Fabulous Prizes II

As brothers our troubles are 
Locked in each other's arms
And you'd better pray
That they never find you
'Cause your back ain't strong enough
For burdens double-fold
They'll crush you down
Down into nothing.

-Townes Van Zandt

There is no alternative to black humor at the county hospital.  Rather, there is no survivable alternative.   If you are too sincere in your pursuit of the monster, you might actually catch it, and then you would have it in your arms.  This is clearly what happened to Townes in the epigraph above.

Morbid jokes supply an artful way of perverting the awful clarity with which you might see your patients, their situation, and your implication in it.  There are better and worse ways of executing this caper, this feigned stumble in pursuit of truth.

One of the worse ways to do it is to make jokes at the expense of patients - to mock the loud demands of the drug-seeking patient for i.v. Dilaudid (tm) or his implausible claim that he's allergic to the oral preparation.  I try not to do this, because in addition to being prima facie disrespectful, people who develop a facility for these jokes become calloused and uncouth.

A better way is to find the joke - this is the equivalent of dumpster-diving veal.  You're not actually paying for the calf to be shut up in a box; likewise, you're not actually mocking suffering, you're just noting its occasionally intrinsic comedy.  You can enjoy the surplus products of institutional cruelty without financing it.  You just need a morality which is more concerned with contingency than with essence.

Anyway, I found the best awful medical joke I have yet discovered in a chart in clinic the other day.  It was so good, in fact, that after close review by the Committee the author has been awarded another of my unsolicited prizes, the widely coveted "Most Concise Argument for Healthcare Reform" award in the Medico-Legal Documentation category.

I was seeing a patient for a colleague on leave, and I came across the following sentence, which she had written without any apparent irony:

Pt is a resident of the US but could not wait for appt with Adult Medicine so he went to Korea for diagnosis.

But this is not quite the best part - it's wildly hilarious, of course, that the waiting list for our clinic is so long and the private hospital alternatives so expensive that somebody would fly to Asia to avoid both.  But what swayed the Committee was the fact that the diagnosis the patient received in Korea was one of papillary thyroid carcinoma in situ, which is to say that he had a very dangerous tumor in his thyroid gland which had not yet spread.  The difference between papillary carcinoma in the thyroid only and metastatic papillary carcinoma is the difference between a minor operation and probable death.  He was smart to go to Korea; he waited "for appt with Adult Medicine," he might well be getting palliative radiotherapy right now instead of enjoying his cancer-free life with his wife and young children. 

He returned with his diagnosis and had his operation here, although I'm not entirely sure why.  He was taken a little more seriously when he presented his pathology report from the Seoul University Medical Center.  I'm thinking of advising my uninsured patients who can afford the initial investment to take their health problems to Seoul.  As a matter of fact, when I finish residency and lose my employer-mediated health insurance, I may join them. 


안녕히계세요!



  

The Archivist

Everybody knows Dr. T..  He has been at the county hospital, minus some stints at other facilities, for around forty years.  He came here from Brooklyn after finishing his pulmonary fellowship in 1962.  Forty years have not dulled his strong accent.  He is recognized as a deep well of knowledge and experience and frequently consulted about inpatient cases.  He is also to varying degrees notorious for being, as he proudly proclaims, "the only conservative" at the county hospital, and for baiting his liberal colleagues relentlessly with various conservative talking points.  He was most recently reviled for his vocal support of Sarah Palin, which he taunted the more progressive members of our already left-leaning faculty at every public opportunity.  I was on his service once before, as an intern, and when he found out I went to medical school in England he was delighted by the opportunity to explain the pitfalls of socialized medicine to our team.  At the end of my rotation he gave me a generally positive evaluation then handed me an two articles - one on the great global warming conspiracy and one on the inevitably Stalinist destiny of any government-run healthcare program - and said, "You don't know this yet, but you're a project of mine."  (I didn't mention that he is also a project of mine, in that I am still trying to figure out why a man so dedicated to free-market economics and living with the consequences of the choices you make has chosen to spend his life treating the unemployed, the homeless, the addicted, and other "non-productive" members of society, for which service he is mainly reimbursed by Medi-Cal and other government-run systems.)

He is also famous for his apparent immortality.  He is in his early seventies, but looks about sixty.  Only if you look closely at his hands can you detect the slight wasting of the small muscles that comes with old age.  His skin is relatively unlined and his hair and beard are still very much more pepper than salt.  His constitution and conduct of his daily activities seem unfazed by seven decades of active life.  He can still deliver two-hour extemporaneous lectures on most subjects in his field which are focused and coherent, and his appraisal of the cases he consults on is always clear and subtle.  When people comment on his miraculous mental and physical preservation, he attributes it to his diet, which, as far as I can tell, consists mainly of blueberries, strawberries and green tea.  He always has a large tupperware container full of the former in the battered backpack he brings to work, and a box of the latter on his desk.

But these are all relatively minor features of his repuation.  What Dr. T. is really famous for is his free-standing, completely illegal one-man Medical Records Department.  Everybody who works at this county hospital, and probably any county hospital, is engaged in a constant, losing war of attrition with Medical Records.  Every doctor has had the experience of seeing a patient for a return visit after seeing them a month before, opening the chart to where the last note should be, and finding nothing.  The unreliability of Medical Records in their ability to produce the patient's chart, and even in that event, to produce it in an unmangled condition containing the information that was in it the last time you saw it, is so widely known that almost all clinics maintain their own "shadow files" on their patients.  These are simply photocopies of clinic notes or hand-written summaries - they contain no information about what has happened in other clinics, but at least they save you from having to ask somebody you saw two weeks ago what the plan was at that point.

Dr. T. decided a very long time ago that this was inadequate.  He maintains a comprehensive library of shadow charts for every patient he has ever seen.  He makes them himself out of scratch paper which he tears into corners and sticks together with scotch tape.  These "pages" are then covered with his characteristic scrawl.  New pages are added every time he gets new information about the patient, which is as often as possible, and as much as possible.  New interns on the service are often shocked by the volume of data they're expected to record, duplicate, copy, and present for every patient.  Dr. T. stops them continously as they present patients they have seen to him in his office, asking for pieces of data they never thought to collect:

Intern: So Mr. Jones has been doing well overnight.  His temperature this morning was 98.6, although he did spike to 102.1 last night.

Dr. T: Uh huh..., and what time was that?

Intern: Last night.

Dr. T: Yeah, you said - but what time was it?

Intern: Um...I'm sorry, I didn't write that down.  He also had a chest X-ray this morning that showed -

Dr. T:  Oh, good.  Do you have the report on that?

Intern:  No, but it showed -

Dr. T:  Too bad.  When you getta chance, could you print out the report on that for me?

Gradually, they learn to collect every number within twenty feet of the patient's bedside and print out every piece of data that has been entered into a computer.  The difference, they realize, is that while other attendings they have worked for are content to know that a chest x-ray report is uploaded to the data reporting system and they can look at it whenever they want, Dr. T. has adopted an attitude of radical mistrust towards all hospital data.  If it's not printed out and scotch-taped to something in his office, it is in danger of vanishing into thin air at any moment.

Because of this obsessively acquisitive orientation to data and his...organic style of organizing it, his office is a mess.  Actually, it's more like a Superfund site.  It's the kind of mess that can only be made over a period of decades.  There are two large bookshelves which are completely stuffed with old journal issues, ancient textbooks, and innumerable scraps of apparently irrelevant paper.  The desk has only one small clearing near his chair where he keeps the scotch tape and his scratch paper - the rest is piled about a foot high with loose leaf.  These strata are mainly composed of journal articles he's used for teaching and redundant data which didn't make it into the charts.  They grow every day and every day become more precarious, until there is a predictable but always dramatic landslide.  An intern gets up to hand him something, catches their scrubs on the corner of a stack, and swoosh, an avalanche of disjointed confidential medical records come sliding down around their feet.  At this point he usually makes some joke about how carefully organized it was, and how long it will take him to put everything back in order, before adding the debris to one of the even more extensive piles of paper against the walls.  Because they are stabilized, some of these have attained heights of several feet and because they have been built up a few sheets of paper at a time they are extremely old.  So old, in fact, that there is a noticeable color gradient from the new, white sheets at the top to the yellow, cracked ones at the bottom. 

The fact that he has been doing this for years is also apparent from the frayed, yellow edges of his little coverless charts, and the presence of type-written reports towards the back.  He takes those pertaining to current inpatients home with him every night and on the weekends, and he keeps the rest in two enormous filing cabinets which dominate what would otherwise be a spacious office (although one assumes that if they weren't there their place would be taken by stacks of paper big enough to actually hurt people when they eventually fell over).  There is no apparent system to the charts' disposition in these cabinets.  When he opens them, all anybody besides him can see is a mass of indistinguishable shreds of highlighted paper.

But not only does he know where everything is, his completely insane, time-consuming, ad hoc medical records system actually does work better than the official one.  I'm currently the pulmonary resident, and I've been approached by residents on other services several times saying something along the lines of "Hey, we got this lady last long call - she's got bad pulmonary hypertension, and I know she's been here before, but there's no reports in the computer and Medical Records say they don't have a chart.  Would you ask T. if he's got anything?"


