All posts by pandabearmd

Ask the Panda: More on Physician Assistants

Mid-Level Madness, Uncategorized

Hey Panda. I’m a PA and I don’t like you much even though I inflict your blog on myself religiously. What do you think about Physician Assistants and Nurse Practitioners taking over from doctors? They might even replace you, Mister Emergency-Medicine-Smarty-Panda-Pants.

Another excellent question and a source of great angst among those who are contemplating primary care. As some of you know, Physician Assistants and their sinister cousins, Nurse Practitioners, practice pretty much independently as primary care clinicians in much of the United States, especially the rural and so-called medically underserved areas. Ostensibly they practice under the supervision of a physicians but this supervision is often pro forma and might involve an infrequent cursory review of a handful of charts by a retired physician not concerned about liability and just looking for an easy gig to make a little extra income.

Let’s get a few thing straight at the outset. First, we live in an egalitarian society that delights in thumbing its nose at authority. With this in mind, you are never going to convince the public that physicians should monopolize health care through anything equivalent to the divine right of kings. The public will turn against any group of uppity physicians oppressing the little guy to protect their ill-gotten six-figure salary. You know what is involved in medical training but I guarantee that the bulk of the sturdy and not-so-sturdy yeomanry don’t have a clue and don’t care about your sacrifices. I may think you deserve the six-figures but it’s going to be a hard-sell to the voter working down at the plywood plant for a small fraction of your salary.

Second, we should be against monopolies. A good or service of reasonable quality should be provided to the public at the lowest possible price which is determined by competition in the free market. I’ve been anti-union and for free trade for my whole life and I’d be a hypocrite to change my position simply because it’s my ox being gored.

The question then becomes, as was implied in the previous post, are the services of a residency-trained physician of greater value than those of a less well-trained physician assistant? I believe they are but let’s not get silly about it. Physician Assistants and Nurse Practitioners are not stupid and are more than qualified to handle the majority of primary care. I think it would be criminally insane to send your aging mother with twenty competing comorbidities to a PA but does it take a doctorate level degree to treat a kid with an ear infection?

Of course not, and this is the hook that mid-level providers have with the legislature. They are cheaper than physicians, they can reasonably demonstrate that they can do some of the same work, and since giving away other people’s services is the epitome of compassion, the mid-levels provide the trapping of political compassion at fire sale prices. Whether the public is being well-served is immaterial. It’s just primary care, after all, and the mistakes are slow to evolve and can be ascribed to half a dozen causes other than clinician error.

So what’s the drawback? As you know I’m an Emergency Medicine resident. Forget what you’ve heard about Family Practice or Internal Medicine, the Emergency Physician is the true generalist. From Pediatrics to Obstetrics to Internal Medicine, the Emergency physician has to be able to make intelligent decisions involving almost every specialty and the amount of medical knowledge and skill required to do this is immense and humbling. Not a day goes by where I don’t come against the limits of my knowledge and I have been hard at it for almost six years. And I still have two more years of training before I can practice independently of skilled supervision. If you think that some guy straight out of a two-year masters program is equal to the task then God love you, you’re a true man of the people, but you are crazier than a shithouse rat.

Also consider the training required for by an internist, the basic foot-soldier of the medical profession, not to mention that required for surgical or subspecialty training. To say that a mid-level is equivalent to a trained physician is the same as saying that we are all wasting our time in residency. And that, my friends, is the question which leads us too…

Will Physician Assistants and Nurse Practitioner take over primary care?

Yes. No. It doesn’t matter.

Yes, because American medical school graduates are not exactly flooding the zone protecting their territory from the rapacious inroads of the mid-level providers. Family Medicine, the paragon of primary care is, for several reasons, the least popular career path. It takes a special person to want to do family medicine as you must not only run between the Scylla and Charybdis of your peer’s ridicule but you must also lash yourself to the mast of primary care against the siren call of more lucrative specialties.

It is no wonder then that mid-level providers can move effortlessly into the vast, unpopulated territory of primary care. They may not be residency trained and a typical graduating family practice resident may have three times the skill and knowledge but (to paraphrase the popular World War II joke) they may not have have more than the doctor but what they have they have over here.

For its part, the family medicine establishment has done everything in it’s power to ease the transition towards primary care by mid-levels. First it was the “gatekeeper” paradigm where the primary care doctor was the traffic cop directing most of his patients to the appropriate specialist for definitive treatment. Many things need to be referred, of course, but it doesn’t take an expensive degree to decide which specialist should see a patient. When you surrender your ability to diagnose and treat complicated patients, or lose your nerve, all that you have left is low-level primary care which really could be done by a motivated high-school student much less a Physician Assistant.

The current paradigm is “community medicine” where the traditional diagnostic and treatment function of the physician, the medical skill for which he is sought, is subordinated to the needs of society, “well-being,” and half a dozen other cockamamie functions which dilute the only advantage a residency trained Family Practitioner has over a social worker, much less a lean and hungry PA stalking wolf-like along the periphery of the sickly primary care herd.

Not to mention that those in the avant garde of Family Practice have fallen so deeply in love with team-based medicine where the physician is just an equal player in one of those goofy, non-competitive games where nobody loses and everybody wins that change will never come from that direction.

On the other hand, even many PAs don’t want to go into primary care preferring to subspecialize as physicians extenders. It seems every specialty group has it’s cadre of PAs and NPs rounding on stable patients, assisting in the operating room, or clearing out the backlog of routine clinic patients. In fact, as one of my readers once pointed out, Physician Assistants perform many of the same functions in private practice as residents do in academic medicine.

So no, despite the snowballing numbers of midlevel providers, physicians will not vanish from primary care. They may just have to practice at a higher level, eschewing the current trend to water down their medical knowledge with all of that creepy social work stuff but there are plenty of sick people out there. Not to mention that there is huge bolus of baby-boomers about to start getting really, really sick and they are going to want to see a doctor, not a school nurse.

But you can probably kiss the typical low-acuity practice goodbye.

Ask the Panda: Physician Assistants

Mid-Level Madness, Uncategorized

Hey, Panda, what’s up with Physician Assistants? There are a bunch of them rotating with me and they say that they are just as well trained as doctors and can make more money. To tell you the truth, they are kind of a pain in the ass.

Excellent question. For those of you who don’t know, Physician Assistants are non-physician clinicians who are licensed to practice medicine under the supervision of a physician. Ideally, they are used in the role of “extenders” and might, for example, round on a surgeon’s patients in the hospital leaving him free to spend more time doing cases. Almost all specialties have a definite need for PAs. In Emergency Medicine, for example, PAs often handle the urgent care or less acute cases. Some rural Emergency Departments, however, are staffed by PAs who have received extra training in Emergency Medicine. This is a direct result of both a shortage of physicians in underserved areas and financial pressures on hospitals, private practices, and municipalities as PAs are generally cheaper to hire than a residency-trained physicians.

Many PAs working in lucrative specialties can, in fact, make more money than physicians working in primary care. I know a PA who has been working for a local neurosurgeon for the last twenty years and without going into the specifics, most Family Practice physicians would be envious of his compensation. But generally, a PA will make considerably less than the residency-trained physician in that specailty. I mention this because you will hear many PAs bragging that they can make more than doctors. This is true, but in any given specialty PAs are hired because they are more economical than physicians for the level of work they do. If the cost is the same or more there is no advantage.

Are they as well-trained as you will be after you finish medical school and residency? Of course not. No doubt a PA who has been in practice for ten years probably knows more practical medicine than a freshly minted intern. But we’re not comparing apples on apples. If you compare, let’s say, the training of a brand new PA who has just finished his two-and-a-half year program with the training of a brand new internal medicine attending who has just finished his seven year training program there is no contest. I am going to get a lot of hate mail for pointing out this simple and obvious fact but a PA, by and large, can practice after he completes PA school. A physician can only practice after both medical school and an extensive period of residency training.

