wm carlos wms memorial blog

and in flew enza

2009-06-20T12:33:00.003-05:00

so i caught the swine flu. and it was okay.

just kidding. it's not okay.*

*one healthy 14-year-old cheerleader and two grown-up ladies, one healthy (and same age as me) and one not, have died from "New Flu" in our fair city so far. these three were supposed to have been the only deaths in our state, but then an immune-deficient sixth-grader died a couple days ago up north, 2 weeks after the local paper reported "swine flu threat fizzled." so i guess the numbers are outrunning the news.

i exaggerate when i say i have the flu; i was merely exposed. the occupational medicine people at my workplace will let me know pretty soon whether i'll have to take some o' that there anti-flu medicine**, as mandated by the cdc.

**interestingly, in japan, one of the side effects of the medicine has been teenagers "leaping off buildings immediately after taking the medicine".***

***overuse of the medicine will inevitably produce drug-resistant flu viruses. however, if the virus to which i was exposed is drug-resistant, then the medicine might**** make it harder for me to spread it by coughing or sneezing on people. it wouldn't affect how far i'd spread it by not washing my hands, however.

****"might" being the operative word here. it hasn't really been studied in humans with h1n1, just in guinea pigs with other flu viruses - and guinea pigs neither cough nor sneeze when they get the flu.

my friend who works at the children's hospital says it's mass hysteria over there, with 2 recent deaths (rumor? or not publicized?) and multiple kids in the ICU. she said i shouldn't worry: "i'm exposed to it 50 times a day. you're young and strong; you won't get it." i replied, "i'm 48 and have mixed connective tissue disease." "shush," she said. "you're young and strong and you will not get it."

on google, "Your search - "Physicians Exposed to H1N1" - did not match any documents."
however, google does offer these evocative headlines:
Colo. Health Officials Test Traveling Youth Choir for H1N1 Virus
3 teens in city juvenile center have swine flu, state says
2 Cases Confirmed in Boy Scout Camp Swine Flu
Respiratory Therapist Tested Positive For H1N1
Old People May Be Immune to Swine Flu
H1N1 flu less likely in Gaza due to siege
Trip To China Ruined By H1N1
and:
FDA Targets Fake Web Claims for H1N1 Products
...Since May 1, the agency has identified 104 such claims and products marketed on the Internet that weren’t authorized by the FDA.
here are some examples (not linked, but you can google 'em):

the photon genie: "an advanced, proprietary processing of full-spectrum frequencies and infinite harmonics... delivered by both an ionized Noble Gas energy-transmission and deeply penetrating mega-frequency life-force energy waves."
$2,995

silvercure: "created to protect you by leaving a thin layer of electrically charged micronized, anti-microbial silver ions on your skin and scalp... combating bacterial and viral infection at the moment of contamination."
price for the "swine flu protection pack" no longer listed, but the (plain ordinary?) protection pack is
$130.

flucinex: "four unique strains of active living cultures delivered in a titanium dioxide capsule technology. We're going to send them directly into your small intestine before we let them out to colonize and multiply. Take Flucinex twice daily during flu season... You will have an excited immune system."
60 capsules $30

nozin: "A swab moistened with a few drops of NOZIN is applied to the tip of your nose [suggested frequency: three times a day]... NOZIN is made from a proprietary formula of pharmaceutical grade ethyl alcohol and natural plant-based moisturizing compounds such as jojoba and coconut oil."
8 ml (about 1.5 teaspoons) $15
the "real" flu medicines retail for $93 (tamiflu) and $64 (relenza).

the conventional understanding is that these drugs reduce the duration of the flu by 9.5-21.5 hours or 19-24 hours, respectively. in other words - for your average of $79, you will be sick for an average of 18 hours less than you would have been if you did nothing. what a ripoff! (this is one reason i have never written a prescription for either drug.)

the directions have always said you need to start the drug within 48 hours of first getting the symptoms. (this is another reason.) the presumption of course is that with "new flu," they will Save Your Life. all over the internets it states that these drugs are a "treatment" for the flu, which to the ordinary person implies "cure" - and this also gets on my nerves.

to use these drugs to prevent getting the flu, you need to take it for twice as long (now the cost is $128-186), and you have to start one of them when you are exposed to an infected person at any time "one day before until seven days after the [person]'s onset of illness."

if for some reason you are exposed to multiple infected people, like my friend at the children's hospital, then you are supposed to start taking one of the drugs from the first exposure until ten days after the final exposure, which would probably be next year sometime, so the cost then would be $384-558 per month.

you can maybe avoid these high prices if you used the cdc-mandated protective gear when exposed to the patient (special "n95 respirator" mask, of which there's a shortage, so at our clinic you have to re-use them an indefinite number of times, and wear another plain mask over them (smother!); disposable full-length gown; disposable goggles; disposable gloves) - which i did not do - because the infected person with whom i spent half an hour in a small closed room - who had developed a high fever and a bad cough and sneeze after hanging out with her cousin who was diagnosed with the swine flu - was not my patient.

my patient was her very healthy 3-year-old son. i did not realize the details about the mom's illness, other than to hand her kleenexes when she sneezed a couple times, until she proceeded with her very healthy child to her own appointment, which was an urgent visit for a headache. she was seen, and immediately swabbed for h1n1, by my co-worker wearing a space suit in a negative-pressure room (has a fan that sucks the germs out).

it's a long story, but the point is that, you know, these things happen every day and that's why the u.s. now has 21,449 cases (more in our state than anywhere! now you know where i live) and 87 deaths.

i note that workers, including healthcare workers, are widely being blamed for spreading the flu by continuing to go to work while sick or convalescing.

this seems rather unfair, considering that as of last month the official (not the complete) unemployment rate in michigan was more than 14%, in oregon, rhode island and south carolina was around 12%, and in california, nevada, and south carolina was in the 11%'s... but that's a rant for another day.

histories of the fire departments

2009-06-13T12:21:00.006-05:00

i have been researching different kinds of health insurance that i, as a self-employed person with a past medical history, might be able to get - and/or afford.

naturally, this made me interested in the history of fire departments!

In 1666, the Great Fire of London consumed about two square miles of the city, leaving tens of thousands homeless. In response, insurance companies formed private fire brigades - the first organized fire protection system in that city - to protect their clients' property. Insurance brigades would only fight fires at buildings the company insured.

...The first fire brigades in the modern sense were created in France... In 1733, the French government decided that the interventions of the fire brigades would be free of charge. This was decided because people always waited until the last moment to call the fire brigades to avoid paying the fee, and it was often too late to stop fires.

...Even after the formation of paid fire companies in the United States, there were disagreements and often fights over territory. New York City companies were famous for sending runners out to fires with a large barrel to cover the hydrant closest to the fire in advance of the engines. Often fights would break out between the runners and the responding fire companies for the right to fight the fire and receive the insurance money that would be paid to the company that fought it.

this history is still disputed. nobody likes to think that monetary motivations could make somebody stand by and watch while a house burned, do they? everybody knows that a fire is a public - shared - calamity, right? if your house starts burning, then everyone's house is at risk, correct? this is why we pay taxes that support the fire department, yes? so that the fire department will serve all citizens without prejudice.

(a) In addition to all other ad valorem taxes levied, the St. Clair County [Alabama] Commission may levy on an annual basis, commencing with the tax year beginning October 1, 1997, an ad valorem tax on all taxable property located in St. Clair County at a rate of two mills per dollar of assessed value of the taxable property, the proceeds of which shall be paid into an expendable fire protection trust fund.

...(b) Within 30 days of payment into the fire protection trust fund of the proceeds from the additional tax levied pursuant to (a), each eligible fire department in the county shall make a requisition to the county commission for a share of the tax proceeds in the fund. The county commission shall divide the funds equally among the eligible fire departments of St. Clair County.

(c) Funds allocated to eligible fire departments shall only be expended for fire protection and emergency medical services... Personnel of eligible fire departments shall not be considered as employees, servants, or agents of the county.

it wasn't always this way, of course.

Fire insurance marks were lead or copper plaques embossed with the sign of the insurance company, and placed on the front of the insured building as a guide to the insurance company's fire brigade... The early fire marks of Benjamin Franklin's time can still be seen on some Philadelphia buildings as well as in other older American cities.

Subscribers paid fire fighting companies in advance for fire protection and in exchange would receive a fire mark to attach to their building. The payments for the fire marks supported the fire fighting companies. If the protected building were to suffer a fire only their fire fighting company would attend the call to extinguish the fire. Even if competitor fire companies were closer to the fire they would not do anything to prevent further damage or extinguish the fire.

firemark of the salop insurance co.

like i said, this history is still disputed. but it raises the question - how was fire - a local calamity - understood at that time? who was responsible for preventing, fighting, and cleaning up after a fire? have our ideas about private responsibility and the public good changed since then? if your neighbor smokes in bed and sets himself afire, what do you do? is it your problem, or not? if you don't do anything, is that against the law? why or why not? should it be, or not?

triangle shirtwaist fire.

12/10/2007 - A decline in public funding for firefighting services has sparked explosive growth in the private sector. The world's largest insurance company – American Insurance Group – now has "Wildfire Protection Units" in 150 US zip codes. During the 2007 California wildfires, AIG's firefighters saved homes in wealthy areas, while less fortunate neighbors were left with rubble.

sometimes maybe a fire department is underfunded, and people don't trust that they will be protected... so they decide that the solution is to hire their own private fire service? what's wrong with this picture?

AIG's Wildfire Protection Unit, part of its Private Client Group, is offered only to homeowners in California's most affluent ZIP Codes -- including Malibu, Beverly Hills, Newport Beach and Menlo Park -- and a dozen Colorado resort communities. It covers about 2,000 policyholders, who pay premiums of at least $10,000 a year and own homes with a value of at least $1 million.

how does our view of public calamity change, when the example is set before us of independent-minded, self-reliant, yankee can-do individualists who have the gumption to hire their own firefighters? the right to do whatever you please with your own property is a fundamental american value; so is the right to do whatever you can think of to make a buck.

...[Homeowner] Mr. LaPeter, who owns shopping centers and splits his time between Idaho and Maui, said the service might be a security blanket for the rich, but that it was also good business... [Fire protection Contractor] Mr. Futral weighed in. "Save one $10 million house and it pencils out pretty quickly," he said. "And there are a lot of nice homes here - Arnold Schwarzenegger, Clint Eastwood." He stopped short of saying whose houses he had sprayed... [Homeowner] Michel Lalanne, who splits his time between Sun Valley and France, watched Mr. Futral apply retardant to a house across the street and asked whether he might obtain his services for a price, even though he was not covered by AIG Private Client Group. "He said, 'No,'" Mr. Lalanne said. "'We've got a long list.'"

private entitlements and public calamities. a firefighter corporation, based on an insurance model, that makes megaprofits, charging whatever frightened people will pay, and only putting out certain fires.

compare that to a publicly funded system of firefighter companies, whose members earn approximately the median US income - a good living - putting out whatever fires they're dispatched to.

sound familiar?

note: a frequent argument against the firefighter analogy is that there is no single-payer system; localities fund their own services. some might point out the obvious problem with this, that a lot of communities are obliged to have volunteer services only. it's hard to argue that that is the best system we can come up with.

May, 2009 - Fifty-seven percent of all volunteer departments (which comprise over 70 percent of all U.S. fire departments) are losing volunteers who need to look for other jobs.

in the meantime, while rome burns, i guess it'll be high-deductible, catastrophic-coverage-only health insurance for me and my family - whatever i can get and/or afford.

march forth

2009-03-22T07:50:00.002-05:00

once again i'm ranting and raving about the american way of birth.
oh, how it offends my delicate sensibilities.
so many things about it that piss me off, that function to displace, reduce,
render comically superfluous, a woman's autonomy, her "experience,"
her bravery, mystery, splendor, achievement.

oh, i was raised a feminist through and through, and i remember as a grade schooler
being astonished and appalled when i learned "they," those anonymous ancients,
used to think a woman was just a "vessel" for a man's "seed."
it sounded crazy, delusional, or an egregious and calculated lie,
and i was so very glad those terrible days were over.

i laughed about the "homunculus" scientifically observed inside the microscopic sperm head,
and marvelled at the way the questions Science asks determine the answers Science gets.
i rolled my eyes at the Health Class filmstrip about the brave army of sperm assaulting
the giant, passive, fortress-like "egg." i still roll my eyes at the shouting over "when life begins"
(in the the tubes, at the moment of penetration? in the uterus, at the moment of penetration?)
versus the cooing over the so-called "first day of life," "first week of life," etc., of a creature
who's been kicking and swimming and hiccupping, in a very lifelike way, for months.
oh, Science - you're so cute.

then i learned how ridiculous obstetrics could get, so much so that some sneaky copyeditor
inserted into the index of Williams Obstetrics (15th & 16th editions), "chauvinism, male,
voluminous amounts, pp 1-1102," indicating the entire contents. oh, those illustrations!
in obstetric textbooks of, well, holes, allegedly representing "the mother,"
shaved and draped and gestured towards with a shiny black-gloved hand.
their terminology for the physiology of labor: "The Passenger, The Passage, and The Powers."
the shaving, the enemas, the restraints, the stirrups, the sharp scissors always poised!
i was so very glad those terrible days were over.

i learned how man doctors gave orders, and woman patients obeyed them,
and the man doctors liked this arrangement very much, and the woman patients
thanked them for it. how a conspiracy of half-educated snake-oil salesmen
legislated "granny midwives" as filthy ignorant filthy swarthy filthy foreigners,
and nearly destroyed completely their place in the world. i was so very glad - almost smug -
those terrible days were over.

now every woman is obliged to have an ultrasound, it's only a question of when,
because we have to see the baby, after all, and the woman's body
can thus conveniently be gotten out of the way.
she will be delighted to see the baby. she will ask and ask for another picture, she'll name the baby and buy the right clothes
from the appropriately gendered aisle, months before the birth.
at the start, she'll be cajoled to have "just a blood test" to find out
the truth about the baby, and if she gets bad news, she'll be urged
to "get the amnio," then she'll wait for a couple of weeks
to be told whether it's a baby, or a monster, in there.
if she's a certain age, she won't tell her relatives she's pregnant
until the geneticist tells her she is. if she forgoes all this,
we'll roll our eyes, and try again: "but don't you want to know?"
it's selfish, because we want to know, Science is working
hard every day, to find new ways of "knowing." new blood tests.
new ultrasounds. new, "less invasive" (of the fetus) kinds of biopsies.
we think we can distinguish between normal and abnormal,
but who can say what the results may ultimately mean?
we'll keep the results ourselves;
they're medicolegal documents now.
everyone's "at risk."

when she labors, it's really the fetal heart monitor,
flashing and bleeping in its multishelved cart, that labors,
that must be hovered over, comforted and consulted, praised and blamed.
why feel any labor pains? once she has the epidural, she'll lie there
watching television for the rest of the day,
tethered to the bed by her dead-weight anesthetized limbs
and the IV line from her hand to the pitocin on the pole,
the epidural catheter from her spine to the box on the other pole,
the "pain button" clipped to her shoulder from the box,
the blood pressure cuff on her arm, hooked to the machine,
inflating and deflating every fifteen minutes,
the urinary catheter taped to her leg, snaking from under the sheets
to the see-through sack hanging on the bedrail, visible from the hall,
the intrauterine pressure catheter taped to her leg,
stretching from uterine cavity (formerly, inconveniently, fluid-filled)
to fetal monitor, and either the elastic belly-band,
or a wire taped from her vagina to to her leg, its fine sharp corkscrew
twisted into the "presenting part,"
all plugged into the flashing, thumping monitor,
to "keep an eye on the baby,"
doctors and midwives and nurses all staring at the
fetal heart rate variability graphed on remote monitors
down the hall, not needing to enter the room
where the woman is simply lying quietly, unable to move her legs, watching tv,

but needing the screens every minute, to tell us the truth
about this birth, to reveal what the woman's body selfishly conceals,
the baby, the baby, how is the baby, is the baby okay,
the baby might be in trouble, always always always and by definition
might be in trouble, as long as it's in there.
if we need to shout at her or lean on her belly or get out
the sharp scissors or the steel forceps or just cut her open
and pull the baby out, we will - and she'll thank us for it.
all that matters is a healthy baby. because. she's just. a vessel.
and i am so very angry.
that these terrible days are not over.

we can teach her from her age of five that abortion is nasty and horrible (don't!),
and "giving up for adoption" is sweet and beautiful (do!), because she's just a vessel.
we can sue her and win, if she doesn't give us the infant we paid for, as a "surrogate mother,"
because she's not a mother, she's just a vessel.
we can put her in jail, and take custody of the fetus in utero,
if she fails her drug test, because she's just a vessel.
she'll be guilty of illegal drug distribution, to a minor,
through "his or her" umbilical cord, because she's just a vessel.
if her boyfriend beats her up or shoots her, it's a crime
against the fetus, because she's just a vessel.
if she shoots herself, it's "attempting
to procure an illegal abortion," because she's just a vessel.
we certainly can appoint the fetus a lawyer and order a cesarean,
because she's just a vessel.
we'll cajole her to quit smoking, to quit drinking, to take her vitamins,
"for the baby," because she's just a vessel.
having health insurance and a warm place to live and enough
food to eat matters, but only after the sixth month.
full-term gestation matters, because the baby matters,
but if starting her labor artificially is ok for the baby
and convenient for the rest of us, then we might as well.
breastfeeding matters, because the baby matters,
but if replacing her milk with something else is ok for the baby
and convenient for the rest of us, then we might as well.
mothering matters, because the baby matters,
but if warehousing the baby in daycare is ok for the baby
and convenient for the rest of us, then we might as well.

her drug abuse, her malnutrition and smoking, her bruises
and broken teeth, her gunshot wounds,
her womb, her breasts, her youth, time, life, place
in this world all matter, because the baby matters,
and - you know - not as much, otherwise.
i am so angry that these terrible days seem to be going on and on and on forever, and we have understood nothing.

in my world, when a woman is pregnant, it's a woman who's pregnant.
when she labors and gives birth, it's her doing it.
when she becomes a mother, she's a mother.
everything we offer her should extend naturally from these realities.
why should this be so difficult to understand
she asked disingenuously?

so i'm trying to prepare to give a little talk to a roomful of fellow physicians
about how no-epidural might be easier, safer, more psychologically sound,
and cheaper than epidural,
how one might consider suggesting to one's "ob cases" that "it's an alternative,"
and i might just as well give a little talk about how someday
we'll all have flying cars and food pills and life will be terrific.
i'd be accomplishing just as much.

don't tell any of them i said this.

last night i dreamed

2009-03-14T08:43:00.003-05:00

because i was asked to fill out a paper asking who is my favorite patient, and why.
i had a list of six just off the top of my head
and was not answering the question right.
so i was asked, commonalities? (maybe the six characters
are actually one author.) well... there's mr. jasper, the guy
who looks just like bernie mac (rest his soul),

whose wit is dry and slow, and he's so strong looking
you would never know he has di-beetus. and there's mr. king,
who said he always told his wife when he dies, the first thing he
wants her to do is to buy a red dress, and the second thing is
get out of town, but she died first, and now, years later, he's
still living. the other day i told him his di-beetus had been perfectly
splendidly beautifully under control, and he replied he'd celebrate

with a big piece of chocolate cake. and there was zina, that goddess,
mother of twelve, statuesque with graves-disease eyes that make her
look like she's looking every direction at once, and with all her kids
and their school uniforms to keep track of, she may very well
be. she has gold filigree teeth and tattoos. she loves her newest
baby with quiet ferocity. i wish they lived next door! she's
pregnant again, and i couldn't figure out how to stay here for her...

mr. pastor is the dashing little old-school puerto rican
spanish-only-speaking man in linens, who comes back every 3 weeks
even though i tell him, through our sad little speakerphone translator,
"i don't need to see you for another three months!" and even though
he always nods agreement. a few years ago, his wife suddenly collapsed
and died, like a bolt from the blue, and then he didn't know how to
do his pills, or feed himself, or how the washing machine worked.
his mom came over and helped him, and then, a month later...
his mom died. now he goes to the latino men's club every day.
he hugs me with his bony little shoulders, and says, with
tremendous force of meaning, "I Do You Tell Me."

there's jamilla, who finally realized she was pregnant
seven months along, outcome of a stupid set of experiments
with her best friend, a boy, not her "boyfriend." a homeschooler,
studying geometry and arabic and hatha yoga. vegetarian. five siblings.
she had a fine strong fearless birth of a sweet shine eyed little gal,
now a year old, and now jamilla no longer homeschooled, is
taking classes at the engineering school. she's sixteen.
you may notice i have a little more to say with every story
every little memory cue is like a pop-up labyrinth
of rich full scary beautiful amazing mansions. who was the

last name on my list? she was actually 3rd. mrs. martin. we have talked
for hours and hours, mrs martin and i. suffice it to say she gets nervous
alone in her hourse sometimes. she takes a nerve pill once in a while
which helps. she works as a church nurse. she goes to the casino
with her friends. her grandchildren hover around her most of the time.
she doesn't like doctors. i see her every month, and we talk.

i hadn't even mentioned mrs gaudio - she's still alive and kicking!
or poor little drama queen, the raving beauty, with her black eyes
and cesareans, or mrs sutherland, on her way to north carolina
where her best friend is dying of cancer, who always calls me "honey"

instead of "doctor," or beautiful, adventurous judy, with her midwest-
glamorous family (soon to move to aspen, to take the midwest off
their shine) - all she needs is a little bit of ativan
to get her through her day - or mr petrovsky, who is deaf as a post,

so i go around all day shouting, after half an hour with him -
his memory is shot, but he's full of stories
about when a service station was really a service station,
down at michigan and cass. what about mr maley and his
hundred-year-old mum (yes, hundred-year-old mum), coral?

my favorite patient? i've got dozens.

so anyway, because of this little exercise, i dreamed
i got down the polaroid and went to the store
and bought a hundred dollars worth of polaroid film
and kept it at the nurses station
and whenever "my favorite patient" showed up on my schedule
i'd say to the nurse, "will you come take a picture of us?"
and i had a big stack of photos of me holding cute babies,

hugging ladies, posing nicely with gruff old dudes. and in my
dream i realized, the kids, the kids' pictures too,
so at the same store i got a medium sized box of crayons
and emptied my pockets of otoscopes and calendars and rx pads
and put the crayons in there instead
and then whenever a child came to visit me, i'd say,
"can you show me how you're doing? show me something new,"
so then i had a big stack of crayola drawings too,

and all these pictures travelled over mountains, and across the high plains,
and came to rest on a bulletin board as long as i'm tall, and in my new world
with my new strange vistas and my good new devotions,
in my new work space built for care, not efficiency,
there they were still, all lined up every day on the board,
smiling and brightly-colored, well-known and true to life - abiding with me.

...then in the morning in a sleepy daze i headed for the polaroid
but took a moment to wash my face and peer in the mirror and think,
do i really want all those pictures with me in them?
i take crappy pictures. i am not the most photogenic ever
in the history of the world...
i hesitated, then forgot.

until now.

ash wednesday

2009-03-09T22:15:00.005-05:00

if you are too busy to write, you might be too busy to learn from your experiences. and when i say "you," i mean me.

i have been going to a couple homeless clinics. they are relaxing to work in, because the volume is lower and so are the expectations, by which i mean, you do not have 15 minute scheduled appointments. you can talk for as long as you need to.

i have been too busy to write.

but i'll tell you what. on ash wednesday last week, in the homeless clinic at the salvation army, i saw this lady from new orleans. she's been here in milwaukee since 2005.

remember 2005?

she had been a chef, and a "minister of music" at church, with a wide circle, she says, of friends and choir pals and extended family. she has been stuck here, in this postindustrial northern-urban wasteland, ever since the hurricane.

the family? we don't talk much. nobody has a phone. a church home? i don't know, somehow i just never got anywhere. a job? been cooking here and there sometimes. not my kind of cooking. now there's no jobs anyhow. plans for the future? want to go back home? i don't know... sometimes you just lose your way.

sometimes

her breathing went bad as soon as she got up here. she was, what, 45 years old, then? she'd had asthma as a little girl, but it went away, and then in high school she played basketball and ran track, and never had any trouble breathing.

down there, it's hot, all year round. it's steaming. i'm not used to this cold air. i can't get used to it. i used to sing. i can't sing. i can't work. i can't do anything. this cold weather all the time.

so she "hits on the pump" - uses an asthma inhaler - 3-4 times an hour, and a few times every night to sleep. (you're supposed to call the doctor if you need it more than four times in one day.) she ran out of her own inhalers right away, but she got one from her neighbor and then a couple more from "this guy in kentucky i know."

this guy i know

i do believe that, as more and more of our friends and relations lose their jobs and with them, their health insurance, this will become a more familiar part of the future face of drug dealing: 'a guy' who can sell you some inhalers. or some metformin for your di-beetus. or some blood pressure medicine. since you can't get to the doctor to get your rx, and you got no more low-copay meds. or, on the other hand, you're the 'guy in kentucky,' making enough money for cigarettes by selling your inhaler, metformin, water pills, to your neighbor.

the lady from nola first came to the homeless clinic 2 weeks ago, and was given an inhaler and metformin and water pills. but she is so very worried, all the time, about her bp and diabetes, she decided she'd need to take all these drugs at twice the prescribed doses. and you know what? not only were these double-doses the same i would have prescribed her anyway... but also, her blood pressure and blood sugar were perfect.

unfortunately, she was blowing all her food money buying extra drugs from other people (not to mention poisoning herself with asthma inhalers). she kept taking more and more medication because she "knew" her blood and her sugar were high.

how did she know they were high? her vision was blurry. the sugar gets out of control and her eyes get blurry, and then the high blood gives her the headache. like right now, my eyes are blurry, she said, trying to read her new prescription bottles.

i had to laugh. "how old are you?" forty-eight. "put these on," i said, taking off my own

cheaters

and handing them to her. she held them up to the light and frowned. naw, these are way too strong. they'll hurt my eyes - "put 'em on! now, can you read this?" and i handed her a fine-print drug foldout.

her jaw dropped. she looked out from under the specs, then through them, then over them, then through them again. you mean, i need glasses? am i gonna have to go to an eye doctor? "look, your blood sugar's perfect. your blood pressure's perfect. and anyway, these aren't glasses glasses, they're just cheaters from the walgreens. they cost, like, seven bucks."

the young, pretty nurse walked in. "are you telling her about these?" she asked, taking her own magnifiers off her head. "i got mine at the dollar store." how much did they cost? "a dollar... it was the dollar store, right?"

dollar glasses

the woman was dumbfounded. you mean, i been taking all these drugs because of high blood and di-beetus, and all along i was just getting old? "we prefer to call it 'mature'," i said primly.

she couldn't stop shaking her head, astonished, laughing.

she pulled out from her wallet a tattered old business card with a scribbled-out phone number written on the back, and said she wants to bring us all lunch, at the clinic, some of these days. here's what she wants to make us:

shrimp jambolay'
an' crab corn bisque
or maybe hambone gumbo
s'm fried tomatoes
an' okra stew
an' maybe a chocolate praline pie.

some of these days

we get a little sentimental after too much hospital

2009-01-25T20:46:00.000-06:00

last night i was charged with taking care of a woman
in the ICU with the following acute problems:
pancreatitis and gallstones, a big swollen painful belly,
esophagitis from a yeast colonization so she can't swallow,
an autoimmune disorder which destroys her platelets,
so her blood won't clot, repeated hemorrhages from the nose
and vagina, severe anemia, as you can imagine,
fevers, kidney damage, and very high blood pressure.

she has the following chronic problems:
AIDS, cervical cancer, chronic pancreatitis, epilepsy,
male pattern baldness, and paranoid schizophrenia.
i am not making this up. she's 37. she has eight doctors.
she's delirious and can't make decisions, such as, for example,
going out for a cigarette, which she really wants to do.

her parents are supposed to make medical decisions for her.
i found myself sort of surprised that she had parents,
as if such terrible things would be somehow prevented
by having parents. she was hallucinating that
her daughter was in the room, and somehow
i wasn't as surprised that she had a daughter.
does she have a daughter? she doesn't get
any visitors. social workers are trying
to find a nursing home that will take her.

then i admitted another 37-year-old, a guy
who had a bellyache for a month, diarrhea
all day every day, lost 20 pounds, kidneys
shut down, CT scan showed "pancolitis,"
meaning his whole bowel is on fire.
blood pressure almost two times normal.
oh, and he has cirrhosis from the hepatitis C he got
back when he was a heroin addict. oh, and
he smokes and drinks heavily. oh, and he's
schizophrenic, but he hasn't gotten any meds
for a month
because he's been
so sick.

in the night i woke up thinking about the
overwhelming burden of suffering borne
by the world, wondering how the earth shelf
on which we stand doesn't just crack into pieces
and fall in the sea, wondering how the air is not
thick with shrieks and cries and moans of grief
all the time, wondering how any of us can go on,
and whether those self-help books really help:
when bad things happen to good people, when things
fall apart, where is god
when it hurts.

i thought about defense mechanisms
Acting-out Affiliation Altruism Avoidance
Conversion Deflection Denial Displacement Dissociation
Humor Identification Intellectualization Isolation
Passive-aggression Projection Rationalization
Reaction-formation Regression Repression
Somatization Splitting Sublimation
Substitution Suppression Undoing

and then i thought about the song, Life is Still Sweet -

"...Just forget what I said last week. Life is still sweet."

we do forget what we said last week.
how can it be?

people tortured in prison still want to live. people whose
children were murdered still want to live - mostly.
suicidal people still love guitar music and have a favorite song.
schizophrenic people with cancer and AIDS still want to
go out for a smoke. we love the sun after rain. we laugh
at animals playing and kids throwing snowalls. we smile
when the first dandelions come out in the spring, we want to
hear the eleven o'clock news, we look ahead for brighter days.

i can't take it. it breaks my heart that life is still sweet.
my faith is that, as the wise man said, when you get
your heart pierced, then it can let more love in, and
i only hope i don't get some bad kind of heart failure
because i already
let in so much.

Scientifically Guaranteed Weight Loss Register Now For Free

2009-01-03T19:53:00.010-06:00

as you know, when americans consider losing weight, the first rule they will hear is "consult your doctor."

so in my practice, i have a lot of female patients interested in losing weight. they usually come in asking for some pill they heard about. unless they have a pretty good reason for wanting to drop just 10-20 pounds in a short amount of time (for a short amount of time, since they're likely to put it all back on) (e.g. "need to fit into my wedding dress" - a popular one), i veto "quick weight loss" schemes.

instead, i try to recruit them to my "cult of dr leigh
life-transformation plan" which focuses on
1. taking the long view,
2. taking the wide (holistic) view,
3. considering body image and function as one and only one aspect of their unique and dynamic life and lifestyle,
4. encouraging consideration, if not construction, of a long term (five year) plan, in addition to a short term (until next visit) plan,
5. looking at "my food pyramid dot gov" and "mayo clinic healthy weight pyramid" online together, and
6. making them fill out food diaries and bring them back in regularly, which secretly is an opportunity to progressively process their feelings and actions around food and their bodies.

most of my patients are poor, stressed, traumatized, dangerously obese, and medically ill or on the verge of it (those young diabetics and young people with kidney failure you read about), as well as smart, brave, funny, creative, proud, and ridiculously good-looking (those young black women with cool names you read about). practically everyone has some degree of eating and/or dysmorphic disorder. plus, practically everyone is some kind of sexual trauma survivor, and whenever bodies are an issue, that trauma is an issue.

i ask them about the other women in their lives, and how they feel about how those women look, and whether those women also have issues with their weight, their bodies, eating; what good family meals have been like for them in the past; how they feel when they try on new clothes; how they feel when they have to go out to their exercise program, whether they were athletic in high school or grade school, how active their kids are physically...

i tell them that losing weight changes everything, and no matter how much you want to be thin, you might not really be ready for everything to change, and one theory is that it might be intolerable and you might unconsciously make it so you change back. and you could maybe counteract this by considering carefully all of the things about your life you'd like to change, and how quickly you can expect to change them, and what it will take, and what it would be like on the other side.

we discuss, for example, how old you'll be in five years, how old your children will be and how you want your relationship with them to be, and how old your parents or grandparents will be and what their needs will be; what you don't want to be afraid of any more by the time you're that old, what you always wanted to be able to do (play piano? bench press your own weight? have a flower garden?) and how you might truly expect to be doing it every day, in the future.

so every opportunity to process is an opportunity to affirm. and not only that, but these are opportunities to demonstrate my confidence in their abilities to get a grip on their lives. after all, limiting oneself to 1200 calories a day is full of fail, while strategizing creatively about how you want your life, your work, your relationships, and your self-image to change, in five years - plenty of time! - is full of promise.

but will it help them lose weight? frankly, i don't think that's the point. how much worse could i do, with my cultish machinations, than all the other current weight-loss plans? how much worse could i do than other doctors? for years i have asked other doctors how they help their patients lose weight, and what i've learned is that doctors are very cynical on the subject - from decades of fail. patients who "ask their doctor," women in particular, adopt an austerity program, lose 25 pounds fast, then gain back 35 and hate themselves double, and stay at home eating ice cream to live with the shame.

not only that, but the bigger you get, the harder it is to lose weight. the bigger you get, the longer it stays, the harder it is to work off.

and there's a big bunch of trauma - child abuse, sexual abuse, spousal abuse - behind compulsive eating that will never be reduced by reducing diets.

and there's a big bunch of that trauma that is caused by living in a white supremacist culture that is violent to women and children.

and there's a bunch of billion-dollar scambag maneuvering behind the amount of trans fat, palm oil, and high fructose corn syrup in "the american diet."

and there's more than one reason nobody knows how to cook from scratch anymore, but the number one reason is that real weekly wages of $277 for nonfarm workers in 2004 are less than was the real weekly wage of $302 in 1964, while a box of cornflakes that cost twenty-nine cents in 1964 cost $2.99 in 2004. who has time to cook, when you've been doing your own job as well as your laid-off coworker's job all day, or you're just home for a few hours before starting your second shift? who has time to teach your kid to cook (your kid goes to her day job when she gets out of school in the afternoon)? who has time to go to the store? and who has the money for the "diet food" experts recommend, the skinless boneless chicken breasts, sea bass fillets, fresh asparagus, 5-inch portobello mushroom caps, prawns, soba noodles and ginger sauce, edamame, fresh nectarines, pork tenderloin, pomegranate juice, artichokes, casaba melon with sweet creamy curry...

i also retain an uneasy skepticism about what it is we want, we doctors, when we want women to "lose weight." more than once i have seen a woman seem to lose in authority what she gained in self-conscious sex appeal, by losing weight. then again, i'm skeptical of the particular way in which we let women off the hook when they stay dangerously big or get bigger. after the thyroid and fasting glucose tests, after the "exercise prescriptions" and lists of low-fat treats, after the stern warnings and documentation, and especially after the 3-month trial of amphetamine and orlistat, doctors rest easy in the notion that their patients "failed" due to "noncompliance" (whether they refer them to surgery or not).

then i come along and ask, newbie to sage, "how do you help your patients with weight loss?" and they tell me they've tried everything but nothing works. one cardiologist told me that the only thing that ever made a difference, was to tell his patients to "Eat Half": "if you usually eat 2 bowls of ice cream, just eat one. if you usually eat a footlong sub, just eat a six-inch." he said that was the only piece of advice that people seemed to be able to understand and remember. then he said he was so glad he was retiring next month.

so i do tell people Eat Half, if they are looking for a very quick guideline and do not want to get into a whole involved cultish program. i have also been on a crusade for two years now to get people to drink water instead of - instead of everything else. instead of soda. instead of sugar-free soda. instead of sweet tea. instead of juicy juice. everybody tells me water tastes bad (the city water is actually just normal water, not horrible fish-water or rust-water), so i keep a supply of water bottles and generic individual zero-cal flavor packets in the office, and show them how to mix them up and carry them along. i figure eventually they'll run short of flavor packets and be stuck drinking water instead. i truly believe that people who are addicted to soda - they drink it before they brush their teeth in the morning, for crying out loud! - have a harder time cutting out other sources of sweets and salties. when actual water tastes bad to you, you know your palate is somehow way out of whack.

