Category Archives: The Barbarous Craft
If you came here expecting humor, don’t waste your time. I’ll try to be funny later.
***
Feeling happy and peppy this delightful Sunday morning? Please, read this diary from Daily Kos. Highlights:
1. I talked to FEMA reps, RC reps, State Health reps and the hospital folks and received the same “we don’t need doctors or nurses to run clinics” (I’ve been placing medical teams)
Today at the Red Cross shelter, the doctor I traveled with…Dr. Ken Levine, was STILL seeing patients that ‘didn’t need him’ when I left at 7 p.m.
This is what bugs me. According to an email I received from the Feds, 33,000 docs have volunteered their services. There should be no shortage of medical care. What if we’re being kept out of the area thanks to dumb-ass mismanagement? But, wait! There’s more:
I have heard that a ‘BOBCAT’ is worth $1000/day paid by FEMA (us), flatbed trucks something like $500/day. Then it seems the contractors try to collect additional money from homeowners, many poor.
It doesn’t surprise me that this disaster is bringing out the worst in human nature. Yes, I realize it’s bringing out the best, too, but this is still heartbreaking.
The author of this diary asks that you contact the national media. Americans in my crowd, let’s take it one step further and contact our Representatives and Senators, too. I’ve posted links (to the right, at the top) that make it easier to send emails to these folks.
***
Another interesting peak at human nature:
According to a recent Rasmussen poll, dubya’s numbers have suffered thanks to his post-Katrina speech. Why?
The spending plan has not been well received by conservative voters–just 43% favor the huge federal commitment . . . while 37% are opposed.
Irony of ironies. Dubya’s in trouble: when he proposes that we throw giga$$ into the NOLA rebuilding effort, he loses support from his base of conservative Republicans (who doubtless don’t like the idea of that much money going to the poor) and fundamentalists (who reveled in NOLA’s destruction, considering it an act of God, a latter day redux of Sodom and Gomorrah). If he does nothing, he loses the rest of America.
Oh, those silly conservatives and fundamentalists. Chill, guys! Don’t you realize dubya wants to funnel that money into Halliburton & friends? And he’ll use the expense as an excuse for further social engineering in the form of cuts to evil programs (Medicaid, EPA, public education . . .)
That’s all for now, folks.
D.
I’m feeling even less scintillant today than yesterday. Except for 45 minutes at lunch, I’ve been on my feet from 8:30 AM to 7 PM. Late day today, thanks to a semi-emergency which required a trip to the OR. My life isn’t usually this screwy.
Now I have a two-aspirin-and-sledgehammer headache and the cold is squawking, “You ain’t seen nothing yet.” This (and Jon Stewart) reminds me of Intelligent Design. Stewart’s counter-argument was the human scrotum. (Take the most sensitive organ in the male body, and hang it out there in harms way.) Mine would be viruses. What good has a virus ever done? Bacteria have a place on this planet — they help break down the dead stuff. But viruses? They’re effing parasites, man. Proof that if there is an intelligent designer, he’s a sadist.
I missed dubya’s speech. Karen says it was excruciatingly boring, and she couldn’t believe the way the talking heads were yapping afterwards how great it was. You know what that reminds me of? The Vice Presidential debate between Geraldine Ferraro and dubya’s daddy. Karen and I thought Ms. Ferraro rocked, while georgie seemed like a milquetoast weenie. Everyone else in the room (my thesis advisor and a bunch of molecular biology post-docs) thought georgie won the debate.
I firmly believe that one of the main things wrong with this country is the fact that Karen and I represent the fringe, rather than the mainstream.
Here’s what else happened today:
I’ve already signed up with Louisiana DHH, but I’ve been conflicted over whether or not I should fax my information back to the Feds. FEMA is still running the Federal relief effort, and you can imagine how much confidence I have in FEMA. Finally, I punted to my lawyer. I sent him the documents and asked him if they looked kosher.
