That's Not What I Said

i noticed recently that when my family members and friends are having health crises and are retelling the stories or asking my opinion, they will tell me VERBATIM what their doctor said. like, "he says it's not an exact science" or "he said we'll have to wait and see." and then they'll reflect on what the doctor meant when he said that, what he might be missing or withholding, and what might be hidden in the message.

so the words we practitioners use matter. a lot.

this is why, when we were trained to do the female gyn exam, we were told to use only the words "healthy and normal." stick with those adjectives, less you worry them ("uh, huh, hmmm") or creep them out ("your labia looks nice" is not a good thing to say).

and know that they are hanging on every word you say. so be cautious. be wise. and be equally aware of non-verbals. a simple glance toward the door or out the window might tell a patient you are impatient to leave them and don't care about their plight. or, it might tell them that you're hiding something or nervous to share bad news with them. when in fact it might actually mean that you thought you heard the tow truck leaving with your double-parked car. on the flip side, when giving bad news, you have to be direct and sympathetic without giving false hope or no hope. it's a very tricky thing to do.

and i'm the same way with my MD's, by the way. when i'm pregnant and my ob/gyn says things are "perfect" (his favorite word), my heart beats a little more evenly.

words matter. which is why accents or unmatching dialects are challenging for both practitioner and patient. and why you have to try to unload your own personal stressors before encountering your patients. they might just pick up on them and think your mood has something to do with them. not easy. but important.

Should We Have to Pay for Our Decisions?

some companies give health insurance credits/premium reductions to those who make healthy choices. not smoking, not drinking in excess, exercising enough, normal BMI and healthy food choices, wearing seat belts, etc.

but what if our government, once they are the even more dominant insurance carrier in the country, does the same? are we ok with them knowing how fat we are? if we smoke? choices we make for ourselves and our children? hmmmm....

and, how far will we go in encouraging preventative measures? an interesting op ed piece on cnn.com today questioned just that, in reference to vaccinating from diseases. they use the example of an unvaccinated child traveling to europe and bringing back the measles in 2008, causing an outbreak of measles in san diego. you should read it, but the gist is, vaccines are cheap, illnesses are expensive. and you have to consider the cost not only of the unvaccinated patient with the illness but also all those who catch the illness from said child and need to be treated themselves, or those in quarantine away from said child. all this medical care and time off work for the parents could have been prevented with a simple, cheap vaccine.

so should those parents not be charged more for health insurance if they're deliberately electing to go against medical advice and to put their family (and others) at greater risk of health issues/cost? this is assuming that we're looking at a future where you get perks for being healthy, conscientious families and get penalties for being families who smoke or are obese, or are otherwise at increased risk by their own choice.

food for thought.

More Sad Outcomes

busy hospitals, understaffed, undercaring...who knows. but this article today on how a serious bacterial infection grew across a child's face as her parents watched in horror while sitting in an ER waiting room...sickening.

is it imperfect? hell yes. is it an outrage? absolutely. is the system broken? obviously. but does it mean you should stop seeking medical help when you/your family is sick? no. she needed iv antibiotics and aggressive management in a hospital. she just needed it sooner.

so...if you're blocked or dismissed by a medical practitioner when you are certain something is wrong- what should you do? my advice- (and i know full well what i'm saying here, since i might be on the other end of this) go nuts on them. give them a comprehensive and emotionally neutral description of the severity of the situation first and then if you are continually pushed aside, have a shit fit. be a squeakier wheel. sometimes that's what it takes to get things done in this world. sometimes rattling the cage one more time makes us give a quicker or more complete review that might show something crucial.

and your instincts are important. and i know parents are always worried that they're over/under reacting, but if it just feels off and your kid is not acting like your kid, make your voice heard.

also, i would recommend choosing your facilities carefully. this article says you should go online and find which ER has the shortest wait time, but i would say, if it's something that doesn't appear to be life or death, go to an urgent care first. they will a) see you sooner and b) if it's really something bad, will call ahead to the ER and have an MD lined up to see you when you arrive and meanstwhile they can be giving you some treatment.

it is extremely awful that this little girl ended up with so much debility when the parents did the right thing by bringing her in and it could have been stopped sooner. i know that after this story got released today, all triage units in ER's and urgent cares across the country are evaluating their process. let's hope that makes a difference and saves another family this tragedy.