i think the final phase of my cultish life-transformation program will arrive when i have the time to just walk over to people's houses and go through their cupboards with them, and assess that they have for staples, equipment, and storage, and then sit down and show them how to make a shopping list. right now, in the hamster wheel, with the fifteen-minute appointments and the collapse when i get home at 7 pm, i am unable to muster up the energy to do this - and thus i will not, in fact, be able to "help them lose weight" to the degree that i should... but in the meantime - and i share with them, in fact, when it comes up, that i was a single mom too, i dropped out of high school too, i was on food stamps too, i survived sexual assault and domestic violence too - i am showing them that it is in fact possible, at least in theory, to get a grip on your world.

five years from now, when i am _____ years old,
i want to live (where):
my living space will have:
i will live with (who or what):
if i live with animals, i want them to be:
my main daily transportation will be:
i'll spend my weekends:
i'll spend my winter holidays:
i'll spend my summers:
five years from now, when i am _____ years old,
i want my main work to be:
i'll feel committed to this work because:
the challenging part of this work will be:
if i have a job that's different from my work, i want that job to be:
that job will help me with my real work by:
five years from now, when i am _____ years old,
i want my closest relationship to be:
i want most of my other relationships to be:
people will be comfortable calling on me for:
people will think of me as:
five years from now, when i am _____ years old,
when i want to have fun, i will:
when i want to unwind, i will:
i want to have enough time to:
my most creative activity will be:
i'll spend about this much time in creativity:
my most satisfying spiritual practice will be:
i'll spend about this much time in spirituality:
i want sleep to be:
five years from now, when i am _____ years old,
i want to be strong enough that i can:
i will have enough endurance to:
i will be physically flexible enough to:
i want to be able to walk, run, or roll (how far and how fast):
i want to be able to lift or carry (what):
i will enjoy doing these kinds of fitness activities:
i will enjoy playing these kinds of games:
five years from now, when i am _____ years old,
i want my body to be:
i want my face to be:
i want my hair to be:
i want my eyesight to be:
i want my hearing to be:
i want my arms and legs to be:
i want my hands to be:
i want my heart to be:
i want my appetite to be:
i want my weight to be:
i want my back to be:
i want my breathing to be:
most of the time i'll feel:
most of the time i'll look:
five years from now, when i am _____ years old,
i will no longer worry about:
i will no longer regret:
i will no longer be angry about:
i will no longer wish i were:
i will be ready to forgive (person/s):
for (action/s):
i will have been be forgiven by (person/s):
for (action/s):
i won't feel like doing this anymore:
i won't be afraid to do this anymore:
i will have left these things behind:
i will be so glad i chose to:

puttin' the "no" back in nosocomial

2008-12-31T16:01:00.004-06:00

last night i admitted a lady for the third time
of her 8 recent admissions
she is 5 years older than me
and until last march, she had a normal life.

then she got sick. her kidneys stopped working.
i mean, stopped working. she got a dialysis catheter placed
and the nephrologist took a kidney biopsy
and sent it to the mayo clinic for evaluation.

it turned out she had autoimmune kidney disease
her immune system was killing her kidneys
so she went on steroids to tone down her immune system.
then she became diabetic because of the steroids.

then she developed a huge retroperitoneal hematoma
from the kidney biopsy. it bled and bled, with the pressure
building up from the blood trapped around her kidney.
she stayed in the hospital for a long time while everybody
tried to decide what to do about this.

as a consequence of lying in bed for a long time
she developed giant blood clots in her deep leg veins
and a piece of clot broke off and went to her lung.
as you know, blocked blood circulation to the lung,
so you can't oxygenate, is a life threatening condition

so despite the bleeding kidney, she had to be put on
blood thinners. this made everybody very nervous, since
she was still bleeding into the limited retroperitoneal space.
eventually she reached an equilibrium between
clotting and bleeding and went home. for two weeks.
then she got a belly ache.

do you know what a diverticulum is? from the latin
for "little detour." it is usually described as an "outpouching"
of bowel lining between the muscular walls. like a bulge
in a weak tire. as folk grow old, they usually get a lot of these.
(of course, this woman doesn't really qualify for 'old.')
sometimes a diverticulum gets jammed up and gets infected
and bursts, kind of like a burst appendix.
this is bad.

you can't just take out a teensy bit of bowel,
due to the way the blood supply is set up. instead
you have to take out the affected bit as well as
all the other bits that are served by that same
blood vessel. the blood vessels are in fan-shaped
arrangements called "arcades." you might recall
from previous writings that i think the intestines are
actually very beautiful, like crinolines or pretty tree fungus.

anyway, she was obliged to have the left half
of her colon removed, trading it for a colostomy bag.
colostomy is from the words for colon and stoma,
"mouth." it's an artificial mouth for the colon.

diabetes gives people problems with wound healing.
so do steroids. so the lady who is five years older than me,
who had a normal life until around st. patrick's day,
started getting all these belly wall abscesses.
these abscesses had to drain, so they were opened
and cleaned and packed and allowed to just drain.

it was hard to tell if they were originating
from a defect in the gut or what. but one thing for sure,
they were infected with antibiotic-resistant superbugs
only found in hospitals. so they could only be treated
with "gorillacillins" - high-tech, hard-core IV antibiotics.
so she went home with a "PICC" line - a semipermanent
IV from her upper arm snaking down almost into her heart -
to get the IV meds without going back to the hospital.

she got a little better - her kidneys got better,
and she could stop dialysis, although she stayed
on steroids to keep her immune system from
whaling away on her kidneys. it had been 3 months
and she was able to stop the blood thinner...
until her legs started hurting and turned red
same way they did when she got the clots before.
and then she began having trouble breathing
whenever she stood up. she started the blood thinner
again, but it didn't help. so last night she came in.

it was a puzzler. she was tested for a blood clot
in her lungs, but she didn't have one of those,
and her blood was quite thin. she was tested
for heart attack and heart failure, and she didn't
have those. not pneumonia, since she didn't
have any fever, she sounded clear, and her
x-ray was normal. the PICC looked properly placed.
we wondered if she had a bad infection
from the still-draining abscess, the colostomy wound,
the PICC line, or the apparent soft-tissue infection
of the legs, since she did have an elevated white cell
count... then she went into "A-flutter." atrial flutter.

this means the atrium of her heart was just
twitching instead of pumping. she said she felt fine -
just pain in the belly and legs, and not breathing rght,
same as before. i wasn't sure what to do -
leave it alone? she felt okay, and her pulse
and blood pressure were doing fine without her atrium...

could it get worse? should i nip it in the bud?
should i give this woman - with the semipermanent
PICC and on the IV gorillacillin for her
nonhealing belly abscess, anticoagulated and
diabetic, on steroids with an autoimmune process,
with the red legs, in pain, struggling to get air -
something to change the very way her heart beats?
and why did she come back in on my shift?

glumly i remembered all the mean phrases
we're not supposed to use, like "trying to die,"
"voting herself off the island," "DMA" (dying
with medical assistance), "transferring to the 10th floor"
(if you have 9 floors), and "prepared for celestial discharge,"
and how the NICU nurses would warn the sick babies,
"step away from the Light"...

anyway, i gave her one dose of flecainide, just before
the cardiologist called back and told me there was no
indication for flecainide, and he'd scan her in the morning.
i'd already given her some morphine. so when i headed
back in for the last time to check on her, she smiled at me
very sweetly and said, "i feel so much better now..."
and then, still smiling, two fat tears rolled down her cheeks.

iatrogenic: induced by a physician's words or therapy

iatrogenesis is a little script that spews out random stuff to a bunch of people every day
iatrogenesis is a country that is ruled by those who do not love her
iatrogenesis is 10 years according to the arranged horoscope table

iatrogenesis is the more silent as it penetrates deeper
iatrogenesis is an automatic claim on everyone else's life
iatrogenesis is unevenly weighted

iatrogenic keratoconus causes the cornea to bulge
posterior screws were used despite the risk of iatrogenic injury to the vertebral artery
iatrogenic injury to the saphenous nerve and vein, as well as to the popliteal vessels

iatrogenesis is connected neither to any good or bad deeds
iatrogenesis is often due to no specific cause; it is simply the bad fortune of an individual; a link in the chain of events; an evil independent of his own
iatrogenesis is really a lesson to be learned

iatrogenic events can be a source of intoxications in our community
a few of the overdoses resulted from physician-initiated inadvertent addiction (iatrogenic addiction)
36% of 815 consecutive patients on a general medical service of a university hospital had an iatrogenic illness

iatrogenesis is a good story the beginning of a good film
iatrogenesis is what you chose for your evening meal
iatrogenesis is entertaining

iatrogenesis is one of darkness' other goblin minions
iatrogenesis is the tip of the iceberg

emergency delivery may result in severe iatrogenic prematurity
ominous iatrogenic events are frequent in neonatal units
nurses' fingers were contaminated with bacteria known to cause iatrogenic infections
iatrogenic blood loss due to lab testing can result in the need for blood transfusion

iatrogenesis is applied failure
iatrogenesis is not determinable by an outsider's measurement of it
iatrogenesis is due to a defective apprehension which the wider view confirms
iatrogenesis is called "first" because there's always a second one

fatal iatrogenic hypoglycemia: falsely elevated glucose meter readings due to a maltose-containing intravenous immune globulin
iatrogenic injury to the lateral antebrachial cutaneous nerve and superficial branch of the radial nerve
iatrogenic CJD or kuru acquired through the use of cadaver-derived growth hormone

iatrogenesis is worse if one "gets the hook" unexpectedly
iatrogenesis is not just a misfortune
iatrogenesis is our own creation

a 21 year-old woman presented with unrecognized renal tuberculosis and underwent bilateral ureteral stent placement which led to dissemination of the mycobacteria through the blood causing pulmonary tuberculosis and multiple tuberculous abscesses in the paraspinous muscles, pleural space and skin.

iatrogenesis is now available at the bodacious blunder section to your right
iatrogenesis is stuck at ten reads and three reviews with a status of good

if the doctor gets stays sick

2008-12-28T14:32:00.002-06:00

comments from an almost entirely anonymous, subscription-only listserv - concerning chronically ill physicians.

After all of our training, it's still not "OK" to be sick. It is often perceived as a failure, especially among physicians.

Some people have the terror of facing a terminal diagnosis, while others have a reasonable chance of living a long time with/despite their disease (not always a happy thought). Some people, such as myself, feel really truly lousy on even the best of days. Until I got sick in this way, I never understood how severely ill a person could be most or all of the time for years on end. I understood loss of function, and even chronic pain, but the idea of feeling sick all of the time (without being terminally ill) never seemed to hit my radar screen.

I think there must be a huge transition point when you realize that chronic relapses and remissions are going to be part of your life - with a lot of struggle and distress beforehand. Also there is the hope things will get better, with just a little more rest, etc. But then you plunge into anger and loss of what was, not knowing what exactly will be.

I continue to work part-time, but I am in a fairly constant state of low grade pain which is incredibly wearing and draining.

I've been on full disability for over 5 years, and it was an awful decision to make, but no real choice due to severity of my symptoms. I have kept my license up, hanging on to the thread of hope that some great biologic will come along and put me back in the game.

It is incredibly challenging to look well and have others expect you to function like a normal person. Most people don't know that my round face is not robustness, but Cushing's secondary to long term steroids.

I've recently begun to give 2 hour workshops for women with autoimmune disorders. In these workshops, I've been keeping a list of what they tell me, that reflects the collective unconscious of our culture around illness. These negative thoughts about people with chronic illness are embedded in all of us, and it often affects how we treat ourselves and our patients. Here's the list:
malingerers
too-sensitive
drug abusers
sickly
high maintenance
hypochondriacs
you are the cause
you deserve it
undependable
lazy
self indulgent
doomed
will die young
failures
free-riders
irrational
awkward to be around
alarming
unattractive
repulsive
downers
don’t try hard enough
have given up
not fun
defensive
faking it
to blame
pampered
unattractive
weak
does not want to heal
stressed-out
needy
can get over it
controlling
unreliable
self-absorbed
feeble
whiners
dependent
Autoimmune diseases are particularly unglamorous, as you know. MDs think chronic, uncurable, etc. and glaze over.

There are a large number of us with chronic diseases out there and it appears as though most of us keep our diagnoses to ourselves. I have been suffering from a seronegative arthritis since 1985 with very little response to meds so have had to develop a coping strategy on my own- got very little support from my colleagues, especially those treating me. I do share with patients who have chronic pain, as I feel they need to know there is hope for surviving with the pain and that we as the carers can empathise with them.

I, too, have a chronic condition, polycythemia vera, and like others who have posted, have encountered lack of awareness and appreciation from clinicians (as well as friends and family) about the impact that a chronic condition has on functioning.

What I can tell you all who are in practice, is that even for non MDs, just knowing that you care, you think about us, and you are trying means everything. I'm on a Sjogren's e-list of about 800 people, and this theme is repeated over and over again.

I require quite high doses of fluvoxamine to stabilize my mood, without which I am sure I would not cope at all with my illness. However, I feel this has a marked "flattening" effect on my mood - I rarely either cry or laugh, and this is very sad for me. I feel it also reduces my capacity to care - to empathize with my patients. If I am feeling sore, and someone comes in with a "trivial" problem, I sometimes feel like telling them to stop complaining and count their blessings.

I used to think I was treated so poorly because I was expected to treat myself and to emotionally support myself and family while I was dying; and now to find new avenues of treatment as well as suggest alterations in my treatment when treatment is not going well. But after communicating with thousands of other individuals with chronic illnesses I have come to learn that nearly everyone with chronic illness is treated poorly. We just happen to know enough to realize we are being treated poorly. I have no desire to explore the reason for the state of chronic care, but I do know that at least part of it stems from our physicians becoming bored with us.

It sometimes appears that physicians with chronic illness are disappointed that their doctors will not personally assume their burden of suffering. That is more than compassion or competence, and it involves a blurring of boundaries and, if practiced continually, a complete exhaustion of the doctor. "Good fences make good neighbors".

Let's remember that although Robert Frost did write the line "'Good fences make good neighbors'" the poetic context he constructed starts with the line, "Something there is that doesn't love a wall..." and respond to his irony as he repeats toward the poem's end, "Something there is that doesn't love a wall,/That wants if down." Understanding his irony and his warning to the reader is the quiet lesson.

When dealing with ill physician colleagues, might our tendency to identify (along with resultant anxieties) be intensified to the point our personal defense mechanisms kick in louder and more frantically? We can feel tremendously guilty when our best efforts at "cure" don't seem to help, and end up disengaging in response. If our personal or professional self-esteem relies on our "cure rates", we're in very big trouble dealing with people who are chronically ill. This anxiety could be heightened if our patient is a fellow physician. Our wish to be helpful can morph into an insatiable need to "help". It can also get more tangled still, perhaps with us wanting to turn our backs or run away.

We are trained to fix the problem. If we can't fix it, then underneath it all, we have failed, are failures (so says the inner critic). So in an effort to avoid the inner pain of failure, it's easier to move on, blame the patient in some way. The patient HASN'T cooperated by getting better and boosting the self-esteem of the doctor. The patient can interpret that as boredom, rejection, lack of empathy, all of which may be true. But bottom-line, I think, is self-esteem. Why? Again, back to medical education. Humiliation and belittlement remain rampant in medical education.

Thanks for mentioning the "inner pain of failure". I am reminded of how often we do try to transfer this to the patient, even in the way we write medical histories. In many medical charts, I've seen sentences like, "The patient failed treatment with _________" (fill in the blank). If that doesn't speak loudly about our unconscious attitudes, I don't know what does.

I found in my own experience a lack of any sort of understanding from some of my own treating doctors of the experiential and emotional aspects of my pain, as opposed to the purely medical problem of my "diseased body part".

The idea that a doctor could be ill even with an acute minor respiratory infection, let alone a severe chronic illness, seems to strike people as very strange. When you think about it this is totally ludicrous. We are only human, and prey to all of the ailments from which our patients suffer. But there is this expectation in the community, and also among physicians themselves. I know I give myself a hard time.

Sometimes the most loving and compassionate thing we can say is "No" - otherwise the rest of the team turns to toast. Reasonable plans for covering the workload are needed, and unfortunately not all medical systems are sane about this as we know. I wonder if this part doesn't lead to ill feelings from our partners when one of us becomes too ill to work.

Why do we feel we have to hide our illnesses? I know we have many reasons. A big one is that we fear being criticized, by others and our own "inner critic." When I finally "came out" at work years ago and left my practice, I got the most wonderful letters from patients. I should have been more open all along. It would have helped my patients.

I have lived with pain in my back and ribs since my accident, and the need to cut back on work, and continue wearing a brace. It sometimes seems that until someone has actually lived with severe pain themselves, they don't actually understand the experience of it, and how debilitating it is. So it may be really VERY important for people who have the experience of these conditions to try to tell the rest of us, and try to help us understand.

for the record

2008-11-23T14:35:00.005-06:00

typical call night.

4 pm.
i received a discreet warning that the intern
with whom i'd be working needed her work double- and
triple-checked, "especially her orders." then i got the sign-out:
which people had inexplicable symptoms or paradoxical reactions,
which ones were closest to dying, which ones whose "full code"
revival would be impossible to achieve if the worst should happen.
which ones had the fewest resources - lung capacities; arterial
integrities; brain waves; abilities to tolerate pain, hospital food,
and waiting.

6 pm.
we admitted a mentally retarded middle-aged man
with a nonhealing big-toe wound. he'd been in the hospital
a few months back, and the x-rays looked like an infection
of the bone, but the surgeon advised us to send him home
on antibiotics for a month. he finished the antibiotics - a nurse
comes every day and gives him his medicine - but the wound
never healed, and now it was so bad he could almost feel it
(through the neuropathic numbness of late-stage diabetes)
and everyone in the hall could certainly smell it. a band-aid was
falling off; reddish pus wept out, coating the toe and its neighbor.
i squeezed it pretty hard, to see if it could be emptied. it was like
squeezing a rotten onion.

7 pm.
we asked the surgeon to come take a look. actually, we asked his
nurse, who was answering his pager while he was in surgery.
it turns out the patient had never kept his "follow-up" appointment
with this same surgeon, and it was eight o'clock at night when he
visited, after a long day of surgery. we weren't there; the intern
went to update her patient list, and i went to my room to eat some
canned pineapple and watch a doctor show on tv. so per the nurse,
the surgeon kind of stomped in to the unit and rolled his eyes at the
wound, sneered at our notes and declined to look for the x-rays,
cancelled our wound-care orders, changed the antibiotics,
and left a note saying he would not be on call this weekend.

8 pm.
a code blue was called in labor and delivery. as usual when i
heard "attention, attention, attention" over the loudspeaker, i went cold
and tingled for a minute. we ran down the stairs. but when we got there
the charge nurse was on the phone chewing out the dispatcher;
it wasn't a code blue, just an unexpectedly rapid birth.

9 pm.
a woman whose large fulminant perineal abscess had been
cut opened and drained (our attending inserting a gloved finger
deep into the buttock meat to break up the loculations so the
jellied pus could be scooped out, replaced with sterile packing)
- she spiked a 105-degree fever and was, you know, delerious.
the nurses were taken by surprise and wanted to move her
to intensive care, or failing that, at least an icebath. i suggested
we start with a gram of tylenol and they check her temp every 20 min
for 2 hours. apparently that was that. no more calls.

10 pm.
i went to my room and ate some cheese and crackers sitting
on the bed watching animal planet and nervously re-reading
what you're supposed to do in an obstetric code blue.

got a call from a lady who said her stomach hurt real bad,
would only stop hurting if she lifted it up in her hands
and held it to one side while lying on the other side in bed.
fifth pregnancy. morbid obesity. she didn't want to go to the ER.

11 pm.
admitted a guy with his third pneumothorax - the first one
was spontaneous, the second one from being stabbed in the chest
while in prison, and this one possibly related to the giant consolidated
pneumonia in his right upper lobe. it looked like the upper lung was
scarred to the chest wall, so nobody wanted to put in a chest tube
and accidentally pierce the lung itself. when he coughed, i shivered.
we put him on high-risk infection precautions, among other things,
and had his oxygen levels checked continuously. he was awfully thin.
he tested positive for cocaine. he consented for an hiv test.
the chest surgeon said, leave him alone, i'll look at him tomorrow.
he asked, coughing, to go outside for a cigarette, and we said no.

12 am.
meanwhile, the guy my age with terminal heart failure stopped
making urine. nephrology came and saw him and stopped his antibiotic,
saying it was nephrotoxic, and ordered a test for adrenal failure
because of his weird blood electrolytes. later in the night he made a little
orange-colored urine. he's in such bad shape, but he's afraid that if he
makes himself DNR - do not resuscitate - they won't put him on the
transplant list. so he remains full code, with a heart like wet papier-mache,
barely able to hold blood, much less pump it out.

1 am.
i got a choco-taco out of the freezer and got into bed.
got a call about a month-old baby coughing with a fever. sent them
to the children's hospital emergency room, and turned off the light.

2 am.
phone rang; time to admit a little old lady with pancreatitis.
she had never had pancreatitis before. she had no risk factors
for pancreatitis. a lifelong tee-totaler, with a healthy gall bladder;
the preliminary report on the imaging showed thickening
of the head of the pancreas and the surrounding fascia, plus
some spots in the liver and kidneys. while we were admitting her,
we kept getting calls from intensive care...

3 am.
...where our 27-year-old souse, who says he doesn't drink,
here with his fourth severe pancreatitis, was having severe problems.
he couldn't stop vomiting and his blood pressure was going up and up
and his heart rate doubled and he was shaking all over and sweating.
he swore on his mother he wasn't withdrawing from anything.
we had a few theories. we tried a few drugs. some of them helped.
he stopped vomiting for a while. then he lost the ability to pee.
ultrasound showed half a liter of pee in there, but nobody could get
a catheter in. then he started vomiting again.

4 am.
the nursing home called about one of their patients.
she's a 30-something, a private patient of my program director's,
temporarily in a rehab center to build up her leg muscles so she could
go back to independent living after surgery. they couldn't get a
blood pressure on her, they said. and she was cold to the touch.
none of the machines could find her blood pressure. her pupils were
dilated and her pulse, according to the machine, was 40. none of the
night staff knew how to take a manual blood pressure, and they
couldn't feel her pulse themselves.

she'd fallen down the previous day and complained of right hip pain,
but she was still able to walk. now she was awake, despite having
almost no vital signs, and complaining of right belly pain. maybe you'd
better send her to the emergency room, i said sweetly. they said
they guessed they would. i printed up her clinic notes and med list
and went down to the ED and briefed them.

5 am.
the old, old guy with the do-not-resuscitate orders
developed respiratory distress. the nurse said he desaturated
down to 60 (which means the machine indicated that he only had 60%
of the right amount of oxygen in his blood - optimal being 100%)
and his respiratory rate was 48 breaths a minute (normal about 14).
he refused to use the breathing mask. i suggested morphine
and a tranquilizer, and then maybe he'd find the mask more to his liking,
but when the intern went to see him, he was saturating at 86%,
not terrible, and breathing only about as fast as the intern, who'd
taken the stairs. and he was sleeping (mask -free). who knows?
then the lab called with a critical value. his INR had doubled again
(2nd day in a row), so his blood was now 8 times thinner than normal.

i decided to abandon the intern and lie down again. it's winter now,
still dark until seven am. then i got another call. it turned out that -
remember the lady with no blood pressure? they sent her
to the wrong hospital. so the ED doc at the other hospital
called me up and said the patient had a rock-bottom blood count,
appeared to be hemorrhaging from somewhere, needed blood badly,
could we transfer her to our ICU? so i went downstairs to the ICU,
and while i was asking, the nurse manager came running,
waving her arms at me: "No! Stop! We're overflowing down here!"

6 am.
by this time, the nurses were turning the day lights on and
there was a smell of coffee in the air. i took a call about a
teenager 3 months pregnant who was worried her backache meant
she was miscarrying. the intern took a call about a lady who says
the hospital lotion makes her itch, then another one saying
that one of the patients needs to know what time he can leave.

7 am.
i went around and doublechecked the intern's orders. she
did fine. so then i handed off the pager to the next "sucker emcee"
as they used to say, and went home. i write these things down so
someday when i have a better life, i can remember what it was like,
that things like this really happened and were a part of the everyday
surreal, and i went along with it and did my work and got through.

miss diagnosis loves mister e. symptoms

2008-11-22T16:56:00.004-06:00

Brain cancer symptoms include: Abnormal pulse,
headaches, difficulty walking or speaking, dizziness,
vomiting. It is important to remember that most headaches
are due to less serious conditions.

5yo female, tired and moody, losing weight. normal exam,
normal blood and urine tests. 10 days later, "she started
holding her arm against her side and dragging her leg."
went to emergency room. "by that time she could not walk
without falling." "the MRI went well" but "when we walked in
there were seven doctors sitting around the table
who looked like they were terrified to be there."

The delay in the diagnosis of pediatric brain tumors
is certainly multifactorial. Infants and young children might
not be able to voice complaints.

5yo male, clumsy and falling down a lot, prescribed
glasses for farsightedness. three months later, the
left eye would no longer move from side to side.
MRI showed a large brainstem tumor, inoperable and impossible
to biopsy. "earned his angel wings" the following year.

8yo male, seeing double. multiple ophthalmologists.
negative exams, labs, and CTs. MRI: brainstem glioma.

6yo female, fell down and hit her head on the monkey bars,
got a headache and threw up - for several months.
"diffuse and infiltrative" brain tumor.

6yo male, fell off the monkey bars and broke his arm;
two weeks later started having headaches. medulloblastoma.

13yo male diagnosed with oligodendroglioma
"after weeks of persistent hiccups."

The lack of specificity of the most commons signs
and symptoms (such as headaches and vomiting), which may
mimic other more common diagnoses, often contribute to delays
in the diagnosis of brain tumors in this age group.

12yo male with a headache. family doctor said fluid
had built up in his ears and sinuses and gave him
antibiotics. the following day, he felt dizzy and had
double vision and slurred speech. doctor said not to stop
taking the antibiotic but to call again if concerned.
emergency room MRI: pontine brainstem glioma.

15yo female, vomiting in the mornings. negative
pregnancy test. diagnosis: sinusitis. the following week,
crashed her snowboard into a tree and walked away
staggering. medulloblastoma. "i wasn't frightened at first.
i was furious."

11yo female, needed glasses, sometimes clumsy.
during vacation, nausea and vomiting - on and off
for two weeks - always "having a good day" when visiting
the pediatrician - normal exams and labs. then - severe
headaches - "couldn't eat or get out of bed." MRI:
"the doctors were astonished that she hadn't had seizures
due to the tumor's size and location. they told us we
were lucky."

Contrary to expectations, the introduction of
modern imaging techniques has not influenced the delay
between the first symptoms and the diagnosis. However,
once the diagnosis is suspected, modern imaging techniques
undoubtedly facilitate the diagnostic process.

7yo male, no symptoms until "a funny turn at school...
barely conscious when the ambulance arrived." diagnosis:
migraine. next few weeks, problems with reading and memory.
headaches on and off, then a seizure. "we were surprised
and distressed to learn how aggressive this type of tumor is."

18 month old female, no symptoms. pediatric exam
suspected "lazy eye." MRI: large brain mass, "drop mets"
"like a sugar coating" down the spinal cord. first diagnosis:
medulloblastoma. second diagnosis: highly invasive rhabdoid tumor.

10yo male, "misdiagnosed for 7 years
with tourette's syndrome and laughing seizures,
until an MRI identified a hypothalamic hamartoma."

Recent reports have drawn attention to the importance
of behavioral symptoms, which account for up to one-fifth
of initial symptoms in children.

7yo female, "suddenly not as lively." lost her appetite.
fell asleep during class. one month later, stopped eating
and drinking. "instinct told us something was wrong."
high-grade glioma.

5yo female. ependymoma. "it's pretty rare. your odds
of winning the lottery are better."

4 month old male with unusual facial expressions
and eyerolling. pediatrician stated the baby "was just
trying out new faces and had gas." put on antacid.
emergency-room MRI: cerebellar ganglioglioma.

Increasing awareness of the issues associated with the
diagnosis of brain tumors in children among community
healthcare professionals may contribute to limiting delays
in diagnosis. However, whether this may translate into
improved outcome is still unknown.

december: born 7 lb 14 oz.
january: diagnosed with brain tumor, 3 x 2 x 1 cm.
february: tumor 6 x 4 x 5 cm.
march: 3rd course of chemotherapy.
april: 5 x 6 x 7 cm.
june: "she's an angel now looking down
on all of us with love."

between 2000 and 3000 children a year
are struck with brain tumors.

"It's a Tragedy and I can not find any reason
or purpose to why a child should have to die.
The feeling of Pain which is left behind is Immense."

i'm just saying.

curricula - from Latin currere, to run

2008-11-13T12:10:00.005-06:00

Medicine still claimed continued progress, as measured by the new landmarks doctors set for themselves and then reached. --Ivan Illich

1. valid means of investigation, valid means of knowing
2. ideas that are dangerous & who endorses them
3. specific personal and group goals that are possible/impossible
burnout is not mayhem
burnout is mental exhaustion
burnout is an inability to relieve the unrelenting stress
burnout is an index of the dislocation between what you are and what you have to do

burnout is lack of discipline
burnout is dangerous
burnout is acid based

burnout is making me illiterate

burnout is likely to stem from that impossible
burnout is the realization that no matter how smart you are
burnout is the depleting of oneself

burnout is a close look at our lives
burnout is a stressful event in and of itself

burnout is ruining the lives of huge numbers of people
burnout is paved with good intentions

Foremost among iatrogenic diseases was the pretense of doctors that they provided their clients with superior health. --Ivan Illich

4. fairness; how to evaluate deserving and entitlement
5. a theory of "human nature" incl. persuasion and manipulation
6. a theory of "resources" incl. inherent and constructed proprietary relations
brainwashing is a way to change their loyalties
brainwashing is befogging the brain to seduce you into acceptance
brainwashing is taking place

brainwashing is a crude and unwarranted metaphor
brainwashing is science
brainwashing is with knowledge
brainwashing is a technique
brainwashing is part of a larger plan

brainwashing is primitive
brainwashing is when the person is aware of who the enemy is
brainwashing is the same everywhere

brainwashing is the process of deliberately
brainwashing is as follows

The exclusion of mothers, aunts, and other nonprofessionals from the care of their pregnant, abnormal, hurt, sick, or dying relatives and friends resulted in new demands for medical services at a much faster rate than the medical establishment could deliver. As the value of services rose, it became almost impossible for people to care. Simultaneously, more conditions were defined as needing treatment. --Ivan Illich

7. ways of determining who is an authentic member
8. ways of determining who is a suspect member
9. how to display credentials
10. barring and purging
indoctrination is by no means an evil thing
indoctrination is to teach you
indoctrination is instruction in a principle

indoctrination is nasty

indoctrination is a matter of intellectually disabling a person
indoctrination is the programming of irrational fears of ever leaving the group
indoctrination is inherently untruthful
indoctrination is the problem and more of the same isn't the corrective

indoctrination is more important now than ever
indoctrination is tentatively set for the month of august
indoctrination is mandatory

indoctrination is something that really needs to be done in person

indoctrination is organic
indoctrination is what infants get
indoctrination is to insure order and continuity
indoctrination is part of our heritage as a free people

indoctrination is a bit different for those expected to take part in serious decisionmaking

indoctrination is laden with values
indoctrination is loaded with every bit of information you will need
indoctrination is part of my search for understanding

Hospital-born, formula-fed, antibiotic-stuffed children thus grow into adults who can breathe the air, eat the food, and survive the lifelessness of a modern city, who will breed and raise at almost any cost a generation even more dependent on medicine. --Ivan Illich

11. current vs. potential positions, relative to other members
12. appropriate degrees & subjects of enthusiasm; appropriate means of displaying enthusiasm
13. how to embrace foreclosure
Certain tools are destructive no matter who owns them. --Ivan Illich

100 demons

2008-11-12T08:05:00.011-06:00

i have been "learning more about pediatrics in the outpatient setting." the pediatrician for whom i am working is 35 years old and has eight children under thirteen years old, and one on the way. he doesn't have any religious paraphernalia around his private office, so i figure he's not a catholic, but a "quiverfull" type (look it up). for example, he is listed in a directory that says it's "a resource to women and couples who seek physicians practicing medicine in accord with traditional Christian principles." so glad that i left off my rainbow-flag and peace-sign buttons from my white coat before i started!

he has some peculiar ideas. he vehemently counsels teenagers that they are not allowed to go on any dates until they graduate from college (so glad that i never asked him what age he gives the HPV shot! - the anti-venereal-warts shot, which is really the first anti-cancer shot, approved for girls starting at age 9). his version of "anticipatory guidance" (did you know that primary care doctors are all supposed to provide all parents and kids with 'anticipatory guidance'?) is to give a short list of things that are "bad." "don't watch television: television is bad." (i couldn't agree more, but i wouldn't, you know, say it like that - and i doubt he'd endorse my anticapitalist motivations.) "and no computer. stay off the internet." and he tells all parents, at the 2-month baby visit, that when the baby turns four months old they will have to "put baby in the crib every night and let them cry themselves to sleep. that's how they learn self-soothing." and he explains, "you have to do it before they start to get separation anxiety around six months." his patients are all white, upper-middle-class, breastfeeding, and somber.

not surprisingly, it gives me nightmares. i mean literally. i have bad dreams every night. just like when i was "learning about pediatrics in the inpatient setting."

i take my little girl, aged about 5, to my parents' house, where she is to stay for a while because i have an overwhelming workload in becoming a doctor that i have to try to get caught up on. she's playing on the floor while i'm getting ready to go, when she suddenly says, 'mom, can you look at my arm?' and when i look i see that that there's a little ulcer on her elbow, with a little bit of pus coming out, and as i examine it, the skin of her upper arm starts to split open, starting from the ulcer, and i can see the muscle and bone. i try to hold the split together with one hand, and the skin on her lower arm starts to split open, too. i tell her to wait here a minute, not to move a muscle, and i go running down the hall, calling to my mom that i need the car, i have to take her to the emergency room right away. as i run i see that the carpet is all rotten and ripped up, and there's a place where the plywood underneath is all torn up and broken and the wood is soft - you could punch a foot right through it - it's because there's a leak dripping from the ceiling above it, with a huge brown watermark; the railing along the stairs has fallen down and the rusty shards are sticking up like teeth; and even though it's an emergency, my parents just stare at me from the other room with their mouths open; something's wrong with them; they don't understand a word i'm saying.

i dropped out of the "behavioral medicine" track of my program.

i'm still studying it - independently - but i can't devote my few remaining months of training to observing people with terrible psychiatric illnesses that i will never treat, in (terrible) hospitals where i will never work. which means i can't complete the requirements for the track. which means i dropped out. i also dropped out of the maternity-care track, a few months ago, after doing the math and realizing i will never be able (as an MD) to do the kind of (non-hospital) maternity care i could in conscience do. i'm still studying it independently, because it's cool. i don't need to keep struggling, to earn an honorary certificate (which is all you get for pursuing a specialty track).

it all makes sense; it's not a big deal - except when i'm dreaming.

i'm living in a dilapidated mansion, as usual, and i've tried to grow a garden. it hasn't gone well. i've planted corn and green beans and tomatoes and, optimistically, flowers, all along a hedgerow. i figured they could use the support. i did not expect the hedge itself to rear up over them here at the end of the summer, thorny and dense, blocking out the sun. so i'm out there in the rain, trying to see if anything's salvageable; i'm getting wet while the ground under the hedgerow stays bone-dry; the plants are brown and stunted; none have borne, or obviously ever will bear, fruit. my advisor, the psychologist, is walking along, breaking off brittle dry stems of vegetable matter, saying, "how did you ever expect this to grow here?" i am very much ashamed.

i think about starting my own practice all the time. i'm so far in the closet, it's hard to even imagine finding the door. why a closet? because this desire, to be a solo-solo doctor, without even any nurses to handmaiden me, with a patient population so small i could fit them all in my backyard for a party, spending an hour at a time helping them figure out how to deal with their illness, or how to regain their wellness, is treated as naive and flower-child-y at best, and suspiciously disloyal at worst. it's not the "real medicine in today's economy" that i'm being trained for.

