Implements

We’re “Implementing” an “Electronic Medical Record.” An electronic medical record is an exciting new way of storing your patient’s medical information in a brightly colored and incoherent and less efficient fashion. Basically it’s like hiring people who are high to do your filing.

And you aren’t high, you just wish you were because you are working 50% more hours than previously with the same pay.

Having an Electronic Medical Record is important because it is The Future. Also, because the government will pay you to have one. Also because “Meaningful Use.” Meaningful use is where you have a password and you have to try to guess it on a website and then you have to call a lady during work hours and wait for 30 minutes on hold and then authorize her to give your company $10,000 for you to use a computer, meanwhile your patients are piling up in the waiting room like so many angry ranchers in a stockyard.

If you don’t have an EMR, all of the patients will look at you like you’re incompetent dinosaurs applying leeches to wounds and diagnosing “Hysteria” and performing exorcism on patients with cirrhosis. The lab will use chisels to draw bone fragments out for analysis.

If you do have one, all of the patients will look at you like you’re a robot who cares not to look at them during the patient visit and spends most of the time in communion with the wall-mounted machine. Which communion sounds something like this: “I’d rather have a cystoscopy than use this fucking computer program!” To quote Dr. DDx.

After hours, you and your colleagues will continue to labor, bent over the keyboard, brows furrowed.

And you might take comfort, because previously you were the only one there after six.

But then it’s seven, then eight.

You overhear your colleague on the phone. “I know you need your prescription for Norco, but we’re closed. So I’m going to send it to the pharmacy using this computer…..”

Pause for 4 minutes.

“Okay, actually that didn’t work. Now I’m going to try to fax it using this computer….”

Dramatic pause for another 3.

“Okay. Screw this. You at home? I’m coming over on my bike. Be there in ten.”

And that, my friends is the Future.

I'm on a boat

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“You’re on a lifeboat. You only have so much space. Are you going to pull in the ones who are waving their hands at you, calling for help? Or the ones who are swimming away from you?”

Huh.

The communist PA and I look after each others’ patients sometimes. While I was away he saw Yellow Eyes. Who, while not wanting to die, is still drinking himself to death. His legs and belly have grown. We have to see him once or twice a week these days. The story is always the same.

“Yeah, I’m still drinking, but I’ve cut back, a LOT.”

“I don’t drink hard liquor anymore.”

“You know, no one quits unless they are ready. You have to want to,” he tells me.

And I want, so badly, for this to work out for him. But he’s drowning. Can’t really breathe. I don’t think there’s water in his lungs, but the twins-gestation-sized belly he’s grown doesn’t leave a lot of room for the air in the top half of the torso.

The communist asks me about him. I admit I don’t know what else I can do. In fact, I’m not really doing anything, just adding water pills and running out of time.

So he gives me this cryptic advice about boats.

I used to be a lifeguard. (Now the card is expired. I can’t use my CME money to renew it. Apparently.)  Anyway, in training we learned that people who are drowning will grab hold of a rescuer and push you under. Nothing you can do, it’s just their instinct to survive. And you shouldn’t fight it, just go down, away, then up. But in practice, you should try not to let it get to that point. So, always carry that floaty thing, and put it between the drowner and yourself.

168 pounds, Yellow used to weigh, when we first met. Last month he crept up to 180. Now he’s 210, 212, 214. Taking his meds only when it rains or something. Definitely not as directed.

I call a few days after our visit for an update. His daughter tells me he’s in the hospital. They took the water off and he’s decided to detox. That’s good.  Early the next morning I was there to deliver a baby, then stopped by his room after. His belly looked a little more post-partum than gestating. He was, as ever, full of smiles.

“I think I’m really going to do it this time, doc. No drink for 5 days, now. The priest came by.”

And I want to believe it, I really do. But I’m not going to paddle after him.

I wish I had a dermatologist in my pocket. Instead I have syphilis.

Wednesday was Rashes No One Has Ever Seen Before Day.

A lovely pregnant patient came to see me complaining of an insect bite. It was not an insect bite. Unless insects bite you only on your groin and instead of creating a small pink welt they cause grouped clusters of yellow or blood-filled vesicles crossing several dermatomes and only mildly itchy or painful. I got out the atlas. Then I pulled in the Dinosaur. “I don’t know what that is,” he said.

 Awesome.

In the hospital on call a VBAC awaited. Her bag of waters broke early in the morning and there was thick meconium. She had no contractions yet. This is called PROM, only no one wears fancy dresses, least of all me. The nurses needed me to talk to her also about why we weren’t starting her on Pitocin to induce her. The reason is because it increases your chances of uterine rupture from 4 in 1000 to 11 in 1000. And uterine rupture is a bad thing, since it has at least a 10% mortality rate for baby. But the longer we wait the longer we risk infection, which is more likely, just less dangerous. And she could always opt for a c-section, which is less dangerous for baby on all accounts, but riskier for mom. So, a complex discussion to be sure. Try doing it in your second language.

