Complementary and Alternative Medicine

Keep an Open Mind

So they asked me a lot, when I was interviewing for medical school, what I thought about complementary and alternative medicine particularly the use of traditional practices as adjuncts to Western Medicine.

I’m all for it. There are a lot of traditional practices I’d like to see become a part modern medicine. Like snake handling. For my money snake handling has everything you’d ever need in an alternative therapy. You’ve got your snakes representing nature, you’ve got your mystical religious overtones, and you’ve got scads of anecdotal evidence and testimonials in prestigious religious journals attesting to it’s efficacy.

For those of you who don’t know, snake handling has flourished in the folkways of the southern United States for more than a hundred years and is a time-honored method of casting out the demons that cause most sickness, at least those that cannot be ascribed to qi or bad karma. I understand that the NIH offers a fellowship that will equip anyone interested for an expedition to the wilds of Louisiana in which strange and magical land they may sit at the feet of ancient masters of this art and learn the secrets of the serpents.

And don’t forget to try Uncle Skeeter’s Gator-Taffy if your expedition passes through Lafayette.

I also would like to see more faith healing employed in the modern clinic. I’ve personally seen the lame walk, the blind see, and the gaseous find relief all from the “laying on of hands” as the technique is described by the learned shaman who practice it. For those of you who are lacking in cultural competence, the faith healer’s art is practiced in tents or, more lately, air-conditioned football ashrams where a large crowd can direct their good karma (or “prayerful thoughts” as it is often roughly translated) towards the patient. The patient, under the power of both suggestion and an Ayurvedic being named “Jaysus,” has his bad chakra forcefully removed, some would say driven, from his body with a precisely placed blow to the forehead.

The Shaman often yells “Come out!” but this is just showmanship, not unlike the way we yell “stat” in the Emergency Department even though we know that we’ll be lucky to get the labs by next Tuesday.

There is some debate whether faith-healing owes it’s effectiveness to the so-called “placebo effect” rather than any demonstrable physiological process but the debate is ridiculous and anybody who challenges this ancient traditional practice is a close-minded bigot. It’s not like they’re sticking needles into people or something lame like that. We’re talking bona-fide healing here, often before a television audience of millions. It would be highly unlikely that something like this could be faked in front of so many highly intelligent television viewers.

I have also heard of another traditional mind-body therapy for psychiatric problems, this one practiced in the deep hearts of our ancient cities. Basically, the patient dials a talismanic number, usually preceded by the mystical “900″ or any other Number of Power and ceremoniously asks to speak with a priestess whose name is usually Yolanda or Mistress Debbie. The priestess then diagnosis all kinds of psychiatric and sexual dysfunctions, often times correctly pointing out that somebody close to you is cheating on somebody else close to you and “he needs to show you love, girlfriend…and you are so not fat…besides, he digs big women.”

Sometimes they throw in the winning lottery numbers.

Anyways, with all of my patients, the “P” in SIG E CAPS is “Psychic Hot-line.” I understand medicaid will reimburse for it. It’s not as if we’re asking them to pay for something ridiculous like a visit to the chiropractor.

Finally, for my money, nothing can compare to the healing powers of a good old-fashioned poultice like the kind my grandma used to make out of chicken droppings and mustard greens. It was the sovereign cure for a variety of ailments from lumbago to dropsy. Through years of experimentation, traditional practitioners have developed a wide spectrum of salves and rubs that are pushing the boundaries of our understanding of medicine. Our so-called “evidence based medicine” has nothing to compare to alternating layers of gumbo clay, sassafras bark, and chicken bile covered with brown paper and tied to the offending limb with common twine. It’s so good it’s almost magical. For fever, pepper is often added as it is a hot spice. For chills, it’s not uncommon to add the musk of a nutria as everybody knows this hardy animal can gnaw it’s way through the ice that forms every fifty years or so on the bayou. Beaver semen will do, I suppose, but there is no good evidence to support its substitution and I wouldn’t have that kind of quackery in my practice.

Besides, there’s no room to stock it as my shelves are crammed with homeopathic remedies.

Complementary and Alternative Medicine

More Housekeeping

Spam Posts

I tried it for a while but because of annoying spam posts I’m turning “word verification” back on. You’ll have to tak an extra step to post. Sorry. I really think spammers should get the death penalty but until such a time as they do we’re going to have to do what we can.

Comments

Don’t make me have to moderate comments. So far most of the negative posts have been either well reasoned (but wrong), amusing and witty (but wrong), or just so plain foam-at-the-mouth idiotic that they are a joy to read. Remember: good, bad, or indifferent I appreciate the time people take to read my blog, even if I don’t understand why people who hate it keep coming back. Still, if you want to keep squeezing lemon juice into your own paper cuts than that’s your business.