I asked him why they wanted me to sign a loyalty oath (notarized, no less!)
“You’re not going to like this answer,” he said.
“Try me.”
“Our government is run by fascists.”
I knew there was a reason I liked this guy. Anyway, he looked things over, told me none of it looked horrendous and that I’d be safe sending it in. So now the Feds have me in their system, assuming they have their act together.
That would be funny, except that it is so not funny.
D.
I’m floating along on pre-call nerves, the jitters I used to feel on the night before a surgical admitting call day. If my buddy Bruce is out there reading this, he knows what I’m talking about. For the rest of you, let me see if I can describe it a bit better.
You know you’re untouchable for one last night. Sure, tomorrow will be hell, but you might as well kick back and enjoy your freedom while you have it. Except you can’t, because you know how bad it’ll be.
Once call starts, it’s not as bad as you thought it would be. You’re busy as hell, so busy you don’t have time to feel much of anything. But that pre-call anticipation is a bitch.
I hadn’t heard anything from Louisiana DHH today, so I called the number on Otter’s blog. The woman there directed me to some sort of odd locum tenens website, so I bailed on that. Instead, I went to this cheerful Federal DHHS site and filled out their form. Now, I wait.
Here’s the fun stuff (not) from that site:
They really need coroners, medical examiners, dental forensic experts, and morticians.
In case the volunteer has any unrealistic expectations, they state:
**Please be advised that individuals must be healthy enough to function under field conditions.
This may include all or some of the following:
12 hour shifts
Austere conditions (possibly no showers, housing in tents)
No air conditioning
Long periods of standing
Sleep accommodations on bed roll
Military ready to eat meals
Portable toilets
Hmm. Sounds like surgical internship without the 36-hour call shifts. I can do that.
***
Question to you technologically savvy folks (Pat, I know you can help me here): if this actually happens, I want to keep blogging. How can I do this? Assume that I can’t take my laptop and have no ready access to electricity. Please don’t tell me I have to text message from my cell phone.
Yeah, Kate, I probably ought to ask Otter how he does it, huh?
***
My three-year-old female patient has a thing for boogers. Insert finger into nose, transfer to mouth, repeat. I could have set my watch to it.
“Why do you want to do that?” I said. “There are much better things in the world to eat. Oh, like pretzels, for example. Do you like pretzels?”
She nods.
“Aren’t pretzels tastier than boogers?”
She shakes her head.
My logical train of thought just derailed.
D.
OMIGOD. Karen just pointed me towards this post on Steve’s blog. Get a load of the photo. Oh holy sheee-it.
Karen’s comment, “Oh, don’t get so upset. He probably just ate a poodle.”
Yeah, that’s my wife. Don’t dare suggest, “He probably just munched a few spiders.” Oh, no.
Karen insists. With all the bright people reading your blog, she says, someone might have some good advice.
I’ve decided I want to volunteer my services in Louisiana. Lots of great reasons to do it, and only one reason not to — the financial hit.* We have one big concern: this Salt Lake Tribune story, which Jeff excerpted at Pen and Sword, and which Steve Gilliard has spotlighted, also. Seems the government is not beyond using volunteers to bolster its worrisome PR problem.
Mind you, I don’t know if they will even want an ear, nose, and throat doctor, but if they want me, I’m available. I sent off an email a few hours ago to Louisiana DHH, giving them my contact information and a brief CV, but I haven’t heard back yet. I’m hesitant to contact the Federal DHHS because of the concerns (above). I’d rather talk to the State DHH first.
Here’s the question. What can I do ahead of time to make sure I’m used in an appropriate manner, and that I’m not used for some asshat’s photo op? Is it enough to get reassurances over the phone?
D.
*As a solo private practitioner, two weeks away from the practice is one big chunk of change. So I spoke with my parents, and they’ll back us up financially if we run into a crunch. (Thanks, M & D!) Which seems inevitable, given the way we’re hemorrhaging money into our home remodel. Which is also why we have no savings at the moment.