Arguably more fun than regular prom, though.

After I finished the nurses asked me to stay for 2 minutes and translate for their assessment. They have no translators today. They are woefully understaffed.

I needed them to watch my strip for me because I just got called to the ER.

Dr. ER Green Zone had a baby for me to opine on. “He won’t move his arms. He’s 8 weeks old. His xray looks weird. I’m not sure what it is.” Cool. I’m sure I’ll figure it out right away since I know so much about orthopedics in 8 week old children.  We look at the xray right away. The distinguished radiologist has created a differential diagnosis for the diffuse periosteal inflammation that includes several vitamin deficiencies and a disease I have never heard of, Caffey’s. I go in to see the patient. He’s cute, but he hates it when I touch him. His arms seem weak. And there’s a weird rash on his arms.

I should have put on gloves, but the rash is unexpected. I touch the soles of his feet, where the skin is peeling. A scalloped red border extends to the sides. There are plenty of raised pink and red bumps, but in circumscribed areas. There are some ring-shaped lesions. It looks for all the world like nummular eczema, except the two spots that look like ringworm, and the spot on his chin I can’t convince myself isn’t an early herpetic lesion.

Shit.

I ordered some labs and started reading. I asked Swiss to come look at the rash, too. I called the patient’s PMD, who took care of his mother in pregnancy. She came late to care and never did her labs. The hospital drew a paltry few when she was in labor.

I decide it’s syphilis. Swiss, the resident, the medical student and I go back to the ER to take another look. We keep refreshing the computer screen waiting for the RPR to come back. I call the lab. “Oh it is send-out. 3 to 5 day.”

I ship him to the University hospital. He deserves specialist consultation, which we don’t so much have here. Not for derm, not for ortho, not for 8-week-olds, anyway.

The VBAC PROM is still hanging out. I go home and take a nap.

At 1 am a woman arrives at labor and delivery and goes from 5 cm dilated to delivering a baby on the floor in 10 minutes. The resident was sort of in the room at the time.

And then… nothing. My hands may have syphilis. It is not confirmed. That is all.

Love vs. Drama

Termite forgot her anniversary. We laugh about it, because that’s what you do when you can’t believe you forgot your anniversary. What, should we be crying?

Drama seems to surround us. A colleague’s contract was non-renewed, for no reason anyone knows of. She’s the only Suboxone provider for our practice, and for our poorest patients. Leafy might leave our practice, because the Linebacker’s ER job is getting worse every day.

My own life seems remarkably normal.

Termite has had enough of her husband. She just wants to be happy, and it isn’t so at home. She thinks she’d be better off alone, raising her kids herself.

I don’t know what to tell her.

My next patient looks very Mayan. We exchange greetings, but she gets right to the point. She needs me to check a rash. It’s probably herpes: that’s what she was told before. She got it from a man. Not her husband, mind you. No, he’d never do that.

Five years ago she arrived here alone, hoping her family would soon follow. She didn’t follow all the rules, of course, because these days that’s hard to do. So she was without “papeles.” But she had a job. And she sent money to her two kids and her husband.

There was a man at work who took notice of her. She didn’t like it. She told her coworkers, who laughed at her and called her a drama queen. He took more notice of her. Then he took advantage of her.

She doesn’t speak English. She was afraid of the police. He played into that. He threated to report her to La Migra if she told anyone.

This went on for five years.

Of course she was depressed, of course she felt like dirt. He made her feel that way. Obviously she was trapped.

Her husband and kids finally were able to move here as well.

“He’s a good man, my husband” she said. “The best.” But she couldn’t touch him, barely could look him in the eye.

A friend from the Laundromat finally took her aside, ostensibly to help her move some furniture. “You’re sad,” she said. “What’s going on?”

And it broke the ice. Now she’s in counseling, her husband finally knows. Most days she’s on the path to healing. She brought charges against the man, found out he’d done this to 6 other women. She can’t have a normal sex life, she can’t breathe sometimes on bad days, but it’s alright. 

Well, it’s not alright. But she’s alive, and what’s more, she finally wants to be.

When you walk into a room and close the door, you have no idea what world you’re about to encounter. Pain, joy, anxiety, insomnia, anger, mania, hyperactivity. Then you have to leave the room and let it roll off you so you can walk fresh into another world. It’s not that easy, you know.

The words of another patient come to mind. She’s gone admittedly “a little wild” since divorcing her husband. There are bruises on her body, consensual. She occasionally gets PID. She wonders if she might be bipolar. She wants to find out, because “Our job in this life is to be happy. And that is our own responsibility. So I want to find out how I can be happy.”

Me too.