Good Manners

Let’s keep it relatively civil. I will usually delete posts that contain ad hominem attacks, excessive bad language, or an overtly political point of view. I haven’t, recently, because the latest set of rants has been so amusing. Criticism is always welcome and you have my pledge that I will never delete a post just because I don’t agree with its author. I reiterate that I draw the line at partisan politics. You can go to half a million websites and engage in toxic political debates to your heart’s content but I’m sick of it.

Archives

Be sure to sift through the archives. A lot of good stuff.

Humor Workshop

According to my hit counter, I am getting hits from all over the world. Apparently, there are countries out there where humor is either outlawed or does not exist. (We also have people in out own country who are completey devoid of humor, probably secondary to being able to open bottles with their rectums.) American humor is hard for some people to understand. I’m going to have a workshop on this shortly but in the meantime, if some of you from Eulopotamia feel your knee starting to jerk, before you fire off an indignant comment take a deep breath, re-read the post, and try to pretend that you were raised in a country where we don’t kiss the ass of our elected leaders, question authority as a religion, and don’t take everything so friggin’ seriously.

More Housekeeping

Fan Mail From the Edge

(Just a few comments. We seem to have had an explosion of vitriol today which is gratifying in my quest to become the most popular non-midget-porn blog on the web. Interestingly enough, most of the negative comments come from a couple of ISP addresses in India. As to what I have done to offend the Indians over anybody else I am completely mystified.

My biggest surprise is the level of support you can get from the online community if you abuse and neglect your aged parent. Apparently there is no depravity that will not have it’s apologists. I also don’t quite get the anger at my ICU advice post. I challenge anyone to say that anything I wrote is not true. Surely anybody with the energy to type an abusive screed could find posts of mine more worthy of the haterade.

I am also amused by the “compassion police.” I feel sorry for them because whatever their level of compassion, they will be sorely tasked by the majority of their peers, most of whom are just not the plaster saints they expect them to be. -PB)

“The author cannot be blamed if they don’t have humor in your country.”

Bigoted? Check. Narcissistic? Check. Besserwisser? Check. Elitist, superior type A-hole personality? Check.

Funny? Hell no!

(No humor in your country? Check. -PB)

To be a doctor, you’d have to be human. And to be human, you’d have to have a heart.

So, uh… No, I guess you’re NOT a doctor. Happy to help.

(Uh…Okay. But my state board, is going to have a problem with that one. Especially since I am on the loose writing prescriptions. -PB)

How can people say this is the best blog on the internet? Come on, people, get with the program. Learn a little old school empathy and be excellent doctors without taking on an elitist attitude like this fat and mean poor excuse of a physician.

You really really scare me too. And remember, you say “my patients like me”, but keep in mind the fact that they ARE stupid. (Fat AND stupid AND lazy.)

So if they are stupid, and they actually like you, that would either make them blind AND deaf AND dumb, or maybe just maybe you are as stupid as them.

Eat that, fatwad.

(I prefer “stocky.” but thanks for reading my blog. -PB)

You are reading the blog of an arrogant know-it-all who is condescending and elitist. Please get your facts straight. Remember if you were not sucking up to him, he would hate your ass. Try poking him, you’ll see. Just like the rest of us, FAT, STUPID, LAZY types.

(Well, I didn’t delete your post, did I? -PB)

You are like the world’s worst gunner, dude!

(And the world’s most unsuccessful gunner, too, as you would know if you’ve read my blog for any length of time. -PB)

“Servile and compliant” is how you described Mr Neely’s son… But admit it, Pooh Bear, it turned you ON, didn’t it, didn’t it?! ;) It’s okay. Share. Share how that made you feel.

Your powerful stare, looking down at him, all dependent and needy and wanting… Aw, shucks, Panda! What a cute moment that must have been!

(I cannot understand your desire to stick up for a guy who was definitely neglecting and most likely abusing his father. It’s inexplicable, especially since the weak and powerless require someone, occasionally, to exercise a little judgementalism on their behalf and to exercise what little authority they have to protect them. I have my faults but neglecting to protect and assist the weak and helpless for fear of offending somebody’s bleeding heart ain’t one of them. You should be ashamed for expending more vitriol on harmless little me than you probably would in the face of obvious but garden-variety evil. But thanks for reading my blog and keeping the hit-counter turning. -PB)

Get this in YOUR head, *Panda* (if that is your name). You’re a self-aggrandizing, narcissistic, completely empathy-resistant (not to mention POOR) loser with no ability to budge or give other people the benefit of the doubt. Talk talk talk – that’s all that you’re about. Glad I’m not the son. OR the father, for that matter. How DO you sleep at night? Irritating mutha.

