Thursday, November 30, 2006

Twenty dollars

These “hide the money” jokes came up during MICU rounds last week. As they were new to me and quite entertaining, I decided to run with the idea. Variations of the first five can be found all over the web, and I credit J. Tishon for a variation of the sixth. The rest are my own invention.

How do you hide twenty dollars from. . .

An orthopaedic surgeon?

Put it in a medical textbook.

A general surgeon?

Hide it in the chart.

A dermatologist?

You can’t hide money from a dermatologist.

A neurosurgeon?

Stick it to his child’s forehead.

A radiologist?

Give it to her patient.

A cardiologist?

Give it to his wife.

A plastic surgeon?

Hide it in any location with a winter climate colder than Florida.

A pathologist?

Place it anywhere above ground level.

An ob/gyn?

Just send it to her malpractice lawyer.

A malpractice lawyer?

You’re an idiot for even considering it.

An internist?

Hide it anywhere – an internist doesn’t have the foggiest about where to find money.

A resident?

Put it under her pillow.

An ER doc?

Put it in the medical history.

A medical student?

You evil, evil person – would you also steal money from a blind beggar on the street?

Feel free to add to the list!

Sunday, November 26, 2006

Simple tasks (at 04:30)

It sounds simple enough. Every night before the other residents arrive in the morning, it is the duty of one of the on-call residents to update the team census (a spreadsheet containing an enumeration of the team’s patients) with the new patients from call and to assign patients to residents for the coming day. Rules must be followed: the post-call residents (referred to as on-call above) are to take only their new admissions from the night before; the short-call residents should not be assigned patients as they will be called away from rounds to admit new ones; the pre-call residents when possible are given a reduced patient load to help them have an early day before their impending call; and the new on-call residents, who have no chance of escaping the hospital anyway, are to carry the brunt of the patient load. Usually the task of updating the census and assigning patients is performed in the wee hours of the morning, around 04:30, after all of the night’s admission (fingers crossed) have been tucked in. Compared to the other tasks that we perform as residents, this task is remarkably simple; it requires no analytical or deductive thought and demands little in the way of computation. Yet, as often as not the census contains mistakes – a resident gets assigned too many or too few patients, the wrong patient goes to the wrong resident, a patient somehow goes uncovered – any number of mishaps can occur.

You see, 04:30 is an hour inhabited naturally only by insomniacs, whose charged, restless minds mercilessly repel the sleep that their bodies so need and crave, and by new lovers, whose irrepressible affection for each other transcends the need for sleep, allowing them time to blissfully and tenderly dissect each other’s bodies in consummation of their nascent love. It is an hour proscribed from others, and to venture there uninvited is to struggle against the laws of God and nature. Like petting an animal against the grain of its hair, hyper-extending a joint, or building a sand monument on a windy shore, persisting in wakefulness to 04:30 is only to court disaster. The simplest task becomes painful and unbearable as the mind, weighed down by a thick coat of dullness, struggles to function. It enters a dream world, a state of half-wake and half-slumber where every suggestion contains hidden pitfalls and sustaining a thought becomes like trying to harbor a ship in port without anchor: unseen currents inevitably carry it toward a precipitous and calamitous end.

As residents we invade this no-man’s land every fourth night, intrepidly but vainly attempting to swath a path through the fog in order to care for a patient, or to finish our work. We are not, however, blessed with Herculean strength, and although we may rage against the taunting sirens that beckon us with sleep, our endurance is limited. Eventually, and insidiously, our minds becomes clouded enough that we can’t perform even the simplest of tasks without error. Yes, I want you to ask it, I demand that you ask it: what about the complex ones?

The luxury of being half asleep, Ian McEwan writes, is that it allows you to explore the fringes of psychosis in safety. Perhaps from the cozy confines of your Saturday morning bed, but how untrue, how devastatingly untrue at 04:30 in the uncomfortably bright lighting of the hospital ward.

Thursday, November 23, 2006

Medicine for our mothers

In tribute to Thanksgiving, I repost my first substantive posting, Medicine for our mothers, which I had taken down a few months ago because I thought it might interfere with a research project on the subject. I've decided there is no problem.