24

What a day.  Only 5 patients this morning, and it was all I could do. 2 OB’s needing NST/AFI’s. One of course presented at 39 weeks without any prenatal care from our group, with pre-existing hypertension on medications, and without any prenatal records. She’d like to be induced Friday, please, but she’s not sure when her due date is.

Next another patient with severe back/left belly pain. It’s not her pelvic organs, or her gallbladder; those were removed a while back.  It may be something around her kidney, like the liquid she had removed twice with a needle several years ago, now that she thinks of it.  I’m not sure, as I talk to her, that it isn’t actually from her heart. But I am sure that something is wrong with her. She can’t smile, or really move her face at all. Tears come early. She’s anxious, can’t sleep. Nothing is fun anymore. She’s guilty about everything. Energy is gone. She can’t concentrate.

She has lost 30 pounds over the past several months.

She thinks about driving off a cliff nearly every day.

She hasn’t seen a doctor in 7 years. I guess I’m it, then.

We do an EKG, and I examine her. I grab the therapist from her office to see if she can stop by. She does. We make a plan, and order labs and a follow-up appointment. Then she’s gone.

Later I stop by the therapist’s office to ask how the discussion went.  “She sure is depressed. Also, guess what she’s drinking every day?”

I brace myself for the inevitable unearthed alcoholism that the patient had denied previously. I’m wrong.

“24 cans of Pepsi. A day. 24 cans. I asked her three times to be sure.”

What?

Leafy stops by after clinic to catch me staring blankly at the 30 charts on my desk. We talk about the drama currently happening among the staff.

As we leave the building I tell her about the Pepsi. She acknowledges sometimes you just don’t know what to do. Today, her patient complained of being run over by a Studebaker. Which crushed his penis. And now he wants to have an erection.

“But I don’t even know what even will work?”

“Well, can I just have some Viagra?”

“Sure.”

Dangerously Close

The first few months of medical school are consumed with anatomy, biochemistry, and cell biology. Histology, maybe, and the physical exam. Most of those classes are a hazy, pleasant-ish memory to me now. For example, the elderly pathologist who lulled everyone to sleep by reading directly from his overhead slides in an unruffled voice until one day he exclaimed “What’s this? Well by golly it’s a Howell-Jolly Body!” At which point I woke up for 5 minutes.

But somehow no one ever forgets the anatomy lab. It’s recalled with perfect distilled clarity every now and again when I catch a whiff of formaldehyde or phenol. Like, just the other day as I was ablating a portion of my patient’s toenail bed.

I turned my head away from him for a moment. “Es que este olor… bueno, nada mas que no me gusta mucho.”

Before my oblivious patient I was suddenly 22 again, in a room of dead bodies, drenched in repulsive sickly sweet preservatives. Immersion. Handed a scalpel. Told to cut. Against every instinct in my naïve little heart. White as the sheet that used to cover this respected elder who gave her body to science, to us, now lying naked.

Suddenly with a clipboard staring bewildered in the mid-term at tags tied to tendons. Rotating after each “ding” to the next cadaver, longing for my own, whom at least I knew. Willing, teleporting myself outdoors into the blinding heat and late-summer stillness just outside the window. Lost in the last dying days of my childhood. The days when I knew enough and knowing wasn’t everything, anyway.

Wishing there was some sort of mid-term that might test my knowledge of kitchen implements, or garage tools, so I might feel like I knew something at all. Then confidently I could write “This, Dr. Professor Sir, is a measuring cup. 1/3 cup to be exact. Exhibit #35 by contrast is a sieve.”

Staring into the abyss of What I Need to Know. At the crossroads of earnest interest and imperative mastery, the fear of failure gives you the courage to don a white coat and with it delude yourself into believing you’re impervious to pain and death.

I made it through the class.

Several months later we started Neuroscience. After a few lectures we were sent back to the lab. Nothing, not the white coat, not the desensitization of anatomy class, could have prepared us to see our lady’s brain lying neatly on a cutting board. A single serrated bread knife was on hand.

We were told to cut. Sagittal sections, about a centimeter apart.

Nervous laughter.

“So, who wants to cut open the brain?” I offered. No one took me up on it. “I’m not doing it myself.” The holy grail of humanity, the sacred seat of the soul, the great mystery of consciousness. We’d been told the consistency was like tofu, the extra firm variety.

Years ago on an ornithology field trip in the middle of a 30-mile salt flat a group of girls had to pee. Wordlessly we spread into a circle about 15 yards across. We faced in, and all went together.

Somehow subverting our instincts is easier when we do it as one.

I made the first cut. Then I passed the brain to the left, and my partners, in sequence, took their turn.

That weekend I went camping in the desert. We took a guided tour of some caves. In the dark among strangers, it was all I could do not to blurt out “Say, on Thursday I cut up a human brain.”

