this doesn't work, more catecholamines are released, making other nerves and muscles twitch.

Perhaps you arrived at the conclusion of this story before I did. How is a mother who was 17 when this baby was born going to deal with these health problems in her daughter? This mother did not seek medical care when she was pregnant and she did not follow medical advice when she was in premature labor. Yes, social services is involved. And yes, there are days that my prayer is one of thanks that I do not have that job.
The babiesSocialTwist Tell-a-Friend

Sunday, May 16, 2010

Redefining "health care"

When I cease to be amazed, I will be dead.

Today I am sure of this. "Abortion foes capitalize on health care law" is the title of an article being carried this morning by the Associated Press. It does not surprise me that abortion opponents are using federal law to beef up their state provisions prohibiting abortions. This is something I could see coming from the outset of the debate as "pro-life" and "pro-choice" congressional leaders sparred during the health plan debates. What I did not see is the fact that private insurance companies will now regard "elective" abortion as beyond the scope of health care. In other words, "You want it. You pay for it." Which means the rich people will and the poor people, even those with jobs and health care coverage, will not likely be able to obtain safe, affordable abortions. There will be even more unwanted children. There will be even more young women in the emergency room with infections, bleeding, and uterine perforations. Some of them will even die.

I am not "pro-abortion" and I don't support abortion as a means of birth control. Yet, I cannot see how we as a nation can continue down the path we are on. A truth that was lost in the health care reform debates is this: The insurance companies are huge businesses with one goal in mind, making as much money as possible. If you don't believe that, look at the salaries, benefits, and bonuses their CEOs receive. Current health care legislation did almost nothing to restrict these companies abilities to make unconscionable profits. If fact, when I read articles such as the one today, I wonder if we didn't give these companies ways to increase their wealth at the expense of the very people we were trying to help.
Redefining "health care"SocialTwist Tell-a-Friend

Saturday, May 15, 2010


"I'm pregnant? I can't be pregnant! I mean I have had a period every month." Ducking her head to avoid my gaze, she thinks. "Yes, every, agh.." The next contraction takes hold and she has to breathe and then she is overwhelmed and tries to push.

"We have to get to labor and delivery'" I declare as the ER nurse calls report on her mobile phone. Unlocking the bed, I make sure the patient is completely covered before we start the journey that is about a city block of corridors and a short elevator ride. I have never understood why anyone, even a hospital architect would allow so much distance between the two departments.

We do make it to labor and delivery. The patient is thirty-two weeks pregnant. Labor stopping drugs, tocolytics, are used to get steroids, which aide in fetal lung maturity, on board along with antibiotics to protect the baby against infection. Her urine drug screen is positive for cocaine and marijuana and the baby delivers a day later despite our best efforts. She has a rough start in life, weighing just over three and a half pounds.

Even more challenging is the fact that this mother will leave the hospital with a three month contraceptive shot. She will not get any follow up care even though it is free and she willcontinue on the same behavior which got her here in the first place, unless and probably even instead of the fact that she may be put in jail for a short period of time. This mother has a parole officer and a 20 month old son. The 20 month old son is in foster care, taken away because of her drug habit. I suspect this baby will end up in foster care also.

I have already thought about this scenario too much. How does one change this pattern? Where will it all end, for this young woman and for her children?
SurpriseSocialTwist Tell-a-Friend

Tuesday, May 11, 2010

In my prefect world...

...children are not allowed out of their parent's sight until they are self supporting.

...low rise pants cause temporary sterility.

...all ovulating women, regardless of age, develop an aversion to drugs, alcohol, and tobacco. If impregnated, this will last until the off-spring's 18th birthday. in basic household finance, child psychology and development, and human nutrition are required for high school graduation.

...there is a fail safe birth control device which can be implanted at puberty, is safe, effective, and some how encourages abstinence until the individual is mentally, physicially and emotionally ready for parenthood.
In my prefect world...SocialTwist Tell-a-Friend

Monday, May 10, 2010

Early morning ramblings

It is 3:38 AM. I can't wait until 7:00 AM. I usually do not get so involved at watching the clock but I am having crazy thoughts. I think it was the drug addict I just saw. She was busy telling me her 18 month old was "just fine." This was after I had looked up her admission from his birth to see that she was using cocaine and marijuana the night he was born also.

I no longer ask why Child Protective Services doesn't do something about this mother. How can they do something about a population so large it would fill one of the suburbs. These women sell themselves to support their habit so there are usually from one to four sexually transmitted diseases to treat also. No one takes care of their children. And no one cares all this is going on. After a year, I understand why. It is too exhausting to deal with the drug addicts except when you must, which is usually when they are in labor. Two days ago we were able to arrange for a patient to go to a rehab institution that accepts Medicaid only to have the patient refuse and leave the hospital against medical advice. I suspect the baby will go to her mother who is responsible for raising her other three.

