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.