The local MD

"the difference"

2012-01-16T10:56:00.000-06:00

You have heard it before.
Termed "The Serenity Prayer," the saying goes something like "God grant me the courage to change the things that I can change, the patience to accept the things I cannot change, and the wisdom to know the difference."

Wisdom is key.

Yes, you need courage to tackle the tough issues especially those of injustice and inequality in a land flowing with, well, if not milk and honey, then certainly flowing with information and money. Patience is also required. Real change comes slowly usually with Herculian effort, especially where hearts and minds are concerned.

Knowning the difference in what can be changed and what must be accepted, even termporarily, to bring about a since of community and peace, is real wisdom.

I will ...

2012-01-14T10:15:00.000-06:00

not complain.

If I have in the past I am sorry. Please accept my apology and remind me, should I voice my discontent in the future that each day is a gift. While I am not perfect, it is my sincere hope that I can be grateful for each breath and live the moments, hours, and days given to me with grace.

Tough love

2011-09-12T06:00:00.000-05:00

I will always be grateful for the depth and breathe of experience life has given me. It is from this well of experience that I now draw in hopes of helping. I am sure you have heard someone say, "An ounce of prevention is worth a pound of cure." Prevention is where I hope this is headed. For C, cure is now impossible.

As you may have guessed, C is dead, felled by the number one killer of Americans under the age of thirty-five. He took his own life. C had been involved with drugs, violence, and had threatened suicide in the past. His parents were employing "tough love" to deal with his problems. From what I have read, "tough love" is a way of dealing with troubled youth, especially those addicted to drugs. Since he had threatened suicide in the past C's parents were told this was manipulative behavior and to ignore such a threat.

I believe all love is tough at some point in time. All parents experience this when our children push against our rules. It is tough to say no, mean it, and meed out the consequences. Almost any parent will tell you, kids on their way to adulthood will push you to your limit and often past it. That is when love is tough.

I understand not enabling someone with substance abuse problems. I do not understand not taking a suicide threat seriously. I write this as I grieve for C, for his parents, for his friends. I want everyone to take a suicide threat seriously. While I maybe a professional, trained to assess the risk of such a threat, I can tell you that in the face of such as situation with one of my own family members, I would not stop until a thorough assessment could be carried out by an unbiased professional. The threat of suicide is a serious cry for help. Giving or getting help may be tough, but that is love.

On 9/11/2011

2011-09-11T09:39:00.000-05:00

One of the attributes which makes us human is the ability to analyze the past and plan for the future. While it is easy to hold the picture of the twin towers of the World Trade Center burning and falling to rubble in my mind's eye, it is much more difficult to find pictures of peace and reconciliation. That first image of the towers is followed by those of the night raid bombings on Afghanistan, the ground war there and the invasion of Iraq. Ten years of fight is what I think of when I think of my sons who have grown from 10 and 12 year old boys to young men of 20 and 22 years.

An image I have tried this week to pair with that of the burning towers, is that of women dressed in white bonnets, holding hands, heads bowed in prayer. These are the women of the Amish community in Nickel Mines, Pennsylvania. Yes, I had to look up the name and I submit to you that their way of life is as foreign to most of us as the people we blame for those attacks ten years ago. If yo follow my facebook status, I left an interesting article there yesterday. My warning was to read all six pages. I guess no one did. Or if you did you did not "like" it.

There was a great deal of news surrounding the murder of the ten young girls in an Amish school house in Nickel Mines, Pennsylvania on October 2, 2006. A wealth of information is available on the Internet. Yet, the main image my mind goes back to on that day, now almost 5 years ago is the one of the women praying. News of the community has died out. Pacifist behavior does not sell many newspapers. It seems that the gunman's children are growing up without retaliation from the families of the victims.

One this day, when we remember the 2,996 individuals who died in those attacks, as we listen to their families, whose lives have forever been changed, could we please also weave some modicum of forgiveness into our beings. Violence begets violence. This is the truth of 9/11 for me. I have watch as a generation of young Americans has grown up with the idea that to make our world safe, wars must be fought. 1,680 Americans have lost their lives in Afghanistan in the past ten years. 4,792 Americans have been killed in Iraq since the current war began there.

There must be a better way forward on this planet. Please, I beg you, speak peace. Teach peace. Most importantly, live peace. Everything has to begin somewhere. What are the words to that old Christian camp song? "Let it begin with me."

