Wednesday, December 14, 2011

Who will take care of you?

I have written much and published little on this blog.  The fear of a Health Information Protection and Privacy Act violation looms large for me.  I have an interesting job that gives me a unique prospective not only on my chosen profession but on life and what it means to be an American.  I would love to be a syndicated columnist or consultant for a television news program but I have not written enough to be there - yet.  I know that as I have settled into this job of hospitalist, I have become more complacent and at times have been heard to say, "This is not something I have the power to fix." 

One of the problems I can't seem to crack, even in my small corner of the urban health care system, is access to care.  I realize the country is divided on who's responsibility it is to pay of health care.  I realize many do not share my conviction that we are all paying for the lack of health care for particularly children and the poor.  I realize those of us who do have health care receive it in a profit driven system that has made the least compassionate among us physicians multimillionaire.  BUT many of the common maladies of American kind could be treated and even eliminated with a modicum of care.

Take for example hypertension.  Yes, high blood pressure is silent for years before it causes the big problems such as stroke, renal insufficiency, and heart failure.  Again, in this country we pay for dialysis for anyone who has chronic renal failure.  We do not pay of blood pressure medication for those whose blood pressure is elevated.  Even in those who have good health insurance, little is done to help them understand the disease and factors they can control, dietary salt and weigh, along with the fact that medication is a life long necessity.

Our education system for doctors is doing little to help.  Most graduates do not want to pursue a primary care path.  Being a cardiologist, who goes to the cardiac cath or EP lab, thus getting the big bucks for treating heart disease, is the much preferred path to one of a family medicine doctor, who could influence the patient to prevent the heart disease in the first place.  Of course the business people are trying to change this by finding ways to get more money for primary care doctors or have "physician extenders" such as nurse practitioners or physician assistants provide entry level care. 

The bottom line will come in selling this to the patient.  If you are not paying much or nothing, such as those who get health care through an employer or the government, then you will probably accept it an complain.  Interestingly enough, I believe those people will get the best health care.  The rest are being sold a bill of goods.  You don't believe me?  Look up "hydrochlorthiazide."  This is an ancient blood pressure medication that made a comeback when it was found to be more effective, with fewer side effects, than newer, more expensive drugs.

A nurse practitioner, with your best interest at heart, will do more for your health than the best trained cardiologist.  Oh, and to my physician friends out there, when you are having trouble finding work, remember, we did this to ourselves.

Thursday, January 6, 2011

Doing the math

Today I did the math. Since I work 24 hour shifts, it often seems like I have more time off. But 10-24 hour periods is 240 hours a month. If there are thirty days in a month then I have worked a total of 8 hours for every 24. Having figured this out I now wish I had left well enough alone.

Frequently I get a nap, so it is not as bad as it sounds. Usually a couple of hours in the mid afternoon. I have learned to take them. Nights can be long and trying. I operated on three patients last night. All had been sent out of smaller emergency rooms. The first was told she had "gastroenteritis." Her ovary of the size of a small cantaloupe, necrotic or dead from twisting on it's blood supply. The amazing thing to me was that touching this woman's abdomen, since she only weighed about 100 pounds, almost anyone could feel the rock hard tender mass.

The second patient had been bleeding for two months. Her pregnancy test was positive and she was told she was "miscarrying." The pregnancy hormone levels in her blood were the second highest I have ever seen and she had a molar pregnancy. No baby was ever present in this condition that contains on hydroptic or fluid filled placenta tissue. It can metastasize to the lungs and the brain.

The third woman had a ruptured ectopic pregnancy. She was also told she was miscarrying a week ago when she went to another emergency room with bleeding. This time she had a lot of pain and a good deal of blood in her pelvis.

All of these patient are fine and I will be also. This does not include the woman who arrived with twins, both breech, dilated to five centimeters. A hospital down the road sent her home. She was glad she made it to ours for her emergency Cesarean section. Several other patients just came in and delivered. Most of them want to do that. I think we are nicer about it than other places.

I have to agree. We are nice to all of these people and to each other. It is the only way to survive while we take care of all these patients who by virtue of their diseases end up for a stay in the big house with us.