When I do, he rises slowly from his chair, repeating the name a few times to try to jog his memory, and then after a moment of shuffling, triumphantly draws a ripped, tattered collection of quarter-sheets from the depths of a creaking drawer.


"Ah yes," he says with a triumphant smirk, "Mary Johnson.  So, this is a thirty-five year old lady with a history of diabetes, who we first saw in clinic in 1998.  We did some pulmonary function tests," he unfurls a full-sized sheet that had been carefully folded into quarters and taped into the chart, "and we found that she had a normal FEV1/FVC ratio but markedly impaired diffusion.  She was supposed to come back to clinic in two months, but she missed her appointment, although she did get her outpatient CT done in April of that year.  Then, in August...."


I scribble down the things I think will be relevant to the other resident, and thank him.

"Yeah, well," he says, "this is my cawling, ya know?  I coulda been a great baseball player, I coulda been a great cardiac surgeon, but I decided, when I was a boy playing stickball in the streets of Brooklyn, I said, 'I wanna be the Chief Librarian at the county hospital.'

"As a matter of fact, Ben Bernanke was on the phone this morning," he continues, "To see if I knew anything.  He wanted to know if I had any records of what happened, you know, back in October."

I admire the commitment to a clear and comprehensive understanding of his patients that's implicit in this continual frenzy of data collection and collation - but I'm fairly horrified by what its necessity implies about our organization.

Thanksgiving

I only had to work the morning this Thanksgiving, which was a signal improvement on last year. 

I spent the 2008's Thanksgiving at a rather elaborate celebration hosted by an old friend involving smoked turkey and a variety of other nice things, which was clouded for me by the inevitability of an 11:00 PM to 8:00 AM shift in the Emergency Department.  I wondered vaguely what the night was going to bring, imagining a torrent of gout exacerbations brought on by over-indulgence in purine-rich delicacies, punctuated by a predictable flow of alcohol-induced head injuries. 

I was surprised when I duly arrived at eleven, annoyingly sober and carrying a tupperware container of mixed leftovers, to find the place nearly deserted.  The expected battalion of portly men with swollen toes were nowhere to be seen.  The monotony was interrupted by a few bizarre traumas - a seventeen year old boy was brought in around two-thirty after falling from a tree in a local park, although what he had been doing there was never clarified to my satisfaction; and another young man came in with a comparatively minor gunshot wound he received after the hapless reveler he had been threatening wrested his gun away from him - but other than that things were extremely slow.  I think I spent a full hour watching an ED attending de-frost the departmental freezer by excising large slabs of ice using a wound-irrigation rig filled with warm tap water.

One of the few cases I did see, however, disturbed me immensely - so much so that I recalled it on Thursday simply because it was Thanksgiving.  Around three in the morning I picked up a routine-looking patient - a sixty-eight year old woman complaining of pain on urination.  Why she had waited until the early hours of the morning after Thanksgiving to come to the ED was initially mysterious, but after I talked to her for a few minutes and found out that she was chronically homeless, it seemed a little less so.

She had been living for several months in a pedestrian subway in a neighborhood I had actually lived in many years before.  This fact was somewhat humbling to me since during my tenure there I had regarded the subway with fear and opprobium as a certain locus of opportunistic robbery, preferring after dark to sprint across an eight-lane arterial road rather than use it.  She was also floridly schizophrenic and not taking any antipsychotic medications.  She talked to me in some detail about various, mainly intangible problems, a notable exception being the "rats that bite your genitals" (which I know were fictional because I performed a physical examination commensurate to her presenting complaint - I have seen people caught out badly before by assuming that homeless schizophrenics' claims about their bodily afflictions are delusional).

She had, I was fairly certain, a simple genitourinary infection which can be treated with a single large dose of antibiotics, so after I ordered this there was really no reason for her to stay in the ED.  However, when I returned after the nurse had administered her medication to check on her, I found her warmly wrapped in hospital blankets and sleeping soundly.  All of the other beds in her three-bed bay were empty, and if the look on her face was not one of perfect beatitude, at least it was not the look of someone battling with hallucinatory genital-biting rodents. 

So I did what I thought was the obvious thing, and left.  I figured she could stay there until the social worker showed up in the morning and could find her a shelter, or until the bed was needed for a more acute case, whichever came first.  None of this was disturbing, except in the quotidian sense that all manifestations of America's grotesque disparities in health care and radically inadequate mental health infrastructure are disturbing.  What made me remember it was what happened a few minutes later.

As I said, I thought that letting her sleep was an obvious thing to do until her nurse stopped me in the hallway and, with a patronizing look suggesting that I was not benefiting much from my training, said "Hey, that lady in seventeen - does she really need to be here?"

"Well, no," I said, "except that the regular social worker doesn't come in until seven, so I thought we'd just let her sleep until then - as long as we don't need the bed."

"Then why can't she wait in the lobby?" she answered.

"Aaaah," I said, somewhat flabbergasted, "I guess she could.  It's just that, I don't know about you, but I don't feel very good about waking an old homeless lady and kicking her out of the first bed she's slept in in months on Thanksgiving night so that she can go sit in a plastic chair in the waiting room."

"Well, just so you know," she said, "we try to move people through as soon as they've received their medical treatment."  And, after shooting me a malignant look, she stalked away.

What the nurse in this story did wasn't motivated by personal cruelty - it emerged from an extremely common defensive strategy adopted by safety-net health care workers all over the country, which consists in trying to insulate yourself from the monumental inequality and social evil to which you are exposed in horrifying detail by retreating into a narrowly defined professional purview, and denying the legitimacy of anything that falls outside it.  This self-imposed limitation of your field of vision allows you to avoid the unpleasant experience of witnessing things like this and of thinking about your own implication in the system that produces them.  For the nurse, fretting about ED throughput is a way of fortifying her psychic well-being - of avoiding constant anger and depression.  Cruelty is an unfortunate byproduct of self-preservation.


I have seen a number of instances of this kind of institutional, bureaucratic cruelty in the intervening year, some of which I've written about in previous posts, but this one stands out for its concise demonstration of a principle which we should all be thinking about as the frustrating and compromised project of health care reform shambles onward into the new year: the homeless schizophrenics aren't the only people who are brutalized by the current health care "system."  The people who run it, the emergency room nurses, the doctors, and the clerical staff, (and I think I implicated myself rather comprehensively in this group in my last entry) are also belittled and perverted by it.  They're driven to adopt attitudes, simply to safeguard the person they want to be for their family, for their friends, for everyone in the shiny functional world of their stable, employed, housed lives outside the county hospital, which distort who they are in the hospital in frightening ways and lead them to do things like suggest that there's something obviously stupid about letting an old homeless lady sleep in a bed that nobody else is using.

It will be interesting to see how (or if) whatever reform is ultimately passed changes things in ways that allow people at the coal-face of health care in underserved areas to be more like the people they almost uniformly want to be, and less like the people they end up settling for being.

High Hopes For Bobo

"We cannot prepare you for finding out that
you do not much like person you are becoming..."

J. Murray Longmore, The Oxford Handbook of Clinical Medicine

As I mentioned, I am currently working on the renal service and I don't like it very much.  Fortunately I will switch services tomorrow, but until then I remain Dongo the Dialysis Monkey.  I have adopted this sobriquet to foreground the fact that a trained ape could do most of my jobs.  (Actually this is not entirely true, as I discovered when Gorgo (left), the ape I trained to do most of my jobs, was suspended because of certain unmentionable irregularities in his bedside manner.)

The renal service has given me multiple opportunities for insecurity about the person I am becoming.  Most of these arise from a basic tension between the exigencies of county hospital life, and our pretensions about what we do on the renal team - a tension which is often transferred to the doctor-patient relationship.

While the renal service is theoretically also here to give an expert opinion on baffling kidney problems, mostly what we do is outpatient and emergency dialysis.  The former is a regular and predictable affair which involves evaluating patients' needs and filling out a bunch of paperwork every morning, the latter a completely unpredictable one which involves doing the same thing in the middle of the night after being awoken at home by the shrieking renal pager.

Ideally, inpatient dialysis should avoided insofar as is possible in view of other medical conditions - patients in end-stage renal disease should get their treatment in dedicated outpatient centers - and emergency dialysis should be rare and only rendered necessary by some peculiar and unpredictable circumstance.  But two uncomfortable realities vitiate this ideal and create the tension I referred to.  The first is that many of our ward teams put too much stock in the phrase "no acute medical issues" as a magic formula for discharge while paying insufficient attention to the fact that end-stage renal disease is always one missed dialysis session away from being an acute medical issue.  They are therefore prone to discharge dialysis patients without paying enough attention to what will happen in the three days after they leave.  The second is that receiving dialysis is essentially a part-time job - one has to attend a range of outpatient medical and surgical appointments, undergo recurrent elective surgeries, and show up for dialysis for at least three hours at a time three days a week; most of our chronic dialysis patients already have several part time jobs, if they are lucky enough to be employed.  More often they are not and are intensely financially unstable, living lives punctuated by evictions, forced migrations, interruptions in transportation, and undeferable obligations which conflict with their rather demanding dialysis-related schedules.

