Thursday, May 17, 2007
Wednesday, May 16, 2007
In rural Cascade, Idaho, you really get to see it all in a day, from the bedside to the riverside. This morning, Dr. Bedell and I were called in emergently before dawn to evaluate a patient for acute coronary syndrome-like chest pain. While this would not be something that unusual for a Cardiologist or Emergency medicine physician to see on the daily, any emergency room visit in Cascade brings excitment to an otherwise slow-moving country hospital. The beauty of family medicine lies in the breadth and diversity of patient encounters, leaving you to guess what you will see next. In a rural community hospital, where a "mass casualty" alert can potentially go into effect spontaneously given the dearth of local health care providers, we are always kept on alert, and forced to think quickly and act efficiently. Fortunately for the patient, normal EKG rhythm strips and non-elevated cardiac enzymes proved to be reassuring, allowing us to send her swiftly on her way, with a scheduled followup at the clinic in one week.
By sunrise, I was making post-partum rounds on recently laboring mothers, doing the typical stuff Ob/Gyns do, like assessing fundal heights and asking mothers if their bleeding has subsided, and if they've passed gas or had a BM yet. Switching gears between the different disciplines can be daunting, forcing me to focus hard on what I am actually assessing so as not to forget any pertinent questions to ask, or god forbid, to appear confused and stupid. After completing my postpartum check-ups, I transitioned from evaluating mothers to their products of conception, spending the rest of my mid-morning performing newborn exams on one day old infants. Transitioning into the role of a Pediatrician, I again, had to take on an entirely different approach, forced to abandon my practiced questioning skills for purely observational ones. While the little ones do not speak yet, they sure know how to kick, squirm, and cry, all signs of rebellion directed against the precipitous change from the warmly bouyant and nurturing environment of mother's womb to the cool and dry, mountainous environment of central Idaho. All of this change made more intense and less bearable by the cold steel rim of the sthethescope I have placed directly on their bare little chests.
By noontime, I was already at home, not just for a quick lunch, but to help Dr. Bedell inflate, load up, and strap down a 14 feet long raft to the platform of a trailer for shuttling down to the riverside. By 1 pm, we were thundering down the Cabarton stretch North fork of the Payette River, navigating through sets of rapids known to the locals as "Cocaine," and "Howard's plunge." I sat in the front of the raft, sipping on beers, soaking in all the warm sunny rays and the ice cold river water, reaping everything I could from life, not one bit envious of where my peers may be on an early Wednesday afternoon in the middle of May.
Sunday, May 13, 2007
A view from the tent. Taking a break from my Family Medicine book to scope out the scenery and Dr. Bedell.
Wednesday, May 9, 2007
Tuesday, May 8, 2007
Practicing primary care medicine in a rural community can be challenging, as the availability of resources for referal and access to high tech diagnostic tests and acute emergency care can be severely limiting. Sometimes, just getting the basic utility needs can present as a challenge. Dr. Bedell, the family doc I'm working with, performs scheduled upper GI endoscopies and colonoscopys every Thursday morning. As one of the only physicians in town, he pretty much does it all, just shy of major surgery. Last week, during the middle of his colonoscopy procedure, the power suddenly goes out through the entire hospital/clinic, leaving us to stand there in the silent dark, staring at a blank tv screen, holding what remained left of the four feet long black tube inserted 3/4 of the way up this dudes ass. I could only chuckle inwardly, meanwhile pondering the irony and likelihood ratio of something like this happening. I followed the lead of the attending physician and maintained my cool composure. Luckily for the patient, we were able to locate an alternative power source with the aid of an extension cord, thereby allowing us to finish the procedure and safely withdrawing the endoscope. And fortunately for us, the guy was not the least bit aware of our electrical malfunction, as he snoozed deeply through what was supposedly only a small dose of "conscious sedation." Now thats what I call rural medicine.
Sunday, April 29, 2007
Life is quaint out here with lots of pretty country to see. I have found the local folk here to be surprisingly warm and welcoming, always friendly enough to wave as they pass by with a smile. It is a town shared by the blue collar working class loggers and construction crew, as well as the upper middle class elite, who enjoy their nice lakefront summer mountain homes. It is a town enjoyed equally by the elderly and the adventurously young, for no one can deny the beauty and serenity of this place. I recently met this old lady, who says that she has spent some signifiant amount of time in every contiguous United state, but had chosen to take up permanent residence here.
