Top Ten #1: Reasons Your Patient is NOT in 10 out of 10 Pain

10. The patient is sitting in bed doing a crossword.
9. They are jabbering non-stop on the phone with the friend.
8. They ate their entire dinner and then asked for more.
7. They tell you that they're in 10 out of 10 pain in a totally dead-pan bored voice.
6. The patient gets up and walks around the hospital floor all the time.
5. Their blood pressure and heart rate are completely normal.
4. They are supremely worried about the channels they get on TV.
3. They will only take IV pain medications and will not try anything by mouth at all.
2. They are "allergic" to morphine.
1. They don't LOOK like they're in any kind of pain.

Is this cynical? Maybe.

John P. Pryor

We recently read some bad news about John Pryor, a trauma surgeon at the Hospital of the University of Pennsylvania, who died on Christmas day in Iraq.

I never met this guy, but I heard of him. Seems like he was an amazing guy.

Christmas at the Hospital

I think Christmas is probably my favorite holiday of the year. Despite having to spend it overnight at the hospital this year, for whatever reason, I was still in pretty good spirits. There was Christmas music playing on the radio, people are generally in pretty good moods (although there were definitely some sour faces at the hospital), and it's a relatively quiet night at the hospital - I think I got 6 hours of sleep on call, which is absolutely amazing! I played some poker with some other residents, we ordered some Chinese food (the only thing open on Christmas day), and just hung out.

However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.

Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.

Medical errors

They happen... just like they do in other parts of life. It's horrible and unfortunate, but it's a fact. They're also unavoidable. We can (and should) do everything we can to minimize them, but no matter what, they're going to happen occasionally, or hopefully, rarely.

I haven't had to deal with this issue until relatively recently, and I consider myself very very fortunate. It's going to be purposefully vague, but I'll tell a story now because I think it has some valuable lessons to be learned from it.

I was taking care of a patient who was admitted for lung problems, and we were giving her all the appropriate treatment and doing the right studies for her for the first few days. Then the 3rd or 4th day, a nurse went in and gave the patient the wrong medications. Someone from the family was with the patient 24 hours a day, and they didn't notice at first, but then the nurse went in and threw a medication away into the trash without saying why. The family thought this was odd (as would anybody) and they looked at it, and it happened to have a different patient's name on it. In this case, the different medications probably did not cause any harm to the patient, however, giving the wrong medication was definitely an error. It was horrible and should never have happened but I feel that what happened afterward was worse.

The family had to call in a different nurse passing by to see what happened, who then called me. When I talked to the patient's official nurse, the one who gave the wrong medications, she denied certain aspects of it and lied (whether knowingly or unknowingly) about certain things - I only found out the truth later. Moreover, she never explained what happened or what she did to the family or any other doctors, and she never apologized.

No matter what happens, no matter how serious, you ALWAYS NEED TO TELL THE TRUTH. Although I feel particularly strongly about it in this case, I feel that this should be something people adhere to in general when dealing with patients.

Secondly, I believe in apologies, which we did (on behalf of the nurse) profusely to the patient and her family. There's actually some debate about this, although perhaps less so now than several years ago. At one point, I believe lawyers may have actually advised medical staff against apologizing to patients, whether or not some sort of mistake was made. The thought was that if you apologized you would be admitting guilt, which then would make a court case much more difficult. I don't necessarily agree, but I could see a situation in which medical staff apologized for something that was not anybody's fault, and the patient took it the wrong way. However, now people are saying that apologizing, while that may seem like admitting guilt, often deters patients and their families from suing the hospital or the staff. Personally, I think if you or somebody that works for you did something wrong, and it was without a doubt an error, you should apologize. You are guilty in a way, and if apologizing is a way of admitting that, then so be it.

In this case, the family even said that had the nurse come in and explained what had happened and apologized, they would still have been upset, and rightly so, but they would not have been so angry as they were when we started talking to them. Unfortunately, at least at the beginning, the family was threatening to sue... however as time went on and everyone calmed down a bit, they didn't seem as litigation-minded. Actually, since no harm came to the patient from the error, they likely would not have won a court case anyways. Hopefully patients (and their families) realize that health care workers are, for the most part, all trying to do their best, and unfortunately, sometimes mistakes are made and all we can do is try to prevent them and correct them as best as possible.

Dylan's triathlon with Team in Training, the Leukemia and Lymphoma Society

My good friend Dylan Rivas started a blog about his training for the Lavaman triathlon with Team in Training, which is part of the Leukemia and Lymphoma Society.

A few friends have done this (I don't think I ever could) and I think it's a great idea - the triathlon is in Hawaii, which I'm sure is absolutely amazing for the participants. They raise a large sum of money, and 25% or less of what they raise goes towards the participant's flight, coaching, overhead, etc. The Leukemia and Lymphoma Society gets the remainder, which is a substantial amount. Moreover, it supports an active lifestyle, which not many fundraisers do!

Here's a haiku in his honor:

Go Dylan Rivas!
Many miles to bike, swim, run
Good luck and have fun

Respecting patient's wishes

I haven’t been in this business very long, but I have already seen many cases in which a patient’s wishes were not respected. What I write next may be surprising – it’s never the doctors or nurses or medical staff. It’s the family. This especially happens with very old or demented patients, or very young patients. The patient often wants one thing and the family, or at least their closest relative or spokesperson, wants something else.

One case I remember particularly well. This was an 80-something year old gentleman who had lung cancer, diagnosed perhaps a year ago. He had it surgically removed (which is not a small surgery by any means) and was doing relatively well for the better part of a year. However, more recently, he started changing. Whereas he used to be able to walk well, talk normally and knew where he was at all times, he occasionally became unsteady and unable to walk, he started slurring his words, and sometimes became confused about where he was, what day it was, or who he was with. After admitting him to the hospital, we found out he had lung cancer that had spread to his brain. At this point, there were three options for him: do nothing, give him radiation, or operate on him. Doing nothing would obviously lead to death the fastest way possible. Giving radiation is usually not curative, but can buy patients time at the expense of different possible side effects of brain irradiation. Surgery was the only option that really provides any hope of a cure, although the chances are incredibly slim, and for someone who is that old and sick already, there’s also a high risk of never recovering from the surgery.

We (the doctors) talked to the patient and his family extensively. It seemed the patient was learning towards doing nothing, or at the most, going through radiation. However, after many days, the patient’s family was able to convince him to go through surgery. Now, I’m not saying this was a bad choice – I have not yet had to be in this situation, and I’m sure it can be incredibly difficult. It sounded like this patient had been an incredible father, brother, uncle, etc and his family all wanted him to live many more years and have a wonderful life. His daughter, who was the main spokesperson, was a nurse and was a major player in convincing her father to have the surgery. I can’t say I would not do the same, although I hope not.

The patient had the brain surgery, with plans for eventual chemo or radiation after recovering, and slowly, over the next 4 weeks, deteriorated more and more. Before going through surgery, the patient had told the doctors (and I thought the family as well) that in no way did he ever want a feeding tube, or if his heart should stop beating or his lungs stop breathing, did he want CPR with shocks, chest compressions, or a tube shoved down his throat to help him breathe. However, it seems that once he became unable to make his own decisions after the surgery, his family decided that they wanted everything possible done for him.