You might think that if your life depended on doing something three times a week, you would make time for whatever that thing was - but when you imagine trying to keep regular three-hour appointments while you're in the process of being evicted from your apartment, trying to re-establish your lapsed Medi-Cal coverage so that you can get refills of your HIV medication, and dealing with your twenty-nine year old son who has moved home after being released from jail and is trying to balance the reality of his paraplegia with his efforts to control his diabetes which has already rendered him partially blind and is pushing him steadily along the road to dialysis, (with all the guilt and fear that trajectory would entail for you,) you can probably think of some potential pitfalls in scheduling.

Here is an example each of these two realities, which give rise to reflections on the person all house officers are in danger of becoming and whom I "do not much like":


1) Mr. C is a 27 year old gentleman whose kidneys were destroyed by an immune disorder.  His body rejected a kidney transplant back in 2005, and now he's on dialysis for life.  He came to the emergency room in hypertensive crisis (everybody with kidney failure develops high blood pressure) and the admitting team looked at a prior discharge summary and immediately put him on the rather extreme regimen of medication documented there without really verifying that that's what he had been taking.  He was then dialyzed, and four liters of fluid were removed from his blood.  It turned out that actually he had only been taking one medication, which he had run out of, and which is known to cause vicious hypertension as a withdrawal effect.  Because of this overzealous therapy, at around seven O'clock,  his blood pressure fell through the floor and he actually went into cardiac arrest and was barely resuscitated (regular readers may remember him from the post before last).  He was discharged a few days later and, not wanting a repeat of his near-death but also not wanting to keep him in the hospital to titrate his medications, the admitting team, as they documented in their discharge summary, advised him to "follow up with his nephrologist."  In any sane healthcare system this would have been only slightly risky, but in the county system "advised to follow up" is actually a secret, if inadvertent code for "advised to go die somewhere quietly, preferably in another county."  Unsurprisingly, he returned a few days later in another hypertensive crisis, having been unable to get an appointment with his nephrologist on such short notice.  This was so unsurprising that I felt stupid for not having followed my initial impulse when he was discharged, which was to write an undated emergency dialysis order so that when I was called at 3AM I could just mumble, "it's in a ziploc bag in the emergency room toilet tank - just date it call the dialysis nurse."

But it isn't just that things like this happen that bothers me - it's that people are so inured to it that the intern who discharged him for the second time apparently felt no qualms about writing in the second discharge summary "admitted for hypertensive crisis secondary to medication non-compliance."  I have been trying to come up with ways to ameliorate my over-use of the phrase 'Kafka-esque' at work, but I struggle for an equally concise way to describe being tacitly condemned for failing to take medications you were never prescribed.

2) Mr. D. is a 50 year-old Jehovah's witness who was recently admitted having developed a considerable upper gastrointestinal bleed and a concurrent blood infection from his indwelling dialysis catheter.  All renal patients are anemic, bleeding makes that worse, and sepsis lowers blood pressure catastrophically; which is to say that he didn't have enough blood in the first place, he lost a lot, and then he lost the ability to move it around.  All in all a very bad situation.  Moreover, Jehovah's Witnesses observe an inflexible religious prohibition against receiving blood transfusions (a fact which many doctors seem to resent as though it represented some kind of perverse caprice) so there wasn't much that could be done for his increasingly profound anemia.  Everybody involved was quite surprised that he survived.

On Sunday, about a week after he was discharged, I was at home.  I had worked through the weekend and would be working through the next week.  My parents were coming over for dinner, and my wife had arranged for us to meet before hand at the summit of a tall hill in a beautifully laid out cemetery near our house to enjoy a panoramic view of the sunset, which would crown a remarkably beautiful crisp November day, with some olives and a bottle of wine.  I had just gotten up from a much-needed nap, and was trying to contribute in some small way to the preparations for dinner, when the infernal renal pager went off.  The emergency room resident who had paged me told me that Mr. D. was back, and that he needed emergency dialysis.  His hemoglobin was even lower than it had been, and his potassium was dangerously high.  In fact, his potassium level (which is supposed to be around 4 mmol/L) was higher than his hemoglobin, (which is supposed to be at least 13 g/dl) a reliable clinical indicator of terrible evil which I am going to try to popularize as Benway's 'Oh, Shit' Ratio.

When I asked the ED resident how this had come to pass, she told me that he had missed his last two sessions of dialysis.  And my reaction clarified to me further exactly who this person is that I don't like and am trying not to become, because there was a split second where I almost said, "Ok, here's what we're going to do - give him a gun, and he can just shoot himself."

This is an awful, selfish thing to think, and all I can say in my defense is that I realized it immediately and instead said, "All right, I'll be there in fifteen minutes."  And when I talked to him, of course, it was immediately clear that there were a number of reasons why he had missed his dialysis and all of them were poignant and understandable.

Thank God I have clinic twice a week - pediatrics on Monday, where I mainly see vibrant Chicano health, and my own clinic on Thursday, where I see my increasingly well-known and well-managed panel of primary care patients.  In clinic I can see many potential futures where I'm a compassionate physician working together with the sick to overcome the barriers between them and the health they want.  And it's nice to be reminded that there are many alternatives to becoming was the intern who blithely accused Mr. C. of "medication non-compliance" after discharging him with no prescriptions, or the resident who almost said something horrendously insensitive about inciting the suicide of a poor devout man who's just trying to live with an awful disease in a world which makes insane and unfulfillable demands on him.

I leave the renal service on Thursday, but much to my chagrin I will have to do this again at least one more time before I finish residency.  I was tortured by this inevitability. . . and then I met Bobo.  Bobo is an adolescent bonobo interned at the San Diego Zoo, who is much more personable and intelligent than Gorgo.  He shows real potential, and after I liberate him tonight and install him in the modest but adequate quarters I have prepared for him in my closet, I will have a full year to teach him how to respond to patients' concerns with empathy and sophistication.  Depending on how he looks in a lab coat (after I wax him,) there may even be a permanent position in it for the enterprising young thing.  And a bonobo could do worse in the present economic crisis.

Kill Your Television

I am currently working on the renal service.  The renal service at my hospital is run by outside contractors.  We can't currently afford our own pet nephrologist, although I am told such an appointment is in the works.  The check is, I was told when I complained to the Chief of Medicine about certain aspects of our contractors' service, in the mail.  I assume all will be rectified shortly after we get electronic medical records, a couple more ultrasound machines, a new fully staffed outpatients clinic, retrofit the main acute care building, and install the long-awaited daquiri fountain in the lobby.  Until then, however, this is a kind of depressing job.  I have thought of a number of things to write to you about it, but discarded them all as participating in the "misery-loves-company" category - so instead, here's something I wrote during happier days when I was a medical student at a District General Hospital in Surrey in 2007.

.......................

Today I discharged a patient recovering from tetanus.  This is, in the developed world, a vanishingly rare disease because everyone should have been immunized against it and received periodic boosters to maintain their immunity.  Our patient, however, had missed one somewhere and had been picked up by the paramedics with his arms uncontrollably spasming into gnarled claws and his intercostal muscles contracting so forcefully that they bulged out in between his ribs “like sausages.”  

            While a significant proportion of tetanus cases occur in the absence of any identifiable site of innoculation, most are associated with some kind of penetrating injury.  In our patient’s case, there were two recent events which seemed promising as possible points of contamination.

            1. He had recently commissioned a tattoo on his buttock, which read, in flowery cursive, “Your Name.”  (I have a photo, which was taken for clinical purposes, but after a rather short deliberation I decided against including it for reasons of patient confidentiality.)   He had several reasons for deciding to have this cryptic phrase permanently inscribed on his butt.  The first, which is probably obvious, was so that he could bet people in pubs that “I’ve got your middle name tattooed on me arse.”  He claimed it had already “paid for itself in pints.”  He clearly enjoys a more than usually jocular relationship with his ex-wife, since he joyfully related having made her one of his first marks – a practical joke presumably made doubly hilarious by the intense wave of relief she must have experienced when she discovered that he had not, after all, had her name tattooed on his arse.  The second, which is slightly more contingent, he explained as follows: several years ago, on his account, he was apprehended at a major London airport attempting to smuggle three quarters of a million pounds sterling worth of high-grade Afghan heroin into the UK – from where, and for whom, he was naturally reticent to say.  Since his release from the bastille, he  had found himself the target of the frequent and unwanted attention of the police, whom he accused (perhaps slightly overrating his significance as an international criminal mastermind) of “glory-hunting” in their obnoxious habit of stopping him whenever they got the chance.  He described an ecstatic (and not entirely unimaginable) pleasure in barking his new catch-phrase at the arresting officer as he was unceremoniously cuffed and, particularly, in the knowledge that in their subsequent report they would have to document both his defiant claim and its factual accuracy.

            2. As I alluded to above, he had what were somewhat patronizingly and euphemistically recorded in his A&E admission card, he had “mental health issues,” specifically a history of depression and self-harm.  He had grown, he told me, fed up with the stigma associated with the lines of healing cuts on his forearms, and had hit upon a novel plan: he shot staples into his thighs with a spring-loaded staple gun, which caught on his flannel boxers - like a sort of ghetto surplice - turning his self-harming ritual from a series of furtive outbursts into a continual regime of pain and abasement. 

            He was very proud of both these innovations, despite his ready admission that they were both plagiaristic.  In fact, they had a common source: he got both ideas from the popular American TV program “Jackass”. 