We hear it about once a week on wards, at times when particularly troubling or trying decisions arise regarding patient care. Usually, it’s the attending who poses the question, but it’s always spoken from a more senior to less senior team member, as it carries a subtle implication that the currently proposed plan may not be quite good enough: “If it were your mother, what would you do?” The effect that this question has upon the team is both striking and predictable. (It does rely on the assumption that the team members love their mothers, but would they really have become doctors if they didn’t?) Several moments of chin rubbing, head scratching and soul searching ensue, after which it is generally agreed to raise the level of care or renew efforts with yet another attempt at diagnosis or therapy. Occasionally the question instead spurs a move towards patient comfort or palliation. All involved are reassured that the patient is getting the best possible care because it is what they would have done for their own mothers.

The mother hypothetical is a ritual of medicine that I have participated in countless times, although I’ve never raised the question myself. Somewhere between my 4th year of medical school and internship its great irony struck me. As physicians we are forbidden from practicing medicine on our mothers for the very reason that when it comes to them, we are completely incapable of reason, rationality, or measured decision making. Yet with our most difficult decisions, at the times when we most should be relying upon reason to guide us, we instead emotively plea for guidance to the specters of our beloved mothers. Oddly enough, it usually helps. Still, I have to wonder, are we asking the right question? Does mother know best? Perhaps our decision making would be better if we instead pondered about Uncle Albert. Or, an even more novel concept, what if we just asked what was best for that patient?

Saturday, November 18, 2006

News you already know

Is it really such an annoying thing, to receive news that you already know? Granted, your thoughts may have been interrupted, your pager going off might have given you a mini-heart attack, and a few seconds of your time may just have been wasted without any appreciable gain, but somebody did just make an effort to tell you something they thought you might like to know. Even if the person was a complete moron, in all probability the disturbance was actually an attempt to make your life easier. Anyway, sometimes the point isn’t necessarily to inform you, but more to make sure that you are already informed. I’m not saying there’s no such thing as a stupid page or call, but I hate it when good faith is met with irritation. Why not just be courteous?

I find the way in which a person receives news that he already knows to be telling about his character. Is the person someone who always has to point it out when he already knows something? Does the person thank the informer but then later make a snide remark? Along the spectrum from graciousness to malignancy, where does the person fall?

Here are various responses that I have heard at one point or another as a medical student or resident.

1. (gracious) “Oh yes, I heard, it’s worsened, hasn’t it? I agree, he’s going to need a transfusion. . .thanks for calling.”

2. (pleasant) “Right, I just saw that. We’re thinking he’ll need a transfusion. . .”

3. (neutral) “Oh yeah, I actually commented about that in my note. We’re going to transfuse him.”

4. (annoyed) “I know that. I discussed in my note this morning. . .”

5. (uncalled for) “Yes, if you had read my note you would know that I already commented on that. . .”

6. (malignant) “Look, don’t waste my time. Go read my note from this morning and you’ll be able to see what I thought about that.”

Aren’t nice people just so much more pleasant to work with?

Wednesday, November 15, 2006

On the television

Most of the time the television in a patient’s room is more of an annoyance than an item of interest. On continuously, it is usually cranked up to some absurd volume where communication with the patient becomes difficult and auscultation for cardiac murmurs and other subtle sounds becomes nearly impossible. (Say what? Your nurse just gave you a spanking? Oh, pardon me, you said your nurse is bringing you a blanket!) I usually try to turn the thing off when I can get away with it, but for some reason many nurses and family members seem to view the television as comforting to their non-awake patients or kin, leaving it on 24/7. Awake patients do need the television to ward off boredom, that I understand, but it so ends up that nine out of ten occupied rooms in your average hospital will at any time have their T.V.’s brightly lit up, hour after hour drowning ear drums and burning retinas.

Where the television can really become a problem, though, is when there is an item of intense interest to the medical team on the T.V. Instead of paying attention to the patient, team members will steal glances up at the screen, straining their peripheral vision in an effort to discreetly absorb as much information as possible. I can recall several times over the past few years seeing patients while being more interested in their televisions than in the patients themselves. I can’t say I felt great about it, but let’s be honest – it has to be a pretty good story of chest pain to match the excitement of catching a glimpse of the World Cup final. I was only a first year medical student on 9/11, but I imagine that hospital rounds on that day must have been excruciatingly painful. The medical staff, starved for images and information, would have wanted nothing more than to sit down together with their patients and to fix their eyes upon the flashing television screens.