Do the math.

The question then becomes, do you need seven years or more of training to function as a physician? This is the 64-dollar question. As many of you will find out, apart from the legal requirements, a lot of medicine is fairly bread-and-butter and could be handled by a school nurse much less a PA. I have done several out-patient pediatric rotations and with the exception of a few interesting cases, it was nothing but viral gastroenteritis (the craps), viral upper respiratory infections (the coughs), or eczema (the itches). Not to mention “Well Child Checks” that could be done by a trained monkey which is why they have interns do them. Likewise, an otherwise healthy man with hypertension probably does not need your medical degree from Johns Hopkin and your residency training from Duke to have a couple of prescription written every six months.

On the other hand a lot of medicine is not bread and butter. Part of your training is learning to know your limitations and the scary thing about PAs and other mid-levels is that, having only sipped sparingly from the well of knowledge, their little knowledge can be a dangerous thing. Things can get out of hand easily in medicine, either quickly because of mistakes made in acute interventions, or slowly as the result of bad judgement or mismanagement of chronic conditions. Physicians, for their part, are not immune from errors and bad decisions but imagine the danger from someone with a third of the formal training who gets in over his head and doesn’t know enough to realize it except when it is too late.

I had a patient with a Pulmonary Embolus, for example, who despite a history of obesity, oral contraceptives, and smoking was diagnosed with “Viral Upper Respiratory Infection” by a PA in an urgent care clinic only hours before she was brought in by ambulance for severe shortness of breath. This is a pretty simple example and most PAs would pick up the not-so-subtle clues in the patient’s history but there are thousands of permutations and combinations of symptoms and long formal training which includes didactics is definitely a major advantage. Whether this is recognized politically is another story. To a politician or anybody making public policy, “health care providors” are interchangeable components and one is as good as another to demonstrate a compassionate concern for univeral access to health care. It is also easy to make scapegoats out of “rich doctors,” most of who are not actually rich, especially as the public by-and-large has no idea how much low-paid and no-paid training is required to make a doctor. My neighbors sneer at the state of my lawn and opine that a guy like me pulling in the proverbial six-figures could pay to have it mowed more often.

The other thing you’re going to hear a lot from PAs is that they get better clinical training in PA school than you get in medical school. As evidence of this they will point to their greater facility with physical exams, blood draws, and other basic medical skills than you have as a third year medical student. Again, this is not comparing apples with apples. PA students learn practical clinical skills almost from the start of their training so they show up on the wards with a slight advantage. Medical students, on the other hand, learn practically no clinical skills during first and second year as these years are dedicated to basic science and general medical knowledge. By the end of fourth year your practical skills will be far beyond those of a PA student who only acutally does one year of clincal work compared to your two and, at least at the three medical centers where I have rotated with PAs, don’t do call and work substantuially fewer hours than the medical students.

“Oh yeah,” some PAs say, “But most of what you learn in first and second year of medical school is of no practical value and besides, you forget most of it.”

As you know, I am not the biggest fan of medical training. And it is true that a knowledge of some esoteric topics like embryology is rarely, if ever, needed by the majority of physicians. But I have never regreted the many hours I spent learning these topics and I think it is the height of arrogance for both medical students and PAs to decide, based on their limited experience, what is necessary knowledge and what is not. Medical knowlege forms part of your deep medical personality and besides serving as a platform on which to build the knowledge that you should be acquiring for your whole medical career, also allows you to speak intelligently and authoritatively to an increasingly medically sophisticated public.

Besides, this particular sword cuts deeply both ways. Why stop at medical school if we want to eradicate useless knowledge? I’m sure I can ride aggresvely through the curriculum of PA school, nursing school, paramedic school, and any school you care to mention, slashing, burning, raping, and pillaging innocent knowledge from the curriculum with the abandon of a deranged mongol and the bread-and-butter patient would still get his prescription for Glucophage. Let’s just do away with the whole deceptive edifice and recruit motivated and reasonably intelligent high school students to staff highly specialized low-level clinics in much the same way we fill positions in the fast food industry.

In short, while it is reasonable to worry about the encroachment of mid-levels into the practice of medicine, this is a political thing and not a reflection on the intensive and necessary training you are recieving.

Again Apropos of Nothing Part C

Biography

Half-Measures

( Disclaimer: Those of you with weak stomachs or who are excessively idealistic may skip this article in which I describe how one may subvert the conventional wisdom and get accepted to medical school. As you know, I believe the medical school admission process is idiotic. It encourages self-aggrandizement and has more hoops to it than a traveling poodle circus. It is also weighted heavily against the older, more stable applicant who may have a job, a family, and no time for the usual mock compassion of the typical pre-med student.

My favorite character from literature is Odysseus. He was neither the strongest, the bravest, nor even the smartest of the Achaeans but he was certainly the most cunning. Wiley Odysseus could keep his head and accomplish through cunning and a little chicanery what others with more overt prowess couldn’t. Somewhat like Odysseus, I’m not stupid but on the other hand I am not nearly as intelligent, talented, motivated, or even as passionate as the medical heros with whom I had to compete. -PB)

I wouldn’t say I had it harder than a typical pre-med student but I did have some unique problems. First, I had a full-time engineering job at a firm that expected some real work out of me. This would complicate the task of taking the pre-requisites I lacked, about 18 month’s worth at the rate of one course a quarter. But I did have contacts and a solid reputation so by virtue of being a licensed Professional Engineer I was able to start my own engineering firm and get a little more schedule flexibility.

Next, my GPA “blew hind titty” as my advisor was so kind to point out. This only confirmed what my mother warned me about: You do have permanent record and it will bite you in the ass some day. There wasn’t much I could do about it but I did have a couple of advantages. First, from the point of view of an engineer, classes in the biological sciences, at least at the level required for medical school admissions, are ridiculously easy. There are no formulas to memorize, no design problems to solve, and no math is required. It’s all just reading and a little binge-and-purge memorization. Organic chemistry was challenging but I latched onto a professor who didn’t believe in grades and rode out those classes with no worse damage then having to listen to his philosophical ramblings.

Second, I have always been good at math and had gotten good grades in just about every math course from Algebra to Differential Equations. This is important because a big component of your AMCAS application is the BPCM (Biology, Physics, Chemistry, and Math) GPA. The upshot of this was that my BPCM GPA was almost perfect, considering the easy A in organic chemistry, the easy physics A when I was just out of the Marines and studying like a real student, and the child-like simplicity of “Biology 101” and “Anatomy and Physiology (for Sociology Majors).”

Not to mention that Engineering classes, as they are neither math nor physics don’t count in the BPCM GPA, or at least that was my assumption and I guess I was right because the AMCAS bought it. The only ones I counted as either Math or Physics were the ones were I got an A (very few actually) and that I could stretch a bit. I listed Statics as physics and Finite Element Design as math but left Structural Concrete and Fluid Mechanics alone. Hey, at that time I was angling for every advantage I could get. I really enjoyed college in the early eighties and my cumulative GPA was really, really low. (2.8).

Then there was the question of volunteering. As there was no online pre-med community at that time I never felt it necessary to go to Africa to hold dying babies. I figured EMT training might be interesting and, as I had no disdainful premed friends to talk me out of it, I took a course at the famous Delta Ouachita Community College (or the “Harvard of Ouachita Parish” as it is commonly known).

I did the minimum possible volunteering as an EMT, and I mean minimum, to let me put it on my AMCAS application with a clean conscience. What’s the point, really? At that time my wife and I had a new baby in the house who refused to sleep, I was taking classes, working full-time, my father had just died, and I was gearing up for the MCAT. Medical school admissions, as I realized even then, was a game and if I needed to show some volunteering, well, I’d check the box but there was no need to get stupid about it. There are just not enough hours in the day, especially as I now know for sure that none of it really matters. The top students in your medical school class, the ones who shadowed doctors so much that they could get board certified, are all gunning for radiology just so they don’t have to touch patients ever again.