The patient became unable to swallow on his own without choking and eventually, a feeding tube had to be put down his throat so that he could be fed. Even then, he started regurgitating food from his stomach into his lungs and developed a lung infection. His body became weaker and weaker and he could no longer go through physical therapy. His mind also deteriorated as became less able to talk or recognize his family members. I realize that this is a very difficult process, but the family members, including his nurse daughter, seemed unable to process the fact that he was going downhill and it seemed very unlikely that he was going to recover from this. They asked for the feeding tube to be put in (a risk in itself), which after it was inserted, could not be used much anyways because of his risk of lung infection. They wanted everything (CPR, intubation, chest compressions, shocks) to be done for their father, although in his debilitated state it was unlikely to succeed, and they wanted him to go through physical therapy whether or not he was in any condition to go through it.

It was not until 3-4 weeks of counseling the family almost every day or every other day that they finally realized that he may not recover and decided that they didn’t necessarily want him to go through CPR should his heart or lungs fail, although they were still pushing the feeding tube and physical therapy. Purely coincidentally, the patient died several days later. However, if we hadn't gone through those weeks of counseling and reasoning with the family, that patient's heart would have stopped, and we would have gone through 45 minutes of trying to bring that patient back to life, breaking ribs during CPR, trying to ram a throat down his throat, sticking every possible vein and artery with different needles to try and get IV's in or blood drawn, etc etc. All against the patient's wishes.

I tell this story for several reasons. For one, it highlights how someone’s illness is often a whole family’s problem, not just a single patient’s. You often have to not only treat the patient, but their entire family, and that can involve a lot of talking, explaining, and counseling, no matter how much many doctor’s may detest it or try to avoid it. It’s what you would want if your father were the one that were ill. Secondly, it demonstrates how important it is for someone to have that conversation with their family or to have a living will. If you don’t want CPR, or a feeding tube or anything like that, it’s important to explain it to your sons, daughters, other close relatives ahead of time so that they understand, because to be honest, if you tell the doctor, who then try to tell the family, they may not believe the doctor or understand. If you can get this in writing in a living will, it’s even better – then the family has proof of your wishes, and also less power (I believe) in changing how you want to die. I think this is especially important if you’re elderly or sick, but realistically, I think everyone should at the very least, talk about it with those close to them. It can certainly save a lot of heartache and problems later on.

The holidays

It turns out I will be working in the hospital over Christmas. The hospital can't stop over the holidays and not only will I be there, but many other doctors, nurses, staff, and of course, the patients. I have it better than most though - by pure luck, I managed to get off both Thanksgiving and New Year's. No doubt about it though, it definitely sucks to be in the hospital, whether as staff or as a patient, when you know your family and friends are out there having a good time. To be honest, I think it's worse for the patients - not only are they sick, but they're pretty much stuck at the hospital the entire time. For staff, even if they work a 36 hour shift or spend the entire actual holiday working, they eventually get to go home, perhaps see some friends or family if they're not too tired.

In general, I think most people are pretty good at making the most of it and that's probably the best anyone can do. The staff often have small holiday parties in the hospital, which they can attend in between duties with patients. The cafeteria and food services tries to make a nice meal for Thanksgiving or Christmas dinner and sometimes there are holiday activities for the patients, if they can attend or participate. Hopefully, families come to visit their loved ones in the hospital over the holidays, bringing a piece of home with them.

The sad cases are when you realize that a patient doesn't have any family to visit them, or even think about them. It happens quite often in the hospital, especially with the elderly. I haven't seen it myself (yet) but I've heard some families don't want to deal with an elderly relative, sometimes over the holidays, and they just drop them off at the emergency room with a real or fabricated problem, and they get admitted to the hospital for several days so the family doesn't have to deal with them. Sometimes the family doesn't have time, or the desire to visit the relative, even over the holidays. I had a patient once who lived with his daughter. The family was very nice, but the daughter was taking care of 3 of her own children, not to mention a few other younger siblings, and didn't have time to visit her father every day. The son would often come, but he was pretty much useless in terms of helping coordinating care for his father. Unfortunately, the father didn't know his own home phone number, or a way to contact his daughter, so even though we discharged him from the hospital, it was 3 days before we could get word to the daughter to pick him up! Incredible.

And finally, the saddest cases are when you realize a patient doesn't have any family at all. They may have a friend as an emergency contact, or worse, they have no emergency contact at all. Last month I had an elderly female patient who was very very sick - the only family she had at all was a sister who lived 2 hours away and was sick herself and couldn't make it to the hospital to visit, much less help with her care. We could speak to her over the phone, and let her know updates about her sister, but that's about it. Not surprisingly, the patient was pretty depressed and often didn't want to take care of herself or agree to different studies or take necessary medications. It's horrible - what can you really do in these cases?

It just makes me feel even more fortunate, especially during the holidays, that I have a very loving husband and extended family, who will support me no matter what happens.

Extending coverage

I am all for providing as many people with coverage as possible. I don't know many people that would say that they are against that, but I am even perhaps pro-universal coverage. It would come at great cost, and perhaps lower quality health care for the top 10% of the U.S. population, but for the other 90%, it would be a great improvement. However, one big problem we would face is the availability of health care.

It's a well-known and well-cited fact that places that have universal health care often have long long lines for care, to the point where people's treatments are suffering. Just as an extreme example, and because this is in the field I am going into, say there is a patient who needs cancer treatment. Cancer isn't something that waits around for you to treat it... if you need to wait 3-6 months before you can begin treatment because all the slots are filled up, it may be too late for you. What was at one point a localized curable cancer may have metastasized by then, making treatment far more difficult and prognosis likely much worse.

A more common scenario is probably one in which people may have to wait even for appointments or spots with primary care physicians - these are the most used and most needed (and arguably the most important) of all physicians for a patient and if health care is extended to a large percentage of the uncovered population, there will not be enough of these doctors. Massachusetts seems to be facing that problem now, as they have mandated that all residents have health care coverage.

Do I think this should stop us from trying to get health care for more U.S. citizens? Of course not... do I think we should take steps to anticipate and prevent this problem? Definitely. What we need to convince more people to go into primary care (whether those are doctors, nurses, etc), but that, ladies and gentlemen, is a whole different post.

West Philly Obama party

I know this is mostly a medical blog, but Tuesday was a pretty great day for many different reasons, one of which was the presidential race. Impromptu street parties broke out in several areas in Philadelphia, one of which was in West Philadelphia - my neighborhood. It was absolutely amazing. Drummers and musicians came out to 47th and Baltimore and started playing for hours and hours. We didn't come across it until 1am, the musicians had already been going for several hours, and apparently it lasted until about 4am! People were chatting and dancing in the street, which was nearly blocked off. When cars or trains did manage to make it through, everyone was hi-fiving passengers and each other. "O-ba-ma" and "Yes we can" and "U-S-A" cheers broke out throughout the night to the drum beats. I saw so many people I know from the community there, and it was a really really great feeling. My cell phone couldn't take any good pictures, but somebody managed to capture it on video:

ABATE Philadelphia Biker Toy Run to CHOP

One of my favorite events in the city is the annual ABATE (a motorcyclist rights group in Delaware) sponsored toy run to CHOP. Once a year in November (it happens to be today), thousands of bikers come together to donate toys to the Children's Hospital of Philadelphia.

They clog up the highways and streets for miles and miles around the city, and the city dispatches cops to help manage the traffic. Any and all bikers are invited to join in, so although you see the occasional recreational biker or motorcycle-owner in the long line of donors, most of them seem to be real "bikers." There are a lot of negative preconceptions about bikers, and it really warms my heart to see some of them, whom I'm sure have very little themselves, donate their time and money to help some sick kids. Nothing beats seeing a big huge bad-ass biker riding his Harley with a huge stuffed bear on his handlebars - it makes me feel like there's still a lot of good, and a lot of people that want to do good, in this world.

