Medicine From The Trenches

Experiences from medical school, residency and beyond.

Hospital Haiku

“hospital moonlight

cacophony of machines

teardrops cascading”

As we come to the end of National Physician’s Week and today, National Physician’s Day, I related this haiku from one of my most gifted and amazing friends. Some years back, he suffered a  critical and life-threatening illness that resulted in profound changes in his life with some time in the intensive care unit. This illness changed a man who is talented beyond belief, a brilliant creative genius and professor in ways that few of us can relate or even imagine. Still today, he’s affected by his illness and the events that surrounded it.

I share this haiku because it brings to mind, something that we as physicians must always remember about our patients. They place their health, their trust and many of the most intimate aspects of their lives in our hands. With our hands, we have to care for them; relate to them, in many ways hold them, and be mindful of the honor and privilege of having them place their lives in our care.

As such, we also have to be mindful that illness changes their reality and in many cases their lives profoundly especially when they are critically ill. We have to reach out and extend more comfort over the “cacophony of machines” that becomes the background of their intensive care and sometimes hospital care experience. We have to block that “cacophony” whenever and wherever we can.

I remember watching a tear roll down the side of the face of one of my ICU patients who appeared comatose. The nurses were bathing him and chatting with each other as they turned him. I saw the tear; asked them to speak with him over the ICU noise background. I asked them to play music in his room and I always held his hand when I entered the room to examine him. I am sure that my soul could feel his soul even though he didn’t ever speak to me. I never saw that tear again, after we began speaking and focusing on him, holding his hand, touching his face, and playing his favorite music even though he did not recover from his illness.

I seek to connect with my patients without exception as that is my honor as a physician/surgeon. I spent years learning the science and techniques of medicine and surgery but in these, the later years of my clinical practice, my focus is on the art of medical practice. Within that art is my chance to give some of my heart to those who have placed their trust in me (and my training). I strive to be more human and more comforting. To do less of the science and more of the art is great joy for me. My joy is in the connections; kind of strange for a surgeon.

On this National Doctor’s Day, I am honored to be a physician and grateful for all that this profession has given me. This profession has given me far more than I can give back but I will spend as much time as possible giving as much as I can to those who are in my care.

30 March, 2017 Posted by | medical school, medicine, practice of medicine | , , | 2 Comments

The Rosary

I stood there at her bedside seeing the white rosary clasped in her small thin hands. In my church, we don’t have objects such as a rosary as symbols of our faith. Perhaps the Book of Common Prayer comes closest to a rosary as it’s ever present. In the cathedral where I serve, we seldom use the actual books as our services are printed each week for worship along with our hymns. Everything one would need for service is in one’s hand along with instructions as to standing and sitting ease for the many visitors each week. Still, having a rosary in my hand would be wonderful.

As I stood next to her bed, I watched her breathing slow down and become shallow; tangible evidence that her body was dying. On my late evening run, my thoughts were of where one “goes” at death. Perhaps one stays around those loved in life or perhaps one goes. My childhood visions of death, rising souls that are ghostlike but where does that essence of humanness go? As I settled into a chair, I touched her cool hand and touched the white rosary. I always sit with patients who have no family as they become my family. It is my honor as a physician to do so.

She wasn’t even my patient though I did serve in a consulting role in her care. I looked in on her only to be told by the nurse that “they” decided to do nothing. Well, I never decide to “do nothing” because there is always “something” to be done in patient care. I guess, I needed to care for this patient thus there I sat in a familiar role, caring for one who is dying and would die.

When I saw the rosary, I questioned how many times she had said the rosary. I wondered if the rosary brought comfort to this elegant woman. I wondered what the moment of my death would be like? Where would I go? Would I even go? Would I stay? My heart in tears but not sad. My tears are for the people who loved this woman; not here with her in her last hours and minutes of life as we know it. Still, her long fingers, draped by the rosary and her beautiful white hair brushed neatly from her thin face; still the rosary. I made sure that it stayed with her, in her hands as the nurses prepared her body for the morgue.

14 February, 2017 Posted by | life in medicine, practice of medicine | | Leave a comment

Crisis Averted

I try to meet my challenges in academics, my religious studies, medical practice and physical conditioning as they come. Recently, my academic work, specifically my teaching style, came under sharp criticism (very negative) and increased scrutiny. Now, I don’t mind criticism and will listen with an ear for what might be worthwhile but none of what I faced was even worthwhile; directed as a personal attack upon me. This scrutiny forced me to question everything and forced me into a position of vulnerability that I couldn’t help. I was in a tailspin; looking for anything of validation.

