Category Archives: Medical

Health Care Culture

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woman-fitting-in

I usually find a way to fit in a new job pretty quickly. Years of working as a locum tenens makes fitting in a survival skill.  I am surprised that I am feeling a little more guarded than usual. A friend of mine would call it “well defended”.

So much of healthcare is cultural. In some places every one handles colds in one way ( everyone gets a ton of medications) and in some places, we recommend tea, honey and rest.  In the first weeks I am in a new place, there are always folks who misunderstand my “style”.   With some patients I have to WORK really hard to convince them that I am really on their side.

Then, there is the whole culture of handling urgent issues.  Some places have protocols- anyone has a blood pressure greater than 180/90 gets the 911 treatment, no matter what the provider thinks is right.  Some place rarely send anyone to the ER and try to handle everything possible in the clinic.  Today was one of those days of explaining that I know what I want to do with this young patient, but I need to know how this clinic handles things. Labs/imaging and then to ER, or just skip it all and send to ER. Direct admit? What goes with her? Do I print the note, or write a new one on a script?

Some clinics work as a team, while some are just people in the same building without much interaction. Some folks are much more serious, some laugh and goof off all day between patients.  I am trying to find out where I will fit in this new place.  I feel “stressed out” trying to adjust. I am trying so hard not to be too much of me. I am working this time on having unspoken thoughts.

But, somehow it ends up like this…

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( I am also trying to let go of wanting things to be perfect- like blogging.  )

Chronic Pain

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Chronic Pain

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I was half listening to my latest audible book on the way to my first day of orientation at the new job. I say half because it is probably the 3rd time through those last few chapters. It isn’t because the book isn’t holding my attention, it is just it is one of those books I am talking back to as I drive and listen. It is one of the books that I will order in print and highlight and take notes in the margins.  I will review the book in more detail in some future post.

But she said something that had me wanting to scream.  She said that not treating patients in chronic pain amounts to torture.  I may be assuming too much, but it seems she was overly emphasizing opioids as a treatment for chronic pain. Firstly, opioids suck at treating most chronic pain and cause many more problems that they solve most of the time. Secondly, no one has a right to a pain free life. No one.

I was getting all judgy, as I am wont to do. Talking back to the book.  Really? Torture?  How is it my fault that you smoke, don’t exercise, drink like a fish, are 75 pounds over weight and now your knees and back hurt? Really? Sounds like that chronic pain is on your side of the net that divides us in this debate over opioids. I am not going to continue every patient in pain on the unholy trinity of Norco, Soma, and Xanax.

Then, doing my best Tevye impression ( from Fiddler on a Roof), I said, “On the other hand”, What about the obese, sedentary smoker who needs medication to control their blood pressure and blood sugars both of which are out of control because of their lifestyle choices? Do I want to say, No more Metformin for you unless you start exercising? No. Of course not.  But on the other hand, I don’t see Metformin sending the patient down a slippery slope of every escalating medications with all motivation sucked out of them now do I?

I should hold off my opinion of this book until I finish it completely.  I am finding it to be a fascinating if not somewhat biased account of the state of chronic pain diagnosis and treatment.  As loud as I shouted in the car at the author, she did not respond, so I am just venting a bit here.  Torture and not giving opioids to every chronic pain patient are entirely different things. Seriously.

I am not just frustrated with the patient, I am more upset with the system that got us on opposing sides in the opioid wars.  We all know it doesn’t work to just give folks opioids. It is so much more complicated than that.  Pain management is always a trial with an “n” of 1.   Each person is different.  Even that one person is different on a day to day basis.  Not giving out opioids to every patient is NOT torture.  Please review the history of any war of your choice to get a much clearer idea of what torture is and is not.

Zebra Hunter

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Zebra Hunter

zebraI am admittedly a Zebra Hunter.  In my defense, I worked acute care pediatrics in world famous children’s hospital when nearly all 300 of the kids were zebras of some sort. If not, they were more easily cared for in the community hospitals. For the years I worked there, I was surrounded by the most brilliant minds, amazing caregivers trying to puzzle out the most complex children. I had no idea that it was possible for so many chromosomes to be off just a little.

Everyday things were life threatening. Sinus infections and ear infections somehow had turned into empyema of the brain.  The rarest cancers, the most complicated neuro surgeries.  Once when Infectious disease and neuro surgery looked at images together, the neuro surgeon picked up that baby to RUN him to surgery.