            I can’t help searching for morals in a story so frought with articulate significance, but I am at a loss.  Being a drug-mule doesn’t pay?  Keep your tetanus vaccine up to date? Only patronize scrupulously clean tattoo parlours? Autoclave your staple-gun?    Then I saw a bumper sticker bearing the title of this post, and I realized I need look no further.

Overheaded to Bedside at 1900

Last week I did my first overnight on-call as a second-year resident.  I hoped that it would be calm and that nobody would call me.  When you’re an intern, sleep is impossible because the pager goes off every ten minutes, but when you’re a resident, sometimes you can sleep, precisely because the intern’s pager goes off every ten minutes - so long as you don't get called to help admit patients from the emergency room, and there are no emergencies on the wards, and the intern doesn't need help.  I was working through some dictation in the now-empty Adult Medicine Clinic around 7:30 when I heard the overhead system paging the "medicine resident on call to SDU" and was somewhat alarmed to remember that I am now the one who needed to start pelting down the hall when this happens.

I wrote a note after the ensuing situation stabilized, to document everything and for the primary team to refer to in the morning.  I have reprinted below the section which describes what happened, anonymized with some minor alterations for clarity (e.g. I have expanded many abbreviations).

Medicine R2 Backup Note

Overheaded to bedside at 1900.  Arrived to find Mr. C moaning and diaphoretic, with a systolic blood pressure in the 60s.  He complained of feeling faint.  BP confirmed by manual measurement.  Stat EKG showed sinus rhythm with junctional complexes and prolonged QT interval.  Ordered a 1 liter bolus and started dopamine drip.  BPsys continued to fall; external jugular line, which was patient's only vascular access, was displaced during manipulation and code blue was called.  ED team arrived, code run by ED Resident.  Brief period of pulseless electrical activity on monitor during which chest compressions where initiated, with spontaneous reversion to normal sinus rhythm – no antiarrhythmics given.  Oral airway was placed and bilateral femoral lines attempted, successful on the left.  Pt. began resisting strenuously and screaming, although BPsys remained below ninety.  L. femoral line was placed and bolus resumed.  Dopamine max dose reached in SDU.  BPsys stabilized in 60s-70s on dopamine drip.  Pt. continued to complain of dizziness and headache.  I supervised Mr. C’s transfer to ICU and started norepinephrine drip.  BP rose to BPsys 90, and fluids were stopped.  At the time of writing he is stable and says he feels much better.  Headache and dizziness have resolved.

As I wrote this, I was struck by the style of medical documentation I was writing in, (which I've been trained to write in and which is completely conventional).  The curt, assured tone is so at odds with the reality of these situations that it still feels somewhat ridiculous to assume.  This kind of documentation has been developed most clearly to meet one basic requirement beyond the simple communication of medical information, which is that it be medico-legally blameless - something must be written, because sub-standard documentation is a liability in and of itself, but it must not be something like, “shucks, I didn’t really know what the hell to do, so I gave him another shot of adrenaline."  But the process of evolution isn’t efficient or teleological; there are other elements to this style that are reminders of its contingent origin in a professional context heavily informed by science and Enlightenment rationalism generally.

For instance, objectivity is a basic tenet of this style.  The rejection of all subjective properties as fit subjects of documentation has evolved from an articulated philosophical principle into a subconscious aesthetic.  I work with people who routinely write things like "ambulate" instead of "walk," and "lower extremity," instead of "leg."  These are arbitrary substitutions which add nothing to their description except an aptmosphere of Latinate scientific legitimacy – but people adopt them compulsively, apparently because Anglo-Saxon words are somehow considered to be more emotional than Latin ones.  Like every aesthetic, this one has its connoisseurs and virtuosos.  I actually know someone who described an interaction which ended with the patient weeping in front of him with the sentence "left patient lacrimating with tragic countenance."

Another major commitment of the style is the exclusion of uncertainty.  Details which don't fit the overall picture are rarely included - moments of enigma and confusion are elided insofar as this has been rendered possible by subsequent events, collapsed into the test results they generated the impetus for obtaining, without ever being mentioned.    (This stands in stark contrast to the way doctors actually talk to each other, which often consists mainly of equivocation – more on that in the future.)

Finally, the overwhelming passivity one adopts when writing this was is striking.  "I" never start the dopamine drip - the dopamine drip always "was started."  Operative reports are particularly dense examples of this, most of which do not have a single first person pronoun in them, despite being eyewitness accounts of procedures performed by the narrator.  Instead, they are so detached that they seem to describe a magical anatomy executed by an invisible deity.  One imagines muscles dividing themselves, retracting themselves, organs revealing themselves and biopsying themselves.  A representative sample: “Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit." (As an aside, I worried for a moment about whether and how to cite the source I got this from before I realized that the whole point of the style it’s written in is to be anonymous and reproducible, making any claims on such texts as intellectual property totally meaningless.)

Clearly, you can make arguments that these kind of things have a necessary rationale - say, concision to save time, or the objective conveyance of reproducible information as in "other” branches of science, and there must be some truth to these arguments.  But it's also true that these ways of writing and documenting (which are therefore also ways of structuring experience and reflecting) have aesthetic and conceptual tendencies which cast their writers in certain roles and which aren't simply about some commonsense efficiency but rather the result of a long and largely unconscious historical evolution.

I think we should pay attention to these tendencies, because, as I just said, in addition to simply documenting and communicating information writing structures experience and stimulates reflection.  The second part of the note I wrote is a good example of how this can work for one and one’s patient.  It's quite boring so I won't reproduce it here, but I took the opportunity after everything calmed down to write a systematic differential diagnosis which helped me think about the case as I went and arrive at an understanding of exactly what had happened in physiological terms, which then enabled me to confidently plan the management of the case for the rest of the night. 

I think the first part of my note is a good example of how the conventions I've been talking about can work against one, since, while they may placate lawyers, they exclude certain kinds of reflection.  Isolating and qualifying things like the style of medical documentation is important, because it allows us to see what exactly it is that the ways we’re asked to think exclude – in this case, the note provides an opportunity for extended reflection dedicated to imposing coherency on what was actually a fairly incoherent situation, and more importantly of making diagnoses and corrolary plans.  It does not provide any time to, say, think about both yourself and the patient as a subjective entitie characterized by emotional states which are powerful, difficult to control, and highly relevant to the interaction; it does not provide any means of self-criticism, of identifying weaknesses in one’s response to the situation and figuring out how to address them next time; it does not create a space to reflect on elements of the situation which remain ambiguous.

My point is not that it should.  Aside from rare flashes of intriguing material, it would probably be extremely obnoxious and a waste of everybody’s time if the medical record was full of this sort of thing.  My point is that things you do often and unconsciously shape you.  I can tell from some of my older colleagues that if you don’t use your capacity for other modes of thought than that implicit in the style of my note, you definitely lose them.

"Can She Go?"

I stopped by the ICU today to steal the only reliable opthalmoscope handle in the hospital and to check on Ms. S.  Ms. S. was my patient for the entire month that I worked in the ICU, and she is still there.  She is thirty years old, and she has a terrible disease called scleroderma, which is characterized most obviously by a progressive thickening and tightening of the skin.  Hers has a dull shine to it and has been getting gradually smaller over the last several years.  Her mouth is constricted as though it were being cinched closed with a drawstring; her fingers are curled into her palm to and cannot be fully extended; her nose is being drawn down towards her mouth. 

Ms. S. had advanced scleroderma lung disease to begin with.  She came to the hospital originally with flu-like symptoms, and her condition deteriorated rapidly.  She had to be intubated and attached to a ventilator.  She developed a loathsome condition called Acute Respiratory Distress Syndrome, which can be caused by almost any grievous insult to physiology (e.g. trauma, septic shock, pancreatitis, etc) and basically consists of generalized inflammation of the thin membranes in the lung across which oxygen absorption and carbon dioxide excretion are supposed to happen.  It ultimately turned out that in her case the precipitating even had been the dreaded H1N1 “swine” influenza. 

When we first met, she was intubated and lightly sedated.  I could wake her up, with some effort, and she could respond to my questions with nods and shakes of her head.  She was dependent on the ventilator to breathe, but we hoped to “wean” her off.  Unfortunately, this wasn’t how things went. She couldn’t tolerate any reduction in her level of breathing support, and she became increasingly uncomfortable and began having epic coughing fits during which her blood oxygen fell to dangerously low levels. The only thing we tried which worked in supressing these fits was heavier sedation, so for the last three weeks I took care of her she was basically comatose.  I saw her every morning, and almost every morning I took an arterial blood sample from an artery in her groin, which was the only one we could reliable find through her thickened skin.  Every day on ward rounds the attending physician and I tried to think of something we were failing to do that could improve her lung function.  We tried a lot of things, none of which worked.

This long pre-amble is by way of explaining that I was fairly interested in what was going to happen to her – you can’t see somebody who’s desperately ill and stab them with needles on a daily basis without developing some investment in their course.  When I walked into the room, I thought for a moment some kind of miracle had taken place, because she no longer had an endotracheal tube tied into her mouth and she appeared to be fully conscious.  Then I realized that the ICU attending physician had finally given up and gotten the surgeons to perform a permanent tracheostomy on her, so she could continue to be mechanically ventilated without requiring constant sedation to help her tolerate the tube in her throat.  The ventilator settings were exactly where I’d left them.