Couple my largely “mental tailspin” with my loss of my friendship of one of my most valued friends. I had retreated back to a point of reliving the death of Gene and my almost catatonic reaction post. I was feeling most of the same types of issues that I faced when I thought my world had come to an end. These were feelings that I couldn’t control but now I have learned that I can feel them and use them to force me to meet challenges with renewed strength.

My spiritual challenges are there but with my renewed strength, I allow myself to serve and feel without apology. I make mistakes in performing my duties at the cathedral during Sunday mass but I learn from my mistakes and from my very generous mentors. I know that they question me but by questioning me, I am forced to question myself too.

My friend who has been quite generous in advising me in my academic work is back in my life which gives me renewed hope that I can learn more from him. I should have listened to him in the first place but my extreme fears would not allow me to benefit from his wisdom. I am blessed and grateful that he spends even two minutes with me and I appreciate all the wise counsel that he has shared with me.

I have watched him interact with his students, his infinite patience and critiques. His student population is more vulnerable and more difficult to teach but he is kind and had great insight into where each student lies in their learning. I learned patience and kindness from him. One day, I watched him answer questions as he walked with his students into the parking lot; surrounded by those who truly appreciated what he had to say. Whenever I see him, I know that I am in the presence of someone who is far greater than myself.

I headed off to interview for another academic job challenging in that I had to deliver a grand rounds presentation and interact with some of the greatest surgeons in this country. I more than passed that test; surprising myself with how wonderful it was to assist on cases that I haven’t performed in years. Sometimes a skills check with master surgeons is good for the soul too. It also helped that a couple of my former professors from residency affirmed that they were proud of how I have made my way in practice.

My physical conditioning continues to be a source of challenges and growth. My trainer balances weight training with running so that I will conquer the marathon distance and I will continue to enjoy vigorous good health. I am getting faster and stronger; finally seeing some of the definition that I sought but with a smaller muscle mass. I am enjoying my increased running mileage while meditating; keeping my head together. I observe the world as it moves past me.

My spiritual growth comes in the form of reaching inside myself for affirmation these days. I am alone with my thoughts and examine each one carefully. I am happy with my solitude, enjoying exploration of my creative side (not very creative at all) and some of the artistic resources in my city. The creative resources of our local artists, musicians and actors have brought a kind of renewal of spirit for me. I seek to interact with humanity and I am acquiring the tools to do so. In that acquisition of tools of spirit, I know that I am not alone and that I am quite happy with the spiritual state of my life.

I don’t focus on material objects much as they have always had little meaning for me. My connections with my patients, my students and my colleagues have been most important. I read the writings and poetry of my like-minded physician colleagues always surprised by the insight and the richness that they bring to my world. One in particular, posts a daily affirmation that moves my meditations quite often. I am truly blessed to know this extraordinary individual who gives so much to the world.

I know that happiness in life comes from the “good stuff” and I have the “good stuff” in abundance these days. My crisis of spirit is no longer a crisis but an acceptance that while I am not good enough for some people; not valued by most, I value and accept myself. I am made by my creator and I seek to be kind, generous and accepting of those around me; no longer a crisis.

30 July, 2016 Posted by | academics, life in medicine, practice of medicine | | 2 Comments

In Today’s Climate…

Over the past couple of weeks, I have listened to the speeches at both political conventions along with the news reports of law enforcement officer killings/GSW injuries and civilian killings/injuries. Watching and reading new media reports have to be taken within the context of one’s experiences. My experiences have been as the daughter of immigrants, a biracial woman, a physician and a theological student. My heart breaks for those who are suffering and those who suffer. My oath, the Hippocratic Oath, that I swore many times as a medical student and now physician compels me to alleviate suffering wherever I find it.

The suffering may be physical or mental as many seek out our help in getting and keep them healthy. We, by our training, have to find, by any means necessary, a method of navigating the health care systems under which we practice as well as the political/social climate that we encounter. Sometimes that navigation can be as simple as a touch, a connection and sometimes that navigation involves working with every resource at our disposal to give the best care that we can achieve. My hope, my prayers, my experiences and my training have giving me insight.