currently, as someone who is "almost done" (you can say that again), i'm trudging through days and days and days of fifteen-minute appointments with people who are really, really sick and scared and needy, trying not to dump a ton of the scutwork that i actually do need to learn (clean out this ear! repeat this blood pressure! show this patient to the lab!) on the nurses - as we're admonished over and over again to do, "just like you would in real practice." so i don't have time today to tell you that you're going to need a biopsy - or not need a biopsy - because i have too many fifteen-minute appointments today, and will be running two hours behind by the end. i'll try to call you tomorrow, even though i know you're sitting by the phone right now. it's not just you - multiply yourself by a hundred. or make that, multiply yourself by 2,465.

i keep catching myself asking myself how i can stand it. how, after all, do i do it? how do i keep from cracking under the pressure? or am i cracking? is this how you can tell you're cracking? when you start wondering how you're going to make it? not mention when you start asking yourself, daily - several times daily - if this whole idea was a terrible, terrible mistake.

i can't believe in it. i can't commit to this shitty level of care. i can't imitate my teachers. can't, can't, can't - but must, must, must - which in my psychology quickly turns into won't, won't, won't. and what if something goes wrong, and i can't open my own practice? then what? more of this? even more?

i'm at work and i see that my schedule is full with appointments for a family of ten, all who have achondroplasia (dwarfism). all are angry at being made to wait, because as usual i'm running behind. the first patient wants a prescription for testosterone to make his muscles bigger. i tell him i don't know if that is safe with his condition, but i'll do some research on it and get back to him, and finally flat refuse to write a prescription; he leaves even angrier than he arrived. the next patient is a kid, with his mom, who wants him to get growth hormone, and i tell her i don't think it will actually make him any bigger, and she's very VERY angry, and we have to talk (i talk, she argues) about it for a very long time. i check my schedule again, and see that the next patient, also with achondroplasia, is here for "acute chest pain," and has been waiting now for half an hour, and i look down the rest of the list and just despair.

i was on call on monday night. i got to the hospital at four in the afternoon, and found i was on with a medical student. this meant i would do all the work as well as show her how to do it as well. she would do work too, but none of it would be part of the medicolegal events of hospitalization, so it would be double the work instead of, as if i were on with an intern (who has a medical degree), half.

for some reason - the medical student said, "full moon?" - our little community hospital was doing land-office business. lots of interesting cases. "land-office business" and "interesting cases," to ordinary people, of course, mean a tall building chock-full of people engaged in their worst personal nightmares. to me, it meant that every two hours the emergency room called me with another admission, half to the intensive care unit.

let us all count our blessings that we do not have acute-on-chronic kidney failure plus flash pulmonary edema (how can you get the water out of the lungs, if you can't pee it out?), nor a (putative) busted arterio-venous malformation in our small intestine (the blood keeps pouring out the rectum, and we keep pouring it back in the vein - a jugular line, the last one that works), nor sickle cell disease rendering the blood supply to our lungs painfully ("painfully" in the literal sense) useless.

we've got THAT going for us, at least.

conk! and some offhand medical sayings

2008-10-30T07:50:00.006-05:00

dang, i'm conking out. the last 2 weeks have been grueling. why is it so hard to just go to work every day? i'm on call again tonight.

gruel.
wait, i know - duh! i haven't been sleeping. or rather, i do fall asleep - uncontrollably, at 8:30 pm - but when 2 am rolls around, it's apparently time to get up. plus rufus, plus thyroid and vitamin d problems, plus the workload, plus the stress load. my world is currently composed entirely of sick, suffering, and crazy people - and a hell of a backlog of scut. things impossible to avoid. things make a body tired.

but i forget - probably because of the tired, which produces delayed mentation - that these are actually good reasons i can't keep up, that these are actually good reasons yoga breathing and medicine and healthy snacks and a prayerful attitude do not suffice. there's no way out, right? but i forget, and engage in negative self-talk ("stupid, stupid, stupid!"). but the only way out is through, right?

not to mention,
"at what point is the enemy of good better?"
- tired obstetrics chief resident

and, "easy to become anger is a stage."
- tired russian fam med resident

and, "you get into a shrinking box of danger
with some of these people."
- tired doctor with yeeeeeears of experience

i'm just saying.

sunday morning

2008-10-05T11:21:00.007-05:00

pity, modernity, and the spectacle of suffering part two
that title just gets me somehow. it's medicine all over.

as long as you stay at home, there's only unrelenting pain - vomiting - being too tired to get out of bed. there are only these things, and suffering. but when you start to wonder what the medical explanation is, then along comes the spectacle of suffering - "the patient presents..." - the patient auditions - the doctor applauds, or boos and hisses, or looks bored (the doctor has a hallway full of other performances to attend, and has been attending all morning, all week). both need to collaborate, or to see the other at least as a collaborator, to finalize the presentation, to organize the illness, to diagnose. otherwise, the doctor might break the cardinal rule and treat without a diagnosis, or might retaliate and write something cruel in the diagnosis box ("axis II [personality disorder]," "somatization," "worried well") which insurance will not pay for. (insurance also will not pay for a blood test, a urinalysis, or an MRI of the brain accompanying such diagnoses.) if the patient presents properly, their reward is not only some kind of medicine to relieve some of the symptoms (and possibly the underlying condition), but also a diagnosis, an explanation, a story with a beginning and middle and therefore, one hopes and expects, an end; a tremendous comfort. a work excuse - well deserved; a week in bed - well deserved; a story.

i see that i'm at the top of the google list if you enter "pity modernity" today - you'd think the anti-postmodernist league or somebody like that would be there instead - i do not like publicity. it's because i cited the paper, which i have not been able to read, since my online library doesn't carry it - i was only able to to quote the pub-med abstract, which i found very tasty. if you only google 'pity', you get the wikipedia entry, which reveals that the notion of pity has been suspect for a long time - it is distinguished from sympathy, empathy, and compassion; pity is a bad thing, and the others are good. but anyway, when boys and girls enter medical school, of course, it is because they "want to help others." they write a little essay describing one or two specific others they have wanted to help. same when they leave; they interview residency programs to specialize in their favorite version, or the version that seems most pragmatic, of "helping others," and they develop a little speech about why their specialty is the helpiest.

once they start taking responsibility for "evaluation and management," once they start writing down diagnoses, they begin practicing pity, which philosophers apparently define as niceness mixed with contempt. leaving residency, they're schooled in pity, and rely on it to get them through the day: hannah arendt's "sentimental distance," which doctors actually congratulate themselves on maintaining without sentiment. the "boundaries." nobody comes right out and says, treat the disease, not the patient, but everybody knows that's Good Medicine. "you have to have That Distance." it's assumed that without it, you'll crack, or, worse yet, you'll be tricked. you'll be naive.

we quote osler - the older guys do, anyway - "listen to the patient. he is telling you the diagnosis" - but that's not seen as truly necessary. there are successful pediatricians and veterinarians, after all, and furthermore, patients lie. your reported pain is "out of proportion to the exam" (drug seeker). you say you were vomiting all night, but you're not vomiting now, and i see on the computer that you had a negative GI workup last year for the same complaint (somatizer). it doesn't help that you obviously don't like doctors, and you used a swear word, and there's coffee on your blouse (axis two). patients are unpleasant, and we don't like to be too closely associated with them, but we are blessed with a technology of detection, so we're doctors. thanks to pity, modernity, and spectacle, we're doctors. thanks for playing. glad you could make us elite.

my psychologist pal tells me he thinks my desire to start a solo-solo micropractice is a symptom of my residency burnout - the need for more control. he has insufficient information - i've been studying and reading and learning about this, pretty steadily, for a year now. i read the witnesses of doctors who really burned out, who were disabled by cognitive dissonance as a result of "wanting to help others" plus probably not "having That Distance" so they were unable to adjust properly to the 15-minute doctor visit. plus i look around me at the personalities of physicians; they have terrible self-esteeem and are anxious all the time; they are afraid of 'missing something' and 'having something bad happen.' they never recover from their sense of inadequacy, and i really think it's a consequence of their work environment, not to mention their training (in an even worse environment). i never liked the setting as a patient or as a patient advocate (i reminisce about spending lovely long hours on the phone telling breastfeeding mothers to fire their pediatricians), so i don't want to spend the rest of my life there.

i also remember lovely long hours, literally at the kitchen table, with folks i knew pretty well, talking about pains and infections and fertility and how to keep out of the doctor's office. that, i can do for the rest of my life. 'family medicine' with its notion of 'the medical home' (the notion, not the program) offers such a wonderful opportunity to actually be a personal doctor, to actually know people well. how would that change the spectacle of suffering?

how would it change the way i present my own (casual) complaints of burnout to my psychologist pal, if he knew how i spent the 35 years prior to encountering the stresses of residency? how much would it speed up my beloved spouse's presentation of "my back hurts, i'm worried i'm throwing another stone" if that was actually all he had to say, because the doctor knew how this all started? if i were my patients' personal doctor in a personal way - if they were my patients rather than the clinic's patients - would i finally figure out why the sickle cell teenager takes so damn much vicodin, and why the puerto rican guy's thyroid levels are through the roof one month and through the floor the next and then back through the roof? and would i finally, finally, finally have time to finally, finally, finally make it clear that it's not the three days after your period that you can get pregnant. and would i have seen the "longstanding domestic violence" before i got the emergency room report in my mailbox.

and could we have a cup of tea while we talk. and if you're really just in a hurry and want somebody to look in your ear, why, we can just look in your ear. i've been there too (it's hard to look in your own ear).

one of the solo-solo micropractitioner fam med docs told me a story about sewing up a kid's hand - it was full of interesting technical details - but her conclusion was that she had to just do it herself because she knew the family couldn't afford to go to a hand surgeon, and the kid wanted to go into the army, and he couldn't fire a gun without the repair being done in this particular way. and she showed me, wiggling her fingers, just how it healed, and the negligible little bit of range of motion loss from just one joint, and how it wouldn't limit him, and finally how he went off into the army, and how the family's coping with that. i might hear a story like that from one of the mega-team high-volume docs i work with. but their stories are usually those of comic diagnostic-surprise punchlines - "turned out there were a bunch of plastic spoons in his stomach!" "turned out she'd had a tubal ligation, so the test was a false positive!" or tragic diagnostic-surprise cautionary punchlines - "but she never told us she was HIV-positive." "and it turned out his father had it, too." and it's that constant element of surprise that freaks them out, maybe even makes them into mega-team high-volume adrenaline junkies who wouldn't practice any other way.

and maybe, when all is said and done, one can't practice any other way. (i have another degree, other than medicine - something to fall back on.) maybe the super-high-volume doctor world will spank you too hard, for spurning their clubhouse. when i was interviewing for residencies, i kept hearing sad sighs that family doctors make less than other primary care doctors, and the most idealistic ones often go broke and have to stop being so idealistic, and finally i asked, in exasperation, "what is 'being broke' for a doctor? how much does a doctor have to make to not feel poor?" because i think doctors make an awful lot, personally. and the person told me, it's not just the money, for most folks. it's that you don't get invited to the best cocktail parties. you're not a member of the club. especially if you take care of poor people, you are somehow tainted by your association with them.

awwww.

no, really, it must be an awful disappointment, especially for those who were born into doctor families and groomed for the elite since childhood, who made the awful mistake of going with the vogue of "wanting to help others" and found themselves locked into being a lower-caste physician. as a solo-solo doctor, i would be just a shadowy name that appears on an ER form once in a while. as one of the micropractitioners said, when a local anesthesiologist takes a CPR class, it's front-page news in the hospital newsletter, but when i publish another article in a national medical-economics journal, it's nothing.

i had not realized, when i entered medical school with the personal goal of subverting the american healthcare system, the implications of being a member of an elite; however, i am greatly pleased to have located the counter-elite (or in my case, the kitchen-counter elite). i entered residency right after one of my mentors, crazy neurology guy, told me, "family practice isn't medicine - it's a cult" and i had replied, "i think i'd be a good cult leader," and i think i'm finally getting back to that...

The idea of a doctor and patient falling asleep together while holding hands has the potential to cause a variety of responses amongst those in the medical field ranging from disapproval to alarm to dismissal as something that can occur only when a doctor has absolutely no other demands on her time. All these responses stem from the fact that as doctors we are trained to see patients as clinical cases first and as scared and suffering neighbours second. --narayan

then again, as i entered residency, and told my advisor why i chose to live near the clinic, in a somewhat-poor, somewhat-dangerous neighborhood, "where my patients live," he laughed and said, "you can never be in the same place as your patients. you're a doctor, and they're not." he used to live in cabrini green - but never in the same place, after all, as his patients. and in fact, nowadays, now that he has kids, he lives in a very different neighborhood indeed - not near the clinic, or the hospital - not near anything, except a church.

can doctors overcome the 'sentimental distance'? should we? can patients? is it too big a risk, or no risk at all? is it a bigger risk not to do so? is it still medicine, or just cult behavior? is there a difference between being a good neighbor and being a good doctor? should there be? shouldn't there?

pity, modernity, and the spectacle of suffering

2008-10-04T14:39:00.005-05:00

a thing i did not expect was that thinking about how to make my own medical practice (as opposed to figuring out how to accomodate myself to becoming a physician-employee) would make me start doing medicine differently.

i am doing more teaching and giving more backrubs. i am doing more therapeutic teaching and giving more diagnostic backrubs.

this makes me slower than ever.

i was already slow, but now i'm the slowest. however, i ask the patients if they're "on a timeline", and if they are, i'm very speedy indeed. and if they're really just there for one thing - med refill; earache; strep throat check; newborn weight check - i'm speedy. but i stopped regarding a lot of single-issue visits as single-issue visits. coming to see a doctor to talk about losing weight is a not a single issue (how are you sleeping?). coming to see a doctor for a diabetes check is not a single issue (did your wife quit smoking too?). coming to see a doctor for birth control is not a single issue (are you having sex about as often as you want to, or do you end up having sex when you don't want to?).

i'm slowly relaxing back, as First Wife suggested, into "what you wanted to be before you felt you had to protect yourself." i am trying to incorporate the practice of medicine into that. i'm trying to become less divided. but it's hard to do the work i am good at and know best, in the setting of the hamster-wheel clinic with its 15-minute appointments.

i was telling my urologist pal the other day that the most important thing i think i've been taught in residency has been how to avoid diagnostic testing. i told him, "at first, i would have been a fan of the full-body PET scan; 'why wouldn't you want to know everything?'" i used to think The Technology was Good. i used to think the truth was out there. i used to be a health fundamentalist, which is funny, considering how oppositional i was toward medicine; i used to think there was a physical truth about a body.

now i'm a doctor, and i don't think there's a truth. i think there's a temporary set of conditions, description of which is dependent on the conditions of observation. i guess i'm a quantum physician. what are the implications? the main implication is that it takes longer to explain things in a way that is salient and instrumental to the person concerned, the patient. the person has to be more patient, ha ha.

i have had a beef for a long time about the diagnosis-driven nature of american medicine. it's so very diagnosis-driven that folk even get angry if you simply make that statement. but diagnosis is an arbitrary place to start a medical, uh, discourse. a medical "thing." a medical pastime. we have trouble imagining any other way. but relying on diagnosis as the truth of medicine has certain implications, too.

i'm not saying, toss diagnostic schemas out the window - i'm just saying that diagnoses are contestible, thus are diagnostic methods, thus is the supremacy of diagnosis itself. i'm just saying. medicine actually has room for diagnostic uncertainty - it's not simply a marker for incompleteness, or incompetence - but patients generally don't know this, and insurance won't cover it, and doctors don't generally play that way. but it's where a lot of my patients live - especially those in the land of chronic pain - chronic fatigue - chronic anxiety - chronic dysfunctions of various types.

cf. Pity, modernity and the spectacle of suffering (Radley A. J Palliat Care 2004 Autumn;20(3):179-84)
...This world is one where the relationship of individuals to society is contested in the context of medicine, with all its technologies of treatment and uncertainties of prognosis. For patients who criticize or oppose medicine in order to recover their dignity, it is necessary to articulate or to portray their suffering. In this way, they are able to show not only that they live in spite of illness, but that they also live by virtue of it. From this perspective, dignity is shown to be part of a collective response to a medicalized world.

and
Negotiating the diagnostic uncertainty of contested illnesses: physician practices and paradigms (Debra A. Swoboda, Health 2008;12;453)
...Emergent, contested illnesses... share a number of characteristics: (1) their symptoms are broad and nonspecific, and differ in kind and severity among individuals, even among those with similar exposures and histories; (2) their pathogenic mechanisms have not been identified; (3) their causation is disputed as to whether it is psychological, biological, or both; and (4) their treatment involves competing therapies.

...Receiving a contested illness diagnosis involves a series of diagnostic negotiations... When physicians are confronted with a set of symptoms that are unclear or mysterious, they attempt to arrive at an 'organized illness'...One form of error involves faulty information gathering, which is linked to errors in understanding patient complaints... A second form of medical error, faulty verification, occurs when physicians fail to ensure that all symptoms are explained by the assigned diagnosis... Verification error is most likely to occur when test results are inappropriately used... or when the predictive limitations of tests are not acknowledged... Context errors often result as a function of typicality, when physicians attempt to explain symptoms in terms of what is most typical rather than what is possible...

so my mom sends me this column - my mother, the zebra, to me with my rufus! - and it's about diagnostic uncertainty - and even more interesting is the way the comments - it's a blog column - veer between the terse autocratic pronouncements of doctors and doctor-partisans ("questioning undermines the very core of medical progress") and the pitiful tales of actual patients vicitimized by the diagnostic imperative - and they don't even get started on how they're paying their medical bills!

if you're a patient, you're going to think the problem (with the folks making most of the comments) is that they were misdiagnosed. if you're a doctor, or a doctor-partisan, you're going to think the problem is that they had hopelessly unrealistic expectations - or that they're hopelessly ignorant (if not crazy). my point is that the number one thing at stake is always the diagnosis. the presence of the diagnosis. dealing with the diagnosis. longing for the diagnosis. i'm just saying.

"Diagnoses... carry powerful assumptions about our bodies and our place in the world... When the diagnosis trajectory and patient picture don't match, we are left with an 'atypical,' 'complicated,' 'idiopathic' or 'undiagnosable' case. One of the risks for these patients, in addition to prolonged physical discomfort or suffering, is that without a diagnosis, their experience may lose meaning and relevance in the eyes of others... We seem unable to harness the power of diagnoses and give full weight to the meaning of an individual's illness experience."

...from the 166 comments:

How is a doctor supposed to treat something when he or she has not arrived at a diagnosis?

Doctors and patients need a diagnosis to get insurance coverage.

Without the revolution in diagnosis, there would never have been the revolution in treatment... Ex post facto questioning undermines the very core of medical progress.

People who want hand holding and emotional support can look to other non-md sources.

the question really is do you want a dr like the one on the tv show "house" that is smart and tries to figure out the root cause of the problem and is good at it but totally rude?

You have to realize that the days of marcus welby are over. With hourly patient quotas set at one patient every 15 minutes there is no time to dally.

Beyond encouraging caring people to go into medicine, I'm not sure how a system can solve a problem like this one.

Perhaps in some distant future this will change, with mindful reform, but until then it's silly to complain.

Do you want an empathetic doctor who doesn't know what your diagnosis is???

The most important thing when seeing a new doctor is to do your utmost to appear a sane, rational person. Remember that you are auditioning.

Until you find the doctor who figures out a diagnosis, you don't get taken seriously.

Without a label to an illness, a patient is often treated like a sad individual seeking attention or as just a waste of time.

My husband was once told, "to get a life," because he kept going back to the doctor with heart-related complaints. He finally convinced someone, only hours before he probably would have had a massive heart attack.

I had mild chest pains for several days. I was willing and able to live with it but my wife insisted on getting some medical diagnosis... I ended up in the hospital for 24 hours... They ruled out heart disease, but at that point no one cared about my mild chest pain.

I was diagnosed with fibromyalgia, and then suddenly everything became about that... I got my regular doctor to test me. And lo and behold, I had a thyroid condition! ...Also, I had sleep problems. I was told that was typical for fibromyalgia... It wasn't until I went - again on my own - to a sleep specialist and discovered I had sleep apnea!

Thirty years ago, I was diagnosed with rheumatoid arthritis... In 1995, I found out I didn't have rheumatoid arthritis; I had lead poisoning... At this point, I wouldn't take my dog to a medical doctor for a broken nail.

I've been suffering from chronic cough for 11 years now. After 5 different doctors, I still have no diagnosis... I intend to pursue alternative medicine just as soon as I can afford to fly to Tijuana for treatment.

My spouse had a fungus that was overlooked for years.

I am a 56 year old post menopausal woman and I was just told that my blood test came back positive for pregnancy... I figure I'm just a medical misfit.

From birth, one of my daughters (now age 30) had all sorts of little problems... One side of her mouth drooping, failure to thrive as an infant, 6 fingers on each hand, not much muscle tone... attention and learning problems... constant infections (ear aches, strep throat, pneumonia, bronchitis, sinus infections)... Finally, when she hit 21, I did some research and discovered that this whole collection of miscellaneous symptoms adds up to Velo-Cardio-Facial-Syndrome (VCFS), a deletion on Chromosome 22.

I have a medical condition, cavernous angioma (a type of vascular malformation in the brain) that was diagnosed three years ago after I had acute symptoms. Yet for years, I had dizziness, and doctors, rather than look closely, simply wrote it off as "stress".

After 8 years and 6 different specialties, I still don't have diagnosis... I now rely on Google for medical information and pray that my illness doesn't get worse.

Most doctors proscribe pills for what they believe ails you without any thought to how the pill may otherwise adversely affect you .,not until a crisis arrives ,then they throw another pill to conteract the original pill,they read what a pill is supposed to do without any thought how otherwise the patient might feel or harm it might do .. as for experts…get five and you will have five different conclusions as to what ails you.. just mention "lyme disease " and see what games are played while the patient suffers .

The autism and Alzheimer's epidemics has been mainly caused by medical doctors and dentists.

I have cancer, and have been on chemo continuously for over 4.5 years... What concerns me is that the cancer docs don't seem to address other health issues that I have, such as thyroid disease, hypertension and slighly high blood sugar.

I recently helped treat Patient B who was sent up from the ER with a diagnosis of acute pancreatitis causing severe stomach pain... I began doing some digging and questioned Patient B further. Patient B had been diagnosed and treated for erosive esophagitis due to acid reflux years ago... We ordered a scope (EGD) for her stomach to follow up on the acid reflux and potentially treat it.... Instead of the ulcers or inflammation of the GI tract that I expected, it showed plastic spoons in the stomach. Patient B's psychiatric illnesses, including a personality disorder, were apparently not as well-controlled as previously thought. Patient B also had no idea how those spoons got there. The GI fellow was thankfully able to remove the spoons without surgery using the EGD scope... As a clinician once told me - If I had to choose between being lucky and being good, I'd choose lucky every time.

A patient has high cholesterol and is overweight by more than 40 lbs. Under the current system, the doctor gives the patient a prescription for a cholesterol-lowering medication, tells the patient to exercise more ("walking is good"), and may give the patient a handout of diet guidelines... The doctor has made the diagnosis, but the patient has to treat the disease...
Under new protocols [suggested by this commenter], doctor tells patient what diagnosis is and says patient will be referred to a lifestyle intervention program... Physical therapy twice a week or more for first three months and transitions patient to personal trainer and public gym for next three months...
A nurse practitioner/dietitian/nutritionist meets with the patient and the patient's entire household. The family group members are all required to attend several meetings about diet and nutrition... Then the family goes to cooking class with other families once a week for the rest of the six months...
Patient receives preventive and any other dental care needed... Concurrently, nurse practitioner/dietitian/nutritionist conducts a work analysis for the patient. This involves looking at the patient's schedule, how the patient gets to and from work, how the workday progresses, where the stressors are, etc...
The employer may be required to make accommodations, such as a treadmill desk where the employee can work while burning off some calories, or a stationary exercise bike at a desk, or a way to work some of the time from home to free up time for exercise instead of commuting, or for a refrigerator and microwave at work to store and prepare healthier lunches, or for schedule changes (if the business can fit them in) so the employee has time for breakfast and is home early enough to eat dinner well before bedtime...
After six months of intensive lifestyle therapy there is another six months of maintenance with the personal trainer or a physical therapist...
At the end of the year, cholesterol is measured again.

Why can't they have something like a video game that posits every symptom known to medicine with yes, no, maybe buttons.

Treat the patient not the diease, diease comes in differnt forms and shape and when it attacks the person (mind and phisical) is not just phisical but instead is a combination of the whole, mind, spirit, and phisical. I dont agree with the thought thought physician should only focus on the fisiopathological area, instead like the father of medicine it should serve the public with a humble mind and a loyal spirit. regardless of what the pharmacology industry preasure.

You know what, over the past few years, I've come to realize that most of the problems with healthcare in American can be traced right back to the patients.

Diagnosis can be tough, but that's why you get the big bucks Doc!

crazy person of the day

2008-09-26T17:21:00.010-05:00

this week my job is to come and do psychiatric evaluations of medically ill hospitalized patients whose doctors are concerned that they might be crazy.

65-year-old thin white man with the longest white beard and white hair, and the lowest blood count and vitamin b-12 level, anyone on the floor has ever seen. he came to the hospital because he couldn't walk, and figures he probably needs his legs amputated. he is an incredibly fast and tangential talker. his main topics are his family - "good old fashioned german farm stock from up north who moved to the city after the war like everybody else!" he hardly even stops to take a breath... i heard about

his father's world war two experiences when he became malnourished and had to get blood and his great-aunt's anemia which resulted from a chronic metabolic problem that also caused some problems with her thought process and his brother's psychology degree in english lit and how his brother works over there in the building across the street and will be paying all the hospital bills so we don't have to worry the bills won't get paid. he won't be staying too long anyway,

just long enough to get some bags of blood and possibly have his legs amputated; he had a bike accident last december riding his bike, a schwinn varsity, you know the varsity used to be the most popular bicycle model in the nation back in the sixties, he found it in an alley for nothing, so he was riding across the monroe street bridge during that big ice storm late at night, and he fell and wrecked his bike and hurt his legs, and although he knew he should go to the emergency room, he didn't, and his legs have never been the same since then. the next day, he went to the emergency room and they took x-rays and said he had a broken ankle

but they never put a cast on it, and it's probably a good thing, because it would have just gotten wet, because he was living on the streets; right before that, he had been living in the library, conducting secret research into what you might want to call economic realities; but mostly he always lived on the streets, and he can tell you, things have changed out there; there's no more of what you might call man's humanity to man; it's dog-eat-dog out there nowadays, because of all the cocaine.

i keep trying to steer the flood of conversation back toward a psychiatric interview, and he shares that one time, when he was a grade-school kid, maybe ten years old, or maybe eleven, he was in the hospital for a little while, and they diagnosed him with tourette's syndrome, which was a new thing at the time, kind of a new popular thing with the doctors, back then, but they said there wasn't anything they could do about it; they didn't have the kinds of drugs and devices that they use nowadays, they didn't have the science for it, you know; so they sent him back home to mom and dad. he's had a few run-ins with psychiatrists over the years, you know, the rumor mill, they went with the stigma;

he's been crucified by them before, but he always takes it in stride; he doesn't let anything bother him too much; all that bothers him right now is he's been living in this hotel with the rent paid by the trust fund his parents set up for the whole estate, from the farm and all the livestock and the farm equipment and everything, to be divided evenly between all the three sons, but now he can't walk right, his legs feel all crinkled up all the time, they feel all crinkled up, even when he's just lying still watching the cable, and that's why he's pretty sure they'll both have to be amputated pretty soon.

is he crazy? no. he's just eccentric, with a 'medical knowledge deficit' and a vitamin deficiency.

One Home (William Stafford)

Mine was a midwest home - you can keep your world.
Plain black hats rode the thoughts that made our code.
We sang hymns in the house; the roof was near God.

The light bulb that hung in the pantry made a wan light,
but we could read by it the names of preserves -
outside, the buffalo grass, and the wind in the night.

A wildcat sprang at Grandpa on the Fourth of July
when he was cutting plum bushes for fuel,
before Indians pulled the West over the edge of the sky.

To anyone who looked at us we said, "My friend";
liking the cut of a thought, we could say "Hello."
(But plain black hats rode the thoughts that made our code.)

The sun was over our town; it was like a blade.
Kicking cottonwood leaves we ran toward storms.
Wherever we looked the land would hold us up.

57-year-old plump, sweet-faced lady who recently developed an overactive thyroid that was "treated" (inactivated/killed) with radiation, then never saw any more doctors or got any thyroid replacement medicine, resulting in a complete thyroid hormone deficiency. she simpers. sometimes she forgets and gives a long suspicious grimace, but then makes eye contact and deeply simpers instead. she whispers, "do you know John the Baptist? he was a Special Man."

her husband says, "honey, tell them about the--" and makes a gesture of two hooked fingers stabbing downwards at his leg. he mouths to us silently, "SNAKES!" she looks suspiciously over at us, then bats her eyelashes and whispers, "i don't know if i can tell you that. i don't know if it's safe to tell you that." he husband makes the fang-gesture again and mouths, "SHE SEES SNAKES!" and she simpers at us and whispers with extreme syrupy sweetness, "god loves me. i am one of his children. i'm like - you know - like john the baptist... i had a Revelation."

she agrees to take some thyroid medicine. it will probably make the snakes go away. she's pretty concerned it will make god go away. she isn't crazy. in the old days, children who were born without thyroids were called "cretins," from the french "chretiens" meaning "saints," for their emptyheaded innocence; they were considered to be beyond good and evil, and could do no wrong.

Mad Girl's Love Song (Sylvia Plath)

I shut my eyes and all the world drops dead;
I lift my lids and all is born again.
(I think I made you up inside my head.)

The stars go waltzing out in blue and red,
And arbitrary blackness gallops in:
I shut my eyes and all the world drops dead.

I dreamed that you bewitched me into bed
And sung me moon-struck, kissed me quite insane.
(I think I made you up inside my head.)

God topples from the sky, hell's fires fade:
Exit seraphim and Satan's men:
I shut my eyes and all the world drops dead.

I fancied you'd return the way you said,
But I grow old and I forget your name.
(I think I made you up inside my head.)

I should have loved a thunderbird instead;
At least when spring comes they roar back again.
I shut my eyes and all the world drops dead.
(I think I made you up inside my head.)

49-year-old red-faced burly-looking white guy who came in with chest pain and recurrent laryngospasm. this means his throat locks shut. he has a 'fibrillating' vocal cord (seen on bronchoscopy). a year ago, he was a firefighter who drove a ladder truck and "directed all the roof work," with nearly 30 years on the job. (he talks about his job in the present tense, but nobody else does.) in 2006, he got a hand injury that produced a chronic regional pain syndrome, and when they gave him an injection into his neck last year to numb the hyperactive nerves to his hand, it made his throat start locking up - twenty to thirty times a day, with no air for 60-120 seconds at a time.

now he also has atypical angina (seen on cardiac catheterization) - his coronary arteries go into spasms randomly, making the heart muscle starve for oxygen, producing chest pain - on and off all day long. the lack of oxygen to his brain is wrecking up his memory - he can't pay attention long enough to read a magazine article or fill his own pill boxes anymore. "hypoxic!" he says in triumph. "that's the word, hypoxic!" he's brain-damaged. these events do cause him some anxiety. it got worse when he was denied disability, since the hospital bills are piling up, and the medicines cost a lot, and his wife doesn't make much down at the grocery store. he babysits his grandkids during school vacations. antidepressants help a little. is he crazy? no. he's having problems with adjustment.

Outside History (Eavan Boland)

These are outsiders, always. These stars -
these iron inklings of an Irish January,
whose light happened
thousands of years before
our pain did; they are, they have always been
outside history.
They keep their distance. Under them remains
a place where you found
you were human, and
a landscape in which you know you are mortal.
And a time to choose between them.
I have chosen:
out of myth in history I move to be
part of that ordeal
who darkness is
only now reaching me from those fields,
those rivers, those roads clotted as
firmaments with the dead.
How slowly they die
as we kneel beside them, whisper in their ear.
And we are too late. We are always too late.

77-year-old skinny puerto rican fellow with a bushy gray moustache and grizzled old jowls, under emergency detention for bringing a concealed weapon into the hospital. when you ask him a question, he closes his eyes and appears to sleep for about 20 seconds, by my watch, before starting to answer - and sometimes he actually does fall asleep, so i wake him up, and we start over.

he states "... ... ...i must've been in a big hurry" and that's why he was carrying a loaded gun. he also says that the place where we are right now is "... ... ...my room, my place," the first time, and "... ... ...the hospital," the second; can't say what hospital. he says the date is "... ... ...september, 1977."

yesterday, he went to another hospital across town, where his wife was admitted several days ago. "... ... ...she's got lung cancer." he falls asleep. i wake him up and ask, do you worry about your wife's health a lot? and he says, "... ... ...i used to give my wife a pretty hard time." i didn't know what to say to that, so i shook him awake and asked, how did she take that, when you gave her a hard time? "... ... ...sometimes she'd yell... ... ...most of the time she didn't do nothing." i ask him if he has worries about his own health as well, and he says very matter-of-factly, "... ... ...nobody cares what happens to me."

he "... ... ...can't remember" what the plan is, where his wife is now, who her doctor is, how long they've been married, or when it was they got married; how many kids they have, or where the kids live now ("... ... ...they don't care what happens to me"); where he used to work "... ... ...welding" or what kind of welding he used to do, what kind of car he drives or where his car is now. (he drove himself, his gun, and $374 cash to the other hospital, where he was intercepted "dishevelled and smelling of urine" by a security guard.) what do you like to do for fun? he shuts his eyes and gently shakes his head. do you like to hang out with friends? he gently shakes his head. he falls asleep.

i wake him up. i introduce myself again. he says he hasn't been feeling sad, blue, depressed, disappointed, or frustrated, but when i ask about feeling "guilty," he perks up and says, "... ... ...i get so angry." he watches the silent television for a few moments. "... ... ...i get so angry about things i have done in the past." two or three times, casually dropping it into the molasses-textured 'conversation,' i ask him, in different ways, what the gun was for, why he bought the gun, what he carries it around for, why he owns a gun, etc., and each time he says, "... ... ...for anything i want... ... ...for anything."

he says he bought the gun 8 months ago, not from a store, but from a private owner, not anyone he knew before, not from an ad in the paper, but "... ... ...i just bought it." he keeps it loaded all the time. have you been having any trouble with your memory? "... ... ...that's a good question," he says, and closes his eyes. he is demented, not crazy - it shows up, the shrunken brain, on CT. but i say to keep him detained. he's at high risk for murder-suicide.

889 (Emily Dickinson)

Crisis is a Hair
Toward which the forces creep
Past which forces retrograde
If it come in sleep

To suspend the Breath
Is the most we can
Ignorant is it Life or Death
Nicely balancing.

Let an instant push
Or an Atom press
Or a Circle hesitate
In Circumference

It - may jolt the Hand
That adjusts the Hair
That secures Eternity
From presenting - Here -

70-year-old rail-thin mediterranean-looking lady with big hair and a large pancreatic mass - good prognosis for complete cure if resected (no metastases). because of the mass, she is becoming more and more jaundiced, and this would cause permanent brain damage eventually. she refuses to have any surgery, because god has touched her, and she has been healed because she is a holy woman. she has died several other times in the past, and been brought back to life, and she has taken dead babies in her arms and brought them back to life, too. it was god that gave her her social work degree and her lawyer degree and her doctor degree. she raised ten children and they all call her mama, and they come to her to ask advice, she doesn't go to them, and they don't tell her what to do.

so far today she has called the governor, the city mayor, and channel 12 news, to tell them all that she is being held prisoner here by a man with the devil in his eyes who wants to cut her open and expose all her organs. he is satan. he is no friend of hers. she doesn't eat anything here, because she doesn't know what the devil may have told people to put in her food. they keep trying to make her sign the papers. she won't sign the papers. did the news crew arrive unannounced, with lights and cameras and microphones, asking to speak to the hospital's attorney as well as to the patient herself? they did. is she crazy? i'd say so.

A Sick Child (Randall Jarrell)

The postman comes when I am still in bed.
"Postman, what do you have for me today?"
I say to him. (But really I'm in bed.)
Then he says - what shall I have him say?

"This letter says that you are president
Of - this word here; it's a republic."
Tell them I can't answer right away.
"It's your duty." No, I'd rather just be sick.

