Tuesday, December 25, 2012
Another night in the Free Clinic; I’m not sure it’s worth five hundred an hour and it’s a full moon. There’ll probably be werewolves in every room.
“Dr. Barnes there’s a patient in room 2, infected leg, I think.”
“Thank you Miss James,” nice legs, I thought, staring at my assistants shapely calves. Keep your mind on work Jimmy boy.
I opened the door and was immediately greeted by an overwhelming pungent force, a combination of month’s old sweat, unwashed clothes and rotting flesh. I called out into the hall. “Miss James, could you help me or send someone in here please?”
“There’s only me tonight, just a moment, doctor,” came the reply from down the hall.
I turned to the patient and tried to smile, while doing my best to keep my dinner down. “Mr. Smythe, I’m Dr. Barnes. What seems to be the problem?”
“It’s these legs, doc. Last month at the clinic they told me they was all healed, but now look at them.” He smiled a broad smile revealing his three remaining teeth and bent over to roll up his pant legs. Crusted dirt fell to the floor. The pants would not roll up over his swollen limbs.
“You’ll need to take them off,” I suggested. Where’s that nurse or aid or somebody.
I helped him unsnap the beltless pants and started to slide them down. He was wearing underwear, at least, although it was stained brown and tattered. As his trousers hit the floor they didn’t crumple into a heap; instead they almost stood up by themselves. His legs were just as I expected, swollen to three times normal size, colored a mixture of violet and brown with valleys of green black tissue, pus dripping from each wound. The ulcers on the left leg were cleaner, crawling with tiny maggots gorging themselves on the dead tissue, while leaving the healthy, vital tissue behind.
“Mr. Smythe, it appears your venous stasis ulcers have returned. How long have you had them?”
Mr. Smythe stroked his gray beard and a roach fell to the floor. “Well, I had those blood clots about ten years ago and ever since then my legs have been swolled up and these sores come and go.”
I looked at his legs again. His thighs sported the healed scars of previous skin grafts. The ulcers had only minimal cellulitis and did not seem to extend to the fascia or muscle. At that moment the nurse came through the door.
“Miss James, I need to clean up these leg ulcers and we need some ethyl chloride for our little visitors here,” I ordered while pointing to the maggot infested wound on the left side.
Together we cleaned up Mr. Smythe’s wounds, removing dead tissue, pus and maggots. I debrided the right leg, while the maggots had done an excellent job on the left, leaving healthy pink tissue behind. We dressed the wounds with sterile gauze and offered to transport Mr. Smythe to the hospital for admission. He politely refused; we gave him a follow up at the wound care clinic, advised him to keep his legs elevated as much as possible, gave him enough gauze for a week of dressing changes and the address to the nearest homeless shelter. He smiled as he left and I went on to my next patient.
Left breast pain; Evella, an unusual name, I thought as I marched through the door.
“Good evening Miss Evella…” I started to say, before I was interrupted.
“I am Evella, Goddess of the Night, young man,” she exclaimed in a loud, melodious voice.
“I’m sure you are, Miss Evella,” I replied in a flippant manner. Sitting before me was a lady, mid fifties, probably over three hundred fifty pounds, white hair on the right and jet black hair on the left, dressed in a skin tight black dress with a neck line that plunged to her navel, but covered by a sheer silk shawl. Despite this covering, her ample cleavage, along with tattoos depicting skeletons, angels, demons and black snakes, was clearly visible. The left breast didn’t look right, even through the sheer covering. She smiled, revealing her tongue pierced by six gold rings and her top and bottom incisors sharpened into sharp fangs.
“OK, Miss Evella. It says you are having problem with your breast?”
“Please address me as Evella, Goddess of the Night, little man.”
“Very well, Evella, Goddess of the Night, and I am Dr. Barnes. Now how long has your breast been hurting you?”
“What does it matter to you, doctor. It’s obvious you don’t really care. You look at me and think, ‘another crazy old woman, I’ll try to be cordial.’ Meanwhile your body language patronizes me more than your words and your eyes are already looking towards the door and your escape. You don’t have to answer, Dr. Barnes, that look on your face has answered for you. Well, let’s get on with it. My breast has been hurting for about six days. I tried Advil and warm soaks, but now it’s red and swollen.”
I looked into her eyes and then looked away, a bit embarrassed, not at the prospect of examining her breasts, more because she had figured me out so quickly and so completely and called me out on it.
“Was it painful at first?” I asked.
“No, it was just red and swollen. The pain started to be really bad yesterday and I can hardly stand it. I tried some of these, but it only got worse.”
She handed me a bottle of pills, Keflex, expired in 1998.
“How’s your health besides this?”
“Oh, the usual, diabetes, high blood pressure, high cholesterol. Here’s a list of my meds and allergies. Dr. Stanly Fried is my regular doctor.”
I examined the list: Lipitor, Metformin, Metoprolol. Allergies to Codiene, Demerol, Dilaudid, Morphine.
“You’re allergic to lots of pain meds. What happens when you take it?”
“Let’s just say me and narcotic pain meds don’t get along, Dr. Barnes. Aren’t you going to check my breast?”
“Right away, Evella, Goddess of the Night. I’m just waiting for the nurse.”
At that moment Miss James popped her head in. “Do you need any help Dr. Barnes?” She smiled a broad smile and showed me a bit more leg than necessary.
“I need to examine the goddesses’ breasts. Could you get her ready? I’ll be back in a minute.”
I stepped out into the hallway, took a deep breath, waited about a minute and then stuck my head back into the room.
“She’s ready Dr. Barnes,” Miss James informed me.
“Good, thank you,” I answered. “Lay back and put your arm behind your head,” I instructed the Goddess. I lifted the gown away to find a red edematous breast, skin dimpled, a hard mass in the axilla; clearly inflammatory breast cancer.
“How long has this breast been swollen, Evella, Goddess of the Night?”
“Maybe a few weeks. Is it something bad, Dr. Barnes?”
