Category Archives: The Barbarous Craft
That’s what we used to call it in residency . . . so named because it would punctuate the ubiquitous comment in the nursing notes. As in,
Mr. Ramirez’s IV infiltrated and had to be removed. Unable to give 2 AM dose of labetalol. Current blood pressure 224/110. MD aware.
It’s the ultimate ass-cover. The doctor knows about all this and no orders were forthcoming. And if the 1:50 AM phone call was only, “Doctor, Mr. Ramirez’s IV doesn’t seem to be working,” the note in the chart makes it a he-said she-said situation. Worse: the nurse’s note is in black and white, and if the doc tries to correct things the next morning, it looks like fighting in the chart — a classic “gimme” for the malpractice lawyers.
We had another saying in residency: “They can always hurt you more.” Applies to patients, ERs, nurses, call centers. Sometimes it makes me long for the bad old days when we were truly resident in the hospital. If you were there, you could assess the situation firsthand. You didn’t have to depend on someone else’s report. Reminds me of how in med school, on an internal medicine rotation, we’d sometimes make ICU pee rounds, checking folks for their urine output.
There were good reasons for this, but they escape me at the moment.
But you know, you have to have a life, too, which means you have to trust other people to do the right thing. And by and large they do.
D.
(No, nothing bad happened . . . but calls in the middle of the night always make me think about this issue.)
Kudos to Dr. Karen Weatherby, who has proven that staring at cleavage can add five years to a man’s life.
And now some funky formatting wherein the blockquote falls below the photo. Okay . . .
Weatherby explained the concept stating, “Sexual excitement gets the heart pumping and improves blood circulation. There’s no question: Gazing at breasts makes men healthy.
“Our study indicates that engaging in this activity a few minutes daily cuts the risk of stroke and heart attack in half. We believe that by doing so consistently, the average man can extend his life four to five years.”
In addition, she also recommended that men over 40 should gaze at larger breasts daily for 10 minutes.
SO, let me get this straight: next time I get caught doing this, I can claim it’s for my health?
D.
Currently reading Dexter by Design on my wife’s eBook reader. At Kizer Kamp this week, lots of people noticed it and said, “Oooh, is that a KINDLE?” No fraid not and it ain’t a Nook, either. Wish it were, since black-on-gray kills my eyes in dim light. I’m not young anymore.
This Dexter is slickly written, or at least I thought so until Lindsay sent Dex traipsing off to Cuba. Lindsay’s Cuba pales besides memories of Martin Cruz Smith’s Havana Bay. Speaking of which, am I really going to have to wait until MARCH 2010 for Smith’s next Arkady Renko novel? (BTW, what a crappy blurb.) Dex in Havana? The book stumbles into a crawl just as it should be zooming along. Still, it’s been a fun novel up until now.
Something I learned the other day at Kizer Kamp: Disneyland has closed It’s A Small World. Why? People are too fat. They’ve been bottoming out the boats. But that’s okay — that ride sucked donkey balls. Even when I was five, I couldn’t see the point.
Women are fatter. I wish I could remember the stats, but I think it ran something like this: average American woman’s weight in the 1950s was under 140 lbs; now it’s 170. To me, even 140 sounds heavy, but then I’m married to a ninety-pounder.
Happy patients today, some deliriously so. Some of the happiest patients you’ll ever meet are the ones who have parted with their unholy tonsils. Bill Cosby had an old routine wherein the young Bill would question the doctor, Why do I need to have my tonsils taken out? The doctor replies, Son, tonsils are like soldiers fighting in a vicious, bitter war . . . and yours have joined the other side.
So true.
Sometimes I look at my blogroll, and it’s like looking at a reflection of an earlier me. A fossilized me. Where are some of these people nowadays? Some of them haven’t come around in years. Nor have I visited their blogs. Why do I hang onto them? Is it just inertia?
Karen’s watching Shadow of the Vampire. What a fun movie!
D.
One of my favorite things to do in the OR is remove nasal polyps. Got to do it twice today — so this was a very good day indeed.
This is how polyps look when they’re inside the nasal cavity:
Imagine trying to breathe around that.
Here’s how polyps look after we’ve yanked ’em out:
I like removing polyps because it’s a relatively safe and easy (albeit potentially bloody) thing to do, yet it creates a singularly happy patient. These are folks who have had to put up with facial pressure, sinus infections, and often severe nasal obstruction for months or years. The relief they get can be overwhelming.
Chronic tonsillitis patients are similarly pleased, but the operation is so painful it often takes a month or two before they thank you. Nasal polyposis patients are often delighted as soon as they recover from the general anesthesia.