Then he tells me there are letters saying everything
That I can think of that I want for them to say.
I say, "Well, thank you very much. Good-bye."
He is ashamed, and turns and walks away.

If I can think of it, it isn't what I want.
I want... I want a ship from some near star
To land in the yard, and beings to come out
And think to me: "So this is where you are!

Come." Except that they won't do,
I thought of them... And yet somewhere there must be
Something that's different from everything.
All that I've never thought of - think of me!

51-year-old obese asian guy with bipolar disorder, who was just here 2 weeks ago with an infected foot, recently in hot water for using his insulin needles to inject crushed-up pain meds directly into where it hurt, hospitalized now with chest pain, and i'm to see if he is a suicide risk.

yesterday afternoon the balcony collapsed while his 28-year-old daughter was standing on it. he tried to revive her by rubbing her arms and talking to her. she got up and was staggering around saying her chest hurt until the ambulance came. he thought she had probably broken a rib, and stayed home to babysit her 2 small children. half an hour later he got a call to come identify the remains. when he got to the hospital they told him she died of a broken neck. he passed out and started having seizures, and that's why he's under guard in the hospital now.

he says he's not upset - "i think i'm in denial" - and he hasn't been thinking about anybody's death but hers. i talk to his regular psychiatrist, who says he's at an extremely high risk, to judge from his many previous suicide attempts in response to 'acute emotional stressors'. the patient says he just hopes he can be discharged once the rest of the family arrives for the funeral. later that day he starts coughing and and he can't get any air and it turns out he has bilateral pulmonary embolisms - the dreaded "blood clot in your lung," both sides - which means, basically, he's not going anywhere soon. his bipolar disorder and his narcotics addiction are pretty well controlled. he's "only" bereaved.

Eyes Fastened With Pins (Charles Simic)

How much death works,
No one knows what a long
Day he puts in. The little
Wife always alone
Ironing death's laundry.
The beautiful daughters
Setting death's supper table.
The neighbors playing
Pinochle in the backyard
Or just sitting on the steps
Drinking beer. Death,
Meanwhile, in a strange
Part of town looking for
Someone with a bad cough,
But the address somehow wrong,
Even death can't figure it out
Among all the locked doors...
And the rain beginning to fall.
Long windy night ahead.
Death with not even a newspaper
To cover his head, not even
A dime to call the one pining away,
Undressing slowly, sleepily,
And stretching naked
On death's side of the bed.

44-year-old handsome snoring black man with "multiple medical problems." he has been "inpatient" - hospitalized - for 18 days - one wants to write "impatient for 18 days," but surely it's much longer than that. the nurses roll their eyes when his name is mentioned. he has been purely evil to every single "care provider." he was admitted with chest pain and shortness of breath a day after his most recent crack smoking, and so was obliged to receive the full court press "rule out MI" (heart attack). then he mentioned he saw some blood on the toilet paper recently, and that his right hand seemed weak. all this necessitated investigations by a lot of different people and machines, over days and days.

meanwhile, he became angrier and angrier that his chronic pain "all over" was not being treated. he "needed air" frequently, so he'd go outside and disappear for hours at a time, in his little hospital gown, in a hospital wheelchair (left leg amputated as a consequence of uncontrolled diabetes) - the dialysis team kept having to go out searching for him to give him dialysis three times a week (he has end-stage kidney failure as a consequence of uncontrolled high blood pressure).

when i went to visit him, he was incoherent because as usual he had demanded and gotten all his "prn" (as-needed) meds at once, together with his scheduled narcotics - nurses are extremely reluctant to ever dose a patient this way, but he bullies them into it, another reason they hate him - so he was dozing peacefully under dilaudid, oxycodone, IV benadryl, and valium, with the television blasting and the room heat up to 85.

he was able to slur "i aaaiiinnnn swiss-idol!" and try to push me away from the bedside, before nodding out again. the day before, he'd told the medical student he might as well empty the vending machine downstairs and take all its tylenol at once, and this was interpreted as a suicide theat, and that's why i'm here.

he's a young handsome muscular guy with dead kidneys and a missing leg, a non-healing wound on his remaining leg - according to the records, it's been an open wound since june, three months ago - and, according to the records, has been impotent since diabetes killed the nerves to his you-know-what. he got strep throat in his 20s that wasn't treated, and developed rheumatic fever, which ate up his heart valves, so he has two mechanical heart valves and has to be on hardcore blood thinners for the rest of his life. he takes the same three asthma meds he's taken since childhood. his life expectancy is maybe a year.

is he crazy? i wrote "UTA," unable to assess, "d/t sedation."

Life Is Fine (Langston Hughes)

I went down to the river,
I set down on the bank.
I tried to think but couldn't,
So I jumped in and sank.

I came up once and hollered!
I came up twice and cried!
If that water hadn't a-been so cold
I might've sunk and died.

But it was Cold in that water! It was cold!

I took the elevator
Sixteen floors above the ground.
I thought about my baby
And thought I would jump down.

I stood there and I hollered!
I stood there and I cried!
If it hadn't a-been so high
I might've jumped and died.

But it was High up there! It was high!

So since I'm still here livin',
I guess I will live on.
I could've died for love -
But for livin' I was born

Though you may hear me holler,
And you may see me cry -
I'll be dogged, sweet baby,
If you gonna see me die.

Life is fine! Fine as wine! Life is fine!

why are doctors such great big crabs?

2008-09-15T19:35:00.003-05:00

2007 SURVEY OF PHYSICIANS 50 TO 65 YEARS OLD
10,000 physicians in multiple specialties located in all 50 states... 1,175 completed responses to the survey... 36% in primary care.

a typical respondent
How do you now find the practice of medicine?
50-55
Very satisfying 8%
Somewhat satisfying 66%
Unsatisfying 26%

56-60
Very satisfying 9%
Somewhat satisfying 70%
Unsatisfying 21%

61-65
Very satisfying 13%
Somewhat satisfying 59%
Unsatisfying 28%

Sixty-one percent of physicians cited "patient relationships" as the single greatest source of their professional satisfaction, while 21% cited "intellectual stimulation" as their single greatest source of professional satisfaction.

Please identify your single greatest source of professional frustration:
Long hours 15%
Malpractice worries 18%
Reimbursement issues 33%
Medicare/Medicaid regulations 13%
Patient attitudes today 8%
Pressure of running a business 11%
Other 15%

Consider the dedication and work ethic of physicians coming out of training today. Are physicians being trained today:
Less dedicated and hard working than physicians who entered medicine when you did? 68%
More dedicated and hard working than physicians who entered medicine when you did? 0%
Just as dedicated and hard working as physicians who entered medicine when you did? 26%
Other 6%

lazy!
We find that younger physicians today generally prefer and expect fixed hours, a good call schedule with reliable coverage, and regular vacation time. A much higher percentage of young physicians today are female than was the case in the past, and female physicians work 18% fewer hours per week than male physicians, according to the AMA. For these reasons, it may take two younger physicians to replace a more senior doctor.

If you were starting out today, would you choose medicine as your career?
Yes 56%
No 44%

About half of physicians responding plan to take steps that would either take them out of patient care settings or reduce the number of patients they see.... 18% of physicians surveyed indicated they already have closed their practices to new patients. When asked to comment on their view of retirement, 38% of physicians surveyed said they planned to retire from clinical practice as soon as they can.

so. not. me.
Would you encourage your children or other young people to choose medicine as a career today?
Yes 43%
No 57%

Interestingly, those physicians in the oldest age grouping (61-65) seem less negative about their choice of a career... With the end of the tunnel in sight, some senior physicians have come to terms with their choice of career.

The Council on Graduate Medical Education (COGME), a panel of health care experts charged with reporting to Congress on the state of physician supply and demand, has endorsed a study predicting a shortage of 96,000 physicians by the year 2020. Other sources project that the United States could face a deficit of up to 200,000 physicians by the year 2020.

this is more how i see myself.

2008-07-22T16:51:00.003-05:00

patients is a virtue
another endless night at the hospital
another night where one marvels that anybody can sleep through it
we look out the high windows at the twinkling city and marvel
that anyone can sleep

patients is the art of caring slowly
i tucked in a woman my age while her
gray-grizzled husband stood solemn at the bedside
the floor splattered widely with charcoal-slurry vomit
next door they were "packed like sardines" as the icu nurse stated
gathering at the bedside of somebody deep in white sheets and pillows
and they stood around in the hallway outside the unit

patients is a minor form of despair
i tucked in a woman my age while the intern showed the
empty pill bottles to the puzzled pharmacist and made a little joke
and the pharmacist chuckled quietly and wrote something down
and a little old woman came to the counter
from the crowded room next door and asked humbly
did we have any more kleenex, and i told the gray-grizzled husband
she might need extra help to breathe, and i pulled the curtain
because the hall outside the room next door was suddenly full of some
folks who looked like maybe they'd all gone to high school together
a few years ago
they were stylin'
they were lookin' good
they were so quiet

patients will achieve more than force
once in a wide sweep of a hospital-clock second hand
she'd take a quiet breath
but then nothing and the machine over the bed would light up its little
flashing red APNEA sign
i dropped a white sheet over the charcoal pool beside the bed
and stepped on it and listened for her breathing
this woman my age
she took a lot of pills
"on accident," her son said, "she takes so many medications"
about 570 pills appeared to be missing
the family bought three months worth at a time for convenience

use disappointments as material for patients
next door was a 25 year old. he took something.
he had some kind of a seizure. this is the word on the icu "street"
and the room was full of people and they took it in shifts, coming
and going silently in the middle of the night, using up
all the kleenex, waiting for everybody to get here
before the organ harvesting team would be called.

to lose patients is to lose the battle
the woman my age i got her intubated and started fiddling with her blood gases
and her husband went home because he had to be at work in 4 hours
so i tucked her in good and headed for the call room, walking behind
a somber, sad-eyed couple from the room next door who plodded along slowly, heads down
when all of a sudden the man flailed his fist in the air and said loudly
"why does this keep happening!!" and my heart leaped in anguished affirmation
but then he sighed in exasperation
and kneeled down to tie up his shoe
which i guess keeps coming untied
up and down the hall sad teens and tweens and middle agers
gazed on blankly
and then looked away

have patients with everything unresolved in your heart
and try to love the questions themselves

quotations misappropriated from chaucer, ciardi, bierce, burke, hanh, ghandi, rilke

heart failure

2008-06-29T07:51:00.002-05:00

mr king came in and confessed he was worried because
he'd gained a lot of weight lately. not overnight,
but over the past few weeks.
and he was having trouble breathing when he had to walk anywhere
just like when he had to go to the hospital for heart failure.
and he was drinking a little more, "but just brandy," he said, and
"eating like a fool," he said, "that's what my wife
always used to tell me,
i'm eating like a fool," popeye's fried chicken every day
and the other night, a big piece of chocolate cake.
and his legs were swelling up so it was hard
to even get his socks on.

i said, "isn't it about, what, two years now, since your wife died?
i never got to meet her." "two years," he said,
"two years last wednesday."
mr king and i used to talk a lot, back then, about how
she had had a heart problem and swore him to secrecy about it
she didn't want any doctors or their kids to find out about it
and then all of a sudden she fell over dead, and he felt so guilty,
like he kind of killed her by keeping her secret.
i asked, "do you think that has something to do with how you're
taking care of yourself now?"
"i think about her every day," he said, "i dream about her."

"just last night i dreamed about her.
i was trying to do something, and i thought i'd better
ask her first, so i looked around and found her, and i asked her,
and she was laughing at me, saying 'you don't have to ask me
for my permission anymore!' and i realized, that was true,
because she's dead. so i went back
to do the thing i was trying to do, but by then it was
too hard to do - i should never have wasted the time
asking her permission."

"we always thought i'd be the one to die first - i'm the one
with the sugar and the high blood - and i always told her, when i die,
the first thing i want you to do is buy a red dress,
and the second thing is, get out of town.
you got to get on with it."

i said, "is that what you need to do now?"
"maybe," he said softly. "maybe i'm supposed to get on with it."
"i think you have your wife's approval," i said.
"she certainly has mine," he answered.

.

thank goodness!

2008-05-17T09:25:00.004-05:00

no, really - i mean it. go ahead and thank goodness.

...for she who is mighty
has done great things for me.

the pregnant mom about whom i'd worried - couldn't tell her dates because she started prenatal care at 7 months - first baby - thus apparently 1 week overdue today, couldn't get her on the phone for a week, finally came in today and showed a flat strip on the fetal heart monitor, but then was 4 cm dilated when i checked her, sent her to l & d and, yes, started some "pit..."

and saw 1,000 feverish, crying, and mentally ill people in clinic all afternoon, until i could scramble over to the hospital, where she was breathing over the contractions like the yogini she is, despite her stern mother (this would be her sixth grandchild) barking out, "breathe! i said breathe!" over and over again, patting her leg hard enough to shake the bed, but dang me, if she didn't feel like pushing all of a sudden, and i just had time to pop on some gloves, and right out slips the little baby, holding her cheek in her hand as she comes, like a little jack benny.

nuchal hand.

the baby was yowling and kicking and squirming about in my lap, but mom didn't want to hold her "until she's cleaned up," and the nurses just stared at me when i said, "want to take the baby?" so i just hugged her and wiped off her face and had granny cut the cord and then carried her over to get "cleaned up." glad i was wearing sleeveless today. i didn't have time to put on scrubs OR a gown OR my glasses, just a pair of gloves, and wearing my regular clothes, the slippery-naked little girl was baptized with a bit of cat hair.

mom tore a little, and i blame the nurse who exhorted her to pull her thighs apart farther and farther and farther, and push harder and harder and harder, during the 6-minute 2nd stage. i didn't even have time to ask her to pipe down. but with the nuchal arm, i guess it could have happened that way anyway.

the stitching took 3 times longer than the birth. then when i gave mom the "cleaned up," wrapped up little baby, who was loudly sucking on her own hand and glaring all around the room, the girl took her in her arms and just let loose with the waterworks, her whole face awash with tears as she laughed out loud in astonishment. it took 3 kleenexes to wipe her up til she could see again, and then she laughed again and cried some more.

jeepers! for once, a slick-n-easy birth, no fighting with the doctors and nurses, no epidural immobilization, just yoga breathing and coming on like gangbusters. right off, mom and baby started nursing "like they've been doing it for months already," as the nurse remarked.

baby's name is a pretty arabic word meaning "rightfully guided." appropriate choice to make, i think, for a fifteen-year-old first mom.

thank goodness!

cunning, baffling, powerful!

2008-05-04T09:42:00.005-05:00

my psychologist pal and i were talking about impaired physicians. that's a technical term, impaired. usually it means drunk/stoned.

last month a surgeon stoned on painkillers and other drugs crashed into a van, killing its passengers - a pregnant lady and her daughter - who were stopped for a red light "on Highway 67 at Pabst Road." sheesh. he had multiple convictions for drunk driving and lost his driver's AND medical licenses multiple times.

"He had consumed one oxycodone tablet and four or five each of Ambien and Xanax on Friday morning... [He] told authorities he was going to a pharmacy to pick up six Cialis and six Viagra pills... [His] Cadillac Escalade was traveling about 50 mph..."

cadillac escalade, named best s.u.v. by playboy
manufacturer suggested retail price:
$54,145.00 - $59,640.00

of course he will be charged with fetal homicide as well as everything else. the papers keep noting that the funeral home will hold a "special visitation for [the woman] and her unborn child and daughter." a necessary subject order, i suppose, but it sounds like a creepy priority list... one imagines the fetus laid out on white satin, umbilical cord and placenta tastefully arranged, beside the dead mom and little girl...

i just got done reading Dry, the drunkalogue by the guy who wrote Runing With Scissors. it really is stunning, the huge splashy mess some people make when they hit bottom (and bounce).

like the president's daughter!

there are strict measures in place to neutralize impaired physicians - as long as the physician's behavior endangers others in the workplace or in the work of doctoring. a lot of doctors, naturally, like the first one i mentioned, are careful to avoid this (the guy who wrote Dry did not harm others when intoxicated in his workplace - a large ad agency - other than socially/aesthetically).

so while it's important to know the rules about impaired physicians who are drunk/stoned, i am more interested in the other forms of impairment, like the obstetrician with parkinson's, or the "8000 physicians in current practice" with dementia. and my psychologist pal told me some of the amazing antics of a physician impaired by, apparently, an unpleasant nature (personality disorder?):

"Failed to keep legible, complete and accurate dispensing logs for controlled substances and to account for all controlled substances... Inappropriate sexual conduct, sexual contact, and other sexual behavior. Making threats to injure patients. Making threats to have patients involuntarily committed to mental institutions... Prescribed medications without noting adequate justification..."

narrative here. somewhat hysterical self-defense here. but he was so busted.

this story is made even more interesting by the information that the doctor in question apparently has achondroplasia. hospitalists would call him for a consult, and they'd see this dwarf walking down the hall and they'd think it was a patient, not their consultant - nobody knew what he looked like...

not the same guy.

my psychologist pal asked "what about mental illness? how would that impair the physician?" all i could really think of was maybe a depressed md who couldn't get out of bed to go to work - but dr. psychology told me the amazing story of a doctor - now retired - who had his license suspended and had to enter treatment because of a fixed delusion. her was hospitalized for a long time, and allowed to reenter part-time practice only under the closest supervision. he was a pleasant, professional man, and there didn't seem to be anything wrong with him at first - until he confided that the authorities simply didn't understand just how many serious diseases could be cured with flagyl. (flagyl's approved uses are for anaerobic bacterial and minor parasitic infections - gut and vaginal.)

he'd been prescribing flagyl for everything. in the end he promised, reluctantly, never to do it again. other than the flagyl thing, he was totally competent. it was a fixed delusion. "About 10% of cases will show some improvement of delusional symptoms though irrational beliefs may remain; 33-50% may show complete remission; and, in 30-40% of cases there will be persistent non-improving symptoms. The prognosis for clients with delusional disorder is largely related to the level of conviction..."

then there's the guy who was ~~treating~~ ~~killing~~ treating patients with intravenous hydrogen peroxide for multiple sclerosis. i don't know if you can call that a fixed delusion or not. here are some of the other things the internets say you can use intravenous h2o2 for:

Lowered insulin requirements in diabetics
Lowered blood cholesterol levels
Reduced high blood pressure
Normalization of cardiac arrhythmias
Relief from leg muscle cramps
Reduction in allergic symptoms

Normalized weight
Enhanced sensory input: better sight, hearing, taste
Hair loss stopped and reversed
Reversal of impotence
Alzheimer's Disease symptoms reversed
Cosmetic changes, including more lustrous hair, added eye sparkle, stronger unsplit nails, better skin color, fewer visible wrinkles and a more youthful appearance.

yes, that's intravenous hydrogen peroxide.

here are some other things the internets say hydrogen peroxide is good for!

If the garment is white or light colored, use hydrogen peroxide on a cotton swab to dab at the stain.

I use a solution of hydrogen peroxide to clean paper surfaces. The paper is usually printed posters and the inks are not affected by the cleaning wash.

Combine 1 tablespoon flour and 2 Tablespoons of hydrogen peroxide. Rub on copper surface to be cleaned. Then wash with detergent.

Hydrogen peroxide can clean your toilet bowl to a sparkling shine. Just pour in a cup of peroxide and let it sit overnight.

Has your dog been sprayed by a skunk? Mix 1 quart of hydrogen peroxide with 1/4 cup of baking soda and 1 teaspoon of mild dishwashing detergent. Rub this solution into your dog's coat.

To clean icky grout, pour hydrogen peroxide on it, and watch it bubble. After about ten minutes all the gunk will be loosened and will wipe away.

Homicide and suicide cleanup... Hydrogen peroxide is wonderful to remove bloodstains.

During the course of nuclear power reactor operation, corrosion products and impurities from the make-up water and condenser leak, accumulates on the tubes and tube sheets of the steam generators... Hydrogen peroxide could initiate a fast exothermic reaction resulting in the total decomposition of the formulation constituents.

...so anyway.

in other news, here is the handwritten problem list i was given by a new patient, who also wanted me to know that her "regular" doctor used to give her 180 percocets a month:

3 BAck Injuries
Gun ShoT
STomch - ulver
Leg Pain - Pin & Neddles
AUther
VAP & Tunal - wrist - SHolDers
Broncitius - smoking
Foot PAin
Post DramaTic STRess SYmdrome

what's the street value of oxycodone-acetaminophen, also known as percocet? according to the internets, "i'm an oc addict and since it hase 1.1 percent acetifemin in it it lowers street value some but since its 5 mg of oxy it would be around 2.50 on the low end and 5 dollars on the high end."

$900 for a month's worth of chronic pain medication? and the citywide unemployment rate at 8% - 15% for black females - 44% for black males.

i'm just sayen.

Land of the Normal Physical Exam

2008-04-05T12:22:00.004-05:00

last month was really busy, and twice the clinic was closed because of blizzards. i took a couple of sick days.

so you've been waiting for this appointment for a long time. you weren't able to get in when you needed to. now you've been sitting in this exam room for 35 minutes.

i tell you i appreciate your waiting, that the person before you needed a little extra time, and they only schedule 15 minutes for these appointments - but it shows that when you need it, you'll get a little extra time, too.

then i smile and say, "now, how can i help you today?"

normal: according with, constituting, or not
deviating from a norm, rule, or principle

1. the pain is so bad you can't stand it any more. it woke you up over and over again all night. you had to curl up in a ball and couldn't walk. it actually made you cry.
2. you can't eat. you're afraid to eat because you don't know if your stomach will hurt worse because of it.
3. you have to pass gas all the time. it's very embarrassing. sometimes the pain goes away when you fart, so you keep wishing you could fart on demand. you've never in your whole life wished for this before.
4. when you move your bowels, the stool is very small and hard, like little balls. you have never seen stools like this before.
5. it all started last week, the day you were put on a blood thinner after having a life-threatening blood clot. so you stopped taking the blood thinner.
6. you can't live this way. you've never thought about ending your life before, but you know you simply can not tolerate living this way any more.

conforming to a type, standard, or regular pattern

1. you told the nurse you're here because your wrists hurt. you fell out of a tree in the 1970's and your right wrist hasn't been the same ever since.
2. you feel like somebody's after you. you can't answer the phone any more. it's like everybody's out to get you.
3. in the night you heard a car engine outside your house.
4. you went to the neurologist and he put you on medication for parkinson's disease. now your hands don't shake and you can talk louder, and that is nice.
5. you realize it's probably a delusion that god and the devil are struggling for control of your mind, but you're starting to think maybe it's true. something happened at the gas station that made you think this. you can't tell me what it was.

occurring naturally

1. you haven't had a period since january and you would like a pregnancy test. you've been trying to get pregnant. you want to have a baby - a little girl.
2. you're 52 years old.
3. your psychiatrist recently changed your medication from anticonvulsants to antipsychotics, to avoid birth defects.
4. you've had some legal trouble, and have a court date next week. you got in trouble when you ran out of meds. you beat up a girl in the parking lot of the pick'n'save, and you hit a bus driver on top of his head. this happened last month when you ran out of money. you have a five-dollar co-pay on each medication, and you're taking six medications, including prenatal vitamins.
5. your boyfriend told you it was okay if it turned out to be menopause. but there was that lady last year who had a baby when she was sixty. so you have to keep trying.

having the property of commutativity under multiplication
by the transpose of the matrix each of whose elements is
a conjugate complex number with respect to the
corresponding element of the given matrix

1. you're having belly pain you had last august, but it's a lot worse now.
2. you have a mucous discharge from your vagina - and your rectum - and your throat - and from your nose - and even your ears. mostly just the right ear.
3. you can't sleep all night because of the pain. your seven-year-old and four-year-old have to take care of the baby now because the pain is so bad, you can't do anything.
4. pain medicines make you sick.
5. you went to a lot of other doctors and they did all these tests and they kept saying everything was normal. you had an x-ray and a colonoscopy.
6. you wanted to get your tubes tied and the doctor said he wouldn't do it until the stomach problem got fixed. you can't use any birth control because it makes the pain worse. while we are talking, you start crying and go curl up on the floor in the corner of the exam room, sobbing and holding your belly.

of, relating to, or characterized by average intelligence
or development; free from mental disorder

1. you're here for a prostate exam.
2. you just thought it would be a good idea.
3. you do not believe you're too young to need one.
4. you just want to take good care of your health.
5. you'd like to have some blood tests too - whichever ones seem appropriate.

having a straight-chain structure

1. you give up on insulin. no matter what you do, your sugars go crazy.
2. in the morning your sugar is high no matter what you did the night before. you take your insulin and it makes you too sick to eat. then your blood sugar goes down to 30 and you're about to pass out. (normal is 80.) so you eat a sandwich and drink some juice. then your sugar goes up to 400. so you skip lunch.
3. same thing with your blood pressure. it doesn't matter whether you take the medicine or not. sometimes it's through the roof, 180/100. other times it drops low and you feel like you'll pass out when you stand up.
4. your father died back in february. the only time your blood pressure and blood sugar acted normally was when you were taking care of him. ever since then they've gone crazy.
5. you give up. you've tried everything. after you've left the office, the nurse says your blood sugar, which she checked but forgot to tell me about, was 37.

having the property that every coset produced by
operating on the left by a given element is equal to
the coset produced by operating on the right
by the same element

1. the left side of your body is numb - everything on the left side. it's all numb and can't feel anything. no pins-and-needles sensations and no muscular weakness, just numbness.
2. no, not your left foot, or ankle, or knee - just above the knee.
3. and not the hand, or the arm - just the shoulder. not the ribs or the belly.
4. the left side of your face. not the jaw, not the neck.
5. it all started last summer, when you bent down to pick up a frisbee. it just won't go away.
6. you're embarassed to say this - you didn't know you'd get a girl doctor - but the numbness includes your left testicle. no pain, no swelling, no lumps or bumps, just numbess. your number one concern is you might have metastatic testiclular cancer.
7. you haven't had trouble with mania since your house burned down last spring - just depression.

perpendicular to a tangent at a point of tangency

1. the baby's urine turned orange.
2. it was just the one diaper. it was bright orange. it didn't happen again.

relating to, involving, or being a
normal curve or normal distribution

Results: about 2,280 for "the doctor said it was normal"

The doctor said it was normal for women who'd had a couple kids. The only problem was I have never had children.
The doctor said it was normal for girls to have some bowel problems.
The doctor said it was normal (and after a week, the blood was gone).
The doctor said it was normal for people with concussions.
The doctor said it was normal for head injures.
I had a lump behind my right ear and the doctor said it was normal.
I asked about the burning in my arm, shoulder, neck, face and back and the doctor said it was normal.

The doctor said it was normal and to keep on trying.
The doctor said it was normal but wanted to see me anyway
The doctor said it was normal for that kind of trauma.
The doctor said it was normal for limbs to twitch during the night.
The doctor said it was normal to have pain even after the MRI showed nothing.
The doctor said it was normal. He said it was a release of the nervous system.

I didn't get my period for a year. The doctor said it was normal.
The doctor said it was normal for young women and it was a blessing not to have your period every month.
They found fluid in her pelvis but the doctor said it was normal. But she is in pain every day.
The doctor said it was normal. Now, however, I have a discharge out of both sides.
I have had vaginal pains for 8-9 weeks now. The doctor said it was normal.
The doctor said it was normal, prescribed evening primrose oil tablets, but i remember he said 'Hmm they are a bit lumpy'.
The doctor said it was normal, that my weight was just shifting toward the center of my body

The doctor said it was normal considering I have a nerve condition.
The doctor said it was normal, esp in families with skin conditions.
The doctor said it was normal to dream a lot, and it certainly kept her mind active - a fugitive demon hunter.
I'm mostly worried about her being sick all the time even though the doctor said it was normal since she just started daycare.
The doctor said it was normal. Jaundice, normal?
My cholesterol is the highest it's ever been - but the doctor said it was normal.
The doctor said it was normal. But I knew it couldn’t be normal. If only the blood test had shown something!

attention attention attention.

2008-03-08T19:57:00.002-06:00

part 1.
i went to a code and i did not panic.

this was a big thing to me.

i have become so superstitious that i hesitate to even recall the auditory memory of the calm lady's voice from the overhead speakers, "attention, attention attention. code blue, 2-i.c.u. attention, attention attention. code blue, 2-i.c.u." when i am at work, i keep the sound out of my imagination for fear of summoning it up in real time. but that's what happened, i heard it with my ears and i got up from my seat and i headed for the stairs.

i practiced breathing.

in the room a naked woman, my age, was thrashing around on her bed with a big mask on her face, struggling to breathe. the bed was surrounded by people in scrubs, and i pushed my way to the side of the bed and started listening to her chest, bobbing and weaving to stay with her. a young nurse, with a giant full-color tattoo of a staff of aesculapius made into a crucifix on his arm, wiggled in next to me and started reciting.

alice is a 46-year-old female admitted today for intractable rectal bleeding who just received her second unit of packed red blood cells per dr martin's orders when she suddenly stated she was short of breath and brady'd down [dropped her heart rate] to 30. we gave her a milligram of atropine and started chest compressions and she came right back and became tachycardic in respiratory failure like you see right now.

her chest sounded like someone crushing and uncrushing a big paper bag - loudly.

do you want i.v. lasix?

just then a tiny hospitalist raced into the room yelling, start lasix now! alice, can you hear me? alice, can you hear me? it was her patient.

so i scooted back out of the crowd and checked my pulse.

just then i realized that one of the reasons i even felt okay going inot medicine in the first place is that i have always been "good in a crisis," never panicking until it was all over, if at all. what happened? now i am counting as a big victory the fact that i was able to stand there without becoming faint.

and still, still, still, it's the phenomenon it's just not okay to talk about.

the next morning i went to see how alice was doing, down in 2-i.c.u. "she's posturing," the nurse said tiredly, passing by on his way home. she just kept pouring out blood all night and they kept pouring it back in. liver failure from the booze and hepatitis c from i.v. drug use made it so all the big vessels leading to her shrivelled, woody old liver just swelled up and burst. she was experiencing a "critical care clotting catastrophe," and brain damage now was making some of her muscles strain while others went limp - posturing... her long-lost sister was going to try to come in before work, or rather, the sister to whom alice was long-lost... decisions were going to have to be made by this sister... for example, alice remained full-code so that as she crashed over and over again, "everything will be done"... same old, same old, i'm afraid.

alice could not have done all that drinking and drugging all by herself - where were her running mates? maybe they should stagger in and decide what to do with what was left of her.

and maybe this is why in sudden urgency, can't kope - i can't keep my mind on doses of bicarb and tidal volumes and shockable rhythms - they seem crazy inadequate - i get all smeared off into the Land of Seemly. dammit, jim, i'm a social worker, not a doctor! but that's not really true - i'm a midwife, not an auto mechanic. it's also not true that i "can't keep my mind on." the problem feels like a problem of all those freaking-out nurses and rapid-responders staring at me going what do you want? what do you want? with naked dislike in their eyes - likely they all dislike the code as much as i do - as well as dislike white coated doctors and snotnosed residents in particular and likely the Old One most of all - especially if... well anyway.

it's okay to go on and on about this like this, because this is my journal.

i'm just saying.

part 2.
i have been sick for a month and a half - that's what rufus does, makes it impossible to recover - and only starting just now to see daylight at the end of the incredibly long and difficult tunnel, after two courses of antibiotics and a week of high-dose steroids. so many things i have wanted to write about, but unable to even get my own damn glass of water.

last night i caught another baby. i can't even go into the details. suffice it to say that there's little worse than a nurse who hates her job and is angry about it, especially in a room with an anxious first-time mother hoping to give birth naturally one moment and crying for general anesthesia the next, along with little old me, so tired, so tired, and therefore so disheartened whenever the angry nurse rolls her eyes and sighs as i go about my back-rubbing, deep-breathing way of fending off the epidural.

that afternoon The Funny One, our attending, had been giving a lecture about how "there's no such thing as a low-risk obstetric patient," provoking me to loudly say from the back of the class, "or at least that's our ideology," and then duck my head down, but he knows very well who i am; as The Funny One, part of his office is to provide the jokes and gag gifts for the graduation roast the residents "get to" participate in, and he already made it plain that my personal vocabulary term "vaginal ecology" would be a part of my display...

so anyway, due to his offhanded and totally confident assertion that "it's the ones you think are low risk that go to crap on you," i found myself again and again, over six hours, nervously starting at the computer monitor of the fetal heart strip and obssessing about every single contraction, and had to go take a walk when i realized how utterly stupid and, well, actually, harmful it was. my anxiety was not helped a bit by the cynical and - and i never say this about another worker - lazy obstetrics resident, who sits on her lazy ass drawling, "her heart tones have been crappy all day, and i should know, since i'm the one who had to watch 'em all day - " (which was her job, while i was in clinic all day). i mean - not that i needed her help - it was just - like wading through molasses - to get through all the bad vibes and gloomy predictions - to stand between them and my girl in labor who was just struggling to get through it, sixty seconds at a time.

did the birth turn out fine? no thanks to the rest of the staff, it did. interestingly, nervous norvis, our attending, was there to lend a hand; i was able to ignore his nervous mutterings about what could happen any minute "to the heart tones." he very generously assured my girl, repeatedly, what good hands she was in - with me. "you've got the best labor coach we have," he told her.

so now mom and baby are nursing happily, and it turns out i guessed right for the first time - eight pounds. i had actually, literally, taken 4 liter bags of normal saline and heaped them up on a counter at the clinic and put a towel over them and felt them up all over to see if it felt like how big her belly was. it wasn't quite that big. so i guessed three-and-a-half liters, or about 8 pounds, and was right.

later, my patient told me the nurse had told her twice, "we'll just see how far you get before you ask for the epidural." she also told me, "it hurt so much! it was horrible! i can't believe i did it! i stuck to my birth plan! i did it!" i wish i could show you a picture of how beautiful this six-foot-tall, 23-year-old coffee-colored goddess is, with long angel wings tattooed down her back, her eight! pound! daughter in her arms.

part 3.
it's not all misery. the other day i was very happy because i felt like i did a good job in clinic.

a sixteen-year-old girl came out to me. she didn't need a prescription for birth control, because "i'm just talking to girls right now." she wants to be a poet. she entered one contest and won the editor's choice award. so i told her about my mother who became a poet and about the importance of getting your stuff out there. i also got her vaccinated against cervical cancer. i also told her about her civil rights as a teenager, and the privacy of her health information.

then i went to talk to her thirteen-year-old brother. he's been having a hard time with his parents because they don't want him to watch video games anymore - "they say i'm too old for that, and i should have outgrown it by now." so i told him about my son who has a new job as a video game developer. the boy's eyes got as big as saucers. he wanted to know all about how my son applied and what the interiew process was and what kind of qualifications a person might need. i told him how to make a privilege contract with his parents. i also told him about his civil rights as a teenager, and the privacy of his health information.

then i talked to the mom, who's just real tired with her new 6-month-old - the baby that came along as soon as she sold the crib.

then i talked to the sickle cell kid who just turned 18 on valentine's day. he's taking a lot of narcotics and being really squirrelly about it, too - getting himself in trouble, like a kid. i talked to him for half an hour. at the end, he had an enthusiastic plan in hand to get his g.e.d, take the driver's licence test, and register to vote. i thought it might be good for him to get his mind off his chronic pain for a little while.

once in a while you get a glimpse of what i normal life could be like.

i'm just saying.

part 4.

up in 6-i.c.u. i was taking are of a little old lady who was having a very hard time breathing until an interventional radiologist stuck needles in her chest and sucked out a couple of liters of fluid. after that, she was ready to go home, and i couldn't convince her to have anything else done at all. her right breast is twice the size of the left, woody hard, with a soft oozing center where the nipple used to be. no bad smell; nontender to palpation; she was fine with it; she was really quite sweetly at peace with the whole situation.

she explained the situation to me:

"i was in church and i laid my hand on my breast, and the lord spoke to me and said, you have cancer.

"this holy oil is all the pain medicine i need. i don't want no more blood tests, i don't want no more oxygen, i don't want no more medicine. don't get me wrong, i know you doctors have to do your doctor business, but i don't need no doctor. my faith is in the lord and he will heal me if it's his will.