It hasn’t escaped me that it’s preposterous to worry about the home remodel when these folks don’t have homes anymore.
P.S. One of the good things about homeschooling Jake: I have control over his homework assignments.
Correct the following sentence.
George W. Bush said, “This ain’t my problem. Its someone else’s.â€
Hey, this one is clean enough for Reader’s Digest.
My patient, an older lady, told me about her daughter’s recent wedding. When the minister asked, “Who gives away the bride?” her husband didn’t respond. My patient realized in horror that he hadn’t gotten his ear wax cleaned in a while. She spoke up: “He does!”
D.
During my second year of ear, nose, and throat residency at LA County Hospital, one of our chiefs (call him el Jefe) did a study on ear foreign bodies. Very simple study: he reported on the first one hundred ear foreign body patients to walk in our clinical door. It took el Jefe only three months to rack up 100 cases. If you’re easily grossed out or still have nightmares of the Night Gallery earwig episode, skip the next paragraph.
The number one foreign body? Not earwigs, but Blatella germanica, the German cockroach. But don’t freak out. LA County Hospital’s patient population can’t be generalized to the world at large.
Here’s my favorite ear foreign body story. No bugs.
No Elmos, either.10 PM on a Saturday night. I trotted out my broken Spanish on a 28-year-old guy who had just told me he’d put a piedrito in his ear. Piedrito? A little rock?
“Why are you putting rocks in your ears?” I said in my not-half-bad Spanish. “Little children put rocks in their ears. You’re an adult. What’s the matter with you?”
What is this damned thing? I thought as I looked at his ear under the binocular microscope. White. Hard. Wedged in pretty tight.
“I can’t believe it,” I said, still in Spanglish. “A grown man putting a rock in his ear. What were you thinking?”
My patient started talking a mile a minute to my nurse’s aide, and he started laughing.
“No, Dr. Hoffman. Not a rock. A rock of cocaine.”
Aha. Well, that explained it. (In case you’re thinking Huh? These folks stuff the rock in their ear when they think they might get busted.) This solved my problem, though. I irrigated his ear with alcohol, dissolving the rock.
My patient was not a happy camper. He’d expected to get the rock back.
***
That’s not my favorite mangled Spanish story, though. This one is.I told this one to
Michelle not long ago, but I don’t think I’ve shared it with the rest of you. Let’s backtrack a few years to my last month in medical school, when I did an Emergency Medicine rotation at Santa Clara Valley Medical Center. Like LA County Hospital, SCVMC served a poor, largely Spanish-speaking population. As we go back in time, we also go downhill in the quality of my Spanish.
My attending physician asked me to do a pelvic exam on a sixteen-year-old girl with vaginal discharge. “It’s her first pelvic,” my boss said, “but don’t worry. From the sound of it, she’s been very active.”
So what if she’s sexually active, I thought. This is her very first pelvic exam . . . it’s bound to be stressful. I vowed to put her at ease by speaking slowly and calmly, doing my best to reassure her and let her know this was all very routine, nothing to be afraid of. I’d tell her in great detail what I was about to do before I did it.
After explaining to her the general idea of what we needed to do, I held up my gloved and lubed hand, my index and middle fingers standing at attention like proud little soldiers, and said,
“Voy a poner dos piernas en su vajina.”
To save you from having to Babelfish that one:
“I’m going to put two legs in your vagina.”
Ever hear the expression bug eyes? We somehow managed to sort out the misunderstanding, and to her credit, she let me go ahead with the exam.
And, yes, I used my fingers.
D.
Yes, that is punctuated correctly.
Those of you who know me are probably thinking, “OMG, what’s he done now.” Nothing, nothing. Only my job. And yet that was enough to earn me those three complements today.
It wasn’t even, “He’s a god.” It was, “He’s God.”