On my way out, I saw the intern who took over her care from me when I left the ICU. 

“Hey,” I said, “I saw Ms. S.  I guess things haven’t changed that much…”

“Yeah,” she said with a look of mock anger, “Thanks for the rock.  Jesus, she is never going to leave the unit.”

A “rock,” you’ve probably guessed, is a pejorative term applied to people who require extended hospital stays.  This strikes me as an odd appelation for a doctor to apply to their patient.  You really have to hear somebody say it to appreciate the implication of truculent intransigence it carries.  When I’ve handed over patients who were obviously going to require prolonged care, I’ve heard my replacement say dismissively “Oh, so she’s a rock,” and likewise when colleagues have signed their patients over to me they often begin by literally apologizing for their “rocks,” as though to suggest that they had done their bit, but the inconsiderate clod in bed 15 was refusing to hold up their end of the deal.  Aside from being offensive and dehumanizing, this strikes me as a pretty peculiar attitude.  After all, the people who talk about their patients like this have spent at least nine years in higher education, have worked remarkably hard both physically and intellectually, and have usually gone deep into debt in order to be exactly where they are.  So it seems strange that they should be trying to blame that situation on the ostended caprice of people who, by definition, are in a state of total dependence and to whom they have committed their professional lives, both tacitly by their conduct conduct and explicitly by doing that whole Hippocratic oath thingy.  

But the “rock” discourse isn’t anomalous; it’s part of a larger mania for discharge which often assumes a character that can only be described as surreal.  Some people are so consumed by it that they seem to forget everything they ever learned in school and every particular of the present situation in their mad yearning to get patients out of the hospital.  (As an aside, the language which is deployed around this is really singular – for instance, people often refer to discharge as “sending,” i.e., “I think we can send him today.”  Where, exactly, we are going to “send him” is seldom specified, and sometimes it is so vague that the goal sounds almost astral.)  For instance, when I was an intern on the wards about six months ago I had a patient who was admitted from the emergency room with a formidable list of active problems: she had uncontrolled diabetes, which had left her, at the age of twenty-six, legally blind.  She had no health insurance, and our county aid program does not pay for any of the prosthetic devices that allow blind people to accurately dose insulin, so her prospects or achieving adequate control at home were basically nil since her dosing strategy was to draw up, guided only by touch, “about as much” insulin as she thought she “probably” needed.  She had gastroparesis, a form of diabetic nerve damage which results in paralysis of the stomach, and the only thing she could keep down was high-calorie liquid nutrition.  She was dependent on narcotics, which had been liberally prescribed to her at another hospital when she had suffered a thigh muscle infarction the previous year (watchers of the show House will appreciate that this is a stunningly painful condition).  She had an extremely intimate and fantastically agonizing soft tissue infection.  She had been kicked out of her parents home, where she had been living, and was sleeping in unlocked cars, and, as though the ante needed to be raised any higher, she had a foot ulcer which had eroded all the way through her skin and muscle and set up a chronic bone infection. 

Even if the bone infection had been her only problem, she would have required weeks of intravenous antibiotic therapy, which given her catastrophic social situation could obviously only be reliably administered on an inpatient basis.  And yet, every single morning for three weeks, the resident on my team would say, “Hey man, that girl in twenty-one – can she go yet?”  And every single morning I would say, “Well, let me think about it – if her labial cellulitis resolved overnight, and you somehow got her one of those clicking insulin pens, and everybody else on the Center for the Blind’s waiting list died, and her stomach started working, and social work found her a place to stay, and we magically gave her four weeks of IV antibiotics in the last twenty-four hours, then, um, yeah – yeah, I guess she can go.”

What’s so bizarre about this compulsive fixation on discharge is that it has no detectable rationale.  From the point of view of the county hospital’s bottom line, of course, it’s clearly imperative to achieve the highest patient turnover possible, because our payors (mainly federal, state, and local charitable insurance programs) pay the most for admission and initial workup.  The longer someone stays in the hospital subsequently the more money the hospital loses.  But the housestaff don’t care about that.  We’re salaried, and there are no performance incentives.  We gain nothing from saving the hospital money, nor do we receive any pressure from our superiors or the hospital administration to incur fewer costs.  The fear of litigation, (even in our hospital, which primarily serves people who if they had the money to hire a lawyer would probably use it to buy health insurance,) is so pervasive that most patients are subjected to more tests and treatments than are medically indicated.  It’s called “treating the lawyers.”   In fact, the only incentive we do have relative to discharge is the “bounce back” system, under which patients who come back to the emergency room within a month of discharge are automatically “bounced back” to the resident who discharged them.  This system which was established to deter premature discharges, and it doesn’t even work that well – bounce backs are actually quite frequent.

Even if the bounce back system didn’t exist, even if your only abiding motivation was to spend less time at work, it still wouldn’t make sense to rush sick people out of the hospital, because the number of patients you get depends on the number of patients you already have.  On the wards, for instance, no intern is supposed to be taking care of more than ten people at one time.  The worst thing that can happen to an intern, then, is to have ten new patients who are all sick and require constant attention – that’s when you end up coming in at five and leaving at ten.  The converse situation, where you have ten “rocks” who are stable and simply undergoing a predictable plan of treatment, is actually quite manageable.

So where does this lust for precipitous discharge come from?  A possible answer is suggested by the experience of friends of mine from medical school who are working in England.  I talked to one of them recently, and he had exactly the opposite complaint..  On his account, (and this is consistent with my experience in medical school) patients on English wards who have nowhere to go and some persistent condition that makes discharge tricky simply get stuck in hospital limbo and remain there for far too long. 

What’s interesting is that again, this only really makes sense from the point of view of macroscopic economic relationships.  I don’t think that English house officers have any more incentives to discharge people according to any particular time frame than American junior doctors, (I invite corrections from readers here).  However, the English health care system, unlike the American, is based on a robust primary care infrastructure which is funded by taxation.  From the point of view of the National Health Service, the British taxpayer, and….ah…the patient, it is ideal to avoid needless re-admissions to the hospital by insuring that patients are actually, definitely well when they are discharged.  Because all medical and social services are publically funded, there is nowhere to pass the buck, and an approximation (which, lest I sound to Panglossian I should emphasize is still somewhat uncomfortable) is reached between economy and patient welfare. 

What this suggests to me is that the influence of economic ideology on patient care is actually much more pervasive and, in the context I work in, pernicious than you might initially expect.  It seems that junior doctors, the footsoldiers of any healthcare system, will obsessively instantiate the values of the system they work in regardless of whether those values serve their interests.  My successor in the ICU isn’t complaining about Ms. S. because her situation actually imposes some kind of preventable hardship on her – clearly Ms. S.’s situation is urgent and necessary (this is, after all, the intensive care unit) and discharging her from the ICU will not benefit my colleague in any conceivable way  (she’ll just be assigned to some other patient who is acutely unstable and will require her to stay in the unit until seven, unlike Ms. S. who will allow her to leave at five).  She is complaining because Ms. S.’s chronic need offends an economic sensibility which has been inculcated in her through a process of slow diffusion both vertically, from the hospital administration down through her attending physican and the resident supervising the team, and horizontally from the culture she was educated and lives in, which construes patients as value-generating commodities with a brief shelf-life, rather than people who need help.  Neither inculcation is explicit – both are transacted, not through direct injunctions or incentive systems, but through a much more diffuse and subtle conditioning that’s disseminated through things like the language which is used to describe patients and their condition, general conceptions of the role of the acute hospital in medical care, and other fuzzy background notions which she has picked up by osmosis throughout her acculturation into the world of hospital medicine. 

This does not, however, make things any better for Ms. S, or other “rocks.”

The Phones Are Restless

This month I’ll be spending one afternoon a week at our local psychiatric emergency room which, rather bizarrely, is called the H____ K____ Psychiatric Pavillion, which is an extension of the county hospital. I'm not sure what definition of the word the architects had in mind here. I guess maybe they hoped, through a chain of connotation, to evoke a wholesome county-fair ambience – if so, it didn’t work. The Pavillion is actually a complex of permanent buildings which are locked and lightly guarded. There is an emergency room where voluntarily and involuntarily committed patients are evaluated, and series of locked wards totalling sixty-odd beds where those deemed to be a danger to themselves, a danger to others, or gravely disabled can be admitted for short stays. Most patients are discharged from the emergency room, and a smaller proprotion are admitted. Of these, a very small proportion may end up as long-term patients in one of the four (4) State mental hospitals which survivied Ronald Reagan’s governorship – although most of our patients are “civil” rather than “forensic,” and only two State hospitals even admit the non-criminally insane, and their beds are divided between fifty-eight counties.