(Well, actually my name is Gus. I thought everybody with a few functioning neurons could tell that very few children are named “Panda Bear” by their parents. I guess in your humorless country it might sound like a real name. “Panda Bear,” by the way, was my radio call-sign when I was the mortar section leader in my Marine Corps rifle company. I also don’t uderstand why my being poor is an issue. I’m a resident. Of course I’m poor. It kind of goes with the territory. As always thanks for reading my blog. -PB)

You are just about the single most conceited person in the medical profession. *This is what you’re supposed to do blah blah….Why don’t you stick your little marine cap up your bum and choke on it? Do us aaaall a favor.

(Come on now. The most concieted? You obviously don’t know too many doctors. Oh, and I’d have to stick it up my bum pretty far to choke on it although I suppose it’s technically possible. -PB)

Dude, I am only human. Everybody has a cruel streak and I guarantee that if you told me a little about yourself I could easily pick out a group or two who’s misfortune you relish.”

See how he flips it?! Now it’s YOUR mistakes he’s after.

Doctor?? Hell, no! Choose politics instead. You’d be a natural.

(So what’s your point? Do you think that physicians are any less human than anybody else? Taking a morbid pleasure in other’s misfortune is so common that the Germans even coined a lovely word for it. If you think that by becoming a doctor you become emotionally celibate then you are in for a major disappointment in the the profession and most of your collegues. Now, you are obviously not immune to anger. I know for a fact that you would take great pleasure in any of my many misadventures in life if you were aware of them. So you’re sort of being a hypocrite, although since hypocrisy is the natural state of man I for one won’t get all worked up over your hypocrisy. You are who you are. As always, thanks for keeping the hit counter turning. -PB)

Can’t find it, Pooh Bear. You’re a bigot, and you always will be. :D I think you even spellt Dhaka wrong. But why would you even care enough about that? Silly me!

(There are, of course, many accepted ways to spell some city names (Bejing vs. Peking, Athina vs Athens) but to my knowledge, there is only one accepted way to spell “spelled.” Silly you. -PB)

“My main criticisms of this blog are its borderline plagarizing of “House of God” and the attempts by the author to mimic an experienced ER physician when he’s still a naive resident.”

(I have never read “House of God” or any other book about residency or medicine so it would be difficult for me to plagerize anything, borderline or otherwise. As for mimicking an experienced Emergency Physician, I am an Emergency Medicine resident so that’s what I write about. If you notice, most of my articles about the ED, of which I believe I only have three, are character studies, not emergency medicine textbooks. I am as qualified to comment on the character of patients as anyone, both because I have seen thousands of patients in the last four years and because I am reasonably intelligent and observant. The medical background of the patients is important to the narrative and where possible I try to be accurate. When I make a mistake invariably somebody will point it out and I will humbly acknowledge their correction. If I’m wrong about something I’m wrong. But you need to get it out of your head that I somehow don’t deserve to discuss things I learned on my ICU rotations because you think I’m not qualified to know these things.

I also am in no way naive in any sense of the word, either by age, upbringing, or life experiences. I think you’re confusing me with some other guy. I do not beat people over the head with my CV but I’ll do it if necessary.

Other than changing the names and a few characteristics of the patients to protect their privacy, I challenge you to find one instance where I have written anything which is not authentic. Or, for that matter, where I have not conceded that I am not perfect and still learning the profession. If I have to precede every statement with a disclaimer that I am only a PGY-2 and thus cannot speak for the entire medical profession it would be a very dreary, unreadable blog. I appreciate your taking the time to comment and your attention to my writing but the natural question is, if you find it so objectionable why do you inflict it upon yourself? -PB)

Fan Mail From the Edge

Crunch Time

The ICU and You, some Do’s and Don’ts

Some of you will rotate in the ICU as medical students and most of you, whatever your specialty, will do at least one critical care month during your residency. Here are just a few general tips. I have made most of the mistakes described below. Keep in mind that your level of autonomy will vary depending on your program. At a big academic program you will likely be tightly supervised and always have immediate skilled back-up. At a smaller program, especially when you are on call, it might be just you and your senior resident with an attending on home call.

1. Stay ahead of your patients. They are in the ICU for a reason and this is usually because they are too unstable to be cared for on a general medicine floor. Things happen quickly. A patient can look fine and two hours later require intubation emergently. If you had paid attention to his arterial blood gases and listened to your experienced ICU nurses you might have been able to intubate under controlled conditions with everything in place and everybody calm rather than during the unavoidable excitement of a code. This is especially important if your patient is a “difficult airway” as it is always nice to have anesthesia at least standing by if you look down the blade of the laryngoscope and see everything but the vocal chords.

