Cascade Chaperone

A couple pictures taken during my afternoon of work as a chaperone on a 2nd grade field-trip.

Dr. Bedell has been as enthuiastic about teaching me how to successfully diagnose and manuveer through a Class 3 rapid as he has with teaching me how to sew up lacerations and perform a thorough work-up of a patient presenting with atypical chest pain. Bedell has the charm and knowledge of a rafting guide and the modesty and experience of a true outdoorsmen, all qualities which make him this great doc to work with, and for his patients. More than just concered with teaching me medicine, Bedell extends his obligations to introducing me to new life experiences. On the river and on the trails, he'll make up case scenairos of potential wilderness medical situations, even if only seemingly to disrupt the silence and monotony of a long hike. We'll hit up topics including high altitude sickness, contact dermatitis, giardia illness, tick and animal bites, traumatic c-spine and bone fractures, and lightining strikes-- real life stuff that interests me, but not necessarily what you get from reading textbooks or attending class. If Bedell thinks that there is more to gain from hiking to the summit of a local mountain than there is from a slow day spent in the clinic, he'll make sure that I've brought along snowshoes so that he can send me packing. The same is true for a day spent as a chaperone for an elementary school hike around the scenic Lake Cascade. Who'd have ever though I'd be riding in a boisterous yellow school bus packed full of second graders in the middle of Idaho? My boss' daughter had a school fieldtrip to Crown Point, and I was offered the opportunity to attend as a chaperone. Yes, there are certainly worse things in life than spending an afternoon under the sun, taking a pleasant stroll along a scenic lakeside trail with funny little school children.

Wilderness Medicine

Big Boss Bedell behind the captain's wheel

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.

The Gospel Hump

Taking a waterbreak midway into our hike on the second morning. I'm sitting rather comfortably, aside from being mildly dehydrated and achy from the toes up from the previous long day of hiking, and a night spent rehydrating on beers and sleeping on the ground.

A view from the tent. Taking a break from my Family Medicine book to scope out the scenery and Dr. Bedell.

Obsidian Stout, aka "Sid," the third member of our trip, posing for a pic at our private sandy river side campsite. The flow of the Salmon River was especially high and fast from the recent snowmelt, charging her way through the canyon. If only we had decided to bring the raft...

A view of the Idaho Centennial trail switchbacking its way up from our Salmon River campsite into the Gospel Hump Wilderness.

The Full Experience

For all the loan money I have invested into my medical education, I am finally beginning to cash in on the returns with a full hands-on medical training experience. While staying at the house of the doctor who is overseeing my Family medicine clerkship seemed at first like a terrible, "I must always be on my best behavior at all times," freedom restricting idea, I have come to realize that there couldn't possibly be a more complete "family" medicine experience.

Today, my morning began with a rude awakening, not from the alarm clock set for 7:00 am, but from the phone ringing at 5:45am to herald the news of a woman in full contracting labor (aka, we need a physician, promptly). I sprung out of bed, hair unkempt, mouth nasty tasting, sleepies still caked around my eyes, threw on a pair of scrubs, and met big boss Bedell in the hallway as instructed, "like Batman and Robin, should the phone happen to ring at night." Practicing medicine as the only family doc in town means that you are continuously committed to the care of your patients, be it morning or night, in the rain or shine. Rural medicine can transform unpredictably from a chill, laid back clinic day to a hectic "get your gloves and gown bloody, we've got lives to save" kind of day. My day began with the assistance in the delivery of a healthy 38 week old, small for gestational age infant, and didn't end until I had successfully performed an excisional skin biopsy of a possible melanoma, applied two Voler splints to probable distal arm fractures, sugar-tong splinted a man's compound wrist fracture/dislocation after unsuccessfully attempting to reduce his radius and ulna bones back into place from their "jagged bones protruding from skin" orientation, and performed two venipunctures to start up IV lines, meanwhile running back and forth from the clinic and ER to work-up scheduled clinic patients for pharyngitis, acute COPD exacerbation, recurrent yeast infection, and acute alcoholic intoxication, among other diagnoses.