Why? It felt like a confession I needed to make. Like it might absolve me of the crime. Also I wondered a little what they all might think if they knew.

All I was trying to be was a doctor. I felt like a monster.

I said nothing.

Now there are a million moments like this that set me apart. Horrors we see and do every day that give us an air of mystery and a privileged place in society.

My landlady works with veterans, as a psychologist. She’s busy at the moment with the returning Iraq and Afghanistan troops.

She sat opposite me on the couch. “They are all suffering so much. So many of them have anxiety, panic, PTSD. They’ve seen such terrible things, it’s like they can’t be normal again.”

“Is it all of them?” I asked. “Do you think some will turn out to be okay?”

“Well, I worry more about the ones who seem unaffected. Those are the ones who do worse. Humans can’t see that kind of devastation and be unaffected. If you’re numb to it something’s wrong. Those are the sociopaths, the killers.”

The ones who can mutilate a brain and then casually go on a cave tour. The ones who can pump on a teenage chest for 30 minutes and then give up and have a sandwich. The ones who can look into the eyes of a heart that’s breaking and feel nothing, and glance up at the clock.

My God, what sort of “healers” might we be at the end of all this? To stay alive in this profession we’re strategically deadened. Afraid for our own survival, we jump through all these hoops. Some drop out. They’re “weak.” We’re worn down to exhaustion working night after night, so we never complain. Worn down to the point we’re relieved to see that the struggling cirrhotic has died overnight and we have one less patient to round on in the morning.

Did I just say that out loud?

Outsource the empathy to the nurses, folks, because there’s nothing left here. Nothing but an empty, encyclopedic brain and beating, mindless heart.

Can it be true? Has it all been bled out of me?

See the patients faster, Doctor, that’s not fast enough. They might cry, they might beg, but you’ve got others waiting. Give them a piece of paper, they’ll be fine.

You’re just trying to take on too many things. Set a reasonable agenda. Tell them to save the other 8 items for next time.

That baby just died? Here’s another one on the way. This one needs to be removed surgically. And the answering service has someone on the line who’d like to know what flavor of pudding to mix with ciprofloxacin.

She has cancer. He’s suicidal. She’s had her foot removed. Talk to them, sure, but no more than 10 minutes apiece.  She’s been kicked. He’s addicted. She doesn’t understand her diagnosis. His cat just died.

I’m neck-deep in charts and urinalyses. What the cadaver horrors didn’t drain from me the endless ticking clock will. This is primary care. This is the trenches. I’m dangerously close to numb.

Fortunately, so is his toe. It took a bit of extra lidocaine but the digital block worked. He’s smiling. The ingrown toenail was a pain. He’d tried to remove it himself with pliers. Apparently I did a slightly better job.

I believe I’ve killed the nail bed with phenol. My soul may yet survive. Maybe.

*Note: the suffering and death seen by most physicians pales in comparison to the trauma experienced by many veterans. I don’t equate our lot with theirs, and I give them the credit they are due. This was written merely to make an interesting comparison. And, mostly, to hold out hope that humanity and empathy can be reborn, even when all seems to be lost.

Waiter

coffee

I read somewhere about endorphins artificially causing people to fall in love. Adrenaline, and then the presence of someone, can later cause you to feel that same rush whenever they come around again. This was probably not in a major medical journal that I read this.

Coffee increases adrenaline. I love coffee.

I need it lately. It may or may not need me.

I don’t remember what the surface of my desk looks like. It’s always covered in a pile of charts. Sometimes, on good days, I leave the office with just a single layer of papers, sticky notes, and refill requests covering it. On bad days…

Coffee propels me into a higher frequency oscillation. I dart in and out of rooms and my thoughts race just fast enough not to be bothered by the sheer impossibility of the tasks on my desk, or the puzzles awaiting in each of the rooms.

Inside the rooms, and in the waiting area, people wait. 5 minutes, 90 minutes. Mostly, they’re calm. Even the kids. Sometimes they wonder what’s taking me so long.

I wonder too. I’m moving as fast as I possibly can.

Maybe I do too much. Maybe we need to set a more reasonable agenda. Each patient has waited months or years to see me, the urgency’s there. But so are the other patients.

Waiting.

A man visits me for the first time. He’s anxious, heart racing, weak, edematous. He has double vision when he looks up.

The ER did part of my job for me. They diagnosed him with hyperthyroidism and gave him some methimazole, and told him to find a doctor.

Six months ago. He’s been out of the meds for a little bit.

I grab the retired neurologist with strabismus who hangs out with the residents on Mondays. Apparently I’ve forgotten the innervation of all the eye muscles. He’s nice to me and suggests an MRI of the orbit. Graves’ disease can cause eye muscle paralysis, apparently.

