Hot potato
There’s a certain kind of patient in the ICU who crashes early and hard, who comes in from the medical floor, nursing home, or community clinging to life by the frailest of threads, and who only through aggressive resuscitation is kept alive. These patients are so sick that there is no hope of meaningful recovery. They are doomed from the outset; critical care interventions have been initiated too late to have a chance of reversing the process already set in motion.
When you have one (or more) of these patients, and you are one of four residents rotating and trading call and code responsibilities, the patients represent a constant source of anxiety. If the family is understanding, and the patient is made Do Not Resuscitate for the inevitable cardiac arrest, the situation is defused. If not, passing the patient becomes a frenetic game of hot potato. As laboratory markers and vital signs tell you that the game is nearing an end, each pass of the code pager grows more desperate, as each resident frantically tries to temporize the patient just long enough so that the whistle doesn’t blow on his watch, so that his hands will not be the ones to futilely pump and crack that stiff chest.
Law number three
At first I thought it was one of those guerilla veins that vanishes into thin air as soon as you think that you have him. Alternatively, Dr. Heisenberg, looking down from above, was trying to teach me a lesson about the uncertainties of a vein’s location at any given time. No matter how many times I stuck, I could not find the rascal. I put two fingers over the artery and felt the pulse bounding strongly. A finger-breadth medial, the vein had to be there. Yet it wasn’t. Switching positions, I couldn’t feel the pulse with my left hand. Checking again, yes, it was there with the right. Wait a minute, this was bizarre. Was I losing feeling in my left hand? Could it have been peripheral neuropathy from undiagnosed diabetes? Had I damaged the ulnar nerve putting it to sleep too many times from lying on it in awkward positions? But it was 3 am; strange things happen at that hour. Better to worry about it in the morning. I felt again with my right hand: there was the pulse. Stick and stick. No luck. Actually, wherever I placed my two fingers, there I seemed to find that pulse. Maybe all of the extravasated blood from my poking had made a soup that was diffusing the conduction of the pulse waves. Then I noticed, the pulse on the monitor was faster than the pulse I was feeling. I checked my own pulse. There it was, mocking and traitorous. I had disobeyed the Fat Man’s law. Using my left hand from then on, I found the vein and placed the line.
Blog or blot
Well, the end is in sight -- it's time to begin searching for hospitalist positions for next year. Apparently, it's a doctor's market; the day after I registered an online profile with Locum Tenens, I was bombarded with phone calls from physician recruiters, and a week later I'm still receiving multiple phone calls daily. I'm currently brushing the dust off my resume, preparing it for the market, but I've realized that I have a bit of a dilemma on my hands. Namely, Foggy Bottom Lantern. Should I include it in my resume?
My blog is, after all, one of the most interesting and original things that I do, and outside of work, it is the project into which I invest the most time and energy. A few months ago, perhaps in a moment of daring after a particularly satisfying post, I tagged it on to my resume. Creator and author, I called myself, and listed it under Community and Extracurricular Service, figuring that several of my posts have been informational and possibly of service to the world online community. Now, though, that I'm actually distributing my resume to potential employers, I'm not sure that was such a good idea. At least in the medical community, I'm afraid, blogger is a title more associated with trouble than anything else.
Oddly, when I first started my blog, my hope was that if it became successful, it might be a boon to my program and to my university. That it might become some tidbit of trivia on program tours, that potential residency candidates might hear something like, "Our residents have a variety of interests and hobbies. . . one of them runs the blog Foggy Bottom Lantern, which maybe you've heard of. . ." I wanted to make my program director proud. I saw all of this potential upside and thought that if done carefully, the downside could be reasonably well controlled. Now, though, like everyone else in the medical blogging community, I'm just afraid.
I've kept Foggy Bottom Lantern professional, and I do believe that if a potential employer actually read my blog, his or her impression would be favorable. There's been some talk on the blogosphere of blogs eventually replacing
resumes. Simply listed, though, a blog raises concerns without having any power to overcome them. On a first and blind paper date, that's not what I want to do. Thus, Foggy Bottom Lantern is off of the resume for now. In a more open and sensible future world, perhaps it will reclaim its rightful place.
The ICD gap
We should be proud of ourselves as Americans. This past week, the Journal of the American Medical Association published
two papers showing that white males receive significantly higher numbers of ICD’s (implantable cardioverter-defibrillators) than black males or women. These are little machines that shock your heart if it goes into a deadly rhythm, often restoring a normal rhythm and in the process saving your life. Having one is like having a whole resuscitation team, electric paddles and all, tucked neatly inside your chest. That white men are receiving them disproportionately should bolster our faith that our free market health care system is working: it proves that if you have money, you can buy better healthcare. Granted, patient preferences may explain part of the ICD gap, and bona fide racial and sexual discrimination may also be occurring. When the devices cost $30,000 each, though, and the disease against which they protect (heart failure) affects many pre-Medicare age people, we can rest assured that financial restraints are playing a central role. That’s where we’ve done well; that’s precisely what makes this country so great. Here, the wealthy don’t have to stand in line with everybody else. If they did, you might as well be living in France or Sweden; we might as well just have adapted the socialist model. No, in the U.S., money still makes a difference, and the American Dream is still alive. We didn’t want to share our health care resources with the poor, and the JAMA studies show that under our current system, we don’t.
Medication reconciliation
Aspirin. . . zocor. . . clonidine? I don’t like that drug. It’s dangerous, shoots the blood pressure all over the place. A single missed dose and the BP can bounce up to 200 systolic. Besides, this guy doesn’t look like the kind of patient who is going to take every dose. Maybe I should stop it. Eh, this probably isn’t a good time. It’s not like he prescribed the medication for himself; a doctor wrote it for him because the doctor wanted him on it. Somebody who knows him a lot better than I do decided this is a good drug for him. This drug is hardly good for anybody, though. But why should I override his primary care doctor, who is the one who will be following him after this hospitalization anyway?
Ah, Mr Lamb is back, recently in the hospital. Let’s look at the discharge meds. . . aspirin. . . zocor. . . clonidine? Was thinking about pulling that one. Bad drug. The guy was on it when he first came in, never could figure out why, didn’t want to overhaul his meds on his first visit, though. Maybe I should stop it. But he was just in the hospital and they deliberately left him on it. Maybe they thought he needed it. Maybe they tried to wean him off of it and had trouble. They had him in-house, under observation, that would have been the perfect time. Better leave him on it for now. . .
