Archive for August 2006

Green hills

August 25, 2006

Dr. Signout is on holiday! And instead of lying in bed all day and reading Vanity Fair as she had no small urge to do, she has shuttled off to enjoy a cool-weather summer holiday in the southwest of Ireland.

When I’m on holiday, you’re on holiday. No hospital politics, no patient-family shenanigans, no elegantly structured, economical-yet-lyrical discourse on learning to care for sick people. Just green hills, cold cliffs, and dips in the frigid Atlantic. And perhaps a bit of Guinness.

I’ll be back before two weeks have passed. Meanwhile, sweat an extra bucket for me.

Women behaving badly

August 20, 2006

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Today has been an unbelievably frustrating day in the hospital, but I don’t want to bring anyone down. In an effort to promote peace, harmony, and blogular happiness, I’m going to instead write about something everyone can get excited about: the patriarchy.

Earlier this year, the venerable American Medical Association (the AMA) put out this press release, which describes the findings of a recent study of young women’s behaviors on Spring Break and their subsequent gnawing regrets.

I found the press release appalling. For starters, by leaving men out of the story, it tacitly sent the message that women drive the bad behavior that happens on Spring Break. I mean, come ON.

Even worse, by not addressing men’s behaviors or feelings, the release seemed to imply that only women regret doing dumb things while drunk, and that only women use alcohol as an excuse to do outrageous things. In doing this, the AMA neglected both the roles and the health care concerns of college-aged men in these scenarios. It’s almost as if they were saying that there’s nothing that we as health care providers can or should recommend for our dudely patients in this age group–that raping and pillaging while hammered is just what they do.

I wrote to my regional student representative to the AMA: “Presenting data on women behaving badly in a situation where men are also behaving badly suggests that women should shape up, while men should…well, keep doing what they’re doing.”

He huffily dissented and proceeded to shower me with factoids about the AMA, as well as a bunch of verbiage about the context in which the study was done. It was all part of a study on advertising; it was funded by a grant whose purpose is to help all college students make good choices; yadda yadda yadda. None of this really mattered to me: the press release was context-free, and it still sent the message it sent.

There were more emails. More from him, more from one of his dumpy little underlings, and then a final, sneering one introducing me to the director of the study, who passed me off to the public relations people, to whom I explained (while feeling up fruit in the grocery store) What Their Problem Was. But the study was built only to study women, they whined. Whatevs, I said. If your study only inquired of women, it was built on a faulty foundation, because men are subject to parallel pressures and risks, and they merit equal investigation. Your study is the suck.

She pretended to validate my point of view, I pretended to think she gave a damn, and we called it a day.

It so happens that I am now a resident where the huffy AMA representative is in medical school. And several days ago, when each team acquired a new set of medical students, he turned up on mine. I was very excited about this: it was going to be my chance to introduce him to the angry intern behind the angry feminist. But alas, he had been assigned to us in error, and he was whisked away before I got a chance to get totally wasted and accidentally do even one table dance.

I am full of gnawing regret.

Tragedy

August 16, 2006

I have heard through the grapevine that certain people are not so interested in reading what I write here because it is, and I quote, “too sad.”

It’s never occurred to me that my job is especially sad. Yes, I’m surrounded by sick people, and yes, most cheese danish to be found in our hospital is abysmal. But by this point, most of my colleagues and I have created so much distance between ourselves and our patients that it takes a lot to really make us feel sad about our work. Plus, we can always bring in danish from outside the hospital.

With the exception of the occasional paperwork nightmares and especially sleep-deprived days, I often have a lot of fun at work. There are just enough smart, snarky types to have a good verbal tussle with here and there, and it’s really fun to solve problems, both logistic and medical. If I stay focused on my own tiny little world, it’s possible to actually feel effective on a near-daily basis, which is really the foundation of job satisfaction.

If you want real human tragedy, consider that at 5:45 a.m. today, I was tugging at a grey hair I’d spotted in a hospital bathroom mirror, thinking, “How did I get this old?” then, “When was the last time I went on a date?” then, “Who wants to date people who have to be in the hospital at 5:45 a.m.?”

When I get sad about my work, it’s usually because I grieve my independence, my free time, my mobility, my old hobbies and dreams, and what’s left of my youth. I can separate myself from someone else’s illness enough to maintain an even emotional keel, but I have trouble avoiding the occasional sense that my patients aren’t the only ones wasting away.

Post-operative complications

August 13, 2006

Since I came on the medicine service, my team has been taking care of a man who because of one of his unfortunate afflictions I will call Mr. Scrotum. Mr. Scrotum is a 70-something man who came to the hospital with an infected prosthetic knee joint. He had surgery to clean it out, then came to our service to get medically stabilized prior to beginning physical rehabilitation. Unfortunately, Mr. Scrotum had some post-operative complications, including some wacky mental status changes and a fairly reversible kind of kidney failure.

Mr. Scrotum’s medical course, while not ideal, is a fairly common one. His family, however, is exceptional. Although Mr. Scrotum has full mental capacity, he defers to Mrs. and Daughter Scrotum for all of his medical decisions, and I imagine it has quite a lot to do with how unbelievably exceptional they are.

Mrs. Scrotum is the kind of person who, after she is served lemon butter instead of parsley butter with her lobster at the club, asks to speak with the manager; has the waiter fired; writes a series of angry letters; forms a community coalition; hires a lawyer; and still isn’t satisfied after she wins, because it’s the principle of the thing. Her daughter is the same way, only with younger, sharper teeth. It is really very unpleasant to be regarded daily by these people with such spectacular anger, distrust, and paranoia.