"this bible right here is all i need. see this, psalm 116, this here's all the medicine i need. read this. go ahead, you read this to me."

i said, sorry, i have a meeting right now - maybe later - got to go - can i get you anything before i go? okay, then, i'll see you this afternoon... but later i felt bad and i went back where the book was lying open to the same page in her lap, as it was all day and all night, and i went ahead and read it out loud at her bedside.

The sorrows of death compassed me,
and the pains of hell gat hold upon me:
I found trouble and sorrow.

Then called I upon the name of the Lord;
O Lord, I beseech thee, deliver my soul.
The Lord preserveth the simple:
I was brought low, and he helped me.

Return unto thy rest, O my soul; for the Lord
hath dealt bountifully with thee.
For thou hast delivered my soul from death,
mine eyes from tears, and my feet from falling.
I will walk before the Lord in the land of the living.

I believed, therefore have I spoken:
I was greatly afflicted:
I said in my haste, All men are liars.

What shall I render unto the Lord
for all his benefits toward me?
I will take the cup of salvation,
and call upon the name of the Lord.

I will pay my vows unto the Lord
now in the presence of all his people.
Precious in the sight of the Lord
is the death of his saints.

later, after she'd gone home, one of the other residents told me how he'd rounded on her late at night, "and she got me to read this bible chapter out loud to her - " and the intern, overhearing, said, "you guys are suckers. i just said no."

she also showed me a booklet of pictures of her house. the last photo in the booklet was from the seventies. she was on a plaid couch wearing a purple velour jumpsuit and a big gold cross, with a big jheri-curl afro, her arm around the shoulders of a skinny white guy with one of those little christopher-street moustaches. "who's this guy?" i asked. "oh, he died," she said, clucking her tongue and shaking her head.

precious in the sight of the lord is the death of his saints.

part 5.
my final story is just a little transcript. i was working in the pediatric emergency department in the middle of the night, and one of the nurses asked if i could take a little time to sit with a mother who was very upset. "she's crying so hard, i can't understand what she's saying." her eleven-year-old son - the patient - was in the next exam room, stable, waiting to be seen by social workers and cops.

the mother, like the lady said, was sobbing and sobbing, having a hard time talking. she was hunched over a bible she held closed on her lap, wiping her face with her fingers. it seemed that her husband of five years - he just never did like her son. she said, "all along it was just the verbal abuse, telling him he was stupid, calling him a liar all the time, calling him names - i knew it was wrong, but i thought i could h-h-help him to ch-ch-change." this time he had seized the kid by the chest and thrown him up against the wall, then dragged him sideways like that down the hall, then let go of him, cold-cocked him, thrown him onto the bed, picked him up again, threw him at the window, and so on... as medical staff i was responsible for getting the details of exactly how he landed each time - hit his head? lose consciousness? hit his back? twist his arm? - details that are inextricable from the story of how her son is a good boy who wants to be a minister of the lutheran church when he grows up and attends a youth entrepreneur club where he sells bible-story board games he invented himself, from which he was home late, causing his stepdad to go insane, his mother running down the hall after them, crying and screaming to please please stop.

she said she'd call the cops, causing the stepdad to start crying, begging her not to, then scoop up the four-year-old sister and head on out on his motorcycle. yes, i said motorcycle. yes, it's february, with ice-covered roadways.

oh, she cried and cried and cried and cried and cried as she told the story. it turned out that when the boy had recovered, he said, "we've got to get out of here," and talked her out to the car to drive to the store and get boxes. then as fast as they could the two of them started packing boxes. they spent about 4 hours doing this, until about ten pm, then packed the car and drove over to grandpa's (maternal grandfather's) house. turns out stepdad had dropped four-year-old sister off there previously, and gone off again on his motorcycle - so they were all pretty much safe and sound, until about two a.m. when the boy suddenly woke up crying and begging to go to the hospital.

by this time mom was able to take some big shuddering breaths. she was pretty much cried out. so i went in to talk to the boy.

he was a skinny kid, a typical little pitcher with big ears, lying very solemnly in the hospital bed. the lights were out and the curtains pulled, so there was just a little glow of light from the quiet, dead-of-night, emergency-room hallway. his mom and i pulled up chairs to the bedside. his mom hunched over her bible again, and as my conversation with him went along, she started murmuring, "yes, lord," "amen, and "do, lord," to what her son was saying.

and what he said was so surprising, to me, that when i was done writing orders i grabbed a progress note and wrote it all down verbatim.

my chest hurts here, where he grabbed me. see this? when i cough, it hurts. at first i thought i couldn't breathe and i was scared. i thought maybe i was having a heart attack, and that's why i wanted to come here. but now it just hurts. if i press on it, it hurts. i didn't hit my head. my arm's okay.

when i woke up, i was having some kind of a dream where i was walled in by boxes, and that's what was making my chest hurt. i guess we packed too many boxes today. i don't know if the boxes were going to fall over on me, in my dream - they were like walls moving in on me.

but you know - i've been thinking a lot about this while i've been lying here, and i don't feel bad that this happened.

i don't feel bad that this happened. the way i see it, everything happens for a reason. god lets things happen to you for a reason. if this didn't happen to me, i would have never know what would happen. i would have gone on being afraid of what would happen. it's like a sneak preview of the test. now when i come to the test, i'll know i can pass it. i know i can handle it.

it's like you have a destiny. everybody has a destiny. you have to meet your destiny, and accept it. god shows you what your destiny is, and then you know that's your destiny.

my mom says she blames herself for what happened, but i tell her it's not her fault, it's not anybody's fault. i know my mom wants to do what's best for me and my sister. i know my mom loves me. i would never blame her or even blame anybody for what happened. and i don't blame myself, either. we're all in god's hands. god shows us his plan for us.

don't get me wrong. i think my dad should be charged with something, because he did wrong. but i believe it's god that let these things happen, and god makes everything happen for a reason. i can't let what happened hinder me from my purpose. it says, "you will not be turned aside."

then it was time for the cops to talk to them.

The Staff of Aesculapius is the healer quest artifact.
It is neutral for wishing purposes. Its base item type is a quarterstaff.
It deals double damage to all monsters and also gives hungerless regeneration.
If invoked, it heals half the points you would need to return to full health, and cures sickness, blindness, and sliming.
It does not cure blindness caused by a cream pie.
--from Wikihack

so that was my month.

you guys are always there saying relax!

2008-03-08T15:15:00.002-06:00

so jpw and i were sitting around and he was telling me about somebody who had emailed him complaining about some legislative overreaction to the not-illegal, not-illicit herbal hallucinogen salvia divinorum, a member of the sage family (mint clan).

although interested, because all things medicinal-herbal-related are interesting to me, i was extremely dubious that this herb was actually getting people high - i remember people smoking banana peels and eating packets of burpee morning-glory seeds and insisting they were soooooo high - and youtube videos of giggling teenagers just were not enough to initially convince me.

so naturally i started out at pubmed, the national medical research archive, where i began to find out...

all about salvia divinorum

Eduardo R. Butelman et al., Laboratory on the Biology of Addictive Diseases, Rockefeller University, New York:

The main aim of these studies was to examine the neuroendocrine effects of the widely available hallucinogen salvinorin A [natural source, salvia divinorum] in an assay shown to be a useful biomarker for kappa-opioid agonist effects in rhesus monkeys.

...IV salvinorin A caused robust dose-dependent prolactin release in male rhesus monkeys... As expected from prior studies in humans, probe experiments with salvinorin A in gonadally intact female monkeys revealed quantitatively greater effects.

...In summary, the widely available hallucinogen salvinorin A produced effects consistent with high-efficacy agonist actions at kappa-receptors... consistent with reports of fast onset and relatively short duration of salvinorin A-containing preparations in humans.

what is the significance of kappa-opioid receptors? Wikipedia:

Kappa-opioid receptor (partial) agonists have hallucinogenic ("psychotomimetic") effects... It is thought that the hallucinogenic effects of drugs such as butorphanol [Stadol, narcotic used in childbirth]... serve to limit their opiate abuse potential. In the case of salvinorin A... these hallucinogenic effects are sought after. While salvinorin A is considered a hallucinogen, its effects are qualitatively different than those produced by the classical psychedelic hallucinogens such as LSD or mescaline.

Activation of the kappa-opioid receptor appears to antagonize many of the effects of the mu-opioid receptor [classic opioid receptor, bound by narcotics]. Kappa ligands are also known for their characteristic diuretic effects, due to their negative regulation of antidiuretic hormone (ADH). Kappa agonism is neuroprotective against hypoxia/ischemia. Kappa-receptors are located in the periphery by pain neurons, in the spinal cord and in the brain.

Non-specific opioid receptor antagonists (e.g., naloxone [Narcan, antidote for heroin overdose]) as well as the mixed opioid agonist/antagonist buprenorphine [Subutex, used to facilitate narcotics withdrawal] can be used to reverse the effects of kappa agonists.

Débora González et al, Departamento de Psicología Biologica y de la Salud,Universidad Autónoma de Madrid, Spain:

Retrospective assessment of the subjective effects induced by salvia was conducted by means of self-assessment questionnaires. The following questionnaires were administered:

The Hallucinogen Rating Scale [1994]... includes 71 items distributed into six scales:
Somaesthesia, reflecting somatic effects including interoceptive, visceral and tactile effects;
affect, sensitive to emotional and affective responses;
volition, indicating the volunteer's capacity to willfully interact with his/her “self” and/or the environment;
cognition, describing modifications in thought processes or content;
perception, measuring visual, auditory, gustatory and olfactory experiences;
finally intensity, which reflects the strength of the overall experience.

The ARCI [1971] consists of five scales or groups:
MBG, morphine-benzedrine group, measuring euphoria and positive mood;
PCAG, pentobarbital-chlorpromazine-alcohol group, measuring sedation;
LSD, lysergic acid diethylamide scale, measuring somatic-dysphoric effects;
BG, the benzedrine group, measuring intellectual energy and efficiency,
and the A scale, an empirically derived scale measuring amphetamine-like effects.

The State-Trait Anxiety Inventory-S [1970] is a brief 20-item self-rating scale for the assessment of state anxiety.

The Altered States of Consciousness Questionnaire [Aussergewohnliche Psychische Zustande, 1998] includes 72 items distributed in three subscales:
Oceanic Boundlessness [Ozeanische Selbstentgrenzung], measuring changes in the sense of time, derealization and depersonalization;
Dread of Ego-Dissolution [Angstvolle IchAuflosung], measuring thought disorder and decreased body and thought control associated with arousal and anxiety,
and Visionary Restructuralization [Visionare Umstrukturierung] referring to visual phenomena, such as illusions, hallucinations and synesthesia and to changes in the significance of objects.

...The source of the salvia was a "smart shop" in 88% of the cases and in the remaining 12% it had been obtained from a friend, without further specifying the source... When asked about the psychotropic potency of salvia, 75% of the participants described the experience elicited by salvia from 'intense' to 'very intense' or 'extremely intense', with only 19% as 'moderate' and 6% describing it as 'slight'.

...The most commonly cited positive effects were the 'trip' the drug elicits (41%), followed by its euphoric (28%) and dissociative effects (19%). Among the worst aspects, its short duration (38%) was the most frequently cited.

...Fourteen volunteers (44%) reported having experienced some degree of malaise, hang-over or 'comedown' immediately after the acute effects of salvia. These effects... essentially describe physical and mental tiredness. All volunteers unanimously agreed that these unpleasant effects were no longer present 1 day after salvia use, and that they had never experienced any mid-term unpleasant sensations they could attribute to salvia. Only one volunteer commented on having had problems with studies, work or relatives due to the use of salvia. He complained that friends who do not habitually use psychotropic substances were worried about his experimenting with drugs.

...When asked if they would like to take salvia regularly, only 44% of the subjects responded affirmatively.

...Scores on the HRS subscales confirm the psychedelic-like effects of salvia... The score in the volition subscale, which reflects the subject's degree of incapacitation, is the highest ever observed by our group... and is even larger than that recorded by Strassman and colleagues after the highest intravenous DMT dose they administered [1994].

...Scores on the APZ-OSE subscale provide insight into the high degree of derealization experienced by the participants, in line with the most frequently cited positive aspect of the drug, i.e. the sensation of entering another reality.

...An interesting aspect of the subjective effect profile of salvia is the simultaneous high scores on the LSD and PCAG scales observed. This is not a characteristic feature of the classical psychedelics... However, this unusual pattern combining modifications in somatic-dysphoric effects and sedation/impairment has been reported for agonists of the opioid kappa receptor.

...To sum up, smoking extracts of salvia appears to be the most common form of use of the drug among recreational users. In the sample studied, this form of administration led to a very fast onset of effects which were intense but short-lived. The psychotropic effects reported bear similarities to those induced by the classical psychedelics regarding changes in perception, mood and somatic sensations. However, the increased derealization observed and the consequent decrease in the ability to interact with themselves and their surroundings appears to be particularly high for salvia.

sage-smoker.

John H. Halpern, Biological Psychiatry Laboratory, Alcohol and Drug Abuse Research Center, Harvard Medical School:

Salvia divinorum is from the mint family (Lamiaceae) and contains the psychoactive neoclerodane diterpene salvinorin-A... Traditionally consumed by Mazatec Indians of Oaxaca, Mexico... these plants are now grown and sold in the United States for ingestion by people who obviously do not have a historical ceremonial connection to this plant. The leaves are sometimes smoked, but these new consumers are also purchasing concentrated extracts of the plant.

...When smoked, salvinorin-A is psychoactive for 15 min at doses of 200-500 mcg; oral absorption leads to a less intense intoxication lasting up to 1 hr. Although the Drug Enforcement Administration (DEA) has not scheduled Salvia divinorum, they are closely monitoring it as a possibly emerging drug of abuse... With no reinforcing properties, harm from Salvia divinorum most likely occurs from inadequate preparation or from settings in which it is dangerous to be intoxicated with any drug at all (e.g., such as driving).

...Many other Lamiaceae ornamentals may ultimately prove to be psychoactive similar to Salvia divinorum, including Coleus spp. plants that are very popular in gardens and prized for their intense leaf colors. Indeed, leaves of Coleus blumei and Coleus pumilus are sometimes chewed by Mazatec Indians instead of Salvia divinorum, although to date, only Salvia divinorum has been found to contain salvinorin-A. A more determined search for a Salvia divinorum substitute might be triggered by placement of Salvia divinorum into Schedule I. If such a plant exists, a whole Pandora's box of legal nightmares might be unleashed in trying to restrict popular access to these common houseplants.

however, per sagewisdom dot org:

Louisiana, Missouri, Tennessee, Oklahoma, Delaware, Maine, North Dakota, and Illinois are the only states in the USA that have laws prohibiting possession of Salvia divinorum. Louisiana and Oklahoma have provisions in their laws that allow possession of the plant when it is not intended for human consumption. In Oklahoma, plain Salvia divinorum is legal, but extract-enhanced leaves are not. The state of Maine only prohibits possesion by minors.

...In October of 2002, a bill was introduced to the United States Congress that proposed to place Salvia divinorum and salvinorin A in schedule 1 of the Controlled Substances Act... It died with the dissolution of the 107th Congress at the end of 2002. The author of the bill, Representative Joe Baca of California (democrat), has recently stated that he will not reintroduce the bill.

from livejournal's salvia_world:

I smoked some 15x Salvia divinorum extract the other night with my best friend. We smoked quite a bit and started to feel really... trippy... It felt like we kept bumping and sort of... merging into one another. Then I'd just randomly stop moving because I'd think of something out of this world and then seconds later I wouldn't be able to comprehend what it was I was thinking.

The trippiest thing that happened was I leaned against my wall and there was a woman attached to me... She wasn't actually a woman but rather represented a woman, and all I remember is that she was blue and was kind of guiding me or commanding me. And then it seemed like my friend was attached to my other side, but then he moved away and broke the attachment and I was like calling him to come back.

Anyone have any similar experiences?

...

I recently introduced my ex-girlfriend to salvia and she had a terrible experience. I don't want to say this to worry you or dissuade you, but she was too nervous. If you're too nervous, don't do it.

There are thresholds you can reach that are naturally weird and scary. It's part of the process of "entering the wormhole" or "spiraling through the hidden dimensions" or however you'll come to describe it. Sometimes even my best, most meaningful consultations contain moments of sheer terror.

But if you're mentally prepared and comfortable taking salvia, it can be an amazing experience. You can reach a place that I feel is the end-state of time, where a number of other benevolent beings exist. Most people only talk about the sage goddess, but I've felt more presences than her alone, for sure. You will see fantastic things but you will only remember shreds. I believe they permit you to retain just as much as you need to go on... When you make the breakthrough it will all be worth it.

...

I've had a repeating experience with Salvia. The last time was very pronounced. I feel like she likes to correct my posture. When I am with her, I feel the urge to sit up with my spine straight and if I don't do so I get uncomfortable pressure in my head.

The last time, I was repeatedly making adjustments and corrections until my posture was perfect and the effect has lasted long after the duration of the experience. The sensation was very interesting because it seemed to be happening without my conscious will involved. My spine kept rolling upwards and straight without any control on my part. My friend said he could see it happening and my friends have noticed how my posture has improved. Thank you Salvia!

discourse, discourse

from a russian salvia community, bluelight dot ru:

Q: I need some help finding pictures of salvia goddess ive seen her on my 2nd hit and didnt even know wut is she ... named her "mother flower" i dunno why... then my friend told me the story and shown me a pic but it was some nonsense syekelic drawing ... i look for the pic on google could find only 1 similar picture with the same circles on her head but it was named as uhh maria the shepherdess or some other crap... the one i found was lookin too innocent

A: Was she dressed in white? not kidding, serious question

Q: no she wasnt dressed i could just see her head... eyes were clozed and had few circles over her head... she her face was actually more like sleeping or just standing there listening to me or smt dunno ..i mean not angry not happy ... and there were 2 vines on her sides.

A: I don't know what pic you mention, but yes the salvia goddess is known as Ska Maria la Pastora or Leaves of Mary the Sheperdess. Obviously the name of the plant has undergone change through christianity hybridizing pre-Conquest native beliefs.

Leander J. Valdes III et al, Journal of Ethnopharmacology 1983:

The following report is based on fieldwork with a Mazatec curandero... over many visits during the summer of 1979 and spring of 1980.

...One learns to become a shaman through an informal apprenticeship, although the Mazatecs will insist they are taught by a progression of visions from and of heaven, rather than by people... Vision inducers are taken systematically at intervals of a week to a month. Once one becomes a healer the hallucinogenic plants are ingested much less frequently.

The process begins by taking successively increasing doses of Salvia divinorum for a number of times to become acquainted with the "way to heaven"... Ska Maria Pastora is, pharmacologically, the weakest of the three hallucinogenic plants. Following its ingestion the Virgin Mary is supposed to speak to the individual, but only in absolute quiet and darkness. The relatively mild experience is readily terminated by noise (such as a loud voice) or light.

... According to Don Alejandro, ni-to, or the mushrooms-that-one-takes [psilocybin] are unlike the other two plants. The fungi are delicado (delicate), nervioso (nervous), una cosa de envidia (a thing of envy). Unfortunately the English translations of these terms do not convey the Indian-Spanish concept of magic that has a dangerous and sinister side. Santa Ana and San Venanzio, the Saints the curandero associates with the mushrooms, were not as good at healing... Eating too many of the fungi can "leave one crazy" and the visions are often trucos (tricky)... As Don Alejandro stated it, "The Maria, on the other hand, accepts you (La Maria, en cambio, te acepta)."

...A low dose serves as what the investigators interpreted to be a "tonic"... to cure the following "illnesses", although there may be other possible uses:
1. It helps one defecate and urinate. It stops diarrhea (the plant apparently is believed to regulate eliminatory functions).
2. It is given to the sick, old or dying to revive them or alleviate their illness. People who are pale, white and almost ready to die (they have "anemia") may recuperate on taking la Maria.
3. It may be taken to relieve headaches and rheumatism.

...S. divinorum may be prepared as an infusion from 20 (about 50 g) to 80 (about 200 g) or more pairs of fresh leaves to induce visions... At this dosage level, the Salvia is used to foretell the future, find the causes and cures of illnesses and obtain answers to questions about friends, enemies and relatives.

In shamanic training, the future healer takes la Maria to learn the ways of healing and the identification and use of medicinal plants (there is supposedly a tree in Heaven with all such herbs in it and one talks to God and the Saints about them under the influence of the hallucinogens).

...The shaman repeatedly emphasized that it was important to describe one's visions: "If you are going to learn or if you are going to understand what it is all about, you must speak." ...Following Mazatec custom, at least one person didn't participate, in order to watch over the rest.

...It is beyond the scope of this paper to comment on the efficacy of S. divinorum in treatment of the various "folk ailments"... However, it should be noted that many Salvia species are used medicinally throughout the world, and the genus name itself comes from the Latin salvare, to save. The Middle English name for sage was save or saue, from the Latin Salvia via Old English Saluie, and Chaucer mentions it as a cure for wounds and broken limbs in "The Knightes Tale". Salvia miltiorrhiza, or tan-shen, is one of the five astral remedies in Chinese medicine... and is listed in "A Barefoot Doctor's Manual"... Diaz lists nine species as being used medicinally in Mexico.

"the separation of consciousness
from the body's shell in the form
of a rowboat exiting the face backwards" [salvia art]

Marine Corps News, 12/8/2005:

Salvia is not a controlled substance and is not illegal, according to the U.S. Department of Justice Drug Enforcement Administration. The drug can still get you in trouble in the Marine Corps, and any Marine caught using or in possession of salvia will be charged with Article 92 of the Uniformed Code of Military Justice, which is failure to obey an order or regulation... Punitive action, adverse administrative action or both can be taken against personnel who use salvia.

"Actually, it's not very new to those in the know, but the use of salvia divinorum is on the rise in the military," said Col. Mick McCue, the staff judge advocate with Marine Forces Atlantic. "It is currently not listed on any of the Controlled Substances schedules and is therefore not currently covered by Article 112A of the UCMJ." ..."No one has been caught on Lejeune because it is not tested for at the [urinalysis lab]," said Staff Sgt. Gregory Hubbard, the substance abuse counselor for Headquarters and Support Battalion, Marine Corps Base.

random internet prices:

Dried Salvia divinorum leaf imported from Oaxaca Mexico. 15 g $16.50
5X Recommended potency. 1 g $15.00
10X Because of the extraordinary potency of this product, it is recommended only for those already experienced with Salvia. Please use extreme caution with this product. 1 g $25.00
20X Because of the extraordinary potency of this product, it is recommended only for those already experienced with Salvia. Please use extreme caution with this product. 1 g $35.00
40X Because of the extraordinary potency of this product, it is recommended only for those already experienced with Salvia. Please use extreme caution with this product. 1/2 g $35.00

so now you know as much as i do. jpw, i stand corrected.

RANT RAVE RANT RAVE true confessions, identity crisis fun, and the jungle patrol, with poetry, video, and song lyrics through the ages.

2008-02-03T10:08:00.001-06:00

for starters,

When I say 'hit it,' I want you to go two up and two back, double cross, and come out of it with the rifleman.

Hit it.

Crazy. Now when I say 'hit it,' I want the strong M, erase it, and back to the Madison. Hit it.
Walk on. You're lookin' good.

Now then when I say 'hit it,' it'll be T-time. Hit it. Big strong line!

Now when I say 'hit it,' I want the Cleveland box, and back to the Madison.
Hit it. Crazy.

Now when I say 'hit it,' I want the big strong basketball, with the Wilt Chamberlain hook.
Hit it. Two points!

-- Madison Time, the Ray Bryant Combo, 1960

oh, the madison, yes, it can brighten up the gloomiest most disaffected february day. better men than i have come this way, bloody feet have trodden smooth the path by which i came here, sisters, and still found it in them to do the madison.

so in the past month two acutely mentally ill women (manic episode, atypical postpartum depression) have asked me nicely for psychotropic medication that they have taken successfully in the past (adderall and depakote), and i was sternly prohibited from giving these by three panicked attendings who stated "this is way, way, way outside our sphere of practice," "our" presumably meaning "all of us family doctors."

so instead, following directions, i ~~told them to go away~~ "referred them" to psychiatrists, which they never did see...

couldn't get in to see; couldn't face the half-hour call to their insurance company (their medicaid h.m.o.) to find out how much, how long, and how they could get coverage for assessment and by whom; couldn't scrape up the copay and figure out how to get the bus, ten miles to the suburb where the psych clinic (at the medical school) would be...

so they're "noncompliant" now, and i have been reassured, "the patient has to take some responsibility for their own health," which lets me off the hook. (not my own [or the patients'] hook - everyone else's - meaning - my preceptors'.)

following orders, i also told these young women, alternatively, ~~to go away~~ they could go to the psych e.r. (same suburb). in the unlikely event they do go to the e.r. or clinic, who'll see them? residents (like me), who will do what? prescribe the medication they asked me for - since the best indication for a psych med is a previously successful psych med. it's a no-brainer.

but i was not allowed to to the prescribing, because, as one physician told me regarding the second patient, "she could go and blow somebody's head off, and it would be our fault!" and as another said regarding the first, "there was a family doctor in town who got sued for millions of dollars for continuing a prescription of antipsychotics for a schizophrenic - the patient developed severe side effects, and the physician was nailed to the wall. the head of the medical college was called as an expert witness, and had to admit that even a third-year medical student would recognize" these side effects.

POETRY BREAK

I am done with apologies.
If contrariness is my inheritance and destiny, so be it.
If it is my mission to go in at exits and come out at entrances, so be it.
I have planted by the stars in defiance of the experts and tilled somewhat by incantation and by singing, and reaped, as I knew, by luck and Heaven's favor in spite of the best advice.

...When they asked me to join them I wouldn't and then went off by myself and did more than they would have asked.
"Well, then" they said "go and organize the International Brotherhood of Contraries." I said "Did you finish killing everybody who was against peace?" So be it.
Going against men, I have heard at time a deep harmony thrumming in the mixture, and when they ask me what I say I don't know. It is not the only or the easiest way to come to the truth. It is one way.

--The Contrariness of the Mad Farmer, Wendell Berry, 1967

SO in the interest of avoiding heads-blown-off and to-the-walls-nailed, i followed the "standard of care" of my betters and did nothing, politely and professionally, and so must ~~pretend~~ presume that it is less dangerous to leave mania and postpartum depression untreated - and that "referral" is, relatively speaking (i guess), treatment. i followed the "standard of care" and became a puppet of my preceptors although i disagreed with their assessments (among other things, these women were not objectively or subjectively on the verge, as they say, AND nowhere in 'the literature' do i find the aforementioned prescribing to be out of the sphere of 'our' practice), partly because my preceptors are obliged to sign off on my decisions at the end of the day - but mainly because three of them at once cornered me in the hall and told me to do what they said.

i am a polite person and i play by the rules - a statement that might surprise those who know me well - the thing is - i have this particular set of rules.

i think i can go on record as consistently nonparticipating in systems of violence. i dislike being tricked into participating in them. i get a little, as we say, "reactive."

...when i first became interested in health care, it was because of midwifery. i was vividly struck by a dream in which i walked down to the park by half-moon lake, and came across a large group of midwives, all sitting at a long, long picnic table (they'd pushed two tables together). i wanted to walk by and spy on them, but they saw me and called me over - all scooting down the long long bench to made a seat for me.

i think the image must have come from years of girl scout picnics - and from living next to half moon lake, skating alone all the way across it to the high cliffs in the winter, playing on the sandy shore by the railroad tracks, with my baby and the cat and our little plastic animals, all summer. the image of those ladies at the long, long picnic table, and the particular way you have to scoot, to make room on a bench - it's so vivid and iconic to me, i was surprised not to zip right to it on the google image search. but it's not there. it's in my heart.

later when i became a single mom with three kids - a high-school dropout with a 12-year hole in my resume (and it was more cost-efficient to get loans and grants and go to college, than to get a waitressing job) - i thought well maybe i could be a nurse-practitioner, because they give the best care anyway. i didn't want to be a nurse-midwife and do hospital births. hospital births are so different from home births, they're like the difference between a restaurant and home cooking. just completely different, including different clientele, different standards, different ingredients...

anyway - my town didn't have a registered nursing school at that time. so then i thought well as a doctor, i could could back up the work of midwives and nurse practitioners. so i went to medical school. but then it seemed like i could only back up midwives if i became an obstetrician - and i was absolutely unwilling to enter that particular reindoctrination camp.

i feel like i have something to offer childbearing women, but every time i go to a hospital labor-and-delivery unit, my heart sinks. every room, there they are, lined up like hospital patients in every other unit: gowned in identical dreary cotton gowns and lying on disposable paper pads, tethered to the iv pole and the monitor, staring up at the television in the ceiling, asking why can't they eat something, accompanied - maybe - by a loved one wearing a coat. worse than restaurant food - bland anonymous institutional cafeteria food, same thing, every day.

so i don't like birth much anymore. oh, i'm nice to everyone. and i try to compensate. i keep the lights down. i minimize the amount of gowning and masking. i sit on the bed. i catch the baby and put her in my lap and wipe her face off with a cloth and then hand her to her mom. if you don't know how different this is than (normal? regular? ordinary?) the other kind of delivery, you'll just have to take my word for it.

and i tell ladies they can take their own clothes to the hospital and they can sit wherever they want, etc, but most of them are really uncomfortable bucking the system. and the nurses - well, i only just now got a clue that i am not, as a physician, actually supposed to be hanging around during the labor. that's nurse territory. they really do not like it. i could be cynical and say, they just hate trying to talk a mother into an epidural while i'm sitting on the bed. except - it wouldn't be cynical - it would just be true. it messes up their plan to avoid having to readjust the monitor every ten minutes, if i keep tempting the mother to sit in the rocking chair instead of lying quietly in bed. and they drum their fingers waiting for the mother to demand the epidural, a process i greatly impede. so it gets rather unpleasant to go to a birth in a hospital where the nurses are unfriendly. to me! i wanted to be a nurse myself!

yeah, i kind of hate childbirth now.

...last week a guy came into the clinic with a red puffy knee, clearly not normal. it wasn't very painful, but he generally felt like crap, a little feverish, etc. sad but true, by any objective medical standard we needed to tap that knee - i.e., drain off the effusion of infected joint fluid (and send it for culture). he asked nervously, "h-h-how do you 'drain it'?" and i replied soothingly, "in a way that doesn't hurt, as much as possible - we'll use spray to freeze the skin, and then inject local anesthetic, so when we tap the joint, it shouldn't hurt. let me know if it does hurt."

then i went to get my preceptor. bummer - (do you understand that the preceptor is supposed to instruct and observe and make sure nothing goes wrong, while i do the deed?) - the preceptor doesn't think pain medication is necessary ("it's not a long procedure," he explains). he doesn't even think sterile gloves are necessary, which is kind of living on the edge. and he seems to like the larger-caliber needle. long story short, excruciating pain for the patient (multiple pokes - we call them "pokes"), all presided over by yours truly. not my fault? but my responsibility.

now, the preceptor, if you asked him, would say, "never (ever) make promises to patients," so i didn't mention, in front of the patient, my prior conversation with the patient... and i certainly didn't say, later, to the preceptor, how bad i felt. i did apologize to the patient. not for the change of plan, although i feel awfully guilty - for what? change of plan? for not preparing the patient that anything can happen? but i didn't know anything could happen. i apologized for the pain, but that's not all i was sorry for.

after that, i said nothing. you're not supposed to feel guilty about what happened to your patient - it's one of the unwritten rules. express it and you will be met with shocked silence. you aren't supposed to have anything to be guilty for. if you do, you're a bad doctor. but instead of suppressing bad doctoring, we suppress guilt. i lied to my patient, trying to do what i understood to be the right thing. i pretended to 'first do no harm,' but i wasn't allowed to 'first do no harm.' and needles in joints give me the creeps under the best circumstances.

it was strangely reminiscent of attending hospital births. my point is i don't know if i'll keep doing births after i enter full practice. but this seems ass-backward crazy to me! why did i even start any of this? not because i love formulating complicated insulin regimens! not because i want to do more throat swabs!

it was because i wanted to back up midwives. but as a fam doc, i don't think i can, medicolegally, provide much in the way of technical backup. however - ray of hope - my own primary doc (fam doc) recently told me she's one of 3 local lady fam docs who do provide home midwife backup - they basically consult on confusing cases, and order labs, and do ultrasounds and newborn screens and so on. they don't do cesareans, but i guess then if a lady needed to transfer to the hospital, she could be cared for by the midwife (over cover as "doula") and the fam doc, who would call in the cavalry if surgery was needed.

so i could kind of see that...

right now what i'm visualizing would be something like a lifespan women's health center, me solo beside a midwife practice - i can do the gynecology and the pediatrics and the geriatrics (not to mention the irritable bowel, fibromyalgia, and chronic fatigue), and they can catch babies. maybe they'd let me help out sometimes. you know who else should have a room down the hall? a social worker/psychologist. hang a big old rainbow flag out front, and we're set.

so whenever i have a little free time, i'm reading up on solo practice, putting ekg and ultrasound machines on my amazon wish list [note: do NOT buy any expensive equipment from my wish list without talking to me about it first. not that you can afford it, ha ha], and visualizing, as hard as i can, some way to reconcile ethical practice with the material medical world as we know it.

recently i was google-surfing phrases we all use (current favorite source for found poetry), like "do i really need to go to the doctor?" and "i hate doctors," and it really reminded me of... of reality. reality is not rolling your eyes angrily at the drug-seeking crock who came back for the third time this weekend. reality is not "time for your iv - it's routine, dear." reality is not "a two-year-old male with pyelonephritis, a really interesting case, check it out!"

reality is "i tried to be good and stay sick for 2 weeks before coming in, but the doctor laughed at me anyway." reality is "i hate western medicine, nobody knows who you are and nobody gives a shit about you." reality is not knowing how much of the truth you can tell your doctor, and deciding not to tell any of it. y'all know this. but with the thick soft wooly blanket of medical culture over your head, you wouldn't remember it either.

every day, in every way, as i am regarded more and more as a "real doctor," the pull of indoctrination, the pressure to look at people the doctors' way, gets more intense. it makes me angry. i visualize visualize visualize to resist.

and why am i being regarded as more and more of a "real doctor"? is it because i go ahead and drill a fat sharp needle under the kneecap without anesthetic? because i use the word "hypertension" and "episiotomy" when i could have said "high blood pressure" and "cut open your vagina with a pair of scissors"? because i worry i could get sued, ostracized, or assaulted, for first doing no harm?

what a life!

SONG LYRIC TIME

She tells me about last night and her hundred and third first date.
She counted, she counted her pairs of pants again, "I’ve only got fifty-three, minus the ones I’ve got on."

I want a restorative beer to take my mind off these tears.
I want a restorative beer.

Get the catalogue free from Desert House HD3 Box 111111 Albuquerque.
Talked to my 25-foot phone extension cord about the needlepoint therapy blues.
And then I knew: I want a restorative beer to take my mind off these tears.
I want a restorative beer.

I want a restorative beer to take my mind off these tears.
I want a restorative beer.

--Restorative Beer, the Fiery Furnaces, 2004

that's it! we're joining the jungle patrol.

The doctor laughed at me and told me that I should "get off of the Internet."

2008-02-02T20:37:00.000-06:00

from Results: about 1,150 for "I suppose I should see a doctor"

After every shower I find myself coughing. And it's not just a little tickle. I suppose I should see a doctor, but as this has happened for as long as I can remember

now the left one really, really hurts whenever I use it. I suppose I should see a doctor about it, but who's got time.

i suppose i should see a doctor - that loss of blood actually gave me a buzz.

I feel like my tongue has swollen to mammoth proportions. I suppose I should see a doctor for this, but really isn't this just a bit ridiculous?

still not really getting better. coughing, dizzy, eh, i suppose i should see a doctor, but today is saturday

I'm limping, and there's a swollen bump on the left side of my left foot. I suppose I should see a doctor, except that I don't have a doctor.

from Results: about 27,300 for "Do i really need to see a doctor?"

I sprained my ankle badly two weeks ago and still can't walk. Do i really need to see a doctor?

Do I really need to see a doctor after my car accident?

Do I really need to see a doctor? Or if I continue to keep it clean and bandaged will it eventually heal itself?

Do i really need to see a doctor to get it diagnosed, even though its really freaking obvious?

I got a hard time peeing because its burning and so painful from scratching it so often. Do I really need to see a doctor?