Although this video is not of great quality, and lasts quite a long time - you get the idea:

Night Float

What can I say - I've been on it this month and it sucks. Let me count all the reasons why:

1. You're taking care of 12 interns (plus or minus some medical students) worth of patients at night, which is up to 120 patients. All the little (and big) crap that interns normally get called about during the day gets funneled through to night float. Depending on the intern, sometimes they don't do a very good job of taking care of issues before they leave for the day, so then you have to deal with it at night.

2. You're exhausted. At Pennsylvania Hospital, we work from about 5pm until 7:30am for an average of 3.5 days a week. If you say that's about 15 hours a day, that averages 52 hours a week, which isn't bad, but the timing is horrible. Usually we work 3-4 days in a row. For those days, I usually get home around 8 or 8:30am, shower, maybe get something to eat. I finally get to sleep around 9 or 9:30am, and then get some bad sleep before getting up at 4pm again to go to work - even if I sleep the whole time (usually I waken quite a few times, sometimes for more food), that's barely 7 hours of sleep, and it's never good sleep.

3. You feel very isolated and you never seen anyone. You're completely time-shifted and if you live or have a significant other, you often leave for work before they get home, and you often get home after they've already left for work. So if you work a number days in a row, you might not see them for quite a while. Moreover, you work during the nights half the time, and the other half the time, you're exhausted or recovering from working multiple days in a row, so you never see your friends since they all get together during the evenings. You don't even see your colleagues much - you see most of them for signout when you get there and before you leave. You really only see a couple of people throughout the night, many of whom are also busy. So you spend much of the time alone - it's very isolating.

4. Nighttime is generally a bad time for patients - for whatever reason, if patients start to deteriorate, they often do it at night, so you deal with a lot more critical issues and patients whose hearts may stop beating or who stop breathing. There are many fewer doctors and nurses around at night, so you have less help and have to make many more crucial decisions on your own, which can be daunting at times.

5. The food is horrible. I basically eat cafeteria food around the clock when I'm working, so I usually get cafeteria food only for 3 or 4 days in a row. It's horrible. Although one saving grace is the pancakes on the weekends. Sometimes residents will order out, but unless they take care of it, I often don't have time. Plus that costs a lot of money, so I don't want to do that too often.

One more week to go.

Scrubs

An interesting article in the New York Times sent to me by my mother-in-law:

In case it won't let you read it, here it is:

Should hospital scrubs be worn in public places?

That’s one of the questions asked by my Well column this week, which looks at the role clothing may play in the spread of germs by health workers. The issue of scrubs on the subway and other public places has been raised often by readers of the Well blog.

“I cringe every time I see a medical professional on the subway in their scrubs, which is a regular occurrence,” writes reader A.K.

“What drives me crazy is the sight of someone wearing scrubs while shopping for groceries, going to the post office, picking up their kids from day care, and so on,” writes Jenny, a nurse. “Someone wearing scrubs has been around germs all day. That person is too lazy to keep their patients’ problems away from you, and now they’re handling the apples and cereal boxes that you or someone you love may handle next.”

As my story explains, there’s no evidence that wearing soiled scrubs out of the hospital poses a threat to the public, but part of the problem is that the issue of physician attire and germs hasn’t been well studied. To read more, read the full Well column here, and then post your comments below.

I think the best part of the article are the comments below it from readers - not surprisingly, I agree and sympathize with the doctors. If you work in an operating room, or somewhere that requires clean clothes for the patients' sake (for example if they are all immunocompromised), even if you wear scrubs to work, you have to change into new clean scrubs at the hospital, which you take off before you leave. Otherwise, scrubs are no different from other clothes (for example a suit) that you wear to the hospital. It's really just a public perception that they are dirty - people wearing nice clothes touch the same patients, do the same procedures, go into the same areas of the hospital as people wearing scrubs. From my own perspective, if something happens to a patient and we have to do something emergent, or there's some blood spilled during a procedure, it is easier to clean scrubs than it is to clean a suit or a nice blouse, not to mention that scrubs are often much more comfortable and allow me to do procedures without restriction or care about my clothes. Although not relevant to the safety issue, I also agree with some of the other comments saying that many non-medical personnel wear scrubs too just because it's convenient, and these people often include janitors, technicians, medical students, researchers, etc. In the end, I guess what would be needed to settle this point is a study looking at people wearing scrubs in the public compared to other medical and non-medical people wearing regular clothes and seeing if there are any differences in "germs", and moreover, even if there were differences in amounts or types of germs, if this actually made any difference in terms of infection rates of people they came into contact with. I doubt anyone is willing to spend thousands of dollars to find something like this out.

Steps involved in medical care

I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.

A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).

At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).

Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).

After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).

Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.

As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.

The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.

LuBang! horah video

Well, it took long enough to upload, but here is the ever-anticipated Lubang horah video. I think the highlights are the parents.

God and medicine

I'm not particularly religious, but I know many patients and doctors are. Although I don't believe in the same thing they do, I feel that I have plenty of respect for their beliefs and don't usually have a problem with it. However, I have a small pet peeve about something I hear a lot of patients say. It's not a big deal, really it isn't, but I dislike it when there's a test or therapy patients don't want to take and they say "it's in God's hands." I completely respect patients' wishes (and sometimes agree with them) when they don't want to take something or do something - it's their right. However, I have a problem with them using God as an excuse. I'd rather them tell me they just don't want to do it, even if it's against all logic, than use what I call the God excuse.

For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.

But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.

Medical Time Suck

I cannot believe the time I spend doing non-medical things for my medical patients. Some of course are necessary, for example - speaking to patient's families. In a way, you can consider that part of a patient's health, especially if they partially or completely depend on their family for assistance at home or for their medical care. However, I would bet that the majority of my time is spent doing non-medical tasks. Let me give an example.

Today I had a patient who was admitted several days ago from a shelter for fainting and having chest pain. At first it sounds serious, but it turns out he probably is an alcoholic and "passed out" after drinking too much, and his chest pain looked clinically like a mild rotator cuff injury. Moreover, he had no idea what his medications were, which shelter he lived in, what kind of past medical history he had (cardiac or otherwise). For this patient, not only did I spend hours on his medical care, but I also spent hours calling 4 or 5 different shelters trying to find out where he lived and what medications he took. I called his health center many many times trying to get a hold of his doctor, and when I finally reached her, she didn't know anything about him. I spent time talking to the medical records department of another hospital, getting the patient's authorization for medical record release on paper, faxing it to the medical records department, and then waiting for them to fax me the studies he had when he was admitted there. Then finally, it took quite a while to get him discharged as we had to involve social work so that he could get sent to a shelter using a cab voucher and could get medical follow-up (which he probably will not do) with our cardiology department.

These are all very frustrating things, and unfortunately it's the poorest and neediest patients who often need all this extra attention. Sometimes they come in to the hospital partially to find a warm, dry place to sleep, a place to clean themselves, and 3 meals a day in addition to medical care. I think a lot of doctors and nurses often take a look at these patients and brush them off since they don't have a good medical reason to be in the hospital or sometimes are actively lying and trying to deceive us in order to stay in the hospital. However, I see it like this - if you spend the time on them now, then hopefully they will have good medical follow-up afterwards and won't get to a state where they have to be admitted to the hospital again, thereby decreasing the amount of our work. Of course, some patients are just hopeless - they're well known to the Emergency Department and the medical staff, and I guess that's just something we all have to accept.

Attitude

The longer I live, the more I realize the impact of attitude on life.

Attitude, to me, is more important than facts. It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do. It is more important than appearance, giftedness, or skill. It will make or break a company ... a church ... a home.