2. Don’t be afraid to intubate. Generally, if you think you need to you probably do. If the patient asks you for the tube then that is a pretty good indication for the procedure, especially if the patient has been in the ICU before.

3. Don’t let the vent intimidate you. At first it seems that the ventilator has a bewildering selection of knobs and displays that seem to have no relation to what you read in your critical care book. It’s hard, at first, to keep the various ventilation modes and pressure or volume options straight in your head. You will usually have a respiratory therapist at the bedside when you intubate and they are usually happy to explain things to you. As a resident or medical student nobody will think the worse of you if you ask questions. You aren’t really fooling anybody, anyways. Everybody knows you are new. Know a few common parameters and this will give you some time to figure things out.

4. But don’t screw with the ventilator. Write an order and let the respiratory therapist do it. If you don’t know what setting would be appropriate ask her opinion.

5. Understand how to interpret ABG (Arterial Blood Gas) values. It seems kind of arcane in medical school but after a few times doing it for real it will start to make a little sense. You will at least know when to panic and when not to.

6. Don’t let your patients almost bleed to death before you decide to transfuse or drop their electrolytes to dangerous levels before you decide to supplement. Stay on top of the patient’s labs, correct aggressively, and then make sure you have a good idea why things are heading south.

7. Don’t believe the crap about “treating the patient, not the labs.” Or the monitor. Obviously the lab values and the monitor don’t tell the whole story but they do tell you a lot, particularly because the patient can compensate for a wide range of deficits before suddenly deciding they’ve had enough. “Looks good” does not equal “Is doing good.” Get that family medicine, touchy-feely philosophy out of your head. These patients are sick and it’s better to be a pessimistic but alert bastard than Little Mary Sunshine.

8. Don’t be timid. If the patient needs a procedure then do it. Don’t dither looking for excuses to put it off because you are afraid of it. The ICU procedures that you will be expected to do are placing central lines, arterial lines, chest tubes, and endotracheal tubes. You will also need to know how to do a lumbar puncture, thoracentesis, and a few other things.

9. On the other hand, think about it first. Not every patient needs a central line, for example. The nurses like them because it simplifies their management but sticking a large gauge needle into somebody’s internal jugular vein is not without the possibility of complications especially in ICU patients who are usually coagulopathic. You can easily nick the carotid artery, even under ultrasound guidance, and this can be a disaster as a patient can lose a lot of blood into the fascial planes of the neck and mediastinum before you even notice it. You might also give the patient a pneumothorax (“drop a lung”) as the needle is long and the apices of the lungs can be high. Good rule of thumb, if you’re sticking a needle in the neck and you’re aspirating urine, you might be too deep.

As much as I like ICU nurses, making their lives easy is not an indication for central venous access. Being too timid to put one in, on the other hand, is not a contraindication. If you don’t know how, call someone who does, have them show you, and then do the next one.

10. For God’s sake, never force the needle, the wire, or anything else. If it won’t go in, it won’t go in. If the wire hangs up, pull it back a little and try again. A well placed wire in a vein or an artery should slide smoothly with very little resistance. If it doesn’t, you are either not in the vessel or the vessel itself is calcified and tortuous. Admit defeat, pull out, and try again. But the patient is not a pin-cushion and if you are obviously screwing it up pass it off to somebody else if they are available. If not, pick another site and try again.

11. Be ready. Know your ACLS because you are going to use it. This month we have never had fewer than three codes overnight and we usually have more. We once had three patients coding at the same time. The senior resident cannot be everywhere and you are going to be expected to take charge. Still, the ICU nurses know what they’re doing so if you don’t know something, ask and take your cue from them. If they suggest something it’s probably because they know what they’re talking about. As you get more experience and if you pay attention you will get more comfortable. The ICU residents are typically on the hospital code team and expected to respond to codes on the other wards. You will usually find a crowd of people milling about. If someone is in charge let them know that you are available to intubate, put in lines, of do anything else they need. If no one is in charge, take charge and remember the basics.

12. One of which is that most patients will not be hurt by a liter bolus of fluid and fluid can make a big difference. A liter is not actually that much. Two liters is better (most of the time, know when it’s not). Giving a 250 milliliter bolus is like spitting on the patient. It’s worse than useless. 250 milliliters is about a cup or so. If you decide to give fluids be a man about it and don’t get all girlish.

Same with magnesium. Two grams won’t hurt anybody and if they are in V-tach when you get to the room you might as well have somebody push it. You never know. It could be torsades.

13. I know this is not always true but generally, you can’t do much to hurt somebody who is already dead. If you give them a little too much atropine or epinephrine it’s not going to make them any more dead. It’s likely that when you arrive at the room of a coding patient, you will know nothing about the patient so you have to stick to the basics of airway, breathing, and circulation. Take a breath, follow the algorithm. You can give CPR for a minute between shocks. Take advantage of this time to calm down and get in the rhythm of things.