A few months ago, I noticed I had some warts. I know that this has to be HPV and that this disease could cause cervical cancer, but I'm afraid to go to the doctor. Do I really need to see a doctor?

it has been going on for 6 months i believe. it isn't bright more dark colored. im always hungry and i tend to see the dark blood or clots on the paper and in the toilet water. there has been some clear liquid that comes out too. do i really need to see a doctor cause im scared to tell my parents.

from Results: about 281,000 for "I don't want to go to the doctor"

I don't want to go to the doctor, the cut is very minor, what I'm concerned about is the piece of something stuck under my nail. If anyone knows anything about tetanus can you please let me know what is suggested?

I guess this is whiplash? But I don't want to go to the doctor because all he's going to do is send me home with instructions to take a lethal amount of ibuprofen, and then charge me a ridiculous amount of money.

How do i know if i have the strep or not? I don't want to go to the doctor.

I don't think I'm anorexic, I'm just not hungry and I don't know why. I'm losing weight. I don't want to go to the doctor but I don't know what to do.

I don't want to go to the doctor because I'm too embarrassed.

I don't want to go to the doctor just to ask her a question.

I don't want to go to the doctor and be diagnosed with ADD. I'm not a troublemaker. I'm just bored and I can't learn this way.

I don't want to go to the doctor. They will just say it is because my husband is gone and dope me up. I know a lot of it is because he is gone.

I wake up late almost every day to go to work. I'am not on no meds. I rather sleep than get up to watch tv. I need help can sum one help me. I don't want to go to the doctor. I need advice

I don't want to go to the doctor, as it is our family doctor. If I shave off my pubic hair, will that get rid of it?

after the third time the burning started. i don't want to tell my parents and also i don't want to go to the doctor. what could it be???

I haven't had one for a long time, about four months. I can't be pregnant and I'm not taking any medications. I don't want to go to the doctor.

I don't want to go to the doctor's because they are over 30 mins away. Only I haven't felt her kick or move all day. Can this possibly wait until my appt on Weds?

I'm just worried it could be something like breast cancer. Please help me, I don't want to go to the doctor.

I don't want to go to the doctor again, what if they tell me that I need to take a blood test, and when they do they confirm the thought that's been haunting my mind.

I don't want to go to the doctor I just don't have the money right now. Can you please just tell me if you started out taking 150 mg a day, how long before you tried 300 mg a day?

from Results: about 125,000 for "I can't go to the doctor"

I just have to remember I can't get hurt because I can't go to the doctor for a couple more months.

I can't go to the doctor for another week.

i can't go to the doctor until monday after i collected my pay check if someone could give me some advise i would appreciate it very much.

I can't go to the doctor any time soon. Heck I don't even have a doctor. I really want to stick it out, but what if the symptoms never go away?

And I can't go to the doctor because I am trying to join the army. And, yes, I've thought of suicide plenty of times.

I can't go to the doctor today because I'm the only one in our office at work today but I may have to break down and go Monday.

I can't go to the doctor without having money to pay for it. And I can't go to the E.R. and pay them months later because I still owe the hospital $2,000 from when I was sick for all of January and February.

They told me that since I have already started a claim with them, I can't go to the doctor as they will not pay the bills now. Is any of this even true?

I can't go to the doctor because we don't have health insurance because dad doesn't have a job.

I can't go to the doctor. If I go to the doctor, guess what I'll be doing? Stackin' on bills, stackin' on bills, stackin' on bills.

I can't go to the doctor, no insurance. So I work as hard as I can.

from Results: about 1,760 for "doctor laughed at me"

The doctor laughed at me and told me that I should "get off of the Internet."

finally i got up enough nerve to ask the doctor why and the doctor laughed at me

The doctor laughed at me when I told her we were on our second month of trying.

My doctor laughed at me. He said he'd never heard anything more ridiculous in his whole life.

My doctor laughed at me and prescribed sitting on a pillow for the next week.

my doctor laughed at me, and said to invest in a lot of peanut butter (i hate that man).

The doctor laughed at me. He actually laughed and made some snide remark as if I was some kind of junkie.

I've also had a physical, but not from a woman, so I know how you feel, except the doctor laughed at me when I was naked.

The doctor laughed at me for sitting on the table and instructed me to kneel facing the table. I couldn't believe I was going to be examined bending over the table while on my knees.

they did an EKG and not one skip showed up. the doctor laughed at me and told me i was just having a panic attack.

The doctor laughed at me and made me feel stupid for even getting the test done.

my doctor laughed at me. i thought i was being good by being sick for 2 weeks before i went to the doctor, but he still laughed at me.

The doctor laughed at me and then referred me to the psychiatrist who said I had depression.

The Doctor laughed at me because I was scared.

the doctor laughed at me and said that "sniffing isn't a disease."

My doctor laughed at me today and saw me for 3 minutes.

My doctor laughed at me when i asked him if he would take less than 80 dollars.

The doctor laughed at me. "Trench mouth? What's that?" He only knew it by the more scientific-sounding "acute necrotizing ulcerative gingivitis".

The doctor laughed at me but how was I to know you could suddenly go deaf for no apparent reason?

I asked the doctor if my husband could possibly have a brain tumor or meningitis and the doctor laughed at me.

The doctor laughed at me. He gave me a painkiller and told me not to do laundry for 30 days.

The doctor laughed at me when I mentioned coconut oil.

My doctor laughed at me for taking "anti-age" vitamins.

The doctor laughed at me when I first told him I had diabetes. But I knew.

The doctor laughed at me. I insisted that he refer me to a neurologist.

The doctor laughed at me and my "beliefs."

I stopped taking them after the doctor laughed at me.

My doctor laughed at me when I complained about how hard it was for me to swallow them.

I broke my fake nail completely off, real nail and all! It hurt! My grandfather insisted I go. When I got there the doctor laughed at me.

The doctor laughed at me and told me that I would be using a nipple shield for a very, very long time.

My doctor laughed at me and told me to get over the hair loss 'cos there's nothing you can do about it.

My doctor laughed at me and literally said, "WebMD, huh?" I looked at him with a humiliated half smile. "Is it that obvious?" He did not return my smile.

from Results: about 30,500 for "I hate doctors"

A visitor came today to my blog from Google with the search words "I hate doctors".

I hate doctors. Not all of them - just the ones that treat me and the people I love.

I hate doctors. Im totally going to become one of those homeopathic freak people just because of how many problems I have had with doctors NOT listening to me.

I hate doctors that spends 5 minutes with you and send you somewhere else after you waited months to see em and hours waiting in their office with a cheap looking TV.

I hate doctors. If I was an hour and a half late seeing a client, my ass would be fired. Especially if I didn't apologize once.

I hate doctors because they can't get over the fact that I might have a common- or garden-variety ailment and not some exotic symptom linked to my disability.

i hate doctors too! he can't tell between his arse and a hole in the ground, measles or hiv he can't tell!

I hate doctors who try to diagnose illness by giving drugs and seeing if they work.

i hate doctors. they freak me out and are there for the sole purpose of judging me and medicating me and locking me up and talking quietly and rationally and telling me everything is ok and no one is doing anything and that maybe i should let them sign me in to the inpatient ward. i am freaking out

I hate doctors.... I avoid them if it's at all possible.... I'm supposed to be on eleven perscriptions.... including ones for psychosis....

I hate doctors for ever putting me on antidepressants.

I hate doctors with big sausage fingers. I recently experienced a violation that I never thought I'd ever have the misfortune to experience.

i hate doctors. i'm no longer on birth control and one reason is i hate doctors.

Until I see a doctor do something other than use a thermometer correctly, look in my ear and mouth, or use a list someone else made to give me medicine recommendations, then they shouldn't even get paid. I hate doctors.

I hate doctors. I swear, the next time I get hurt, I'm going to go find my friend with the Boy Scout Manual and the leeches, or the one with the chemistry set, the subscription to WebMD Pro, and the serious addiction to House, M.D.. They couldn't possibly do worse.

I hate doctors. I hate Western medicine. I hate the HMO, you never see the same doctor twice. Nobody knows you or gives a shit about you.

I hate doctors. Let me tell you about a little trip to the ER I had about two years ago.

I hate doctors and haven't been to see one (except for skin cancer) since 1985.

I hate doctors, so I never have been and likely will never be diagnosed with anything.

adventures in web-surfing: neurasthenia.

2008-01-23T16:14:00.000-06:00

so i was telling my psychologist pal about my interest in ailments to which females are prone and which are generally (at one time or another) regarded as non-medical a.k.a. "supratentorial," for example, fibromyalgia, chronic fatigue, irritable bowel, etc. and he said, "like neurasthenia."

all in your head.

and indeed i do find the history of neurasthenia very interesting, and asked him if he had read the yellow wallpaper by charlotte perkins gilman, who, interestingly, was also the mother of home economics, which started out as an actual economic field of study.

harriet beecher stowe's niece.

it's the true story of how she was driven crazy by the "rest cure" for neurasthenia promulgated by the then-foremost-expert, silas weir mitchell. i remembered reading that when mitchell read the story, he changed his whole approach to neurasthenia, but couldn't find any verification of it. i did, however, find this fascinating blog post:

9/19/06 - So this Silas Weir Mitchell fellow I'm working on, he was a doctor first, a herpetologist second... In addition to "the rest cure," for which he's unfairly but universally reviled, Mitchell's also known as a pioneer in the treatment of snake bites... An amateur herpetologist specializing in the chemical composition of venoms, Mitchell collected poisonous snakes... His father and friends thought this could hurt his medical practice:

"The late Professor Henry Smith said to me, "What nonsense to bother yourself about snake poisons!" And a larger man, Professor Samuel Jackson, warned me that every experiment in the laboratory would lose me a patient."

Not to belabor the obvious, but...

okay well i thought this was hilarious.

sleep-deprived postcall therefore hypersentimental somewhat dippy complicated clinic morning.

2008-01-13T08:39:00.000-06:00

talking dinosaurs brought to you by the genius of ryan north at qwantz dot com

1. i've been doing prenatal care with this 17 year old girl whose mother has been cruel to her throughout the pregnancy, because she didn't want the girl to have the baby. then the girl had to go to the hospital bc she thought her waters had broken, and the mother was given a copy of the prenatal record to take home - in which i had carefully documented how the girl had been depressed and tearful because of how mean her mother was to her. and now the mother comes to all the prenatals with her and is actually quite protective of her, and tells little stories about how wonderful it was, the day her daughter was born, and how hard it is to see your baby grow up - "no matter how old she is, she'll always be my baby," which i emphatically endorse, and the girl just rolls her eyes and grins.

2. my little (i mean little - maybe five-four) 70 year old puerto rican guy comes in for a complete physical exam, which is normal. he comes with a male interpreter, thank god, because i am so not trying to do a rectal exam and explain how to use the stool testing cards and persuade him into a colonoscopy with the VERY DEFICIENT and almost always female telephone-speaker interpreter. he knows i worry about him, because last year his wife died suddenly and he has nobody to watch his diet and figure out all his medications. he does the best he can. his only questions are, why does my blood pressure keep getting higher? why don't the blood sugar medicines work? and i tell him i know he's doing everything right; diabetes just naturally keeps getting worse, even when you do everything right. we just keep doing the best we can. we are all in the hands of god (not something i would normally say, but appropriate for this guy). i hope the interpreter is getting the nuances. as he's leaving, i stick my hand out to shake, thanking him for coming in, and he throws his arms around my neck.

3. my paranoid schizophrenic guy comes in, telling the nurse he is here for right shoulder pain. when i come in, he says his ankles are swollen (they're not). finally he says he's "having emotional problems." these started on christmas eve. he is the sole support and caregiver of his very demented father, who on xmas eve stole his car and drove away. "i didn't know your dad could still drive!" i said. "nobody did," he says glumly. my patient says he had the living room full of people praying all day and all night (i couldn't help but wonder how many were corporeal and how many weren't). my patient was so distraught that the police wanted to take him to the psych hospital then and there, but he refused - "i wasn't going anywhere until i found my dad." finally the police found him about 75 miles away, at one a.m. on christmas day. ever since then, my patient has been having more trouble with god and the devil - he's under a lot of pressure. he stated he'd be all right over the weekend - he was going to watch the game and go to church, and he didn't need to go to the gas station or grocery store (particularly difficult for him when he's hallucinating). he agreed to come back and see me on tuesday. when i told all this to my attending, she said, "oh my god - they found him!" and showed me on the internets where the runaway demented father had been heavily covered by the local news. i thought the statement my patient gave to the press at the time was pretty poignant: "dad - try to keep warm, and trust someone."

4. 60-year-old alcoholic lady comes in, stinking of scotch, sitting in a wheelchair vomiting into a bucket, hiccuping and sobbing because her stomach hurts. what do you visualize? well, you're wrong. she's wearing a cashmere sweater set, her hair is professionally done, she's got a manicure and diamond earrings. i call the ambulance, and off to the hospital with her - third pancreatitis admission in one year for her. before she goes, she clutches my sleeve and says, "i'm afraid i'm going to die! ...can i go outside for a cigarette?" she was kind of charmingly sad. she is what she is.

5. one of the hardest working women in the world comes in with her daughter. i've been seeing her nine-year-old, who has a hearing loss, a seizure disorder, and developmental delay. she brings her six-year-old, who has sickle cell disease, because she her stomach hurts all the time and she wets herself, not only at night ("they all do that," the mother says tiredly), but at school every day too. at the children's hospital, they treated her presumptively for a urinary tract infection, but the mother is worried that her daughter might have been sexually abused. the kids' dad was killed last year & new boyfriend just moved in, and even though mother supervises the boyfriend and the kids as closely as she can, she had herself been sexually abused as a child, and remembers that her stomach hurt all the time, so... the little girl's exam is normal, except for the skin down to the thighs all rough and scaly from soaking in pee all the time, and the smell... the best i can do for now is interview carefully (a blank), refer to a peds urologist (a waitlist), and ask her to come back every two weeks so i can get a sense of what the heck is going on (work excuse after work excuse to the dollar store where she works). i notice in the chart that the little girl has been hospitalized with pain crises from sickle cell, every few months since 18 months old. the mom must have the most generous dollar-store bosses ever in history. the mom's eleven-year-old - he seems to be okay. the mom herself? 26 years old, one of the tallest, most dignified, most beautiful women you can even imagine.

6. lady comes in, whom i've only talked to on the phone, because she can't get off work to come in - she works in a doctor's office, of course, so can't get time off work for her own health care. she's kind of defiant, because she expects to get the runaround. she's had a headache since 2001, since shortly before her home was invaded and a robber dropped a 32-inch television on her face. she states she's always been told there's nothing wrong with her physically, it's all in her head, she needs a psychiatrist. so she goes to a psychiatrist - "i KNOW i'm crazy!" - but she still has a headache. i review her chart, and sure enough, she was told to see a psychiatrist; migraine drugs didn't work; stopping all pain meds didn't work; and, well, as she said, she's kind of crazy. in addition, she has had uncontrollable weight gain since 2000 when her son was born. "i gained 30 pounds in 2 weeks after i started the birth control patch." she recites the longest list of weight-loss program attempts i've ever heard. (i start to say, "do you still eat meat?" but then her cellphone rang.) she's mollified when i take her history in a matter-of-fact way, not arguing or challenging what she says, and her face visibly relaxes, and she's able to smile... then i turn off the lights to look at her retinas. sure enough, they're red and swollen-looking, with engorged blood vessels, plain to see even with the crappy wall scopes we use - my attending comes and looks too, and says, "yup." when i tell the patient why i'm concerned, it's like she doesn't understand at first - something might really be wrong - something might be really wrong - then she just looks sad. later that day i talk to my friendly neighborhood neurologist, and then leave a voicemail for her. she'll spend next week getting visual-field and dilated fundoscopic exams, a brain mri, an mri of the venous drainage of the brain, and a spinal tap - then see the neurologist. hope she can get off work. we'll talk about a vegetarian diet next month.

7. teenage muslim girl comes in. not the girl i delivered, but her sister, bringing her 2-month-old in for a well-baby checkup. her tiredly smiling mother, who is also my patient, is with her; her teenage sister is with her, the one i delivered, with her 4-month-old. her other teenage sister is with her, 40 weeks pregnant and on her way to the hospital to have her labor induced. (i couldn't do the prenatal and birth care for the 2 sisters because their u.s. insurance didn't kick in soon enough when they came back from overseas - they had to go to the low-income obstetrics clinic & take pot luck instead.) so the six of them all talking and laughing at once in the little exam room, beaded headscarves and long skirts and fat nursing babies in matching tigger costumes; they've been through so much, i can't imagine. their mother - my age, but looking much older - is a newly single mother - abandoned somehow, it seems, by dad overseas, but not actually divorced - with these three unmarried daughters and two young schoolboys - arabic-speaking only, on welfare, which means she is obliged to take a class to learn how to work in a day care center, which makes it hard for her to get her daughters to all their prenatal appointments; god only knows what happened with all the girls last summer in their far-away homeland, away from their mother, coming home pregnant one by one; god only knows what hopes and fears they carry along with them. young teenage girls, such careful mothers, looking after their little brothers as well, being cool and staying in school. i wished i were as big as a house, so i could gather them all up and hold them, just hold them. they are all very excited because the last sister is scheduled to have a baby girl - the other two had boys.

8. gave a presentation on countertransference - "the surfacing of a physician's own repressed feelings through identification with the emotions, experiences, or problems of a patient." i talked about my gently-smiling brain-damaged lady, who got her new baby taken away from her on christmas day, which gave me nightmares. my presentation was well received. however, nobody commented on my astute use of talking dinosaur slides.

ton of bricks

2007-12-20T08:32:00.001-06:00

i'm working in the kidney clinic. it's not all acid-base chemistry and flow rates:

guy sitting in the exam room with giant black shades on, next to a young bored-looking girl - his niece. i introduce myself and start reviewing meds with him. why does he take vicodin three times a day? because of headaches. i'm thinking his headaches might have something to do with his blindness, even though i'm only supposed to be asking about his kidneys. how long have you been blind? almost one year.

he was at work and his vision got a little blurry. by the end of the day he could hardly see. so he went to the drugstore to get some off-the-rack glasses, bt nothing helped. the drugstore people told him he'd need to get prescription glasses. by this time he could only see light. so he went to a glasses place and saw an optometrist, but they said he'd need a real eye doctor. by the time he saw a real eye doctor, he could see nothing and the ophthalmologist told him there was nothing anyone could do. he had diabetic retinopathy.

that's how he found out he was diabetic. next visit to his primary, he found out he had diabetic nephropathy too - kidney failure, which is progressive and irreversible. i said, you must have gotten pretty depressed. he laughed bitterly and said, you have no idea.

i never thought anything like this would happen to me, he said. people think i've always been blind. yeah, i said, like we see a person in a wheelchair and think they were born that way... i wake up some mornings thinking i can still see, he said, then i realize i can't. in my dreams i can still see. i was seeing for 42 years, you know.

he's 43. it was quite an adjustment, he said, for my kids. he lives at home with his wife and four kids. his last day of work, his last day of seeing his children's faces, his last day of peeing standing up, driving a car, reading a cereal box, deciding what color socks to wear - all one single day, almost a year ago. i can't tell you what medicine i take, he said. my daughter puts it in my hand, and i take it.

in the next room a hmong lady and a teenaged interpreter. she's come for the results of her blood tests. she had gone to a new doctor, since she just moved here, for a backache. they did a few blood tests, which showed she has near-complete kidney failure caused by high blood pressure, and will need to start dialysis as soon as possible.

so i go over her labs with her. she's anemic, she's got low calcium, high phosphorus, etc. i give her a simple, brief introduction to what kidneys do and why it needs to be done. i tell her what happens if kidneys don't work. i tell her how people feel when their kidneys are very sick. i tell her what different treatments she will probably get - the shots to make the blood stronger, the special vitamins, the medicine for strong bones. and i tell her how dialysis works, how the blood passes through a tube that's like a kidney, and comes back into the body all clean and healthy. i tell her it's like pouring water through a piece of cloth or a screen to make the water clean so you can drink it.

i say one sentence at a time, so the interpreter can keep up. i tell her that getting bad news like this makes a person very sad. she says she does feel sad, and her mind is too full to think. i tell her someones people with sick kidneys get very sad and cry a lot, but it's partly because they are sick. when they get their blood cleaned up again, and have enough vitamins and strong blood, then they start to feel happy again. is this true? i'm pretty sure.

then the kidney doctor comes in, talking in paragraphs to the interpreter rather than the patient. "tell her she'll need to get ready for dialysis right away and that this will involve obtaining access so we'll refer her to a surgeon and i'm going to have my nurse come in and give her a shot of erythropoeitin because she's anemic and i'll write some prescriptions and we need to get this rolling right away because there are five stages of kidney disease and she's already moving into stage five, which is end stage renal failure, and she will need dialysis in a matter of months." then the nurse comes in and she seems to be angry - i think the kidney doctor pulled her out of her own appointments to counsel the patient, and she'll run late for the rest of the day because of it.

she also speaks in paragraphs to the interpreter, and also uses her cell phone to call the imaging suite, for an appointment to get an ultrasound of the veins, and the vascular surgeon's office for an appointment to be evaluated for "tell her she'll need a fistula in her arm for the dialysis - is she left or right handed? it'll need to be in the opposite arm." while she's on the phone she's chatting and laughing with the nurses on the other end , whom she knows personally. the hmong lady sits very still with her back very straight, listening to this. she gives her the shot. she tells the interpreter to tell the lady to come back in two weeks, and tells the interpreter she won't need to accompany the lady, because "all we're gonna do is check her blood pressure and take a little blood sample and give her a shot."

on my way out i tell the nurse goodnight, and she pulls a comical grimace and says, "sorry that was so rushed - she didn't speak english," as if i hadn't noticed, as if that explained everything, as if that excuses anything.

ton of bricks is matter over mind
ton of bricks is severe enough to pose a threat to life or a part of the body
ton of bricks is at the other end of the thrill ride

ton of bricks is no accident
ton of bricks is no excuse
ton of bricks is a painful emotional experience

ton of bricks is part of the initial evaluation
ton of bricks is an internal straitjacket created when a devastating moment is frozen in time
ton of bricks is a feeling of utter impotence and powerlessness

ton of bricks is physiological it's about energy
ton of bricks is any forcible disruption of the body by an outside source of energy
ton of bricks is in reality a ton of bricks and no one escapes this imprint

ton of bricks is understood and dealt with as a typical medical illness
ton of bricks is caused by a variety of reasons and nearly everyone has a ton of bricks in one form or another
ton of bricks is a leading cause of morbidity and mortality among all age groups

ton of bricks is real
ton of bricks is at once physical and conceptual
ton of bricks is stored in the brain

ton of bricks is surfacing
ton of bricks is a mental wound
ton of bricks is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature

i don't care if it rains or freezes

2007-12-18T22:45:00.000-06:00

Christmas gingerbread and Christmas cheer: review of the potential role of mood elevating amphetamine-like compounds formed in vivo.
Prague Med Rep. 2005;106(1):27-38.
We three kings and Christmas trees: pharmacotherapy from presents and diseases from decorations.
Med J Aust. 2007 Dec 3;187(11-12):701-2.
Artificial Christmas trees: how real are the lead exposure risks?
J Environ Health. 2004 Dec;67(5):20-4, 32.
No poinsettia this Christmas.
South Med J. 2006 Jul;99(7):772-3.

Highly important during Christmas holidays: elderly persons
are overrepresented when it comes to candle light fires.
Lakartidningen. 2005 Dec 12-31;102(50):3897-8.
The "Merry Christmas Coronary" and "Happy New Year
Heart Attack" phenomenon.
Circulation. 2004 Dec 21;110(25):3744-5.
Images in cardiovascular medicine: Santa Claus in the echo lab.
Circulation. 2003 Dec 23;108(25):3164.
When should EKG be measured? Summer solstice or Christmas Eve?
Heart Rhythm. 2007 Mar;4(3):282-3.
Behold the Christmas miracle of antioxidants.
BMJ. 2007 Dec 1;335(7630):1124.
Wholesome Christmas fish.
Duodecim. 1999;115(23):2673-6.

"All I want for Christmas is my two front teeth":
The story behind the song.
J Hist Dent. 2006 Winter;54(3):109-10.
Christmas survey: How polite are Ear, Nose and Throat surgeons?
Clin Otolaryngol. 2006 Dec;31(6):557-8.
Christmas surprise: the unnoticed journey of a needle -
from bronchus to intestine.
Respir Med. 2005 Dec;99(12):1600-2.
Christmas tree in the larynx.
Paediatr Anaesth. 2004 Dec;14(12):1016-20.
Christmas tree cataract.
Clin Exp Optom. 1998 May;81(3):98-99.
Recurrent bleeding following traumatic
hyphema due to Christmas disease.
J AAPOS. 2007 Aug 24.
Long-lasting "christmas tree rash" in an adolescent: Isotopic response
of indeterminate cell histiocytosis in pityriasis rosea?
Acta Derm Venereol. 2002;82(4):288-91.

Christmas: a light deficiency disease?
Dtsch Med Wochenschr. 2002 Dec 20;127(51-52):2717-20.
Variation in deliberate self-harm around Christmas and New Year.
Soc Sci Med. 2007 Sep;65(5):855-67.
Reduction in the suicide rate during Advent: a time series analysis.
Psychiatry Res. 2008 Jan 15;157(1-3):139-46.
Christmas without memories: Beliefs
about grief and mothering, A clinical case analysis.
J Fam Nurs. 2006 Nov;12(4):426-41.
Christmas in purgatory: a retrospective look.
Ment Retard. 2006 Apr;44(2):145-9.
A Christmas dialysis vignette.
Nephrol Dial Transplant. 2003 Apr;18(4):847.
Inequalities and Christmas yet to come.
BMJ. 2005 Dec 10;331(7529):1409.

Deck the halls with rows of trolleys: Emergency departments
are busiest over the Christmas holiday period.
Med J Aust. 2007 Dec 3;187(11-12):630-3.
How to manage the ED crisis: implementation of
particular interventions during the Christmas crisis.
Eur J Emerg Med. 2002 Mar;9(1):79-80.
I wish for 1,000 new general practitioners for Christmas.
Tidsskr Nor Laegeforen. 2005 Dec 15;125(24):3518.
Confronting the Christmas of our health care discontent.
CMAJ. 2004 Dec 7;171(12):1449-50.
Barefoot in the hospital park or Yes Virginia, there is
a Mrs. Santa Claus known as the administrator's wife.
Hosp Manage. 1967 Dec;104(6):33-7.

Weather dependent nasal erythema in reindeer.
Emerg Med J. 2007 Dec;24(12):848-50.
Epidemiology of reindeer parasites.
Parasitol Today. 1986 Dec;2(12):334-9.
Whitefly infestations: the Christmas Invasion.
Nature. 2006 Oct 26;443(7114):898-900.
Biorational control tactics for suppression of
Nantucket pine tip moth damage in Christmas trees.
J Econ Entomol. 2005 Apr;98(2):409-14.
Oldies but goldies: searching for Christmas trees
within the nucleolar architecture.
Trends Cell Biol. 2003 Oct;13(10):517-25.

Visiting Santa: a further look.
Psychol Rep. 2006 Dec;99(3):993-6.
Social class difference in response to Christmas cards.
Percept Mot Skills. 2000 Apr;90(2):573-6.
A chilling thought for Christmas: might the newborn Christ
have been hypothermic?
Med J Aust. 2004 Dec 6-20;181(11-12):680-1.
Another White Christmas: fantasy-proneness and reports of
hallucinatory experiences in undergraduate students.
J Behav Ther Exp Psychiatry. 2001 Sep;32(3):137-44.
A note on the absence of a Santa Claus in any known ecosystem:
a rejoinder to Willems.
J Appl Behav Anal. 1974 Spring;7(1):167-169.

war is over, if you want it

2007-12-17T07:36:00.000-06:00

so the dreamy-eyed, gentle-smiling pregnant lady who never came to prenatal appointments, whom i'd seen only twice ever, whom we couldn't get ahold of, even when the social workers went to her house? the one where a man kept answering the phone and saying "nah, she not here, she went up the street"? - well, she showed up to one appointment the other day, 37 weeks along, explaining dreamily that she moved into her own place, and she doesn't have a phone. and she doesn't have a car, and she doesn't know how she'll get to the hospital when she has the baby - she guesses she'll just call someone. with no phone.

she guesses she'll borrow somebody's phone. no, she doesn't have enough food to eat - she's been eating cereal. her new place doesn't have a stove or a refrigerator. is it in a safe neighborhood? she wrinkles her brow over this, puzzling for a second, then shrugs.

who will help her when she is in labor? she gazes at the floor and smiles gently. "nobody, i guess." has she been sexually active lately? sometimes - no, she doesn't use any protection, because "it's the father of my kids." any chance she could catch any kind of infection from him? she doesn't know. still smoking about a pack a day? uh-huh.

her mind doesn't work normally. when i first met her, i couldn't tell if she was lying/evasive, or stoned/having auditory hallucinations. i asked her, "why did you want to come to our clinic here, instead of going back to the doctor who delivered your other two kids?" she thought carefully about this for a minute, then said softly, "i guess i just like to go to all different places." turns out she's brain-damaged/developmentally delayed.

she's on disability, with a "representative payee" legally mandated to manage her finances for her - but she's been missing in action all these months, not getting prenatal care, living without phone, stove, or fridge? where money at?

her blood pressure's through the roof.

so off to the hospital in an ambulance - hundreds of dollars on an ambulance to make sure she makes it through the door - to find the baby not growing properly, and she gets a bunch of headaches, and even though her labs are okay, we induce her and she gives birth easily and gracefully and the baby is little, but perfect in every other respect.

the father of the baby - guy in a do-rag, who appears to be in his forties - appears after a little while, to hold the baby, his third daughter by this young lady. note: he has convinced her that he has custody of the other two. even though we discovered and told her this is not true, she still believes it. her two little girls live with him, and she doesn't, but she takes care of them every day while he's at work.

one of the nurses, who coincidentally is a social worker at another hospital, the hospital where the lady had her other babies, stops me in the hallway. "i have a folder this thick on her," she says. turns out the father of the baby used to be (if by some miracle he isn't now) incredibly violent, even breaking down doors and smashing windows to get at her. he turned her out as a prostitute, but she got arrested, and this seems to be how he convinced her she was an unfit mother. there's nothing wrong with his mind - his modus operandi apparently is convincing her she's crazy. she doesn't have the mental capacity, it seems, to do anything other than whatever he tells her.

why does he keep getting her pregnant? he turned off his normal, manipulative, articulate charm and shouted aggressively at the last social worker who asked him this question. it's none of our business.

all perfectly legal, until she is declared incompetent and/or presses charges. what would he do if either of those things happened? and who would take care of the three little girls?

likely she came to us so that all this would be concealed - likely not her idea, either.

her family - one sister, two brothers, mom - stays away from her. she doesn't have any friends. she dropped out of the safety-first counseling and resources program she was in at the other hospital. the father of the baby, and her three daughters, are about all she has in this world.

she's 24.

and so this is christmas
and what have you done?

the hours

2007-12-14T21:56:00.000-06:00

9 am: 24yo G2P0 @ 38 wks EGA comes to L+D c/o 18 hrs severe low back pain constant, low pelvic pain that comes and goes. didn't get any sleep last night. supportive FOB@BS.¹

she's my lady; i've been seeing her since she was 8 wks pregnant. i check her and she is 4 cm dilated - almost halfway - baby looks great²- fabulous news and admitted to L+D for happy birthday. i give her some juice. she walks around and around the unit, she bounces on the birth ball, she contracts q10 min.³ she doesn't need an iv.⁴

we inject 4 little papules of sterile water subcutanously over pressure points on her low back, as specified by her birth plan, and it burns like fire going in, but to my surprise it relieves her back pain almost completely.⁵

she asks me how long i'd expect this to take and i tell her what i was always told: average first time labor, 24 hrs. she looks horrified. so long?

6 hrs later - 5 cm dilated and not really contracting. waters intact and head high.⁶ no real discomfort at this point (defined as: the lady tells me, "no, it doesn't really hurt, hardly at all, now") - just tired. baby looks great. i give her some chicken soup and juice. when i say "i give her," i mean i go to the kitchen and heat it up and bring it to her - the nurses won't do it; they find it alarming that i am feeding her.⁷ but she's tired, so i feed her.

it's a long road to freedom, a-winding steep and high,
but when you walk in love with the wind on your wing
and cover the earth with the songs you sing,
the miles fly by.
6 hrs later - 5 and 1/2 cm dilated and not really contracting. mom eating spanish rice, winning at gin rummy. waters intact and head high. no real discomfort, just really tired, really tired; baby looks great.

at this point the nurses start to express their increasing hostility.⁸ "she's not even in labor." "we don't have the beds or the staff to babysit someone who isn't even in labor!" "who's your attending?!" one of them goes in and tells the lady, "normally, you'd dilate at a steady rate - normally, if you weren't contracting, they'd do something - why isn't your doctor doing anything? you could stay like this for days." then she comes back out and tells me, "she says she's ready for intervention now." so i go in and ask the lady, "the nurse said you're 'ready for intervention'?" and she and the father laugh, saying, "yeah, that nurse is really into that." i tell them i'll be happy to intervene medically if and when it appeared something was medically wrong, but for now - waters intact - no real discomfort - baby looks great, and so on.

i call up my attending, who says, "i completely agree you can't send someone home who's 5 1/2 cm, and of course you can't break the waters with the head high. just tell them: 'i don't want to be on the ten o'clock news when she delivers in the car.' ask them if they want to be the ones on the ten o'clock news. that always shuts them up."⁹

i am afraid to tell them that, but i do tell them the lady needs to sleep and she can have some ambien and get some sleep and she does not need an iv and she does not need continuous monitoring because baby looks great. then i go home and put my feet up.

6 hrs later - 4 am, she's awake again, 5 and 1/2 cm dilated and not really contracting. waters intact and head high. no real discomfort. baby looks great. however, my attending is now getting antsy, so on his (firm) suggestion, i order them to put in an iv and give her "a whiff of pit," low-dose pitocin to see if that "kicks her oxytocin receptors into gear." after all - what harm can it do?¹⁰

always looks great from the top of the hill...
i go in and hang around L+D for a while.

4 hrs later - 5 and 1/2 cm dilated and not really contracting. waters intact and head high. no real discomfort. baby looks great. continuing the low-dose pit. i have to go to clinic.

4 hrs later - 5 and 1/2 cm dilated and not really contracting. waters intact and head high. no real discomfort. baby looks great. i tell them to give her some chicken soup and go as high on the pit as they want.

4 hrs later - 5 and 1/2 cm dilated and contracting q3 min. waters intact but head engaged. lady wants (and therefore gets) epidural; waters artificially ruptured, revealing small amt clear fluid; intrauterine pressure catheter placed, revealing nl contractions; fetal scalp monitor placed, revealing baby looks great.

2 hrs later - i get done with clinic and hurry to the hospital. the obstetric resident catches me on the way in and asks if i'd please let the other attending know what was going on - the one who does cesareans - because he already did two today, and he just went home, and if he was going to have to turn around and come right back, i'd better tell him right away. i say, sure, but i'm going to talk to the patient first of all.

the lady is looking distressed, doing hard yoga breathing through each contraction, says the epidural isn't working at all¹¹, her back is KILLING HER, she's shedding tears, so i pull on a glove and check her and the baby's head is right there.

cute baby and fine placenta born without incident 1 hr later.

unfortunately, due to my attending yelling "push him out right now! push push push, come on!" because heart tones dipped - in the face of a nice pink scalp¹² moving right along - the lady's skin gave way and 20 minutes of mopping up and stitching ensued.

so there goes another one, just like the other one, dilating and descending like gangbusters all of a sudden after the waters were broken, despite really just a little fluid coming out.

i spent much of this time angry at being asked a hundred million times by everyone who even looked my way, "aren't you going to break her waters?" "hasn't she fallen off the friedman's curve¹³?" "are you actively managing her¹⁴, or what?" and telling them over and over again, "i can't see a medical reason to intervene medically. the baby looks great. the mother's not in real discomfort. she's hardly contracting, so she's not wearing out her uterus. but she's five and a half centimeters dilated and i don't see how i can send her home at five and a half centimeters" and asking "is there a medical problem here that i'm not seeing?" and being answered with a stare (either blank or frankly angry) and then a shrug, indicating no, there is no medical problem here.

it's just that it seems wrong to let a woman labor for days and days. but what is labor, then, anyway, if the mother's not in a regular contraction pattern, she's not in real discomfort, she's not progressively dilating, the baby looks great, and the waters are intact? what is it, here, that we are anxious to stop or start or slow down or hurry up? it just seems wrong. do you want to send her home and later be on the news? ...whiling away the hours, i was reading midwives' accounts¹⁵ of "the transfer maneuver," in which a homebirthing woman with an apparently stuck labor (esp "stuck at 6 [cm]"), while being transferred to the hospital for advanced interventions, suddenly dilates, descends, and delivers in the car, an apparent result of bending over to open the door, lifting a foot to get into the seat, and bending over/folding up/ sitting down, as we all do, to get in a car - enough fancy dancing to wiggle the pelvic bones about and get the baby's head, as we surmise, to spin around, straighten out, tuck chin and GO.

active management
...so my guess is, as i told the lady after, the baby's head was not really tucked and was coming down crooked, back-to-back, with the baby's hard occiput jammed into her sacrum, making her back hurt but not putting any pressure on the cervix, until it all came into focus. she replied, "well, it all worked out anyway, and he's so pretty......" smiling and smiling at the pretty baby asleep at the breast.

