One of my patients said something funny in the clinic. She has survived breast cancer. Five years ago, she had her left breast cut off, lymph nodes taken out, chemotherapy done, and she lived with the sword of Damocles over her head for five long years. When she came to see me, a glow was about her. She could barely contain her excitement that it was time for me to order a mammogram. I had never ordered a mammogram for her. Her oncologist had been dealing with mammograms this whole time.

She had graduated oncology, as if oncology was some sort of perverse high school where the hazing of freshmen involves surgery and chemo, and graduation is accomplished simply by being alive after five years. The dropout rate is so atrocious that if it truly was a school, it would've been shut down long ago.

Now it was time for her to be followed by her PCP once again for the routines of life. She had spent five years thinking that the cancer would come back, that her days were numbered. She didn't think that it would be five years. She did not think she would graduate. Now, her joie de vivre was renewed.

"Dr. IFinding, when was my last cholesterol level? Do I need one? Because I'll be damned if I'm going to survive breast cancer just to die from a heart attack." I love my patients so much sometimes.

By the way, I've been putting up flickr pictures to accompany my posts. If you want me to stop, let me know. I think the pics add a little character to the posts, but I can certainly understand if you think they're a detraction.

Positive muffin sign

In medical school, our cafeteria was terrible, but the patients had it much worse than us. Patient food was miserable, bland nastiness. However, there was one tidbit of salvation: the breakfast muffin. Every breakfast was powdered eggs and something resembling sausage, terrible coffee, and what I assume was oatmeal. But the joy of every morning was the blueberry muffin that came with breakfast. It was moist with a little crunch to the crust. The blueberries were rich in flavor.

And I slowly came to realize that one could determine the acuity of illness of any given patient based on the muffin. If it was entirely consumed, the patient was improving. If it was half eaten, then the patient might be stable, or may be declining. If the muffin was not eaten at all, then the patient was definitely declining. Even the dysphagic patients went to town on the muffins, knowing that it was pretty much the only thing worth aspirating.

The muffin was such a reliable estimation of patient wellbeing that I would actually ask patients about why they hadn't eaten their muffin. And in my mind, as we rounded on patients, I would tally up the muffins, and chuckle. My attending would say, "I think he's doing better!" but the patient didn't eat the muffin!

In an alternate universe

Going over this blog, I am surprised that I have not had any posts regarding probably the biggest choice in my life which I made sometime in high school, and that was simply: doctor or priest?

For those of you who may not know, in high school in the midst of my morose, teenage existence, I very seriously contemplated the Roman Catholic priesthood. In the end, I couldn't do it. I thought and thought and thought, but I decided against the priesthood. I just couldn't reconcile being alone for the rest of my life, without companionship or love or intimacy. It was too much of a void.

But fifteen years later, I have had all of two relationships, a number of dates that I can actually count, a complete absence of physical intimacy, and without a date in the last two years somewhat by choice. Now I question my teenage decision. I seriously wonder about such a strange choice, made with the presumption that I would probably be married by now, possibly with children. The plan was never that I would still be single.

I made that choice with the hope of love. I made it with the dream of finding another person to complement me, to share my life. I made that choice based on potentials and possibilities, and not about what I had or who I was. It was a decision of what was outside of me, outside of my control, and not anything to do with what was within me, except the intense desire to be loved.

And still, I have this intense, burning desire to be loved. It's not as much to love; it isn't reciprocal. I want to be loved, to be welcomed, to be held tightly. And honestly, I don't want to love someone as much. Still, I would love to love, to give my heart to someone, but I the idea that I am loved, that I am necessary, this is what has motivated my life.

My decisions and actions since this life changing, teenage choice, they have all boiled down to me being needed. My patients, I treat them with such compassion and earnestness because I seek their approval. I need them to see me as necessary, and to accept me. I am at heart a very selfish person. It is just that my selfishness is manifested by such altruism. It is like what Emerson said: "It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself."

Today, I find myself in such a quandary, because I find that decision in front of me again, and I'm not sure if I made the right choice. I don't know that I would choose the same path, knowing what I know now. It would be nice if I could look into an alternate universe and see what that other life would be like. Maybe I would find it to be the better choice, but I don't know that there is such a thing as better.