So, when I first saw kids in the community with an ear infection or sinus infection, I would want to make sure it wasn’t going to be more serious.  Are those bruises on that toddler ” non accidental trauma.”?  In the hospital, everything was figured out immediately- it was like magic- Any image, MRI, MRA, or weird lab was just done almost immediately. Work ups were quick, often intense, but things were figured out before the child went home.

The “real world” isn’t like that at all. It is full of mostly horses. Sometimes some pretty fancy horses, but mostly mundane. Except for the past few weeks, when I have learned more about endocrine that I had no idea that I didn’t know. I am weirdly excited about it all. I mean, it is fascinating when it is something so unusual.

I think I find the weird stuff in part because I worry about missing something. I also tend to listen to patients.  I like to hear their stories. I like to try to put the pieces of the puzzle together.  I am endlessly curious about everything.

What is so very interesting these past few weeks is that these are things that one would think would be noticed long before I meet the patient. I don’t know how someone else didn’t think it odd that the 40 year old patient with palpitations was so weirdly bendy. Not yoga bendy but something unusual, that makes me ask if they can touch the floor with their palms, encircle their wrist with pinky and thumb, touch their thumb to their wrist. Can I see your palate?  Yeah, no one every asked or looked.

I am not a physician, so I didn’t have much exposure to radiology in school. Well, actually NONE. So I don’t just read the radiology report “impression” I read the whole report. I look up words. I pull out one of my radiology texts. I read, read, read. I question. I want the answers. I need the answers, so next time I will know. More times than I can count, what I read in the “Impression” doesn’t completely match what is in the body of the report. This is probably a reflection of those dreaded “pre clicks” on computer programs. I ask about that nodule or cyst mentioned.

These past few weeks I have been in the middle of a whole herd of Zebras!  Strange lung stuff that we are still working out. Pheochromocytoma in that “anxious” patient.  Some things that are so unusual that HIPPA’s ears will perk up if I think it too loud, but really, really strange endocrine stuff that is fascinating.

The term Zebra Hunter isn’t a compliment really. It would be more of insult, if I didn’t nearly always get that Zebra. As often as I might say that I long for less interesting practice,  I find the hunt makes me look forward to getting to work.  It is like turning the pages in a mystery novel. This next week, the pieces of at least 5 very odd cases will come together.

Don’t you dare!

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Don’t you dare!

I looked her in the eye and said calmly: If you answer that phone, our visit is over. You will need to reschedule.

She stares at the phone with that same look I have seen in the eyes of heroin addict. It is hard for her to lift her eyes to meet mine.  “What?” She asks honestly confused.

I said that if you don’t turn the cell phone off I will leave the room and you can reschedule. I won’t compete for your attention.

Again, she seems confused;  “Why? Does it mess up the equipment?”

“Firstly, it is rude. Secondly, it is distracting to me.  But most importantly  if whatever is on the other end of that phone is more important than your sick child, you need to go right now and take care of it.  You need to be here in this visit with your child for 10 minutes”

“Okay”. She doesn’t turn it off. She puts it down, screen up on her thigh. The toddler is nervous, but she doesn’t notice the kiddos  body language in the same way she notices the phone calling her.

We go back to the visit. The father looks at the mother, clearly annoyed, but she doesn’t notice. She is stealing glances down at the screen and pretending to be present. She isn’t.

The child has candy apple red ear drums and cries when I touch the pinna as gently as I can. It is hard for the mother to help comfort the child, because she only has the one hand for the child, the other is on the phone.

I am talking to the parents about the diagnosis, medications, the risks and benefits. During this, I start typing the prescription into the computer and ask the mother a question, she doesn’t answer.  She is texting. I am annoyed but the visit is nearly over except for the discussion about the medications, risk and benefits, supportive care and what to watch for.

She asks me what I just said.  I told her that I am not repeating.  The father was listening and she would have to ask him. The father gave her another annoyed look, but she didn’t notice.  I can tell that she truly doesn’t get it.  She doesn’t understand that her behavior is not just rude, but unsafe. It is important that you understand what I am telling you. Really.

This happens more often that I can count. I no longer ask for the patient’s attention more than once.   The signs are posted everywhere. The Medical Assistant tells them that the must turn them off.  If they are on the phone when I come in, I tell them I will come back in a while.  I don’t mind if they are playing games to pass time, but calling the phone company, their bestie for lunch is not okay.  I tell them after I see the next patient, that the cell phone needs to be off.

