Interns Can't Move Meat

'Moving Meat' is a phrase for quick discharges in the ED. It's a prized skill and one that I, the Intern, do not have. Dear God did I have trouble with dispo last night. We're starting off with an orientation month in our program, and I guess I took 'starting slowly' literally to mean 'wait six to eight hours to dispo your patients'. Horrible.

So what? Well, a recent article in slate pointed out that people who are boarded (kept in a bed) in the ED are 4% more likely to die. There is a mortality effect to keeping patients around when they don't need to be there. Not to mention the experience of angst over discharge ruined my whole shift and probably those of my attendings and the nurses.

Why couldn't I send the quadriplegic with a UTI and no fever home? Root cause? I felt sorry for her. What, compassion bad in an MD? Well, feeling sorry for someone isn't compassion, it's pity. And pity kills. Compassion would've been to see her as a capable human being, and if she said she was OK to go home alone and handle her own follow-up and get her own drugs (as she hadn't last time) I should've probably let her. It sure was simpler watching dispo as a student then doing it. Sigh.

MedFlight Tribute Page

UW Health has posted a tribute page where anyone can post remembrances, here. It also contains a link to the page itself to read what others have submitted. Thanks to commentators here and to those from around the country who have sent their condolences.

Dear God, No. No, no, no!

At the risk of losing anonymity, I have to post the passing of one of those docs I most admire, one of the best I've worked with or seen, who will truly be missed. There was a crash last night, just to the west of La Crosse, Wisconsin; one of UW Madison's EC-135 copters went down with few details known yet. As of what I've heard now, there were three crew members lost.

It's covered in this article in the Wisconsin State Journal. I didn't know the other two crew members, who will be sorely missed as everyone I've ever interacted with has been pure class at Med Flight. Dr. Bean was a leading light to me, a mentor, an example of what I want to be. He was a doctor and a teacher I will sorely miss.

The best way I can think to memorialize Dr. Bean is to tell stories about him. He helped me see that EM was the field for me. I never saw him treat anyone badly, patient or colleague. When he talked to a patient, he sat down as if he had all the time in the world for them, but damn if he didn't know how to run trauma, and how to run a department. As with so many EM docs, he was also the local EMS director. At conferences with other services, his was the honest question, the insightful comment, always in the spirit of increasing cooperation, coordinating.

My fourth year rotation on EM was awesome. Dr. Bean would regularly 'hold court' after shifts, even those that ended in the middle of the night. My best memory of teaching in the ED was at 3 am after a 4-1 shift. Patients were all 'purple' (admitted) or 'green' (discharged). The Intern, who was awesome too, decided to run a session on airways because he had just been re-taught. He took me into one of the trauma bays and we picked tubes, discussed doses. The other intern came in and joined in. Dr. Bean came last, and the first thing he did was listen to the interns teaching me. Then, he ran cases for at least half an hour. What induction drug, what dose, what are you worried about. 'If you're worried,' he said, 'take out a pen and write your doses on the gurney while they're bringing the patient in. Better to take the time to be sure than get the dose wrong. Believe me, we all get rattled sometimes.' He said that, but I never saw him be rattled. More than the teaching points, which I loved, I noticed that this attending was there, two and half hours after his shift, teaching. And I also noticed that he carried himself as an example. Confident, not arrogant.

He also took the time to do the little things right. Wound exploration was a great example. It's not enough to clean the wound; explore, look for tendon injury. He would take time to discuss the proper tension on a nailbed repair, for example, along with suture choice. His attention to detail was impressive, and it pointed out that even though we're generalists, that shouldn't prevent us from taking pride in our work.

My father-in-law said, 'not all those that die, deserve to.' Amen to that. So the next time you're drinking, raise one for these folks. The next time you have a moment, make it a moment of silence. I sure will. I'll be lucky if I'm half the doc Dr. Bean was, but I'm damn sure going to try.

I'll try and keep up announcements, if any on this topic.

Entitlement

150 people in an auditorium, I asked the prof a question, and then pointed out when he responded that his explanation didn't match the book or some such 2nd-year med student snarkiness. I got, in response, a long, loud, diatribe about how we were the most entitled bunch of whining babies he had ever seen come through the school. I achieved enough notoriety that some smart fellow yelled out to tell the doctor, quick, as I went up to read my match day assignment.

I was hurt at the time; I had worked hard to get there--working full-time and completing pre-reqs as well while trying to see my newborn daughter every once and a while--and he was telling me I was entitled?

But now that I've seen more patients, and seen more of the system, I see that I was--admittedly a bit spoiled--but also just the last straw for an ID doc who was sick of people whining about wanting antibiotics, vaccines causing autism, people not doing their jobs and patients wanting more, better, faster, and cheaper.

Over at M.D.O.D., the posters have little, if any, patience left for the people we treat as a community, who think health care is a right, and that anything less than perfect, enjoyable care is not good enough. This goes in line with the 'quality' movement sweeping through health care based loosely on the six-sigma line of thinking.

I don't know yet how much this affects the field. I will note, however, that the ED I'm about to begin training at has all private rooms, with flat screens and cable TV in each one. I'll also note that they hand out consumer satisfaction surveys to patients. In theory, this may sound great. In practice, it worries me.

Patients are not customers. Putting cable TV in the rooms certainly improves the wait, I'm sure, but aren't we sending the wrong message? When we spent trillions on health care with only so-so outcomes, are flat screen TVs really where we should put our money?