Tuesday, January 4, 2011

Ignorance . . . not always bliss

Just when I begin to believe I have seen everything, something new appears. This is one of the things I have always enjoyed about the practice of medicine, it is rarely boring. However, one of the things I hate is the unknown. Uncharted territory is rather routine when dealing with patients who don't know their medical history. For those of you who worry about electronic medical records and an invasion of your privacy, let me assure you, odds are some day you will be unable to speak for yourself. At that moment, you will want someone to know all the medical history you now believe you would like to hide.

Take for instance the case of Jane. She is a teenager who was found on the street immediately following what must have been a grand mal seizure. A grand mal seizure is where the patient looses consciousness, arms and legs fail, often bowel and bladder control is lost. If Jane had been at home, or even in her hometown, someone may have been found who could give a medical history. This was not the case, since Jane had run away from home.

Living on the streets of a major metropolitan area, Jane was going to a local clinic for prenatal care. No one around her seemed to know which clinic she had been attending. No one even knew if this was her first pregnancy, let alone any prenatal problems, history of illnesses, family history of diseases, or blood type. The father of the baby was not involved in the pregnancy.

I met Jane in the middle of her third seizure as the emergency medical technicians (EMTs) were transporting her into the labor and delivery area. According to the EMT who had ridden with her in the ambulance, she was incoherent the entire time, probably because she had a seizure just before they arrived. She had another seizure in route and despite medication a third seizure had just begun.

I did not know of any drug allergies, so I pick the drug most often used for seizures in pregnant women, Magnesium sulfate, ordering first a hefty loading dose to stop this seizure, and then a continuous drip to prevent other ones. Disheveled, with tangled black hair hanging in her face, and her clothes wet from sweat and urine, Jane became quiet within a few minutes of starting the drug.

She was receiving oxygen through pronged tubing in her nose and her breathing was regular. My next task was to assess the baby. Fetal heart tones were easily heard in the right lower quadrant of her abdomen. They were normal in the range of 150 beats per minute with moderate beat to beat variability. An acceleration in the baby's heart rate with not decelerations visible in the three minutes I had watched the monitor strip reassured me and my breathing became a bit more regular also.

I listened to Jane's lungs, which sounded clear. Feeling even better I decided not only were she and baby stable but she probably had not aspirated, drawing stomach contents down into her airway and lungs. This is one of the greatest dangers to the mother since pregnancy slows the emptying time of the stomach and there is almost always undigested material there. I again looked at the monitor. Baby's heart rate was steady. Another answered prayer.

I was able to hold Jane's forearm, which was warm and dry, while the nurse drew several vials of blood. I realized I was ordering tests for pregnancy induced eclampsia, along with those to determine if there might be an abruption (bleeding behind the placenta), blood type, and testing for syphilis, hepatitis, and HIV. Another nurse was placing a catheter in Jane's bladder to get urine for a drug screen. The blood pressure cuff on her arm revealed two blood pressures in the five minutes all of this was done. Both were mildly elevated. A quick urine dipstick showed 4+ protein. Regardless of what the rest of the tests would reveal this was almost surely eclampsia or a seizure due to pregnancy.

With a better working diagnosis for the cause of this young woman's seizures and a stable baby, I began to relax. Now I could focus on completing the physical exam, a sonogram to further evaluate the baby, and getting the laboratory studies back. A bonus, with seizures controlled, Jane was beginning to wake up. She still could not answer any of my questions about the pregnancy, her past medical history, or that of her family, but she did know her name, the year, and what city she was in. A runaway, after the events of the morning, she was more than willing to give me her mother's phone number.

Monday, January 3, 2011

Your mother works here?

Walking down the hall separating labor and delivery from the physician call rooms this morning, I turned off the light in each room where the door was open. At 6:30 AM or 0630, everyone is upstairs making rounds. Having just arrived for my shift beginning at 0700, I am changing clothes in preparation for morning check out of the labor board. After turning off all call room lights, I pull open the door to our common room. No one is here but the television is on, 7 Styrofoam cups are filled to varying degrees with now cold coffee, and two or maybe three days of old newspapers are scattered around the room.

I quickly "clean house" before sitting down to the computer to print out the lists of patients on which I will make rounds this morning. I have yet to understand why people who would never think of making this kind of mess where they live feel so comfortable leaving it behind where they work. To weak to turn of the light when leaving a room or to throw out a coffee cup or newspaper when done, the clutter left behind by my colleagues is not what I in my line of vision for any of the next twenty four hours.