To date, my apprenticeship in Family medicine has afforded me the opportunity to sew up lacerations, perform nerve blocks and steroid injections, surgically remove ingrown toenails, order labs and imaging tests, write prescriptions, verbally dictate notes for medical transcription, and most challengingly of all, to defend my clinical decisions with confidence and reason. Dr. Bedell makes me work responsibly hard and expects me to assume the full care of the patients that I see, including the initial work-up, deciding on which labs/tests to order, following-up on those tests, and deciding on a treatment plan of care. He allows me the chance to see his patients before he does and encourages me to justify my findings and assessment with confident reasoning. We'll spend a few moments talking over my treatment plan, at which time Bedell offers a few recommendations, then tells me to make the final call, including writing the prescriptions, filling out the imaging/lab order form, and proceeding with the plan of care. Whenever I remain unsure of my decisions or hint that I am still vacillating between two treatment plans, Bedell will respond by saying "I dont know man, he's your patient. You've gotta decide and tell the nurse what you want done. They're not going to listen to me. I've told them that you're calling all the shots." So it really forces me to be confident with my clinical decisions. When we go in together to see the patient together, Dr. Bedell is always saying stuff like "Andy decided to start you on this antibiotic" or "Andy has decided to order these tests for you," or 'Andy will give you a call this afternoon to inform you of the results of the tests he ordered," which always surprises me a little, but makes me feel like I am actually a part of the care.

Rural medicine

At the Cascade Medical Center, there is an Emergency Room where we see a lot of male Idahoans come in, because for one reason or another, they make a habit out of packing lots of sharp objects into their bags, downing multiple beers, and then hopping onto the back of a four wheeler. Men are known to be dumb, but when you give them the freedom to combine alcohol with the limitless outdoor pursuits of the provincial lifestyle, they become recklessly dumb. If we're not seeing the bloody man from the fourwheeler accident, then we're seeing the dude with the fishhook embedded deeply in his toe, who claims he has no idea why his toe hurts or looks so nasty and swollen, and reports that he has not been fishing for over 2 weeks. And then we see the unfortunately young tree loggers that come in with 10 inch lacerations from their backfiring chainsaws, asking if there is a Doctor that can "sew up my little cut." In just my short stay here, I have witnessed some hilariously dumb folks deep from the woods of Idaho, albeit hardy and tough. These guys present to the office looking awfully grimy and just plain down and dirty, with their clothing soiled and body all banged up, but they are grateful as hell, and smile reverently up at you as their miracle healer when you patch up their wounds.

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.

Idaho, the Gem state

Greetings from Cascade, Idaho, a small lake town of 1000 residents nestled along the scenic mountains of the Payette River valley, which is located just 30 miles east of the Oregon border. While still relatively undiscovered by human settlers, (and partially for that exact reason) there is an abundance of life here; a forested waterfront habitat enjoyed by bears, elk, predatory birds, and rustic/adventure-seeking men alike, not only for the abundance of fishing and wildlife watching opportunities, but for the plentitude of moutain biking, hiking, skiing, and river rafting recreations. The Tamarack pine trees grow tall here, providing just enough sun cover and shade for the wild Morel mushrooms to thrive in the damp, recently snow-thawed soil. Since arriving here, I have quickly learned from the locals that Morels are a tasty delicacy coveted by central Idahoans, who take advantage of the mid- spring season to harvest them from the wild. I have yet to discover these tasty delights, but when our paths finally cross on the trail, I will be sure to try one out. Apparently they look like little christmas trees but with a soft and wavy mushroom cap, not to be confused with its poisonous lookalike, the False Morel. Huckleberries, a tart version of the blueberry, are also known to thrive only in these environs. These apparently, are also a must-try, if you are from the East. I have added it to my list of things to-do, while here. So the locals must have thought I was silly for thinking that the rich Idaho soil was good only for cultivating those extra large Russet potatoes.

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.

Layover

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.

River restoration

The Hillsborough River, Temple Terrace, FL 4/13/07

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.

Buying insurance

In his State of the Union address, President Bush proposed tax cuts to make health insurance more affordable for the uninsured. His proposed policy was meant to be so simple and straightforward that this is what Stephen Colbert had to say about it on his daily Report. "Most people who can't afford health insurance also are too poor to owe taxes. But if you give them a deduction from the taxes they don't owe, they can use the money they're not getting back from what they haven't given to buy the health care they can't afford." Genius.