A new address

2011-01-03T15:46:00.005-06:00

All my thoughts about the work I do are being posted "In the belly of the big house." I have not found a way to move them here without destroying "the local MD." I can leave that blog totally since the physician in the big house is the local MD. To continue reading you will have to look here: http://inthebellyofthebighouse.blogspot.com/ at least for now.

The next moment

2010-12-31T23:59:00.002-06:00

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.

Sports and politics

2010-11-02T09:06:00.003-05:00

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.

Change

2010-10-30T11:28:00.004-05:00

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.

As you shop for health insurance

2010-09-23T02:50:00.001-05:00

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.

Take the money and run

2010-08-31T11:42:00.005-05:00

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.

Changing the world

2010-08-23T07:06:00.004-05:00

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.

American medical care

2010-08-18T13:10:00.003-05:00

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.

Reward

2010-08-17T11:26:00.006-05:00

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.

"I can't...."

2010-08-07T10:22:00.005-05:00

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."

Something new

2010-08-06T17:44:00.004-05:00

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.

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

2010-08-03T08:06:00.005-05:00

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.

Summer resolution

2010-07-31T08:02:00.004-05:00

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.

Needed: New technology

2010-07-07T02:43:00.005-05:00

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.

The full circle

2010-07-05T11:35:00.004-05:00

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.

A story

2010-07-02T19:30:00.004-05:00

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.

"Happy new year!"

2010-07-01T17:24:00.002-05:00

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.

I am here because...

2010-06-26T06:19:00.003-05:00

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.

On to the next step

2010-06-18T17:09:00.003-05:00

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.

Aliens

2010-06-10T11:00:00.005-05:00

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.

Holiday weekend

2010-06-04T12:30:00.006-05:00

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.

Family doctor

2010-06-01T11:45:00.006-05:00

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?"

Jezebel

2010-05-27T09:50:00.006-05:00

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.

SUBspecialist

2010-05-23T15:23:00.002-05:00

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

The babies

2010-05-17T07:30:00.003-05:00

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.

Redefining "health care"

2010-05-16T07:08:00.005-05:00

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.

Surprise

2010-05-15T07:29:00.005-05:00

"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?

In my prefect world...

2010-05-11T06:00:00.000-05:00

...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.

...courses 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.

Early morning ramblings

2010-05-10T03:39:00.003-05:00

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.

Another day

2010-05-09T15:47:00.003-05:00

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.

The game

2010-05-08T14:36:00.002-05:00

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.

Beginning the book

2010-05-06T12:33:00.004-05:00

"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.

Spring

2010-05-04T10:35:00.003-05:00

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.

The quote of the day

2010-04-23T16:37:00.000-05:00

"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.

Role models

2010-04-09T13:36:00.004-05:00

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.

If this is so funny

2010-04-01T14:10:00.003-05:00

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.

Honesty

2010-03-31T09:41:00.003-05:00

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?

It's here!

2010-03-25T11:00:00.006-05:00

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.

Reforming the patients

2010-03-17T14:26:00.002-05:00

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.

The enemy

2010-03-10T11:25:00.000-06:00

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.

Acronyms

2010-02-26T11:47:00.000-06:00

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.

Speaking of hope and change

2010-02-25T11:52:00.005-06:00

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.

Risky business

2010-02-23T16:03:00.004-06:00

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.

Watch out!

2010-02-16T11:46:00.005-06:00

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.

A new diagnosis

2010-02-11T10:52:00.004-06:00

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.

Baby for adoption

2010-02-05T07:23:00.000-06:00

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.

I delivered a Klingon

2010-01-31T09:27:00.006-06:00

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.

Practicing

2010-01-28T17:01:00.006-06:00

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."

A night's work

2010-01-27T14:10:00.011-06:00

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 story

2010-01-22T16:51:00.008-06:00

I first met MW when she presented to labor and delivery for contractions. Her cervix was not dilating but her blood pressure was elevated. She still had five weeks until her due date, set by the residents at the country hospital. Looking at her records she had not been seen by a doctor for at least two months.

Admitting her to the hospital for her elevated blood pressures, known as gestational hypertension, I tried on two occasions to get a twenty four hour urine collection to determine whether she had preeclampsia. This was the medical situation, the social situation was another story.