At least one a week when I walk into an exam room,  I  have a patient put their hand up to tell me that they will be with me in just a few. One motioned for me to come in and wait. Seriously.

If whatever it is cannot wait for our 10 minute visit, I don’t want you to come into the office for a visit.  If POTUS can give a 30 minute speech without checking his blackberry, so can you.

I don’t carry my cell phone into patient rooms. If my family needs to reach me urgently, they know the land line number and they can reach me.  You need to arrange your sitter, dog walker, girl scout cookie, facebook status update, electric bill and parole office contact in any other time slot. You can reschedule with me at a more convenient time.

Alogophobia, Kinesiophobia and Chronic Pain

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Alogophobia,  Kinesiophobia and Chronic Pain

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This morning I fell at work. Hard.  I was in a hurry, putting my purse down in the provider charting area, grabbing my Starbucks red coffee mug and stepped quickly out into the freshly waxed hallway. I didn’t notice that the floor crew had soaked the first two feet of carpet in our little office and my boots were wet.  It was such a strange fall.  I had no sensation of falling at all. I was just suddenly face down on the floor, landing mostly on my left knee, hip and outstretched hand.

My knee is bruised and hand are bruised and my left thigh started cramping up by the end of the day. I put an ice pack on every time I sat down to chart. Here is what I know: I am going to be just fine. I will probably be a little more sore tomorrow but my body is designed to heal. I am not going to sue. I am not going to develop any chronic pain syndrome as a result of this fall. I am not going to believe that I will develop arthritis of my knee or that I did anything to discs in my back that won’t heal on its own.

Sadly, many of the chronic pain patients that I see have had similar minor accidents or falls sometimes as long as twenty years ago that set their lives into a tailspin of chronic pain syndrome. When I talk to them, they tell me that they have degenerative disc/back/knee problems.   There were told by someone they respected that they will develop arthritis in the area of injury. They may have been told that they have a bulging disc, which they may have had before the injury since many times this is asymptomatic. They believe that discs can never improve or heal.

The most interesting thing to me is that they become afraid to move. They are convinced beyond reason that  if they move or exercise they will do damage to their area of injury. This idea remains fixed for what seems to me to be the rest of their life. Physical therapy has never worked for them because they are convinced that the pain means that something is wrong. Really wrong and it not going to heal ever.

Today, I tried to “walk it off” between icing the knee and thigh. I stretched my back gently. I believe that if I sit still, my muscles will spasm. I believe I will be fine. I don’t need Norco or likely even Tylenol for pain. Trust me, the bruises and swelling are pretty impressive. I know I will be just fine because I am not afraid. No one put a soft collar on my neck or took x rays of anything.

I love my vocation. I am happy with my life. But what if I were unhappy? What if I hated my job? What if I believed in lawsuits for slip and fall? What if I didn’t know all the things that I know about pain and the brain? I could be off work for months as many patients that I see are. Some patients are off for more than a year for a very simple slip and fall.

I think one of the most important things we need to do is to teach people that our bodies are designed to heal. There is virtually nothing that is made better by prolonged rest. Teach that the longer you rest, the more the muscles atrophy, weaken and weak muscles hurt when you use them. We need to teach that pain does not always mean disability.

Snitches Get Stitches- Protecting the Guilty

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For weeks, I have been conflicted about talking about a situation in my work world. I am not sure what the “right” thing to do is. No, that is a lie. I know right from wrong, damnit and what is going on is wrong.  I worry about big scary words like slander and liable.  I know that my vocation calls me to protect my patient from harm. Sometimes, that harm is another health care provider.

On the other hand, we all have this not quite unspoken code of keeping our mouths shut when we are all aware of another health care provider who is dangerous.  We talk among ourselves. We roll our eyes. We call someone to the computer and say- “Did you see this?”.  We ask each other how that person gets away with this. Of course, that is as far as it goes, right?

There is a physician who is routinely seeing 70 patients in 5 hours. We joke that on the evening he works later, the whole waiting room looks like a scene from the Walking Dead.  I found myself humming the Leper’s song from Jesus Christ Super Star.  They are all there for Norco, Xanax, and Soma as a cocktail along with more other drugs that I can count. We know this is wrong.  We worry. We whisper. No one says anything to him though.

