Goodbye Tuba City!

Just finished my family medicine rotation in Tuba City Arizona on the Navajo Rez . . . here’s some pics of the place and the peeps

Me, Mark, Dr. Guzman and Dr. Kandell

Me and Ernest – family med nurse extraordinaire

Me and Dr. G

Entrance to the hospital

Our good ole family med trailer

Family med clinic waiting room (at lunchtime)

Our last Friday Flea market (this is where we got the good roast mutton)

Gimme some mutton!

Last day at Dinebito (rural clinic 45 min outside of Tuba)

Couldn’t leave without a nice sandstorm to send us on our way

Me and Mabel

Me and Dr. Tang (lookit my hair!)

Allosaurus tracks in Tuba!

Raptor Ribs mmmmm

I guess I wasn’t the only one who thought that looked good . . . petrified dino dung

Goodbye Monument valley!

A stop in Arches National park (here’s Mark at window arch)

Delicate arch

Turret Rock – looks like a gun turret I guess

Intro to ED

Worked a shift with Dr. L tonight at Tuba City ED. Not too many really sick people but that didn’t mean it was any less educational. My first patient, a 66yo diabetic with a 101.5 degree fever, sore throat, cough and body aches was pretty cut and dried . . . or so I thought. Body aches, cough, no red throat and her age made it VERY unlikely that she had anything other than a viral upper respiratory infection. And our Dartmouth teaching tells us that 90% of the diagnosis is in the history NOT in expensive, unnecessary and ultimately resource wasting lab tests and imaging. Yet we did a rapid strep swab, ordered a chest xray, drew blood from both her arms, made her pee in a cup all to rule out a possible life-threatening sepsis which my history told me she DID not have in the first 30 seconds.

So apparently the thinking goes in Emergency Medicine that to be right about the diagnosis is NOT as important as to be paranoid about the worst case scenario. In fact, forming a “differential” diagnosis in EM is upside down. Its more about looking at the worst possible 3 diagnoses for a patient’s chief complaint, ruling them out with tests and history rather than to gather data and based on that data, come up with the mostly likely diagnoses.

Toward the end of my shift, I also saw an aggravated patient with seizure disorder who was screaming profanities at the medics and staff trying to undress her and draw labs from her. Meanwhile I listened as Dr. L tinkered with the police dispatch radio testing it to make sure it was working in case they needed to contact us.

I guess the question after all this is: do I really want to be up at 4am in the morning dealing with all this stuff? Even if I do get to work 3 days a week and be off at predictable times, have a life outside medicine, etc.

Lately I’ve been thinking about the question “if you take away all the money, prestige, what is it that you would be excited about doing every day?” Would it be staying up all night in an ED?
It should be an interesting summer.

Home visitin’

What an amazing experience it is traveling through the Navajo country with the visiting community health reps . . . I met some wonderful people, helped some, learned a ton about Navajo culture.

The first woman I met was a really lonely 87yo whose husband had died and all she had was her sheep and her prayer meetings to keep her company in her 10’X15′ shack about 10 miles from the 89 highway with probably double that distance between her and the next human being. She was all packed up and ready to move from this, her winter camp to her summer camp down the road. She mixed all her meds up (red, orange, white, yellow, square, round, diamond shaped) all into an old green family-sized motrin bottle because as she said “it was easier to take that way”. The medical student side of me wanted to lecture her about being more “compliant” with her meds, using a pillbox or something more “rational” to take her meds. But another voice told me to listen and try to understand her point of view and most of all not to do harm by confusing her further and ultimately getting nowhere by imposing my view of the world and the human body on hers. As I left her house, I swung by her sheep pen to visit with her family. It was a surreal moment to have about 3 dozen sheep stop what they were doing as I walked up and stare at me. It felt like stumbling into a party where no one knows who you are or what in the heck you’re doing there.

The second person I met was a 78yo guy whose only family for miles around were his six dogs. I’ll never forget pulling up to his one room hogan where he was sitting on his porch chillin while his dogs were curled up in the shade next to him. This elder was also fiercely independent. Despite having a hot frying pan burn a 3X4 patch of skin off his right leg, he was intent on NOT going to the hospital because “they won’t do anything for me”. In addition despite his diabetes and a blood sugar of 226 (nl is around 100), he was dead set on only taking his medications every other day because it made him “feel funny”. Nonetheless, it felt really good making my first medical decison BY MYSELF taking into consideration his vital signs, his wound, his diabetes, his upcoming health maintenance check and deciding not to take him to the hospital and instead putting a dressing on for comfort and instructing the patient to take his medications every day.