I am not saying this to be funny but this job is going to make me a Republican. There is no way the United States can support the drug habit of all these people. While I will never be a fundamentalist of any kind, I must admit that I am coming to believe in a kind of natural selection Armageddon. Why? When I look around me at 3 AM, I know there is no way this country can sustain herself with such a large population of marginalized individuals. I wish this were just a nightmare. Then all I would need to do would be just wake up.
Early morning ramblingsSocialTwist Tell-a-Friend

Sunday, May 9, 2010

Another day

Just as I am getting a cup of coffee and declaring, "What I like about this job? The fact I am never bored." In comes a patient obviously laboring, claiming it is her third baby and she is due. Her other two were born at Major Medical Center but she receives her care at Local County Hospital. Interestingly, Dad looks like he could be her father.

10 minutes later the baby is out. And she is just fine until I look at the hands. Next, the nurse checks the feet. They are webbed also. There is a cleft in the palate and a loud heart murmur. This is Apert syndrome, occurring in one out of 70,000 births, it is much more common when the father is older. This is the first case I have ever seen. Well, I said I was never bored.

Another daySocialTwist Tell-a-Friend

Saturday, May 8, 2010

The game

To be a doctor, you must get up really early. Yes, because you need to make rounds at the hospital before the patients are awake. That way they will not be able to ask you any questions, which will take up too much time and make you late for the office. Of course you must also get to the hospital before the nursing shift changes. Otherwise the new shift of nurses will be waking the patients for vital signs. Then both the patients and the nurses taking care of them for the day will be waiting for your.

Once you arrive at your office, it is important to stay one step ahead of the patients by ordering as many expensive and sophisticated tests as possible. This will not only impress your patients but if you can own or lease the machines that preform these tests, it will increase your revenue.

Also, be sure you employ plenty of physician extenders, nurse practitioners, physicians assistants, technicians, and the like. Those who can preform services that have CPT codes are the best. You can bill for these services as a source of additional income. These extenders are especially helpful when they can work in your office while you are not there. This being the case, you will generate revenue while you are away from the practice, thus helping the practice pay of itself while your office space would otherwise be idle.

Finally, get an electronic medical record with voice recognition software included. This way when you have spent 5 minutes with your new patient, you can say something like, "insert my usual review of systems" and a five page printout will result, making it possible for you to bill for a comprehensive evaluation where limited would be the case if you were taking the time to write out what you could remember discussing with the patient.

It is no secret that I played this game poorly. As frustrating as it may sometimes be, I enjoy tackling the patients questions, listening to their answers to mine, and trying to ferret out a diagnosis from the signs and symptoms as I pondered which tests might be useful and which were a waste of time (and money.) I also loved knowing the names of their kids, where they were going on vacation, and what books they would read when they got there.

After a year, it is now apparent to me why it takes me more than an 80 hour week to do what many of my colleagues consider a part time job. I hope I can always practice some type of medicine simply because I enjoy it.
The gameSocialTwist Tell-a-Friend

Thursday, May 6, 2010

Beginning the book

"If I wrote a memoir many would not believe me and a few people, who thought they recognized themselves would probably sue. If I wrote a book and called it fiction, most would say the stories were based on my own experiences. This later plan seems more safe some how, so that is what I will do...."

I am looking for a place to put all of the experiences, thoughts, ideas that I cannot but in this blog so my writing energies are elsewhere as I have found it is difficult to have a following and remain anonymous.
Beginning the bookSocialTwist Tell-a-Friend

Tuesday, May 4, 2010


Every so often, usually once a month or so, I think about looking for a new job. Sometimes I even go as far as searching Internet sites to see what is available. Once I went to look at a hospital, clinic, and the surrounding area. That was in the middle of the winter, a particularly difficult time, as I was spending even my days off indoors.

Last week was a particularly awful week in terms of outcomes. Cancer in a pregnant woman can be devastating, so I don't understand why I expect something different. I can still remember a post mortem C-section I did as a resident on a young woman with advanced cancer. One of the nurses who cared for this woman told me she got a card with a picture of the baby each year for several years. The woman's parents raised the child and had become so bonded with the hospital staff, they wanted to share the good which came from this tragedy.

There are many situations where those working in this hectic world of artificial light and air never see any good. We are left to wonder what keeps the sun coming up, the moon rising, the seasons changing. Thankfully it is spring.
SpringSocialTwist Tell-a-Friend

Friday, April 23, 2010

The quote of the day

"She is smart but.."

He didn't say anything else. I guess he realized how stupid this sounded. This is the FOB (father of the baby) talking. I am discussing how to spend the next three to four months in the hospital with an 18 year old mother to be. She has already lost one baby when she delivered prior to viability. This pregnancy is going to require a hospital stay and she has not yet graduated from high school.