I want to recount an experience that happened to me as a fourth-year medical student. I was returning home, driving a small red Mazda hatchback automobile, from a shift at one of the large city hospitals of my medical school affiliations. It was late at night, I was exhausted, ran out to my car in scrubs throwing my short white consultation jacket with hospital identification card and my stethoscope on the front seat along with my purse and overnight bag. As I drove through the rain-soaked city streets of this depressed neighborhood, I saw the reflection of police lights in my rearview mirror. I immediately pulled over to the side (I wasn’t speeding because of the weather) and stopped as required by law.

The police car pulled in behind me with two young officers getting out of the car quickly with their weapons drawn. For a split second, it took me in my exhaustion fog, I couldn’t believe that the weapons were aimed at me. I sat very still, keeping both of my hands on the steering wheel as one of the officers shined a flashlight on me; the other pointing his gun through the open window on the passenger side. “Get out of the car and put your hands on the roof.” one of them shouted.

I slowly opened the door, tears beginning to form in my eyes and shaking quickly overtaking me. I complied with his request stating the my identification and automobile registration were in my purse on the passenger side. I said that I was a medical student on my way home but the officer kept yelling at me to spread my legs and “shut up”. I couldn’t stop shaking (I even shake now as I remember how frightened I was). “This car is reported stolen,” he kept shouting in my ear. He began to pat me down. “This is a huge mistake,” I said in a shaky voice. “Please check my identification and look at my hospital cards,”I said.

It seemed like hours but in a few minutes, another police car pulled up with another older officer getting out. “What are you doing?” he asked. “We have the car and suspect in custody”. I was crying from fear and exhaustion. The officers immediately put their weapons back into their holsters as the other policeman said that I was free to go. I was so petrified that I couldn’t put the car in gear for a couple of seconds. I finally drove off slowly weeping uncontrollably.

What would have happened if one of those guns had discharged by accident? I would be dead by mistake. What would have happened if the other police car had not arrived? I would have been arrested most likely. It was a mistake but the first two policemen didn’t show any indication that they would check my identification. It was my first experience of being stopped by the police and not given the benefit of just being treated as a fellow human being.

As I read and hear of stories of any persons being stopped by the police, I still feel that fear from so long ago. I haven’t been stopped since then and I interact with police on a daily basis as I perform my job in surgery. Those interactions are always professional and quite polite but when I see their service weapons, I always remember that stop. I react to police officers through the lens of my experiences as I suspect all people do.

I have infinite respect for police officers as they have very difficult jobs under very dangerous circumstances. I have spent many hours with two detectives in the gang-violence division of my local police precinct learning about gang symbols and gang culture, rampant in the city that I practice in. I want to understand and stem this violence, treat its victims as they frequently end up in the trauma bay. Largely the street gangs in my city are involved in turf wars and drugs. The motorcycle gangs run in the suburbs dealing in drugs and human trafficking, another scourge of city and suburban living.

So today, I end up on the roof of my hospital, being thankful for my life and all I encounter in my practice of medicine/surgery. I always pray for insight, guidance and the ability to give the best to every patient/family member/loved one that I can give. I meditate during my distance runs, post-call in the bright sunshine of the early afternoons, as we are living in a climate of increased polarization by community leaders and populations today. I pray that I continue to live in the “gray areas” and not become jaded or polarized to the violence. I pray to continue to seek insight and solutions to the troubles of those I serve and treat; always remembering that the practice of medicine is my greatest privilege.

Yes, I swore that Hippocratic Oath as a medical student, as a graduate physician and I keep remembering it. I didn’t know back as a medical student, what I was swearing to but I know now, how difficult this profession can be. There are times of despair, depression for me as the hours tick past 30 and hope in humanity as I move thorough my theological studies. As the years have gone by, I am more of a “believer” and more spiritual than when I began this journey. I learn each day and I am grateful for the learning. When I look back, I would not change a single experience, even those that have frightened me.

 

29 July, 2016 Posted by | medical school, medicine, practice of medicine | | 2 Comments

For Father’s Day

I want to share this post by a gifted physician, husband and father, Daniel C. Potts MD, who writes about his father. This post which can be found here: A Father’s Story is an honor to a father from a son who is a father. For me, this wonderful post reminded me of my father who was a physician and my first and best mentor. Please enjoy this post and honor your father on this upcoming Father’s Day.

17 June, 2016 Posted by | practice of medicine | | 2 Comments

One Week to Go to My First Marathon

What have I learned about myself? With every mile that I have run in my training runs, I have learned that I have a mental toughness that I found quite elusive a couple of weeks ago. Now, I have learned to face my mental “demons” with calm reserve, much the same as I approach a difficult case or patient.