Or, to put it another way, medical school admissions is a big fat guy standing between you and the basket. You’re going to have to get by him. He’s fat but suprisingly agile. You can charge him and hope he backs down or you can try to sneak around him. Sometimes he’ll fall for a feint and you can get around clean but the odds are you will make contact and he will get some sweat on you. Getting past him is the challenge and it doesn’t matter how you do it. I’m not advocating kicking him in the nuts or anything like that but fortune favors the crafty and the bold. Later, as you eat the cheeses and hams of victory, you’re not going to look back and regret outwitting the fat guy.

The MCAT was a big hurdle but more of a psychological one. I geared up to study, as I said, but I never actually did except for a few desultory attempts to read the MCAT “Gold Standard.” I figured I would do well enough on the Physical Sciences section, would eat the Verbal Reasoning Section for lunch, and could fake my way through the Biological Sciences section which is pretty much how things went down. I got a 29. Not spectacular but good enough for Louisiana. When I got my scores, my wife read me the sample scores from the front page over the phone which added up to 24. “That’s it,” I thought. All that effort for nothing. She called me back a few minutes later, apologized, and read the actual scores.

The MCAT is a standardized test. It is all multiple choice and designed to test your knowledge in a broad but still limited number of subjects. None of the MCAT questions will come from left-field or require any creative thinking on your part. The concepts are fairly simple, the questions don’t go into great detail, and in the rare case that a question might absolutely turn your guts, you can skip it and write it off to bad luck. You have to know a lot, no question about it, but the most efficient way to study for any multiple choice, standardized (emphasis on the “standardized”) test is to do practice questions. You can take an MCAT review course, you can buy review books and read them religiously. I’m not saying this is useless. But, like the USMLE, to truly focus on testable subjects you need to pay for any or many online question banks and go to it. And make sure the question bank includes explanations for the right and wrong answers.

The authors of standardized tests have a limited repertoire. There are only so many ways, for example, to ask you a multiple choice question on the basics of circuit analysis. If you do enough practice questions you will recognize the pattern. If you just read about it you will rapidly forget the specifics. The same with sitting in Kaplan and listening to some graduate student drone on about it. It is easier to remember a pattern than facts and the facts will come if you remember the pattern. If you don’t agree with me you may do as you please or go to the devil for all I care. The object here is not learn the subjects, you should already have a grasp on them.

The object is to get by the fat guy.

I only completed applications for my two state medical schools. I figured, probably correctly, that if I couldn’t get in at either of these I probably didn’t have a chance anywhere else. I did apply to a few more schools but got bogged down in the secondaries, most of which asked for essays on truly ridiculous topics like “Qualities that Will Make You a Good Physician” or “Describe your Greatest Weakness.” Not to mention, “Why Did You Select Tulane?”

Hey, I’ll do what it takes but I do have some self-respect. The secondary application questions for LSU were along the lines of, “Have You Ever Been Convicted of a Felony?” which I believe is the only legitimate question that should be asked of anybody applying to medical school. It has a simple, easily verifiable yes or no answer and allows no room for the usual cringe-inducing tripe.

After the usual nail-biting, I was accepted to LSU Shreveport and, after a late interview invitation, was also accepted at LSU New Orleans. I liked New Orleans better but Shreveport was closer and the real estate was cheaper. Hey, I’m not fussy. Harvard, LSU, Duke, the Carribean…it’s all the same. Or at least the differences are not worth getting worked up about.

We moved to Shreveport and the rest of the story can be found on my blog.

Again Apropos of Nothing Part B

Biography

Was it That Long Ago?

It was one of those cool, clean April mornings in North Carolina when I was discharged from the Marines. The sun shone brightly in the clear sky as the last of the mist lingering in the shadows evaporated. A gentle wind ruffled the surface of the New River and tugged at the tops of the pine trees.

I saluted the Officer of the day who had come out of his office to admire the weather.

“Good luck, Sergeant Bear,” Said the Lieutenant (who had been my platoon commander) as he shook my hand.

“Thanks, Mister Roland,” I said, “It was a real pleasure working for you.”

“You know you’re going to miss it.”

“Not a fucking chance, sir.”

And that was that. With considerably less trouble than it had taken to enlist, I was honorably discharged. It was anti-climactic, really. Almost eight years, an eternity to a young man, at an end with a respectful salute and a friendly handshake.

Have you ever been free, my friends? I’m not talking about some unobtainable existential freedom. I had money, I had a car, I had a beautiful girlfriend, and I had nothing but time until I started classes. If that’s not freedom, then nothing is. I drove out of the main gate of Camp Lejeune and have never been back.

I started at the University of Vermont that June as a Civil Engineering major. I went to class religiously, studied, and did pretty well. A little self-discipline makes all the difference. Besides, the lifestyle of a college student is an easy one. Other than going to a few classes, your day is pretty much your own. There is plenty of time to study without turning into a jittery freak, especially if you finally see the college lifestyle for the bullshit it really is.

It’s just a job. They can dress it up, put you in a picturesque campus and you can strut around getting educated but strip away the pretensions, the inexplicable loyalty to an organization that takes your money and can cheat you out of your education if you let it, and it’s a wonder the bookstore does such a brisk business in university branded paraphernalia.

Campus politics were ridiculous. The year I returned was the year of “Diversity University,” a little shanty built on the green to protest just about everything. It was a focal point for the usual left-wing crazies making a career out of protesting. It was also the year that the usual band of idiots, in an homage to their equally idiotic parents from the sixties, stormed and, for a number of weeks, occupied the administrative offices of the President of the University…and got course credit for it. The whole scruffy, useless pack of them were eventually driven out but not before they held numerous rallies with politburo style banners of Mao and Lenin.

Nothing but the spoiled children of the elite pretending to stand for something, just like their equally spoiled baby-boomer parents. Naturally I had a lot of fun with them. I was something of a conservative political activist and even started tearing down the shanty on TV before some little tofu-eater threw himself between the shack and my sledge-hammer. I attended all the diversity meetings and agitated for conservatism, politely and in my turn, of course, until they told me that I wasn’t welcome because it’s only diversity if it is left-wing and anti-American. I got in a little trouble and had a few conservative Vermont lawyers offer to run interference for me but it never came to that. The funny thing is that many college students spend their entire four, five or six year college career doing little but political activism. They take the usual Mickey Mouse courses where one bemoans “the Man” but, other than that it’s all posturing and pontificating in the fantasy world that is Academia.

Then they spend their lives wondering why nobody takes them seriously, lamenting their glory days in college with the same intensity as the former high school jock drinking his beers of despair in some fly-blown trailer park. Or they work at Starbucks, the graveyard of liberal arrogance.

Our original plan was to wait until I graduated to get married but we decided that this made no sense and my lovely and highly intelligent wife and I were married in May of 1992. Since she was going to quit her job (in television), we looked around and realized that it made no sense to spend the kind of money demanded by UVM when Louisiana Tech could supply the same education for a fraction of the cost. I transferred and finished my degree in 1994 with decent but not spectacular grades. I did a year of graduate school because we were young and didn’t need that much money to live.

Graduate school is useless in most engineering professions if your object is to work as an engineer. It doesn’t increase your starting salary, either. I had a friend who wrote his thesis on the percolation of water through a sand bed, an important topic to be sure, but very specialized and more likely to make your prospective boss scratch his head and wonder how it’s going to help him make money off of you.

So one day I got an engineering job, started working for real money, and just lost interest in academics. I came home one day and asked my wife for permission to quit graduate school. Working and studying, not to mention grading papers and the other lame things you must do to earn your stipend was wearing me out. Graduate students, like residents, are little more than slaves. Maybe graduate students are house slaves compared to residents cutting the cane but they are slaves none the less.

Besides, I was tired of being the only guy who didn’t speak Chinese in my advanced Finite Element Design class.