Part of what makes this choice not quite as disturbing these days was that when I was thinking about it more than a decade ago, it was with the knowledge that both choices were good ones, that I could live with either. I could never look upon a life as a doctor and say that it was a worthless endeavor. I couldn't see being a priest as a waste of time. It was a choice between two goods, not two evils.

Really, it's not about which choice was better, but which was right for me, because I didn't make that choice based on intrinsics but on what was extrinsic. If I think about who I am (or rather who I was) I'm not sure that I chose right. I'm still not sure, on the cusp of being an attending physician, if medicine was right for me.

I know that I have done good work. I have held the hands of the dying. I have comforted the sick. I have healed when I could, and done my best. I have without a doubt in my mind done good. If the scales of my life were to balance today, I would tip in the right direction.

I remember one of my patients was dying from florid sepsis, and the patient's sister refused to let the patient's boyfriend visit. She barred him from the ICU room. I sat her down in the nursing station and told her, "Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. You have the exceptional duty to carry out her wishes, so please, whatever you may think of this man, please think of what your sister would want." She relented and let him see her as we turned off the levophed and dopamine. They wept and hugged, and she thanked me, she THANKED me, the man who let her sister die. Because love always beats hate.

And I had one patient with severe mental retardation without any family, and I held her hand and sang to her happy birthday, as the nurses turned off the vent and let her expire from sepsis. There was no one there to celebrate that day but me and the nurses. And after exactly 64 years on this earth, I stopped her life and closed her eyes.

There is not a doubt in my mind when I meet my maker that my soul is defensible, that I have done good with my life, and that was never the question. Because everyone is capable of doing good. The question is what was right for me. Because it's not like being a man of God is not without its own benevolence.

I remember I was in the hospital one day, and I met my priest there, standing over the body of one of my patients, a very wonderful lady who blew a vessel in her brain and was now brain dead. My priest thanked me for helping the patient's family. I pronounced the patient dead and left. I have to admit though that I was envious of that priest, that his job was just beginning and mine was done. And I wonder if maybe I made the right choice.

Pharmacy girl, chapter 2

So, still reeling from my magnificent bit of cowardice with the pharmacy girl incident, I decided to take the initiative, and instead of spending a lazy afternoon in the coffee shops, I went to the hospital, with the explicit purpose of 'casually' running into pharmacy girl. Oh, I had other things to do as well, but nothing that I couldn't have done at any random time in the bowels of medical records.

So, after nonchalantly flitting from floor to floor, running into other residents, I was tired, and ready to go home. I went down to medical records, caught up on charts, went to the cafeteria, and stopped by the bathroom before heading home. And of course, OF COURSE, as I'm walking into the bathroom, I run into pharmacy girl.

A little casual chit chat, and then off we went - me to the bathroom and she to wherever she was going anyway. And now, I have been solidly kicking myself in the ass for the third straight hour. I went to the hospital for the EXPLICITLY STATED PURPOSE of running into pharmacy girl, and caught on my way out, eager to empty my bladder, of course that is when the stars aligned.

West Coast (who asked to be called Chocolate Thunder from now on...) and Surgery Girl both chided me for being a complete pussy. I anticipate that this remarkable piece of timidity will inspire further groans.

Better living through chemistry

Last week, I caught an upper respiratory infection, and thankfully, the worst of it was over the weekend, but I still had lingering symptoms for a few days while at work. It was for this reason that I initiated the Better Living Through Chemistry campaign of Winter 2006/2007. Normally, I don't like taking medications, and I will avoid them until it is entirely unavoidable. But I can't justify sneezing and dripping all over patients.

I started with ibuprofen 400mg bid while at work. On top of this, I used triproline/pseudoephedrine 2.5/60mg [trade name Actifed] for the first few days q6 hours while at work, giving myself a break while at home. However, my supply of Actifed ran out, and going to the store, I discovered that all the pseudoephedrine is now kept behind the counter. So, I switched to chlorpheniramine/phenylephrine 4/10mg again q6 hours while at work.

it took about 9 days for symptoms to resolve completely, and I feel fine now, but it's always interesting to go to the OTC aisle. I saw several people wandering the decongestants, looking at one, then pondering another. For all of you reading this, they're all the same! Choosing a decongestant has more to do with your own body's reaction to a specific chemical than anything the drug company can tote.