14. But you have to assess the patient. Listen to the lungs, feel for pulses. If you can feel a radial pulse they have a systolic of at least 80 whatever the cuff says which is generally compatible with life.

15. Sepsis is big. It comes in many forms but it’s a killer, generally from end-organ failure due to hypoperfusion which leads to all kinds of unpleasantness. Generally you treat it with a lot of fluids, pressors, and anything else to keep the blood pressure up. Culture everything, look for likely sources, and cover with the appropriate antibiotics empirically. And don’t forget to check the urine as UTIs are the silent killer of the elderly. Most ICUs have standard sepsis orders (heck, they have standard orders for a lot of things) but go over them before you sign to both make sure you don’t want to change something and to familiarize yourself with the what needs to be done.

16. Pulmonary emboli kill a lot of ICU patients. Suspect them always in the patient who is acutely short of breath because an ICU patient is a setup for clots. The D-dimer is useless. It will never be low. Every ICU patient has an elevated D-dimer for a variety of reasons. If you ever find a low one this is man bites dog. Besides, people with long-standing thrombi can have a low D-dimer and still throw a clot to the lungs. Consider anti-coagulation for every ICU patient except those with GI or intracranial bleeds.

17. Don’t negotiate with families. Bargaining is one of the stages of grief and you may find the family trying to make deals with you over how long the patient can live. It’s best to just give them the facts and the prognosis. I mention this because at a smaller program with no attendings in house overnight it often falls to the residents to talk to the families. If you don’t know much about the patient (if you are cross-covering) then either arrange for the family to meet with someone who does in the morning or familiarize yourself with the chart and admit at the outset that you are not following the patient on a daily basis. One white coat is the same as another to many people and they may be offended if you don’t know their family member backwards and forwards.

18. ACLS is not a menu. Discourage the practice of offering certain items while withholding others. A lot of families want CPR, for example, but no endotracheal intubation. I guess this makes a little sense from an aesthetic point of view but since “Airway” is the first part of ACLS I suspect that not securing the airway is a violation of the standard of care. Some families are offered what is referred to as a “chemical code” where they want all of the ACLS medications (epinephrine, atropine, amiodarone, etc) but no chest compressions, no shocks, and no airway. There is no point to this. All those meds will just sit in the vena cava or the atrium, all dressed up with nowhere to go.

If a patient is to the point where further care is futile you need to tell the family this, respectfully of course, but bluntly and suggest that it is now time to make the patient’s code status DNR (Do Not Resuscitate).

Crunch Time

Apropos of Nothing

1100 Bucks a Month

Just from the outset, let me say that poor 70-year-old Mr. Neely was definitely being neglected and possibly being abused by his son. The first thing they told me was that his hair was so dirty and unkempt that it was like one single dreadlock. The nurses had to cut off the worst of it to wash his hair, possibly for the first time in ten years. His nails were filthy and three inches long. Other than his obvious expressive aphasia and severe peripheral vascular disease, he had no medical history that his son could recall and had not been seen by a doctor (or anyone else, possibly) for the entire twelve years he had lived with him. His right leg has been amputated below the knee at some unknown time and the remaining foot was so swollen that the tissue ballooned out from around the elastic of his feces-encrusted sock. His shin was covered with black, gangrenous eschar and his toes were rotting off.

The son displayed a strange lack of concern about his father’s deplorable state and his medical problems, especially his expressive aphasia which is a symptom of a stroke in the speech centers in the dominant hemisphere of the brain (usually the left). All Mr. Neely could say was, “Wonderful…no…no…wonderful,” which he repeated continuously whenever he was alert.

“When did you first notice his speech change?” I asked, which is a reasonable and an important question when treating victims of strokes.

“About four years ago.” A complete lack of concern from the son.

Jesus.

“Didn’t you think about taking him to the doctor when it happened?”

“Well, it didn’t get any worse so I figured it would get better.” He might have been talking about what he had for lunch.

“When can he come home?” was his next question.

“I think he needs to be in a nursing home. You’re obviously not taking very good care of him,” I said, not trying to be non-judgmental, “What on earth is going through your head when you see him like this?”

Poor Mr. Neely. Trapped in his own private hell surrounded by neighbors who probably didn’t even know he existed. His son had probably gotten used to living off of his social security check in a house whose mortgage had been paid since the time when his parents still had hopes that he would amount to something. He might have died like that except the fear of losing the social security check had finally made his son risk bringing him to the Emergency Department.