The lesson for patients, I suppose, is that if they want to command as much of their physicians’ attentions as possible, they should turn the T.V. off and keep distractions in their room to a minimum. We do care, we’re just a distractible bunch. Besides, it goes both ways – it’s not an uncommon patient who’s more interested in what’s on the television than in what his docs have to say. (“Sir, I’ve been asked to see you because your kidneys aren’t working.” “That’s nice, but I don’t care.”) A few minutes sans T.V. for some sound medical advice – that’s not such a bad bargain. What’s more, we’ll actually be able to hear your heart sounds.

Wednesday, November 08, 2006

Electoral musings

Although this is not a political blog, I figure that election night in DC deserves some sort of commentary. In the past, medicine and the country’s electoral process have had an uneasy relationship. In 2004, we heard about election workers visiting nursing homes and helping demented patients to absentee vote. As illustrated by that case, much of the tension between medicine and our electoral process seems to concern the voting rights of people whose diseases hinder their ability to vote intelligently. As doctors we declare patients incompetent to make medical decisions, but what about making political decisions? Should you have to be able to communicate, for example, the country in which you live, in order to receive the right to vote? It would be an interesting study to find out at what level of orientation people forget their political party affiliations. Is it before or after you forget how old you are? Before or after you forget your spouse’s name? These are uncomfortable questions, but we’re one of the oldest democratic countries in the world, and we teach other countries how to hold free and fair elections. Shouldn’t we have some answers?

My personal concern is that some election night I’m going to be stuck in the hospital on a 30 hour call shift, not having had the chance to vote. I wonder how many hospitals provide absentee ballots for their residents and patients. I sense a possible political scheme here – politically savvy chief residents arranging call schedules to disenfranchise residents of the opposite political persuasion. The West Wing meets Grey’s Anatomy?

Sunday, November 05, 2006

Apologizing is easier (than asking for permission)

The GI fellow I’ve been working with this month recently was telling me about her daily interactions with a particularly grumpy middle-aged patient on our service. When I say grumpy, I mean the kind of guy who responds to a cheerful “Good morning, sir,” crossly with “what do you want?” – and that’s if you’re lucky enough to find him, because most of the time he’s out in the hospital courtyard puffing on cigarette after cigarette. In any case, my fellow confessed that every morning as she would examine and press upon his hip, the maneuver would incite shouts, invectives, and in all honesty a substantial amount of real pain. She would then quickly apologize.
“Why do you do that, when you know it’s going to hurt him?” I asked bemusedly.
“Well, I keep forgetting that he’s tender there.”
“And he keeps letting you examine him day after day, despite this profound agony?”
“Yeah, well, he keeps forgetting too. His memory is pretty bad you know—he still doesn’t even know who I am.”

No wonder the guy’s always pissed off.

You see, as physicians, we’re horrible at asking for permission. Sure, we obtain the required written informed consent before administering blood, performing spinal taps, dialysis, and other major procedures, but when it comes to medications, lab draws, iv lines, and just plain old physical examination, we have a tendency to shoot first and answer questions later. After all, when you only have a couple of hours to run through your census of 20 patients, stopping to ask, “may I now press upon your hip?” is going to be at the bottom of your list of priorities—it’s not that big of a deal (hopefully), and you really don’t have time for negotiations. Granted, it would be nice to have the patient’s permission, and maybe to give him some warning that a little bit of hurt is coming his way, but in the grand scheme of things, it’s just more practical to commit the offense and then to apologize. It’s an imperfect system, and we are bound by the multiple conflicting demands of our work. Hopefully our patients understand that; in fact, we rely on their forgiveness for a lot of the little things we do. In return, I suppose we can cut a guy a little bit of slack when he doesn’t greet us in the morning with a cheerful, “Good morning Doc, it’s good to see you!”