These young parents are not typical of the ones I see. They have a laptop. She reads a novel every couple of days. I see no reason why she could not get her GED online. I did not ask him what he is doing in terms of work or school. He is here most days and they are from a town 70 miles away. Most women in this situation are here by themselves during the week, with husbands, parents, and even children visiting on the weekend.

I have great hope though. There is now talk on the unit, among the social workers, with the nurses about setting up study seasons for the GED exam. There may even be a nurse who gets her certification to proctor such exams. I would love for these young women to leave here with more than another mouth to feed.

A high school diploma, a GED, perhaps even a skill, might put them further along the path of being able to sustain themselves and their children without government assistance. A healthy baby, contraception, and a way to support themselves are worthy goals and we seem to be a few steps closer to providing all of these.
The quote of the daySocialTwist Tell-a-Friend

Friday, April 9, 2010

Role models

I am very tired today. No, I was not up all night and I have not been terribly busy today, so I find myself drawn to reflecting here. I have been at this new job almost 14 months now. I am less tired than I was in private practice. I have days where I have a great deal of energy - usually my days off.

I am, however, constantly bothered by thoughts that I am becoming lazy. This afternoon I gave a great deal of thought to taking a nap. I have worked hard not to sleep during the day. I am constantly thinking of ways to be more organized, to get some writing done. I have several projects, one of which is this blog, that I wish to keep up.

It is difficult to write about events after the fact. While I have a vivid recollection of what I saw and heard for days or weeks, the emotions surrounding these events are less intense the following day. It is that emotion which can propel my words across the page. I was incensed today when a general surgeon refused to see a patient with free air in her abdomen (a surgical emergency) until I, the gynecologist had seen the patient for her total vaginal prolapse which has been present for years. She is in surgery as I write this. Consulting me and insisting I see the patient preoperative was a way to buy time. Time for what, lunch? The only reasonable answer I could come up with when I ask myself this question would be time for this 75 year old woman to die.

Free air in the abdomen on an abdominal X-ray means that her bowel has ruptured. It could be from an ulcer or cancer but there is no way around the problem short of making an incision, finding the hole, fixing it, and treating the cause. That is a question any third year medical student on her surgery rotation can answer. Of course this woman is in poor health, she has multiple medical problems, including heart disease and diabetes, and her family is extremely dysfunctional. The scene in the emergency room was one straight out of ... well, it was probably straight out of "ER."

I certainly hope I played my role better than most of the doctors on "ER" or even most of the doctors in this major medical center. I guess today my true job is to be a role model, especially since I am easily the oldest physician seeing this patient. I delivered the general surgeon's kids, which maybe the biggest reason he was willing to listen to me and take this woman to surgery sooner rather than later. I hope my residents and his remember this woman when they are in practice at Elsewhere General in a few years.
Role modelsSocialTwist Tell-a-Friend

Thursday, April 1, 2010

If this is so funny

then why am I not laughing?

Yesterday I discovered the hospital where I practice is "monitoring" this blog. I am not sure what monitoring means and I have tried to stay anonymous but it makes me nervous all the same. My "mouth" often gets me in trouble and that could be the case with what finds it's way to this space.

However, I am stiill going to tell you about my day. Before noon I had delivered a woman who was all of 23 years old. She has been pregnant 7 times, three children and three abortions. Now this seventh baby is here, healthy, and she did not want to talk about birth control when I visited with her this morning. She was distracted by the two older kids her mother brought up to the hospital for her to watch waiting on this baby to be discharged. The oldest child is in school. And no, she did not have her tubes tied because of the federal law that requires a 30 day waiting period after the consent for sterilization is signed. She was only seen at Major Medical Center once during this pregnancy. This is a problem universal electronic medical records would solve.

Another patient I delivered was 13 years old. That is right. Her birthday was 2 weeks ago. Yes, she was 12 when she got pregnant. By whom? That was the first question I wanted to ask but I waited until she was comfortable with an epidural to ask about the father of the baby. By this point I had already seen her genital warts and lesions of secondary syphilis so it was not a shock when she told me she didn't know who was the father of the baby. Yes, I suspect a boyfriend of her mother's but I was unable to seperate the two of them long enough to ask. Child protective services will do that this afternoon.

Finally, the last patient I want to tell you about weighs over 400 pounds. She is 33 years old and not pregnant. She needs to go to the county hospital where they might be able to help her but she "don't want to!" There is nothing I can do for her. In addition to her pelvic pain, she has diabetes and hypertension. All can be controlled with medication, which it seems she does not take except when she is in the hospital. Long term psychotherapy and bariatric surgery would be good places to begin. Judging by her blood pressures in the emergency room she will probably have a stroke before she is forty.

As I said, it seems funnier to me now that I am off and just reflecting on the day.
If this is so funnySocialTwist Tell-a-Friend

Wednesday, March 31, 2010


It is difficult. I have often wondered what preachers do. Wondering aside, I know physicians are often intellectually dishonest. How so? To talk with us you would think we are the poorest, most maligned people on the planet. Health care reform is going to kill us.