“It looks like what we call inflammatory breast cancer. Have you noticed this lump under your arm?”
“Not really,” she replied. “Is it bad?”
“I can’t say for sure without sampling the tissue, but it is almost certainly a type of cancer. You’ll probably need chemotherapy.”
I went on to explain the serious nature of her condition, that a biopsy would be necessary and I gave her the name of an Oncologist at University Hospital, and I called him to let him know that she would be seeing him Monday morning. She thanked me for my time and disappeared into the night, clutching the paper with name of the Oncologist and the time of her appointment two days hence.
Are there two full moons tonight? Please make the next patient a sore throat. I picked up the chart outside the door to Exam room 6: Edward Hyde, anal pain. Probably a thrombosed hemorrhoid, finally, something simple.
I knocked and then went into the room.
“Mr. Hyde, I’m Dr. Barnes. What seems to be the problem?” A middle aged man stood in the corner, impeccably dressed with a brown derby on his head, black overcoat and pants and fancy, black polished shoes. He fidgeted a bit and had a distressed look on his face. Must be a thrombosed hemorrhoid.
“Pleased to meet you Dr. Barnes,” he answered with a slight British accent. “I have this sharp, throbbing pain in my bum, for five days now.”
“Have you had pain like this before?” I asked, a routine question. “Any bleeding or swelling?”
“This is the first time, doctor, no bleeding, but it feels as if my backside is the size of my hat. I suspect it’s a thrombosed hemorrhoid. I have had some medical training as a doctor of sorts.”
“Let’s take a look, OK?”
He changed into a gown and I checked his backside which confirmed a single, thrombosed external hemorrhoid.
“You are correct, Mr. Hyde or should I say ‘Doctor’, a thrombosed hemorrhoid. I can remove that for you now if you wish.”
“Thank you, Dr. Barnes.”
I set up a procedure tray and slathered Mr. Hyde’s swollen bottom with four per cent lidocaine and took a ten minute break while the lidocaine kicked in. Nurse James was in the break room, smoking a cigarette.
“Those are bad for you, Nurse,” I remarked.
“Oh, I know, but sometimes these nights get to me and I just have to have something to calm me down. I only smoke when I’m stressed out. Full moons always do it to me. I guess it’s the werewolves.”
“I haven’t seen any werewolves, Miss James. We’re in the middle of a city. Do you really believe there are werewolves out and about?”
“No doubt about it; there were four, no five, that came in last month. There was some big rumble between the vampires and werewolves and some of those boys were pretty beat up. Dr. Lyons spent five hours sewing them up.”
“They didn’t try to attack poor old Jack?”
“Well, they were a bit vicious at first, but five of Dilaudid and four of Haldol kept them quiet. We kept them locked up until the sun came up, they reverted back to their human forms and then they left quietly.”
I put werewolves out of my mind as we left the break room to lop off Mr. Hyde’s thrombosed hemorrhoid.
“OK, Mr Hyde, this might sting a bit,” I warned as I cleaned the area around the hemorrhoid with some betadine. A purplish hemorrhoid the size of a jalapeno stared at me. I grabbed the syringe filled with lidocaine with epi and started to inject. I felt my patient tense up as I numbed the area, but, beyond this normal response to my jabbing him with a needle, the area around the hemorrhoid changed. The skin became a bit darker and hair popped up on his buttocks. Don’t tell me he’s turning into a werewolf.
“Are you alright, Mr. Hyde?” I asked, but he only answered with a grunt.
“Miss James, is everything OK?” I asked again, a touch of worry in my voice.
“Vitals are normal, Doctor,” she answered.
I grabbed the nasty hemorrhoid with a clamp and started to cut along its base. Halfway through there was a loud “BANG” and a crash.
“Mr Hyde, what’s gotten in to you,” Miss James yelled, her voice now filled with alarm.
Before I could finish snipping off the offending hemorrhoid, Mr. Hyde had jumped off the table and was flailing away with his walking stick, a heavy wooden staff with the head of a wolf sculpted in to its top. I grabbed Miss James hand and we raced out of the room. Shortly afterwards Mr. Hyde followed. Only he had changed. His face had grown long, unruly whiskers, his white teeth were now yellow and crooked, his hands had hair on the knuckles and his manicured fingernails had become long and dirty. He was hunched over as he bolted out of the clinic and into the night.
“He should have less pain from that hemorrhoid anyway,” I concluded as I held up the clamp with the offending tissue held tight within its jaws. Will this night ever end? I went to the break room for a cup of coffee before seeing my next patient, a Mr. Pire, Chief Complaint: anxiety and suicidal ideation.
I glanced at Mr. V.M. Pire’s chart before going into the room. The space for age was left blank, his vitals were: BP 60/30, heart rate 40, respiratory rate 12, temperature 92.
“Miss James, are these vitals correct,” I asked, not believing the numbers.
“Took them three times, Dr. Barnes, but there’s no need for alarm. You’ll see what I mean when you see Mr. Pire,” She answered in her most professional tone.
This night gets more bizarre every minute. I took a deep breath and let it out slowly, knocked on the door and went in to see Mr. V. M. Pire. I saw a pale, young man sitting on the chair in the corner, dressed in black pants, black shirt and wrapped in a black coat. Even with his coat he looked cold, shivering, his arms held tightly across his chest.
“Good evening, Mr. Pire. I’m Dr. Barnes. What brings you in here today?” I asked in my usual doctor’s bedside tone.
“What’s that supposed to mean? Do you think that I changed myself into a bat and flew in. Or maybe I just danced along the full moonbeam. I know what you’re thinking: Another deluded, crazy who can’t cope with reality,” he spouted with venom in his voice.
“Actually, the way this night has been going, I was truly expecting a vampire. Who else could have vital signs like yours and not be in a coma? So tell me, what’s the problem? If you don’t want to say, you are free to leave. I have plenty of other sick people to attend to.”
He calmed down, stood up and started to pace around the room.