Schoolhouse kids

I began my Pediatrics rotation recently at the Schoolhouse outpatient clinic and can already sense a refreshingly playful change from the scrub-soaked gush of blood and amnion of OBGYN. Fortunately, most of the kids we see routinely are healthy babies, even if they are prone to developing the occasional stuffy nose, sore throat, and fever. But if you think that the cutest, most adorable and healthy two year-old girl is just all fun and games, try looking into her ears with an otoscope while she is squirming around resisting the exam. Its not such an easy task if you wish to avoid destroying her tympanic membranes and leaving her permanently deaf while still in infancy. Attempting to listen to a three year old boy's heart and lungs while he is tugging away at the tubing of your sthethescope is equally challenging. I once had a boy stuff the entire head of my stethescope into his mouth. I got him back by examining him with the same slober-covered instrument. I've learned that to succeed in pediatrics as a medical student, one must learn to strike the right balance between playfulness and professionalism. You gotta throw the kids a bone every now and then, using Sponge Bob and Dora stickers as your ambassadors. I've even resorted to the most childish of tactics at times by placing a Scooby doo sticker on my otoscope and convincing the kids to "let Scooby take a peek in your ears." I think the key is to make the kids comfortable so that the parents feel comfortable with letting you care for their kids. Sounds straightforward, but in reality you need to act like you know what the hell you're doing, or else these parents are gonna give you that threatening look, letting you know its time to lay your grubby paws off their precious child. Demonstrating confidence when examining a newborn can be especially difficult. It takes just the right touch of gentleness and finesse, but enough confidence and forcefulness to perform an adequate physical exam. Even if the newborns wished to comply with your physical exam, they wouldnt have the slightest body control yet to move their floppy limbs out of the way. Learning how to understand and anticipate their behavior is often impossible even for the most practiced of all pediatricians. I find it curious how capriciously children can often behave; docile and calm one minute but screaming and inconsolable the next. As I like to say, from two to terrible, in just one damn blink of the eye. Regardless of your approach, you cant take away the full blown stranger anxiety that exists in 15 month olds. By that age, they're smart enough to know that shots will be coming, and it is only natural for them to be suspicious and fearful of you. And thus, I am resigned to saying ridiculous things like "no ouchies here" all day long.

Bagging High Peaks

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.

Soothing spa bath

In my last week of Obstetrics, I encountered something quite odd, dumb, and funny at the same time. We had this one patient who was being hospitalized for eclampsia (seizures, hypertension, and proteinuria during pregnancy). She was currently receiving magnesium sulfate, which is the standard prophylatic treatment for eclamptic seizures, and required hourly "mag checks" to ensure she was within normal therapeutic range, as elevated Mg levels can cause some potentially serious toxic effects. And since there was a shortage of inpatient room, this patient stayed in one of the delivery rooms which had the necessary facilities for performing natural water births.

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.

Adirondack adventure

The thermometer read 5 degrees on this blistery winter day as we hiked to the summit of Mt Jo in the Adirondack High Peaks region. Beautiful, serene, freshly fallen, powdery, and white. 1/28/07

Bottle feeding

I bottle-fed a newborn child yesterday. he was unaware of my holding him, but already had the rooting reflex to direct his tiny lips and mouth toward anything that was soft or protruding conveniently at mouth level. he began sucking the bottle forcefully, taking in every last ounce and drop of neonatal formula, reaping whatever he could from life, being only but a day old. it was quite an amazing and intimate thing to observe up close, and i would like to say that we shared a moment, a bond. but in truth, his behavior and actions were driven purely by newborn instincts, and anyone who had the gentleness and patience to nurture him could have served as an able surrogate. still, the child found calm and safety in my arms, and i too, must admit, that i found the experience to be quite soothing, albeit sprinkled with some apprehension that i was either cradling him too tightly or not tightly enough to prevent him from slipping through my arms.

Venting anger

While i consider myself a rather mild tempered guy, nothing frustrates me more or brings out impatience in me more quickly, than having to sort things out over the telephone. i am generally pretty good about keeping my cool. it is seldom that i yell or direct my anger outwardly towards anyone. but theres something about having to resolve things over the phone, like for instance, correcting an overcharged bill, or trying to plead with the receptionist to squeeze me into a fully booked apointment schedule, that gets me agitated and often irrate. i become vulnerable to utilizing verbal abuse, and become too overtaken by passionate to proceed with reason.

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.

A Beautiful mystery of life

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.

Winter's a Beach in Florida

80 degrees on this gorgeous winter day in Tampa Bay, as the sun makes her westward descent into the Gulf of Mexico. 12/29/06

Rekindle

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
the metaphor.

Psyched Out

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
inconsistent?

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?

Tough decisions

a lot of medicine is about making tough decisions with hard consequences in the face of uncertainty. the true art of medicine, i've observed is being able to navigate forward firmly in spite of these uncertainies. medicine, in the end is a practicing science, and science is all about making informed decisions given supportive evidence, keeping in mind that these things will constantly change.

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.

No Free Lunch

Is it wrong to acccept free lunch and fancy dinners from drug reps? Will this somehow influence what medicines i am more likely to prescribe in the coming future? i would like to think not, but many in the profession, including members of the nofreelunch campaign, backed up by strong consumer data demonstrating the simple magic of modern advertising, seem to think otherwise. but when a student is expected to cough up 200 grand for a medical education these days, how can one pass up daily catered meals at a noontime conference sponsored by Merck or Astra Zaneca? I havent been able to yet. And the placard of pens emboldened with drug names, including Lipitor and Levitra in the mixed company of Zocor and Viagra, each dangling and dueling colorfully from the multi-overstuffed pockets of my lab coat, seem to confirm that. http://www.nofreelunch.org/index.htm