I had found myself sinking, for lack of a better word, into a spiral of self-doubt and mental vulnerability. My mental shenanigans cost me a wonderful friend but I now move forward with every step and pick up the pace without fear. I can’t reason why I spiraled a bit over my academic work but I did and it’s done. From here on out, I deal from a position of strength rather than questioning myself and my motives.

This past week, I have had the pleasure of thinking long and hard about my medical and academic career. After many years of practice, I believe that self-examination is not an entirely bad exercise but I have also learned that I cannot ask anyone else to “walk in my shoes” or “understand” the things that can send me into self-doubt. My questions were not about my training or my ability but about how I handle adversity in matters that I didn’t fully understand.

Yes, I have plenty of regrets that I lost the friendship of a gifted colleague but I discovered new insight into myself and new support from unexpected colleagues and friends. I took the time today on my last long run, to think of each of my friends and thank them as I ran. I am very grateful for their friendship and I know that I will continue to move forward professionally and personally.

I thought about setting goals and achieving those goals. Certainly, there is no guarantee that I will finish my first (and only) marathon race next week but I feel calm and physically prepared. Mentally, I am in a state of surprise in that I have been able to train for this race and that I will have the toughness to make the needed adjustments to my pace and form that will allow me to complete the distance.

This training has make me something of a philosopher in terms of what I see and hear around me. I have taken great pleasure in simple things like a wonderful warm shower or that drink of water when I have pushed myself to the brink of dehydration. I have tended to avoid the “sports” drinks because I haven’t felt the need for sugar/salt loading. Plain water, not too hot or too cold, has been my best friend.

My training has increased my need for rest and sleep. For most of my career, I have had a love/hate relationship with the number of hours of sleep that I require. Most days, I cannot sleep more than 5 hours but with my increased running mileage, I have moved into the six to seven hour range. More sleep has allowed my body to rest and heal for the pounding that the increased mileage required.

With the end of the school year, I am looking forward to taking a week or so off and heading to California for some much-needed relaxation. I love being near the Pacific Ocean, smelling the salt in the air and just watching the fog cover the Golden Gate Bridge from the deck of where I stay in the Bay area. I have also completed my longest and best runs up and down the hills of San Francisco, a place of unrivaled beauty and wonder.

Finally, I know that I cannot be “all things to all people” and I just need to let things fall as they will. For a surgeon who is quite used to affecting something definitive in most cases, letting go is a new feeling for me. Most of the time, things just work themselves out and I am the instrument. This has been the best part of my marathon training; seeing how I am an instrument of my training and experience.

This training for a marathon has been something of a metaphor for life for me. I set this goal and I have made some progress toward it in some manner over the past year. Though I didn’t reach the distances that one typically associates with distance running, I am very grateful for every step as I have moved along. Yes, I know I am a very secure middle-distance runner but stretching the distance has been good experience for me. With the stretch has come great self-knowledge.

 

8 May, 2016 Posted by | medical school, medicine, practice of medicine, relaxation, stress reduction | , | Leave a comment

“It’s not a sprint, it’s a marathon.”

I am in the process of training for my first marathon. As a middle-distance runner at university, I always toyed with the idea of running 26.2 miles but after running a race of 10 miles about 20 years ago, I discovered that I didn’t enjoy running after the 8-mile mark. This put running the marathon distance on my “back-burner”, so to speak. There the marathon goal stayed until the idea surfaced about 4 months ago when I began running again for physical conditioning.

After graduate school, I attended medical school and found that I didn’t have much time for running as study was my constant companion.  If I had been wiser, I would have carved out time to keep up with my running, even 30 minutes three to five times per week, thus I would not have gained weight in medical school. My medical school weight followed me through surgery residency and fellowship. I kept promising that I would “get in shape” but never quite put a sound schedule together.

Well, after many years of practice and my sister’s wedding-photos of me were terrible, I decided to revisit getting in good physical condition. Since my weight slowly crept up to the heaviest that I had weighed in my life, I made the decision to lose a few stones so that my knees would hold up in my recreational rugby play. I kept up with my weight-lifting but my cardiovascular work was lacking in a major manner.