“I’m…I’m not sure where to start. You see, I…I’ve been having these fantasies and, well, with the full moon and everything, I just couldn’t stand it. I even went to their meeting, thought about joining in their activities.”
He paused for a moment. I could see he was upset and I tried to calm him down. I put my arm around him and lead him to the chair. He almost had tears in his eyes. “Go on,” I said in a soft voice. “What are these fantasies?”
He looked at me with his dark, deep set eyes. “To be a wewuff,” he whispered in a muffled voice.
“I’m sorry, I didn’t understand what you said,” I replied with true concern in my voice.
“To be a WEREWOLF,” he answered loudly. “It’s driving me crazy. I know it’s ridiculous. I mean, I’m a vampire, the best of the best. Last month I downed six units of AB neg in under thirty seconds, all from the same vic…same donor.”
“Sit down and tell me about it,” I suggested, doing my best to imitate a Psychiatrist.
“I guess it started last full moon. I was out at night, like usual, and, as I was flying around the neighborhood, thinking about dinner, I saw a whole pack of them, werewolves. They were circling around some helpless wino and then they attacked. After their kill they all howled at the moon, gave each other high fives and then there were the girls. Dozens of them, all gathered around these vicious beasts, oohing and awing. Meanwhile, every night I’m out, shivering, looking for blood. Alone, hated by everyone, even other vampires who would just as soon cut your head off as share a drop of their precious stash.”
“It must be a tough life,” I observed.
“You don’t know the half of it. Dr. Barnes. So, a couple of weeks ago, I’m laying in my coffin, trying to sleep. It must have been noon and I start to thinking, Wouldn’t it be great to be a werewolf. Get to wear a fur coat, not be cold all the time, only worry about being a vicious monster once a month. Then I say to myself, ‘Get over it, you’re a vampire, you’re better than them.’ But, I can’t get over it; I can’t get the thoughts out of my head. I tried to talk to one of the Elders. Well, you would have thought I was wanting to become a priest, the way he reacted. After that I got scared, I guess, and then I went to see them tonight. All the werewolves were gathered together, I even went inside, tried to meet them. As soon as they saw me they surrounded me. ‘Look at sissy boy,’ they taunted. ‘Afraid of the big bad wolf?’ I tried to talk to them, but they just laughed. I left, feeling more and more depressed. I just wanted to end it all. I even broke into the hospital and stole this.”
He held up a case of thrombin.
“A couple of swigs of this, then all my blood congeals and it’s the end. Well, I got scared and I wasn’t sure what to do. I saw the Clinic sign and decided to stop in. So, here I am.”
I stared at him for few moments, not sure what to say or do.
“Let me get you a blanket, you still look cold,” I observed. “Stay here, I’ll be back in a minute.”
I stepped out into the hallway where Miss James was waiting.
“Dr. Barnes, you look a bit pale. Mr. Pire didn’t attack you, did he?”
“No, Miss James, he only told me his troubles. I need to find the number to that Psychiatrist, the one that takes charity cases; Dr. Van Something….Van Helsing. Here it is. Oh and I need a blanket and a couple of milligrams of Haldol, for the patient, not for me. Thanks.”
I went back in armed with the blanket, a syringe filled with Haldol and Dr. Van Helsing’s office number. I made a mental note to call Van Helsing later this morning and let him know about the referral.
“OK, Mr. Pire. I’ve got a shot for you that will help you calm down and here’s the blanket I promised. Oh, and this is the number to a Psychiatrist I know. He’ll take care of you for free. He does amazing work. After a few visits you’ll forget that werewolves even exist. Now I need you to roll up your sleeve.”
I gave him the shot and let him sit in the room for about thirty minutes, wrapped in the blanket. I definitely needed a few minutes alone after my visit with him and took refuge in the break room, drinking coffee while Miss James took care of a baby with diarrhea and a teenage boy with a sprained ankle.
After finishing my coffee I stuck my head into Mr. Pire’s exam room and saw him sitting up, smiling, the blanket neatly folded on the exam table. He was holding his black jacket and, although still with a ghostlike pallor, he appeared to be in much better spirits.
“I feel much better, Doc. That shot really did the trick.”
“I’ll give you a prescription, Mr. Pire, and don’t forget to call Dr. Van Helsing after nine this morning. I don’t want to see you back here again.”
“Thanks a lot, Dr. Barnes. It is a bit hard for me to call during the day, but I’ll do what I can. Say, you don’t happen to have any old pints of blood laying around, you know, a bag that might be expired that you’re going to throw away anyway?”
“Sorry, we don’t. Good night, Mr. Pire.”
“No harm in asking. Good Night, Dr. Barnes. See you around.”
As he walked into the night, I heard a loud bang followed by howling.
“They’re here, Dr. Barnes, worse than last month.”
It was Miss James at the front door, which she had locked. Outside stood a half a dozen creatures, half upright, cloaked in brown and black fur, displaying long white fangs, deep red eyes and unpleasant dispositions. I looked at the clock, four am, still two and a half hours until it was light.
“Shouldn’t we call the police?” She asked, fear in her voice.
“Take a close look, Miss James. They are the police.”
The six monsters each had a shiny gold badge pinned to their fur and a few sported remnants of the blue police uniform. I thought for a moment and then turned to my frightened companion.
“Let them in, Nurse. We’ll deal with them. Oh, do we still have that nitrous canister, you know, the one we use for little kids?”
Miss James smiled and replied in the affirmative.
“Could you please wheel it into exam room eight, thank you.”
We left the front door unattended, locked every exam room but number eight with its door left ajar. I put some old food from the fridge, along with some bloody gauze bandages, in that room, opened the nitrous tank and let it flow. It wasn’t long before the entire police force had broken in to our clinic and, following their noses, went straight into room eight. They attacked the food and the scent of blood made then even wilder. I quietly emerged from room seven and slammed the door to eight shut and locked it. After ten minutes the growling ceased. Miss James and I relaxed while we closed the clinic for the night and surveyed the damage. The front entrance was torn off its hinges, furniture upended and torn in the waiting room and there were bloody stains on the floor and walls.