I’m only working in the emergency room. It is very unlike a normal emergency room in that there is almost no medical equipment. There is almost nothing at all, really. The main patient care area is a large square atrium, maybe sixty feet on a side. It contains only some built-in benches cushioned with blue mats attached with velcro, a few heavy articulated chairs that can fold down into beds, and a several smaller molded plastic chairs. The unifying principles of design are 1) that everything should be easy to clean and relatively proof against human body fluids, and 2) that nothing should be possible to use as a weapon. There were about twelve patients there today, milling and lolling around, all wearing unisex blue pajamas and yellow socks. All of them will either have committed themselves or, more likely, been brought in against their will on a psychiatric hold. Along the walls of the atrium are a few side-rooms which have only a single bed equipped with restraints in the middle of the floor. The pyschiatrist showing me around took me into one and pointed back the way we had come, above the door, where there’s a ledge that hides some recessed lighting. “If you don’t see the patient through the window in the door,” she says, “They may be on the ledge. In that case it’s probably best not to go in, especially by yourself…” I don't know what the architects were thinking when they designed locked rooms for violent psychiatric patients with ledges over the door, either.


This is a rather chaotic milieu in which to attempt a psychiatric interview, although the psychiatrists who work there have all evolved their own strategies for dealing with it. I tried seeing a patient today over by the phones – I thought this had the advantage of A) being near the nursing station so that I was easily visible to potential help (a doctor who was interviewing a patient in a private room was actually killed at this facility several years ago) B) being near the window, and therefore maybe attenuating the sense of confinement my patient was experiencing and C) being away from the other patients, since the phones are off a corner of the atrium. I didn’t really need to worry about any of this, since my patient wasn’t concerned about being overheard and was completely non-threatening. He had been picked up by the police wandering in the middle of the street trying to touch moving cars and spitting on payphones, with whom, he had apparently said, he was “at war,” but he wasn’t particularly bellicose at the moment - the phones in the Pavillion are free and can only receive calls, which I guess makes them neutral in this particular conflict.


What I didn’t initially realize about my choice of venue was that these are the phones people call to talk to relatives and friends who have been committed, and that they ring in incredibly shrill electronic tones so that they can be heard in the atrium. Moreover, the reception system is rather singular. The first time one rang, I didn’t realize it was the phone and was glancing around nervously in case it was some kind of alarm - but I took a cue from the nurses, who didn’t seem worried. A tall, elderly man in fifties-style glasses with a thick mustache loped around the corner and shot me a resentful look before answering the phone. “Hello, H_____ K_____ Psychiatric Crrrrisis,” he said in a deep and assured voice. He was wearing blue pajamas. He was an inmate. “Ah, yes, hang on a minute.” He padded back over to the atrium and returned with a teenaged boy wearing only an open-backed hospital gown. The boy picked up the phone, and the old man walked back to the atrium.


“Hey look,” said the boy, “I’m really sorry. I just…my mind was just racing, too fast for me to handle. I don’t even remember half the shit I did yesterday.”


Meanwhile my patient was trying to explain that he had been misquoted regarding the payphones by anti-payphone propagandists, and that while he had, for unspecified reasons, destroyed a pumpkin all he was really trying to do was return a lady’s wallet which he had found in the street, even though nobody had ever returned any of the five wallets he had lost over the years.


The phone rang again. The ad hoc receptionist returned. His look said, You know, I’m sitting all the way out there. It wouldn’t kill you to answer the damn phone.


“Hello, H______ K______ Psychiatric Crrrrisis… Well, I don’t know if he’s….Hang on, I’ll check.” He made for the atrium and returned a second later. “Yeah, I’m sorry. He’s a little too out of it to talk to you now. All right. Sorry about that.”


The patient was now explaining to me that all you really need, in the end, to make sure that “you have the four basic food groups, and dabble in drugs and alcohol a little.” I had been struggling to get a word in during his gregarious redaction of the police account, and I jumped in with the one question you’re always supposed to ask if you forget every other question, which in this case was a total non-sequitur and made me sound like an idiot: “Do you ever have any thoughts about harming yourself or other people?"


The boy was still on the phone: “No, they shot me full of something intravenously…No, after the police brought me to the emergency room…I don’t know, I was blacked out.”


“Naw, man,” the patient was saying, “never that, never that…”


The phone rang again, and the receptionist returned. This time he looked really incredulous – You can see me getting up to do this every time, he seemed to say, and yet you sit on your ass asking stupid questions. What’s wrong with you? Answer the phone!


“Hello, H_____ K_____ Psychiatric Crrrrrisis….Yeah….Oh, no, I think he’s been discharged. Yeah, he’s gone. Sorry.”


So next week, I’m not sitting by the phones. Aside from the constant interruption and the distracting conversations, I can’t deal with the guilt-trips. I assume today’s receptionist will be gone by then, but this seemed to be the standard arrangement so I imagine someone will have taken his place, who will probably be equally apalled by my lack of initiative. I’m looking forward to finding out what other administrative functions are open for impromptu staffing by the committed.

The author would like to R. Eley for her awesome techno-skills, which made this post better than it would otherwise have been.

Fabulous Prizes

I have decided to institute a series of competitions in the field of health care. These will be unpublicized and participants will not be made aware that their performance is being monitored, except for unpredictable posts in which I will award unsolicited recognition and, occasionally, cash prizes.

This week's award, granted for the Least Flattering Response to a Conflict of Interest Between Patient Care and Hospital Finances, goes to a local tertiary academic medical center. The winner will remain nameless here, although they will receive a plaque in the mail crediting them, which they may display in the main lobby of their hospital building or some other prominent place.

A month or so ago I saw a new patient, Sra. B, in my clinic. She is an immigrant from Mexico, and she had previously been followed by the transplant surgery unit of the academic medical center I mentioned. She had had utterly intractable diabetes, which had been complicated by end-stage renal failure and a variety of other unpleasant associates of high blood sugar. She is only in her early thirties and has a young child, so clearly this was a disaster. I say that she "had" diabetes, (you don't normally get to say this about people who aren't dead; in general once you've got it, you've got it) because she was the lucky recipient of a combined kidney-pancreas transplant (See fig. 1).

The first kidney/pancreas transplants were performed in the late seventies, and have become more common since although they are by no means considered a standard therapy for diabetes. This is a stunningly ambitious surgery. While kidney transplantation has actually become rather straightforward the pancreas is loathed and feared by everyone, particularly people who have to touch it. It has been described by surgeons as having the consistency of "tissue paper stuck together with spit" and is notorious for its capacity to digest itself and kill its owner in response to the most trivial provocations. It has this propensity because it manufactures the bulk of the enzymes which take the enormous, totally unusable polysaccharides, proteins, and fats we all eat and turn them into small, usable fragments which can be absorbed and turned into fluttering eyelashes and babies' bottoms and other nice things. Clearly, this is a locus of extreme hazard since there isn't really any difference, from the point of view of a proteolytic enzyme, between a fish eye you ate at a cocktail party to demonstrate your gonzo panache and the eye you use to see with. Both, to the pancreas, are offensively baroque, decadent blights which fairly cry out to be reduced to their component macromolecules. Pancreatitis ensues when any part of the pancreas' remarkably fragile system for protecting you from your own concentrated digestive juices is interrupted, which can often happen without any trauma at all. You have a little too much to drink, your calcium level gets a little too high, or you get stung by a scorpion, and all of a sudden your pancreas starts leaking enzymes into its own substance and dissolving itself. Caustic fluids leak out into your abdomen, and produce what is basically a large, internal burn. Pancreatitis can become a self-reinforcing crescendo of inflammation which generalizes to involve the entire body, and it routinely kills people despite maximal medical therapy. The pancreas is the body's self-destruct button.

So just touching this thing is a bit iffy; to take one out of a dead person and stick it in somebody with a defective one in the hopes of curing a lifelong and debilitating affliction takes real chutzpah. And, astonishingly, it works - transplant patients are not only cured of their diabetes and no longer need dialysis (so long as the transplant takes) but often see regression in other complications of diabetes, something which isn't seen to any really exciting extent with any other therapy.

The trade-off is that transplant recipients have to take potent immunosuppressive drugs for the rest of their lives to prevent their immune system, (our bodies' haematological Gestapo,) from picking up on minor genetic differences in the graft and destroying it. These drugs are not benign; some of them cause birth defects so reliably that it's generally recommended that patients take the oral contraceptive pill while on them, no matter what other form of birth control they use. All of them, by design, suppress your immune system which increases your susceptibility to infection. (The Gestapo metaphor is vitiated by the fact that, unlike Germany under the Third Reich, your body really is constantly beset by malevolent, genetically impure monstrosities who want to infiltrate, usurp, and destroy you. At the cellular level, a paranoid police state actually is usually in your best interests; if your cells are doing nothing wrong, they have nothing to hide...). Some of these drugs have narrow therapeutic indices and need monitoring of their concentration in plasma to insure that they aren't dangerously diluted or toxically concentrated. Laboratory tests indicating kidney and pancreas function need to be monitored regularly to catch any incipient rejection of the transplant early. When a patient who is highly motivated, disciplined, and ready to learn a lot about their condition comes together with a healthcare provider who is ready to make a serious, ongoing commitment to ensuring the best possible outcome for them, this operation can be a stunning demonstration of the god-like power of scientific medicine.

People who perform these surgeries select their patients very carefully to try to maximize the probability that things will go well for them; you do not, obviously, want to do something like this to someone who never takes pills or misses appointments or has no fixed address or is just basically perverse and bloody minded, because you'll end up making things worse than they were before you intervened. Now, instead of diabetes and renal failure, the patient will have diabetes, renal failure, transplant rejection, and various drug toxicities.