I was however alarmed to find out that phenylephrine is in my OTC med, the vasopressor that I run into people as a last resort, mainly because it is such a potent peripheral vasoconstrictor that I have induced limb ischemia.

Thank you, Target!

I have long decried the completely esoteric world of prescriptions. The written scripts themselves are in some bizarre language. Sig? bid? Disp? How nuts. But even worse than this is the crime that pharmacies have perpetrated upon their customers. At least when I write a script, it goes to a pharmacist who has a decent chance of deciphering the thing. Most prescription bottles are written out and dispensed in just as confusing a manner as the original slip.

I am a medical doctor for goodness sake. I spent a literal 30 minutes trying to decide if "Take twice daily" was two tabs daily or bid. I ended up looking it up in ePocrates and taking it how I thought I should take it. But seriously, even I have trouble.

So, imagine my surprise when I saw the new Target pharmacy bottles. The name of the medication is written in bold on the top. The instructions are in large print and clear. There is a color-coded band for each family member. The bottles have flat surfaces so you don't have to twist and turn the bottle to read the instructions.

The bottles were designed by Deborah Adler as part of a thesis project for the School of Visual Arts, and was quickly snapped up and patented by Target. She was inspired to do this by her grandmother, who accidentally took another family member's medications.

I tell all my patients to physically bring in their medications to visits, so when one of my patients brought these in, I was stunned. They were clear, intelligible, and my patient, who previously could only identify pills by, "oh, it's the little blue one" could now tell me which one was her Plavix and which was her Lasix.

Normally, I could give a rat's ass about where my patients fill their meds. I don't think that there is any difference from one pharmacy to the next, except who offers a deal or some such. However, I am now encouraging Target for my patients who have a hard time with meds, because I think this is the greatest innovation in prescription medication since the advent of child safety bottles.

Procedure guide

In medical school, I learned a bunch of rules for putting in any central venous catheter. I will admit, I've stolen these rules quite blatantly from a friend of mine. This is not a guide or 'How to' but are quite simply some rules that you must adhere to when doing a central line:

  1. The most important rule for putting in a line is to NEVER EVER LET GO OF THE GUIDEWIRE. If you fail to do this, then I will bring upon you a wrath so fierce that Satan himself will tremble. NEVER let go of the guidewire until it is entirely outside of the patient. But I need to get the dilator! DON'T LET GO! But I need to thread the catheter! DON'T LET GO! NEVER NEVER NEVER LET GO OF THE GUIDEWIRE.

  2. A central line is 90% preparation, 10% procedure. If you do everything you need to prepare, then the actual procedure part will be quite easy. That means consent, examine anatomy, get supplies, clean, prep, drape, the whole 9 yards. If you can't do the preparation, you have no business doing the procedure.

  3. The procedure itself involves a healthy dose of luck. I got the first 5 or 6 on my first try without any help. The site didn't matter: femoral, IJ, subclavian. I was the central line master. Then, I missed 3 in a row. Now, I'm back on the wagon and I've got my last 5 or so attempts, but if you can't get it, it's not because you suck. The stars didn't line up right. (and you may suck too, but hopefully it was the stars)

  4. If you're gonna do the procedure, you should do the admission and get the consent. Procedures are for the strong, not the lazy. Don't come to me wanting procedures but bitching about admissions, and don't you dare prep for a procedure, then tell me you didn't get consent.

  5. Like pitching, the follow through is as important as the wind up and the pitch. If you prepped for the procedure, did a fantastic job on it, but you popped the lung and never got an x-ray to check, you have actually fucked it up, despite doing everything up to and including the procedure correctly. Make sure you follow through.

  6. The last but the second most important rule about procedures is that it is done on a human being as part of their medical care. All the time, I see procedures being done without good reason, so that someone can get another procedure in. When I see this, I get steaming mad. It is your privilege to learn from your patients. They are not there for your amusement.

And there you have it. These are my rules for CVC insertion. You will note at no time do I actually tell you how to insert a CVC. That is because inserting a CVC has very little to do with the process of placing a central line.

EDIT 1/11/07 - What did I tell you about the guidewire?!? That thing poking out of his neck is a guidewire left in by a cardiologist after CVC insertion. It was in there for months. Thanks to NEJM for this one. Click on the image for the story.