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