Did Y'all See This in the News Today??

once AGAIN. vaccines do not cause autism. amen.

and, make the right decision! and even if you have, there's a chance your kids are being exposed to kids who have not been vaccinated and are carrying around scary, archaic diseases and you don't even know it. find out (daycares are a little different than schools, ask yours if they allow for personal/religious exemptions).

Happy Almost Christmas

Times is Tough

there is a lot of worry lately as hospitals in our area are cutting more staff and slashing department budgets. often time PA's (and NP's, CRNA's, midwives) are the first ones cut, since we work directly for the hospital and cost a lot, but don't actually bring in our own clients like the MD's do.

most of the local hospitals that i know who have cut their PA depts end up hiring them all back because the MD's and other staff find that life is difficult without them. but the short-sightedness and new administration constantly coming in and reinventing the wheel and the frightening amount of red on the budget sheet is making all of us a bit nervous these days.

my plan is to ride it out. keep my head down and hope for the best. i think we're vital to the integrity of the surgical dept and that they'll figure it out, i just don't know how many casualties there will be between now and then. (gulp).

i have felt a little insulated from this economic crisis the country has been suffering for years. now i'm starting to look around my house and wonder what i can sell or burn or put into a soup. :)

What is On the BHE's Mind? Cow Farts.

sorry, sports fans. i've been super busy lately. so in light of my hectic schedule, the BHE has agreed to write a post about what he's been into lately.

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so i've been thinking a lot lately about what we eat and how it gets to our table. frankly, the research i've done shows some very significant issues in our food supply. and since 2/3 of all americans are overweight or obese, i think it's a good discussion for us to have.

the topic is wide-ranging, so while we can make good arguments about the safety and sanitation in the meat supply or the damage that pesticides can cause in our bodies, i'll narrow it down to cow farts. i don't know if you know this, but global warming is kind of a big deal. and we spend a lot of time discussing the impact of carbon dioxide and different ways we can reduce our carbon footprint. and that's all well and good. however, if you really want to have an impact in reducing carbon footprint, you don't have to become a smug hippie who drives a prius 10mph below the speed limit. you have to worry about cow farts.

why?

because cow farts are made of methane, and methane is made of carbon. and what's worse, methane traps twenty times more heat than carbon dioxide. the average cow emits as much greenhouse gas as the average car, and worldwide production of beef and dairy are expected to double in the next 30 years. you can see the numbers problem.

so what does this have to do with our food supply? the vast majority of meat sold in the american marketplace is grain fed. even if you reject the resources consumed in producing the grain as food for our food, consider that it gives our cows indigestion. and that makes them burp and fart all over the place. if we fed our food grass rather than grain, or even just a grain diet that mimics natural grass, we can reduce their methane production by nearly 20%. there are health reasons why grass fed beef is much better for you, too. you can read up if you get off on omega-3 to omega-6 ratios.

food for thought.

Chemo is Awful, But Gravel in The Vagine? Whoa Now.

http://pagingdrgupta.blogs.cnn.com/2010/10/14/how-the-ancient-world-dealt-with-cancer/?hpt=C2

really interesting article on how ancient societies faced/treated cancer.

i assume that one day we'll look back at chemo and radiation with the same horror that we look at blood letting, leaches, and, in this article, injecting gravel into hoo-ha's for uterine cancer. eck!

interesting anyway. :)

Veterinary Medicine Might Have Been the Way to Go

my dog won't stop getting injured. she is a retired greyhound and came to us off the track 4 yrs ago in good shape. but she has a tendency to get wounded just by passing by another dog or by running around our yard, or by stepping foot into the dog park. it's ridiculous. i know for a fact we've spent more on her out of pocket this last couple of years than we have on either me or the BHE.

and this week she had to get a claw amputated! the ligament and claw on one of her front feet. she's limping around all pitiful-like. this was clearly a bigger surgery than i would attempt, but i gotta tell you, for the minor lacerations, i am so tempted to sew her up myself. it's just that i don't want her thinking of me as the bad guy and i don't have a ready supply of lidocaine and stuff. i don't think we could train her to bite down on a strap of leather to get through the pain.

so for now, we're putting our vet's kids through college. you're welcome, susie and george.