Yes, medicine as we know it today will probably go away. I have to tell you that I don't believe that to be all bad. This is opinion you understand but the facts get distorted usually by the person reporting them.

Here is a fact I was confronted with yesterday. "Well, one of the reasons health care costs so much is we are practicing 'defensive medicine.'" Honestly, I am not. I try to see the patients, go through my list of differential diagnoses, order the appropriate tests to rule out all but one, and come up with a cause for and a solution to the problem. Often, I encounter other problems which have to be dealt with along the way but I don't believe I am doing tests defensively. My liability insurance, though expensive (remember I deliver babies and have 20 years of liability for each one), is half of what it was when I entered private practice 25 years ago thanks to tort reform.

When I entered private practice twenty five years ago, 9 months of obstetrical care, the delivery and six weeks of post partum care cost $850. Today, in the same zip code, most major carriers will pay over $2000, some go as high as $3000 (and if you don't have insurance you are paying over $3000 which is another reason physicians don't want everyone to have insurance). And physicians I know well are gaming the system by doing sonograms at almost every visit, charging $300 each. One of the reasons I left private practice had to do with our sonography practice and what I believe was unethical behavior. Again, this is my opinion, so don't get me sued for slander.

So why does health care cost so much today? Well, first off, there are all those uninsured people out there but that doesn't affect your visit to your local obstetrician. No, the local OB's office is filled with people to monitor your insurance, make sure you are covered, what level you are covered, and how much you will have to pay for that sonogram. All that along with someone to make sure the sonogram is coded properly so the insurance company will pay for it.

If you feel like your doctor is managing a business rather than your health - you are correct.

Now, I am going to ask a question. Of those 16 million Americans who are at the lower income levels and now required to purchase insurance, how many of them are going to go out and buy a policy or take the chance that they can use that money on a 52 inch flat screen TV and not get caught?
HonestySocialTwist Tell-a-Friend

Thursday, March 25, 2010

It's here!

Yes, the healthcare reform bill is signed and no, you can't drop your existing health insurance. As a matter of fact, my health insurance premium is likely to rise. BUT in six months, my son, who has a pre-existing condition that no health plan in this state will cover will no longer be denied coverage because I changed jobs.

I, like many Americans, have approached this health care reform bill with caution. Unlike most of my friends and colleagues, I have tried not to mix my own opinions with the facts. A friend of mine reported on her blog, "We are entitled to our own opinions but not our own facts."

So here is a fact which has helped me support healthcare reform: The United States ranks 41st on the World Health Organization's list of maternal death rates.

You read that correctly. It is safer to have a baby in South Korea or Bosnia than it is to give birth in the United States. My colleagues are all up in arms that someone (the President and the Speaker of the House) are going to take away their fortunes and tell them how to practice medicine. Honestly, I don't know anyone who is practicing medicine so poorly that women are dying as a result. Yet, I see many ways were physicians could all do better.

Isn't that what reform is about, doing better? I know that your definition of better and mine maybe different, but we can both agree that there are many facts here which need to be changed. As a country America can get better health care for everyone for the money which is spent on a few. Many of the few are not receiving the best, even as they pay for it.

In my mind, healthcare reform will work not just when everyone gets coverage, at any price. Health care reform will be working when the maternal death rate, which has risen steadily in America over the past decade, begins to fall. I believe reform, which will require more documentation and over site will help accomplish this.
It's here!SocialTwist Tell-a-Friend

Wednesday, March 17, 2010

Reforming the patients

I am first and foremost a patient advocate. But sometimes the patients push me to my limit. Today is one of those times. No matter how many times you give a patient the clinic number. No matter how many times you explain to the patient that her contractions must be 5 minutes apart, lasting one minute for at least one hour, she will still show up in the emergency room via an ambulance for false labor. I have no idea how much this cost but I know it comes out of an ever shrinking state Medicaid budget which also pays my salary.

We are at least two generations into this welfare mentality. Most of my patients have never had a job. That is almost as shocking to me as the number of 19 year olds I see pregnant with their third child. I don't know how to change this. In the current economy, it is difficult to imagine a change. I am not even sure there is a way to change it. I do believe it will take at least two generations to begin to reverse this trend. I hope America has that much time and I hope we begin soon.
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Wednesday, March 10, 2010

The enemy

I have tried to stay away from talk about health care reform as much as possible. I find the clinical aspects of medicine and the people I serve far more fascinating than those who are involved in trying to make our health care system work better. For one thing, I believe if doctors spent more time serving patients and less time worrying about how to make more money, even our current system would be a better one.