Understand, now, that I do not take the Scrotum family personally. To me, their collective affects speak of nothing so much as abject terror: They are so, so afraid of losing their beloved Mr. Scrotum. In a flailing attempt to gain control over something that threatens to take him from them, they scrutinize and question what they do not understand. Any barrier to their scrutiny is seen as an intentional, adversarial move–after all, it’s far more satisfying to have someone to blame when bad things happen than to just chalk it up to bad luck.

If we don’t take the time to help the Scrotums identify what they are feeling–fear and frustration–and to explain to them why we are doing everything we do, we run a great risk of making them feel that we are not on the same team as they are. It’s that dynamic that results in lawsuits.

Ironically, the time that we could spend talking with the family once a day–which indeed is a pretty big demand on any doctor’s schedule–we spend trying to cover our asses in case this situation does end in a lawsuit. We call consults, we call attendings, we have bitch sessions. If we could swallow our pride, answer questions for 15 minutes a day, and remember how little control this family feels they have, I think we could avoid a bad outcome, psychosociolegally speaking.

At least, until he dies. At that point, no explanation will alleviate their grief, and anyone who can possibly be blamed will be. I just pray it doesn’t happen in our hospital. 

Broken

August 8, 2006

It was bound to happen sooner or later: I finally broke someone.

Last Thursday, we admitted an 84-year old lady with bad disease of her kidneys and their vasculature. Her kidneys were too sick to make urine, making her a good candidate for hemodialysis. (In hemodialysis, a patient’s blood is circulated through a big machine that sucks waste and excess fluid out of the blood–sort of an out-of-body kidney).

The goal on admission was to manage her acute issues, find her a slot for long-term dialysis as an outpatient, and send her home. Her most acute issue? Her very high blood pressure: she clocked in at 248/160, which we call “hypertensive emergency.”

We were having a lot of trouble keeping her pressures stable on beta-blockers and arterial dilators, two common medical modalities for treating hypertension. So yesterday morning, I suggested we try a drug called minoxidil, a venous dilator. I’d seen it used in another patient with severe, refractory hypertension, and it seemed like a good choice for this patient.

Indeed, minoxidil kept her pressures within our goal range on the first day of therapy. But this morning, her pressures were lower than they ought to have been. When I saw her, she was sitting up in bed, drinking a cup of hot tea, and looking completely adorable–and more importantly, completely conscious. Still, I stopped the minoxidil, asked the nurse to watch her, and left the floor.

Five minutes later, I was on my way to get coffee when I got a page from the nephrologist overseeing the patient’s care.

“Um, hi. Hey, did you see Ms. E this morning?”

Yes, I said.

“Did she seem a little unresponsive to you? Like, just…unresponsive?”

No, I said, I’ll be right there. I hung up and ran.

When I got there, she was lying back in bed, unconscious, with her eyes rolled up and toward the left. Her blood pressures had plummeted to 85/40–worrisome even in healthy patients. We pushed in intravenous fluids, called the neurologists, ordered a head CT scan–all the things we were supposed to do. She hadn’t bled into her brain, which was good. But she also wasn’t getting better with treatment; tonight, after getting 7 liters of fluid over the course of the day, her pressures are in the 120’s/80’s at best.

By this point, it’s pretty likely that this patient has had a brain injury–a stroke–due to inadequate perfusion of her brain. No one knows how to fix her. But everyone seems to agree that it was the minoxidil that broke her.

I think this is the part where I am supposed to feel really terrible, even though minoxidil was a totally reasonable choice in this patient. I mean, when most doctors choose a course of treatment that fails miserably, they usually feel that they have failed miserably.

But I still feel OK. Maybe it’s because minoxidil really was a defensible choice in this patient–a good idea that just played out wrong, and in the most unlikely of ways. Maybe it’s because I am a cold-hearted beastie with a conscience the size of a soybean. Or maybe it’s because she has not yet been declared brain dead.

Either way, my non-reaction to this surprises me a little. Maybe I’m broken, too.

Looking for loopholes

August 1, 2006

On Sunday, we admitted a new patient to my team, a young, kind of hip lady with an 8-month history of progressively worsening abdominal pain, fever, night sweats, and weight loss. All signs pointed to pancreatic cancer, which generally has a very poor prognosis. So it was a little confounding when the initial CT scan failed to show a pancreatic mass.

My team spent about an hour and a half discussing her differential diagnosis–the list of diagnoses she could possibly have–with two different attendings. It occurred to me at a certain point that I so badly wanted this woman not to have cancer that I was reacting defensively to assertions that she did. I was looking for loopholes that didn’t exist. Somewhere in between the lab values and the symptoms and the films and her consuming pain, I was sniffing for something that didn’t stink. Maybe it’s tuberculosis, I said. Or Crohn’s.

“Maybe,” said my resident, “but it’s so unlikely. Like, the gastroenterology people devoted most of their note to discussing which kind of cancer it was most likely to be, without even really considering that it could be anything but a malignancy. And they’re specialists.”

She was right. In this situation, I am very much a learner. I am learning how to broaden both my clinical and my emotional thinking about patients–learning how to think of lists of problems in one minute, and how to cope with the reality of those lists in the next. It was an effort, but I crammed into my head the idea that our lady had cancer, and I stayed with it for the whole day.

Today, she had a special pancreatic protocol CT and a fancy endoscopic ultrasound. Neither of them showed a mass. In fact, neither of them showed much of anything wrong with the pancreas. We now have a patient with abdominal pain, fever, night sweats, and weight loss who doesn’t have abdominal lymphadenopathy, and who more than likely doesn’t have pancreatic cancer! FUCK yeah!

Maybe it’s tuberculosis. Maybe it’s Crohn’s. Big damn deal. We have medicine for that.

See? I’m learning.