The remarkable thing is we have a choice every day regarding the attitude we will embrace for that day. We cannot change our past. We cannot change the fact that people will act in a certain way. We cannot change the inevitable.

The only thing we can do is play on the one string we have, and that is our attitude ... I am convinced that life is 10% what happens to me, and 90% how I react to it. And so it is with you ... we are in charge of our attitudes.

-- Charles Swindoll

This is what I need to think about when a patient complains to me for 15 minutes about how horrible the hospital system is and then refuses to let me examine him so that I can admit him to the hospital.

Dialysis

Anyone with end stage renal disease qualifies them for Medicare coverage. Currently this amounts to about 11 million patients in the US, with over 350,000 of them on dialysis - so about 2% of Medicare patients are on dialysis. For one patient, for one year, Medicare pays $67,000 for dialysis totally over $20 billion per year for dialysis, which takes up close to 10% of their budget. This means that 2% of Medicare patients take up close to 10% of the Medicare budget! And the numbers are only increasing.

I find this disturbing for a few reasons. For one, patients on dialysis are generally relatively sick. The 5-year mortality rate for patients on dialysis is 60%. That means that even with dialysis, a very expensive intervention, 6 out of every 10 patients on dialysis still die within 5 years.

Secondly, it's ethically questionable to spend so much money on a relatively small number of people. With a limited budget, the money could be used in countless other ways to prolong the lives or improve the health of a greater number of patients. Given the fact that 60% of patients still die within 5 years of starting dialysis, the cost-effectiveness of this intervention seems very high.

Finally, irrespective of ethics or efficacy of the treatment, can the U.S. afford this at this time? With rising rates of kidney failure and more and more patients needing dialysis, it may not be a possibility for the United States to continue paying for dialysis for all patients in the future. Not really a question I'm qualified to answer.

So what's the answer? Once someone has Medicare and is on dialysis, it's definitely ethically questionable to take away that treatment and send them on their way towards death! I don't have any great solutions, but perhaps the government will eventually have to stop providing payments for dialysis, with some sort of grandfather clause for those already on dialysis.

Of course, I'm sure if someone I cared about, or I myself, were on dialysis, my opinions and thoughts would be completely different.

Doctors and arrogance

I know a lot of arrogant doctors. I probably am an arrogant doctor. It's probably a good general statement for lawyers and businessmen too, but it's definitely a trend in doctors.

For one, I think it's a self-selecting group. Not many people can say that they want the responsibility of caring for someone else's life. And if you think about it, it takes a certain amount of arrogance to think that you are capable of doing such a thing. In fact, it takes an even greater amount of arrogance to do something wrong the first time around (potentially really affecting someone else's life) and try to do it again. But the surgeon who started the first heart transplant failed something like 5 times before he succeeded. Meaning the first 4 times, someone died. It takes a lot of guts to keep doing something like that with those potential consequences. But in the end, it can mean great strides in medicine positively affecting the lives of thousands of people.

Secondly, I think a certain amount of arrogance can be good for doctors as well as patients. If a doctor had a personality that beat themself up every time they made a mistake, they wouldn't survive. Every doctor makes mistakes once in a while, no matter how good they are. Some mistakes of course are more costly than others. But in the end, you have to be able to move past it, learn from it, and never ever do it again. On the patient care side, the last thing any patient wants to see is that his doctor is uncertain. If a doctor is undecided about a certain course of action, of course they should admit it, but once a course of action has been decided upon, the doctor should be very confident about it. I think if a doctor is visibly uncertain about something, that definitely adds to the patient's stress. I think it also makes the patient lose confidence (subconsciously) in the doctor's ability to make medical decisions, etc.

I guess whether good or bad we're stuck with it.

Drug Dinners

In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."

I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.

The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.

On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.

I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.

All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...

Being on elective

I feel like I'm drowning in free time. They let the preliminary students basically do whatever they want for their elective months (we get three months a year) and I'm choosing to finish up my research with the radiation oncology department at Penn. Not only do I really like the research, but my hours are soooo much better than when I'm doing a floor month. It's pretty much 9 to 5, it's closer to home, and the time I have to work is more flexible. For example, if I have to take an hour during the day to go to a doctor's appointment, I can do that! Also, all my weekends are free, which means I can make some of those weddings and ultimate tournaments this month.

I think it's going to be a great month and a little hard to go back.

Dinner last night

was really good. I don't have time to cook anymore, so when I do, I really enjoy it. Yesterday we set up an interactive appetizer: spring rolls. I showed people how to soften the wrapper. Then we had an assortment of ingredients you could put in. Bean threads, bean sprouts, thai basil and thai mint were the basis, usually with some hoi-sin sauce. Then you could put any number of additional things - we had enoki mushrooms sauteed with a lot of garlic, green onions, jalapeno peppers, different hot sauces, fish sauce, or dumpling sauce. There may have been more, but it was a pretty good spread.

For dinner, we had three dishes. Chinese broccoli sauteed with oyster sauce, honey walnut shrimp and chicken with cashews. I think everything was a big hit. There were 2 and a half pounds of chicken, and 2 and a half pounds of shrimp. By the end of the night, the shrimp were totally gone, and considering we had 8 people, I think that's pretty impressive. We all stuffed our faces.

Eating in the hospital

There aren't too many options for eating when you're working 10-12 hours a day and rushing around all day. To be honest, especially at the beginning, when I'm carrying a lot of patients, I'm so involved and busy I think my adrenaline is going all day, and I don't have much of an appetite! Even when we're at a meeting and there's food in front of me, sometimes I don't feel like eating. If you know me, you know that's unheard of - first of all, I usually have a huge huge appetite. Secondly, if there's free food, I'm there. But I power through - I make myself eat. :)

Even when there's time, and I'm hungry, one of the problems is that the only option we have is the cafeteria. Sure, you can order in or have something delivered, or take a quick 5-10 minute walk to somewhere to get some food, but all that takes more time and also costs more. The issue really is that it takes more time and that it's difficult to leave. You really have to be in the hospital at all times in case something happens to one of your patients, or to answer pages or put orders into the computer. I guess people can also bring food, but that's rare - you hardly have energy to make dinner for yourself after coming home from a 12-hour shift, much less lunch for the next day. A few people with significant others sometimes can do it. And you can do it sporadically, but it's far from common. So you are really limited to the cafeteria, and sometimes you don't even have time to go the cafeteria!

Even when you're able to make it to the cafeteria, the selections are horrible, limited, and repetitive. And the cafeteria closes down around 7:45pm, so if you are working a late shift, you have to make sure to get in early for dinner. For lunch, we don't have 5-10 minutes to wait for hot entrees to be made often (like cheesesteaks or grilled cheese sandwiches), so we often go for the quick already-prepared foods. Soup is always a good option, and inexpensive, but they go through the same soups every week so those get a little tiring. Sushi is also a good option (although it's not like it's great sushi), but it's expensive. The salad bar is actually pretty good, but it's not cheap and you can't eat salad everyday either. The hot entrees are also not cheap, are often terrible, but are very fast items to get besides soup and sushi. Other fast options include ready-made sandwiches (horrible), burgers, fries and onion rings, chicken wings, mozzarella sticks, and some other fried foods. The options are even more limited for dinner. Because of all these things, doctors usually end up eating horribly if they eat at all. There's a joke that doctor's are the least healthy people in the hospital.

It'll be nice when I can cook more again.

