Thanks

Sometimes, it's hard to say thank you. But I've got a lot to be thankful for. I've got a great job. I'm doing well financially. My life has achieved a good measure of stability. However, stable doesn't always equal good. One attending quipped to me as an intern, "All vitals stabilize and all bleeding stops... eventually." (For those of you not medically inclined, bleeding eventually stops when you've bled to death, and similarly, vital signs like pulse and blood pressure eventually stabilize at zero)

My life has reached a measure of boredom and stagnation that is difficult to stomach, even for myself. I've become completely still. I have nothing in my life to enjoy or anticipate. I am, in a word, bored.

And I think about what I want, and I just don't know. Should I be thankful that I'm not going through all the heartache I've lived through before, and that I've found a place of emotional stability, or should I be totally dissatisfied that there is no joy in my life?

The answer, as usual, is in between. I am thankful that I have a good job and a life that is calm and peaceful. And I am sad that I am so dissatisfied with it.

Positive teddy bear sign

If you don't believe me, do a Pub Med search. There is something called a teddy bear sign. It is positive when a patient is found to have a teddy bear at bedside or in bed with them. It usually indicates that the patient is regressing to childhood and also has a high likelihood of non-organic disease. Of course, this only applies to adults. I don't think anyone would fault a six year old for finding comfort in stuffed animals.

However, the teddy bear isn't the only signal that your patient is going to be trouble. Here are some signs that I know of, some of which I've read about, others are my own creation.

Parents Sign is when someone over the age of 40 is found to have their parents at bedside. Always bad news and along with the teddy bear sign often represents mental and emotional regression.

Scrubs sign is when a patient in the hospital is dressed in scrubs, a sure signal that they've spent so much time in the hospital that they start requesting clothing instead of the gowns.

Retrobulbar micturalgia is a screening question used for patients with a 'positive review of systems' syndrome. You ask, "Does it hurt behind your eyes when you pee?" and if the answer is yes, your diagnosis is confirmed.

Radiology sign is when a radiologists marks an x-ray so that even an idiot internist can interpret it.

The radiographic criteria for fibromyalgia are (1) at least 2 MRI scans of spine (count each spine segment, so a CTL scan counts as three), (2) carrying the MRI films and/or reports to initial visit, (3) need for Xanax or Ativan (by name) prior to MRI and CT scans, (4) symptoms in distribution contralateral to radiographic findings. Criteria are met if 2 of 4 findings are present.

Can you think of any others? Most of these are pretty cynical and jaded, but I have to admit are good for a chuckle.

Here's to your health

There are a lot of opinions about how to improve health care in America, and I won't go into my own partisan views, but one thing is worth mentioning. All the discussion about national health care ignores a very basic fact about being healthy in the US: improving access to health care doesn't actually improve health. It helps with secondary and tertiary prevention (finding disease and preventing complications from those diseases), but it doesn't do anything to prevent those diseases from developing.

Nobody wants to deal with the roots of health disparities, but the ugly truth is that poor people are less healthy than the wealthy. The poor don't eat fresh vegetables or whole grains, don't work their dream jobs, don't live in gated communities, don't run for fun, don't shop at Whole Foods, don't know about trans fats. The poor simply do not have the means to be as healthy as the rich. The poor have less control over their financial future, their living situation, even their own personal safety. All morality aside, the poorer you are, the worse your health.

Having universal health care won't fix that. Improved access and more doctors won't fix that. Changing the Medicare and Medicaid pay structures won't fix that. If being poor is the primary constituent to the dramatic health disparities in the US, then the only fix is to change what it means to be poor and rich. Now, if that sounds alarmingly Communist, that's because it is.

I would argue that Capitalism creates health disparities by creating social inequality, and as such, is intimately tied to how we define ourselves as a nation. Thus, it becomes a fundamental question of identity to ask if we are willing to accept this. Because the alternative is to be socialist.

It gets easier... right?

I had the chance to talk to a budding medical student last week, and it's strange to see the medical student perspective again. When I was going to medical school, I had a very self-centered experience. That is to say, I did not notice a lot of what was going on around me because I was so focused on what I needed and wanted.

Now that I'm done with the medical education process, I find I have remarkably little sympathy for the plight of the medical student. Everything seemed so dramatic at the time, but the thing about medical education is that every subsequent year is worse. MS2 is worse than MS1. MS3 is worse than MS2. MS4, while easier from the education side, is far worse with interviews and rank lists and the Match. PGY1 is pure hell. Subsequent PGY's are painful for new and horrible reasons. Being an attending is a whole new basket of terrible issues.

So it's hard to be sympathetic when medical students complain about med school. It's like complaining to a major league baseball player that a 70 MPH fastball is hard to hit. Yes, it is, but if you want to go forward, it doesn't get any easier. In fact, it only gets worse.

Caution if hepatic impairment

I was editing and reposting old entries from the old server, and ran across a post that reminded me of something I'd tried to forget. I had a patient in the ICU, barely holding on to life, with diffusely metastatic cancer, suffering not only from all the complications of the cancer, but all the side effects of the chemotherapy, with cardiomyopathy, neutropenia, anemia, and a host of other terrible side effects.

Even with inotropes [drugs that make the heart beat stronger] and pressors [drugs to increase blood pressure], her systolic pressure was a laughable 60 mmHg. She was having end organ ischemia, and her liver was failing. Her AST and ALT were in the 1000-1500 range. Her renal function was non-existent.

And as a result, we stopped all meds that were toxic to the kidneys and liver. That included her prozac. And every morning that she was conscious, she begged me for her prozac, and I had to tell her that her liver couldn't take it. Her organs weren't working. But she would beg me to give it to her.

Eventually, my attending started the prozac again, despite the miserable state of her liver. 'Ifinding, why not give her the prozac? With everything else going wrong, why not let her have this?' And I felt real guilt. I had been trying to protect this patient from the possible toxic buildup of the drug, but I had taken away the only thing that had made her life bearable. I was worse than the chemo.

And I learned then that the compassionate choice is not always the most medically appropriate, but far easier on the soul.