...such a pretty baby that they've chosen to cut a chunk of his penis off right away, of course, but that's another story altogether.

1
yo = years old
Gravida 2 Para 0 = pregnant twice, never given birth
EGA = estimated gestational age, with avg pregnancy 40 wks long and full-term defined as 37-42 weeks
L+D = labor and delivery dept
c/o = "complaining of," in other words, why she is here
FOB@BS = father of baby at bedside

2
when a woman comes to L+D, one of the first things to happen is "fetal monitoring." this consists of two sensors belted around her abdomen, one which picks up the baby's heartrate via continuous ultrasound, and the other a pressure sensor which is supposed to gauge the strength of contractions. a woman might be "on continuous", in which the machine is always on, or "on intermittent," in which it's on every half-hour early in labor and every 5-15 minutes late in labor. monitors were invented to improve safety, by indicating when the baby's heartbeat is dropping as a result of not tolerating labor. they have never been shown to do so. it's widely acknowledged that their use is mainly defensive medicine, and is certainly no better than just listening with a stethoscope and feeling the belly with your hands. the machines frankly don't work that great. nurses often try to improve the performance of the machine by making the mother lie still in bed, which is a crappy way to try to give birth. furthermore, interpretations of the data vary a lot, from reader to reader. thus babies who appear to be in trouble, rushing to emergency caesarean, may actually be fine, and meanwhile, babies who would otherwise be fine, may start having trouble as a result of the mother trying to lie still in bed to make the machine work right. our hospital has two "wireless" machines, which would allow the mom to be out of bed; but they don't transmit properly, and one of them is missing a sensor, so the nurses get irritable when i ask them to use wireless instead of stationary.

3
q = "every," from the latin quaque "kwa-kway"
e.g. qd, every day; qh, every hour, etc.

4
women typically get iv lines placed "just in case," usually without any imminent medical need. if the iv is "capped," not connected to any bags of fluid, then the woman has her hands free, but she has to be careful - as does anyone who wants to hug or hold or massage her, throughout labor - not to bump the line or get it caught on anything. if she's hooked up, then she can't go anywhere, e.g. the bathroom, the shower, the rocking chair, without wheeling her iv stand along with her. "just in case." this is one of the many interventions that only i, apparently, think are interventions. it sends a definite message:

"The intravenous drips so commonly attached to the hands and arms of birthing women make a very powerful symbolic statement: they are umbilical cords to the hospital. The long cord connecting her body to the fluid-filled bag places the woman in the same relation to the hospital as the baby in her womb is to her. She is now dependent on the institution for her life and is receiving one of the most profound messages of her initiation experience: we are all dependent on institutions for our lives. But this message is all the more compelling in her case, for she is the real giver of life. Society and its institutions cannot exist unless women give birth; yet the birthing woman in the hospital is shown not that she gives life, but rather that the institution does." - anthropologist Robbie Floyd-Davis, Birth as an American Rite of Passage

5
while i was hanging around, i found a bunch of articles on pub-med, the big government research database, substantiating that these "intracutaneous sterile water injections" work well. you basically create a shallow little mosquito bite, a blister of plain water under the surface of the skin. i first heard about them from a midwife who sometimes gets them placed when she throws out her back bending over labor beds. they have also been used effectively - say the studies in pub-med - for kidney pain (renal colic) and whiplash. they are thought to work similarly to acupuncture, and are thought to hurt so much going in because the solution density is so low compared to that of the surrounding tissue fluids.

6
while the bag of waters is intact, germs can't get into the uterus and make both parties sick sick sick.
medical folk like to break the bag of waters themselves, using a thing like a long crochet hook. this is painless, unless you count the effect on the contractions, which can be pretty dramatic - without the balloon to cushion and evenly distribute the force of the contractions, things get intense. the baby also gets squished harder - not usually a problem, uness the cord is getting squished between eg. the baby's shoulder and the pelvic bones. don't forget that all the baby's oxygen comes from the mom through the cord.
when the waters are broken, there's a risk of infection that increases as the hours creep by. there's a lot of social pressure to get the baby out within 18 hours, whether there are signs of infection (moms spike a fever fast, and get a very tender belly) or not.
if the head is "engaged," jammed down deep into the pelvic bones, it acts like a poorly-fitting cork in the uterus, so only water can escape when the bag ruptures (which it usually does by itself, anytime during labor). if the head is high and the waters are broken, the cord can wash down in front of the baby's head and get squished, causing asphyxiation. so you don't break the waters with the head high.
why break the waters at all? it usually speeds up labor. why should labor speed up? good question! see note 14.

7
Fasting in labor: relic or requirement? Sleutel M, Golden SS.
J Obstet Gynecol Neonatal Nurs. 1999 Sep-Oct;28(5):507-12.
CONCLUSIONS: Fasting during labor is a tradition that continues with no evidence of improved outcomes for mother or newborn. Many facilities (especially birth centers) do not restrict eating and drinking. Across the United States, most hospitals restrict intake, usually to ice chips and sips of clear liquids. Anesthesia studies have focused on gastric emptying, measured by various techniques, presuming that delayed gastric emptying predisposes women to aspiration... Only one study evaluated the probable risk of maternal aspiration mortality [meaning death from the mother inhaling her own vomit under anesthesia, despite special drugs, deep suctioning, etc], which is approximately 7 in 10 million births.
[anesthesiologists hate articles like this and publish lots of (theoretical) studies postulating the opposite - possibly having something to do with being one of the most-often-sued specialties - e.g. the average anesthesiologist gets sued every 8 years throughout their work-years. in obstetrics, ineffective practices typically remain standardized because malpractice law favors adherence to "standard practice," even if it's stupid and/or harmful - the same may be true in anesthesiology.]

8
one nurse, signing out my patient to the next nurse at end of shift while i eavesdropped nearby, said "she came in with a birth plan - but, she's, you know, she's not crazy, she'll work with you." i looked over and commented, "i put the birth plan in her chart. i helped her with it and signed it myself," and the first nurse turned back to the second and said sarcastically, "the doctor says the birth plan is in the chart."

9
for example, December 07, 2007 07:05pm
"Jennifer Gold said nurses watched as she gave birth to her son Sonny last Friday morning in a car parked outside the Miles Hospital... Ms Gold said that instead of being admitted, she and her partner were left outside. "Malcolm ran inside and pressed the buzzer to try and get some help and one of the staff has said we weren't allowed to go in there because they weren't a midwife," Ms Gold told Network Ten news. "Malcolm finally came out, they gave him a towel and he delivered the baby himself," she said... He and his mother were finally allowed inside the hospital but left later the same day because Ms Gold said she felt unwanted."

10
not to run it into the ground, but, from micromedex, the big drug database used by docs and hospitals and labs everywhere:
"Maternal cardiac arrhythmias, including premature ventricular contractions... Alterations in fetal heart rate... Hypertension, myocardial infarction, and vasospasm... Water intoxication, hyponatremia, and antidiuretic effect... Nausea and vomiting... Afibrinogenemia resulting in death... Neonatal hyperbilirubinemia... Hypotension, erythema and pruritus on the upper body and limbs, perioral and periorbital erythema and edema, and chest tightness... Seizure-like episodes, headache, memory dysfunction and subarachnoid hemorrhage... Ocular bleeding and blurred vision... Pelvic hematoma, uterine hypertonicity, and uterine rupture... Pulmonary edema, most often associated with water intoxication, has been associated with the therapeutic use of oxytocin..." [and so on.]

11
Google results - about 2,270 for "epidural didn't work".

12
Midwife Elizabeth Davis: "You can use your Doppler at this point, but there is another indicator of fetal well-being you can use as well - the color of the baby's scalp. Once, while attending a hospital delivery, I heard the obstetrician say, "I'll hang my hat on pink scalps." Pinkish-blue is good, blue is less favorable, and white-blue is ominous. The rate of venous return when the scalp is gently depressed is also significant." (Heart and Hands, A Midwife's Guide to Pregnancy and Birth, 2004)

13
in 1954 emanuel friedman published a study of 100 women's labors. they were heavily sedated, dilation was estimated by "frequent" rectal exams "at the peak of the contractions" (good heavens!), most delivered with forceps, etc. he created an s-shaped plot of dilation vs avg time in labor* and ever since then, the "friedman's curve" has ubiquitously been used to compare actual women's labors to an ideal set of time limits based on his sample. "falling off the curve" means "taking too long" and is a euphemism for "you should speed up her labor." there's no such thing as "rising above the curve," or maybe "beating the curve." the only minor rebellions against the curve are current studies seeking a newer, better curve (see Vahratian et al below), not questioning the utility of the thing itself.
although his curve is creepy, friedman was not a bad dude. cf. this by a guy who knew him personally.
*details on friedman's original paper, via pub-med and my excellent library access, in Paediatr Perinat Epidemiol. 2006 Jan;20(1):72-8; Vahratian A, Troendle JF, Siega-Riz AM, Zhang J.: Methodological challenges in studying labour progression in contemporary practice. it's really hard to get the original paper.

14
"active management of labor," also called "the irish protocol" or "the dublin protocol," was developed in the 1980s as a way of getting every woman delivered within 12 hrs of entering the hospital. it is considered a responsible way of controlling everything, and you'd never, ever get in trouble for applying it. its goal is fast labor. the guidelines include sending women home who might not really be in labor (but this part is not practiced in the usa), breaking the bag of waters as soon as possible, checking dilation every 2 hours, pitocin for everyone who "falls off the curve," being liberal with the anesthesia, and if it's still not fast enough, just pulling the baby out. the protocol was developed to lower the rate of cesarean sections.
cf. Foley ME, Alarab M, Daly L, Keane D, Rath A, O'herlihy C.,Department of Obstetrics and Gynaecology, University College Dublin, Ireland: "The continuing effectiveness of active management of first labor, despite a doubling in overall nulliparous cesarean delivery." they want you to know that intervention has nothing to do with it - "prolonged pregnancies" are at fault. Am J Obstet Gynecol. 2004 Sep;191(3):891-5.
note: the cdc just recently released the news that the u.s. cesarean rate has now gone up to 31.1% of all births, infant mortality hasn't improved since the year 2000, and maternal mortality is worse than 40 other countries: "The U.S.'s maternal death rate tied with that of Belarus, and narrowly beat out Bosnia and Herzogovena."

15
right here.

...poet, perhaps known chiefly, and unfairly, for the sadly comic poem To a Fat Lady

2007-11-27T19:31:00.000-06:00

To A Fat Lady Seen From A Train
by Frances Cornford (1887 - 1960)

O why do you walk through the fields in gloves,
Missing so much and so much?
O fat white woman whom nobody loves,
Why do you walk through the fields in gloves,
When the grass is soft as the breast of doves
And shivering sweet to the touch?
O why do you walk through the fields in gloves,
Missing so much and so much?

Comments? Criticism? Kudos? Mail to: Words@

so angelina gaudio. she's my patient. i've admitted her to the hospital four times before.

i walk in the room. she is lying on the bed. she raises her head and laughs out loud - "honey, i was looking for you all along!" she cries. she is a rollicking lady with a fruity, infectious laugh, as italian as can be, with an almost phony-sounding, wildly cheerful, spaghetti-drenched accent. sometimes she talks so fast it's hard to understand what she's saying. "honey, the phone is ringing all night, people all over the world, everybody hear about my period, i tell them, only you i'm telling, i can't tell anyone else, only you, honey - and the nurse, because she's a lady like you, you know - i tell them it's a miracle! i need a kotex! and who's a gonna buy me a kotex! i think it's from the stress. you know, i only have one-half an ovary! you know, i never have no children!" her face is so animated, bubbly smiles and clownish exaggerated grimaces. she's so fun to be around. her curly hair is in little braids tied with yarn, and they flip around as she tosses her head. "my mother tell me, angelina, come home, she'll take me to her doctor. she tell me, impossible i have my period! but i have no passport! five years i have no passport, and i never go see my mother. she comes to see me! now i have to get a passport," she laughs.

how old is her mother? she's got to be at least ninety. ms gaudio herself is 72 years old. she doesn't look it.

part of the reason she doesn't look it, is that the way she looks is really just generally disorienting. she's so vivacious, so funny and charming, but she can hardly move a muscle. she's more than morbidly obese - in fact, she's really worse than i've ever seen her, but even at her best, she's like a - it's so cliche, it sounds cruel to say it, but from a clinical, relatively objective point of view - she's like a huge soggy sack of heavy, immovable flesh, with a tiny chatty head wiggling around at one end. she lies heaped up, flat, naked in the jumbo-giant hospital bed, which is now soaked with urine. a single sheet is tossed across her body, barely covering the traditional strategic areas - and as if she's presumed beyond human modesty, or as if the atmosphere in the room might be asphyxiating, the door is left open. what can be seen from the hall is barely recognizable - lumpy objects, placed so as to ordinarily be designated "thigh" and "flank" and "shoulder," pool out naked across the sagging mattress. a soaking wad of white towels is jammed between the folds of her legs. it's crazily easy to visualize, in the mind's eye, the narrow, spindly skeleton, buried beneath these billows of meat, pinned in place, immobile.

ms gaudio's lower legs are bright red, practically steaming, covered with wide weeping blisters, the skin breaking down under the pressure of the swelling. "stasis dermatitis," secondary to lymphedema. that's actually what brought her into the hospital, this time - a blister on the bottom of her foot made it too painful to walk, as she sometimes does, with short crutches. but then, once she got here, she mentioned how surprised she was to be getting her menstrual periods again, the last three months. "but i can't get pregnant, you know!" she chuckles. "i'm worried," i tell her, seriously. "sometimes cancer can make us bleed. i want to make sure you don't have cancer." i'm worried.

there aren't any pictures on the internets of any women as big as ms gaudio is. you look for "fat lady" or "biggest woman on record" or whatever, and you only find women who can still walk around. it's also hard to find poetry in full - they always want you to pay, to get it all in full... i'm just saying...

this is all wrong. it's very difficult to convey how much i like this woman, how i instantly warm to her. i'm glad to see her again. i get a kick out of her. right now, she's deeply in denial, reassuring me, "no, honey, i don't have no cancer, i already know i don't have no cancer." whenever i talk with her, when we both happen to be in the hospital at the same time, i try to touch her all the while. i'm concerned that she mainly lives without the human touch. she doesn't need chattering to cheer her up, she's got more than that in store - but i pat her shoulder and hold her hand. she clutches my hand while she chuckles. i feel her forehead for a fever. i lay my hand on her belly while we talk, the vast plain that would be her belly, many handsbreadths across. you know, the skin is our largest sensory organ - and in her case...

i suspect that she behaves double-vivacious - triple-charming - quadruple-gaudio, to distract everyone from the festering heaps of flesh in which she dwells. the room is filled with the smell of funk, mostly decayed urine. it's acrid. surely she's inured to it, but i'm not, and it stays on my hands, or stuck in my nose, hours after each visit. surely she'd observe, subliminally react to, or not-so-subliminally anticipate, everyone else's reaction to the sight, the smell; preemptively she distracts, with peals of insouciance, a loony chico-marx accent, a torrent of explanations. she distracts. i tell her bad news, searching her face for the woman inside.

i ask radiology to do a transvaginal ultrasound.

transvaginal ultrasound! what a term! it sounds so sleek, and streamlined, and space-age. i'm in meetings all afternoon, so i'm not able to hold her hand, or explain what the hell is going on, while they're sticking that thing in her - with maybe two or four extra nurses to hold the flesh out of the way. if i were her, i'd be frightened, although she assures me as i leave for the morning, "oh yes, Ultra Sound, i know, that's okay, i know you have to do that, it's okay, honey."

the ultrasound comes back bad, after hours. right now it's up to somebody else to call for the gyn-oncology consult, to explain to her why she's spending an extra night in the hospital, to try to interrupt her long enough to tell her, in plain language, what an endometrial biopsy is.

the attending doesn't want to keep her here; he says we're not doing anything for her here, and that she can "follow up as an outpatient."

it's the same thing every time. the nursing staff are exhausted and frightened by her, and avoid her room as much as they can. when i tell her to press her nurse button (call light) to get the pee-soaked towels and sheets changed, she rolls her eyes and laughs, "they're busy! always busy! i wait all night, honey!" i write orders saying "prior to procedure please give ms gaudio a VERY THOROUGH BED BATH," and either i imagine it, or they really do avoid my eyes and suddenly look busy, whenever i walk by.

but more than all that, i want her to be well, and now that i know what i know, i really want her to not have cancer and not need surgery - even though i know she does. do you know what surgery means, for anybody like her? either she's "not a good candidate," due to her comorbidities, or it's simply impossible, even with a platoon of medical students pulling at retractors as big as tractor-tire irons.

time and again, i've discharged her from the hospital, to "follow up in clinic next week," and emailed her primary doctor - an equally vivacious and charming, but far too fastidious, gay man - to tell him i'd do the gyne exams in clinic with him, or for him - but nothing ever happens. today she confesses, "you know, i can't get comfortable in the clinic, honey - the little table up so high, and never no chairs big enough. i am losing weight though!" ...distract, distract! she hasn't made it to the clinic to see her handsome, horrified personal physician, for the past three years. she just goes to the hospital when she's unable to move about anymore.

so anyway... i hate that we're always rushing her out of our sight, so often and so quickly - so often and so quickly, that not only is she increasingly, terrifyingly enormous, and increasingly, repulsively smelly, but now she has cancer too, almost certainly. i blame "us" - we who can't grapple with the problem too long, because it freaks us out. it's a drama of epic proportions - and one astonishing in which to participate, because she's such a ringmaster, putting on such a show, such a highwire act of glamorous dramedy, that one almost forgets it's likely the end of the world as she knows it.

i keep searching her eyes, for the woman inside. i keep stroking her forehead, hoping, by relaxing my own belly, to get her to talk a little slower, to breathe a little between sentences, instead of frantically laughing joking laughing joking... no, of course it's none of my business - it's just, she's not well, and i just want to do the opposite of quietly rushing away, fanning my nose, the opposite of scribbling "follow up as outpatient," and signing off.

she squeezes my fingers, and says, "no, honey, i don't have no cancer, i already know i don't have no cancer, you'll see."

maybe tomorrow, when i write her discharge orders, i'll see if i can get her to promise to come into the clinic and just see me, and skip everybody else. i'll tell the front desk to give me a heads-up before she comes, for extra privacy, extra muscle, extra air freshener. maybe i can visit her at home. i'm not liking her miracle. i don't think her miracle's going to be good to her. her period! back at age 72! who knew!

* sigh. *

The Fat Lady Sings
From: Prairie Schooner Date: June 22, 2001
Author: McDermott, Sharon F

She knows, when she opens her mouth, it's over
so she chooses her songs with the care of the violin
maker, becomes all ear and light fingers
seducing instruments. She runs her tongue
over the notes, those silver bones...

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running code running running code running running running

2007-11-23T15:45:00.000-06:00

here is what we tell ourselves, the kind of thing some of us recite to ourselves:

Bradycardia: Pacing Always Ends Danger
(Pacemaker, Atropine, Epinephrine, Dopamine)

Tachycardia: Synchronized for the Still-alive, Defib for the Dead

Synchronized cardioversion: Oh Say It Isn't So
(Oxygen, Sedation, IV, Intubation, Suction)

Ventricular Fibrillation = SCREAM
(Shock, Compressions, Rhythm check; Epinephrine, Amiodarone, Magnesium)

I SUCK
(In Sudden Unpleasantness, Can't Kope)

committed to memory? NO?!

i hate and fear codes. it just so happened i was the first MD there. it's not that MDs know any better than anyone else what to do, since they don't. it's just, i guess, that MDs are obliged to take the responsibility. so it was very unpleasant when the nurses said, "who's running this code?" i didn't know what to say or do. one nurse was giving chest compressions, another was giving oxygen, an anesthesiologist was getting ready to intubate, another nurse had given one dose of atropine, and another nurse was getting out the pacemaker pads. when she finally arrived, i elbowed the other resident in the room - one year more experienced than me - and whispered, "you run it!" because i didn't know what to say or do. and what she said and did was - flip through the chart, and endorse what the nurses suggested. then i thought, i could have done that. but i didn't - because - In Sudden Unpleasantness, Couldn't Kope.

did the patient die? she did. was it my fault? nope. do i have to take responsibility? nope, because in sudden unpleasantness, my coworker said, "i'm running it," and i did not. all i have responsibility for is I SUCK. the skills i was taught in my 2-day training in july of 2006 failed me, and i failed to be better prepared and more appropriate and better educated and more skilled than the roomful of ICU nurses and Rapid Response Team members who have worked together doing all this every day for years.

former [ideal] patient.

i have searched through the internets, as i have done before, for reasoning and role modeling on the subject of The Code, a.k.a the Code 99, the Code Blue. what i find is mainly critical care nurses hating residents who just stand there during a code, why don't they do something, and emergency physicians boasting how fast, cheap, and out of control they are in saving lives during their many many codes, just do it.

somebody did a wee study. warning: "code" is written in scary capitals:

Of interest about the medical education process is the assumption that all medical students and residents can function well in a CODE situation... It is assumed that if an applicant can make it into medical school, then he/she is capable of dealing with life-threatening stress situations... Some may freeze when faced with a real-life situation and cannot translate the learned book knowledge into active practice. Freezing can become a pattern, a conditioned response for subsequent CODE situations. One may argue that medical training deconditions medical students to deal with traumatic situations, just by putting them into the environment. I believe that with some people, no amount of training, or attempts at deconditioning can make an "adrenaline junkie" out of someone who fundamentally is not.

...The public believes that physicians have been "trained" to deal with the difficult situations, that somehow we react differently, and are immune from the impact of practicing medicine... [A] survey of residents found 79% of them were scared by CODES, 76% felt that they needed more knowledge and 82% felt that they needed more experience before running a CODE.

seventy-niners

...Within my medical education CODE experiences, there was no instruction in what to expect during CODES. There were no attempts to bring the students or residents involved in the CODES together for any sort of "debriefing" or "defusing." ...There is a significant range of "normal responses and symptoms" which may occur after experiencing a traumatic event... From discussion with colleagues, I discovered that many of them had experienced these many of responses at different times.

Nightmares (more than once/week)
Feeling "numb" or detached
Intrusive memories (more than once/day)
Depressed mood
Irritability
Feeling guilty
Difficulty concentrating
Feeling anxious
Anger/Hostility

Feeling as though the world no longer "makes sense"
Fear and/or avoidance of similar situations
Avoidance of people or things that remind you of the critical incident
Questioning religious values
Hypervigilance
Stress-related physical complaints
Exaggerated startle response
Flashbacks
Difficulty Sleeping
Withdrawal from usual activities
Difficulty remembering the critical incident

...Unprocessed reactions to traumatic events can, in time, progress to have significant negative outcomes... Unprocessed cumulative traumatic events can eventually lead to professional burnout. that is from the american academy of experts in traumatic stress. i find i envy them, these experts in traumatic stress - if only i were an expert in traumatic stress, it would be a phenomenon i would expertly study, rather than an environment in which i clumsily live.

i'm processing already, i'm processing!

maybe you can't see what i'm saying. a well-groomed black lady with salt-and-pepper hair was on her back in bed, hospital gown thrown back to her waist, the skin of her belly and thighs mottled impressionist fishnet purple, a line of silver staples up to her navel. she had mahogany toenail polish. nurses on either side of the bed were probing her groins with gloved fingers, looking for pulses; her pubic hair was neatly trimmed, just starting to fill in after 3 weeks in the hospital, silver threads among the black. her gown was unsnapped at the shoulders, wadded down around her waist. a respiratory therapist in purple gloves was leaning over her chest, pushing straight-armed on her breastbone, fast and hard, making her arms and legs bounce up and down on the bed. she had a plastic tube tightly tied into her mouth, white ribbon cutting across the skin of her cheeks. a respiratory therapist was sucking pink slime out of her throat through one port of the tube, while a nurse forced air into her lungs with loud periodic slurping noises through another. the nurse frowned at me - or else he frowned at the slurping noises. he frowned around the room at everyone. her pink tongue stuck out the corner of her mouth, from under the ribboned tube. her eyes were gently closed; her brow was smooth, untroubled as she bounced up and down on the bed. she had a wide silver pad stuck to her chest - the other was underneath her. her breasts were small and flat, lined with fine, dark stretch marks. after someone shouted "clear", everybody stepped back, as one, and froze; the room fell silent; three beeps sounded, and suddenly she bounced once, by herself on the bed. then everyone stepped forward again. a lab tech pushed a long needle into her groin for a blood sample ("it ain't gonna happen, people," he muttered); somebody screwed a syringe into her elbow IV, calling "epi in"; the frowning nurse went back to squeezing his blue ambu-bag; my co-worker went back to flipping through the chart: "has anyone talked to the family? is she, indeed, full code?" and a nurse in the hallway replied, "she is, indeed, full code." out at the desk, her family doctor, who had admitted her, had the phone pressed to his shoulder, head cocked, listening, looking worried. my glasses, tiny as they are, steamed up. that's probably all you want to see. my co-worker said "let's call it"; shoulders slumped, more in relief than in defeat; the line on the monitor showed squiggles, squiggles, littler squiggles, gentle waves, then the calm, flat, flat line. it was called. it was called. it was called.

did the patient die? she did. was it her first time? had she died before? no; yes: she had already "been coded" twice before during this admission, although i didn't know that. already years in end-stage kidney failure, she never woke up from the emergency abdominal surgery she came here for. i'm not upset because the patient died; she was doing what she was supposed to do; she had already left the building; there was no dark angel hanging up there in the back corner - i know, because i looked; the grim reaper had already been and gone. although i honored the lady's passing, what upset me was that I SUCK, and in fact i expect to get in trouble for it, although realistically, i probably will not. but realistically, i am in trouble. i'm troubled.

from the internets: A friend of mine who finished her residency in June just took a job in a non-medical field. I talked to her over the phone last weekend. She is so happy in her new position, she said, so happy. Sure, I said, who wouldn't love a 9-to-5 job after what you've just finished? You know, it's not even the hours, she said. It's the respect.

See, apparently, when you're not a resident, people sometimes appreciate the time you spend at work. People consider your feelings when they respond to your ideas. When you do something well in the real world, sometimes you even get praise. Praise! Apparently, there are people out there who occasionally own their own time; who feel entitled to ask for support; who, when they are treated like children, can turn their backs and leave.

I used to live in that world. I had lots of weekends then, and what felt like options. I don't live there any more. My job stinks. The hours stink. The way it isolates me socially stinks. The havoc it has wreaked on my relationship with my family and my perception of myself stinks. I used to be creative, and I used to have energy and faith in people. But where I am now, every day seems full of special punishments created by the cosmos just to fuck with me... I haven't had a great story in months. They're still happening, but I am no longer a part of them: I am watching from the outside as people experience my care - able to give them what I ought to, but no longer able to take much away.

and this is by a woman who elsewhere says, Running the code felt comfortable in an unexpected way, like a glove that looks scratchy but feels like your own skin. I knew what I wanted, asked for it, and kept my surprise to myself. Things unfolded quickly...

career ops

she also said, In the space of two hours, three patients crashed elsewhere in the hospital... I learned to put in a central venous line on a dying man, and thirty minutes later, I put in another one on a woman who's probably going to make it. I put in an arterial line - my second - and I did chest compressions that actually worked... It felt like my luck had taken a turn for the better.

so this is where i live: some people, even those who are stressed by their lives, who feel like the cosmos is fucking with them through their jobs, truly are exhilarated by codes, and gently despise those who are not, who can not be - who do not know, in a pinch, despite their standardized training and all those years of book learning, what to say or do, and who just stand there sick at heart, while those who do know what to say and do, make authoritative, swift, correct decisions while waiting impatiently for some MD - like me?! - to assume responsibility.

I SUCK!

sigh.

well i swan

2007-10-23T07:36:00.000-05:00

little drama queen never made it to her follow-up appointment 2 days after leaving the hospital, and her phone was disconnected. so nervous norvis finally - and i wish he'd told me - just drove down to her house. so he got to see how she lives.

it turns out the phone number we have in our records was actually boyfriend's disconnected cell phone number. and it also turns out that boyfriend's mother - mother-out-law, i guess - heard through the grapevine that the little gal's own mother was the one who called the cops on boyfriend over the probation violation. so mother-out-law had paid a little visit.

she let herself in with a key, while little gal was recovering from surgery in the hospital, and trashed the apartment, including taking all the curtains, for some reason - so little 18-year-old black-eye gal came home from her cesarean with her new baby and her 2-year-old, to an empty trashed apartment and no curtains on any of the windows.

and that's how she'd been living. she hadn't made much headway cleaning up the mess yet, apparently. dr norvus tells me that boyfriend's family apparently believes that the girl is the source of "all the trouble." he took out her staples and examined the baby and said that they were doing very well - medically...

i was just sort of thinking about the harpies and that guy they pestered, that blind guy, that guy who told secrets. they didn't take his food away, right? they just destroyed it. as soon as he'd get something nice to eat for himself, they'd ruin it, right?

it's not about the violence, it's about the control. it's the control that's her enemy, and mine, and yours too.

tale of 2

2007-10-20T12:58:00.000-05:00

man what a day - forty hours long, from eight in the morning friday to midnight saturday.

it all started with a lady crying in spanish while her baby was born in a most peculiar way - a way you would not be interested in unless you were really into the nitty gritty of midwifery - then laughing while she held her new cute baby, then crying again while residents stuck their hands in her, up to the elbow - quite a sight, blood up to the elbow - trying to dig out whatever it was wouldn't let her stop bleeding. (what it was - a bit of stuck placenta.)

but that's not the first of the two. she was a grownup, with other children at home and a smiling spanish speaking grownup husband mopping the tears off and holding her hand and kissing the new baby.

actually on thursday i had spent the day labor-sitting my little 18-year-old drama queen - i mean that in the nicest way possible - she is a delicate little thing, and very vulnerable, and exquisitely conscious of every twinge, and worries a lot - so she comes off as a touch melodramatic - kind of like a high school girl in the lead role of the class musical. i blame her not a whit - with her black eye, and the bruises around her wrists, like somebody grabbed her, and on her thigh, like somebody kicked her, and her overattentive boyfriend, and her two-year-old back home with boyfriend's grandma.

she was planning a VBAC (vaginal birth after cesarean). her first birth was cesarean because she "failed to progress" in labor with a nine-pounder. it seemed reasonable she'd be able to birth normally the second time, especially since she was continually convinced, at 37 weeks (of forty), that she was in labor this time for sure, and each time, the baby/fetus appeared to be considerably smaller than nine pounds - maybe six.

i know what you're thinking - black eye? overattentive boyfriend - almost like he wants to watch her all the time? had i tried consistently every time to talk to her alone and win her trust and give her resources and connect her with social services and empower her to make her own decisions? i had. and had i also checked her rbc and platelet count and considered von-willebrand clotting-factor testing? because maybe it's true when she says she bruises easily and hits her face with the freezer door all the time. i had. but she still came in with black eyes and bruises and boyfriend - and normal blood counts - every time. so that part isn't a big part of my story.

nervous norvis, the kindly, though nervous, obstetrician, wanted to play it cool and observe her overnight, contracting and huffing and puffing as she was, although not dilating. gave her some morphine and she calmed down, uterus and all. so friday morning i was able to send her home with instructions to Just Chill.

then the spanish speaking lady started having her baby.

then my little 15-year-old muslim girl came in, full term, in labor for reals.

she was very sweet, sitting there quietly with her hands folded, breathing deeply in and out, with big fat tears running down her cheeks. she had her veil off - i never knew before that she had blonde streaks in curly black hair - very cosmopolitan.

she really really really really really really really wanted an epidural, and although i really really really really really really really really really really really hate epidurals, well, she's the boss, so the anesthesiologist came and poked her back, to her tremenous relief, and then she was able to smile again, albeit a little dubiously.

i left her in the hands of her mom and sister and cousin and aunt, all stately and gentle-eyed in their headscarves, and went to catch the spanish speaking lady's baby and pull out, as i was commanded to do, and as i did not want to do, her placenta. a nurse came running to tell me little muslim girl was ready to birth, all of a sudden - hence i was not among the residents elbow-deep in the crying spanish speaking lady.

my gal - i kind of hate saying "my patient" as it sounds so proprietary and presumptuous - but somehow i don't apparently mind saying "my gal" or "my little blonde surfer girl" or the like - hmmm... anyway, she pushed her baby out bit by bit, and bit by bit the head came out - and came out and came out. then the shoulders, slowly, slowly, slowly - well, finally i just pulled. giant baby! from a wee slip of a girl! 8 lbs 14 oz! it never ever looked that big inside. (note: she did not tear. not even a skid mark.)

when the rest of him had finally slipped out, and i set him in my lap and wiped off his face, he yelled a second while i cooed "hi baby, hi sweet baby," like always - rescucitative sweet nothings - and then he turned his head and looked at me. he looked right at me.

and as we passed him around, he looked at everybody and - smiled. how amazing is that? maybe you can't tell how amazing that is. well, it was quite a sight.

i spent the night on call, visited calm and confident fifteen-year-old, back in her veil; got home in midmorning and tucked into my email, and then my pager rings again.

little drama queen had returned to the hospital for her VBAC. i guess, nowadays, since we ("we") are ever more skeptical of anybody's ability to give birth, we now call it 'TOLAC' - trial of labor after cesarean. she was "dilated" to 3 - pretty much the way she was when i sent her home - and it was speculated that her waters had broken, albeit in the shower, so who knew - the obstetrical resident presumed it was so, but i remained dubious, since nothing leaked out for the rest of the morning. and the afternoon. and the evening. and into the night.

her black eye looked worse. as we say, it was "developing."

she cried loudly when the nurse started the i.v. - she was going to get a wide load of penicillin for her asymptomatic vaginal bugs (everybody does, nowadays). after that, she stayed moaning and crying and sometimes yelling and writhing around on her back, while boyfriend observed her nerously. the nurse rolled her eyes and left the room.

first thing, i got her sitting up and locking eyes and breathing with me, every time. showed boyfriend how to do it (he didn't do it). we were just getting settled into it when the anesthesiologist arrived with his magic epidural.

yeah, she screamed loudly indeed, when the needle went in. and actually she continued to fret all day, complaining it wasn't working, she could "still feel something." like most folk, she expected to actually literally not feel a thing.

the "broken water bag" reappeared and we broke it again, artificially, with a long crochet hook thing.

a crowd of people filled the room for about 2 hours, then they all left. boyfriend too, whom, she said, needed to go get his playstation.

i got my knitting and opened the curtains and turned off the overhead lights and turned down the teevee and she went to sleep while i rocked and knitted. boyfriend stayed away.

i was remembering how when i was in labor for the first time, very late in labor, i kept falling asleep between rushes, and having these wild expansive dreams. i remember dreaming i was flying over a desert and looking down i could see white bones in the sand, gleaming in the sun, beautiful and exquisite in their precise angles and well-measured curves. but i was sleeping the zen sleep of an altered state of consciousness - not the exhausted sleep of a child who'd spent most of the past eight hours crying.

when she woke up, she was shaking like a leaf, teeth chattering; baby's heart rate was up; took her temp and it was 101.7 - i guess just as you'd expect after a broken bag (a beeline from the infectious world to the sterile) plus strange hands poking around in there "checking for progress" every two hours all day and all night, as we are mandated to do for a 'TOLAC.' we started yet more antibiotics while she shivered away. boyfriend still missing in action.

i'm getting tired just telling it.

she slowly slowly slowly dilated to six, and after that more anesthetic and a bunch of pitocin did not accomplish much, as the intrauterine pressure catheter (another two-lane highway to childbed fever) and the constant freaking vaginal exams indicated. nervous norvis tried turning down the anesthetic, and she started to really truly "feel something," and rocked back and forth and huffed and puffed each sixty-second contraction, three minutes apart like clockwork. i kept breathing her through it, talking her through it - it's like you'd try to quiet a frightened colt, and about as effective, which is to say, somewhat - until at one point she said, "i think i'm starting to get the hang of this. i think i can handle this."

and just then boyfriend came back, smelling like smoke, with a paper bag full of burgers and fries for himself, six hours after he'd left. i told him "you're grounded, mister." he was sullen.

but then nervous norvis came in and broke the cesarean decision news. she was relieved. i was exhausted. boyfriend was confused.

so anyway we washed and wrapped her, cut her open, dragged out the five-and-a-half pound girl, pink and yelling; sucked the blood out, stitched up all the layers, and called it a night. nurses escorted pale/trembling boyfriend from the room before we started sewing, so i entertained the gal with amusing one-liners for the last hour. and finally, good lord, i got to go home, and stay there.

next night the cops came and got boyfriend for a probation violation of some kind or other, and she spent the rest of the time, with her bruises and black eye and tiny little baby and staples in her belly, worrying how to get him out of the city jail. she told a funny story about how "the cops came and they knocked on the door and they didn't say who they were, so he laid down on the floor and tried to see who it was under the crack in the door, and then they opened the door on his head."

truly, i am not unsympathetic to the plight of anyone who gets the door opened on his head. and i have heard boyfriend speak about his cat with great tenderness. he is a young boy. he learned these bad behaviors from somebody. my buddha nature recognizes a pure core of innocence in him, as in all of us, that is perpetually unstained by his repulsive behavior and his idiotic life choices. even while i step in to defend the girl who is my patient, and am willing to kick his ass in the process, i hope with all my heart that he will learn better behaviors before he gets hurt, or hurts anybody else anymore.

both girls ended up telling the truth about their miseries to the same kindly nurse - duly documented in their charts - the fifteen year old, how her close blood relative in a faraway land made her get pregnant, and the eighteen year old, how "sometimes he hurts me, but he really loves me."

forget it, jake. it's chinatown.

so that's the tale of the two teenagers and their babies - how the big boy came out of the quiet one with the veil, and how the tiny girl came out of the noisy one with the black eye. they're all nursing - and i think if anything can help save them - save their lives, make their lives splendid and good and joyful - that can.

cry of the afflicted

2007-09-30T11:59:00.000-05:00

I think my vision is getting worse all the time

My vision is getting worse. I can't even see
what is five feet away from me without squinting.