In the back of my mind, I knew that my knees would not want me to start out running, thus I began walking at least 30 minutes per session. I used my walking time to meditate (and pray) largely for stress relief. I had found that while lifting weights did relieve some of the stress, I missed running. I decided that I would attempt to get back to the point of being able to run a 10K if the opportunity presented.

Along with my dedicated walking, I changed my diet to no fried food, no candy, no processed food and certainly no “junk food”. My dietary habits were probably the easiest part of my journey because my wise sister had always been a great example for me. She simply doesn’t eat food that her precious body doesn’t deserve. She always said that it was better for her not that eat food that was processed. As I visit her often, I found that her consumption of fresh fruits and vegetables along with lean meats was a good strategy. She is lean, strong and wonderfully alive.

Soon, I found that by eating three nutritious meals with proper portion control, my weight was dropping. As I lost weight, I became faster finally able to jog and then run. Three weeks ago, when I was in beautiful San Francisco, I broke the 20-mile mark running those delightful hills as my training. It also helped that I have a wonderful colleague who was a world-class marathoner, until a devastating knee injury, but still maintains that wonderful thin body build of a marathoner. I envy his metabolism but he’s a great resource.

Today, I am many pounds lighter and running daily runs of 10 miles with great joy. My stress level is zero; my mind calm and at rest, my body continuing to thin out as my distances increase. While I am a bit worried that I won’t be able to finish the 26.2 miles, I keep running and keep running. I set the goal of completing a marathon and I work toward it daily by running, stretching and weight training also with keeping my diet sound. In short, I understand the concept of a “bucket-list” and I hope to mark “completed a marathon” off my bucket-list.

Another benefit of my running and weight loss is that people who haven’t seen me even as short as one month ago, barely recognize me. I have to say that losing enough weight to become unrecognizable is a wonderful benefit of this training. The only downside for me is that since I suffer from a hemolytic anemia (same as my father), I have to keep an eye on my blood counts. So far, even though I can chew red cells on my long slow distances (LSD), I remain asymptomatic. I can also indulge myself with an occasional beer or glass of wine without thinking about calorie counting. I have learned to savor those little treats of Sam Adams or Cakebread Chardonnay, my rewards for training hard.

Setting a long-term goal, working/training for that goal and getting that goal accomplished are items that are very nice for spiritual growth. Stress-reduction is great for intellectual and physical growth. In short, training for this marathon has been a great learning experience for me physically and intellectually. I can’t say  with certainty that I will finish those 26.2 miles but I can say that the journey so far, has been very positive. I am stronger and more resilient in all aspects of my life as my marathon training has spilled over into my academic and clinical practice making me calm, positive and accepting of things as they come, one step at a time. All in all, not bad and quite joyful at times. Bring on those 26.2 miles!

10 April, 2016 Posted by | life in medicine, medical school, practice of medicine, relaxation, stress reduction | , , | 2 Comments

The Fastest Way to a Surgeon’s Heart

As I sat in my office yesterday lamenting my lack of love on this upcoming Valentine’s Day, I stared at my Mardi Gras beads left over from Tuesday’s dinner. Tuesday had been a long day that was filled with endless paperwork coupled with cold temperatures and snow. I am training for a spring marathon thus I needed to get some road mileage but couldn’t run outside in the new falling snow (ice underneath) and sub-30F temperatures. As I finished the last signature, closed the last chart and checked to make sure my dictations had been sent, I decided to go to a Mardi Gras party with a few friends. It’s the last fling before the Lenten season begins and for me, an opportunity to enjoy the company of some folks who have little to do with medicine. I jumped at the chance.

As I entered the Mardi Gras location, the sound of New Orleans jazz coupled with the fragrance of jambalaya filled my senses. I was enveloped in beads (no I didn’t have to display a bare chest to get them) and hugs. “It’s going to be a good Lent”, one of my friends remarked. “I can’t believe that Ash Wednesday will be here tomorrow. It’s so soon”, I remarked. Both of us scooped up the jambalaya (mine vegetarian) and settled in to enjoy our treats with a glass of wine. What a nice way to shake off the cold and snow outside.

Yes, Tuesday was a great experience; so needed but Ash Wednesday began and then came Thursday and my mini-despair at not having a special someone in my life to acknowledge on Valentine’s Day. This whole St. Valentine’s Day is “hokey”, I reminded myself as a couple of my married partners ordered roses for their wives. Yes, I was a bit envious of those lucky women who would receive them on “the day”. Even my unmarried partner was planning a nice dinner with his new love interest. Oh, this was too much for my cynical heart to bear. I decided to hit the gym and pump some iron to shake off these feelings.