What does this have to do with anything? Nothing really. No big lessons or morals to be teased out here except that maybe there aren’t two sides to every problem. Some things are obvious. Mr. Neely’s son was obviously a scumbag and was obviously neglecting his father. Evil obviously moves in the shadows of our world even if it is sometimes understated and bent on nothing more than a pitifully small government check.

Apropos of Nothing

Barking Mad

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Barking Mad

When in Doubt, Patronize

Some of My Best Friends…

If I suggested to you that different races had easily identifiable personality traits and that not only could I use these traits to predict their behavior but that I should make prejudicial assumptions based on these traits you would rightly label me a bigot. And yet, this idea is running rampant through the medical training establishment and has gained a surprising legitimacy among people who profess to be wholly untouched by the stain of bigotry.

I am, of course, talking about diversity training and cultural competency. In reality, it’s nothing but racial profiling. To be culturally competent, we must modify both our approach and our expectations of patients according to their race. The barely hidden subtext of diversity training is that white, middle class patients who are medically compliant represent the norm and other races and ethnic groups stray from the norm to varying degrees. These differences are usually objectively bad, at least as reflected in medical outcomes and thus a cottage industry has been created to explain why this is so.

Black patients, I learned in one session of diversity training, have a more relaxed sense of the passage of time and thus cannot be expected to always be on time for their appointments or even keep them at all. It’s just part of their culture. Additionally, the race scholars tell us, since African culture is more vibrant and demonstrative than the repressive, protestant culture of the northern Europeans, blacks have different priorities when it comes to health and taking responsibility for their actions.

When the Imperial Wizard of the Ku Klux Klan says pretty much the same thing, that blacks are lazy and shiftless, it causes cries of outrage and an endless stream of self-righteous letters to the editor from the outraged multicultural intelligentsia.

You learn all kinds of stereotypes in diversity training. All of the stereotypes attempt to show things in a good light but if you think about it, if the good stereotypes are true, why aren’t the bad ones? If so, can I extrapolate from my large stock of racially insensitive jokes an algorithm for relating to my ethnic patients? And if not, why not?

Cultural competency, the vicious cousin of diversity, represents forty years of white intellectual guilt and is part of our inexplicable, lemming-like urge to be non-judgemental. A few decades ago Western intellectuals decided that there was nothing of value in the West and that we must look to primitive, less developed societies for inspiration. It is probably part of the never-ending quest for the noble-savage, untainted by the stain of modern life. This point of view has finally spread to the medical profession which had been better able to resist it due to the basic intelligence and skepticism of physicians.

In practice most of us will rarely encouter any cultural situation which we can’t handle by simply applying common sense and good manners. People are not that different, no matter from where they come. An acute abomen is an acute abdomen regardless of whether it belongs to a white baptist male or a full-fledged Inuit from byond the arctic circle. I don’t care what the inuit traditional practices are to deal with abdominal guarding. The fact that he has presented to my hospital means that at some level he has abandoned his traditional healing in favor of something that works.

The consecrated walrus blubber is obviously not doing the trick.

Pray let us not patronize the poor fellow. I once saw an attending dancing around the issue of traditional practices with an obvioulsy foriegn and exotic-looking patient. She was the soul of sensitivity and was being fastidiously careful not to imply that our Western Medicine had the answers.

Finally the patient held up his hand and said, “That’s all well and good but my cousin in Dakka said I needed to be on a beta-blocker and a statin.”

When in Doubt, Patronize

Housekeeping

To make it easier for those poor souls still using dial-up, I’m going to adjust the format to only show the last twenty posts. This should make things load a little faster. If you haven’t already read them, older posts are still available in the archive.

My lovely wife will be “Guest Blogging” periodically on subjects that might be of interest to the spouses and significant others of medical students and residents. Medical training is a long slog and your partner-in-life should know what to expect.

As always, my humble thanks to all of you for taking the time to read and comment.

Housekeeping

Guest Blogger: Mrs. Panda Bear

Party Night

(I’m going to start a new feature here on Panda Bear, MD. Many pre-meds, medical students, and residents are married and have families and I thought you might like a little perspective from the other half of the team. PB)

Our little panda bear cubs have a name for their daddy being on call. They call it PARTY NIGHT! In daddy’s absence, we all have so much fun putting on our one-piece fleecy jumpers, making popcorn and watching a children’s movie (currently Christmas movies). Provided there is no school the next day, the cubs usually stay up until 10:00 pm and we all get to sleep in late the next morning. Many times on “party night” I share our king sized bed with our three snuggly cubs and 3 dogs.

Sometimes my husband gets his feelings a little hurt when the cubs ask if daddy is going to be on call and squeal in delight when the answer is yes. Managing my husband’s fragile emotions and self esteem, I have to remind him that I am trying to make the best of a potentially miserable evening by creating a really fun time for the cubs and me.

