Why My Daughters Are Going to Have the HPV Vaccine Strongly Suggested To Them

A beautiful little cherub sits on the stretcher. Not as cute as my kids, of course, but close. She's reading to herself. Groomed. Haircut is stylish. She's a vision of Nordic charm. Then you ask her how she likes her book. 'Good', she says, 'it's called Who Rang the Doorbell'. Hmmm. Voice is all raspy and soft. I can barely hear her.

That's because she's had genital warts lasered or chopped off her larynx like sixty gajillion times (aka, once every four to six weeks for a year or two). How did she get them? Her mom had asymptomatic HPV at the time of her vaginal delivery that was either missed or tested for and not caught. Now this little girl has to come in and get put under general anesthesia all the time. Today she has re-growth that's 'not too bad' according to the ENT doc. The clusters of new HPV growth are only occluding about 30% of her tracheal opening after six weeks. You can't even see her vocal cords anymore. Her larynx is a tube of scar tissue and virus. There's enough bleeding and swelling after the treatments that she's been hypoxic a few times from acute obstruction, and of course, if she didn't have the surgeries the virus would just keep growing until it blocked her airway and she died.

Compare that to some local injection reactions from the vaccine. Damn those pharmaceutical companies coercing young women into getting a shot just for profit, and forcing their immoral opinions on our young women.

Set-Up For Success

Normally, intubating children produces angst because we're worried if we miss, but overall they tend to be straightforward as long as you do a few simple things. For young kids, you should have their ear at the level of their anterior shoulder, perhaps put a towel under their shoulder to compensate for their giant heeds, use a straight blade, look up, and you're home free.

So when the anesthesiologist brings in a wee laddie in a crib in traction, meaning their legs are up in the air, their chin is slouched into their chest, there's no way to approach them straight from above like we normally do, and then he says, "let's intubate him on the crib", and, "I normally don't use a paralytic", that's an awesome set up. Sterling. Perfect.

We ended up using a paralytic. Then I got it the second time. Gives me a lot of respect for paramedics intubating with less than ideal conditions, including in cars, in fields, and so on. However, when you have time, it seems silly to me not to use every advantage the first time, every time. Ironic, since usually the anesthesiologists call us cowboys, not the other way around.


Healthcare Reform

Sigh. I guess it's time to finally say something about this circus. About this distraction. About healthcare 'reform'.

The biggest thing I can say is that we're missing the point completely. The death panel debate is inane and shockingly uninformed and offensive, but it's really a shell game in front of closed-door deals that signal the true agenda of this bill and 'reform': window dressing for business as usual.

Obama, for all his rhetoric, looks to have sold the public down the river in order to mollify the big contributors, including for-profit hospitals, the insurance agency, and big pharma. How can I say this? Well, it seems obvious that he's agreed to limit contributions from the big players as covered by the NY Times and others. Now, conveniently the dialogue has shifted to co-ops instead of a public option; the 'death panel' idea has been dropped. The talk is about taxing health benefits, requiring people to buy insurance, and avoiding forcing drug companies into concessions on what they charge Medicare, all in the name of 'personal freedom'. These are all shifts away from what he said on the campaign trail, and away from meaningful reform.

The real show is going on behind closed doors. And if you're not outraged at that as a citizen you're missing the point. The big dogs are off making the real deal while we're busy yelling at each other like morons in 'town hall meetings'.

The real discussion needs to occur about the possibility of a single-payer, government run system. Unfortunately, with so much money and profit wrapped up in both politics and all aspects of media, it'll never happen. Does that help me as a doctor? Sort of. I'll keep making a higher salary, but I'll also be little more than a profit engine for corporations providing health care struggling to actually take care of patients. We'll still have uneven distribution of outcomes based on socioeconomic status, the CEOs of insurance companies and pharmaceutical companies and hospitals will still make enormous profits, and the president will get his speech. But, overall, very, very little will actually change except you'll be forced to buy crappy insurance.

What actually needs to happen is to get the monied interests out of the back conference rooms of the white house, and out of congress, and out of politics. When John Adams made his way to the continental congress before we were even a country, he had to do it for free, and he had to close down his law practice to do it. He did it because he loved his country, not for the bennies (which, for current congressmen and women, includes a great health care plan. Notice how they're not talking about giving that up). It's all about campaign finance reform and lobby reform, not health insurance.

Life-saving skills

Stuff that saves people is cool. We can all accept that. The things that really save people, though, are usually not what we expect. Helicopter transport, hypothermia with a cool machine that self-regulates, ICU care, monitors that beep and whistle, recombinant clotting factors that cost more than an SUV per ounce, those save people, right?

Um, maybe; but things that actually do are often eerily simple. Good chest compressions. Needles in the mid-clavicular line. And airway management--with a mask and a chin lift.