Sra. B is covered by a subset of Medicaid which only covers emergencies, and to some extent palliative care, and for which anybody is eligible, regardless of immigration status. It doesn't, however, cover chronic care - like the kind you need to monitor immunosuppression and transplant viability over a lifetime. The academic medical center funded the actual transplant, probably because it was part of a study, or because the kidney-pancreas transplant unit enhances its prestige, or perhaps as a purely charitable gesture. Medicaid definitely does not cover this kind of operation. (Medicaid doesn't even cover insulin dosing pens that make clicking noises so that blind diabetics can dose their insulin accurately.) Moreover, I am sure the transplant was not her idea - she could never have afforded it, and I don't think she even understands exactly what they did to her.

So she had the surgery, and they followed her for a while, but then she lost her emergency Medicaid funding which, in any case, would have eventually stopped paying for her care there. At this point, they were presented with a conflict between the center's financial interest and their duty of care to the patient. And it's because of the choice they made that they win this week's award. They could have said, "You know, we're the ones who suggested that this lady have this surgery, and we did it to her, for free; so really, we've incurred a moral obligation to see it through, regardless of whether we make our money back." This would have been the "right" answer. Instead, the transplant unit told her to arrange further follow-up at my hospital, (which has a mandate to treat all residents of the county regardless of their ability to pay but, glaringly, does not have a transplant surgery unit,) and she found her way into my primary care clinic. They decided that it was more important to use her slot for an insured patient than it was to provide optimal medical supervision of potentially dangerous medical circumstances which, let's remember, they created. The also decided that they were comfortable with the risks they assumed on her behalf by referring her management to someone who has been practicing medicine for exactly one year as of last Thursday, and who (like most of his seniors who have significantly more experience) doesn't know much about the chronic use of dangerous immunosuppressive drugs in transplant surgery patients.

As I mentioned, there are stringent protocols for evaluating people as candidates for transplant surgery - they have to be reliable, easy to locate, reasonably intelligent, compliant with medical instructions, etc., and if they're not they never make it onto the waiting list. This experience has made me think that we should impose similarly stringent criteria on institutions that want to perform this kind of dramatic intervention. For instance, we might require that they state explicitly their understanding that the intervention they propose creates potential dangers which persist for the entire life of their patients; that, given this, they assume a contractual obligation to provide lifelong follow-up care regardless of changes in their patients' ability to pay; and that, should it become necessary, they only transfer their duty of care to facilities staffed by persons of comparable specialist training. This doesn't seem like a lot to ask. After all, it's really just a specific application of a general principle articulated in the Hippocratic Corpus some twenty-five hundred years ago: "to help, or at least do no harm".

Sra. B is doing well. I got the transplant unit to give me an official list of her medications and tell me what lab tests I should be monitoring and how often. I got our "Utilization Review" department to pay for her to go see them when one of these tests appeared to be going in the wrong direction, and for her subsequent admission and treatment for transplant rejection. I've managed, through cajoling, wheedling, and appeals to higher principles a follow-up appointment for her there to make sure everything is going all right, although I had to agree to order all lab tests at my hospital and fax them the results. The ignominy of doing their clerical work, I have to say, has tempered some of the boundless pride I felt at the implication that I was transplant surgeon material contained in the original "referral," but if it means they'll pay attention to her, I guess I'll survive. There's an older doctor here who likes to say, of situations like this, "I'm Board-Certified in grovelling, whining, and guilt-tripping."

I'm seeing her on a weekly to monthly basis at the moment. She always comes to clinic with her daughter, who is nine years old and extremely vigilant about her mother's health. She is also incongrously knowledgeable about the workings of the Medicaid program, since she often has to act as a translator. She stays on top of things and remembers to follow questions up when her mother forgets. Somewhat strangely, I think, she wants to be a doctor when she grows up.

Sleeping With The Fishes

El Sueño de la Razon Produce Monstruos

(The Sleep of Reason Brings Forth Monsters)

Francisco Goya

Fish, as is well known, sleep while swimming. This sounds like a really good trick to learn, especially right now.

I wrote something else last night around 3:00AM that I was going to post today, but as I drove home close to noon I realized that what's really on my mind at the moment is sleep, its absence, and how I feel about all of that. I've been provided with a natural opportunity for reflection on this (in my capacity as experiment of nature) in that as I write, I am cementing a strong lead in the race for my Most Extreme Work to Sleep Ratio: out of the last seventy-five hours I have slept about ten. I got up on Tuesday morning, worked a full day in the ICU, then covered the medicine wards until Wednesday morning, when I went back to the ICU to see my regular patients. Then I went home around noon, tried to have a day (not an especially ambitious one, just a day not spent in the hospital) went to bed around eleven. I worked Thursday morning in the ICU, and spent the afternoon in my primary care clinic. I stayed on overnight, again covering the medical wards, and after an eventful morning in the ICU I am now home, coming up on hour seventy-six. My cats have disappeared. I suspect that they have given up on me, and struck out for someplace where the streets are paved with moths and by-catch; a place where with a with a little bit of hard work and a dream, a cat can make something of itself.

The scary thing is that this sort of thing isn't actually that uncommon in the United States. In my residency program it's rare to do every second day on call like this - I actually did this deliberately, in order to avoid a scheduled night on call next week. At some hospitals (although this is increasingly rare) housestaff are deliberately put on call every third night, although usually it's a team of junior doctors. My hospital, with some audacity, leaves it to one intern who has already worked a full day to cover four wards and an intensive care unit. There is also a second or third year resident at night, but they're usually busy helping admit patients from the emergency room or consulting on surgical patients with medical problems. The chain of referral, in any case, starts with the intern who can then decide to call their resident if they feel the situation is beyond their competence. This means the intern's pager goes off, at best, every twenty minutes and at worst almost continuously. This is not compatible with restful sleep. Moreover, (this has happened to me twice now) if you do try to sleep it's always right when you're drifting into REM that you get a call about someone who sounds actually, properly sick and whom you definitely need to go evaluate personally. This is an awful feeling. Not only is it physically unpleasant to be woken up from a fitful nap on a hospital cot by a screeching pager, it's very scary to be asked to make important medical decisions when you are barely awake. I don't even try to sleep anymore, because both of the times I did it I was called from my bed to evaluate somebody who was moving towards septic shock, something that needs to be approached with decisive intelligence even by the well-rested.

A great deal of research has been done on the effects of this kind of sleep deprivation, much of it conducted specifically on doctors in training, since we are an ideal cohort to study, along with PhD students, truck drivers, and soldiers. Overwhelmingly, this research hows that significant decrements in one's ability to think clearly about medicine increase proportionally to the number of hours without sleep. This brings to mind a friend of mine's characterization of sociology as "banal insights into the blatantly obvious". Personally, I think that succinctly describes at least this observation, but in case you're curious one prospective study published in the New England Journal of Medicine in 2004 compared two groups of interns, one working on a call schedule which required thirty-hour shifts every third night and one working on in more conventional shifts. The authors found that the "traditional" group made over fifty percent more "nonintercepted" serious medical errors than the experimental group, and twenty-two percent more serious errors overall - which is to say, the screwed up much more often, and their mistakes were far less frequently caught before they actually damaged someone.

I find it striking that a bunch of highly educated people all of whom had been through medical residency thought that they needed to organize a prospective trial to prove this. Or, to be slightly more cynical, I find it a rather sinister indication of the status quo's tenacity that they should have to marshal this kind of investigative firepower to prove the intuitively obvious point that the best person to handle an urgent situation involving the possibility of death or permanent disability is not the one who's just fallen asleep after, say, twenty hours of continuous work. Not, I would hasten to add, that this study or others like it managed to change much, at least here. The American Council for Graduate Medical Education recently adopted some self-imposed rules (e.g. the 80-hour week, the 30-hour maximum continuous duty period, the requirement of one day off every week averaged over four weeks,) which mildly ameliorated the situation, but are pretty obviously aimed at obviating legal regulation, not at creating a well-rested workforce. I have a friend from medical school now working in England who tells me that for every night he works he gets not only the subsequent day off, but also an entirely separate day, with its attendant night. When I tell American residents about this the responses are usually notable for their creative deployment of astonished profanity.

Last night, at a sleep-hour to wake-hour ratio of around 9:53, I was called to see a patient, (let's call him Mr. I,) in the transitional care unit, (which is the low-calorie version of the intensive care unit,) who was having trouble breathing. Mr. I is a big man in his early forties with severe lung disease and right-sided heart failure, who is trying desperately to get on a heart-lung transplant list. (In fact, he was brought in by an ambulance from the airport where he was about to board a flight to Vanderbilt to be assessed for surgery. I should write Alanis Morisette with this story - maybe the royalties from the resulting hit single would pay for his operation.) Anyway, I went through his chart and lab records in some detail, and by the time I was done writing orders I was feeling pretty good about myself. I had come up with a systematic plan to stabilize him, organ-system by organ-system, and I was also pretty sure I had identified a major flaw in the clinical reasoning that had been applied to the case so far. I realized that I could improve his breathing significantly just by giving him an intravenous infusion of fluid, (this will probably sound stupid if you're used to dealing with heart failure, but in his case it made sense. Full explanation available upon request), without having to transfer him to the ICU or put in a central venous line or intubate him or anything dramatic and unpleasant like that. This isn't, by the way, any kind of comment on the day team - they had many other patients who required an equal amount of attention and the course they pursued was a pretty standard and reasonable one. I just happened to be called at an ebb in the perpetual pager-storm when I could actually concentrate on the case, and I had a fresh pair of eyes and records of everything they'd done and every test result they'd gotten in front of me all at once.