In a meeting I was recently required to attend, I saw this problem up close. Present at the meeting were several physicians who have been practicing medicine about as long as I. They were in several hospital based specialities. The discussion was not about a great new discovery in medical care which would improve quality or limit suffering. The sole purpose of this meeting was to present a new financial venture between three large physician groups and the hospital. If I could have titled the meeting, it would be: "How to get more money for those who already have too much." I say this because all of the speakers have 7 figure salaries supplemented by investments in pharmaceutical companies, device makers, and surgery centers. I was particularly thrilled to hear this group has "hired a national law firm experienced in defending against legislation which makes [ventures such as this one] illegal."

Please understand, I see many problems with pharmaceutical companies, insurance carriers, and hospital systems. Yet, when our brightest, most energetic physicians are rushing to get an MBA and become managers in these new business rather than spending their energies in direct patient care, something is wrong with the profession. It also explains why my primary care colleagues are selling vitamin supplements and preforming LASER hair removal to supplement their office income.
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Friday, February 26, 2010


In addition to having a special vocabulary, medicine has its own set of acronyms. PERRLA stands for "pupils equal round reactive to light and accommodation." All medical students learn this when doing the first year course in physical diagnosis. Medical students also learn the importance of preforming both the reaction to light AND to accommodation. The reaction to light is when the doctor pulls that little penlight out of her pocket, darkens the room and points the light directly in first one eye and then the other. In the darkness, your pupils should get bigger. The bright light will make them smaller. Accommodation is where you are ask to focus on an object, say the physician's finger held out in front of your face, and watch it as he moves it closer to your nose. With this your pupils should also grow smaller.

As every medical students learns, neurosyphilis reduces the pupils ability to accommodate. Back when medical school classes were made up of mostly male medical students taught by male professors, the way to remember this bit of information came in a story about prostitutes who have neurosyphilis and will "accommodate but they will not respond."

As an intern long ago, I carried a spiral notebook in my pocket with just such a list of acronyms. This was in a time when husbands were confined to the waiting room while their wives were in labor unless they had gone to childbirth classes. This was carried out with such seriousness that certificates were given to the couple and the labor nurse was required to put this certificate on the patient's chart before the father was allowed in the delivery room.

I remember my first solo delivery. As the nurse anesthetist and I pushed the patient's bed to the delivery room, she kept asking me, "Is this an FID?" I had no idea what an FID was and I panicked. Did this woman have a condition which had escaped my attention? Could it affect her health or safe delivery of this baby? Looking in my notebook, I could not find FID. Finally, as we were moving her over on to the delivery table and I realized I would not have time to look through her chart again before the birth of the baby, I whispered to the nurse, "What is an FID?" "FATHER IN DELIVERY!" she shouted back. "No," the nurse replied. "He didn't go to childbirth classes, so he can't come in."

Well, now we have FOBs. FOBs are related to FIDs. Now, instead of pushing the patient down the hall to a delivery room, we have labor, delivery, and recovery rooms or LDRs so everyone gets to come in, at least for the labor and some patients choose to have several people present for the actual delivery. One obstetrician pointed out there was only one thing missing from the LDRs - the bleachers.

But back to FOBs. This is the term which is now quite common for the father of the baby. It is usually used when the patient and the FOB are not married. In private practice thirty five percent of my patients were not married at the time of their first OB visit, however, many did marry before the baby was born. In my current job, many not only don't marry but the FOB is the father of several other babies born to other girls.

In my continuing search for why this state has the highest teen repeat pregnancy rate, I believe accountability of these FOBs is an essential step to reducing our teen pregnancy rate. Accountability? Yes, the FOB's name on the birth certificate. Then they would be required to do more than swagger around the hospital room and brag to all their friends in the hallway. With the FOB's name on the birth certificate, the FOB could be made to pay child support. And if the FOBs are out working and paying child support they would have less time available for repeat preformances.
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Thursday, February 25, 2010

Speaking of hope and change

There is a reason I am a physician, not an attorney or clergy. I have often wondered but I believe it is because my vocation best fits my personality. I am usually too outspoken to be the latter and not enough to be the former. Thinking about my chosen profession on a day when the leaders of our country are trying come to some type of consensus on an equatable way to deliver health care in this country has caused me to reflect on the words: "hope" and "change."

This has also given me pause to reflect on the two words I believe are most critical in this health care debate: "greed" and "apathy."

Two years ago I had a great deal of hope that we would see change in the way health care is delivered in this country. My passion for this has pitted me against many of my colleagues. One of the biggest reasons I left private practice was the unmitigated greed I saw medical practice. This included everything from unnecessary testing to generate income for the profit centers in the practice to poor medical practice in allowing minimally certified office staff to preform triage functions including ordering and reviewing medical tests when the physician was not present, allowing that physician to bill for services preformed when he/she was out of the office. The reasoning given for doing this was the same one I use with my mother when I was in junior high school. "Everyone else it doing it."