Back in MY Day....

we recently launched an electronic (computerized) medical record system at my hospital. i know, i know, we are a bit behind the times. basically, instead of scribbling some illegible order that the unit secretary has to interpret and input into the computer system for the nurse to see and follow those instructions, now we just put our orders directly into the computer ourselves, and they go directly to the nurse's inbox. eventually, progress notes and everything will be on the computer. already, lab and radiology reports, vital signs, lots of stuff has been available exclusively on the computer, so this is just one more step to being paper-free.

there are a lot of positives to this. medication errors should be fewer, and any of us practitioners can access our patients' charts from any computer, which is convenient.

but, the system isn't very intuitive and a lot of people are grumbling. especially our, well, more seasoned physicians. one of my favorite surgeons is brilliant in the OR, but i doubt that he's ever sent an email. watching him attempt to input a simple order for tylenol is like watching a monkey try to do complex math.

things just change so quickly. in the 30 years this favorite MD of mine has been practicing, he went from a simple gall bladder resection taking 5 hours through a blurry, dark camera, cigarette smoke billowing through the halls of the hospital, and all the physicians being treated like gods, to a gall bladders taking 20 minutes, smoking not even being allowed on the hospital campus, and the docs being made to put their own damned orders in a complex computer system. ouch.

the other day i saw a nissan comercial for a remote car starter that uses your cell phone to start the car. for my generation, this makes some sense and doesn't seem all that frightening or sci-fi. but for older generations, this is straight out of the jetsons. it's just too bad that when you text your car to tell it to start, it doesn't fly to greet you at your front door. maybe that's next. :)

A Funny Thing Happened On My Way Into Work...

so, i see weird stuff every day at the hospital. it's just the nature of working with people, i think. people are weird.

yesterday, i saw flesh eating bacteria taking over some poor sap's entire backside before they bothered to come in to get it checked out.

today, i saw an RV parked outside the hospital in the employee parking lot and could totally see inside to some lady blow drying her hair!

what the what?

like i said. people are weird.

Mayhem, Murder, and Medicine

as we near the 5 year anniversary of the devastation of hurricane katrina, news stories and remembrances are popping up. above is a very tragic tale of desperate measures taken during the throws of hurricane katrina and the subsequent legal battle over suspicious deaths of patients. at one of the new orleans hospitals, apparently some 9 patients were not going to be able to be moved/evacuated, presumably because of their degree of dependence (i'm guessing ventilator patients? it never says), and so were given toxic doses of narcotics to facilitate death by the remaining staff physician and pharmacist.

i am dismayed, but not shocked for several reasons. i'm also not entirely sure it was the wrong choice by the caregivers...

during katrina in 2005, i lived in a small town in mississippi, about 3 hrs north of the coast. the hospital where i worked at the time took in patients who were evacuated from our sister hospital in louisiana. from these patients and their families, as well as in local news reports, we heard all sorts of awful stories about hospital wide power failure, then generator failure, and then death for those patients dependent on machines. i heard a lot about MD's having to make tough choices about who could use the remaining resources and who was most likely going to die anyway. there were wings of hospitals quarantined to house the dead and dying with no electricity, no air conditioning, 90 degrees and wet....it was a war zone. and only a scant few of the staff stayed behind to help and didn't evacuate with their families like they were told to do by the state.

things couldn't have been any more bleak and the situation couldn't have been farther from the norm under which these practitioners usually and comfortably practiced (presumably) ethical medicine.

i know i always tend to side with doctors, and i don't know the exact details of these cases. AND the families heart break is compelling. but STILL, if it was as i imagine, put yourself in their shoes... your hospital is drowning, your few staff members have been awake and working for days on end, many of your patients are dying, and you have a choice to either let these few patients who can't get out in time die slow, suffocating, miserable deaths, or you administer meds that will take them quickly.

if that was the situation, wasn't it humane and in fact 'doing less harm' to facilitate death?

you tell me. what would you do?

and then, here's a more happy story about a midwife delivering bebes during the storm.