My vision was fine before but now I can't
read the numbers on a cell phone.

my vision is getting worse i dont think its
that bad but will they still give me glasses,
because my eyes are really hurting.

My vision is getting worse as the weeks float by

Q: My vision is getting worse. What do you recommend?
A: If your vision is getting worse, then you should
wait until it has stopped changing.

My vision keeps on slacking!! And it keeps
getting worse! Why is this?!

Why does my doctor tell me I am I doing fine
when I know my vision is getting worse?

I could live with everything else,
but my vision is getting worse.

My vision is getting worse, finger swelling
is getting worse, headaches are more frequent

My vision is getting worse and i still have
nasty dizzy spells and being off balance.

My vision is getting worse. Each eye
is seeing clearly, but the eyes are not
focusing together (I have to close one
eye in order to see).

my vision is getting worse and it dosnt frieghten
me anywhere near as much as loosing my hearing,
but this stuttering is getting worse

My vision is getting worse, and I make
way more mistakes at work then I used to.

My vision is getting worse each day
and I'm not sure how much longer I will
be able to write

My vision is getting worse so I will
no longer be repairing clocks.

My vision is getting worse and worse.
I lost a wonderful laboratory job
last year because of it.

My vision is getting worse, in the sense that
eyestrain is becoming a constant issue.

My vision is getting worse. Things look pretty foggy.

My vision is getting worse - sometimes
it just seems dark all around me.

OK.....my vision is getting worse all the time
and i still dont no wat to do.....help?

My vision is getting worse. I suppose there are people
worse off. But right now it feels so lonely. Comments (0)

i had to scold the gyn-oncologist today.

2007-09-20T17:24:00.001-05:00

he told a worried lady not to worry, he could cure her cervical cancer, but she would probably need a "laparoscopic/vaginal" hysterectomy.

do you hear how he said it?

i told him not to use the word "slash" so close to the word "vagina."

hysterectomy merit badge

attentuated in short days

2007-09-10T22:00:00.000-05:00

a pubmed search meets belle and sebastian.

Summer in winter
Winter in springtime
You heard the birds sing
Everything will be fine

I spent the summer wasting
The time was passed so easily

Cancer patients lose weight as a result of the anorexia-cachexia syndrome, and this weight loss is associated with significant morbidity and mortality.

Cachexia is derived from the Greek words "kakos" meaning "bad" and "hexis" meaning "condition".

Weight loss alone does not identify the full effect of cachexia on physical function and is not a prognostic variable.

Often misdiagnosed as a condition simply of weight loss, cachexia is actually a highly complex metabolic disorder involving features of anorexia, anaemia, lipolysis and insulin resistance.

Cancer cachexia is characterized by complex, multilevel pathogenesis. It involves up-regulated tissue catabolism and impaired anabolism, release of tumor-derived catabolic factors and inflammatory cytokines, and neuroendocrine dysfunction. These culminate to create an energy-inefficient state characterized by wasting, chronic inflammation, neuroendocrine dysfunction, and anorexia.

But if the summers wasted
How come then I could feel so free

Increased production of reactive oxygen species and reduced activity of antioxidant enzymes contribute to development of anorexia and cachexia in cancer.

Many of the same inflammatory factors that promote tumor growth also are responsible for cancer cachexia/anorexia, pain, debilitation, and shortened survival.

The cancer-bearing state affects protein synthesis and breakdown in different tissues of the body in a different manner.

Lean body mass depletion is one of the main features of cachexia and it involves not only skeletal muscle but also affects cardiac protein.

Weight loss alone did not define a population that differed in functional aspects of self-reported quality of life or health status and differed only in objective factors of physical function.

Even patients with the highest intakes had weight loss, which suggests that the diets of those persons were consistently inadequate for weight maintenance.

I spent the summer wasting
The sky was blue beyond compare

Tumour cells interact with host cells within the tumour mass resulting in the production of catabolic mediators which degrade host tissue.

Muscle wasting is the most important phenotypic feature of cancer cachexia and is mainly related to a hyperactivation of muscle proteolytic pathways.

Conditions as diverse as cancer, renal failure, and heart failure show a remarkable similarity in their associated cachexia, exhibiting changes in metabolism and endocrinology, including marked increases in levels of cytokines that accompany these diseases.

Biblical passages such as: "I forget to eat my bread" and "My knees are weak through fasting, my flesh failed of fatness" and "My bones cleave to my skin" indicate anorexia, loss of weight, and cachexia.

Decreasing intake led to ongoing and spiraling losses. Caregiver intake patterns also changed.

The meanings people attach to their lived experiences of cachexia are unknown.

A photograph of myself
Is all I have to show for
Seven weeks of river walkways
Seven weeks of staying up all night

Higher metabolic rates were mainly determined by the tumor burden and aggressiveness in association with response to treatment clearly disclaiming the effect of weight loss and/or dietary intake reductions.

The concept is that the tumor itself may lead to cachexia and immune dysfunction but also cachexia is related to and mediated by immune dysfunction.

Because cancer cachexia differs significantly from starvation, nutritional supplementation must be used in conjunction with other anti-cachexia agents to reverse the chronic systemic inflammatory state and the effects of circulating tumor-derived factors seen in cachexia.

Increased gluconeogenesis, from lactate and from gluconeogenic amino acids, is the main factor responsible for increased glucose turnover.

In growing tumours the oxygen concentration is critically low. Since mammalian cells cannot ferment fatty acids, in vivo tumour cells completely depend on glucose fermentation. Therefore, growth of these tumour cells will require about 40 times more glucose than it should require in the presence of sufficient oxygen. The liver must invest 3 times more energy to synthesize glucose than can be extracted by tumour cells in an anaerobic way. The liver extracts the required energy from amino acids and especially from fatty acids in an oxidative way. This may account for weight loss, even when food intake seems adequate.

I spent the summer wasting
The time was passed so pleasantly

This process results from a failure of the adaptive feeding response seen in simple starvation, and includes cytokine production, release of lipid-mobilizing and proteolysis-inducing factors, and alterations in intermediary metabolism.

Although the proteasome remains a preferred choice for therapy, the continually emerging upstream signaling molecules serve as additional promising therapeutic targets.

Hormonal and/or other drug strategies that can target key steps in the molecular pathways that regulate protein synthesis and protein degradation are needed.

Understanding the traits that a cancer acquires to successfully grow and metastasize to distant sites gives insight into how tumors produce multiple factors that result in multiple different clinical syndromes such as cachexia.

Say cheerio to books now
The only things I'll read are faces

Altered body image impacts on other aspects of embodiment: the emotions, spirituality, relationships and social functioning.

Because of the possibility to identify the patients' needs and expectations by assessing their quality of life, it should be generally included into their nutritional evaluation to be able to tailor the adequate nutritional support.

Only 14% of the subjects reported no chemosensory complaints of any kind, whereas 86% reported some degree of chemosensory abnormality. The most common complaints were persistent bad taste in the mouth, taste distortion, and heightened sensitivity to odors.

Low intakes and a high risk of weight loss were associated with decreased frequency of eating and with dietary profiles showing little variety and unusually high proportions of liquids.

Achieved improvement of nutritional intake was proportional to a better quality of life.

The early provision of the appropriate mixture of foods and textures using regular foods may modulate outcomes.

I spent the summer wasting
Under a canopy of green

Conventional cardiovascular risk factors (e.g. hypercholesterolemia and obesity) are paradoxically associated with better survival in distinct populations with cachexia.

Further study of cancer-cachexia pathophysiology and the role of endocannabinoids will help us to develop cannabinoids without psychotropic properties, which will help cancer patients suffering from cachexia and improve outcomes of clinical antitumor therapy.

Adipocyte lipolysis is increased in cancer cachexia not due to weight loss per se, but most probably because of enhanced expression and function of adipocyte hormone-sensitive lipase.

Adipose tissue from tumour-bearing mice contained shrunken adipocytes that were heterogeneous in size. Ultrastructure of 'slimmed' adipocytes revealed severe delipidation and modifications in cell membrane conformation.

Low serum carnitine levels also contribute to the progression of cachexia in cancer patients.

Seven weeks of reading papers
Seven weeks of river walkways

Effective therapeutic interventions for several aspects of the syndrome include antiserotonergic drugs, gastroprokinetic agents, branched-chain amino acids, eicosapentanoic acid, cannabinoids, melatonin, and thalidomide, all of which act on the feeding-regulatory circuitry to increase appetite and inhibit tumor-derived catabolic factors, antagonizing tissue wasting and/or host cytokine release.

The sum of these data support the concept that immune cell-derived cytokines are closely related with the regulation of metabolism and have both central and peripheral actions, inducing anorexia via hypothalamic anorectic factors, including serotonin and dopamine, and inhibiting the neuropeptide Y orexigenic network leading to a reduction in food intake and body weight, emphasizing the interconnection of the immune and neuroendocrine systems in regulating metabolism during infectious processes, cachexia, and obesity.

Seven weeks of feeling guilty
Seven weeks of staying up all night

Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress.

The severity of acute-phase sickness behaviors (anorexia, cachexia, neophobia, and social withdrawal) were attenuated in short days.

For patients, eating-related distress was characterised by obstruction to eating, poor and capricious appetite, a disconnection of oral intake and ability to gain weight, and continuous efforts to eat. Their partners expressed feelings of deep concern, frustration, and insufficiency in their loving and innovative efforts to prepare appealing food.

Fatigue, cachexia and anorexia were the three most distressful symptoms in the last week of life in this group of patients, but caregivers and physicians failed to rate them in agreement with patients.

Summer in winter
Winter in springtime
You heard the birds say
Everything will be fine.

what's the buzz?

2007-08-25T12:14:00.000-05:00

my foot hurts.

one of the effects of rufus is that it occasionally gives me weird migrating joint pain. i looked it up on the internet & discovered the painful place today happens to be my cuboid bone. cf. "cc joint" above, also known as cubo-calcaneus joint, but really my whole cuboid hurts. and don't give me all that stuff about "cuboid syndrome," either, because i am neither a baseball player nor a ballet dancer, and it doesn't hurt on the underside, but on the lateral side. i blame rufus!

it turns out the cuboid bone is kind of interesting, or at least has produced some interesting writing on the internets.

"The most significant of the feet bones is the cuboid bone, the bone on the outside of the foot between the heel bone and the little toe. In the pre-Saxon foot, the bone is indeed cuboid. In the Saxon foot it is more quadrilateral.

"It is obvious that these differing shapes are a formative factor in the outer border of the foot; other bones have their characteristic shapes, but the cuboid is always the first I look for and hope to find."

"...During the 1980s I worked in Egypt and worked in a fantastic place there - now a national park - called valley of the whales, or Zeuglodon Valley. And we found hundreds of whales there in the desert, and we started to look for parts of them that weren't well known. How many vertebrae they had wasn't well known; it wasn't known at all what the hands looked like, and of course we thought the feet were gone. We thought that they, too, would be reduced like they are in modern whales.

"At the end of six seasons, we found the feet of whales, and we found that they still had toes. The only problem with that was that the ankle bones themselves... We found that the ankles of whales are not like mesonychids [extinct wolf-like animals].

"And I can tell you that for the first week after finding this in the field I was in denial, because I couldn't believe that the ankle bones are exactly like those of the artiodactyls [the ancestors of hippos and camels]. I couldn't believe it. So mesonychidae are out of the picture, and whales and artiodactyls connect to each other.

"...It only took a week to get over the shock, because we found that first find was two bones. One called the astralagus, that's the main hinge bone in our ankle, and the other was the bone called the cuboid that sits just on the side of it in front.

"...The cuboid, I looked at it and it was very distinctive and it had a big notch in the side of it. After a week I was able to find a goat ankle in the field... and it has a perfectly notched cuboid, and I realized, "Get used to it. This is going to be the answer." ...So it's over! There's no doubt about it anymore."

so anyway. my plan: ibuprofen. if that doesn't work: prednisone. also: crutches.

here is the way ibuprofen (located at "inhibition by nsaid") works:

this explains why it's so hard on your tummy (cox-1 inhibition along with cox-2), and why the holy grail of arthitis medicine is the selective cox-2 inhibitor.

where, you might ask, do the cox-1 and cox-2 come from, anyway? they come from the metabolism of one of my favorite molecules

arachidonic acid, which even though its name actually comes from the latin word for "peanut," always reminds me of one of my favorite martyrs

arachne.

in response to something or other, part of a cell's membrane is taken apart a little bit, the phospholipid is chewed up a little, yielding arachidonic acid and glycerol. happens all the time. supposed to happen! what do corticosteroids do to this process? take the teeth out of the chewing up. hence i may resort to both prednisone and ibuprofen for my cuboid pain, because i do not have time to sit around with my foot on a pillow.

it ain't the gout!

i could not make this up, or, adventures in counter-transference

2007-08-18T12:16:00.000-05:00

... now sealed with cute kittens for your protection.

acute office visit
44 yo male, married with 2 kids, high school graduate, full time long term employee in auto plant, former smoker, nondrinker. handsome, articulate, thin, well-groomed, wearing somewhat dusty work uniform. appointment time 4:15 pm.

problem #1. diabetes concern.
pt concerned he might have diabetes. his father was thought to have died from complications of diabetes. blood sugar check here, performed by nurse at pt's request, is normal, 97 mg/dL. he believes it is high, however, because when he has had it checked in the past, he states, it is always 87.

he asks me to review the nutritional content of a bag of cheese puffs and a bag of miniature sandwich cookies he has brought in, to tell him how to limit his carbohydrate intake to keep his blood sugar at 87.

no symptoms of diabetes (polyuria, polydipsia, polyphagia, poor wound healing, frequent infections, etc.).

problem #2. review cholesterol studies.
lipid panel of ten months ago. pt irritated nobody went over results with him. reminded that he and i had an extensive phone conversation about the meaning of his normal results. he now remebers the phone call but is skeptical that the results were correct & would like the panel repeated.

no family history of high cholesterol or heart attacks.

problem #3. concern re liver disease.
brings a letter written by another doctor dated eight months ago. letter explains that the very slight elevation in liver enzymes seen at that time is not a cause for concern and may indicate a mild degree of fatty liver, but that he need not change his diet or become a strict "tea totaler."

pt concerned that he may be developing liver cancer, citing a television show which he had also mentioned at our last visit ten months ago. he is also concerned that the other doctor is suggesting that drinking green tea, which he frequently does, might give him liver cancer. (explained that the other doctor simply misspelled 'tee-totaller' the old-fashioned term meaning 'capital-T totally' abstinent from alcohol.)

no history of hepatitis C per repeated hepatitis serologies performed over the past 4 years by another doctor.

problem #4. back pain.
two weeks ago while lifting sheet metal at work, pt developed acute bilateral lower back pain, now resolved. he is concerned this may indicate kidney disease, and asks what are the symptoms of kidney disease.

he denies change in urine volume, frequency, or color, states no dysuria (painful or difficult urination) or fever, and has never had an abnormal urine test.

problem #5. coating on tongue.
complains of longstanding problems with this, despite admonitions from his wife, mother, and friends at work that it does not appear abnormal. while explaining this, he repeatedly scrapes tongue with fingernail to show me coating (no coating present). he read in a magazine that a coated tongue could be thrush, indicating the onset of AIDS.

denies risk factors for HIV exposure, no history of imprisonment, iv drug use, homemade tattoos, sex with other men, or close exposure to someone with AIDS.

also complains of dry mouth for the past ten years. he would like me to research possible non-HIV causes of coating on tongue and dry mouth.

problem #6. anal irritation.
complains that when he scrubs vigorously with toilet paper he sometimes sees small spot of blood on the paper, and when he uses a mirror to inspect the area, it looks very red and raw. the area is often itchy afterward for some time.

he would like me to examine the area as his other doctors have done, as well as to quantify his risk of colorectal cancer.

he reminds me that i refused to screen him for prostate cancer with a digital rectal exam during his last visit ten months ago and states he is still concerned about developing prostate cancer and would like to know what the symptoms would be.

no family history of colorectal or prostate cancer. he denies any blood or clots in toilet water or on stool, and no urinary problems as stated above.

problem #7. leg size discrepancy.
pt notes his right calf is still larger than his left calf. "seems like a bad sign."

on exam, right calf is 38.5 cm around & left is 37.5 cm around, no change from last visit.

problem #8. rib size discrepancy.
pt notes he still has a "knot" in the mid-sterno-costal junction, where the rib head meets the breastbone. he is concerned it might be a tumor.

he does have a subtle prominence there, nontender, fixed and bony, but within the bounds of normal variation.

problem #9. lipoma.
pt has a lipoma (bump caused by local proliferation of fat cells, benign) on his forearm. it has not changed in size for many years, is nontender and not inflamed. another doctor characterized it as a "tumor." pt is concerned it may become cancerous and wants it removed.

problem #10. nasal congestion.
pt states he has nasal congestion every morning when he wakes up, persisting for about 1/2 hour then clearing for the rest of the day. he can't recall when it started.

no fever, sneezing, drainage, sore throat, snoring, or allergies.

he states concern that "i could have cancer spreading down from my nose to my liver, and by the time i had the symptoms, it would be too late."

problem #11. anxiety.
when informed that he appears anxious, pt replies that he is concerned that he is the only one with so many health problems - none of his family and friends have the same symptoms.

he denies that thoughts about his health are intrusive or disturbing, instead stating, "if i just ignore it, then it'll be too late."

he denies engaging in any special behavior to keep feelings of nervousness or worries away. he denies concern about being very clean or about having things arranged just so.

he states he sleeps well and is not troubled by racing thoughts or thoughts of self harm. he denies any previous problem with depression or mood swings and has never taken any medicine for same.

he states his previous doctor told him he worries too much and needs to "just forget about it," and states tried to do so through the past winter with some success, but then he realized he still has the same physical symptoms, so comes to see me now.

of everything that is bothering him, he states, it is the coating on his tongue that bothers him the most, because he doesn't want to have AIDS.

physical exam - lipoma on arm. genital/anal area not examined due to time constraints. exam otherwise normal.

assessment -
1. lipoma.
2. anal trauma vs hemorrhoids.
3. concern re HIV status.
4. anxiety disorder.

plan -
1. referral to surgeon.
2. use toilet paper gently and return to clinic in 1 week for rectal exam.
3. hiv test today.
4. rack brains to think how to help this person with his anxiety, as he denies being anxious.

i hate to use the term "hypochondriac," because it has a pejorative cast, but he actually fulfills all the criteria for the diagnosis.

but how can i discuss this diagnosis with him? he doesn't trust me at all, occasionally becoming irritable & implying that i am not a very good doctor because i didn't screen him for all the sorts of cancer he fears. and who could blame him? he probably gets the same reaction all the time. he clearly sees other doctors for his concerns. the tone of the other doctor's letter was frustrated - or i was projecting that into it.

this patient was driving me nuts because he could not stop talking, could not stop pulling out cheetos wrappers and doctor's letters for me to read, could not stop rolling up his pants legs and lifting up his shirt and asking me to repeat his blood tests, recheck his blood pressure, and examine his butt, and meanwhile 2 other exam rooms were full of other, probably angry, patients to be seen, my nurse needed to go pick up her kids from daycare, the lab was closing, the secretaries already went home, and it was almost 5:30 pm.

...one issue we all confront all the time is how much we want to know.

in family medicine, our bag is prevention. we're probably the only doctors whose job it is to tell you to change your smoke alarm batteries. but more and more our job is to put the brakes on screening tests, especially as people see on tv that they could find out "everything" from a whole-body PET scan, or can get a 3-D color photo of their 5-month fetus, or that x-y-z may indicate they need this or that medication, "ask your doctor today!"

here's the problem/s.

every kind of test - HIV test, prostate-specific-antigen, triple screen in pregnancy for down syndrome, and so on - is going to have a certain rate of false positives - oops. and the more unlikely the disease is, the more likely any positive result - oops - will be false.

however, we developed the screening test in the first place because the disease is very bad. so there are two immediate effects of a positive test result: first, the patient freaks out: i have AIDS, i have cancer, my baby has down syndrome.

second, the doctor bums out: even though the chance of the patient being sick is much smaller than the chance of the test being wrong, you have to do more tests to show that the screening test gave a false positive. so the patient has to wait again, longer, for another result, at the least, or has to have a biopsy taken, or a long needle stuck into the uterus, or whatever.

now, nobody - doctors or patients - is going to begrudge all this flurry of anxious investigation, when the patient has a high risk of disease. but when the odds of having a disease are very low - for example, the odds of a young healthy man, from a healthy family, having prostate cancer - you just do not perform a screening test at all.

but the young healthy man needs to know that he is free of disease, and needs to know it over and over. so why not screen? we're supposed to prevent disease. it seems like we just don't care, or are stupid.

wise older doctors always say to squirts like me, "be careful what you test for - you might find something." or, when i say, "maybe we'd better check an MRI," they peer at me and say, "are you sure you want to do that?" the other axiom is, "if you thought about doing it, you'd better do it" - especially said of spinal taps. it's all about "index of suspicion." everyone is uneasy about doing spinal taps, and you wouldn't even think about doing one, unless you were even more uneasy about your patient's risk of bad disease.

the other part of "you might find something," is that you might find something else, something you weren't looking for, that will freak the patient out in an entirely new direction, and that you will have to also follow up. if it's a previously-unobserved lung mass, then okay - but it's more likely to be a very slightly elevated blood calcium level, or a small number of red blood cells in the urine, in a patient with no symptoms. and then you have to do something, and keep doing somethings - x-rays, medications, dietary changes, surgeries - until a healthy person is turned into a medical showcase of curiosities. it sounds like an exaggeration, even to me, but it happens, mainly because we are obliged to follow "best practices" and "clinical guidelines" and never ever to say, "you worry too much; forget about it." we want to be responsible. we want to take care.

an emergency room doctor told me that once she hit fifty, she found she was in the age group where her family and friends all started asking her what they could do to keep healthy. her number one answer was, "stay away from doctors." and she was a doctor! and she takes her own advice!

i struggle so hard to keep from developing an attitude about my hypochondriac patient. he has an anxiety disorder, and a sore bottom, and a lipoma on his arm. i arranged for all future appointments with him to take one hour. maybe he'll only come in every ten months. maybe i can get him to take an antianxiety drug, in a spirit of experimentation. but i doubt it. if i went to doctor, with cancer - a young strong woman, with children to raise, struck down in the prime of my life! with maybe only a year or two left to live! - and was given prozac instead of a diagnosis, i'd be pissed.

Specify With Poor Insight if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable.

...better do a little research.

Basic management principles:
The most powerful therapeutic tool is the physician's attention, concern, interest, and careful listening, which can potentially break a pathological cycle of interactions between the patient and physician, and movement from physician to physician.

Optimize the patient's ability to cope with the symptoms, rather than trying to eliminate the symptoms.

One difficulty with which physicians struggle is related to countertransference (ie, physicians' own emotional reactions to the patient). Typically, physicians feel angry, hopeless, and/or helpless because their assessments and interventions are not effective or are ignored. These feelings may lead physicians to reject or withdraw from patients with hypochondriasis.

Frequent regularly scheduled visits, attentive but focal physical examinations, and benign remedies (eg, bandages, lotions, vitamins, heating pads, massage, slings, and vitamins) help to provide tangible evidence of the physician's interest and acknowledge the patient's concerns.

If the patient needs access to the sick role, access should not be contingent upon symptoms or demonstration of preoccupation with illness.

Establish one primary care physician as the patient's main physician. Acknowledge the patient's pain and suffering. Explain to the patient that he or she is not crazy. Understand the symptoms as a form of emotional communication. Review the patient's medical history to build an alliance and to rule out medical disorders. Reassure the patient that evaluation will be ongoing. Look for signs rather than symptoms of illness. Use good judgment when deciding whether to perform elaborate diagnostic evaluations. Set up regularly scheduled visits at least every 4 weeks. Allow for time-limited, structured discussions about somatic concerns. Treat comorbid psychiatric disorders concurrently. Be aware of emotional reactions toward the patient. Focus on care of the patient, not on a cure for the disorder.

well all right then! rock and roll.

what a day!

2007-08-15T19:41:00.000-05:00

i started off, after a healthful muesli breakfast,

in the operating room holding clamps for a "lap choley," also known as "band-aid surgery to remove a rogue gall bladder". while the surgeon was affably remarking that hardly anybody pierces and strings their gallstones for necklaces anymore, i got paged 4 times. it was my pregnant lady now checking into labor and delivery, 2 stories up from where i was standing. the surgeon said the lap choley would just take another 1/2 hour, right before accidentally nicking the gall bladder itself

after which he said i might as well get going to l&d, since now the surgery was going to be a very long one indeed, as we watched bile and little green pebbles run in a pretty rivulet down into the hidden valley ranch of the pink and pretty guts.

my lady labored sweetly all day long, getting like nowhere, man - after 7 hours, still just 6 centimeters (out of a possible 10) - but i was not frustrated or misled, because i knew this was her eleventh pregnancy and the possibilities were endless.

her waters had already broken that morning by themselves

but now after taking a stroll around the hallways she had a newly "bbow" - bulging bag o' waters - so i thought i'd help her along by breaking it - and then she went

i threw a gown and gloves on and shoved a clean sheet under her bum and she crowned and the baby slipped out head, shoulders, and all, before i could say "jack robin." that was four minutes, i want you to know, people, from when i pulled out my crochet hook til i had a wiggly little gal in my hands.

the baby was great. mom had a little buttonhole cut inside and i gave her one stitch. one! and that was that.

i must say i have been very fond of this mom all along. she has gold teeth. she's regal.

the baby cracked me up by making pouty sulky-temper lip as i was wrapping her up in a blanket to give her to her mother. sulking, and still wet behind the ears! mom said "she's a cry baby! i can't wait to show. her. off."

on my way out i rode down in the elevator with an english lady who is here visiting to learn advanced laparascopic surgery for endometriosis, so she can go back to england and teach others how to do it. she says too often only harf-arsed surgeries are performed, and ever after that one is told "it's all in your head," when of course, she pointed out, "it's all in your pelvis!"

then by the craziest dumb luck, just inside the front door was installed, sometime today while i was working, a brand new life-sized white marble

...well, okay, it wasn't that one, it was a big, lovely, softly gleaming white marble virgin mary, the ultimate teen mom, hugging her happy marble baby. i looked for an online picture to post, but there wasn't one, so see the above for her secret superhero identity.

i tickled her foot. then in the parking garage i rode down in the elevator with a cheerful hippie guy in a tie-dyed t-shirt, cutoffs, and sandals, who said he'd just stopped by to make a visit of Comfort and Encouragement to someone in the burn unit. he showed me his extensive scars on both legs, caused by an accident with gasoline in 1979. he said they only hurt when he jumps into cold water. he was pleased to see that his burn surgeons have memorial plaques upon the wall now. he stepped out of elevator on his two good legs, and chirped, "have a nice day!"

i had a nice day.

story missing.

2007-07-23T16:17:00.000-05:00

i can't tell you about my new patient
because if someone back home finds out about her
she might be in danger. google news archive op cit...

Fifteen-year-old girl died after taking ecstasy 'to ease emotional pain'.
Fifteen-year-old girl charged in felonious assault; Police suspect underage girl was served alcohol.
Fifteen-year-old girl leads police on high-speed chase.
Fifteen-Year-Old Girl Takes Poison.
Fifteen year-old girl reported missing.
Fifteen year-old girl reported missing again.
ATTACKED BY OHIO RUFFIANS; Fifteen-Year-Old Girl Dangerously Injured.

15 year old girl arrested in pro-independence protests in Lhasa.
The fifteen-year-old girl who jumped from
the burning steamer with the two-year-old
child of the Hoboken family by whom she was
employed, is now said to be safe at North Brother Island.
A fifteen-year-old girl who suffered a serious head injury on in-line skates last week has died in hospital.
Anaplastic carcinoma of the nasopharynx in a fifteen year old girl.
Incomplete paraplegia of fifteen year old girl following scoliosis surgery.
Anorexia Nervosa affects 1 fifteen-year-old girl in every 150.
Fifteen year old girl sterilized after her third delivery by Caesarean section.
Fifteen year old girl searches for identity but becomes a drug addict.
JEALOUS LOVER SHOOTS FIFTEEN-YEAR-OLD GIRL.

Fifteen-year-old girl gang-raped at gunpoint.
I chose her as "my saint" because
she was a fifteen year old girl in
Antioch who threw herself from a roof
in order to preserve her sexual purity.
Authorities in Vietnam arrested former British glam rocker Gary Glitter, 61, following allegations concerning his relationship with a fifteen-year-old girl.
Republican benefactor of conservative Christian groups charged with rape for allegedly paying a fifteen-year-old girl for sex.
Fifteen-year-old girl takes school to court for refusing to allow her to wear a chastity ring.
GIRL FAGIN A PERJURER; Admits Her Story Implicating Two Men Was Made Up.

Five teenage boys have been released on bail in connection with the rape of a fifteen year old girl in Guildford.
A fifteen-year-old girl was hacked
with a sickle by her brother last night,
when she refused to take the prasad of a
puja performed by her family to "ward off
the evil spirit possessing her".
A fifteen-year-old girl from Domremy claimed that she received visions from St. Catherine and other dead saints.
A fifteen year old girl from the inner city illegally took a car and drove it across the median on I-275 hitting a car, injuring a man and killing his pregnant wife.
Fifteen-year-old Girl Is Charged with Repeated Thefts. Stole from Stores and Families Under Direction of Older Woman.
BABY STARVED TO DEATH; Left For a Week With a Fifteen-Year-Old Girl.

Appellant threatened a fifteen-year-old girl with a BB gun, telling her that he was going to shoot her with it if she did not let him "fuck" her.
She was very slender for a fifteen year-old girl, and couldn’t have weighed a hundred pounds. I later discovered that I could hold her wrist in my hand, and touch my middle finder to my thumb! She was hardly more than skin and bones!
A fifteen year old girl with dyed-green hair was found beaten today outside of Lansing.
The body of another fifteen-year-old girl was found August 1.

AMBITIOUS fifteen year old GIRL, to do any odd jobs. Preferably in Ramsay. Baby-sitting, lawn mowing, car washing, etc.
At the urging of his cousin,
the defendant hired a homeless
fifteen year old girl in need of
money to appear in the defendant's
amateur pornographic video.
According to the medical examiner, Candice, a slight fifteen year old girl, had enough amphetamine and methamphetamine in her system to kill four 150 pound men.
A 29 year old Newark, New Jersey man, accused of fatally stabbing a fifteen year old girl at a bus stop, remains at large today.
Why would a fifteen year old girl kill her own baby?
HAS DAUGHTER ARRESTED; Fifteen-Year-Old Girl Went Away with Farmhand to Wed.

Police are looking for the people who supplied a mortar-like device that blew the hand off a fifteen-year old girl.
A fifteen-year-old girl with a
severe peanut allergy did not die
from kissing her boyfriend following
his snack of peanut butter, a local
coroner said yesterday.
Fifteen-Year-Old Girl and Two Male Companions Arrested. She Was Hopelessly Intoxicated.
Way to Go, Dead Fifteen Year Old Girl!

more drug addiction resources

2007-07-14T11:20:00.000-05:00

best amazon recommendation list ever: Two Thousand Years A.D.: When Drug Lords Ruled the Earth, with everything from the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition by the American Psychiatric Association, to The Worst of Jefferson Airplane by Jefferson Airplane.

dope is all over
dope is awesome
dope is better now than in the 60's
dope is for kicks and for thrills
dope is good i haven't smoked it since the anxiety and depression kicked in
dope is all that

dope is so 2002
dope is the first in the grouping and covers all sorts of inane topics
dope is used on the previously flanged body before the seaming operation in a simple way
dope is all that we're fed

dope is modular in design
dope is all over laugh lines
dope is launching an aggressive media campaign
dope is all that we're fed so fuck all your protests

dope is the dedicated object processing environment
dope is critical for the overall quality of the film
dope is 'to get beyond the misery'
dope is also why the hindenberg went up so fast

dope is tegenwoordig populair en hoe kom je eraan?
dope is all that we're fed so fuck all your protests and put them to bed god is in the tv

updateski

2007-07-14T09:07:00.000-05:00

apparently... the cops went to my patient's house, shrugged, and left.

she left an angry message for me at my clinic, but isn't answering the phone when i call her back.

ah, well. she lives a block away from me, so i guess i could smell it if she burned her house down.

in medical school i spent some interesting times working with the pain doctors. they were good pain doctors. they knew a ton, were active researchers, creative thinkers, and singlemindedly determined to treat pain - even the pain of annoying patients (many people in pain are annoying). i emphasize this because lately i have run across some other kinds of pain doctors who seem primarily interested in keeping my patients out of their clinics.

anyway, one weekend one of the good pain doctors sent me home with the big book of addiction medicine. i had made the mistake of asking how often his patients become addicted to their medication - disingenuously - really hoping to get a rise out of him - i like soapboxes and hope everybody always has one handy - so he dropped the 8.2-lb book in my arms and said, "i want you to go through this book and find the relative addictive properties of the different opiates we use for chronic pain," or some such mumbo jumbo.

you already know the punchline: drugs aren't addictive, people are. (you also know the difference between tolerance and addiction.) but it was nice to have it confirmed by the big book of addiction medicine.

i'm just saying.

cf. top 10 reasons for prison not treatment