I worked as an engineer for a few years. No real complaints. It’s a good career and I highly recommend it.

Why medical school? I don’t remember. That is, I remember getting the idea of being a doctor in my teeth and not being able to let it go but I don’t remember from where the idea came. I had never been to a hospital except for the birth of our first child and in no way did this spark an interest in medicine, even if I did say it did in my AMCAS personal statement.

Hey, I lied. Doesn’t everyone?

The nearest I can tell, one day I was mowing the lawn under the merciless Louisiana sun and just got sick of it. I asked my wife what it would take to hire a lawn service and she said, “Maybe if you were a rich doctor we could afford it.” This was kind of silly, of course, because I was doing pretty well as an engineer and we hired a lawn service the next week. But, like I said, I got the idea in my head and a little research revealed that it was not impossible. I don’t believe the numerous medical school discussion forums existed back then so I had very few places to turn for advice. There were a few books at Barnes and Nobles, and the head of the pre-med advisory committee at Louisiana Tech, after the obligatory “crap shoot” remarks conceded that it was possible.

More importantly, there was, as I discovered, a medical school just down the road (well, fifty miles away).

After a lot of discussion, we decided to give it a try.

Next: The Plan. MCAT Secrets.

Again Apropos of Nothing Part A

Biography

Random Musings on the New Year

The years roll by. I have vague memories of time passing with glacial slowness. Waiting for summer vacation. The eternity of high school. The time when it seemed that I had alway been in boot camp and always would be. The months I counted during the first Gulf War waiting to be reunited with my beautiful girlfriend who I later married.

And yet, it has all come and gone in what seems like an instant. Was it really nine years ago when my oldest was born? It doesn’t seem like it. The memory is too vivid. With easy reflection I recall the eternity of of sleepless nights spent walking the baby back and forth in the nursery, the fatigue from the second child who refused to sleep and spent what seemed like her first six months of life perpetually crying, and the death of my father from what I now know was brain mets from a malignant melanoma.

So I remember this time six years ago when, like many of you, I was checking the mailbox every couple of hours for the fat envelope announcing that I had been accepted to medical school. I had to wait a little longer, unfortunately, as I wasn’t accepted until early March.

You almost wish that you could get an answer-yes, no, something, anything-right after your interview. Of course this is not the way admissions work. Medical schools angle for the big fish, patiently working the lure hoping for a strike. After the pool is played-out they may throw a common worm on the hook and go after some trash fish. I guess that was me but I don’t care. One of the top students in our fist year class who was probably offered admission on her interview couldn’t handle the stress and quit halfway through first semester. I am sorry to say I felt vindicated. I may have been on the third-string roster but obviously there are other traits besides a 4.0 GPA and a 39 on the MCAT that maybe aren’t selected for as aggresively as many of you, oh my patient readers, would hope.

I don’t know why I decided to apply to medical school. There was certainly nothing in my background that would point anybody in that direction. As many of you know, I began my career as a United State Marine back in the early 1980s. I had just been kicked out of the University of Vermont for bad grades. Well, I actually had almost no grades as I seldom went to class and a couple of times didn’t even know where or when to sit for the final.

Have you ever had that dream where you are late for a big exam for which you forgot to study? That was pretty much my reality. I partied a lot too, although that’s not much of an excuse because a lot of people party and study (the college ideal). So with no prospects, no interest in academics, but also no desire to flip burgers for a year before I re-applied I thought I’d give the military a try. I directed my pasty, lackadaisical body to the local recruiting station and presented myself to the representatives of our country’s military might, slowely recovering at that time from the ravages of the both the Carter years and Viet Nam.

The Army, Navy, and Air Force were like car salesmen and tried to sell me on the options. “College!” said one. “Travel!” another. “Great lifestyle!” said the third. Sign with us and reap the tangible benefits of job-training, medical care, good pay, good chow, and easy promotion.

The Marine recruiter on the other hand, the most ferocious-looking individual I had ever seen, looked me up and down contemptuously and said, “Son, I’d like to take you but I just don’t think you have what it takes to be a Marine.”

Bait taken, hook set, nothing to do but reel me in.

Three weeks later I was sworn in at the Manchester, New Hampshire MEPS station and eventually found myself on the famous yellow foot-prints aboard Marine Corps Recruit Depot, Parris Island. After boot camp I went to the Basic Armor Crewman Course at Fort Knox, Kentucky and spent my first four years as a Tanker, eventually becoming a Tank Commander of a 62-ton M60A1 RISE Passive Main Battle Tank. A pretty good job, all things considered. Plenty of firepower, big engines. And limited walking. All the more reason my Battalion commander thought I was crazy when he re-enlisted me for another four years and a transfer (or lateral move) to the infantry.

I did my second enlistment as a machinegunner and then a mortarman in the heavy weapons platoon of an infantry rifle company, Company K (or “Kilo”) of the Third Battalion of the Eighth Marine Regiment…or “K 3/8” for the cognoscenti. I know I complain a little on this blog about the difficulties of medical school and residency. I have apparently grown an ovary or two since my Marine days. But the life of an infantryman is a hard one and I laugh whenever some idiot surgery attendings justifies his abuse of me by how tough he had it.

Mother-fucker, I have operated for weeks at a time above the arctic circle humping a 120 pound pack as well as a machine gun, a mortar tube, or some other heavy ordinance. I have slept in the snow and longed for nothing more than a pair of warm socks to make my life perfect. I have baked in the desert, thankful for the shade of a low bush and a couple of warm gulps of plastic-flavored water from my canteen. You were on call in a nice, air-conditioned hospital while I swam in the dark, through the close, humid underbrush of a nightime jungle and while you were mistreating your medical students and junior residents I was leading some of the finest men you are ever likely to meet, without belittling them or treating them like they were somehow inferior by virtue of enlisting a few years later than me.

So this explains my low tolerance for abuse. Put on your body armor. Shoulder your pack. Grab your 19 pound machinegun and thirty pounds of ammo and lets go humping, you and I, up and down the mountains. Then we’ll talk about your so-called difficult life and your right to talk down to me. You’d have your ass kicked in the Marines by the first Private First Class to whom you opened your stinking cake hole.

But I digress. I was honorably discharged as a Sergeant and decided to go to back to college for the right reason, that is, to get a well-paying job.

Next: College. A job. You want to do what? The Plan. MCAT secrets.

Again Apropos of Nothing Part A

Biography

Random Musings on the New Year

The years roll by. I have vague memories of time passing with glacial slowness. Waiting for summer vacation. The eternity of high school. The time when it seemed that I had alway been in boot camp and always would be. The months I counted during the first Gulf War waiting to be reunited with my beautiful girlfriend who I later married.

And yet, it has all come and gone in what seems like an instant. Was it really nine years ago when my oldest was born? It doesn’t seem like it. The memory is too vivid. With easy reflection I recall the eternity of of sleepless nights spent walking the baby back and forth in the nursery, the fatigue from the second child who refused to sleep and spent what seemed like her first six months of life perpetually crying, and the death of my father from what I now know was brain mets from a malignant melanoma.

So I remember this time six years ago when, like many of you, I was checking the mailbox every couple of hours for the fat envelope announcing that I had been accepted to medical school. I had to wait a little longer, unfortunately, as I wasn’t accepted until early March.

You almost wish that you could get an answer-yes, no, something, anything-right after your interview. Of course this is not the way admissions work. Medical schools angle for the big fish, patiently working the lure hoping for a strike. After the pool is played-out they may throw a common worm on the hook and go after some trash fish. I guess that was me but I don’t care. One of the top students in our fist year class who was probably offered admission on her interview couldn’t handle the stress and quit halfway through first semester. I am sorry to say I felt vindicated. I may have been on the third-string roster but obviously there are other traits besides a 4.0 GPA and a 39 on the MCAT that maybe aren’t selected for as aggresively as many of you, oh my patient readers, would hope.