 A child has headaches. Turns out she recently fled another state with her mother, because her father was beating up her mother. In the shelter there are a lot of kids who don’t always share their toys. Now she had headaches. A man with diabetes forgot to see me for 4 months and now his foot almost rotted off. We decide we need to start insulin. A patient who visits me monthly for a tapering dose of the oxycodone he takes chronically arrives with a cut over his eyebrow from a road rage fight on the way to the clinic. We sew it up. I’m already late for the next appointment, with a young woman who is “having too much unprotected sex.” I provide an emergency IUD insertion at her request.

It doesn’t stop.

A longtime patient of mine comes an hour late to her appointment. I ask her to wait until the end of the day. She does. When we finally sit down she tells me her rib might be broken, because her husband kicked her. Two weeks ago. She went to the ER at the time but waited 12 hours and finally left without being seen.

She says she’s leaving him today. We make a plan, and a follow-up appointment. She says she loves him and he’s just really suffering from schizophrenia right now. But she promises she’s going to leave.

He needs her. She may or may not need him.

She loves him. Adrenaline.

I watch her turn the corner into the hall. Now it’s my turn to wait.

Brown Rice

This morning I woke up and was instantly excited. It was time for the Quarterly All-Staff Meeting!

This is exciting in the same way as Grand Rounds might be if we had it, or the way it’s fun to eat brown rice for a change.

I was not disappointed. The morning started off with “Hooray! Lucille has worked here for 29 years! And, here are some new people we hired for medical records!” Then we learned why OSHA hates us and wants us never to eat at work. Afterward several people asked the same question in a row about whether it was okay if patients brought food to eat during their office visit.

This was followed by a 45 minute lecture about HIPPA designed to make all of us paranoid about using our smartphones, and to create passwords which no one can ever remember. In a fit of anxiety I had to tune out the guy and check my email.

Next we lined up by birthday! This is called team-building, we were told.

Then, hooray! Off to Provider Meeting.

Provider meeting is when all the doctors, CNM’s, PA’s and NP’s sit in the board room with one of the nurses who is lost, and who quickly leaves when she figures that out.  There is an agenda that is pretty accurate if you multiply each time frame by a factor of 3.

Firstly, a nice lady always comes in and tells us how we are billing wrong. This is followed by several providers giving examples of well child checks in which you also freeze off warts, asking “so how do you bill for that?” Soon enough we start worrying that the complexity of our visits are not being reflected in our billing, and someone becomes impassioned about sometimes needing to undercode for self-pay patients and someone else fights them about ethics. And throws in the word “fraud.”

Then we have to talk about access. Access is how no one can actually get in to see us but we still have lots of space because no one shows up to their appointments either. Our medical director suggests we should just take care of more things over the phone, and also that we try not to fix people’s entire lives in one visit so that the visit doesn’t take 45 minutes. Someone fights him about patients who present with chest pain, suicidal ideation and scabies all at once.

By then enough people are arguing that I raise my hand and make a feeble and vague comment intended to bring us to common ground, using keywords such as Patient-Centered Medical Home, which is mostly tangential and confusing to everyone else.

This is a perfect transition opportunity, so then we talk about how we still have no medical director after July.

Next an update on how we still don’t have an electronic medical record!

Finally it’s time to talk about productivity. We are each given a small grid detailing the average number of visits per session of the various groups of people. Everyone immediately believes the numbers are not accurate. “Well, are you keeping track of when I see a patient for carpal tunnel and then after that I put in their IUD?” “No way. I see like 15 patients a half day.” “What if the patient escapes from the clinic without turning in their papers? Because that happens a lot. Do you count them?”

Then we’re done! It’s time for Morbidity and Mortality conference! And tacos!

After all that excitement, we finally get to see some patients. Which is nice.

Day of Women

Today is March 8, 2012.

It is my dad’s 54^th birthday. When I called him this morning he told me it was also International Women’s Day, and that for his birthday he wanted me to do something for the Women of the World.

Kind of a large task if you ask me but I remembered there was something I wanted to try to write. And I’ve been wanting to write it for a while.

I’m angry at a yogurt company. It might not be yogurt, actually, it could be tampons. I wasn’t really paying attention to WHAT they were advertising. It was just that the advertisement riled me up.

And I know I shouldn’t be wasting my time with Glamour magazine anyway, but, whatever. Guilty pleasures when your flight is delayed at the airport.

This yogurt/tampon advertisement I found showed a cute young woman’s face looking thoughtful. Above her head was a bubble of all the thoughts she was having. And the advertisement was about how you shouldn’t have to worry your pretty little head about ______________________, when you’ve got so much else you’re busy thinking about. (Yeah, yogurt doesn’t fit well in that blank. Probably it was something to do with leak protection. Tampons it is.)

Here are the sorts of important things this woman was thinking about instead of her tampons.

Gaah! Bad hair day!