A good blog

This is a great blog:

Stuff white people like

ha

Look at this site about what a proctologist is... more specifically, look at the girl they put on there! That's a proctologist? Ha. Or you might get they funny looking guy with the stare. Interesting way of depicting proctologists. :)

A lesson well-learned

The call system for Pennsylvania Hospital is a little different from other hospitals. I won't go into it now, but suffice it to say there are three types of calls - short call, medium call, and long call. Over the last 3 weeks, on medium call, I've generally been able to get out at 6 or 6:30. So I thought yesterday would be no different. In fact, we had already bought tickets to go to a large music festival with the rest of our friends. The plan was for me to get out, Pete would pick me up, and we would go directly there to join everyone around 6:30 or 7. It was a pretty crazy day and I picked up the max number of patients I could possibly pick up (which has been the case for the last 6 calls I've been on), and there were some complications with other patients. I didn't get out of the hospital until close to 8:30pm, at which point, not only was I exhausted, but I hadn't eaten, and we would only get to enjoy about an hour of the music festival by the time we got there. So I just went home.

The moral of the story? Don't buy tickets, especially expensive ones, ahead of time unless you are sure that you will get out in time.

Medicare sucks

There are a lot of changes going on in health care. One is that pretty soon in Pennsylvania, it will be mandatory for hospitals to report hospital-related infections. Now, I believe this is a very good step overall. For one, it's important for hospitals to keep track of something like that, and to take steps to lower the numbers. It is probably impossible to completely eliminate it, but it's crucial to reduce it as much as possible. Although hospitals should already be taking measures to do so, I think mandatory reporting will go a long ways toward speeding hospitals along. Secondly, I think it's good that patients will be able to access this information and see the rates of hospital-related infections at different institutions. This may help them make health care decisions, which in turn, will pressure these institutions to lower their rates of hospital-related infections.

However, I also see some potential problems. For one, I have heard that Medicare is going to stop paying for hospital-related complications and infections. Now while I believe that many hospitals will be able to reduce these by quite a lot, hospital-related infections will never be completely eliminated. Let me give an example.

A patient comes in because he had a heart attack. He's on the older side, also has hypertension, and congestive heart failure. The heart attack really does a number on his heart and it starts failing. He can't pump his blood well, fluid builds up in his lungs, he can't breathe, and he gets sent to the ICU and gets intubated - that's getting a tube thrust down your pharynx so that you can breathe with the help of a machine. This is a life-saving intervention. Without it, this patient would have died. However, several days after intubation, the patient develops a rip-roaring pneumonia. He gets treated with antibiotics and gets better. Eventually, the patient's heart gets better, he gets extubated (the breathing machine is removed), has open-heart surgery and lives another happy 20 years.

A relatively high percentage of patients that are intubated develop pneumonia. While this is serious, it can be treated with antibiotics. Medicare is saying that they will not pay for the antibiotics, because this type of pneumonia is a hospital-related infection - even though this infection was the result of a life-saving intervention! This is not the only example of something like this - there are many others.

Who is going to pay for the cost then? The patients? No - they never have enough money. So it will go to the hospitals. They will have to eat the costs and make up for them by billing more for just about everything else. Would it be ethically okay for the hospital and doctors and nurses to say, well, this patient will probably develop pneumonia if we intubate him, and we won't get paid for that, so nevermind. Let's just let him die. Of course that would not be ethically acceptable, and of course that won't happen.

I think it's ridiculous and sustainable for neither the insurance companies nor the hospitals.

Paul Levy, the president and CEO of Beth Israel Hospital in Boston posted about this topic and I think he also brought up some very good issues.

The neverending bag of patients

I have had a lot of patients on my list everyday - nearly the max an intern can carry. Today I discharged four patients. That's a lot. But it didn't matter - I admitted another four in the afternoon into night, and there will probably be another one I get there in the morning.

Sigh.

Frustrations with giving medical care

I'm sure there are a many frustrating things during intern year, and I'm sure I will blog about quite a few of them. Here's one.

There are so many patients in the hospital who fight with you about their care. You're trying to do something for them which will make them better, and they don't want to go through with it. And I'm not talking about interventions that are risky, or have lots of side effects, or ones that we're not sure about or ones that don't matter that much. Sometimes they're life-saving interventions! Here's my example from intern year:

I had a patient who had a horrible infection - she needed IV antibiotics. She wasn't about to die just yet, but if she didn't get the IV antibiotics soon, she would get horribly sick. And we know this because we see it happen all the time. Sometimes we don't even know people have infections in the hospital yet until they're horribly sick - we got lucky and managed to catch this patient before they got to this point. She tried to refuse the IV antibiotics! She said vitamins or herbs might do just as well. Ridiculous. She also had made some really bad medical decisions that had got her in this situation in the first place. I spent close to an hour talking her into, first, letting us put an IV in her arm, and then second, getting the IV antibiotics. What if I had said, fine, don't get the IV then. She would have gotten seriously sick! But of course, I spend more than an hour arguing for her, and she got the IV and the IV antibiotics, which probably saved her life.

The problem is that it's very difficult for doctors to say something like oh well, it's your call, go ahead and die to a patient. First of all, they genuinely believe in the therapy and believe that they're right. Secondly, if they didn't try their absolute hardest to argue with the patient for their own good, doctors would be held liable. It's very frustrating, but I think we're stuck with it.

Blue Moon

I can't believe it. Blue Moon is a wheat beer, one I often order at bars and enjoy quite a bit. I just found out that it's not a microbrew, never even started as a microbrew, but in fact was created by one of the giant brewing companies. I'm sure had I known that before I started drinking it, I may have looked down on it a bit more.

But taste is taste - it's still a good beer.

George Carlin - anorexics and bulemics

Here's another one, much shorter than the first. It's about anorexics and bulemics. Man, that was a funny guy.

George Carlin video about swear words

Well, George Carlin died of heart failure today so of course this news is everywhere. I just watched this video for the first time. It's his famous bit about swear words. I'm not going to say much about him because I honestly didn't know him that well or watch him that much, but this is HILARIOUS.

First Call - to Code or not to Code?

I had my first overnight call as an intern. It wasn't too bad. Pennsylvania Hospital is actually pretty nice to their interns. Typically, interns stop admitting around 1 or 2 am if they're on overnight call. Which means they probably get 3 or 4 hours of sleep, which is great! Of course, I spent about 2 hours with my resident doing a paracentesis (sticking a big needle in somebody's abdomen - you usually do it when fluid is building up abnormally in a patient's abdomen, making it all poofy. Yes that's a medical term. Poofy.) and trying to get IV access and blood drawn from a very difficult patient. So I didn't even start admitting until around midnight, and I felt bad, so I ended up doing 4 admissions, which lasted until about 4:30am. Plus there was a code - which is the thing I actually want to talk about that happened that night. I ended up getting only about an hour of sleep.

So the code was interesting - a resident and I are doing admissions in the ED, and suddenly a code call goes out across the hospital-wide PA system. "CRT... CRT... " and it told us the location. Apparently that means somebody was going through cardiac arrest. I found out later that this patient had been doing fine after his surgery and was being monitored by telemetry. That's where they attached a lot of electrodes to a patient's chest, it monitors their heart, and somebody in a centralized location watches a lot of monitors 24-7 to make sure all those hearts are working properly. This person noticed that at 1am, this patient's heart suddenly stopped working for some unknown reason and called the code. When my resident and I got in there, there were 4-5 people already there working on the patient and giving CPR. It turns out giving CPR (which at its most basic is simply chest compressions and giving breaths) is the most important thing in bringing someone back from the dead and giving them the best chance of survival afterwards. Somebody had already gotten IV access, and he was being pumped full of fluids, they were attaching a monitor to his chest. His heart was in ventricular fibrillation, which is a type of arrhythmia, that if left untreated, usually leads to death. They shocked him, and he immediately went into PEA, or pulseless electrical activity, which means the electrodes were sensing electrical activity by the heart, but it wasn't actually pumping, and the patient was pulseless. At this point, shocking doesn't help anymore, and you basically continue CPR and start giving all these different types of medications meant to jump-start your heart.