A short time later the sun came up and we let the town’s police force out, gave them paper gowns to wear home as they sheepishly emerged wearing nothing but their badges and slight grins. As they left I presented the Chief with a bill for the damage done, the cost of a tank of Nitrous Oxide and use of the exam room for two and a half hours.
The day shift crew arrived thirty minutes later and Miss James I left together, went to PJ’s Diner for breakfast, both of us vowing never to work Night Clinic during a full moon again. At least not until next month.
Look for more episodes of “Night Clinic” in the weeks and months to come.
Saturday, December 15, 2012
I had a conversation with a Family Practice physician today, a man who is far closer to the end of his career than the beginning. He is part of a private practice group that recently was sold to one of the larger hospital groups in the area, which put him on a salary, but also allowed him to work only three days per week. He stated that the decrease in earnings was more than compensated by the better lifestyle and benefits he receives while being an employed physician.
He also commented on how their group practice has changed. There are several physician’s assistants and nurse practitioners within their group. They handle the acute problems: sore throats, URI’s, etc. He spends his time caring for his long term chronic patients, most of which are on multiple medications with multiple co-exisiting medical conditions. “They take more time,” he said, as a statement of fact, not a complaint.
“Managing such patients requires a knowledge of disease interaction that our physician’s assistants and nurse practitioners don’t understand.” His words, not mine.
I thought about this for a while and thought even more about my general surgery practice and the way medicine is practiced in all the hospitals I attend.
Look at the typical scenario: a patient comes to the ER, sent by a Primary Care physician who doesn’t admit to the hospital. The ER triage nurse sees the patient and orders a battery of tests, lab work and imaging studies and then reports to the ER Physician, who looks at all the tests, may go to see the patient briefly and then decides on that patient’s disposition.
A very ill patient will be admitted to the ICU, with hospitalist as attending, consultation with an intensivist and any other appropriate specialists and the patient is cared for by committee. Renal monitors the kidneys, GI does the inevitable endoscopies, surgeons go by and palpate the belly and order Abdominal CT Scans, Infectious Disease changes the antibiotics and orders lines changed and, in the middle of all this is a very ill patient and family trying to get some idea of what is going on. The answers come in dribs and drabs.
“The abdomen seems OK,” I’ll tell them, “The primary problem is pneumonia.”
“I think it’s a UTI,” Pulmonary states, “there may be s a touch of pneumonia, but I don’t think it is the primary source.”
“Kidneys are improving, BUN and Creatinine are lower,” Renal reports.
All the while the family sees Grandpa on a ventilator, multiple IV’s, five different continuous infusions blinking on and off, intermittent piggybacks and numbers flashing on monitors which may or may not represent good news. The family wonders: “Does anyone really know what’s going on?”
I wonder myself sometimes. But, through all this the patients usually get better, because of or in spite of the multitude of specialists. It is different for my patients that undergo surgery or have a specific condition that falls within my scope of practice. I usually know every detail about such patients, every lab and imaging result, the latest vital signs, urine output and overall physical condition. These ICU patients are usually seen twice a day and I always call in the evening to check on them. That’s just my paranoia and belief that surgical patients need the care of someone who truly understands their particular surgical disease.
This brings me back to the topic of this article. The inexorable rise of mediocrity in health care.
I have read several articles recently about the changes that are occurring in medical education.
“There’s too much medical science to learn; no individual can know everything.”
“We need to emphasize compassion and ethics in medical education, learning the science of medicine should be de-emphasized.”
“If a patient asks me a question, I usually excuse myself from the room, then look up the current literature on ‘Up to Date’ and then give them the ‘evidence based’ answer.”
If this is the way medicine is being practiced then why do we even have four year medical schools, or residencies? Just give a few basic courses in smart phone utilization and turn the student loose to diagnose and treat based on the latest evidence based practice.
There is an assumption in the practice of medicine, commonly made by insurance companies, government officials, hospital administrators and, probably, many practicing physicians. This assumption is that one doctor is as good as another. One GI doctor is the same as any other, all general surgeons are equal, or that every interventional radiologist is the as good as the next. Of course, being flawed human beings, this can’t be true. Those of us who care for the sickest patients know it isn’t true.
How do we know? The fruits of the labor give the answer. Infection rates, lengths of surgery, recovery times, complications all are indicators of an individual’s quality of care. From the choice of patients, to the timing and type of intervention, to the post operative management, each step requires thoughtful decisions and judgment. Our government strives to eliminate such judgment, reasoning that standardization of care, protocols and appropriate monitoring will lead to improved outcomes. If only humans were automobiles.
Years ago I cared for a mounted policeman, not mounted on a horse, his mode of transportation was a bicycle. I first saw him with rectal bleeding. He was hospitalized and an extensive workup revealed internal and external hemorrhoids which did not appear to be bleeding and had no manifestation of recent bleeding. Colonoscopy revealed nothing else. His bleeding stopped and he was discharged. About two months later he came to my office with a referral requesting a hemorrhoidectomy. He had experienced two more episodes of bleeding, had another colonoscopy and the only finding was hemorrhoids. He did have enlarged, symptomatic hemorrhoids so the surgery was performed. He recovered uneventfully and two months later had bleeding again. He came to see me and I referred him to a different GI specialist. Another colonoscopy revealed an AV malformation in the right colon which was cauterized and was the end of his recurrent LGI bleeding. Presumably, this abnormality had been missed on the previous colonoscopies.
Two vascular surgeons may operate on similar patients. Why does one have infections after almost every procedure while the other’s patients heal without any negative sequelae? How can one surgeon perform complicated surgery in 2 ½ hours and send the patient home in 4-5 days, while a second surgeon requires 8 hours for the same procedure and then sees their patient linger in the hospital for weeks?