Post Op Day 2, From the BHE

the OR is really bright and really cold. it took me two days to remember this, because anesthesia is retroactive.

i woke up from surgery on tuesday afternoon, and i'm glad to say the results are considerably better than the surgeon expected. he was able to remove 8 pounds of skin and fat that i wouldn't be able to exercise away or otherwise remove by my own effort. and my amazing wife tells me i look entirely different from every angle. so that starts to make the discomfort i've been in since then generally worth it.

i was told by the doc that i'd be "pretty sore" for about a week. and that's generally true, except that pain meds work. i have a pain pump delivering lidocaine directly into my abdominal muscles and i also have been taking a regular dose of vicodin. so my whole core feels very tight and my range of motion is severely restricted, but my actual pain level is really less than that of a sprained ankle. and that's a pretty crazy thought.

but i have to take a moment to commend the doc, the nurses, the techs, and even the transport personnel at MBH for taking amazing care of me. every single person i encountered at MBH had a big smile and a deep well of concern for my well-being. i felt like a VIP (i kinda was), but i also think my level of care wasn't that much greater than what anyone else receives at MBH. and that is pretty impressive.

most of all, though, i owe a tremendous amount of love and gratitude to the regular author of this blog. she has been incredibly supportive of me from the time i started to losing weight, through keeping it off, through running a marathon, and now through the decision for surgery and my aftercare. she is a model of love and sacrifice, and i'm incredibly blessed to have her.

Post Op Day 1

surgery is done and he's home and feeling pretty good and looking AMAZING.

more details from the BHE to follow.

Guest Blogger: Transmissions from the BHE

hello from the BHE! my former-PA-student-and-current-practically-a-doctor wife has asked me to share about my experiences leading up to what is a very exciting day tomorrow.

i am having abdominoplasty surgery to remove excess skin from my midsection (which she mentioned in her previous blog, "to cut or not to cut"). in fact, i just received a call that i was rescheduled from 9:30am to 7:30am. i have to be to MBH at 6am.

for as much as i've been really excited about results, i'm also a little nervous. i have no relevant experience upon which to base my expectations.

i grew up fat. i was a fat little kid, i was a fat high-schooler, i was fat in college, and i was fat as a young man living his own life. for brief moments, a couple times, i had lost enough weight that people noticed. but i could never sustain the weight loss, and i've always been fat. at my peak i weighed 285 pounds. and then i got married fat. with her help and encouragement i was able to work all that weight off and reach a minimum of 199 pounds. and since then i've put on 20 pounds of muscle. i'm at the peak of my health. i've run a marathon, two half marathons, two 25k races, three sprint triathlons, and an olympic triathlon. i've kept the weight off for four years. i'm ready for the operation. but i've always been fat, so i don't know what it will look like not to be.

the process of elective surgery has been very interesting. there are a lot of procedures and precautions that have to be taken beforehand, and there are a lot of preconditions that need to be met in order to undergo what is very major surgery. surprisingly, because i'm spending a night in the hospital, i'm eligible for FMLA leave, and short term disability insurance, which means i'll be getting paid for about half the time i'm out. it seems a little wrong, but after paying for the surgery in cash, we really could use the money.

i think it will be most fruitful to compare the information i've received and the process i've gone through to this point after the procedure. but i can't help but be impressed with the amount of information that both my doctor and the hospital have been able to convey to me in a very approachable way. but we shall see if the two align tomorrow.