As I was leaving the surgeon’s lounge, the nurse manager of the operating room touched my shoulder. “Hey doc, here’s a package for you”, she said. “Gee”, I thought, “someone is actually sending me something?” She handed me a small parcel that was sealed with iron-clad tape, addressed to the hospital operating room that was clearly from a surgical supply company. How did she know it was for me?

I tore open the box with my car keys. Inside, there were several small shiny instruments. Ah, new Castroviejo’s (instruments for delicate work). Be still my beating heart. Someone remembered me and my Valentine Day came early.  Yes, I am feeling the love!DSCN0534

 

13 February, 2016 Posted by | medical school, practice of medicine | , , | 1 Comment

Square Pegs in Round Holes

Introduction

At a luncheon, I listened to one of my primary care colleagues explain the realities of the 20-minute office visit. She happens to be very knowledgeable in treating developmentally challenged pediatric patients but her problems apply to any patient with developmental, physical or intellectual challenges. Like most physicians who are employed by health systems, she has productivity quotas and goals that are set by people who are outside the realities of medicine, usually administrators/business managers.

Medicine is not a Business, even a Home Business

The reality of being the primary care physician who treats patients with cognitive, physical or some combination of both types of challenges is that these patients have needs that will affect every aspect of their office visit. Many times, their transport to the health care location will involve public transportation or some other means adapted for them. Sometimes just getting to the transportation source requires hours of planning by the patient/caregiver only to find that their transportation left early or did not show up at all.

Imagine if it takes 20 minutes for you to dress your special needs daughter, it’s going to take 20-minutes to get that same child undressed for vital sign measurement and evaluation in the physician’s office. Keep in mind, that many special needs patients have behavioral and cognitive issues that prevent them from understanding the vital nature of complete and comprehensive health care assessment. For them, they are out of their secure and familiar environment; in a place where there may be excess and unfamiliar stimulation that will affect their behavior for the rest of the day.

The other reality for the intellectually or physically disabled is that they may have very complex health problems that they may not be able to address or their caregivers may not be able to relate to the physician. Couple this with unfamiliarity of the physician in terms of the diverse needs of this population, just because that physician may not have more than one or two challenged patient sin their practice and the business of medicine has created a situation where problems may not be properly addressed. My solution in terms of wound care for these often fragile patients has been to go to their facility/home but my primary care colleagues do not have the luxury of leaving their clinic to do home visits with any regularity.

Why we entered medicine in the first place

Most of us were trained to solve patient problems by identification of those problems and application of extensive medical knowledge. With the emphasis on getting patients in and out of clinic as rapidly as possible, many problems are never addressed or solved. Imagine if you are not cognitively or physically challenged but are the appointment following or concurrent with the patient who has these issues. Not only will your visit be abbreviated or affected, much of the office staff will be spending time and resources on the patient who needs more help. As a result or dealing with possible frustrations on the part of the needy patient, the physician may not be able to focus on your needs or the needs of other patients in the office because they have been frustrated as they are attempting to give the best care possible to their impaired patients.

At this time, we are better in terms of identifying those with physical and intellectual challenges as opposed to addressing their medical needs. We know that great rewards come with treating these populations especially when we are able to prevent or slow any discovered disease processes. Providing the highest level of care is always paramount in the mind of the primary care physician. To this end, my primary care colleague said the the primary care visit should be longer, because it’s often more comprehensive and the specialist visit should be shorter, because it’s more focused. Regardless  of specialist or primary care, the office visit should reflect the needs of the patient and should not be limited by a “one size fits all” approach to office visit length. Rather than decrease the costs of health care by shunting more bodies through the door, the “numbers” approach likely ends of utilizing more health care dollars because of missed opportunities to address the comprehensive needs of patients.

Those Patients

On another occasion, I listened to a colleague speak about not wanting to treat any patient who would not fit in the chairs of her waiting room. This was her way of stating that she would not treat obese patients. “They bring down my productivity,” she said emphatically. I can’t afford to lose money on treating these types of patients so I made sure that they don’t fit in the chairs in the waiting room if they weigh more than 200 lbs. Imagine if you are a patient who is morbidly obese, more than 100 lbs overweight, who enters a physicians office and can’t find a chair that will accommodate you so that you can attend your office visit.