First she told me "my child's father is not paying me enough attention." Then I found him in bed with her on early morning rounds. Though she did not go into labor, her blood pressures became so high, her labor had to be induced. She quickly tired of labor and begged for a C-section. Despite epidural anesthesia, labor "hurts too much." She told me. I tried to explain that incisional pain after a C-section was also a problem.

After a long induction her labor did stall and she was on the operating room table when she asked me, "I get to eat after this, right." My reply of "No, not exactly..." and an explanation of the need for a clear liquid diet until her bowel function returned was met with cursing and crying. I understand frustration. My oldest was the product of a Cesarean section after 27 hours of labor, but this seemed a bit much. The entire OR staff allowed her to ventilate before bringing "the father of [her] child" to the delivery room.

I pulled screaming baby boy out of the incision in her abdomen about 15 minutes later. Being cleaned and dried, weighed and measured by the nursing staff, I exchanged several glances first with the circulating nurse and then "the father of [her] child." The baby's skin color did not match his.

Despite bracelets placed on baby, mother, and daddy in the delivery room, the next day this young woman was claiming those of us in the delivery room had some how drugged her and exchanged babies. She got no support from the boyfriend in this and finally gave it up.

On the day she left the hospital, I discharged her with an appointment in two weeks to see her clinic doctors. She complained about this but in a much more subdued way than all the issues of the past 8 days. As I removed the staples from her incision, she said, "But I want to come to the clinic and see you." When I explained to her that it didn't work that way, that she only had me for the days she was in the hospital due to the fact that I was on call, it began to dawn on her that our relationship was ending.

The reward for my eight days of patience came with the very last words she spoke as I turned to walk out the door. Sitting in the bed holding her son, she meet my eyes and quietly said, "Thank you."

Least favorite

2010-01-06T19:41:00.001-06:00

This month called January is my least favorite of the year. One reason maybe the weather. Even though I am located in the south where it is often sunny, January is usually cold and cloudy. Winter has just set in and spring is far enough away, I rarely think about it.

Another reason for my discomfort during this season is the resident training cycle is half over. Often, I think I am the only one who realizes the true meaning of "half." Interns are now much more comfortable presenting patients they have evaluated. Good skills have been developed, things begin to move a bit more quickly, and yet, it is a common time for them to begin missing things, too. There will usually be a few cases which make us all pause, reflect, learn the importance of being thorough once again. I find myself becoming hyper vigilant once again. As a person who makes few New Year's resolutions, I think this is a time for my favorite one: To do better.

Better can be a confusing term but in the sphere of my work, it means I will strive to be more accurate in my diagnosis, more compassionate with my patients, a better colleague to those with whom I work. I will learn at least one new thing each day and at the end of the year I hope I will be a better physician than I was at the beginning. Medicine is no place for complacency. If this year's class of interns are learning this then my enjoyment of these cold winter weeks will increase. Hopefully, so will the temperature.

Our Great Society

2009-12-13T17:05:00.006-06:00

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

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

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

*http://blog.sojo.net/2009/11/25/the-three-most-important-issues-what-the-manhattan-declaration-gets-wrong/

Next patient, please

2009-11-26T12:38:00.006-06:00

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

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

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

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

Evidenced based medicine

2009-11-20T11:43:00.013-06:00

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

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

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

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

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

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

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

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

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

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

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

Thirteen

2009-11-19T20:57:00.005-06:00

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

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

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

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

*all names are changed

The future

2009-11-10T09:16:00.004-06:00

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

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

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

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

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

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

My office

2009-11-08T12:38:00.004-06:00

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

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

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

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

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

The flu

2009-10-30T20:45:00.000-05:00

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

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

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

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

Another world

2009-10-26T20:55:00.003-05:00

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

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

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

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

Day of hopelessness

2009-10-24T15:52:00.004-05:00

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

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

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

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

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

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

Playing by the rules

2009-10-22T21:01:00.004-05:00

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

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

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

Doctor: "Oh, you two are married?"

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

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

Silence.

My crystal ball

2009-10-18T07:58:00.010-05:00

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

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

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

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

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

Falling through the cracks

2009-10-11T12:34:00.005-05:00

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

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

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

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

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

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

Down time

2009-10-05T23:17:00.002-05:00

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

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

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

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

Well, it is time to go upstairs to the OR but this is what I should be doing with the down time.

The gift of life

2009-10-02T23:27:00.002-05:00

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

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

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

Why health care reform?