Guest Blogger: Mrs. Panda Bear

Sound and Fury

Family and Community Medicine

Latravia Kell was my favorite patient. I can’t think of one bad hand that life hadn’t dealt her but she was unfailingly cheerful, polite, and compliant with all of her treatments. I met her on my first day of family medicine clinic and saw her at least every month afterwards. I didn’t do too much for her. She had a small platoon of specialists following her various medical conditions. Rheumatology had dominion over her SLE, Orthopedics claimed her osteopenia, Infectious Disease had suzerainty over her HIV and OB/Gyn was following her for various pelvic irregularities. In fact she seemed to have all of her bets covered and I was not sure what she needed from me.

“I’m here for my Depot shot,” she said on her first visit, “All you have to do is sign the form and the nurse will give it to me.”

“Well hell, we can do that,” I said, a little relieved because she seemed a monstrously complicated patient to inflict on an intern. “Is there anything else I can do?”

“No, not really. I’m good.”

Although we later became friends and she hugged me and cried on my last day at Duke, on her first visit I think even my brief physical exam annoyed her.

Later I had to dictate our standard clinic note hitting all of the high points of the chief complaint, history of present illness, and review of systems even though these were completely incidental to the purpose of her visit. I suppose this was to give the illusion that we were actually doing something besides routing her to the shot nurse but it seemed like a lot of sound and fury for nothing. My assessment and plan was basically a list of who was following her for what condition.

But that’s family medicine, at least at a big academic medical center.

I had other regular patients. It’s not as much fun as they make it out to be and occasionally you look at your panel for the day and hope that particular patients decide to skip their appointments.

Like Mrs. Ribitz. I knew that she was old and sickly. I was aware that her bones were fragile sticks and that she had recently fallen and broken her hip and her arm. I knew that ortho had pinned and casted her and that she was in a lot of pain. Hell, she looked terrible. And she smelled like the crappy nursing home where she lived which is not a nice smell as it is basically the smell of stale urine and dried food stains.

But my God could that woman complain. About everything and everyone. After the obligatory “What can I do for you today” she would stare at me malignantly for a few seconds and then launch into a tale of pain and suffering that would have made stones weep if it was anybody but Mrs. Ribitz telling it.

And then she would cough, gasp for air, and take a rest while sucking air through her nasal cannula. Her emphysema didn’t deter her from smoking and my eyes watered in the small examination room from the fumes that permeated her clothing.

“Well, Mrs. Ribitz,” I began while her coughs subsided, “I’m sorry to hear that things aren’t going well but if you had to pick one problem to address today, what would it be?”

“My feet are swelling,” she said curtly, “And my back hurts.”

I took off her slippers and urine-stained socks to examine her feet which were indeed swollen and pulseless, an alarming finding except they has been like that since I started seeing her and no combination of medications or therapies had been able to make a dent in the problem. I threw the Doppler on her and was able to hear the faint, plaintive sound of her tired blood struggling to supply her foot with blood. It was all peripheral vascular disease and poor medical compliance (which sounds nicer on the note than saying, “Patient is an idiot.”) She had already lost three toes to gangrene and I noted that most of the rest were heading that way. There was nothing to do as Mrs. Ribitz was the poster-girl for poor surgical candidates. I confirmed her next appointment with vascular surgery but that was the extent of what I could do for her.

“Tell me about your back pain,” I said with profound regret.

The floodgates opened and I heard, for the tenth time, the story of her chronic pain (from vertebral compression fractures) which was untouched by enough narcotics to drop a small herd of elephants, after which we both looked warily at each other. A physical exam to assess her pain was out of the question. She would probably have a heart attack from the exertion of standing up, which she couldn’t do anyways because of her hip.

“I’m out of Percocet.” A statement. “I need another prescription.”

At one time Mrs. Ribitz had a pain contract but I believe by the time she had exhausted two residents the clinic surrendered and just gave her what she wanted.

“I’ll just write you a prescription and you can be on your way.”

Mrs. Ribitz grunted in satisfaction. I verified the dates of her next appointment with ortho, checked her vitals and stood up to let the nurse wheel her out.

“And don’t even start about my smoking,” she snarled.

“Ma’am. You’re 85. I’m not your father. I’m not going to lecture you but if you want to quit I’m ready to help you.”

Surprisingly, on my last appointment Mrs. Ribitz sobbed uncontrollably and told me I was her only Doctor who wasn’t a pain in the ass and that she would miss me. I guess I kind of grew to like her myself, once I realized that her visits were primarily social calls. She had the usual cadre of specialists addressing her medical problems. All I ever did for her was write for the occasional narcotic and listen to her complaints.