The rule of thumb is that you don't continue to code a person past 10 or 15 minutes because (1) the chance of survival is way too low after that period of time and (2) even if you bring them back to life, they've been "dead" for too long, and their functionality is horrible. There's a good chance they'll code and die again before they leave the hospital. However, in reality, codes often go on for 20-40 minutes, especially in patients where it is unexpected. Time goes super fast in a code, and people are reluctant to give up. This code had gone on for about 17 minutes... people were starting to give up, they'd loss IV access (I actually managed to put a new one in on the foot that lasted about 2 seconds). And then all of a sudden, someone says "I've got a pulse." Crazy. This guy was dead for 17-18 minutes, and then all of a sudden his heart starts working again. And the monitor shows that his rhythm, although not idea, is a workable rhythm, and he's "alive" again, and somewhat stable. All this activity starts up again and he eventually gets intubated (a breathing tube shoved down his throat) and transferred to the ICU. I don't know what happened to him after that - I guess if you follow statistics, there was a good chance he coded again and died.

Afterwards, I finally found out the rest of his story. This patient has esophageal cancer, one of the worst cancers to have. The treatment is surgery - they take out your whole esophagus, which is an extremely hard surgery to live through. Then afterwards, many patients have to go through chemotherapy and radiation, which is definitely no joke either. And after all of that, there's a good chance of it coming back anyways! So even if this patient lived and was stabilized, first of all, he would probably have little to no brain function since he got very little oxygen to his brain for 17 minutes. He'd be a zombie, on life support, for the rest of his life. Even if a miracle happened and he woke up, he'd die of his esophageal cancer pretty soon, or have to go through chemotherapy or radiation, which might kill him too.

So my question is... should he really have been coded? If I were the patient, I would not have wanted that. But not many people think of these things when they're going in for surgery anymore. In many countries, they trust the doctors to make these decisions, but in this country, and in the era of litigation, that's just not possible. Because of this, we waste millions of dollars on codes and life support and everything else. But more importantly, it leads to horrible situations that families have to deal with.

Faith in American patients

Today may have restored my faith in American patients. Way back when, I posted about how much better African patients were than American patients. Today was my first day of internship and I was prepared. I was prepared for the gripes from the patients: "My cable TV isn't working!" "I asked for mashed potatoes for dinner, not broccoli!" "I refuse to take that medicine!" "I demand a private room!" And of course, I was not expecting any gratitude or help with the patient care from the families. I was not even expecting the patients or their families to know anything about their own illnesses. I expected a lot of drug addicts, HIV patients, gun-shot wound patients, people with no family support, rudeness, impatience, an air of presumption and expecting things they should expect.

I was surprised. Three of my patients or their families expressed extreme gratitude for my help. Some of them were pretty demanding, but in the end they were grateful for all that I did. A fourth patient started out pretty surly and unfriendly. To be fair, he's been in the hospital for close to 3 weeks, and he's not that much better yet. But after talking to him and joking around with him for a few minutes, he warmed up, and even thanked me at the end for talking to him.

I think in the end, you get what you put into the patients. They may be very demanding (especially compared to Botswana patients), but if you really care and try to help out, they'll see that in you and be appreciative. If you don't care about them, of course they're going to realize that and see that in you. Maybe American patients aren't so bad after all. Or maybe it's my first day and I'm still being naive. :)

The first day of internship

Today was my first day of internship at Pennsylvania Hospital! There were a few hitches - we didn't have our own long white coats (the universal symbol of being a doctor), so we had to borrow other people's. Not a big deal - we put tape over their names, which are stitched over the pocket. A few of us also didn't have our logins or passwords to one of the main computer programs used in the hospital. Without it, we couldn't enter electronic orders, or really check labs on patients. It took a couple hours to sort it out, so that definitely ate into our working time. Also, I still don't have my email account. Oh well - hopefully nothing crucial was sent to us! All this was a little annoying, because you would think these things would all be taken care of weeks ahead of time, since we found out we were going there in May. But it's not a big deal.

Despite it being the first day, I think it went relatively well! I had 7 patients to start, and 3 of them were discharged. My resident helped me out, as well as the other intern on the team quite a bit since we didn't know these patients at all. We were also lucky - my co-intern (Christina) and I both know the programs and the system relatively well, so we were able to do things much more efficiently (I imagine) than some of the other new interns. Some of the newbies definitely had frazzled looks on their faces. :)

Tomorrow will be much harder for us - we're on call. Christina has to stay until 10pm, and I am staying overnight until the next day at 1pm, and we are taking patients during most of that time. That means not only will we be busy with the patients we already have, but we will also be admitting patients from the ER, which takes on average 1 - 1.5 hours per patient. We can each take up to 5 new patients, in addition to the ones we already have. It's gonna be interesting!

The Making of the Lubangs

I just got married!

We had a crazy 3 weeks, starting with my graduation. You'd think this would be a bigger deal since I spent 9 years trying to get this diploma, but it got a bit eclipsed with the wedding. But it was still a good time - my parents came into town, as did Pete's mom. We had a nice dinner that night, and the next night, my parents through a big banquet dinner for me and my friends. It was so nice of everyone to come!

That next week we spent getting ready for our wedding, which takes way more time than you might think. I can't even remember what I was doing anymore, but every day was super busy doing super important wedding stuff. Plus we were picking people up from train stations and airports and my brother his girlfriend, and my sister and her boyfriend were staying with us.


The wedding itself was so much fun for us! We started with photos to get them out of the way, and then it was on to the ceremony. My brother Bruce was our officiant, with Karen, my sister, as my maid of honor, and Ben, Pete's brother, was his best man. We had Ben's two twin sons, Jacob and Aaron, as our ring bearers. During the rehearsal they were so cute, in their tuxes carrying the ring pillows. I wish I could have seen it myself, but I hear during the actual ceremony, they did great! And of course, there are probably a bazillion pictures documenting their cuteness. :)

Bruce did an awe job as the officiant. I'm lucky he let me read a draft of his talk the day before, because when I read it I was bawling, and that probably would not have been the best thing to do during the ceremony. He made it very personalized for Pete and I, which was great. You know those parts of ceremonies where you almost fall asleep? Well completely objectively-speaking, there were none of those parts during our ceremony. I for one, did not fall asleep. :) Tons of people came up to us afterwards though and told us what a wonderful job Bruce did. There were even a few requests for Bruce at other weddings!


Afterwards came the cocktail hour. We holed ourselves up in our private room for 30 minutes or so then stepped outside for some socializing. The private room was great - family members came in to see us, we played with the twins for a bit, and we even had our own food! I didn't have many of them, but people said the appetizers were great. We had a table with lox and whitefish and bagel fixings, a table of cheeses, olives, and crackers, as well as an assortment of butlered hors d'ouvres brought around to guests: shrimp tempura, wild mushroom phyllo, scallops wrapped in bacon, coconut chicken, beef tenderloin with eggplant, asparagus with goat cheese, peking duck rolls, and crab cakes. And, of course, it was open bar.