Lest you think physicians are the only greedy ones, hospitals and insurance companies are right there and they make a bigger impact on health care costs than physicians. Without naming names I challenge you to look at some of the publicly traded health care companies from health insurance, physician groups, and hospital corporations. Or better yet, go and look at how your local nonprofit hospital is set up. You may find many for profit arms protruding from the altruistic body. These for profit connections receive money from the non profit base and they are owned by the officers, board members, and physicians, who are employed by or practice at these institutions.

Like the cardiologist once explained to my father, then in his 70s and only taking a baby aspirin daily, "We have a huge industrial-medical complex here and we need to get you to participate more to keep it running."

Which brings me to apathy. The employed and retired American public that by and large has health insurance is very apathetic when it comes to helping those who do not. If you are over 65, you probably have Medicare and many in this age group also have gap policies provided by their former employers. (Look at your TEA Party groups and you will find those who maybe taxed enough already but they are also happily getting their health care from a younger generation's tax dollars while many in that younger group are going without health care coverage.) Those who are too sick to work, disabled, or self employed know how difficult and expensive it is to obtain health insurance. Having always been self employed, I have always been aware of the cost of health insurance. With tort reform, I now pay more for health insurance than I do for liability coverage.

And there is patient apathy. For example we all want heart health achieved by prescription drugs, brand name at that, not the self care and work which is required to eat a healthy diet and participate in daily exercise.

I could go on but I will stop here. I remember as a child being told the only person I have the power to change is myself. I continue to work on this and yes, even my attitude after a year of this health care debate. I will also keep on talking with patients about contraception, diet, exercise, and sexually transmitted diseases because I have hope that some will listen and begin to change.
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Tuesday, February 23, 2010

Risky business

The most common cause of maternal death is hemorrhage. Massive bleeding which is uncontrollable and often times the severity of which goes unrecognized until it is too late. I had a close call recently with a situation where the bleeding was uncontrollable.

The patient had a condition call placenta increta. The placenta grew through her old Cesarean section scar. The odds of this increase with the age of the mother and the number of C-sections. In her cause these numbers were 23 and 1. That's right. She is twenty three years old and she has had one other pregnancy, a now two year old.

The other terrible part of this case history is the baby. She has a cardiac abnormality. That fact and the placental problem put both mother and baby at high risk which is why she was transferred to a major medical center for delivery.

Outcomes: The mother lost her uterus. While better than losing her life, a hysterectomy was not the outcome I had hoped for going in to the C-section. Realizing the baby may not live caused me to delay longer trying conservative measures before I began the hysterectomy. This resulted in enough blood loss to warrant the transfusion of several units of blood and blood products.

The baby is very sick. One surgery has been done and another is planned. I know one baby cannot replace another but thoughts of harvesting eggs and IVF with a surrogate donor have already crossed my mind. At best this couple has a long road of treatment for this baby's heart defects.

This is the type of scenario I think of when someone says to me, "Delivering babies, what a wonderful job!" I would agree. I have a wonderful job but most of the people who say that have no idea how dangerous pregnancy can be.
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Tuesday, February 16, 2010

Watch out!

Over the course of the past eleven months I have composed a new list of dangers. This list goes beyond the normal one I present to the residents when trying to raise their awareness of the likelihood of complications such as a shoulder dystocia or post partum hemorrhage. These dangers are more common on certain days.

Rainy days would be one type of day for which I have gained a new appreciation. I will almost always end up seeing at least one pregnant woman who has been injured in a motor vehicle collision. And I will never forget the woman brought in at term, a full code in progress. Neither she nor her baby survived despite the emergency Cesarean section in the emergency room.

Having treated a severely hypothermic expectant mother, I am more aware of cold days but carbon monoxide poisoning was not on my radar until recently. After a bout of extremely cold weather combined with prolonged power outages, a pregnant woman arrived with symptoms of carbon monoxide poisoning. I am happy to report that she and her fetus both did well after a trip to the hyperbaric oxygen chamber.

Holidays are also a time I worry. As I have tried to explain to my teenagers, even though you aren't the one drinking, if you are out and someone is drinking and driving, you may end up being casualty of their short sightedness. Stay off the roads, especially when it gets late, is my advice. I have seen too many victims.

Imagine my surprise when I walk in to the labor board check out at 7 AM to find someone already wearing Mardi Gras beads. Today is one of those days where I will worry a little more than usual about what might show up in the emergency room. I hope I am wrong. I hope everyone stays home to finish up that last piece of chocholate cake.
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Thursday, February 11, 2010

A new diagnosis

I was ill last week. Originally, I believed my illness was food poisoning. As I heard of more people having a similar illness, I decided it was just something going around. My case was unusually severe, requiring a full day in bed and then another five or six days before I could eat normally. In talking with one of my colleagues about the fact that I was almost unable to get out of bed for an entire 24 hour period, he said "You know, I think you may have had 'man flu'."

"Man flu," I cried, "What in the world is that?"