Do I have something stuck in my teeth?

Elevator with the boss-man. Be witty.

Holy shmoley this research project is like ultra-boring.

MMMM! Fro-yo!

Ooh. Yoga. I likey.

At bar with the girls. Super-cute guy at 11 o’clock. Wink wink.

Listen, ladies. Either we are actually incredibly vapid, or we’ve been completely undersold and are somehow totally cool with it.

Where’s the outcry? I mean, probably I shouldn’t have started yelling at the magazine in the actual airport. I get it. We’ve all learned to ignore stupid advertisements/bosses/politicians because anger doesn’t get us anywhere and we’ve got bigger fish to fry. But. Are we frying those fish? I don’t even know how to fry fish. I’m a vegetarian. I’m a weakling.

I do little things to promote egalitarianism, attempting to balance out various injustices in the world. Little things like providing discounted health care to folks without insurance. And teaching my kids to respect others regardless of race/gender/orientation/religion/BMI. And not honking at drivers who cut me off. Because maybe they were in a hurry. Because I like to be understanding. And also because my horn doesn’t work.

Yeah. It’s not enough. Because those tampon people think they’ve pinned me. They think I’m going to sit in my suburban track-home all my life and contentedly buy things, my mind consumed with major concerns like whether I’m paying too much for cable television. I think maybe they’re in cahoots with major politicians.

Now, I don’t follow politics, in the gossip-column sense. I know what I believe about the world, and I research the candidates, and I vote.

But something has managed to catch even my attention recently. Women are seriously being attacked. We’re being used as scapegoats, as political ammunition. We’re left out of congressional committees whose purpose is to determine the right of companies to decline insurance coverage for one of our most rights: the right to family planning. Abortion issues aside: folks want to pretend birth control is not a basic health care necessity. Like access to birth control has not been one of the most important determinants of a woman’s health and happiness in the past 100 years. It’s right up there with antibiotics and vaccines, people. And political pundits think they can get away with calling women prostitites who ask to have that medication covered by their insurance, like antibiotics are, and vaccines. And insulin and dialysis and colonoscopies and Viagra.

What the hell, America? It’s 2012. I was supposed to have my personal space ship by now.

Many of the women I know are quietly ignoring this. And that includes me. Why? Are we afraid to speak up, to be labeled something *gasp* unladylike? Or do we just think that if we ignore them they’ll go away? And what’s up with our men, too? Are they cool with their wives and girlfriends being treated this way?

Here’s the thing, too. We womenfolk make up 51% of the population in this country. Sure, a few ladies are out there with signs. They’re applauded in some circles, ripped apart in others. I’m not going to tell people not to make signs about what they believe in, or to stand outside and protest and demand change.

But it seems that on the whole most of us are “too busy” to do something about this trend. In perhaps the most progressive century in history, in perhaps the most powerful nation on earth, we’re accepting outright 1890’s behavior in our leaders (political, media, and otherwise.)

I’ll put it another way to try to ruffle a few feminist feathers: we’re too busy taking care of everyone else to demand what we need for ourselves.

I don’t have any posterboard and I can’t find any markers. I’m asking us to consider something simpler. We make up over half of the voting populace. We’re fortunate enough in this country to have a representative-ish government. Sure, your congressperson may not look like you, but they’re paid to represent you. When was the last time you told him or her what you think?

Because we do think.

And despite what my tampon advertisement nemeses believe, here’s what we think about:

The kids need to let go of my legs so I can go to work.

Let. Go. Now.

Where are my keys?

I’m leaving for work. I hope my kids know how much I love them, even though I have to leave every day. I hope they know I do it for them.

Maybe when they start school that will distract them.

I hope the school cares about my kids almost as much as I do. I hope they teach them things. I hope it gets better before they start school.

And when they learn stuff and graduate, it would be nice if they had jobs, too.

I hope they can get jobs.

I hope they like their jobs.

Do I like my job? Yes. I do. Mostly. It’s just hard. Not just the thinking part. It’s hard that so many people are sick right now, without insurance, without jobs, without homes, without hope.

How come I never change the oil in this car? It’s been… 3 years? Can that be right?

I totally forgot to bring a lunch.

At least I have food at home. I’m lucky I have a job, too.

If things are this bad in America, how awful must they be in other places?

Imagine if I didn’t have food for my kids.

I hope it gets better for those folks, too.

I hope. I still have it. Do you? Good. But hope is completely actionless. It’s waiting, passively, for the world to change. It’s like waiting in a castle for your prince charming to rescue you. Not gonna happen. Sounds boring, anyway.

Instead of hoping I’d be a doctor one day, I studied. I took way too many tests. I went to school for a lot of years. I stayed up all night, heart racing, feet running up and down halls to codes, deliveries, surgeries, patients requesting dilaudid. I helped people be born, and watched others die, and everything in between. I did all that. And now I’m a doctor.