Time went so fast! Before we knew it, it was time to go into the reception hall. Bruce went in and was announced first, followed by my parents (Phillip and Catherine Jang) and Pete's mom (Carol Lubetsky). Then we were announced as Mr. and Mrs. Lubang! It was such an amazing feeling to go into that room with everyone cheering and applauding. After our entrance, we went right into our first dance. I know this is what everyone wants to see, so here, courtesy of Jen (my sister-in-law, Ben's wife, and mother of Jacob and Aaron), is a video of our first dance on youtube. We had it choreographed to Let's Get it Started, by the Black Eyed Peas.



The first dance led right into the hora, which was the best idea ever because all the energy from that was transferred into the hora. I've never been lifted or pumped in a chair before, but it's great!! I can't believe they even got my parents up there. And everyone said my dad looked so good in his yarmulke. :) After that, there we had toasts from Ben, Catherine (and Phillip) and Carol. And then we started dinner! Even though we didn't get to eat too much of it, everyone told us the food was so good! I think it was just as good as when we tried it at the tasting dinner. Just because food is my thing, this is what the guests were served:

Appetizers:
Butternut squash soup (delicious!!!)
Caesar salad

Main entree: Guests had a choice of
(1) sweet potato-encrusted NY strip steak grilled medium rare with roasted potatoes and julienned vegetables,
(2) chicken olympia (seared European chicken breast topped with sauteed spinach, roasted red peppers, and feta cheese in a lemon-thyme sauce) with garlic mashed potatoes and julienned vegetables, or
(3) a vegetarian option that I -believe- consisted of tortellini. I guess this shows how much we cared about the vegetarian entree... :)
Kids got something like chicken fingers and fries.

Dessert: wedding cake! (with coffee or tea) The wedding cake was a layer of vanilla and a layer of chocolate, separated by a coffee ganache and a raspberry layer. The wedding cake was awesome - we got it from Dough Main Bakery. Pete keeps talking about how he wants to order another cake from them. :)

The rest of the wedding was fantastic! We had a father-daughter and mother-son dance, which ended up with all of us dancing together. We did cake cutting and a few more pictures. We talked to so many people, although not nearly as many as I wanted to. At some point we tried to make it around to all the tables, but we probably didn't even get to half of them! I felt really bad about not talking to some people, so I figured it out... the entire reception was 5 hours, but we spent half of the cocktail hour alone, then there were the different dances. Also cake cutting, toasts, etc. - so there were really only about 3 hours to socialize. If you divide that by the number of guests, each guest would only get a little more than a minute! So if I talk to someone for 5 minutes, I shaft 3 to 4 other people! So no wonder I didn't get to talk to everyone - I'm justified by math. And yes, this is pretty nerdy. :)

It was a wonderful day and I think it set the tone for a wonderful life.

The beginning of intern year

Yesterday marked the beginning of my intern year at Pennsylvania Hospital. I haven't done anything clinical really since September when I was in Botswana. I guess I took a radiology elective, but really, I didn't work too hard. I had to get up at 6am! I know, it's a tough life. I'm hoping to be able to blog about life as an intern throughout this year with some stories and insights into hospital life, but this being intern year, we'll see how much time I have for that.

For these first two days we have ACLS training. That is, Advanced Cardiac Life Support. We learn to run codes, which are when somebody suddenly dies, and you go through the appropriate steps to try to resuscitate them. Have you ever seen an emergency situation on a show like ER? And they yell out orders and give medications, and maybe eventually shock a patient with electric paddes? It's like that. Exactly.

It's actually pretty complicated. Depending what's wrong with the patient, you have to give different medications, treat them differently, order different labs. CONTRARY to what you do see on ER, you don't shock every patient and not every patient gets epi (epinephrine, also known as pure ol' adrenaline). And everything is happening pretty fast - the patient is getting bagged or intubated (getting a breathing tube shoved down their throat), they're getting put on the monitor, somebody is inserting an IV or two into the patient, someone else is drawing labs, someone is giving medications, someone is giving CPR and doing chest compressions, someone is monitoring their heart rate, blood pressure, and a few other things. Not to mention all the bystanders there either just looking on, or trying to be available to help. So there are probably 10-20 people crammed into this small room with the leader yelling out instructions, and sometimes it can be pretty difficult under pressure to remember all the things you have to do, and to communicate effectively with all the people.

That's what all the new interns got certified in today. This is certainly not an unknown issue, but it's a little scary to think of new interns practicing a medicine, much less running a code. I don't think we would be bad, but almost certainly slower. But interns have a huge learning curve. I think by the second week, people are usually up and running, and while the knowledge base is still building, interns can get things done pretty effectively.

I think I would feel relatively confident running a code. Maybe not perfect, but ok, and I'm sure that will improve. I think many of the interns were a little worried or scared about running a code. Thankfully, usually it is a senior resident (a 2nd or 3rd year resident) who runs a code. The interns usually just help out, and when they have enough experience, then they run the code. I know this is a horrible thing to say - I guess that's why I'm in medicine - but I'm a little excited to take part in my first code! Look at it like this - I don't want anybody to die, I just want to help bring someone back to life! :)

The absurdity of the airline industry

I've been traveling a lot over the last year and I've had to spend a lot of time in airports. Of course, everyone has gripes about traveling. But lately I feel it's been getting absurd. Take a story that my mom told me.

My parents had to be in Boston for a wedding, so I arranged all their travel plans for them - their flights, the rental car, hotel, etc. My parents aren't poor, so instead of going for the cheapest flight, which is usually a red-eye or leaves at an insane hour, I book a reasonable return flight for them going from Boston to Sacramento, which leaves at something like 9am in the morning, has an hour and a half layover, and makes it to Sacramento around 2pm. About a month later, I get an email notice from this un-named airline (but which rhymes with Smelta) telling me that their flight has been changed. Not only does the flight now leave at 7am, but now there are -two- layovers, one of which is 30 minutes long (yeah right, my parents would never make that), and now they don't get home until 6pm at night (9pm EST). This is important because they need rest. My dad is asleep usually by 9pm, and moreover, they were picking up more family at the Sacramento airport the next day from China, Taiwan, and Hong Kong to show them a good time in ol' Sacramento. Anyways, so I call, raise hell, and eventually they rebook my parents - they still have to leave at 7am, but now they only have one layover (45 minutes, still tight), and get back to Sacramento around 1pm.

So the day of their return flight, my mom calls me around 11am. Of course, I'm assuming that it's during their layover, but noooo. My parents made it to the airport around 5:45am - a good hour and 15 minutes before their flight takes off. I would have thought that at 7am, probably the first flight of the morning, this would have been plenty of time. Unbeknownst to them, Smelta apparently has around 7 or 8 flights leaving all at 7am from Logan International. The lines were horrendous and since everyone was in the same boat, they were not letting anybody skip ahead to make flights. My parents finally make it past security with a couple minutes to spare and my mom makes a run for it - my dad was a little slower since he had to put shoes back on and he's old, so he has to sit for that, and tie his shoes and everything. My mom actually makes it to the gate, it was still open, and they were letting in 4 more people. She pleads with the woman and says her husband is coming up right behind her. The gate woman says sorry, it's too late, and closes the doors. Literally a minute later my dad comes running up as well, and she wouldn't open the door for them even though the other people had just gone through and probably were still in line on the bridgeway to get it their seats. It was 7:01am.