Imagine the embarrassment if you have to ask for a properly sized chair so that you can sit and even fill out the paperwork to prepare for that visit. Imagine how welcome you would feel if you receive less than respectful and comprehensive care.  The morbidly obese, the developmentally challenged and the mentally challenged individuals in society all have medical issues that need to be addressed. By its nature, morbid obesity is a chronic metabolic problem yet my colleague who makes sure the chairs in her waiting room discriminate against morbidly obese individuals, would treat them differently from the Type I diabetic or the patient with chronic obstructive lung disease. Is is ethically sound to discriminate against a population of patients who are simply seeking, and paying for your services by not accommodating them in your office?

Taking Back Medicine

Imaging a situation where patients get the care that they need without exception. In this situation, the physician determines the patient’s needs and has the time to address those needs. Rather than being pushed by time constraints, the physician (and office staff) would have plenty of time and resources to treat patients with special needs. In truth, patients do not come to physician offices to socialize but come because they need care. It is up to the physician to take back the delivery of that care and set the parameters in which that care is rendered. When a patient receives less than optimal care because of the time constraints placed on the physician, the physician bears the brunt of the criticism. “Those money-grubbing doctors didn’t take time to talk to me”.

As physicians, we need to set the standards of patient care, much the same as we set the standards of practice of medicine. One of those standards needs to be ensuring that the limited resources of primary care physicians are addressed. A good primary care physician can be the resource that decreases health care costs if giving the tools to address all problems in a comprehensive manner that reflects the individual needs of the patients. As specialists, we are often given an advantage at the expense of our primary care colleagues and their vital work. This leads to burn-out and frustration on their part but also leads to increases in health care costs because patient needs are not addressed.

These problems are not solved by increasing the number of mid-level practitioners who often lack the medical knowledge/training to lead the comprehensive care team. While mid-levels can assist with comprehensive patient care, they are not the solution to effective or efficient delivery of comprehensive care. It is the primary care physician who should and does leads the best comprehensive care team and who can provide the most cost-effective care if given the tools and resources for their work. The greatest and most needed resource right now is time to deliver care. The public enjoys greater satisfaction and those of us who are in specialties, are able to obtain the best information to perform our services when the primary care physician can expedite a sound referral. In short, we as physicians need to take back the management of health care and deliver the best health care on our terms as the patient needs not according to a general plan that is even frustrating for relatively healthy people let alone those who have multiple chronic problems.

15 January, 2016 Posted by | medicine, practice of medicine | 4 Comments

We have a mess here…

I settled into an evening of reviewing my lecture for the next day. It is a lecture on the early recognition of the signs of shock, a topic that is “near” and “dear” to most surgeons. This lecture is one of my favorite topics because I deliver this information in a “user-friendly” manner that I wish I had received in medical school. It took years of training in graduate school, medical school and residency/fellowship for me to “make peace”, read comfortable, with early recognition of signs and treatment of shock. Once the peace had been exchanged, I worked out what experience has taught me and my colleagues and pass that on to my students.

As I tweaked a slide here and there, the emergency tone on my phone sounded. Odd, I thought, for me to get this call on this day because I was not even on back-up duty. I called the number and heard the voice of one of my colleagues who is a trauma surgeon. “I have a young woman; shot multiple times in the upper torso and neck”. “Can you come in because we have a mess here and I need another pair of hands?” Of course, I would come in if called, without hesitation as one of the sheer joys of what I do is the old surgical mantra “A chance to cut is a chance to cure”. Besides, if I had made the same call to any of my colleagues, they would be at my side as soon as they could.

I drove my 1997 rusty gold Toyota Corolla through the sheets of rain that were falling as I made the 20-mile trip to the hospital. If I had been on call, I would have stayed at the hospital but since I wasn’t, I had to drive in. The rain pounded my wind screen in the early evening darkness. Why do these  types of situations happen on cold, rainy and foggy nights? Even my chihuahua would not venture out on a night like this. (I left my heated throw on low for her to snuggle into as I left my townhouse). ” A night that is not fit for man nor beast.”

I arrived at the hospital, parked the car and headed in through the emergency department. This was the quickest way to get to the operating room and would allow me to check out the radiographic studies before I headed upstairs. I scanned all of her films with the radiologist on duty and headed up the four floors to the main operating room. “They are in Room 6”, the desk clerk said as I removed my wet coat and entered the women’s locker room.