No one knows what causes polyps to grow, but they seem to be associated with chronic inflammation from sinusitis and/or allergy. Some folks with these conditions form polyps, some do not. Once they form, they’re like weeds. We can weed the garden, but we know they’ll be back. Provided we keep the patient as sinusitis- and allergy-free as possible, we can sometimes keep the polyps at bay for years.
D.
I really did. If nothing else, I had to rave about Charlie Huston’s conclusion to the Hank Thompson trilogy, A Dangerous Man, which was every bit as good as the first two books in the series. If you’re shying away from these books because you’re not a fan of the hardboiled shoot-em-up genre, you don’t know what you’re missing, because this story is so much more than that.
But I am on call, and after a quiet first part of the week, I finally saw some action. Got called in for a pediatric foreign body, which was billed as dog food-in-the-nose and turned out to be peanut-in-the-nose. Big difference there, since a piece of dog food would tend to break apart with manipulation, might dissolve somewhat over time, and is, well, smaller than the average peanut. Peanuts, on the other hand, won’t dissolve, will tend to swell as they hydrate, and are HUGE compared to the size of the toddler nose.
I felt a little reluctant going in since I knew I wouldn’t have the right tool. The right tool is a right-angle hook, a delicate but strong instrument perfect for getting behind something and pulling it out. All they had at urgent care was an alligator forceps (so named for the way the jaws of the forceps are shaped, and the way they open), which was all wrong for the job.
I kludged together three right-angle hooks at home, one from a fragment of clothes hanger, two more from lengths of copper wire, but all were far too big and nasty for the job. In desperation, I went through our Big Black Box of Goodies, which is primarily stocked for stopping nose bleeds, draining pus, and suturing lacerations. And lo and behold, like a gift from heaven, I found (separately wrapped, nothing else like it in the box) the perfect right-angle hook.
After that, it was a simple matter of overcoming the feeling that I was the reincarnation of a gestapo torturer long enough to dig this thing out of the child’s nose. Half the peanut came out with my instrument. When the kid sneezed, the other half beaned one of the nurses assisting me. Hazard of the profession, I guess.
Mom was happy, the nurses were happy, and the child was relieved if not happy. Mom made her thank me, though. I’m not sure how I feel about that. It’s kind of like making your kid thank you for administering corporal punishment.
Anyway, that’s how my weekend started. And you?
D.
It used to happen all the time up in North Coast Country: I’d be in the gym, in the store, on the beach, you name it, and a patient would recognize me and say hi. The supermarket was particularly rich with my folks. Got so that sometimes, I’d have to steer the shopping cart down alternate aisles to avoid people I didn’t want to greet. (One guy who had once made a death threat cornered me, apologized profusely, then begged me to take him back as a patient. This was in the dairy section.)
I never expected it to happen in Bako, which is a much larger town. But tonight in the locker room of my gym, a man recognized me. He said, all smiles, “I KNOW YOU!” Since I’m not presently posting nude photos in the personals section on Craig’s List, I figured he must be a patient of mine. I said, “Sure, I’m your doctor!” And I was right.
Kind of a good feeling, really.
D.
I doubt many of you still check the Other Blog since I haven’t posted there in months. I haven’t posted there in months because that’s my place to bitch about work, and I haven’t felt the need to bitch.
Things are actually pretty good.
Today, I had two separate docs — one an internist, one a pediatrician — tell me they’re very happy with the feedback they’re getting from their patients. Both invited me to come talk to their groups. Not that I enjoy lots of extra work preparing talks, but educating one’s referral base is a useful thing to do, and it’ll be a great way to meet my colleagues (also known as the people who will one day vote on whether I make partner).
I’ve got back the first round of numbers from patient surveys. They grade you on a one to ten scale on a variety of questions. How well did your doc explain things to you, do you feel confident in his abilities, did he use language you could understand, etc. The Kize wants us to get 8.5 or better, and all of my scores except one were above nine. My one “low” score, which was still better than 8.5, was for the question, “My doctor was familiar with my medical history.” So now I make a point of dropping info to prove I’ve been snooping around their charts. Sneaky me.
They keep me busy. The schedulers overbook the day, figuring on a certain percentage of no-shows, so it’s a bitch when I have no no-shows. When I was in private practice, my patients didn’t often no-show because word had gotten out that I would discharge patients for repeated no-shows. Can’t do that at the Kize, of course, but I suspect my no-show rate won’t be that high, at least not for my followups. Most people like me. Anyway, I like it busy; the day flies by.
It’s taken a while, but I’m finally getting that comfy feeling I had back up north — the feeling that I know the ropes, I understand the system, and that I’m able to deliver for my patients. It’s one of the main things I hated giving up when I left private practice.