How ridiculous is that? Do you know how many times I've been kept waiting by airlines? Not even for weather reasons. For cleaning reasons, mechanical reasons, reasons not explained to us, the customers. These delays have over my lifetime probably cost me days and days of time. If I said, oops, sorry, you were a minute late, I'm not paying - how do you think they would take that? Probably not well.

the genetics of race

When I was in high school, I got into a debate at school. I said that if different races were separated long enough to evolve different skin colors, then other things could have evolved differently too. For example, blacks are stereotypically thought of as good athletes. Asians are thought of as good at math. I know this is really oversimplifying it, but it's certainly possible that over time, blacks developed a "strong muscle" gene (or set of genes) or maybe a "hand-eye coordination gene" and Asians developed a "math" gene (or set of genes). I'm not saying that's what happened... it's just what is possible.

I was watching a TV show (I think it was Without a Trace) and although I'm sure nobody really picked up on it, there was this one part that I think really made this statement. In this episode, there was this white kid who disappeared, partly because he was having an identity crisis. His mother was white and the father who raised him with his mother was white, and the kid looked white, but his father was black, and he just found that out. In one of the flashback scenes, they show the kid when he really young, and he's talking to his adopted father, saying that he doesn't "feel right". I'm not getting the words completely right, but he basically says that he feels different from his father and all the other (white) kids - they don't like the same things, act the same way, or even look the same. And after the flashback, the father says about his adopted son, "he always knew" (that he was different).

Now at first glance, this doesn't seem to mean much. But actually, what's it's saying is that even though there was no difference in skin color for this kid, there were other characteristics - facial or other body features, personality, attitudes, etc. - that made him feel different. And then he finds out he's half-black. The point is that this one scene in the show is suggesting that there may be other differences to race than skin color (whether genetic or otherwise). It's interesting to me that this was brought up, albeit in a very subtle way, on TV, while in reality, it's something that society as a whole isn't really ready to talk about yet.

Free pens and pizza for doctors

A couple of years ago, my hospital banned any sort of pharmaceutical advertising, including free pens, lunches, dinners, prescription pads, drug samples, anything. This was a huge deal. Half the resident lunches were paid for by pharma, and they always coincided with mandatory meetings and conferences, so residents could eat while the attended and knock out two birds with one stone. I certainly understand. For one, without the free lunches at these meetings, residents often don't have time to get lunch! They don't even take the time to go the cafeteria and grab something to go. Even from an outsider's perspective, I think this is understandable - why feed yourself when you could work more on your patients and provide better care? Perhaps even save a life? Secondly, residents do not make a lot of money. They make about $40-45K a year ($30K after taxes), and many of them have $200K in debt after medical school. They haven't saved anything for retirement yet, and some of them have kids and families to support, so the loans are often just gathering interest during residency. So actually, these free meals were a source of income for the residents! Sure you can bring food and eat cheaply (and be much more healthy too) but the average resident does not have time to do this. The alternative is eating at the cafeteria or elsewhere, where an average meal probably costs $5-7. However, if you eat a free lunch off of the drug company (which usually is just pizza or ordered in chinese food or sandwiches), you save that money. You may even have enough left over for dinner if you're working late, which you usually are. Taken over a week, that's $20-$30 you save. Taken over a year, that's $1000-1500 you save, which for a resident, is a lot of money.

Despite these reasons, I've always been hugely for this. I've always thought these free pens and everything else could easily influence (hopefully subconsciously) doctors' prescriptions of these drugs. For example, say you want to prescribe a proton pump inhibitor to a patient, and in your line of sight is your clipboard, with "Protonix" all over it. You might not even realize that you saw it, but the next thing that happens is that you prescribe Protonix for your patient, and they're on that for life... not a bad way for the company to get a patient for 30 or 40 years, huh? And it's even worse with the free samples. I completely understand that free samples are how a lot of poorer people get their medications, and I think that's certainly a benefit. However, if you have a sample of drug X, and it works for a certain patient, even after they stop giving out free samples, that patient is probably going to stick with it, even though it might be 10 times as expensive as drug Y. It's also a huge source of medication confusion - so many patients I've seen have switched from medication to medication, for, say, their hypertension. And it's basically because they switch to whatever is being given out for free for that particular month. That is bad medicine, and bad for the patient.

Of course, we never knew if this was true or not. These are just theories. But why would pharma keep doing this if it didn't work, right? I'm sure they've done their research, and I've actually heard statistics from some ex-drug reps about it. So it's real. And hospitals and practices should ban pharma from advertising in their space. Of course, that's just my opinion, and there are plenty of differing views on this.

Here's an interesting recent article by Art Caplan, a pretty well known medical ethicist.

Food and Personality

I think how and what someone eats is incredibly indicative of their character. In fact, in the past, I've used it as a way to decide whether or not I'll go on a second date with someone.

The trend I see is that the more adventurous someone is at the restaurant, the more adventurous the character. Someone who orders chicken all the time is not that adventurous. Somebody who decides to try the goat or the alligator (and they do not have to like it!) probably has a more adventurous personality.

I love to eat, and I love to try different foods - there's no way I could date or see anybody long term who didn't share those interests. For example, I could never date a vegetarian, or somebody who didn't like seafood or red meat or something. Even somebody who was allergic to nuts, or shellfish, or something like that - I would get so frustrated! But that's just me.

I guess I actually know plenty of adventurous people who place limits on their food - often that's health-related, or because they're concerned about the environment, or religious. Sometimes it's because of taste, which I think is fair. And those people are fine - I can like them just fine. But I could never date somebody like that. :)

Tonight's Menu

Appetizer: cheese, crackers, and olives
First course: Mushroom soup (yum!)
Main course: Prime rib, with sauteed spicy broccoli and asiago cheese potatoes
Dessert: summer berry gratin

Korean food in Philly

We've been really getting into the Korean food lately. There's an asian grocery store called H-Mart near the 69th street station, and on the second floor, there's a Korean fast food court. It's great. There's Korean food, Japanese food (with a Korean accent), Chinese food (with a Korean accent), a Korean bakery, and even a place that sells fried chicken (with a Korean accent). We always go to the Korean fast food counter - it's soooo good. They have all sorts of barbecued meats, soups, fish, tofu, you name it. Some of it's not spicy at all, but some of it is pretty spicy (one or two peppers on the menu). I think my favorite is the marinated beef short ribs. TASTY. And it's so cool - all the dishes come with rice (or noodles depending on whether you get a rice dish or a soup dish), maybe soup, and about 3 or 4 other small side dishes. They always give you kimchee, and the other 2 or 3 might be things like pickled vegetables, broccoli, bean sprouts, tofu, whatever. Even better, they recently put up pictures with their entrees, so now I'm not stuck wondering if that's what I got last time, or if that's something I'd like to try. I had been thinking of starting to take pictures with my cell phone and labeling them with the menu order number. Not a bad idea huh?

So for Pete's birthday yesterday, we went to a new Korean place, in the same general vicinity. However, this was an actual sit-down place where you order and they take it to you at your table, and you get tea and water and everything. It's called Moo Jin Jang. I didn't even realize it had my name in it until I got the receipt. I think it was a good omen. It's not a fancy place - there's no alcohol, they serve the tea in big plastic pitchers (not even a teapot), and the menu is this laminated card on every table that lists about 20 choices. The one waitress was the only one that spoke English, and I think she translated for her mom and dad. But everything still looked good. I only recognized maybe half of the menu - all the other items listed things I had never heard of before. I was tempted to try one, but I stayed with tried and true. I ordered the barbecued pork (spicy) and Pete got the beef short ribs. DELICIOUS!! And unlike the little fast food counter, this meal came with about 8 different little side dishes - it was great. We got fish, broccoli, bean sprouts, kimchee, pickled vegetables, hot pickled vegetables, little meatballs (which I think were marinated hot dogs), pickled potatoes, I can't remember them all. It was a lot of food, and of course I took it home. I'm pretty sure we'll go back at some point.