I changed into scrubs and grabbed my headlamp from the top shelf of my locker. I piled my wet hair on top of my head, pulled on a scrub cap, shoe covers and then placed my headlamp; tucking the cord into my back pocket. I peeked into the room where my partner,covered with blood, winked at me as a sign of relief. I  grabbed my surgical loupes from their wooden box, already placed on the circulator’s table, and said I would be right in as soon as I finished scrubbing.

The surgical scrub is where I take the time to center myself and get into the ritual, the mood of beginning a case. I always say a prayer for God to guide my brain and hands and to guide the hands of those who will operate with me. This has been my brief meditation as I scrub since medical school. I take the time to relax my arms, shoulders and breathe slowly, deliberately before I move into the operating room. With all of the tension of the drive, the rain and the run up four floors gone; I am ready to get to work.

I never want any surgical case to be mindless. I want to be mindful of every step and every event that will unfold. For the patient on the operating table, nothing about what I do is ever routine and will in all likelihood, be a sentinel event in their lives. Once something is cut, it’s never the same as before the cut. No, there is no mindless routine for me or for the patient but for me, there is a sense of compulsive perfection to get it right and to get it done.

The patient had been shot multiple times with wounds in the neck, upper torso, abdomen and shoulder. She had been standing outside her house with a group of friends when a car pulled up and multiple shots were fired. A policeman, was present in the operating room to take all bullet fragments that we would remove. As I donned my surgical gown and gloves, my partner motioned for me to take over the shoulder vascular repairs that he had been working on so that he could move to the abdomen. From training and experience, get control and make the necessary repairs and move onto the next task.

My partner had completed only a tiny portion of what needed to be completed in this complex wound. The bullet had shattered two bones in its trajectory but the vascular damage was immense. I completed a couple of repairs to larger vessels and proceeded to take care of some of the smaller vessels. It was going well and she would have a good blood supply around this mobile joint.

I moved to the upper arm as my orthopedic surgery colleague moved in to do his part with this case. The bone repairs needed plates and screws. Not great to put hardware into places where filthy bullets had been but there are techniques to avoid infection. Most of the tissue that had been in direct contact with the projectile had been removed because it was not salvageable.

The upper arm wound was a clean pass-through which I explored and closed. This would need broad spectrum antibiotics but not a major vascular repair. My trauma surgery colleague had started to explore the abdominal wounds assisted by a resident as I completed the upper arm repairs. The anesthesiologist said that she was holding well and wouldn’t need any further transfusions. We were getting ahead of the damage one “mess” at a time.

“I am going to run the bowel and get out of here”, my trauma surgeon colleague said. “How’s things going up there?” , he asked. “We are almost done,” my orthopedic surgery colleague said. I looked at the neck wound which had amounted to a superficial graze with no penetration of the platysma, a sign the residents had not missed on their initial exploration in the emergency department. The torso wounds had been superficial largely, because of the angle she stood from the shooters.

I helped the orthopedic surgeon close above his work and then turned my attention to helping my colleague close the abdomen. In all, there were seven people around this patient, a diminutive young woman of 19 years. She would not remember those of us who worked on her that night in that operating room but she would bear the scars of being in the wrong place at the wrong time. She would live with some loss of range of motion in her left shoulder but she would be able to live a relatively normal life.

What would she change about her life after this event? Even more important, who is she and why was she in front of 8 bullets on a cold, rainy and foggy night?  Who was so cruel that they inflicted this on this woman who was approximately 25 feet from the car when she was shot? This woman is 19-years-old and just starting adulthood but could have been dead from this event. I would receive answers to some of these questions in the coming week after this case but some of the answers will never be known.

There is no “ego” to making these repairs and doing this work. There is a compulsion, on my part, to try to get the best outcome possible for every patient. I see damaged vessels and try to affect the best repair possible for restoration of their function. The wounds have to be explored, evaluated and repaired. There is no value judgment on these types of wounds; only repairs and restoration of blood flow. Get control and get the repair done as safely and as completely as possible.

This young woman is an honor student today with a passion for the study of literature. She has almost completed her undergraduate degree and is poised to enter graduate school. She is mindful, contemplative and readily shares her story with those who have a life of violence either by choice or not. She was visiting her grandmother the evening of the shooting and had just arrived in our city. She didn’t know any of the young people in the car, that shot her.

 

 

 

27 December, 2015 Posted by | medical school, on-call, practice of medicine, surgery, trauma, vascular surgery | | Leave a comment