So life is good, which is great for life but crappy for humor. Which, after all, thrives on pain.
D.
Middle of the night come to the ER at once emergencies get my adrenaline running. It’s a necessary rush: I need the jolt of epinephrine to wake me, get me on the road, keep me focused.
But when the ER calls me for a middle of the night get here right now emergency and I’m not the right doctor, all that adrenaline has nowhere to go.
This job would be a lot easier if people wouldn’t make mistakes like that. Took me two hours to get back to sleep.
D.
At our monthly meeting this afternoon at the Kize, they played for us the latest radio spot and TV commercial. The radio spot was unmemorable (something about the Bone Health program for seniors), but the TV commercial was a thing of beauty. Once it hits YouTube, it will surely go viral, and I’ll post it.
So, picture it:
A young woman and man stumble through the front door of a not-too-upscale apartment. Neither looks like an actor — they might have been nabbed off the street to appear in this commercial. They’re all over each other, convincingly enough that one of the docs in the room said, “Hey! You got the wrong video!” The two lovers fall to the floor in a passionate clench, disappearing behind a couch.
Change camera angle. They’re still in their clothes, but the woman sits astride the man. “Hold on,” she says. “Do you have protection?”
He whips out a condom and waves it, cheesy I’m-definitely-gonna-get-some grin on his face.
“But condoms aren’t 100% perfect,” she argues. “What if you have genital herpes, or pubic lice? When were you last tested?”
“Last week, and my doctor has already sent me my results.” And now he whips out his laptop, which is already fired up and the Kize’s patient home page is there and he’s tap-tapping away showing her his test results.
She makes a sort of “Wow!” sound of awe, takes the laptop from him, and tap-taps away, looking at her BF’s test results.
There’s some sort of voice-over about how Kize patients can go online to email their doctors, change appointment times, check test results, etc., but no one will pay attention to that. Everyone will be looking at the guy rubbing his hands together slowly, wearing the look of the cat who is about to eat the canary.
Two of the older docs quipped, “Hey — what? I don’t get it!”
D.
At our hospital in Antioch, a great big picture of Sidney Garfield decorates the lobby’s wall, side by side with photos of one of his first hospitals and quotations regarding his philosophy of medicine. The man was a visionary, recognizing in the latter days of the Great Depression the fundamental illogic of fee-for-service medicine and recognizing that a system providing incentive to keep patients well would ultimately benefit everyone.
At the retreat (my retreat, not Jake’s), they handed out a book to every one of us: Courage to Heal by Paul Bernstein, a fictionalized account of Garfield’s early days in medicine, his nearly disastrous attempt to found a hospital in the middle of the Mojave Desert to take care of aqueduct laborers, his introduction to Henry Kaiser, and the work they did together to change medicine. These guys came up with the idea of a health maintenance organization when those words still retained their meaning: a network of health care providers, facilities, and insurers whose business is most successful when they keep their patients healthy.
Nowadays, HMOs are often considered sharks that want to take premiums and administer as little care as possible. Speaking as someone inside the system, though, that’s not how Kaiser Permanente functions. They really do want their patients to stay healthy, and there’s an ass-ton of emphasis placed on preventive medicine.
Yes, I drank the Kool-Aid. I’m a believer.
When I learned that the Kaiser-Permanente model was conceived by a landsman, the son of a Russian Jew, who if not a socialist was at the very least considered a socialist by the medical establishment of his day, I got that warm and fuzzy all over feeling. I’m part of an organization that shares my attitudes about caring for people. I’m part of a pro-labor outfit, one that has been pro-labor from the start. I’m doing good. I’m part of the solution. And it doesn’t hurt the warm-and-fuzzies that they pay me well and give me great benefits for doing good and being part of the solution.
The book is mesmerizing — not because it’s well written (it’s not), but because the story itself is compelling. But the author is unapologetic about being inventive; this is a novel, and he comes right out and tells you in the acknowledgments, “I have tried to respect history wherever doing so served my purposes as a novelist, but wherever it did not I have, cheerfully, and without regret, ignored it.” So there’s no telling how much of this is BS. I figure the love story is probably all hooey, but the bones of the story are probably true.
Not to worry, though, because Tom Debley and Jon Stewart (not THE Jon Stewart. The OTHER Jon Stewart) have written a more factual account: The Story of Dr. Sidney R. Garfield: The Visionary Who Turned Sick Care into Health Care. Yes, I’m going to buy this puppy, even if it means I have to buy it from Amazon since Barnes and Noble doesn’t have a copy available. I figure it will be fun to learn the boundaries of Paul Bernstein’s creative license.
And besides, after a while, Kool-Aid’s addictive.
D.
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