I don’t know why I decided to apply to medical school. There was certainly nothing in my background that would point anybody in that direction. As many of you know, I began my career as a United State Marine back in the early 1980s. I had just been kicked out of the University of Vermont for bad grades. Well, I actually had almost no grades as I seldom went to class and a couple of times didn’t even know where or when to sit for the final.

Have you ever had that dream where you are late for a big exam for which you forgot to study? That was pretty much my reality. I partied a lot too, although that’s not much of an excuse because a lot of people party and study (the college ideal). So with no prospects, no interest in academics, but also no desire to flip burgers for a year before I re-applied I thought I’d give the military a try. I directed my pasty, lackadaisical body to the local recruiting station and presented myself to the representatives of our country’s military might, slowely recovering at that time from the ravages of the both the Carter years and Viet Nam.

The Army, Navy, and Air Force were like car salesmen and tried to sell me on the options. “College!” said one. “Travel!” another. “Great lifestyle!” said the third. Sign with us and reap the tangible benefits of job-training, medical care, good pay, good chow, and easy promotion.

The Marine recruiter on the other hand, the most ferocious-looking individual I had ever seen, looked me up and down contemptuously and said, “Son, I’d like to take you but I just don’t think you have what it takes to be a Marine.”

Bait taken, hook set, nothing to do but reel me in.

Three weeks later I was sworn in at the Manchester, New Hampshire MEPS station and eventually found myself on the famous yellow foot-prints aboard Marine Corps Recruit Depot, Parris Island. After boot camp I went to the Basic Armor Crewman Course at Fort Knox, Kentucky and spent my first four years as a Tanker, eventually becoming a Tank Commander of a 62-ton M60A1 RISE Passive Main Battle Tank. A pretty good job, all things considered. Plenty of firepower, big engines. And limited walking. All the more reason my Battalion commander thought I was crazy when he re-enlisted me for another four years and a transfer (or lateral move) to the infantry.

I did my second enlistment as a machinegunner and then a mortarman in the heavy weapons platoon of an infantry rifle company, Company K (or “Kilo”) of the Third Battalion of the Eighth Marine Regiment…or “K 3/8” for the cognoscenti. I know I complain a little on this blog about the difficulties of medical school and residency. I have apparently grown an ovary or two since my Marine days. But the life of an infantryman is a hard one and I laugh whenever some idiot surgery attendings justifies his abuse of me by how tough he had it.

Mother-fucker, I have operated for weeks at a time above the arctic circle humping a 120 pound pack as well as a machine gun, a mortar tube, or some other heavy ordinance. I have slept in the snow and longed for nothing more than a pair of warm socks to make my life perfect. I have baked in the desert, thankful for the shade of a low bush and a couple of warm gulps of plastic-flavored water from my canteen. You were on call in a nice, air-conditioned hospital while I swam in the dark, through the close, humid underbrush of a nightime jungle and while you were mistreating your medical students and junior residents I was leading some of the finest men you are ever likely to meet, without belittling them or treating them like they were somehow inferior by virtue of enlisting a few years later than me.

So this explains my low tolerance for abuse. Put on your body armor. Shoulder your pack. Grab your 19 pound machinegun and thirty pounds of ammo and lets go humping, you and I, up and down the mountains. Then we’ll talk about your so-called difficult life and your right to talk down to me. You’d have your ass kicked in the Marines by the first Private First Class to whom you opened your stinking cake hole.

But I digress. I was honorably discharged as a Sergeant and decided to go to back to college for the right reason, that is, to get a well-paying job.

Next: College. A job. You want to do what? The Plan. MCAT secrets.

Complementary and Alternative Medicine

Complementary and Alternative Medicine, Uncategorized

Keep an Open Mind

So they asked me a lot, when I was interviewing for medical school, what I thought about complementary and alternative medicine particularly the use of traditional practices as adjuncts to Western Medicine.

I’m all for it. There are a lot of traditional practices I’d like to see become a part modern medicine. Like snake handling. For my money snake handling has everything you’d ever need in an alternative therapy. You’ve got your snakes representing nature, you’ve got your mystical religious overtones, and you’ve got scads of anecdotal evidence and testimonials in prestigious religious journals attesting to it’s efficacy.

For those of you who don’t know, snake handling has flourished in the folkways of the southern United States for more than a hundred years and is a time-honored method of casting out the demons that cause most sickness, at least those that cannot be ascribed to qi or bad karma. I understand that the NIH offers a fellowship that will equip anyone interested for an expedition to the wilds of Louisiana in which strange and magical land they may sit at the feet of ancient masters of this art and learn the secrets of the serpents.

And don’t forget to try Uncle Skeeter’s Gator-Taffy if your expedition passes through Lafayette.

I also would like to see more faith healing employed in the modern clinic. I’ve personally seen the lame walk, the blind see, and the gaseous find relief all from the “laying on of hands” as the technique is described by the learned shaman who practice it. For those of you who are lacking in cultural competence, the faith healer’s art is practiced in tents or, more lately, air-conditioned football ashrams where a large crowd can direct their good karma (or “prayerful thoughts” as it is often roughly translated) towards the patient. The patient, under the power of both suggestion and an Ayurvedic being named “Jaysus,” has his bad chakra forcefully removed, some would say driven, from his body with a precisely placed blow to the forehead.

The Shaman often yells “Come out!” but this is just showmanship, not unlike the way we yell “stat” in the Emergency Department even though we know that we’ll be lucky to get the labs by next Tuesday.

There is some debate whether faith-healing owes it’s effectiveness to the so-called “placebo effect” rather than any demonstrable physiological process but the debate is ridiculous and anybody who challenges this ancient traditional practice is a close-minded bigot. It’s not like they’re sticking needles into people or something lame like that. We’re talking bona-fide healing here, often before a television audience of millions. It would be highly unlikely that something like this could be faked in front of so many highly intelligent television viewers.

I have also heard of another traditional mind-body therapy for psychiatric problems, this one practiced in the deep hearts of our ancient cities. Basically, the patient dials a talismanic number, usually preceded by the mystical “900” or any other Number of Power and ceremoniously asks to speak with a priestess whose name is usually Yolanda or Mistress Debbie. The priestess then diagnosis all kinds of psychiatric and sexual dysfunctions, often times correctly pointing out that somebody close to you is cheating on somebody else close to you and “he needs to show you love, girlfriend…and you are so not fat…besides, he digs big women.”

Sometimes they throw in the winning lottery numbers.

Anyways, with all of my patients, the “P” in SIG E CAPS is “Psychic Hot-line.” I understand medicaid will reimburse for it. It’s not as if we’re asking them to pay for something ridiculous like a visit to the chiropractor.

Finally, for my money, nothing can compare to the healing powers of a good old-fashioned poultice like the kind my grandma used to make out of chicken droppings and mustard greens. It was the sovereign cure for a variety of ailments from lumbago to dropsy. Through years of experimentation, traditional practitioners have developed a wide spectrum of salves and rubs that are pushing the boundaries of our understanding of medicine. Our so-called “evidence based medicine” has nothing to compare to alternating layers of gumbo clay, sassafras bark, and chicken bile covered with brown paper and tied to the offending limb with common twine. It’s so good it’s almost magical. For fever, pepper is often added as it is a hot spice. For chills, it’s not uncommon to add the musk of a nutria as everybody knows this hardy animal can gnaw it’s way through the ice that forms every fifty years or so on the bayou. Beaver semen will do, I suppose, but there is no good evidence to support its substitution and I wouldn’t have that kind of quackery in my practice.

Besides, there’s no room to stock it as my shelves are crammed with homeopathic remedies.

More Housekeeping

Uncategorized

Spam Posts

I tried it for a while but because of annoying spam posts I’m turning “word verification” back on. You’ll have to tak an extra step to post. Sorry. I really think spammers should get the death penalty but until such a time as they do we’re going to have to do what we can.