In this hospital housekeeping is the rate limiting step. The lowest paid are the employees on whom labor room and operating room turner over depend. No wonder they will clean the operating rooms and labor rooms first and do "the back" only if there is time. There are two housekeeping staff here from 0700 to 1500, one from 1500 to 2300 and one from 2300 to 0700 the next day. That is if we are talking weekdays. On weekends, only one person per shift is allowed. At critical times, the scrub techs and even the nurses will clean in the operating rooms and labor rooms.

I have a great amount of respect for the women who clean here. It is back breaking work that the rest of us depend on yet they are paid a fraction of we make. Since I often clean in the back, and also because I have taught many of the residents not to leave instruments and equipment laying around in the delivery rooms, I have developed a good rapport with housekeeping. I also posted a sign: "We are pretty sure your mother does not work here. Please clean up before you leave." I bet even housekeeping is appalled at how messy doctors can be.

Sunday, January 2, 2011


Today is a non-work day for me. I am not on call and I do not have to make rounds. What I do have to make is good use of this time. When I return to work tomorrow at 7 am (07:00) I will either be on-call or rounding for the next 9 days. Then I will have only one 24 hour period totally off before another set of "every others."

Every other day on call is a bit misleading, as it is rare to get out of the hospital after just 24 hours of call. There will still be rounds, seeing all the patients who are admitted to me and one or at times two of the other hospitalist, paperwork, and occasionally a meeting before I can leave for home. Greeting me at home are all the things not done in the last 24 hours. Yes, I sleep, but not enough for two days. In preparation for this stretch of work I will do laundry, buy food, clean house, and rest.

Saturday, January 1, 2011

The "big house"

In medical school, when I decided to pursue a career in obstetrics and gynecology, I was amazed all the practicing obstetricians were under the age of forty. At that time I did not appreciate the grueling nature of the profession. Women, calling their physicians at all hours of the day and night, usually with complaints better reserved for their mothers. More about this later.

Anyway, in interviewing for residency training programs, I met an obstetrician who was the son of an obstetrician, who loved delivering babies so much he was determined never to give it up. He could be found at 3 o'clock in the morning, long after his patient was delivered, quizzing the residents about the other patients on the labor board, asking why nothing was being done to get those babies delivered. The answer to this question was usually that their obstetrician was asleep and had instructed the residents to do nothing with would interrupt that sleep. Even the most naive of us know medicine is a twenty-four hour a day proposition and especially when obstetrics is involved.

Lucky enough to be chosen by this particular residency program, I was also privileged enough to practice with this obstetrician for many years. I learned a great deal about obstetrics and about life from this brilliant, compassionate human being. When my kids ask me who the best doctor or smartest person I have ever known is, this man always comes to mind.

He grew up around doctors and hospitals. He father was a physician, chairman of the Ob-gyn department at two hospitals, chief of the medical staff at one, and dean of a medical school for a time. My mentor was also a philosopher with an undergraduate degree in the subject. I am sure most of his life was surrounded by the practice of medicine. He called the hospital, "the big house." I believe to him, and many of his generation, who actually lived in the hospital for the year of their internship (first year of training after medical school), the hospital was a kind of home.

I find it kind of a home too. This is especially true now that much of my time is spent there rather than in a clinic or office setting. About ninety percent of the patients I see each week are in the emergency room, labor and delivery, or as hospital in-patients. On a busy day or even a sort of busy day, I feel much like Jonah must have felt when he was thrown overboard while sailing to Tarshish and was swallowed by a big fish. In my case, I feel swallowed by the hospital or the big house. Frequently I wonder if I will ever see the light of day again.

In the past two years, unlike Jonah, I have learned to take events as they come, deal with the problem at hand, and be thankful for victories when they are achieved. I am always in search of ways to do it better but I have also realized that there are many more people involved in each scenario than just me. If we all work together much can be accomplished. All I am responsible for is my part. The patient, the residents, the nurses, hospital administration and yes, probably even God (who I believe is probably a hospital administrator), are involved in the outcome.

All this said, I have chosen to keep blogging but under a different title. I am, after all, no longer a local MD. It has changed me and mostly for the better. I will be telling the stories I have experience in this "belly of the big house." The names are changed, the situations are disguised but yes, all this stuff really happened.