"Actually I learned about it from one of my patients," he told me. "She said that when she has the flu, she is somehow able to get up and care for the kids, do some cooking, and keep the house straight. When her husband has the flu however, it is so severe he is not able to rise from bed except to go to the bathroom."

Man flu. I hope no one else at my house gets it.
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Friday, February 5, 2010

Baby for adoption

By noon on a recent call day I was ready not to be so entertained by this job. After a morning full of teenagers having their second or even third baby, a 23 year old woman with limited prenatal care arrived in obvious labor. By limited care, I mean two brief visits to a free clinic. The patient’s fundal height (measurement of the pregnant uterus) was so small, at first I believed the due date she gave of 3 and 1/2 months from now. Her cervix was 4 centimeters dilated on arrival to labor and delivery. I did not have much hope of stopping her labor but I ordered the tocolytic, magnesium sulfate before I doing a sonogram. There is now some literature to suggest that premature infants whose mother receive magnesium sulfate to stall or stop preterm labor also have a better neurological prognosis, so I figured it could not hurt.

On doing my sonogram, I discovered this woman was very close to a term due date. In fact, her other two babies, which were 28 and 14 months old, weighed 6 and 6 1/2 pounds. This one fell right in that range on sonogram. The patient got her epidural and we began to have a less frantic conversation. Her other two children were with her mother in law in a small town an hour east. The patient and her husband could barely support themselves and these two children. They were placing this baby for adoption. Or at least that was the plan they made at the free clinic. And no, they had not made any arrangements with an adoption agency or and attorney nor had they even called one of the phone numbers given them.

So the baby arrived weighing just over six pounds. A girl with a very good set of lungs. She was screaming and pink within a minute of arrival. She left for the nursery after the 5 minute apgar with the pediatrician's approval for the newborn nursery. Mom never held her. Dad didn't even look at her. He was gathering up his jacket to go to work when I left the room.

Of all the babies I delivered this morning, these parents seemed the best equipped to raise a child. In fact they were raising two. The same situation, no health insurance, which landed this woman in my care, has contributed to her getting pregnant three times in as many years. And yes, she would qualify for Medicaid at least for the pregnancy. It is complicated, these issues of access to medical care.

Now I wonder if this free clinic provided birth control, would she have gone after her first child? I wonder if she kept this baby girl, would her chances be any better than her mother's? This last is the question I have about almost every baby I deliver. What I do know is this problem of unintended pregnancy is not getting any better. Cheap, easily obtainable contraception, and the motivation to use it needs to be a societal priority. No matter what you believe about the rest of health care, on this we cannot afford to wait.
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Sunday, January 31, 2010

I delivered a Klingon

The one word I would never be able to use when referring to my current position is dull. When a new patient rolls in at 2 or 3 AM, I am almost always greeted with an entertaining story. This morning the entertainment happened to be the fact that the partner of my new patient believed himself to be part Klingon. For those of you would are non-Trekkies out there, the Klingons were often the bad guys on Star Trek.

This part of the social history became apparent when the admitting nurse ask the patient what language she spoke. If you have been reading along, you will know many of my patients do not speak English as their first language. In fact, many do not speck English at all. So, in answering the language question, the patient stated she spoke, "English, French, and a little bit of Klingon."

Well, not to be out done, the nurse, who has a great sense of humor, clucked her tongue twice, and said, "So do I honey, so do I."

Later, talking to the dad I learned he had many roles (or personalities) and Klingon was only one of them. I think he had been with Arthur at the round table, and with Lawrence in Arabia. I am not sure where we were this morning but I was very hopeful it was in a labor and delivery unit somewhere around the year 2010 on my small spot of the planet Earth.

Everyone did just fine and a beautiful baby was the result. The residents did waste some time on the Internet where there is a translation site. Several of the staff now know how to say, "live long and prosper" in Klingon. Of course these are the people who's ears are slightly pointed and can separate their middle and ring finger of their raised right hand.
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Thursday, January 28, 2010


This week we are working on our skills managing the complications of labor. I would prefer exercises from a book or a lecture series but it seems the scenarios are coming courtesy of the unassigned patients. Two days ago I was receiving checkout and a premature laboring patient's bag of waters ruptured spontaneously and the umbilical cord prolapsed. This is an emergency and we quickly moved to the delivery room to preform an emergency Cesarean section.

Today a patient rolled in by ambulance almost completely dilated with her fourth baby. The baby did not appear particularly large, the woman was not obese, and none of us were there that long before we had a shoulder dystocia on our hands.

To me having the baby's head out and the shoulders stuck behind the pubic bone is the most frightening situation in obstetrics. I called for the nurse to put the patients legs back as far as they would go on her chest, McRobert's maneuver. Asking for suprapubic pressure, I tried first to screw the anterior shoulder counter clockwise, Wood's screw maneuver, then the posterior shoulder clockwise, Rubin's maneuver, and finally I reached in and was able to get the posterior hand and bring the arm out reducing the diameter of the shoulders and dislodging the baby. She is fine and not a huge baby, only 7 and 1/2 pounds.