Judgment, experience, innate talent all combine to create physicians who may be a cut above their peers. What is disturbing is that today’s training programs appear to be ignoring the fact that some physicians are not cut out to be surgeons, or interventional Radiologists or Cardiologists. They pass them through and send them into the world to flounder or worse. Surgeons such as these may struggle, rationalizing that it was a difficult patient and try to cover up bad results, but in the end it is the patient who suffers.
It is obvious to me that there is inherent variability between individuals, be they doctors, baseball players, musicians or ditch diggers. Most professions reward the skilled and talented individual. Top athletes, entertainers, even lawyers are rewarded. Yet the trend in the health care world is to establish strict guidelines and protocols that stifle the thoughtful, skilled practitioner while rewarding the individual who best “fits the mold.”
The truly sad thing is that such a physician has no incentive to tackle cases that may be complicated or time consuming or “interesting.”
“I’ll stick with gallbladders and hernias. And I don’t want to take ER call, those patients may be too ill and might mess up my profile. I’ll send the complicated cases to the Med Center, the gastric cases to the ‘foregut surgeon’, the colon cases to the ‘colo-rectal surgeon’ and don’t even begin to talk to me about trauma.”
Common words among general surgeons.
Today I received a note from Sheila reporting that she was free of disease on her recent PET Scan and thanking me for taking care of her. Sheila had come to me eight months ago with painless jaundice. She underwent a Whipple procedure, which is removal of the head of the pancreas, duodenum, portion of the bile duct and sometimes a part of the stomach,for pancreatic cancer and recovered uneventfully. She had travelled two hours to see me, because she had been unable to find anyone on her insurance plan that performed Whipples. She had, literally, picked my name out of her book. Admittedly, the Whipple procedure should be done by those with some experience. Have we reached the point in surgery where surgeons are not trained to do complex cases or are taught to refer such cases to tertiary care centers? But, what if the tertiary care center refuses? Such was the case recently. A patient was admitted to one of the hospitals where I work with painless jaundice and a mass in the pancreas, presumably cancer of the pancreas. She had been told by her Primary Care doctor to travel six hours to the world famous cancer center, which is just down the road from me. She, however, did not have insurance. She was turned away and showed up in the ER at my hospital and was admitted. She underwent a Whipple procedure and is recovering uneventfully at this moment.
I have similar experiences on regular basis, sometimes for conditions as simple as inguinal hernia or cholecystitis in patients who may have some sort of complicating condition. Maybe I’m setting myself up for a lawsuit. These patients, however, are often desperate and suffering after experiencing nothing but the run around from physicians and hospitals who don’t want to be bothered.
Where are all these ramblings leading? The physicians of today have given up their unique soul. To be a doctor use to mean to live a life of dedication to the medical arts and to the care of patients. The medical school selection process was highly competitive, the curriculum was intense and rigorous and those that were not up to certain standards fell away, sometimes in medical school, often in residency. The residency programs believed it was their duty to produce doctors of the highest quality, skilled, knowledgeable, ethical, and dedicated. Is this still true?
Saturday, December 1, 2012
Today I experienced another example of the growing efficiency of the healthcare world: The Steward of Scripts.
First, a little background information is necessary. After I perform surgery it is necessary to perform a number of immediate post operative duties. The operative note must be dictated, a brief note is written in the chart, post operative orders are written and, for patients that are going home the same day, prescriptions must be written. Such prescriptions almost always include pain medication, along with any other medications the patient may need for proper post surgical convalescence.
Typically, the surgeon will sit in the Post Anesthesia Care Unit (PACU), formerly known as the Recovery Room, and do the necessary paperwork and dictation. Years ago blank prescriptions would be readily available in an envelope in the area where we surgeons would sit to chart. A few years ago, an unknown entity in the hospital review stratosphere, most likely someone at an accreditation agency or state health department decided that prescriptions should not be left in the open to be seen or available to just anyone. A directive came from somewhere on high decreeing that prescriptions should be put away, out of sight, so that common lay people would not be tempted to take one and forge a prescription for themselves or someone else. I don’t think it was ever proven that such a problem truly existed, but it seemed like a good idea to a bureaucrat somewhere in the vast hierarchy of healthcare administration gods.
Prescriptions, therefore, were put away, usually in a cabinet, out of sight, but sometimes locked up with the narcotic medications. Thus, convenience was replaced by a relatively minor annoyance. When it came time to write the post op scripts, the surgeon had to go the cabinet to get a blank prescription, or bring his own or remember to pick one up on his or her way to the dictation room.
Today, however, saw the birth of a new process, a better process, a safer process, at least in the eyes of these unknown and unseen health care gods. Today, when I went to get my blank script, it was locked away in a safe with a combination lock. One of the PACU nurses had to leave her fresh post op patient, unlock the safe and hand me one blank prescription. She also wrote my name in their “Blank Prescription Logbook.” The time, date, my name and number of prescriptions bestowed upon me was recorded for all posterity, perhaps to be reviewed at a later date by the Blank Script Gestapo, an elite team of healthcare administrators, Quality Assurance nurses and DEA agents. Physicians falling out at the either end of the bell curve will be called in immediately for interrogation.
My first thought was that this is another idiotic rule designed to take doctors and nurses away from the task of actually attending to the patients under their care. Therefore, I made the following proposal:
The PACU should hire a nurse whose sole responsibility would be to guard the safe where the valuable scripts are kept and to dispense them to those physicians deemed worthy. Certainly such an important position deserves an equally lofty title: High Priestess of Prescriptions, Holy Guardian of the Pad. Such a vital post would warrant special attire, perhaps a leather tunic adorned with golden spikes, gold amulets, hair braided with triplicate prescriptions and combat boots, accompanied by two pit bull terrier guard dogs and fully armed with sidearm, sword and syringes filled with propofol. A bit extreme one might think, but the post of HPP/HGP is one that should not be treated lightly. The High Priestess should be fully equipped to handle any sort of assault on the holy scripts.