Comments

Don’t make me have to moderate comments. So far most of the negative posts have been either well reasoned (but wrong), amusing and witty (but wrong), or just so plain foam-at-the-mouth idiotic that they are a joy to read. Remember: good, bad, or indifferent I appreciate the time people take to read my blog, even if I don’t understand why people who hate it keep coming back. Still, if you want to keep squeezing lemon juice into your own paper cuts than that’s your business.

Good Manners

Let’s keep it relatively civil. I will usually delete posts that contain ad hominem attacks, excessive bad language, or an overtly political point of view. I haven’t, recently, because the latest set of rants has been so amusing. Criticism is always welcome and you have my pledge that I will never delete a post just because I don’t agree with its author. I reiterate that I draw the line at partisan politics. You can go to half a million websites and engage in toxic political debates to your heart’s content but I’m sick of it.

Archives

Be sure to sift through the archives. A lot of good stuff.

Humor Workshop

According to my hit counter, I am getting hits from all over the world. Apparently, there are countries out there where humor is either outlawed or does not exist. (We also have people in out own country who are completey devoid of humor, probably secondary to being able to open bottles with their rectums.) American humor is hard for some people to understand. I’m going to have a workshop on this shortly but in the meantime, if some of you from Eulopotamia feel your knee starting to jerk, before you fire off an indignant comment take a deep breath, re-read the post, and try to pretend that you were raised in a country where we don’t kiss the ass of our elected leaders, question authority as a religion, and don’t take everything so friggin’ seriously.

Fan Mail From the Edge

Uncategorized

(Just a few comments. We seem to have had an explosion of vitriol today which is gratifying in my quest to become the most popular non-midget-porn blog on the web. Interestingly enough, most of the negative comments come from a couple of ISP addresses in India. As to what I have done to offend the Indians over anybody else I am completely mystified.

My biggest surprise is the level of support you can get from the online community if you abuse and neglect your aged parent. Apparently there is no depravity that will not have it’s apologists. I also don’t quite get the anger at my ICU advice post. I challenge anyone to say that anything I wrote is not true. Surely anybody with the energy to type an abusive screed could find posts of mine more worthy of the haterade.

I am also amused by the “compassion police.” I feel sorry for them because whatever their level of compassion, they will be sorely tasked by the majority of their peers, most of whom are just not the plaster saints they expect them to be. -PB)

“The author cannot be blamed if they don’t have humor in your country.”

Bigoted? Check. Narcissistic? Check. Besserwisser? Check. Elitist, superior type A-hole personality? Check.

Funny? Hell no!

(No humor in your country? Check. -PB)

To be a doctor, you’d have to be human. And to be human, you’d have to have a heart.

So, uh… No, I guess you’re NOT a doctor. Happy to help.

(Uh…Okay. But my state board, is going to have a problem with that one. Especially since I am on the loose writing prescriptions. -PB)

How can people say this is the best blog on the internet? Come on, people, get with the program. Learn a little old school empathy and be excellent doctors without taking on an elitist attitude like this fat and mean poor excuse of a physician.

You really really scare me too. And remember, you say “my patients like me”, but keep in mind the fact that they ARE stupid. (Fat AND stupid AND lazy.)

So if they are stupid, and they actually like you, that would either make them blind AND deaf AND dumb, or maybe just maybe you are as stupid as them.

Eat that, fatwad.

(I prefer “stocky.” but thanks for reading my blog. -PB)

You are reading the blog of an arrogant know-it-all who is condescending and elitist. Please get your facts straight. Remember if you were not sucking up to him, he would hate your ass. Try poking him, you’ll see. Just like the rest of us, FAT, STUPID, LAZY types.

(Well, I didn’t delete your post, did I? -PB)

You are like the world’s worst gunner, dude!

(And the world’s most unsuccessful gunner, too, as you would know if you’ve read my blog for any length of time. -PB)

“Servile and compliant” is how you described Mr Neely’s son… But admit it, Pooh Bear, it turned you ON, didn’t it, didn’t it?! 😉 It’s okay. Share. Share how that made you feel.

Your powerful stare, looking down at him, all dependent and needy and wanting… Aw, shucks, Panda! What a cute moment that must have been!

(I cannot understand your desire to stick up for a guy who was definitely neglecting and most likely abusing his father. It’s inexplicable, especially since the weak and powerless require someone, occasionally, to exercise a little judgementalism on their behalf and to exercise what little authority they have to protect them. I have my faults but neglecting to protect and assist the weak and helpless for fear of offending somebody’s bleeding heart ain’t one of them. You should be ashamed for expending more vitriol on harmless little me than you probably would in the face of obvious but garden-variety evil. But thanks for reading my blog and keeping the hit-counter turning. -PB)

Get this in YOUR head, *Panda* (if that is your name). You’re a self-aggrandizing, narcissistic, completely empathy-resistant (not to mention POOR) loser with no ability to budge or give other people the benefit of the doubt. Talk talk talk – that’s all that you’re about. Glad I’m not the son. OR the father, for that matter. How DO you sleep at night? Irritating mutha.

(Well, actually my name is Gus. I thought everybody with a few functioning neurons could tell that very few children are named “Panda Bear” by their parents. I guess in your humorless country it might sound like a real name. “Panda Bear,” by the way, was my radio call-sign when I was the mortar section leader in my Marine Corps rifle company. I also don’t uderstand why my being poor is an issue. I’m a resident. Of course I’m poor. It kind of goes with the territory. As always thanks for reading my blog. -PB)

You are just about the single most conceited person in the medical profession. *This is what you’re supposed to do blah blah….Why don’t you stick your little marine cap up your bum and choke on it? Do us aaaall a favor.

(Come on now. The most concieted? You obviously don’t know too many doctors. Oh, and I’d have to stick it up my bum pretty far to choke on it although I suppose it’s technically possible. -PB)

Dude, I am only human. Everybody has a cruel streak and I guarantee that if you told me a little about yourself I could easily pick out a group or two who’s misfortune you relish.”

See how he flips it?! Now it’s YOUR mistakes he’s after.

Doctor?? Hell, no! Choose politics instead. You’d be a natural.

(So what’s your point? Do you think that physicians are any less human than anybody else? Taking a morbid pleasure in other’s misfortune is so common that the Germans even coined a lovely word for it. If you think that by becoming a doctor you become emotionally celibate then you are in for a major disappointment in the the profession and most of your collegues. Now, you are obviously not immune to anger. I know for a fact that you would take great pleasure in any of my many misadventures in life if you were aware of them. So you’re sort of being a hypocrite, although since hypocrisy is the natural state of man I for one won’t get all worked up over your hypocrisy. You are who you are. As always, thanks for keeping the hit counter turning. -PB)

Can’t find it, Pooh Bear. You’re a bigot, and you always will be. 😀 I think you even spellt Dhaka wrong. But why would you even care enough about that? Silly me!

(There are, of course, many accepted ways to spell some city names (Bejing vs. Peking, Athina vs Athens) but to my knowledge, there is only one accepted way to spell “spelled.” Silly you. -PB)

“My main criticisms of this blog are its borderline plagarizing of “House of God” and the attempts by the author to mimic an experienced ER physician when he’s still a naive resident.”

(I have never read “House of God” or any other book about residency or medicine so it would be difficult for me to plagerize anything, borderline or otherwise. As for mimicking an experienced Emergency Physician, I am an Emergency Medicine resident so that’s what I write about. If you notice, most of my articles about the ED, of which I believe I only have three, are character studies, not emergency medicine textbooks. I am as qualified to comment on the character of patients as anyone, both because I have seen thousands of patients in the last four years and because I am reasonably intelligent and observant. The medical background of the patients is important to the narrative and where possible I try to be accurate. When I make a mistake invariably somebody will point it out and I will humbly acknowledge their correction. If I’m wrong about something I’m wrong. But you need to get it out of your head that I somehow don’t deserve to discuss things I learned on my ICU rotations because you think I’m not qualified to know these things.