Precipitous labor is a minor risk factor for shoulder dystocia but unlike the prolonged second stage, from the cervix becoming completely dilated until the baby delivers, which is normal less than two hours, precipitous labor gives you less time to think about the maneuvers you will preform if the baby does get stuck. Today we got it right. Tomorrow there will be other problems. More practice. I wonder when we will be "knowing medicine."
PracticingSocialTwist Tell-a-Friend

Wednesday, January 27, 2010

A night's work

I smelled like a goat. Well, I have never been that close to a goat but after my two hour nap, not only did I smell like what I imagined a goat would smell like, if I ever got next to one, but I felt a bit like I had been herding them all night.

For the third time in eight months, I took a nap when I got home on Monday. I went straight to bed taking only my shoes off before plunging beneath the sheets. It was almost noon and I set my alarm for 2. I do not want to become one of those people who sleep in the day on their days off. Or in the day on the days I am working, as is frequently the case with some of the other hospitalists.

While the daytime is occasionaly slow, the nights are not. I worked Wednesday, Friday, Sunday last week. Here are a few vignettes.

Just as the nightly news is over two nurses from the antepartum floor came through the doors of labor and deliver pushing a patient on a stretcher. A man who looks to be the husband is following them. Much of the talking I do not understand because the patient only speaks a Vietnamese dialect.

Taking the chart from one of the nurses, I read that her pregnancy is 23 weeks and 6 days gestation (about 17 weeks shy of term) and she has been in the hospital 4 days for an incompetent cervix dilated to 3 centimeters on admission. This was her first pregnancy and the patient had been having pain for 2 hours but was monitored and no contractions were detected. When she began bleeding the nurses rushed her downstairs. No one had ever called me about the pain. Grabbing the portable sonogram, I determined that the baby was a double footing breech presentation with the feet in the vagina. Fetal heart tones were good. Calling for anesthesia, I asked for the translator phone. "Yes, the patient wants a C-section to increase her baby's chance of survival." Quickly the risks and benefits are explained to she and her husband.

We all move to the delivery room where I help the nurses get the patient on the operating table as the anesthesiologist gets the drugs and equipment ready to induce anesthesia. I put a Foley catheter in the patient's bladder while the nurse listens again to a strong fetal heart. Rubbing antiseptic gel on my hands, I gown and glove myself while the scrub nurse and circulator count instruments, and sponges. Placing the drape on the patient, I have another nurse hold the translator phone to her ear. "Tell her we will take very good care of her, I will not start until she is asleep." I can't believe she is not struggling. She is just waiting. Her baby weighs 590 grams (1 pound and 1 ounce) but is doing well in the nursery on day 4 of life. I will have my fingers crossed for months to come.

Next I am off to the emergency room. There is a 16 year old miscarrying. Her parents dropped she and her boyfriend and the older sister off but went to eat dinner because the wait was so long. This girl is bleeding a lot and I cannot get all the tissue out of the uterus so the bleeding continues. Giving her pitocin in the IV slows the bleeding a bit. She will need a curettage to get the tissue out. I am never sure a 16 year old can consent for herself when she is not actually pregnant. There has been much in the news about this in Texas and I want her parents back. The sister is calling them on the cell phone.

While this is happening in section C, a morbidly obese woman in section D has a fever of 103 degrees. She could have appendicitis, gastroenteritis or pelvic inflammatory disease. Of course medicine and surgery think I should admit her for PID. When I examine her she simultaneously vomits and urinates on me. She gets admitted - to surgery. I told them I would follow with them and we agree on antibiotics as I write my note.

The 16 year's parents are back, consent is obtained and I change clothes on the way to the OR. Once this is done, the curettage is easy and she is off to the recovery room. Talking to the parents, the mother is upset and wants to know how this could happen. At first I think she is asking how her daughter got pregnant but I soon realize she is upset about the miscarriage. I want to talk with all these people about how to keep this young woman, who is smart as well as beautiful, from getting pregnant again. The mother and I have a discussion that night. The girl and her boyfriend, who is 17, and I have a detailed discussion the following morning.

I could go on. In one of the routine deliveries, I catch the father of the baby just before he passes out. The patient is 15 and he doesn't look like he shaves more than one a week. His mother and hers are both in the room pushing with the patient during the second stage of labor, from the cervix being completely dilated to the birth of the baby. They could care less about the 'baby daddy.'

All of these events were between the 6 pm news and midnight. Other events happened after that and I was too busy to take my 7 am shower before rounds with the residents. After rounds, I just wanted to get home and get into bed. I hate to sleep in the day but I knew some rest was necessary if I was going to survive to tell this tale.
A night's workSocialTwist Tell-a-Friend