In addition an altar would be erected and offerings left to our sacred guardian. Donations to the Holy Order of Prescription Priestesses would be obligatory of any individual wishing to receive the favor of a script from the Holy One. And, should the hapless physician need to prescribe more than one medication, the necessary offering would, of necessity as these printed pads carry great value, increase exponentially. Monetary offerings, jewels or animal sacrifice would all be accepted.
Should this pilot program be successful, as demonstrated by the surgeons developing appropriate rise in blood pressure, pulse and frustration level, a protocol would then be developed and the program presented to the Department of Health and Human Services. The protocol, once fine tuned, could then be administered under the Affordable Care Act as “Meaningful Use”.
The cult of Priestesses would grow, the patient population would be protected from unscrupulous physicians purveying unnecessary prescriptions and the world would be a far safer place.
Thursday, November 22, 2012
Many of you reading this article are probably aware that I’ve recently released a new book, Minotaur Revisited. It’s a story which follows the Minotaur of Greek mythology through thousands of years of human history and lands him squarely in the middle of our modern world. What most of you probably don’t realize is that a novel with the same theme was released in 2000, The Minotaur Takes a Cigarette Break by Steven Sherril (Picador 2000). In this very different, but, in many ways, similar novel the Minotaur is alive and living in a trailer park in the South, working as a cook and spends much of his free time fixing old cars, while trying to cope with a modern world that barely tolerates an immortal half man half bull “monster.”
I stumbled across this book while reading the Wall Street Journal one Saturday. There was an article about an author’s favorite books about non-humans and the book by Mr. Sherril was listed first. I thought it an incredible coincidence that two very different authors could conceive of the same idea. Mr. Sherril is a poet, a true man of letters. I’m just a dumb surgeon with an overactive imagination.
I truly had never heard of The Minotaur Takes a Cigarette Break when I started writing my Minotaur story. I began by imagining what would have happened if the events of the Minotaur myth never occurred as reported. Rather, like so many things today, the truth was distorted by the protagonists for personal or political gain (Sorry about my cynicism, I get it from my mother). I made Theseus a scoundrel and allowed the “fierce” Minotaur to escape, and, what was supposed to be a short story, blossomed into a novel.
So, we have two Minotaurs, M. of The Minotaur Takes a Cigarette Break and Quint of Minotaur Revisited, each living for thousands of years, confounded by a world in which they don’t quite fit, yet, in the end being given the single thing that brings true happiness. The contrast is striking and the presentation is almost opposite, revealing much about the authors of each story.
M. speaks in short syllables, each word a struggle to form. His past is filled with rage and anger as he lived the mythical life of solitude in the Labyrinth; he truly was the monster of mythology. But, he is beaten down by years of living with humanity which doesn’t understand and barely accepts a beast that is so different from the norm. He lives in the midst of people who are everything from kind hearted to cruel, all the time doing his best to fit in, control the rage that is buried inside, yet desperate for love and true happiness. The story provides brief glimpses into his past, thousands of years, during which M. went from a feared monster, capable of devouring young maids and youths, to an anachronism, a curiosity left over from ancient times. He lives in a trailer park, works at Grub’s restaurant, pines for Kelly, and pays special attention to his unique grooming needs. His life is filled with fixing cars, carving prime rib, sewing his own clothes and trying to get by, knowing that his present mundane life will eventually end and he will be forced to start over. It’s the pattern he’s lived for five thousand years; centuries are like hours to him. All the while, however, he yearns for more. He has a deep longing for true love. And, while he waits, he suffers. Suffers the indignity of his monstrous body, the ridicule and derision of narrow minded humanity, while being grateful for those moments of kindness which fall his way.
Then there is Quint, who is first encountered as he addresses an overflowing auditorium at an unnamed university. He is well dressed, eloquent and sophisticated. His story is not about his present day struggles. Rather, he recounts his escape from the Labyrinth and the highlights of thousands of years spent wandering among some of the best and worst of humanity. He, too, was a feared monster, but only in name. He is truly a peace loving, gentle intellectual soul, one who is always on the lookout for the best of mankind, but finds himself repeatedly disappointed by those he encounters. Who does he meet? Pharaoh, Moses, Martin Luther, Picasso and many more cross his path and he leaves his mark upon all of them. But, he never seems to completely fit in and over his long life splits his time between humans, cows, and solitude, repeatedly returning to the Labyrinth, be it physical or psychological. Often his solitude is self imposed as he battles depression throughout his long life.
Finally, after his greatest period of suffering, he finds true love with the “wolf girl” whom he meets in a circus side show. Their time together is magical, but far too short. In the end, he tries to end the misery of immortality only to find, at last, acceptance by society. He is poised to take his place in this modern world. But, modern, mainstream society is not ready for him and the story ends on a note that can either be considered sad or hopeful, depending on the reader’s point of view.
What is the statement these two similar, yet very different stories make? Is the here and now of M. all that matters, or is the journey through life most important. M. faces our troubled world with an existential shrug of his massive shoulders, while Quint goes from complete solitude to total engagement with those that surround him and back to solitude. M. finds happiness after thousands of years of misery. Quint leads what should be a full and satisfying life, but only finds happiness during those moments when love fills his world and such moments are far too brief.
I would recommend that anyone interested read both stories and decide which is best. Or, are they really the same story told from two different perspectives?
Sunday, November 11, 2012
“You are required by law to get a flea shot,” the voice mail stated. I didn’t quite believe the message, so I listened again.
“You are required by law to get a flea shot.”
No doubt about it. The caller clearly said “flea,” not flu which is what I would have expected. I’d already been given my flu shot, almost tackled to the ground by one very insistent nurse at the hospital.
“It’s for your own good,” she screamed as she jabbed a twelve inch needle into my shoulder.
“It’s more effective with a bigger needle,” she cackled in a voice that I was sure came straight from Macbeth.
I’m positive she cut a notch into her stethoscope after she had satisfied her sadistic needs. But, back to the voice mail.
“You are required by law to get a flea shot.”