How Would You Design Your Brain?

i would be able to ballroom dance really well and i would speak several languages fluently. i would have a WAY better memory for details and, specifically, things like geography and how to spell werds correctly. i would take out some laziness or complacency and replace it with gettin'-after-it-ness and the tendency to act now instead of sit around for a while instead. i would have already read and retained all the great literary works. i would take out the think/say mean things about other people part and put in more, be-kind-to-them-this-may-be-their-first-time-driving-on-the-street-with-other-cars part. i would greatly enhance the "likes to exercise"part. i might take out the "enjoys peanut butter directly off the spoon and has been known to dip it in chocolate chips and just go nuts for a while" part. i would lose some insecurity and gain some peace of mind.

The World Is a Dirty Place

when you go into medicine, you know you're probably going to get some human waste on you at one time or another. i remember warning my little sister about this when she was considering going into nursing. i promised her that any number of colorful bodily fluids would end up finding their way to her clothes, skin, possibly and awfully, into her eyes/mouth. not at all pleasant to consider, but definitely does happen.

and that's not even counting that funky spunk that could be in said fluids.

yesterday, i was doing a PICC line (peripherally inserted central catheter), which is a fairly invasive, bloody procedure, on a patient with hepatitis. no accidental needle sticks or scary oopses occurred, but this happens not infrequently that we are at risk of exposure. we health care professionals do procedures like this and surgery on patients with hepatitis, HIV/AIDS, chicken pox/shingles, MRSA/VRE, tuburculosis, etc, etc quite often.

we use this safety protocol now called "universal precautions" which means we pretty much never should be touching a patient without wearing gloves. and if they have any known current infection (in lungs, on skin, in stool, etc), we might also wear a gown and mask. but it can get pretty lax. in the OR, we all wear sterile masks, gowns and usually 2 pairs of gloves and we're uber careful when passing/using knives and needles. but i must admit that if we know a patient has a blood borne infection, we proceed with extra EXTRA caution.

lately, everyone in my department has been trying to get pregnant. and though we get fairly cavalier about the whole exposure thing when we're only putting ourselves at risk, it's a whole other ball of wax when you're talking about a vulnerable fetus inside you. in addition to all these nasty pathogens, we work in a fairly hostile environment for growing bebes. cement and xray are both known teratogens and we do our best to stay out of cases that use them (total joint replacements, fracture repairs, etc), but it's a challenge.

some days it feels like to be totally risk-free i would have to leave medicine all together. which i'm not going to do. so i guess you do your best to protect yourself and don't take undue risks while also not living in total paranoia.

no problem, right?

Gross. And Sad. And Gross.

it seems like lately at work, i've been surrounded by more death and dismemberment than i am comfortable with. every time i go down to the cafeteria for lunch, just minding my own business, trying to get a sandwich, there are undertakers in black suits in the morgue hallway, transferring a bagged body onto a gurney.

why you ask is the morgue near the cafeteria? i think it has something to do with refrigeration.

heh....bleh.

it puts me off my feed, but it also is a painful reminder of the gravity of the work that we do. even though all lives will ultimately end in death, and we know this...i can't help but feel a little bit like we failed that one who's being wheeled away, since one of our core tasks as health care providers is, you know, making people stay alive.

most of my days involve elective surgery for hernias or gall bladders...or even for more harrowing things like breast or colon cancer...still, typically, our patients are fairly well when we get to them, and most of them go home at the end of their hospital stay without major problems.

but this week, i had to help amputate a foot for gas gangrene. the patient will hopefully survive, since we got to him soon enough (barely), but part of him will be sent to the morgue.

if you have a clearly infected limb (discolored, bad smell, redness/blackness, hot/cold to touch, non-healing sore, fever) GO TO THE ER. DO NOT WAIT.

i don't want any part of you to be sent down to that cold hallway near where i make my salads.

right then. so we've agreed on that.