The last patient I saw today was a cute lil ole lady who lived with her son who complained that she kept getting gas in her belly after using a nebulizer for residual wheezing from a pneumonia she had a month ago. Although I did not do much more than read the instructions from her prescription label to take the albuterol ONLY AS NEEDED instead of every 4 hours as she was doing, it felt really good explaining the physiology of swallowing vs breathing and reassuring a patient who was motivated to be healthy but just didn’t have access to the right information.

I guess what this day made me realize is that one CAN make a difference one patient at a time and that it DOES feel good to help those who cannot help themselves. All it really takes is listening, staying open minded and caring. I recall Dan telling me one time that he would never practice medicine in this country. Maybe he’d change his mind if he met these three wonderful patients.

Good day in Family med!

I had a great day in family medicine today. Worked with Dr. K in Walk in who is one of the best preceptors I’ve worked with because a) she is patient, never rushes me b) is very observant and opportunistic about areas she can teach me c) lets me do as much as possible (in fact, I think she let me see and manage every one of my patients today by myself and didn’t even bother to come in and “check my work”. She also let me talk to a funny Navajo guy named Dodger who was a real character and extremely open. His father was actually a Code Talker in WWII and he is a vietnam vet who was called a gook by the other soldiers and had several near misses in Nam and even won a purple heart, which he says he doesn’t want because it just reminds him of “not ducking fast enough”. Then in the afternoon, I had a great time working with Dr. M in Peds clinic. Got to remove some sutures, meet a really cute 3yo whose grandma wanted her to see speech therapy because she couldn’t understand a word this girl said, watch a brave 5yr old get a toenail removed, make a 14yo girl with a cough laugh when I joked with her about basketball and talk to a 16yo skater who had sprained his ankle. Again, part of it was the preceptor who really let me do a whole lot including remove the sutures, counsel the kids, set up appts, write orders for medications, write orders for vaccines and agreed with my notes and diagnosis.

Maybe I feel good because its family medicine, I am pretty relaxed and well rested. Maybe I feel good because I ran 4 miles without stopping yesterday, maybe I’m getting more confident with my exam and diagnosis skills and that feels good, or maybe its the friendly people here who are responding to my greetings and jokes. I dunno what it is but I am feeling pretty good about being here right now and being in family medicine. Who knows, I just may work as a family doc for the Indian Health Service someday!

Stars aligning in OB

Wow, what a crazy day yesterday. I saw two caesarian sections, caught two babies, saw one bicornate uterus (a heart shaped uterus). Raquel was the last one who delivered around 8pm and the stars really aligned for her. She was a first time mom in her mid 20s with a history of bipolar disorder, had a painful fracture in her pelvis, was a half a pack a day smoker and had preeclampsia (a form of pregnancy associated hypertension where you get all swollen up, your blood pressure can get to dangerous levels and you can get seizures). On top of all this, her baby had two cords around its neck which we initially picked up because the babies heart rate got really low during her labor. Despite all of her physical risk factors, she was emotionally one of the strongest and most vivacious patients I’ve met and she had such an amazingly supportive family and OB team around her. Besides myself, Dr. H and Ella her nurse, her husband offered to drive through the rain and slush to get her “whatever meal she wanted” after delivery because the cafeteria food wasn’t good enough and her mother who was so supportive and encouraging, sitting all day with her to pick out a name and never once imposing her wishes on Raquel. The support and strength was apparent because even at the low point in the labor when Raquel was in a lot of pain, had a headache and couldn’t catch her breath, she pushed and pushed exactly as she was told. She was so good that she ended up delivering her baby in 45 minutes of pushing (most first time with epidurals moms women deliver in 3-4hrs). The baby came out with meconium stains all over (meconium is baby poop which is a sign of fetal distress), two loops of cord around her neck and looked a bit sluggish and needed to be actively resuscitated because she was not active or breathing on her own. She ultimately did great but not without a good 20 minutes of uncertainty.

Through it all was Dr. H, who was calm but firm and direct with the patient, telling her what she needed to know as well as constantly preparing for the worst whether it was a c section or a vacuum assisted delivery and when it came time, taking decisive action such as cutting an episiotomy and maintaining a high index of suspicion, realizing that when the head didn’t come through the episiotomy, something was holding up the baby. All this while walking me and the patient through what she was doing and in the process both reassuring and teaching all of us.

Afterwards, she let me write the delivery note, taught me about how to manage a baby with meconium staining, how to suspect a nuchal cord compression by looking at the recording of the baby’s heart, and how to get a patient through a difficult situation. After all of that, she introduced me to her favorite drink after a long night: a pink lady (ginger ale + cranberry juice) and as we sat together sipping, it occurred to me that I had just seen another miracle in medicine.