The rest of the night was comparatively reasonable, relative to some of my worse experiences on call. There were periods of, oh, fifteen minutes when my pager didn't go off at all, and when I was called it was mainly for minor things I could handle over the phone. I even had time to do a little reading. I pulled up a few articles on sleep deprivation - it seemed topical. I was not called to see Mr. I again.

When morning finally came I was beginning to flag. I can always tell when physiological exhaustion is setting in because I start losing my short term memory and become increasingly dependent on notes. I wrote up the morning lab reports and overnight vitals for my one ICU patient, came up with a plan of action for her, and wandered down to Grand Rounds, the Friday Department of Medicine morning lecture, to see if some free bagels and omega-3 rich smoked salmon spread would improve my failing higher faculties.

This is where the whole thing devolved into a sort of hallucinatory nightmare.

The Grand Rounds lecture is given in part of the old hospital building where there's no overhead intercom system. This is relevant because that's one of the ways the hospital operators announce medical emergencies, which all members of the ICU team are supposed to attend to whenever they're in the hospital. We were all at the lecture - however, of the four interns, two residents, and one attending physician, least three of us always carry "code pagers" which are little walkie-talkies that are supposed to emit a shrieking noise whenever there's a major medical emergency, (or "code blue") followed by an announcement of its location. Theoretically, then, we shouldn't need to be in earshot of the PA system to know when there's a code. For some reason, which I have insistently pursued without any success, despite enhanced interrogation techniques, there is often a failure to communicate between the operators who announce code blues and the pagers. This fact never loses its novelty for me, since it is transparently imperative that the code pagers work reliably; they are, after all, probably the only pagers in the hospital on which life and death may actually hinge. As you must have already guessed from all the bitter asides, there was a code blue, and not a single one of them went off. We heard about it by word of mouth, which is a totally moronic way to convey this kind of information. Pagers were invented in the first place so that people who need to know things immediately, like doctors and crack dealers, could circumvent exactly this problem.

I have to confess that my first thought was, Shit. There goes my ten O'clock exit visa. My second thought was also Shit, because the code had been called in Mr. I's room. The gentleman I had been feeling so chuffed about having managed in such a systematic and creative way the night before. Mr. I, who I hadn't transferred to the ICU because I'd been confident he would be fine in the TCU. Mr. I, who I was pretty sure just needed a little more intravascular volume to enhance his right ventricular pre-load, and was definitely, definitely, not going to be emergently intubated or go into ventricular fibrillation or otherwise explode. Shit, I thought, I'm a statistic. I haven't slept enough, and I just committed a major, nonintercepted medical error. I screwed up something crucial last night which I would have gotten right if I had been more awake, and now he's going to die. Shit.

The scene which evolved when we arrived was horrendous, and only made more so by a persistently farcical which quickly developed. Mr. I was lying on his back on the bed, his eyes rolling dysynchronously. He was being ventilated by an Emergency Department resident with a bag-and-mask apparatus. Apparently, he had been returning from the bathroom and had collapsed on his bed, unresponsive.

Codes are supposed to be swift, decisive, methodical, and run according to evidence-based and generally known algorithms. They are like this to some extent, but usually the first five minutes (which are obviously the most important ones) are pretty chaotic. Everyone within three floors comes running and crowds into the room. The problem is usually that it's not entirely clear who's in command. Technically it's the medical resident on call, but most of our medical residents feel diffident about assuming responsibility because the emergency room residents are much more experienced. The ED residents know this and many of them try to politely defer. The attending usually cuts through the chaos to demand that absolutely imperative things like attaching defibrillators and blood pressure monitors happen, but they also usually try to induce a resident to assume control - so there's often this awkward few minutes where it's not entirely clear who's in charge or what order things are supposed to happen in, and so everything starts happening at once while the attending, the medicine resident, and the emergency resident engage in the medical crisis version of "I insist," "Oh no, I insist," "No, no, after you," "Oh no, I couldn't possibly," etc. The defibrillator is attached, and there's a frenzy of flying needles as people try to insert large-bore lines into any vessel they can see or feel. At the head of the bed there's a running conversation about how the bagging is going and whether we're going to intubate, while at the foot there's an independent debate about the rhythm on the monitor, and somebody is loudly demanding to know where that blood pressure cuff is, while someone else is yelling for a central line kit, and yet another person is trying to figure out if they should be starting chest compressions. Eventually somebody assumes command, and things become slightly more systematic and fall into a recognizable resuscitation algorithm. At this point, people get bored and drift out, and things become slightly more manageable. This code, however, was more hectic than most. First there was an incredibly ambivalent debate about whether or not Mr. I in fact had a pulse to go with the electrical activity on the monitor. Nobody, including me, could be absolutely sure. Then it emerged that the crash-cart, which is supposed to have all the stuff you need in it, was missing all kinds of things - sterlizing scrubs, sutures, etc., and there was a mad exodus of residents pelting down to nursing stations at either end of the building to search desperately for the right kind of suture or an extra arterial blood gas kit. The problem is that all the wards, for mysterious reasons, have their own budgets and are therefore reflexively defensive of their supplies - this habit of mind is so ingrained that even when I sprinted into the nursing station of an adjacent ward to requisition some minor antiseptic products, saying breathlessly, "Quick, it's for the code!" the clerk gave me a look of disgusted persecution and whined, "Don't they have that stuff on TCU?"

And then the room flooded. I got back just as my immediate senior, who had been the resident on-call the night before and slept only a few hours more than I did was putting a central line into Mr. I's femoral vein. The line splits at the end into three tributaries, and you have to fill them with water so that when you inject into them you don't shoot air bubbles into the patient's circulation.

"Flush," she said, "I need a flush."

I grabbed a few syringes of saline and started emptying them into the central line tray so she could draw them up with a sterile syringe. Behind me, someone said "Jesus, what's all this water?"

"It's just saline," I said, "for the line."

"Really?" she replied. Then I realized that somebody had put the intubation tray on the sink, which had pushed the cold water tap on, and that it had been running onto a towel which was blocking the drain for several minutes. We were all standing in an inch of bloody water.

And, naturally, as all this was going on, I was dredging my increasingly dysfunctional memory, trying to fiture out which part of the brilliant plan I had formulated the night before had contained the moronic oversight which was going to turn out to have caused this absurd, deadly situation.

..................................

I like to think that I would still be telling this story had the whole thing actually been my fault. Reviewing what I did afterwards with some older doctors, it appears, mercifully, that I was right; it was a good plan, and it probably averted a slow decline towards respiratory failure. It looks, at this point, like whatever happened was a sudden and unpredictable event, (probably a pulmonary embolism,) which I definitely had nothing to do with and may have even delayed. Mr. I. was stable in the ICU when I finally left around eleven, receiving empiric therapy for his presumed PE. Unfortunately he is too large for any of our scanners, (an increasingly frequent problem, for which the radiology technicians have no sympathy whatever since somebody cajoled them to accept a patient over the scanner table's weight rating and the table promptly broke) so we won't know exactly what happened until (or rather, unless) we can deduce it from his clinical course and some indirect testing.

It is nice to be fairly assured that I'm not (yet) the author of a "nonintercepted" serious medical error - although, like a smoker with unexpectedly normal lung function tests, I have to fight the consequent impulse to assume that I'm somehow an exception, that the formula which relates sleep deprivation to misdiagnosis, inappropriate treatment, and simple mistakes somehow doesn't apply to me. And who knows - maybe if I had slept more in the last few days I would have seen something last night which would have allowed me to predict and avert this.

Fish, as is well known, sleep while swimming. This is because fish are stupid and the scope of their professional lives outside of the closely circumscribed fields of sex and predation is basically insignificant. Also, they have developed such that in order simply not to swim, they have to be dead. Even then there is some gray area. I recently caught a fish which, as is standard practice in these matters, I hit on the back of its head with the blunt side of a hunting knife until it had no apparent reserves of centrally controlled executive or automatic function, even within the stunningly narrow ambit of quotidian fishy activity. Its gills ceased to move. Its cold, clammy little heart lay still in its slimy breast. It's gooey brain ceased to issue programmatic statements on the laying of eggs and eating of bugs. I left it on the river bank and went looking for other places to catch fish, and when I returned, it was gone. I found it after a few minutes of searching (it was a big fish) lying in the shallows on its side, dead, its tail twitching as motor complexes hard-wired into its spinal cord burned through their last reserves of energy.

So bollocks to the fish. I breathe when I sleep, and sometimes I move a limb aimlessly, which is about as impressive as sleeping fish swimming - i.e., not very impressive at all. When I am not sleeping, however, I enjoy my membership in a species of highly complicated mammal, and the privileges which inhere therein. These include, but not limited to the pursuit of elaborate, elegant non-genetic structures of cognition and discourse like music, language, art, and medicine. And if I'm going to participate in these at the level to which I aspire, I need a little more sleep.

Good night.