I also am in no way naive in any sense of the word, either by age, upbringing, or life experiences. I think you’re confusing me with some other guy. I do not beat people over the head with my CV but I’ll do it if necessary.

Other than changing the names and a few characteristics of the patients to protect their privacy, I challenge you to find one instance where I have written anything which is not authentic. Or, for that matter, where I have not conceded that I am not perfect and still learning the profession. If I have to precede every statement with a disclaimer that I am only a PGY-2 and thus cannot speak for the entire medical profession it would be a very dreary, unreadable blog. I appreciate your taking the time to comment and your attention to my writing but the natural question is, if you find it so objectionable why do you inflict it upon yourself? -PB)

Crunch Time

Uncategorized

The ICU and You, some Do’s and Don’ts

Some of you will rotate in the ICU as medical students and most of you, whatever your specialty, will do at least one critical care month during your residency. Here are just a few general tips. I have made most of the mistakes described below. Keep in mind that your level of autonomy will vary depending on your program. At a big academic program you will likely be tightly supervised and always have immediate skilled back-up. At a smaller program, especially when you are on call, it might be just you and your senior resident with an attending on home call.

1. Stay ahead of your patients. They are in the ICU for a reason and this is usually because they are too unstable to be cared for on a general medicine floor. Things happen quickly. A patient can look fine and two hours later require intubation emergently. If you had paid attention to his arterial blood gases and listened to your experienced ICU nurses you might have been able to intubate under controlled conditions with everything in place and everybody calm rather than during the unavoidable excitement of a code. This is especially important if your patient is a “difficult airway” as it is always nice to have anesthesia at least standing by if you look down the blade of the laryngoscope and see everything but the vocal chords.

2. Don’t be afraid to intubate. Generally, if you think you need to you probably do. If the patient asks you for the tube then that is a pretty good indication for the procedure, especially if the patient has been in the ICU before.

3. Don’t let the vent intimidate you. At first it seems that the ventilator has a bewildering selection of knobs and displays that seem to have no relation to what you read in your critical care book. It’s hard, at first, to keep the various ventilation modes and pressure or volume options straight in your head. You will usually have a respiratory therapist at the bedside when you intubate and they are usually happy to explain things to you. As a resident or medical student nobody will think the worse of you if you ask questions. You aren’t really fooling anybody, anyways. Everybody knows you are new. Know a few common parameters and this will give you some time to figure things out.

4. But don’t screw with the ventilator. Write an order and let the respiratory therapist do it. If you don’t know what setting would be appropriate ask her opinion.

5. Understand how to interpret ABG (Arterial Blood Gas) values. It seems kind of arcane in medical school but after a few times doing it for real it will start to make a little sense. You will at least know when to panic and when not to.

6. Don’t let your patients almost bleed to death before you decide to transfuse or drop their electrolytes to dangerous levels before you decide to supplement. Stay on top of the patient’s labs, correct aggressively, and then make sure you have a good idea why things are heading south.

7. Don’t believe the crap about “treating the patient, not the labs.” Or the monitor. Obviously the lab values and the monitor don’t tell the whole story but they do tell you a lot, particularly because the patient can compensate for a wide range of deficits before suddenly deciding they’ve had enough. “Looks good” does not equal “Is doing good.” Get that family medicine, touchy-feely philosophy out of your head. These patients are sick and it’s better to be a pessimistic but alert bastard than Little Mary Sunshine.

8. Don’t be timid. If the patient needs a procedure then do it. Don’t dither looking for excuses to put it off because you are afraid of it. The ICU procedures that you will be expected to do are placing central lines, arterial lines, chest tubes, and endotracheal tubes. You will also need to know how to do a lumbar puncture, thoracentesis, and a few other things.

9. On the other hand, think about it first. Not every patient needs a central line, for example. The nurses like them because it simplifies their management but sticking a large gauge needle into somebody’s internal jugular vein is not without the possibility of complications especially in ICU patients who are usually coagulopathic. You can easily nick the carotid artery, even under ultrasound guidance, and this can be a disaster as a patient can lose a lot of blood into the fascial planes of the neck and mediastinum before you even notice it. You might also give the patient a pneumothorax (“drop a lung”) as the needle is long and the apices of the lungs can be high. Good rule of thumb, if you’re sticking a needle in the neck and you’re aspirating urine, you might be too deep.

As much as I like ICU nurses, making their lives easy is not an indication for central venous access. Being too timid to put one in, on the other hand, is not a contraindication. If you don’t know how, call someone who does, have them show you, and then do the next one.

10. For God’s sake, never force the needle, the wire, or anything else. If it won’t go in, it won’t go in. If the wire hangs up, pull it back a little and try again. A well placed wire in a vein or an artery should slide smoothly with very little resistance. If it doesn’t, you are either not in the vessel or the vessel itself is calcified and tortuous. Admit defeat, pull out, and try again. But the patient is not a pin-cushion and if you are obviously screwing it up pass it off to somebody else if they are available. If not, pick another site and try again.

11. Be ready. Know your ACLS because you are going to use it. This month we have never had fewer than three codes overnight and we usually have more. We once had three patients coding at the same time. The senior resident cannot be everywhere and you are going to be expected to take charge. Still, the ICU nurses know what they’re doing so if you don’t know something, ask and take your cue from them. If they suggest something it’s probably because they know what they’re talking about. As you get more experience and if you pay attention you will get more comfortable. The ICU residents are typically on the hospital code team and expected to respond to codes on the other wards. You will usually find a crowd of people milling about. If someone is in charge let them know that you are available to intubate, put in lines, of do anything else they need. If no one is in charge, take charge and remember the basics.

12. One of which is that most patients will not be hurt by a liter bolus of fluid and fluid can make a big difference. A liter is not actually that much. Two liters is better (most of the time, know when it’s not). Giving a 250 milliliter bolus is like spitting on the patient. It’s worse than useless. 250 milliliters is about a cup or so. If you decide to give fluids be a man about it and don’t get all girlish.

Same with magnesium. Two grams won’t hurt anybody and if they are in V-tach when you get to the room you might as well have somebody push it. You never know. It could be torsades.

13. I know this is not always true but generally, you can’t do much to hurt somebody who is already dead. If you give them a little too much atropine or epinephrine it’s not going to make them any more dead. It’s likely that when you arrive at the room of a coding patient, you will know nothing about the patient so you have to stick to the basics of airway, breathing, and circulation. Take a breath, follow the algorithm. You can give CPR for a minute between shocks. Take advantage of this time to calm down and get in the rhythm of things.

14. But you have to assess the patient. Listen to the lungs, feel for pulses. If you can feel a radial pulse they have a systolic of at least 80 whatever the cuff says which is generally compatible with life.

15. Sepsis is big. It comes in many forms but it’s a killer, generally from end-organ failure due to hypoperfusion which leads to all kinds of unpleasantness. Generally you treat it with a lot of fluids, pressors, and anything else to keep the blood pressure up. Culture everything, look for likely sources, and cover with the appropriate antibiotics empirically. And don’t forget to check the urine as UTIs are the silent killer of the elderly. Most ICUs have standard sepsis orders (heck, they have standard orders for a lot of things) but go over them before you sign to both make sure you don’t want to change something and to familiarize yourself with the what needs to be done.

16. Pulmonary emboli kill a lot of ICU patients. Suspect them always in the patient who is acutely short of breath because an ICU patient is a setup for clots. The D-dimer is useless. It will never be low. Every ICU patient has an elevated D-dimer for a variety of reasons. If you ever find a low one this is man bites dog. Besides, people with long-standing thrombi can have a low D-dimer and still throw a clot to the lungs. Consider anti-coagulation for every ICU patient except those with GI or intracranial bleeds.