The caller ID revealed a number from one of the hospitals.
I wonder what she means. A flea shot could be a vaccine for me to prevent my becoming infested with fleas. Perhaps the nursing administration had heard about the growing number of canines occupying our house and become alarmed that I was about to become a carrier or become infested myself. But, I’ve never heard of a vaccine that prevented fleas. It would be a good idea, however. One shot and no more fleas, that is, a good idea for dogs. It would save me a fortune on “Frontline”. I, however, am not and never have been infested with fleas. Well, we did battle head lice years ago, brought home from school by one of my daughters, but there hasn’t been a louse around my house for fifteen years. (relatives don’t count) Lice and fleas are related, but I doubt a flea vaccine would have any effect on lice. But I digress.
Maybe I’m supposed to have some fleas injected into me. That would certainly be a way to become immune, a new take on live virus vaccination. I think I would politely refuse such an injection. Fleas are nasty little beasts, fully armored, almost impossible to crush, like other insects. The best way to dispose of a flea is to flush it away. No, I’m sure I don’t want any fleas burrowing away under my skin.
It could be the other way around; inject something into some fleas. It would take a very tiny needle. Even with a thirty gauge needle, I don’t think a flea would survive. And, there still would be the problem of getting through the flea’s armor. Why should anyone want to vaccinate fleas, anyway? From my perspective fleas have almost no redeeming social value. They infest our pets, get into our furniture, carry diseases and are, in general, total nuisances.
I’ve decided. I’m going to refuse the “flea” vaccine. It may mean I have to wear a mask when I come into contact with patients, I suppose it could even cause me to lose hospital privileges. What if the state gets involved, revoking my license for lack of proper vaccination. I could lose my livelihood. Maybe a certificate from my veterinarian would suffice. Maybe, I’ll just give in and get the vaccine. How bad can it be?
Saturday, October 20, 2012
“Will this case take very long?”
“If the surgery gods are with me we should be done in an hour”
The above brief exchange took place between me and the anesthesiologist attending to my patient on a recent surgery. The patient was a middle aged woman who was about to undergo surgery to relieve a small bowel obstruction. She had been visiting her husband in a distant city where he was working and had become ill. She was hospitalized and after several days of testing surgery was recommended. Her husband was reluctant for her to undergo a major operation in a city far away from home and their regular doctors.
He drove her home against medical advice and she was admitted to the hospital. I was called in as a consultant and it was clear she had a small bowel obstruction. Despite this obvious fact, she did not appear toxic. She had a mildly elevated white blood cell count, her vital signs were completely normal and her abdominal exam was unremarkable. Her medical history was most significant for multiple previous abdominal surgeries: Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy, Partial Colon Resection, Cholecystectomy, two Cesarean Sections, and Exploratory Laparotomy for a previous small bowel obstruction.
Thus, my reluctance to rush her into surgery. A day of watchful waiting would not harm her in the least, she’s already had eight days. The operation had the potential to be long and tedious, given her surgical history. She was as comfortable as coud be expected with a nasogastric tube decompressing her stomach. But, her obstruction persisted and surgery became necessary; thus my supplication to the surgery gods.
The operation commenced with a midline incisions. Upon opening the fascia and saw bowel adherent in this area.
Where are you gods of surgery.
The adhesions were gently lysed and I was able to enter the peritoneal cavity. I had managed to open the fascia at the only point where there were adhesions to the abdominal wall. The remainder of the abdominal wal was completely free and the incision was opened into the peritoneal cavity without further difficulty. The markedly dilated small bowel was delivered into the wound and followed distally to the point of obstruction. The adhesions in this area were divided and the obstruction was relieved. The bowel was inspected from its beginning at the ligament of Treitz all the way to the terminal ileum. It all looked healthy with no other adhesions and no holes. It was returned to its home in the peritoneal cavity and the fascia and skin closed without difficulty. Thirty minutes from start to finish cured the patient’s condition and started her on the road to recovery.
In this case the gods of surgery smiled upon me and my patient as the surgery was uncomplicated and the problem fixed with a minimum of fuss. This is not always the case, however. Small bowel obstruction is a common diagnosis. High grade obstructions that require surgery are most commonly caused by adhesions; scar tissue which arises in response to inflammation, most often after previous operations. Such adhesions may be only a single fibrous band that the bowel can wrap around or travel under or through causing a slight kink or a tight stricture or a complete obstruction.
Other times there are cases like the one presented. A few adhesions are present and the bowel manages to find a path that leads to blockage. Despite persistent attempts, the trapped bowel can’t break free and surgery becomes necessary. Often, the bowel finds a way to free itself, perhaps by breaking free from flimsy adhesions or figuring out a way to liberate itself from the entrapping web. The patient begins to feel better and surgery is avoided.
Then, there are the extreme cases; patients who have had multiple previous surgeries or previous severe intrabdominal infections. The bowels are glued together by a mass of adhesions that require painstaking dissection to carve out the many feet of bowel and find the point of obstruction. In such cases the surgery gods are definitely not smiling as the operation proceeds millimeter by millimeter, hours pass and adhesions seem to form as quickly as they are divided. Cursing the gods of surgery may make the surgeon feel a bit better, but often leads to enterotomies (holes in the bowel). Such difficult cases, when the gods are upset, call for post operative penance such as child sacrifice, self mortification or donation to the Obama campaign.
The surgery gods can be your best friend or your worst enemy. They can shine their face upon you and keep the common bile duct from sneaking away from its normal position to a vulnerable point directly behind or even lateral to the gallbladder, or, if angry, can command the ureter to adhere to the back wall of the colon, leaving it vulnerable to division by sloppy surgeons. These gods can be vindictive if not properly appeased.
And, if one chooses to ignore the gods of surgery, it is in one’s best interest to be fully knowledgeable of anatomy and pathology and how one can affect the other and vice versa. In the end, knowledge and experience will always trump these capricious gods, but it doesn’t hurt to try to appease them with a token sacrifice from time to time.