5 Babies Have Died From Whooping Cough in California...If Only We Could Have Prevented this Tragedy

tetanus (vaccine= DTap) polio (vaccine= IPV) pertussis (vaccine= DTap)


this just pisses me off.

living in fear and making dumb decisions out of ignorance. how many times do we have to explain that vaccines have not been shown to be linked with autism? and yet people are still not vaccinating their kids. how many ways do the folks associated with the original publication have to rescind their opinion and demonstrate that further studies don't back up the link? how many kids have to be maimed or killed from these awful (SHOULD BE ERADICATED) illnesses? what is wrong with people??

my fear for the kids in our country is this: as long as only small pockets of people aren't inoculating their kids, those kids should be safe, since the rest of the country is covered and won't spread the diseases around...BUT, if this community of un-vaccinated kids gets bigger and, if in our well- traveled, global community, they are exposed to kids from other parts of the un-vaccinated world, these nasty bugs will be shared among friends and we will have epidemics and lots of childhood death here. that were preventable. big kids might just get sick or end up with disabilities. but babies die. and all that sucks. and is preventable.

please read this article from cnn last week. it covers the whole vaccine scare controversy and there's some interesting added juice about how the spear-head MD from the original article that started everything was working for a competing vaccine company and was in it for greed, etc, etc.

the doc i scrubbed with today spent some time doing medical missions in africa and saw the damage that things like polio and measles and tetanus can cause. he said the middle bottom tooth of all the adults is removed so that WHEN they get lockjaw from tetanus, they can still get food and water through the gap. that is how prevalent/expected/normal it is there. this MD has been practicing in the US for 20 yrs and has NEVER seen a case here. we do not expect it. because we have forced it out of our community with vaccines. this generation has no idea what these deadly and mangling illnesses look like. check them out above. not pretty. and those are only a few of them.

please get your kids caught up with their vaccines. for their sake and for that of their friends, family members, classmates, neighbors, and, most importantly, my future children. :)

at the very least keep reading and asking questions about it. check your sources when you're reading "compelling evidence" against vaccines. here is the current cdc recommended vaccine schedule. it's big and complicated. you can also just go see your pediatrician. and i am happy to help find any info you need or do any research to answer questions/discuss these issues.

Good Doctor? Bad Businessman?

so i've twice gone to this dermatologist for various little skin shtuff. i happened upon him because he was on my plan and was extremely local to work.

nice guy. young. clearly a new grad. i know this in part because when i call, i get in within a matter of days (not months) and when i arrive, i wait a matter of minutes (not hours).

he's sort of goofy. i think i mentioned this way back when. when i was complaining about my dry skin patterns on my hands, he showed me how to "fake" scrubbing my hands for surgery, or recommended that i quit my job and find something that would be less traumatic for my hand skin. right.

so, he's a little different. and....either he's supremely ethical and is a trust fund kid with no med school loans, or he simply hasn't caught on yet that he might be inadvertently putting himself out of business.

exhibit a) steroid cream for my eczema/psoriasis itchy winter stuff. most derms i've seen in the past give you a script for wee little pocket size doses of the precious. it lasts about 2 days, covering about 1/8 of your skin problem, and you have to go back to them to get more. this guy gave me a shitton per order with multiple refills- putting himself out of an office visit to get new scripts.

exhibit b) today i went to deal with some plantar warts that have been on the bottom of my feet for an embarrassingly long amount of time. they don't bother me, and i forget they're there until the BHE has my feet in his lap as we do, and he starts making gaggy faces when looking at said warts. they're tiny and not in painful spots, but none the less, to avoid the gaggy faces, i went to again see this doc. he explained that unless i get padding for my shoes and can avoid rubbing those spots and building calluses, wart burning/freezing/excising won't do any good. he gave me instructions on a $10 fix from the drug store and said the warts will either go away on their own or an over the counter remedy will likely cure them. so i was sort of annoyed that he got my $20 copay for just advice and no magic treatment, but he gave me a good 15 mins of his time and a cure instead of a quick fix. but if i follow his instructions, there will be no need for me to come back to him.

maybe that's his trick. maybe he knows that people are non compliant and we will always be back as we will never practice real prevention as we're told. hmmm....

but i appreciate his honesty. he kept saying that he could burn/freeze/dig them out, but they'll just come back until i fix the root problem. and he seems genuinely interested in doing that.

so i like him for his integrity but i do worry for his longevity as a business owner.

thoughts on this?