Wednesday, November 01, 2006

A curious encounter

After finishing a long workday at the hospital last week, I was trekking through its long corridors on my way out to the parking lot when a rather peculiar experience befell me. Just as I had turned a corner and was heading down a particularly dimly lit green hallway, I felt an icy draft on my neck. Startled, I spun around to look behind me, only to see an empty hallway. Slowly I turned back around, but in doing so I bumped right into a quickly moving dark-clad figure.
“Whoa!” I said, falling back a step, and gaining a chance to size up this new obstacle in my path. Before me stood a tall, slender, pale-white man in his forties, impeccably groomed with slicked back hair and a black and red cape covering an all-black outfit. He was fumbling with a red handkerchief.
“A bit early for Halloween, isn’t it?” I asked.
“Atchoo!!!” was the only reply, and he raised the handkerchief to wipe his nose.
“Bless you,” I said, moving to walk around him and continue on my way. Before I could take two steps, though, I felt a cold hand on my shoulder, deceptively strong and firmly preventing my progress.
“Excu-use me, doctor-r?” he intoned in a thick foreign accent that I couldn’t quite place.
I nodded.
“For-r-give my intr-r-usion, but I am si-ick and need help. I seem to have caught something dr-r-eadful out in ze cold.”
I looked at him blankly.
“I’m sor-r-r-y, please allow me to intr-r-oduce myself. I am Count Dr-r-acula.”

My first urge was to point out the sign to the psych ward, but as I was in a relatively good mood, I instead decided to play along with him.
“Dracula? Don’t you live in Eastern Europe or something?”
“Y-es, that is tr-r-ue. But my friend ze Fr-r-ankenstein monster-r –- he invite me for-r a par-r-ty in ze White House. You know it? It’s called ze Monster Mash. It is always a gr-r-aveyard smash.”
“Nice! Frankenstein throwing a monster mash in the White House?! Why does that not surprise me?”
“Y-ess, well, next week, on Halloween. As you point out, I am ear-r-ly. I come for sight seeing. This Washington, what a s-splendid city.”
“Oh yeah, the sights are great. I take it you’ve been to the different monuments and museums?”
“N-no, no. No time for-r such nonsense. I visit ze Arlington cemetery, and ze unknown soldier – actually, we invite him to ze par-r-ty, but I think he don’t come. He says he must s-stand watch. And ze staircase vere my friend from ze Exorcist had so much fun. You know zis s-staircase? Ver-r-y inter-r-esting. Las-st night, I visit a place, Madam’s Or-r-gan. Mz. Or-r-gan, she under-r-stand ze car-r-nal pleasur-r-es in life. I enjoyed zis ver-r-y much. Except I have a ver-r-y nas-sty cough. So I come to you. How can you help me?”
I go through a quick history and perform a cursory exam – it turns out that our friend, in addition to his cough, has swollen tender cervical lymph nodes and white spots on his tonsils. Oddly, he feels unnaturally cool to the touch.
“Well, Mr. Dracula, I’m afraid you have a case of strep throat, in addition to a touch of bronchitis. You need a course of antibiotics.”
“Penic-cillin? I know zis medic-cine, it iz ver-r-y popular in my countr-r-y. In fact, I know wher-r-e I can find some. My fr-r-iend R-r-ush, he has a ver-r-y lar-r-ge medicine supply. He will give me.”
“That’s nice, but why don’t we get you your medicine here? Come with me, I’ll show you where.”
I start leading him down the hall towards the psych unit. As the unit clerk comes into sight I wave.
“We’ve got one of yours down here!” I call out.
She waves back.
“These nice people will take care of you,” I say. “Just head down to the lady at the desk.”
“Doctor-r your-r assis-stance is-s gr-r-eatly appr-r-eciated.” He bows formally.
“No problem. I suppose if treating the undead bothered me, I wouldn’t be doing my residency in DC.”
I start heading back out to the parking lot, but before I turn the next corner, I can’t help but take a peek back over my shoulder. The psych unit clerk is still at the end of the hall, but Mr. Dracula is nowhere to be seen.
“Where’d he go?” I call out.
She shrugs.
"Crazy patient," I mutter. Shaking my head, I continue towards the exit.