Team Noah

I have a friend and classmate who is fighting Burkitt’s lymphoma a rare but deadly cancer of the lymph nodes. We all got bracelets and donated as a class in Noah’s name to the Leukemia and Lymphoma society. Go Noah! Just wanted to share the website to anyone who might be interested in donating or reading about his story

http://teamnoah.info/bracelets.html

Suggestibility in medicine

My current OB Gyn attending Dr A is probably one of the best physicians I have ever worked with, knowledgeable, professional, efficient, caring, funny. He’s one of those people you see doing something you aspire to do that you wonder if you could ever live up to. However, I observed something very interesting today. Despite the best intentions, physicians are constrained by the rules of economics. The scenario was as follows:

A 50yo patient came in with a few months of perimenopausal bleeding and a family history of cervical cancer which was clearly her first priority. In the process of eliciting a more detailed history of present illness, my attending actually asked several questions about her urination, whether she wets herself, how frequent etc. He then proceeded to perform a physical exam and take a endometrial biopsy (which involves scraping the inside of the uterus for a sample to test for cancer). In his physical exam, he discovered that she had vaginal wall weakness and urethral prolapse (where one’s urethral ligaments are stretched or broken by prior childbirths and cause urinary incontinence). Despite her repeated questions about the biopsy, risk for cancer, etc, he kept redirecting the discussion toward a procedure called apogee/perigee/monarc which is a surgery to repair the walls of the vagina to prevent prolapse. What was interesting was to see my attending talk like a mechanic who examines your car for a routine maintenance and then tells you about the sale they are having on Michelin tires and how you really should think about changing your tires.

My attending was very up front about this saying that “my practice has been built around helping women with these problems” and “most women we do this procedure for say that it changed their lives” and “think about it, if you want I can have to talk to several of my patients who have had the procedure, they will attest to its success”. It was as if he was creating demand for a procedure to treat a symptom that was never the patient’s primary concern.

This brings up the question of suggestibility in medicine. Unlike the mechanic’s customers, most patients trust their physicians to be objective yet from a business model standpoint, physicians make their money similarly to mechanics and are subject to the same financial constraints. The line between mechanic and physician is very fine and easily traversed if one is not careful.

Reflecting on critical care

I was just reading an article in the New Yorker about Critical Care and found myself very excited by it. In fact, I would say that the experience of having a patient who I saw one month earlier with multiple organ failure wake up, talk and walk out of the hospital may be one of the most satisfying experiences I have ever had. Knowing that you saved someone’s life . . .

In fact, the prospect of working in the ICU really excites me most about medicine . . . unfortunately the training is another year.

stark reality

After “the interview” I talked to Dr. C about why he left his job as a therapist (presumably where he learned how to heal with words). He told me how emotion laden and energy consuming the work was, where every movement, every sound, action was scrutinized by both the therapist and the patient. So much so that he was exhausted and could work no more than 25hours a week actually seeing patients. And when managed care came along, he realized that the reimbursements would start to shrink and he would have to struggle to justify the time spent with patients so he left. He told me that he thinks if he were to go back to it now, he could only take patients who paid in cash and could justify charging $200 an hour which would result in about $250k a year but leave him very little energy for his art where he would rather focus his energy. Finally he told me that what I saw today, the time and opportunity for real “healing” in medicine no longer exists.

Emergency Medicine and Psychiatry

So unlike most of the people in medicine, I have developed insomnia. I think it really comes from the perpetual jet lag of being on call. On the other hand, you always get to do more stuff on call. As my psych resident tells me, the patient to paperwork time ratio is the highest on call (she happens to think this is advantage residencies where you take MORE not less call since you get to do more). For example, I got to see two patients last night. Both were depressed. The first, a gruff looking, burly 50yo gentleman who was crying and wringing his hands as we talked (kind of like a big ole teddy bear). He had developed depression and insomnia over the last few months and had some suicidal thoughts after losing both parents and having his son move away. I think he felt guilty because he cared for his mother who had a terminal illness and literally tried to kill her by illegally cranking up the morphine machine to double the rate. The second was a 16yo who slept with a 45yo for money and had been depressed and suicidal for several weeks. Both were pretty cool and I felt myself wanting to be the one helping them “explore their inner conflicts” especially the first guy. Somehow also hearing a story like that, of a guy who is usually not a whiner as he describes who had a very close family and is now dealing with two recent deaths and having trouble sleeping really struck an altruistic cord in me. I guess it must be my mom’s influence somehow countertransferred onto the patient.

Anyway, the other funny thing that happened while I was on call was I bumped into my resident Chatterjee who was running a trauma and really felt like I wanted to be doing it, doing the procedures, evaluating and diagnosing the patient. In short, it made me feel like I really wanted to be an ER doc. Plus the shift work and schedule sounds pretty sweet – 8hr shifts 3 X per week, 4 days off a week and once you leave the hospital THEY DON’T CALL YOU BACK.

I wonder if there is a psych ER residency out there?