Sunday, October 14, 2012
You’ve spent much of your life alone, almost like you’ve been in solitary confinement, has this been difficult for you?
At first it was extremely hard. I was only twelve when I was first shut away in the Labyrinth. I may have appeared to be a fearsome monster to others, but I was just a scared kid, left alone with absolutely nothing. I thought I’d be dead before the week was out. My god, was I wrong.
Before I go any further discussing my life after the Labyrinth, I need to give you a little background. I was, technically, royalty, the son of Pasiphae, who was married to Minos, king of Crete, although I’m sure that Minos was not my real father. Pasiphae, my wonderful mother, did her best to protect me. What that means is she kept me from being thrown into the sea while taking it upon herself to educate me. In the beginning my life was confined to the palace, specifically, Pasiphae’s opulent quarters, which were like a prison for me. I didn’t venture outside her three rooms for the first ten years of my life.
But, you can’t keep a good bull down and shortly after my tenth birthday I was allowed to “play” with the other children in the palace. I’m not sure play is the right word, because no matter what I did or how I did it, I just didn’t fit in; those other children weren’t very friendly.
The first time I went into the courtyard the other boys squatted down and started to make mooing noises. At first I thought it was a game, but then they started to laugh and point and I just wanted to run away. I did my best not to cry, but I couldn’t bring myself to face them again and all I could do that first day was sit in the far corner by myself. In retrospect it was a glimpse into my future. Every once in a while one of those boys would run by, snort and paw the ground or put their fingers on either side of their head pretending to have horns. I thought that morning would never end.
Thankfully, it started to rain and the torture was cut short. My mother knew I was upset and I tried to tell her, but she started on about how wonderful it was that I could be like all the other children and how I was destined to be follow Minos and be the next King. I was next in line for the job of King, being the eldest living son of Minos’ many offspring. (There had been another older son, but he died shortly after birth). The fact that I wasn’t really his son shouldn’t have mattered. He never really acknowledged my illegitimacy. Anyway, I stiffened my upper lip and prepared for the next day with my “siblings”.
The following day was more of the same, only worse. There was more mooing and pawing and an occasional stone thrown my way. I went to “my” corner and sat by myself. Days, weeks and months went by without a change. I wore the grass down in my little corner while the boys and girls continued their bullying. I suppose this was my first taste of solitude, as well as giving me what I consider an accurate picture of humanity. Then things changed. Demetrius, the ring leader of my tormenters came up to me and offered to shake my hand. He apologised for their “immature” behavior and said that I could play with them the next day. I was filled with hope.
The following day things did seem to be better. None of the boys seemed to pay much attention to me at first. But, then they let me play in some of their games: the stone throw and the javelin. Even though I was only ten, I was pretty strong and I could throw both the javelin and the stone farther than any of them. But, those juvenile delinquents had more in mind than mere sport.
After the javelins and stones are tossed, it becomes the responsibility of the each participant to retrieve the apparatus for the next contestant. After I’d made my throws I dutifully went to gather up the three javelins and three sixteen pound stones. As I started back I looked up just in time to see javelins and stones flying through the air and headed straight for me. Of course, there wasn’t much I could do. I dropped my gear and prepared for what I thought was to be my end. I was frozen in place as stone and spear rained down around me, forming an almost perfect circle, but missing me completely. Needless to say I was more than a bit perturbed and I charged at the other boys, but mostly aimed for Demetrius.
He started to run as fast as he could, but I quickly caught up to him. He reached the wall at the end of the courtyard where he was trapped. I put my head down and gored him with my horn, right through his left thigh. Blood squirted out everywhere as he crumpled to the ground. My anger melted as I forgot his bullying, bent down and pressed my hand against the gaping wound, stemming the flow of blood and probably saving his leg. He eventually recovered, even though he had to walk with a cane for the rest of his life. I, however, earned a new, and as far as I’m concerned, undeserved, title: “Fearsome Beast.”
That was the end of my playing with other kids, I was kept isolated in the palace, more or less in prison and two years later I was shut away in “The Labyrinth”, a place I returned to, physically and mentally, over and over as my long life went on.
“The Labyrinth”; it was my true home off and on for the next several thousand years. When I was first locked away I did nothing for the longest time, just sat and sat, wallowing in a sea of self pity. I ate very little, drank only a little bit more, didn’t talk, didn’t howl at the moon or any other such nonsense. Mostly, I sat. An occasional tear welled up and ran down my cheek, but I still just sat. I think I was a bit of a disappointment to Minos who was using me for his political gains. He created the most dreadful lies about me: I was vicious and vindictive, devouring innocent children for my own perverse pleasures. He called me fearsome beast, using that poor boy’s playground injury to his utmost advantage. That, along with some fabricated “eyewitness” accounts of my brutality was all it took. A legend was born.
The fierce, vicious Minotaur, half man, half bull, one hundred per cent monstrous. In the beginning I was completely unaware of how I was being used. I was little more than a child and ignorant of the world and politics. Apparently there was a parade of “victims” that testified about how I’d attacked them, cutting off arms and legs and heads, consuming them to satisfy my voracious appetite for raw meat. Why, I would have been afraid of me, too, if any of it was the slightest bit true.
All the time these lies were being spread I was isolated in the Labyrinth. I planted a garden and began tending vineyards and olive trees in the heart of the Labyrinth, alone, depressed, at times almost suicidal.
Over the years I grew accustomed to solitude, but to a prepubescent half man half bull beast it was the worst form of torture. Only one thing kept me going. I believed that somewhere in this world there was something or someone that was truly good. Someone who wouldn’t care if I was a bull or a man or made of green cheese. I knew I wouldn’t spend my entire life locked away. I would find a way to make my escape and then I would find it or him or her. If you hear the story I have to tell or read my book, you will learn that, after thousands of years, I did find what I was looking for.
"Minotaur Revisited" e-book is now available on Amazon.com and Barnes and Noble online.