You can find almost one of everything in town, but rarely will you find more. There is one movie theatre at the center of town which plays a different movie each week. There is one coffee shop in town which serves up one cup of Daily Special each morning. There is one grocery/general store in town, which shares the same parking lot with the town hall and clerical buildings. There is a Main Street downtown strip, which spans the lengh of one town block. There is a Cascade public school, which has a shared attendence by students of K thru 12. There is one local gas station, utilized by country folk who drive trucks or tractors, as well as those who prefer to ride four-wheelers, fishing boats, or camping RVs. There is one main paved concrete road, which connects to all the others dirt and gravel paths. There are no stop lights, for there are no rush hours and traffic jams, only stop signs. And for better or worse, there is no McDonalds here. No Wal-mart, and no BurgerKing. There is a medical clinic at the edge of town, which offers both outpatient and emergency care services under one roof. There is one medical doctor on daytime duty, and two doctors who take turns receiving overnight calls. And there is one third year medical student there who finds himself far away from home, displaced from his usual routine, new to his surroundings, unfamiliar to his patients, but enjoying the change of pace, the change of scenery, and the change of lifestyle.
Friday, April 27, 2007
Some people get stressed out with the idea of traveling. After all, there are the bags to pack, the flights to catch, and if you are someone like me, there is the money to spend on food along the way, inevitably. For others, it may be the endless moments spent in waiting that draws out the day, the ennui becoming progressively too much to bear. There is of course the terminal side waiting prior to boarding, where it always strikes me as odd that special privileges still exist for different boarding classes in this day in age. I can only justifiably understand the reasoning for mothers traveling with the little ones. But eventually we all board, even those in boarding class C. But there is more waiting. First, an anxious anticipation of take-off drawn out impossibly long by the slow runway taxi-ing. Not to mention the eternal thumb-twiddling sitting and waiting on the actual plane flight, which of course includes wondering when the flight attendant is going to come around with the cart to offer you honey-roasted peanuts and a drink of choice. Furthermore, there is also the eager anticipation of touchdown landing prolonged by the half-hour long final approach. And then the painstaking wait to deplane tag-teamed by more waiting at the mercy of the slowly snaking baggage carousel, both brutal reminders of the constant, unrelenting tick of time. Unchanging irregardless of your status of arrival.
But amidst all the time I've had to spend waiting, presently slouched in one of those sleek looking, but deceivingly uncomfortable, interconnected airport chairs, I have found an activity out of observing human behavior and interaction, or more simply called, people watching. The sixty something year old woman sitting across from me is reading the latest popular fiction bestseller, apparently too enthralled by the plot to notice the fledgling mother disciplining her son in the adjacent seat to her right, or to care to eavesdrop in the conversation of the man in the black suit who is broadcasting details of business carelessly to the crowd because of Bluetooth, or to notice that I have made myself privy to it all. In these moments, it always humbles me to think that there are so many people in this world, each going about his or her own separate way, each living one unique, unwritten life, just coming and going, to and fro, doing their own thing by living a life thats never been lived before. And how I have gotten so caught up in my own life to care or notice that all of these people I'm currently staring at now all are important players in their own play of life. Each one a lead actor, a protagonist with a different plot to play, different conflicts to face, and different places to go, be it happy or not. And I am lucky to be watching just one scene play out before my eyes. Alright, thats enough sitting. Enough waiting. Enough thinking for now. I think its time to knock back a couple brews at the nearest airport lounge.
Saturday, April 14, 2007
For the first of my two weeks of respite following inpatient pediatrics, I have been letting the lazy days drift by in Tampa FL. I have trusted in the power vested in warmth, water, and an abundance of sunlight to rejuvenate my youthful vigor and restore my outlook on medicine and life. Sometimes its tough to see life in the big picture when you're trapped within the artificially lit corridors of the sick and infirm. Its nice to be back at home, with family, outside, alongside the river, under the bright Florida sun. Even if that means having to swat at the mosquitos.
Sunday, March 11, 2007
Thursday, March 1, 2007
Tuesday, February 13, 2007
I went midwinter snowshoeing in the Adirondacks again this weekend. The views along the way were incredible. I'll let the pictures do the talking.
Me, overlooking the Adirondack High Peaks as I cruise along the summit of Cascade Mountain.
Another view of the high peaks, this time from the summit of Porter Mountain.
Another view from the summit of Porter, looking back at Cascade, and Whiteface in the distance.
Being a student on the OB wards, this is where I come in, eager and happy to be assigned the task of performing hourly "mag checks." On my first bedside visit, I noticed that steam was coming from the pateint's bathroom and that there was someone in there actively in the process of filling up the tub with hot water. Because the patient said that it was her boyfriend, I didnt think too much about it, and instead proceeded on with my history taking and physical assessment. Two minutes into my pulmonary exam, I hear the faint ring of alarms going off, and had I not had my sthethescope on at the time, I might have heard the beeps coming from the same bathroom, signaling to everyone at the nurses station that there was an emergency in my room. Within seconds, three resident nurses hustle in and turn towards me, seeking an explanation and some direction for action. I look up in calm, take off my sthethescope, and offer back only a puzzled look of confusion, unaware of their sense of urgency and worry.