The lightning bolt has not struck yet, but let me tempt Him further. If I’m Him, why haven’t I allowed Me to win the bloody Super Lotto? Why can’t I heal my wife and son of their ailments (not to mention my loathesome summer cold)? Oh, yeah — I work in mysterious ways. I should know better than to question Myself.
Profound question for the evening: why is that the only pronouns we capitalize are for Him — the Big Guy — with one exception: I, I, I, I, I?
Back to my happy patients. As much as I’d like to believe I’m doing that spectacular a job, I know better. Truth is, many patients (especially those who haven’t been burned yet by the medical community) really want to believe this. A German friend once told me that in his country, there’s a phrase for doctors: Demigotts im weiss* = demigods in white. Folks want to think we’re either channeling God or we have a direct line to Him, no call waiting. It’s comforting to think that.
Kevin Sorbo as Hercules: another demigod in white
Scarier is the fact that many doctors believe this, too. Even those of us who understand our limitations have to admit we didn’t have the cleanest reasons for joining the biz. Yes, sure, I wanted to help people. But didn’t my fear of sickness and death have more than a little to do with it, too? And don’t I have (at some level) the irrational idea that my MD gives me a Platinum Card with the Lord? That I can, in fact, put off my own death indefinitely, just by being a doctor?
In the face of all this psychological weirdness, it’s tough as hell being agnostic.
And for you newbies, please don’t ask me if I’ve been saved.
So I feel the need to come out and say this, say it in supersized font, even though the folks who read this blog are smart enough to know it already. But here goes.
Doctors are human.
Pretty scary, huh?
D.
*Gabriele — did I remember that right?
Edward Jenner 1749-1823
Do the ends justify the means?In 1979, the World Health Organization declared that smallpox had been eradicated. The death toll for the 20th Century alone had been estimated in the 100s of millions. Over the centuries, smallpox had decimated populations, and had left many more blind and/or scarred for life.
So what can we say about the man who took the first steps towards the death of smallpox? Our cars should all have “What Would Jenner Do” bumper stickers, right?
Edward Jenner was an English country doctor who participated in the practice, common at the time, of variolation. Old, dried fluid from the sores of smallpox patients would be used to vaccinate people in the hopes of preventing smallpox. The variolated patient would develop a mild form of smallpox (usually), survive the disease (usually), and thenceforward be immune to bad-ass smallpox (always). Variolation spelled trouble, however, since the freshly immunized patient could spread the disease to infants and the elderly — basically, anyone with an imperfect immune system. And, as those ‘usuallys’ suggest, the process was not always benign.
Being a country doc, Jenner knew of the widely held belief that women who milked cows were immune to smallpox. He reasoned that these women were developing cowpox, a similar but far less lethal disease, and that this gave them immunity to smallpox. He took this idea and ran with it. First he experimented on his own son, Edward Jr., using swinepox. Later he would focus on cowpox, and his subjects seemed primarily to consist of women and children. (There were a few men in the bunch, but this article suggests the preponderance of his subjects were children and paupered women.) His methods were always the same: he would vaccinate them cowpox, and later try repeatedly to infect them with smallpox.
His theories were sound, his method saved lives, and now, most everyone regards him as a hero. Apologists like Dr. Tom Kerns bend over backwards to prove that Jenner’s methods were ethically sound. But the guy experimented on children, and on women who were pregnant or nursing. This bothered the hell out of me when I first learned about it in medical school. It still bothers the hell out of me.
I’ll ask it again — do the ends justify the means? If you want to torture yourself with that question, I can’t think of a better case than Jenner’s. Think about it: he probably put only a few dozen peoples’ lives in danger. There are no recorded injuries or deaths from his studies. His work resulted in a far safer means of immunization, making life better for the millions of Europeans who adopted his method.
But, did he do the right thing?
D.
PS: Bare Rump is still MIA in Hollywood, but her lover, Lord Valor, AKA Captain Argh, has updated us on his efforts to rescue her from the clutches of the Rabbit.