17. Don’t negotiate with families. Bargaining is one of the stages of grief and you may find the family trying to make deals with you over how long the patient can live. It’s best to just give them the facts and the prognosis. I mention this because at a smaller program with no attendings in house overnight it often falls to the residents to talk to the families. If you don’t know much about the patient (if you are cross-covering) then either arrange for the family to meet with someone who does in the morning or familiarize yourself with the chart and admit at the outset that you are not following the patient on a daily basis. One white coat is the same as another to many people and they may be offended if you don’t know their family member backwards and forwards.

18. ACLS is not a menu. Discourage the practice of offering certain items while withholding others. A lot of families want CPR, for example, but no endotracheal intubation. I guess this makes a little sense from an aesthetic point of view but since “Airway” is the first part of ACLS I suspect that not securing the airway is a violation of the standard of care. Some families are offered what is referred to as a “chemical code” where they want all of the ACLS medications (epinephrine, atropine, amiodarone, etc) but no chest compressions, no shocks, and no airway. There is no point to this. All those meds will just sit in the vena cava or the atrium, all dressed up with nowhere to go.

If a patient is to the point where further care is futile you need to tell the family this, respectfully of course, but bluntly and suggest that it is now time to make the patient’s code status DNR (Do Not Resuscitate).

Apropos of Nothing

Futile Care, Uncategorized

1100 Bucks a Month

Just from the outset, let me say that poor 70-year-old Mr. Neely was definitely being neglected and possibly being abused by his son. The first thing they told me was that his hair was so dirty and unkempt that it was like one single dreadlock. The nurses had to cut off the worst of it to wash his hair, possibly for the first time in ten years. His nails were filthy and three inches long. Other than his obvious expressive aphasia and severe peripheral vascular disease, he had no medical history that his son could recall and had not been seen by a doctor (or anyone else, possibly) for the entire twelve years he had lived with him. His right leg has been amputated below the knee at some unknown time and the remaining foot was so swollen that the tissue ballooned out from around the elastic of his feces-encrusted sock. His shin was covered with black, gangrenous eschar and his toes were rotting off.

The son displayed a strange lack of concern about his father’s deplorable state and his medical problems, especially his expressive aphasia which is a symptom of a stroke in the speech centers in the dominant hemisphere of the brain (usually the left). All Mr. Neely could say was, “Wonderful…no…no…wonderful,” which he repeated continuously whenever he was alert.

“When did you first notice his speech change?” I asked, which is a reasonable and an important question when treating victims of strokes.

“About four years ago.” A complete lack of concern from the son.

Jesus.

“Didn’t you think about taking him to the doctor when it happened?”

“Well, it didn’t get any worse so I figured it would get better.” He might have been talking about what he had for lunch.

“When can he come home?” was his next question.

“I think he needs to be in a nursing home. You’re obviously not taking very good care of him,” I said, not trying to be non-judgmental, “What on earth is going through your head when you see him like this?”

Poor Mr. Neely. Trapped in his own private hell surrounded by neighbors who probably didn’t even know he existed. His son had probably gotten used to living off of his social security check in a house whose mortgage had been paid since the time when his parents still had hopes that he would amount to something. He might have died like that except the fear of losing the social security check had finally made his son risk bringing him to the Emergency Department.

What does this have to do with anything? Nothing really. No big lessons or morals to be teased out here except that maybe there aren’t two sides to every problem. Some things are obvious. Mr. Neely’s son was obviously a scumbag and was obviously neglecting his father. Evil obviously moves in the shadows of our world even if it is sometimes understated and bent on nothing more than a pitifully small government check.

Barking Mad

A Day In The Life Of..., Medical School, Specialty Selection, Uncategorized

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Guest Blogger: Mrs. Panda Bear

Uncategorized

Party Night

(I’m going to start a new feature here on Panda Bear, MD. Many pre-meds, medical students, and residents are married and have families and I thought you might like a little perspective from the other half of the team. PB)

Our little panda bear cubs have a name for their daddy being on call. They call it PARTY NIGHT! In daddy’s absence, we all have so much fun putting on our one-piece fleecy jumpers, making popcorn and watching a children’s movie (currently Christmas movies). Provided there is no school the next day, the cubs usually stay up until 10:00 pm and we all get to sleep in late the next morning. Many times on “party night” I share our king sized bed with our three snuggly cubs and 3 dogs.

Sometimes my husband gets his feelings a little hurt when the cubs ask if daddy is going to be on call and squeal in delight when the answer is yes. Managing my husband’s fragile emotions and self esteem, I have to remind him that I am trying to make the best of a potentially miserable evening by creating a really fun time for the cubs and me.

Housekeeping

Uncategorized

To make it easier for those poor souls still using dial-up, I’m going to adjust the format to only show the last twenty posts. This should make things load a little faster. If you haven’t already read them, older posts are still available in the archive.

My lovely wife will be “Guest Blogging” periodically on subjects that might be of interest to the spouses and significant others of medical students and residents. Medical training is a long slog and your partner-in-life should know what to expect.

As always, my humble thanks to all of you for taking the time to read and comment.

When in Doubt, Patronize

Uncategorized

Some of My Best Friends…

If I suggested to you that different races had easily identifiable personality traits and that not only could I use these traits to predict their behavior but that I should make prejudicial assumptions based on these traits you would rightly label me a bigot. And yet, this idea is running rampant through the medical training establishment and has gained a surprising legitimacy among people who profess to be wholly untouched by the stain of bigotry.

I am, of course, talking about diversity training and cultural competency. In reality, it’s nothing but racial profiling. To be culturally competent, we must modify both our approach and our expectations of patients according to their race. The barely hidden subtext of diversity training is that white, middle class patients who are medically compliant represent the norm and other races and ethnic groups stray from the norm to varying degrees. These differences are usually objectively bad, at least as reflected in medical outcomes and thus a cottage industry has been created to explain why this is so.

Black patients, I learned in one session of diversity training, have a more relaxed sense of the passage of time and thus cannot be expected to always be on time for their appointments or even keep them at all. It’s just part of their culture. Additionally, the race scholars tell us, since African culture is more vibrant and demonstrative than the repressive, protestant culture of the northern Europeans, blacks have different priorities when it comes to health and taking responsibility for their actions.

When the Imperial Wizard of the Ku Klux Klan says pretty much the same thing, that blacks are lazy and shiftless, it causes cries of outrage and an endless stream of self-righteous letters to the editor from the outraged multicultural intelligentsia.

You learn all kinds of stereotypes in diversity training. All of the stereotypes attempt to show things in a good light but if you think about it, if the good stereotypes are true, why aren’t the bad ones? If so, can I extrapolate from my large stock of racially insensitive jokes an algorithm for relating to my ethnic patients? And if not, why not?

Cultural competency, the vicious cousin of diversity, represents forty years of white intellectual guilt and is part of our inexplicable, lemming-like urge to be non-judgemental. A few decades ago Western intellectuals decided that there was nothing of value in the West and that we must look to primitive, less developed societies for inspiration. It is probably part of the never-ending quest for the noble-savage, untainted by the stain of modern life. This point of view has finally spread to the medical profession which had been better able to resist it due to the basic intelligence and skepticism of physicians.

In practice most of us will rarely encouter any cultural situation which we can’t handle by simply applying common sense and good manners. People are not that different, no matter from where they come. An acute abomen is an acute abdomen regardless of whether it belongs to a white baptist male or a full-fledged Inuit from byond the arctic circle. I don’t care what the inuit traditional practices are to deal with abdominal guarding. The fact that he has presented to my hospital means that at some level he has abandoned his traditional healing in favor of something that works.

The consecrated walrus blubber is obviously not doing the trick.

Pray let us not patronize the poor fellow. I once saw an attending dancing around the issue of traditional practices with an obvioulsy foriegn and exotic-looking patient. She was the soul of sensitivity and was being fastidiously careful not to imply that our Western Medicine had the answers.

Finally the patient held up his hand and said, “That’s all well and good but my cousin in Dakka said I needed to be on a beta-blocker and a statin.”