We ladies know how to get things done. We start with hope, but then we do something about it. We’re good at that, as long as it’s within the realm of home, self, and work. But what about everything else that affects us? The schools, the city, the country, the world? This world needs to get some things done, folks. This world needs us.

It’s not going to happen without us.

So I’m taking all my thoughts, all my hopes. And I’m doing everything I can to make them real. Starting today.

Starting with:

I’m telling my kids how much I love them. I’m showing them I care by working for something I’m passionate about, something that matters. Something that’s bigger than I. I’m going to actively make a difference in the world, try to make it a better place for them. I’ll start by fighting for the rights of women. When the kids are old enough, I’ll explain this to them, so they know. They are the reason I need to do this, and why I need to leave them every day. One day it will be worth it for all of us.

I’m taking charge of my kids’ education. I’ll learn alongside them while they’re little, and I won’t accept mediocrity in the school system. What I can do there to make a difference, I will.

I’m changing the oil in my car. Probably.

I’m letting my government know I’m not happy. With all the focus on me keeping an aspirin between my knees I’m pretty sure more important things are being left by the wayside. Like my kids’ education. And other kids’ hunger. And lack of adequate health care. And jobs, and war crimes, and famine and rape and subjugation of women the world-over. Not cool, government. Let us fill you in on what matters. I’m not voting for you if you don’t care about what matters.

And if they don’t listen, then we need to take over. Let’s be elected officials. Let’s be presidents. Let’s get this done. We know what we need, ladies, and there’s no dragon keeping us from stepping outside this castle. Let’s go out into the world, and make it the place it needs to be. For our children. For our sisters’ children. For our men. For us.

Just as soon as I find my keys.

Budd Gets Better

Remember Budd-Chiari? Here’s what I love about family medicine: I get to be part of the story.

Here’s what I hate about family medicine: the hospitalist thinks I’m stupid.

A couple of months ago Budd-Chiari was sick, no doubt about it. After I called several specialists and read everything I could on Up-to-Date, I ordered some tests.  And the tests showed he was marginally sicker. His sedimentation rate, a marker of inflammation, was climbing to 100. His white blood cell count, while not outlandish, was high. Higher than before. And he was still having fevers, with hallucinations.

This is not normal in a 35 year old.

And I had it on good authority that it wasn’t explained by the clot in his liver, either. And by good authority I mean the jovial gastroenterologist I managed to reach by phone. I don’t know what the hell I’m doing.

So I sent him that evening to the emergency room, for further work-up on his spiking fevers to 103, with delirium and worsening lab values.

The dictation for his admission goes something like this:  “35 year old male sent over by primary care doctor for abnormal lab values, including elevated sedimentation rate. There is really nothing wrong with him and so I don’t know what the big deal is and why I had to waste my time on this admission. Obviously he has a clot in his liver and that is why he feels sick. Stupid family doctors who freak out about the Erythrocyte Sedimentation Rate. Temp 101.5. Whatever, dude. I’m going back to bed.”

I may be paraphrasing a bit. Not much.

Sure enough, they sent him home the next day. No antibiotics. Still spiking fevers. Still delirious.

I was disheartened to say the least. Now the enigma was back in my lap, and I had even less confidence than before.

A week later the blood cultures from his overnight admission came back growing gram-negative rods. At the same time the blood cultures I had drawn with the ESR and CBC came up positive as well.

It was my day off. They called the residents, for reasons I don’t understand. The residents called me. I called the family. They weren’t keen on going back to the hospital, understandably. We talked about options. They felt he was better and might be able to take oral antibiotics.

Then he spiked a fever again and they called the answering service, who connected them to Leafy.

Leafy is just like me, fresh out, 6 months younger than I am if that’s possible. She told him to go to the ER. Leafy has an asset I don’t: her husband is an ER doctor who may also be a Linebacker. He took the case.

She called me. “Yeah, I read that history and physical from his earlier admission. A little passive-aggressive, I thought.”

“Me too! I knew something was wrong with that guy. And they totally didn’t take me seriously.”

“And they implied as much in their dictation. But you were right – he was sick. Not cool, hospitalist.”

I was right. –ish. I mean, I didn’t know what was wrong with him, just that he was SICK. And none of us could ever have guessed, nor spelled, the cause of his illness:

Erysipelothrix rhusiopathiae.

He got lots of attention in the hospital. IV antibiotics, ID consult, the works.

And then he got better. I saw him 2 weeks out, smiling, laughing, a quick wit. He told me about his heavy metal band, and the impending birth of his daughter.

What a difference a few antibiotics make. 

It’s pretty great to see the end of the story, to see him get better. I kind of want to call that first hospitalist to let him know. But I don’t think I’ll allow him that gratification.