And you thought I was all serious today ;o)
Let’s say you know this young woman named Angela. Perhaps she’s the niece of your best friend. Angela’s a good kid — never arrested, never even got drunk. Always so serious, too.
You weren’t at all surprised to hear she’d been her high school class valedictorian, or that she’d been accepted to a top university. You’re getting used to hearing regular reports of Angela’s greatness. Roundly praised by her professors; gets straight As, and finds time to do volunteer work; has a boyfriend, but she’s so focused on her studies that their relationship may be in doubt.
Lately, you’ve been hearing some disturbing things about Angela. She fell in with a different crowd, a group that’s taking up all her time. Her mom is worried sick about her. Says Angela lives on fast food and Twinkies, stays up to odd hours with her nose buried in books of arcane lore, never talks to her old friends, and rarely talks to her parents. When her mom does manage to get her on the phone, Angela seems distracted, and often uses language no one can understand. She’s learning so much from her teachers, she says; and yet her mother sees her drifting farther and farther away.
Her parents had their 20th anniversary last week, but Angela missed it. Said she was too busy to even remember to send a card. Her college boyfriend? He’s history. Angela won’t even return his phone calls or letters.
It gets worse. Her parents hear she’s doing things to people now. Hurting them, often with casual nonchalance, and joking about it afterwards with her friends. She has an almost religious fervor when she discusses her experiences — with dead bodies. She goes up to perfect strangers, asks them highly personal questions, then touches them in inappropriate ways. And she has the nerve to call this a history and physical.
On the very first day of my class’s orientation to medical school, we had a formal Grand Rounds presentation. The lecturer, one of our medical professors, presented the history of a young mother recently diagnosed with breast cancer. Her treatment involved a mastectomy and post-operative chemotherapy, and although she seemed to be doing well, her cancer was high grade. He discussed her chances of survival and they weren’t great.Throughout the professor’s monologue, the patient stood at the front of the lecture hall in a hospital gown and jeans. He finished the history, then asked her to take off her gown so that he could examine her in front of us. After he finished, he dismissed her with a simple thank you. She put her gown back on and exited down a side aisle.
The strange thing about this 22-year-old memory: I’m not sure how much of it is real and how much is imagined. I’m certain the woman was present throughout the professor’s third-person run-down of her history, but I don’t remember if she disrobed. But to me, it felt like she’d been disrobed. Is that why I remember it that way?
I also recall wanting to run after her to apologize. I doubt I was the only one who felt that way. A room full of 80 first year medical students on their first day of school, and not one of us ran after her.
I’m not the only one to see medical school as a form of cult indoctrination. This link goes overboard, I think, but the author raises several valid points. Nor is the problem limited to medical school: all graduate programs may share this to some degree.
That Day One Grand Rounds exercise was not accidental. Head first, we were thrown into the objectification mind set. These are not fellow human beings; they’re patients. You care for them, but don’t let yourself care about them (except in the most generic sense of caring). You develop calluses, but you must never appear callused. Empathy is not one of your better human qualities; it’s a healing tool, and it can be honed if you make a deliberate effort.
Most humans don’t touch dead bodies, let alone carve them to pieces. Most humans don’t ask strangers personal questions, step inside their personal space, touch them in intimate places, stab them with needles, cut them with knives.
But us folks in health care aren’t most humans.
Imagine walking up to someone who is barely an acquaintance — perhaps you’ve talked with him five or six times in the past, but never for more than five or ten minutes — and having this discussion with him:
“Your cancer has recurred. Unfortunately, you now have a decision to make. You could undergo a painful and maiming operation which will leave you forever changed, and you might still die from your cancer. You could let the cancer kill you, but it’s an ugly death by slow suffocation or, if you’re lucky, a quick hemorrhage. Or you could kill yourself.”
Many doctors skip this conversation. They tell their patient what they should do and leave the second and third options to the patients’ imagination. I was taught not to dictate to my patients, but give them all the information necessary for them to make a choice. Consequently, I’m sometimes obliged to have the above conversation, more often than I’d like.