Yesterday, I shared clinic hours with him. In my defense, I was in and out of rooms too, and doing some much needed catching up on four inch stack of labs and images. I was working as hard as I could to stay on task and focused. Once, I walked into the common nursing area and heard folks talking about “not responding right” and he was standing the doorway and I assume this is his patient and he is a physician who has this handled. I went back to office/charting area a few doors away.  In the hallway I heard someone say something about an ambulance and again, assumed he was taking care of his patient and had called the ambulance. I was only mildly concerned because I had worked in clinics where it is just protocol to call 911 for things as minor as elevated blood pressure. I briefly wondered if one of the COPD patients was having a very hard time.

I went back to the nurses station area to get some forms as ambulance was arriving, the physician wasn’t in sight, so I assumed he was in the room with the patient. I had called 911 in other clinics and stayed with the unstable patient until care is turned over to the paramedics.

But no. Later, several assistants came in the providers charting area and asked me if I knew what happened. The physician walked into the room, the elderly female patient seemed groggy to him. He came out after a minute and told the assistants- “She won’t answer my questions” and said something like she had probably taken too many medications. He gave no orders, no concerns and moved on to the next patient. It took a few minutes for the assistants to figure out to go in the room and check, and they found her nodding out and barely responsive. One got a blood sugar of less than 30 and called the ambulance. On their own because he was ignoring the whole situation.  They didn’t come to me, because HE is the DOCTOR.  He continued seeing all his patients and ignoring the whole scene and the patient who became completely unresponsive before the ambulance arrived.

I find this out after the ambulance has gone.  We are all not as shocked as we pretend to be. We know he is horrible. We know he doesn’t examine patients. We know. We talk. We DO nothing.

I came in this morning and looked for a trusted colleague and he told me he had just heard the whole story. I told him, I am not staying silent. I am going to the clinic director.  We each spoke with her today.  I doubt anything will happen. Not for her lack of trying, but he is a powerful person in this community.  This is not the first or even second time I have been to a clinic that is so scary.

I am scared for his patients.  When I see them and update the problem and medication list, explain that some medications are not safe to be taken together or shouldn’t be taken with their condition, or that they need some tests and I do a physical exam, they tell me that it is the first time someone has touched them or examined them in 3,5, or 7 years.  I am quiet.  I don’t criticize other providers.  I think I am a coward.

Who are we protecting when we stay silent? Are we protecting the other provider? Are we trying to protect the patient? Are we protecting ourselves?

I am the locums. I am the outsider. I was raised that tattling is the worst thing you can do. No one likes a tattletale. “Snitches get stitches”. “Not my circus, not my monkeys”

What do you tell yourself when you protect the dangerous provider with your silence? We all know these “bad apples”, don’t we?  Have you confronted them personally? Do you think administration will handle this?  What do you do? I really want to know.

Mad Scientists

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http://www.amazon.com/gp/product/0143113100/ref=as_li_qf_sp_asin_il_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=0143113100&linkCode=as2&tag=doegas-20&linkId=DZ4D4HZFZYWCD6O5

As fascinated as I am by neuroplasticity, I don’t know if I can finish this book.  I had just finished this author’s book, The Brain’s Way of Healing and I liked it so much I ordered extra credits on my Audible just so I could listen to this on my drive.  I was a little creeped out by the way he kept referring to any sort of kink as a perversion with its roots in childhood medical illness with painful procedures. I thought Okay, this guy is a little old fashioned using the word “perversion” to describe so many sexual acts that are not normal intercourse between a man and woman.

But then…

He started describing those experiments that Taub conducted on monkeys. I was interested in the research as it pertains to neuroplasticity, especially in stroke victims. But as Dr. Doidge described in more detail how Taub, severed nerves in the poor creatures, amputated their fingers, repeatedly opened their skulls and restrained them for weeks/months as you see below,  I couldn’t concentrate on what the whole point of the studies might have been.  I actually yelled ” What the F…” while I was driving.

When I got home this afternoon, I Googled the creep:

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I want to go grab Taub and shake him.  We had a pet monkey, Pepe, when I was young. He was like the most annoying sibling in the world but he was child like in his affections ( and tantrums). That monkey in restraints looks so much like Pepe. I can’t imagine putting any living thing through that sort of torture, but this just breaks my heart.   I know that this horrid man advanced the field of neurology and the information gained has changed the lives of so many human victims of stroke and other CNS injury. But can we honestly believe that there was not another way to get this knowledge?

images( He looks like such a nice guy, doesn’t he?)

The book may be a great source of information, but I don’t know if I can go back to it. The author seems to be excusing Taub’s methods. I just had to turn the book off for now.

What do you think? What limits should be there be in using other animals in research? Does the good outweigh the bad?