2009-10-01T02:47:00.004-05:00

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

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

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

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

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

"Amazing," you say.

"No, America. And it is why America needs health care reform."

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

2009-09-28T06:00:00.001-05:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*quote from one of my attending physicians 28 years ago

I dunno

2009-09-27T22:06:00.005-05:00

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

"Yeah, I had a baby last year."

"When last year?"

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

"How much did your baby weigh?"

"Dunno."

"Is the baby doing alright?"

"Dunno."

"Doesn't the baby live with you?"

"No."

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

"I gave her to my mamma."

"Don't you live with your mother?"

"Yeah."

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

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

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

"She gave the baby to my grandma."

The 4th floor

2009-09-22T15:21:00.002-05:00

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

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

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

Perhaps there is a purpose besides time saved when I take this "short cut." I believe I will continue. That is at least on the days I have the time.

Sometimes the best teacher ...

2009-09-20T17:00:00.002-05:00

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

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

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

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

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

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

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

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

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

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

Degrees of sadness

2009-09-17T10:18:00.003-05:00

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

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

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

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

I then ask if I could speak with her grandmother.

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

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

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

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

Sad, however, has reached a new level today.

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

An oxymoron

2009-09-16T11:59:00.005-05:00

Safe sex.

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

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

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

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

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

Air and light

2009-09-08T13:00:00.001-05:00

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

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

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

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

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

In case you didn't know

2009-09-07T08:57:00.004-05:00

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

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

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

Sunday's child?

2009-09-06T15:45:00.004-05:00

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

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

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

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

So that is how this Sunday has gone.

Enough of this self pity. It is time to get back to work.

Special day

2009-08-30T10:36:00.001-05:00

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

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

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

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

On leaving private practice

2009-08-27T20:07:00.001-05:00

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

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

Still here, still breathing.

Deposition Day

2009-08-25T13:28:00.002-05:00

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

Capitalism or socialism

2009-08-23T07:35:00.007-05:00

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

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

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

"Denial ...

2009-08-21T08:30:00.000-05:00

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

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

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

Dr. Seuss didn't tell me

2009-08-16T08:30:00.001-05:00

The street is hot.

The ER is not.

The result for me:

More patients to see.

Yet, I recall

It will soon be fall.

Cooler days, football

Will clear the halls.

A break will be great.

'Cause a similar fate

In winter I will find

As temperatures decline.

Twins

2009-08-04T04:25:00.001-05:00

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

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

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

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

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

Cost or compliance?

2009-08-03T15:40:00.002-05:00

August is here.

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

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

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

So, while the rest of the country is debating the cost of health care, those of us providing health care know compliance is key. We also know compliance is not always tied to cost.

Night in the ED

2009-07-29T23:13:00.006-05:00

The smell is still with me.

Cancer.

An 80 year old woman

brought in by her daughters.

She wanted to die in Mexico.

Her daughters wanted her here.

The daughters won.

Now I will share their nightmare.

When (not) to call the doctor

2009-07-28T22:00:00.000-05:00

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

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

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

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

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

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

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

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

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

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

(No, I didn't say what you know I was thinking.)

More (writing) next month...I hope

2009-07-27T22:22:00.001-05:00

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

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

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

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

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

And yes, I know I should not be counting.

The gift of July

2009-06-30T18:15:00.003-05:00

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

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

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

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

"duh"

2009-06-20T12:09:00.005-05:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Still, there is nothing like seeing, talking to and examining the patient.

The loco MD

2009-06-14T13:20:00.001-05:00

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

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

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

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

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

I write these things to say that I was not as well prepare for this job as I thought. Still it is what I wanted. And still it is work worth doing.

Vocabulary

2009-06-03T18:46:00.002-05:00

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

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

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

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

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

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

Inside out

2009-05-17T00:53:00.000-05:00

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

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

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

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

A new norm

2009-05-02T21:12:00.009-05:00

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

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

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

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

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

QA

2009-04-28T05:30:00.002-05:00

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

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

It works like this:

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

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

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

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

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

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

Finding a cure

2009-04-27T13:38:00.003-05:00

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

"See one, do one, teach one"

2009-04-20T22:32:00.001-05:00

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

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

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

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

"I gotta push doc!" the woman pants.

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

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

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

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

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

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

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

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

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

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

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

The ability to cut

2009-04-19T17:29:00.016-05:00

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

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

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

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

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

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

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

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

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