It turns out that the patient's boyfriend was soaking in the tub, and had purposely pushed the emergency alarm button so that he could get some assistance with turning on the jets to the tub. This made me laugh. Who was this guy, and what made him think he was staying at the Hilton? Did he not realize that the facilities were meant to be for the patients only, and not to be confused with a full service spa and jacuzzi? Did he not realize that the tub he was just soaking naked in was actually a tub used by obstetricians to perform waterbirths in? That it was a contanier for laboring mothers to sit in and bathe within a mixture of warm water, blood, feces and amniotic fluid. Gross and well deserved. I hope he found it refreshing.
Sunday, January 28, 2007
Thursday, January 25, 2007
Saturday, January 20, 2007
She says let me transfer you to customer relations. he puts me on hold. he says let me transfer you to my supervisor. fine, defer your duties. share your responsibilities. make life easier for yourself and a bitch for me. make me explain to them my concerns again. and again. then reexplain for the third time, and if i'm lucky, i'm not thinking and swearing aloud by now, wtf, did i just get disconnected? so i redial, frustrated. gotta listen to that annoying fake female robotic voice drone on slowly again about transfer options like when to press one and rehear that para espanol, pressiones dos nonsense. and god forbid i have to verbally voice my selection into the recorder only to have to repeat myself again and again. i admit it, my tone of voice is low and deep. thats ok. i just have to try hard and hold the phone closely. apparently closer. and speak louder and more clearly, goddam it! enunciate. overly enunciate, if thats even possible to do. alas, thank god they finally understood me correctly that time, but now i have to verbally confirm that yes indeed, i did speak correctly. and all of that was just so i could get through, and speak with a real human, competent or helpful still no guarantee. so tell me, how does having to speak, respeak, and confirm that i spoke correctly. then reconfirm that i did confirm correctly, speed things up any? it fuckin doesn't. and it gets me mad before i even get the chance to talk.
Wednesday, January 17, 2007
I helped deliver a baby last week. Brought new life into
the world. I was so pumped up for the next few days
afterwards. It was probably one of the coolest things
I've ever done. But to say it wasnt also one of the most
weird and out of the ordinary experiences of my life would
be a lie. I'm not sure anyone can ever be prepared for
such a moment, until you've taken part in one. Its definitely
one joyous tear filled occasion. But its bloodier than you
think. And yes, they'll poop, the mothers that is, amidst
all the hard work and glory.
Since returning from break, I have found myself plunged
deeply in the crevasses of Obstetrics and gynecology.
Admittedly, it has always been a mysterious world to
me/men, and while it may not be something we would like
to concede, this much is true. Coming into this rotation,
I knew next to nothing about pap smears, child birthing,
hysterectomies, and c-sections. Talk about feeling out
of place when patients see you wearing a white coat and
automatically confer upon you a wealth of knowledge and
trust, in a field I know next to nothing about. And while
I could probably tell you all the stages of the menstral
cycle in gory detail, like when the hormones should peak
and ebb, and when the endometrium will slough off and the
bleeding begins, how is that understanding supposed to
help me identify with the wrenching pain of menstral
cramps, the labor of delivery, and the anxiety of
expectant mothers? I'm not sure it can, but I'm gonna
try and find out and inch myself one step closer to
understanding this one mystery of life.
As i sat there by the firepit chatting up an old high-
school crush (a mutual one back then) while tending to
the hot coals with the poker, gingerly coaxing a flame
back to life, i couldnt help but wonder at the time
whether or not she also picked up on the subtlety of
Observations from within E2/E3, the acute Psychiatric Unit
We could all use a litle more common sense. We had this
one patient who shuffled around listlessly, his eyes half
shut, appearance dishelved, and hair unkempt. We asked him
daily why he appeared so somnolent and presented with so
much lethargy, as if it were too big a mystery to figure
out. This guy was juiced up on near-maximal doses of
Depakote, Haldol, Zyprexa, Lithium, Ativan, and Ambien,
each one, when taken individually at the therapeutic dose,
could likely do that to either you or me.
Our patients are disgruntled. We place them on mood
stabilizers and antipsychotics. We ask them daily why they
are feeling so irritable and vexed to be here, as if there
would be nothing incongruent with appearing content and
happy to be held against your will inside a locked acute
psychiatry unit. How do you react when you see someone
smiling in their mugshot? Does that not strike you as being
Can a cocktail of the most clinically effective
antidepressants possibly ameliorate a depression caused
by the sores of troubled relaionships, exhausted financial
recources, and a life mired deeply in substance abuse? Do
pills really have the power to reforge troubled bonds,
replenish a lifetime of frivolous spending, and exhume a
life buried by drugs and alcohol?
So why do we continue to keep pushing meds? I am starting
to wonder whether all those free catered lunches have a part
to play in all of this? Are the pharm companines having it
their way unjustly?
Tuesday, January 16, 2007
how do you convince a patient that taking medicines is essential for his health and well-being while simultaneously respecting his right of autonomy to refuse? when the duty to act and protect begins to blur with the boundaries of respecting a patient's right to choose, how does one find a reasonable resolution? beneficence, one of the defining principles of medical ethics implores healthcare providers to "do good." Implicit in this guiding principle is the duty to act in the best interest of the patient.