Panel Management

They say, and “they” are some study I never read but heard about from Dr. DDX, so that’s pretty much as good as gospel, that it takes 14 hours a day to manage chronic disease. As in, 14 hours a day for just your patients with diagnoses like high blood pressure and diabetes, just for panel management. Ensuring they get tests done, follow-up labs, check their blood pressure, learn to eat better, stop smoking, see specialists, etc. etc. etc.  This is called panel management.

14 hours a day for those guys. Not counting prevention of disease in healthy persons. Not counting managing folks who are acutely ill or have an extensive work-up going on.

Not counting, you know, actually seeing patients and the like.

This is how much time it takes to do our patients justice. And how much is allotted providers for this in reality? 35 minutes? Nothing at all?

When I think about this I have a panic attack and 5 more of my hairs turn grey.

Thus I have created a simple, elegant and entirely inadequate Panel Management Device.  I have limited it to the patients whom, when I think about them, I have a panic attack and 5 more of my hairs turn grey. That is my selection criteria. I call it the Shit List.

Now, do not misunderstand me. The patients on this list are wonderful people. The list is not named for them. Nor is it named because they are on my bad side, or because I am angry with them. It is so named because it is the first and only thing I could think of naming it. Also because it is what I might do in my pants if I can’t track these people down for follow-up. Another selection criteria.

No one else knows what it is called. I have labeled it simply S.L. and have drawn attractive and distracting designs on the back side.

Now what I do is occasionally look it over and review outstanding items. I make sure folks got to see specialists. If an imaging study hasn’t been done I have someone remind the patient to do it. Everyone on the list has a follow-up with me in the next month, and a working phone number listed. Hopefully. There’s a revolving list of specialists to curbside, cases to talk through with colleagues, and topics to read about.

Then I have a panic attack and give 17 sticky notes to my MA.

I’m pretty sure this is how panel management works.

Fire?

Strategic history and physical today of a 4 year old hyperactive child with headaches:  

He begins by shouting into the intercom phone in the room.  We complete our HPI talking on imaginary phones.  Observing him slide in and out the pap stirrups = motor exam.  He dives into the biohazard bin.  I ask him to please not dive into the biohazard bin.   Gross motor+language comprehension.  He discovers the pap light.  No photophobia, it seems.  Pupils are equally reactive to light.   

He shines the light on the wall. 

“Oh no, guys, it’s a fire!”  He yells.

“Really?”

“Yeah! Get in the car!”

I wheel my stool around the room.  He drives the procedures cart.

“Grab the hose!” I shout.

He grabs my pen.

“Fire!!” He yells.

“Put it out!” We both spray the wall with the hose.  We have to hold on tight because it is one of those huge ones on fire trucks, you know. 

The kick back causes the procedures cart to crash into the wall.

My medical assistant bursts through the door.

“Are you guys alright in here?”

“Um, yeah,” I say.

“Guys!  There’s an alien! WATCHOUT!”  He bolts from the room.

I guess we’re done?

Week 2

This morning I’m in the hospital.  I will be here occasionally in this job.  It is large and daunting but I have found the cafeteria.  It’s not busy this morning apparently and the guy I’m supposed to follow around isn’t here yet.  In fact I may have awoken him with my 6:56am call.  There’s free wireless though so I can do facebook and pretend I’m somewhere familiar. 

Last week was remarkable for the presence of a Day Off.  This is a marvelous phenomenon which apparently exists in the real world of real doctors.  In it, you do not work on that day.  Except probably you spend the whole day unpacking boxes and go for a 4-mile run while the kids are sleeping.  But that turns out to be lovely.  And then when you go back to work the next day it is Friday and so it is only One Day Before the Weekend and you can do anything for one day.  Even if one of the patients requests you get a second opinion from a doctor who "looks older than you do."

Even if you discover in clinic that there are no ortho supplies.  Or crutches.  And you had to send a poor little girl hopping to the ER holding on to her mother’s arm.  That is unfortunate.  You can think about that on your day off.  Actually, maybe you shouldn't.  But you probably will anyway.  Hmmm.

**********

Here are some things I thought about, 10 minutes too late, today.  First impressions matter.  As you meet people while touring a hospital, probably don’t comment on people’s impressively western outfits, or tell them about your previous experiences with mentally ill nephrologists, or let them know about your fringe activities in the medical field.  Probably don’t  try to pronounce their name unless it’s John Smith.

But then I had my first delivery of the likely many to come.  One nice thing about babies is that they all come out in the same one of two ways no matter where you work.   And almost all mothers think at the last minute that they can’t do it.  And then they do.  Lovely little boy.  The thing is that in every hospital all the forms are different and the protocols are different and the delivery tables are set up differently and you’re never supposed to put the laps in the same place.  But whatever.  Babies.

Bless the babies.