But — damn it — it isn’t natural.
My patients like me, most of them. I’ve had few angry letters and fewer death threats. When it comes to bedside manner and patient rapport, I get high marks; I play the game, and I play it well. I’m an accomplished actor — I’m on stage eight hours a day.Medicine is a tight-rope act. Don’t care enough, and you’re a shit heel; care too much, and you burn out like a Fourth of July sparkler. Sometimes, I think I’m pretty damned good at walking that tight rope.
Other times, I want to hop off the rope, run after that young mother with breast cancer, and apologize to her. Like any normal human being would do.
D.
I gave my first deposition ever today. Afterwards, the lawyer for the defendant told me, “You’re the best witness I’ve ever deposed when it comes to understanding questions with negatives in them.” The plaintiff’s lawyer agreed. (And I’m thinking: Erm . . . that was just a compliment, right?)
Can’t divulge the details because, after all, that would be violating doctor-patient confidentiality. Let’s just say it’s a case of the little guy going up against The Man. Or, maybe it’s a case of the little guy trying to make a buck off The Man. I don’t know, and I don’t need to know; that’s the beauty of being a witness (rather than a defendant!) All I had to do was tell the truth. I love telling the truth. I could tell the truth all day.
As long as I’m in super-honest mode, this deposition wasn’t held in a courtroom, as the above title would suggest. But “What I learned in some poorly ventilated downtown office” makes for a crappy title. So there.
***
Let’s say you’ve been wronged by The Man. Here are some dos and don’ts I learned today, simply by being a careful observer of the lawyers’ questions.
1. Don’t waste any time getting to a doctor. If you wait even a day before seeking attention, it looks suspicious.
2. Don’t trust the doctor to write down the things you tell him. Look over his shoulder. Come right out and ask him, “Hey, did you write down that bit about the salted bamboo shoots under my fingernails? And the Cajun spice-and-Pepsi Cola nose wash — Jeez, what’s the matter with you? YOU MISSPELLED EMERIL!”
(Note to any legal-type person connected to the case who reads this. That last quote was make believe. It’s what we writers call a stab at humor.)
3. Do make sure you tell your doctor about every last symptom. Don’t hold back.
4. Do tell the same story to each and every doctor you see. Inconsistencies will bite you in the ass.
5. Do hire the smartest lawyer you can afford.
***
True story:
In my first week of my first clinical rotation of medical school, I examined a young child with an injury. The boy came from a broken family, and was the rawhide chew toy in a bitter custody dispute between two pit bulls. The injury occurred while he was in his father’s care. Dad claimed one mechanism of injury, Mom claimed another.
The child’s mother brought him in for the visit. After the clinic closed, the father found me (somehow) and begged me to write something favorable on the chart for him. Stupid, ignorant medical student that I was, I did as he asked. I changed the chart.
Some time later, I was subpoenaed to appear in court to testify (at a custody hearing) as to my chart entry. No one bothered to depose me prior to the court date. Maybe custody hearings don’t warrant that much work. Anyway, five minutes beforehand, a couple of lawyers cornered me in the hall.
Lawyer A: How many years have you been a doctor?
Me: I’m not a doctor. I’m a medical student. That means I don’t have an MD yet.
Lawyer B: Okay . . . how many years have you been seeing patients?
Me: I’m in my first clinical year. When I saw that patient, I was in the first week of my first clinical rotation.
Lawyer A: I don’t think we can qualify him as an expert witness.
(That story always makes me chuckle.)
In the courtroom, I answered all of their questions honestly, and when the time came, I fessed up to fanoodling with the chart. Afterwards, the judge just about patted me on the head, and both sets of lawyers seemed delighted with me. Funny thing, I’d thought my testimony was damaging to both sides. Mom and Dad sat on opposite sides of the aisle, and they both beamed smiles at me, too.
To this day, I’ll never figure out what I said that made them all so damned happy.
D.
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