Not every patient was so complicated.

“I’ve got a drip,” said Mr. Ryan nervously after the nurse closed the door.

“I guess we’re not taking post-nasal, right?” I had seen Mr. Ryan several times before.

“Naw, it’s down there.” He gestured down there. “And it hurts when I whiz.”

“Sexually active?”

“Yeah. Do you think it’s the clap?”

“Could be,” I said, “Let’s take a look…yup…certainly looks like it. Tell you what, I’ll send these swabs for cultures and we’ll treat you in the meantime.”

“Hey Doc, don’t tell my wife, Okay?”

“Maybe you need to tell her. I think she needs to know.” This is one of those moral dilemmas they’re always talking about. His wife is also one of my patients.

I had seen his wife just a week before for unusual vaginal bleeding. Of course we ended up referring her to OB/Gyn, just to be safe.

The latest fad in family medicine is identifying “barriers to care.” Naturally, some of these barriers were intuitively easy to identify. Being poor and unable to afford a doctor visit comes to mind, as does being unable because of a disability to travel to the clinic. But some of the barriers are a stretch. Being angry and deciding to express this anger by not taking one’s free prescription medications seemed kind of weak to me but this was exactly the kind of barrier I was supposed to take seriously.

One of our initial clinical assignments was to visit a patient at their home and identify their “barriers to care. My patient was an obese, pleasant, single mother of two with the usual comorbidities, all complicated by medical non-compliance. We weren’t actually supposed to say “non-compliant,” instead substituting the more optimistic and non-judgmental phrase “pre-compliant.’

Having lost her Section 8 housing because of some fraudulent activity which involved subletting her subsidized apartment while she lived with her mother, she lived in a small but adequate house, the rent for which ate up most of her meager income from the public treasury. The first thing she complained about was the poor upkeep of the house and asked me what she was expected to do about it. The social worker who accompanied me nodded empathetically as if to say, “Here, you newly minted doctor and representative of ‘The Man,’ here is a barrier to care. How will you help her over it?”

In my written report I suggested that this was a matter far beyond our scope of practice, something best worked out between the tenant and landlord either amicably or in the City small claims court. Besides, this in no way effected her access to our clinic as her visits cost her exactly nothing and a broken window and leaky faucet are not exactly homeowner’s emergencies.

My wife and I managed a housing project years ago (before my wife quit after discovering a dead tenant which is another story) and we used to get calls at 3AM demanding that we drive across town to unclog a toilet. The helplessness of the dependency class does not admit to any effort, no matter how small, to take responsibility for anything in life. The typical response to the natural question, “Do you have a plunger?” was, “I’m not sticking my hand in the toilet.”

I once got a frantic call from a tenant’s whose apartment was on fire.

“Did you call 911?” I asked.

“No. Do I need to?”

“Not unless you think I’m going to get in my private fire engine and drive over there.”

But I digress.

I also pointed out in my report that despite her claims of poverty, the patient must have had other income. She had furniture, the babies were fed, there was a large (but not extravagant) entertainment center in the living room, and I saw no signs of deprivation of any kind. The children also looked clean and well-cared for. She even had a working automobile.

Apparently her mother helped out.

Lack of daycare was another barrier to care, as it prevented her from coming to clinic even though my wife sometimes has to drag all four of my kids to her doctor’s appointments. I discovered however that while the baby-daddy’s mother, the baby-granny, wanted to take an active role in caring for the children, my patient had refused her access to her grand-children until she bought them expensive clothes as a propitiatory gift. My patient bragged about this. Apparently greed and arrogance were also legitimate barriers to care.

It turned out that she was angry. Yes angry. Angry that when she came to clinic no one listened to her concerns and nobody explained her treatment regimen in a manner which she could understand. Nor did we respect her sensibilities as an independent, intelligent African-American woman.

“I just don’t feel like you take me seriously,” was her explanation as to why she didn’t take her insulin as directed. The social worker soothed her ruffled feathers and I held my tongue. I was not kind to her in my written report. She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care.

Her anger, I wrote, was a form of transference. Impotent and ineffectual in every other aspect of life, she gave herself the illusion of control by making her social worker and the physicians at the clinic jerk like puppets to her whimsy. The clinic, after all, was probably the only place in the world where she was taken seriously. In every other venue she was just a fat, dumb, single mother without the sense to take advantage of the help she has been given by the State.

Tragic, perhaps. A crying shame and a waste of her potential, no doubt. But not a medical problem.

This report was not received well by the program chairwoman. As if I was a third-grader, I was asked to rewrite my homework, not once but twice, in order to please the sensitivities of the program. And the second rewrite wasn’t good enough either. I was asked to write it again but decided to blow it of and never heard about it again.

Sound and Fury