Terrifyingly recently, anesthesiologists would do a suprising number of cases without intubation and without a machine, just bagging the patient with an ambu bag. You breathe for the patient, literally.

On peds anesthesia this week, the best cases were the ear tubes, becuase for five minutes or so it'd just be me and the bag and the patient not breathing. This skill, as much as intubation, saves lives. Just a bag. No big fiber-optic scope, no fancy stainless steel LED-lit laryngoscope or, as my trauma surgeon called it, 'dog and pony show'.

It's all well and good to talk about lifting the jaw up into the mask with your pinkie, ring and middle finger spread from behind the jaw to the chin, but like any motor memory task, it takes time to learn it. Once you do, there's no feeling like holding the jaw up, squeezing the bag, and watching that little chest rise just enough to avoid inflating the stomach while still giving them oxygen. And to think we walk around normally breathing without even thinking about it. Want to manage a person's airway? Learn to bag. Don't know what to do with a failed airway? Learn to bag. Save a life.


FMOE: What do I do with this rhythm?

Gimme an M! Gimme an A! Gimme a G! What's that spell? That's right, the electrolyte that's also a code drug. Let's hear it for magnesium. 1 to 2 grams IV like, stat.

And for all the med students out there? Want an obscure cause of Torsdes? Try cardiac sarcoidosis. We had a woman with a strip like the above who we loaded with mag after a self-limited run who had just been diagnosed with sarcoidosis. The cardiac MRI was negative, unfortunately for science, but fortunately for her.

Rat Poison

He finishes dinner with his wife, the first they've had in weeks as he's recovered from hospitalization. Both feel better. Renewed. Maybe a bit hopeful. His balance isn't what it used to be, he's still tired, unsteady at times. Weaker than he was. She finishes the dishes while he, complaining of being tired, heads for bed upstairs.

On the third step, he remembers something and, naturally, turns to go back down. His balance, though. Not what it used to be. He falls the three steps, foreward into the foyer. And weak; doesn't catch himself. His nose bleeds. And bleeds. Bleeds even after she holds pressure and calls 911, bleeds to the hospital. Bleeds with anterior packing.

By the time he stops bleeding with a postieror pack, he's intubated; mental status, airway protection, and all that. Multiple facial fractures are found. He's admitted to the ICU for a hopefully swift recovery. Opacity at the base of his lung is watched; perhaps he breathed blood. Hard to say.

By day 3 or 4, it's not hard to say. The lung fills in, the tube stays after the packing does. He spikes fevers. He doesn't wake up. Now 4 to 5 days without nutrition, fractured, infected, a tired body, issues layering on each other.

His wife knows that he wouldn't want all of this. Wouldn't want the tracheostomy, the feeding tube, the supportive care to see if he comes out of it. That's were we were. Stuck. Or, not stuck, because the family was sure of his wishes, and all of them agreed.

The Navy man who drove the boats for the landing on Guadalcanal had care withdrawn on the 4th of July. How terrible, you may opine. How macabre. But. The monitors were shut off. The tubes removed. His sons and daughter were there. His wife was there. They held his yellowed, bruised cool hands. Draped in a home blanket. They spoke to him, and we shut the door and the curtains, watching the monitor still on outside slow, and become more and more shallow until they stopped.

This is the situation the supposed 'death panels' were for. It was as good a death as we could offer for a good man. No bureaucrat showed up and told us we had to let grandpa die, nor would they if we had kept the 'death panels'. The family happened to know what he wanted, and because of that, we could let him go. What if they had been gone? What if they had disagreed? Weeks and months could pass, hooked up to machines and tubes, sustained, exactly as he didn't want to be maintained.

It's terrible when anyone dies. It's worse when they are treated with guesses as to their wishes. No one deserves guesses like that. The family is often asked to 'guess' what they might have wanted. Imagine, having to feel as though your decision will either end the person's life or lead to a full code and then the end of their life, not knowing if they wanted to leave quietly, or fighting to the last.



The concept of burnout isn't new; the pre-game is brownout, and it feels like it sounds. There's no crack, no explosion, no drama. Just a slow fade. The exams of patients get a bit shorter, the reliance on data higher because it's emotionally easier to look at a scan or a lab. The morning is harder.

Empathy starts to slip and is replaced by pity and sarcasm. Families aren't comforted or updated as often. It's not terminal. Your work doesn't slip to poor, just from excellent to good, or good enough.

Time to leave the ICU. Time to leave the one long hallway lined with an ever-changing but remarkably similar parade of random victims, the drug dealer next to the teenage model UN attendee struck by the drunk driver. Time to leave the purring ventilators and whispering pumps and step into the sunlight. Three days. Thirty-six hours, give or take. Not that I'm counting.

I am not who I was.