I happen to favor national health care a la the system seen in the UK, the NHS. However, I also acknowledge that this is often advocated in a very indignant way, as if it is an injustice that we don't yet have it. I used to feel the same way. How can the US, which is so advanced and spends so much money, not yet have universal care? Being a schizoid combination of realism and idealism, I like the idea of universal health care, but having watched our government screw up a lot of other things--public education, welfare, land management, and so on--I'm pretty sure we'd screw up health care, too. Instead of decreasing idiotic subjective meaningless griping surveys, it would probably increase them, and JCAHO would metastasize, becoming totally inoperable.

We are becoming a nation entitled. They say it's bad parenting now to tell your children that there are starving kids in Africa that would gladly eat those carrot sticks, but isn't it totally true?

We should tell patients that, too. You just waltzed into this ED at 2 am because you need a refill on your Percocet and got seen within an hour while you sat in your private room and watched the Top Chef marathon on the Food Channel. You personally will not be charged for this visit because we won't be able to find you, and because I am totally exhausted you might even get some narcs out of me. Then, you'll complain how I wasn't compassionate enough on the survey the nurse is required to hand you, knowing full well that the parent of the pediatric resuscitation that went perfectly down the hall won't have the time or energy to fill out a survey because they have more important things to worry about. There are patients in Africa who would gladly take this level of health care.

It's nice going into residency being pre-jaded. At least I won't feel the pain of my ideals burning away.

Iron Man = Hypomania

Had a rare day 'off' today after getting the house ready to sell, and I went to see Iron Man. That guy is totally hypomanic.

First, he's the millionaire playboy who engages in exaggerated risk-taking, especially sexual, and has an exaggerated sense of self (mania, anyone?) After finding his purpose in life, he's able to work for days, perhaps weeks on end, without anything but coffee (lots, makes me feel better) and a nice trinket from his assistant (who happens to be Gweneth Paltrow) to keep him going, in which time he makes a cool suit of flying armor.

The movie was fun and not too bad. Interestingly, though, he's totally symptomatic. Watching the movie, I wondered about the continuum between disease and benefit. In his case, hypomania was totally profitable and benefited those around him--there was no way that anyone normal would've been able to do what he did, and there was a significant amount of risk-taking involved in innovation. The NY Times, if a search is completed on hypomania, notes that there may be an abnormally high amount of hypomania in the U.S. population since we tend to be risk-takers as the descendants of immigrants. So, this is an example of a disease state--acute mania, treated with an IM injection of haldol and lorazepam--that is on a continuum with arguably one of the most important personality traits known, since the hypomanic folks were the ones who likely talked us onto the boat, invented the lightbulb, the atomic bomb, and PopTarts.

Being nerdy ruins everything. I can't even enjoy a good blockbuster without wondering about diseases. The lady who sold me vases this afternoon has Parkinson's, treated, I'm sure after watching her fill out the receipt, which she insisted on doing by hand. It sucks being a med student.

Why I Love My Gal

A Jeep pulls up next to us, the driver's hand on the wheel with a cigarette between digits 2 and 3.

"How can people smoke? What are they thinking? Why not just wear a T-shirt that says, 'I'm a total f@$*ing idiot?"

That's why I love her. Well...one of the many reasons, actually.

Waxing Poetic

Well, it's finally arrived. My big transition, the great leap, the fall, tipping into the abyss, the milestone, the ceremony, crossing the rubicon: graduation. Three weeks from now, I'll be more than just tyro (novice), I'll be tyro, MD.

In honor of this occasion, I'd like to try and figure out what the color attributed to each degree means. We all have separate colors, see. My hood should be black with 5 inches of forest green velvet trim. Sweet. I'm wearing it to the gym, I don't care if it's typically only worn to commencement or the encaenia (doubly sweet! Who goes to those things?)

forest green: MD. Obviously, this means we're a loving, caring profession that is a welcoming and nurturing as Gaia, the earth goddess. We continue to grow in our knowledge as we seek to propagate the growth of all. Alternatively, one could comment that the medical profession is like a terrifying forest at night full of hungry wolves waiting to stick tubes down your throat or lines in your subclavian vein. Ask me again after internship.

purple: Law. I wasn't surprised to discover that purple comes from the Latin purpura, as in 'manifestation of a terrible systemic disease that will kill you shortly'. If I see purpura on a patient, I should think of overwhelming sepsis or meningitis. I will leave the fair reader to draw their own conclusions about the similarities and differences between lawyers and dread systemic diseases. Alternatively, I may be a tad unfair. It may just be that purple, associated with royalty from antiquity, represents how lawyers are only available to the wealthy. Oh, sorry--I was supposed to be positive with that one. I suppose everyone has their growing edges.

silver: oratory, speech (i.e., politics).I didn't make this up, from the silver article on wikipedia:

Silver is the most popular color for automobiles because police surveys have shown that because silver is a bright color, silver automobiles are involved in crashes less often than cars of any other color.

Now, if that doesn't describe a politician, I don't know what does.

So I guess our colors do help define us. Good thing we wear those hoods.

The Female of The Species

In reference to this post:

Rudyard Kipling's Verse By Rudyard Kipling:
"...the Himalayan peasant meets the he bear in his pride
He shouts to scare the monster who will often turn aside
But the she bear thus accosted rends the peasant tooth and nail
For the female of the species is more deadly than the male"

A comment on the momma bear post brought Kipling up as a previous observation that there is something to mother's instinct that defies logic or expectations. Although Kipling's work does wax a bit dated, it bears out the same observation.

For the Dearly Departed

Worth reading: a post at a great blog about the price some first-responders pay to help out.

White Cloud?

Crap, it didn't work. I guess fate doesn't listen after all. I'm going to bed now, that'll do it.