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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project
Saturday
Mar252006

The Heart Is a Shingled Dwelling

I was in my front yard, a roofer standing next to me. After a few brief words, clipboard in hand, he stepped away, then paced back and forth along the length of my lawn. His sun dried eyes squinted at every angle of my house, and he recorded each observation on a form.

“Dbl. peaked roof,” he said. “House 1800 sq. ft. 30% grade. 2 skylights. ” He spat out his words in short, tight breaths, the very tone of his voice implying that he spoke as well as wrote in abbreviations. After filling in a few blanks on the form, he punched up some numbers on a calculator, tore off part of the sheet and handed it to me. “Here’s your est.”

I glanced down at the paper, and couldn’t believe my eyes. It was the cheapest roofing estimate I had ever seen. “Are you serious? You can replace my whole roof for this price?”

“Sure can,” he said. “I just got a new shipment of roofing materials from a friend in Mexico. Cheapest stuff you’re ever gonna see.”

“Cheap? As in cheap price, you mean? This is good roofing material, right?” I asked.

“Oh, no,” he replied. “Junk. Pure junk. The shingles are a light as paper. That’s why I can put it on so cheap. So light one guy can lift 5 sq. on his back and climb up the ladder one hand free. We fasten it up there with plastic staples. Cheap, cheap stuff.”

Now I was just confused. My voice halted. “Why . . . why, would I want a cheap roof? I want a good roof.”

“Now, think about this, Mr. Hebert. I’ve been talking to a lot of people lately and selling a lot of these cheap roofs. Hear me out.” His hand moved to his breast pocket instinctively. There was a pack of cigarettes there. “Today is nice. Light wind, sunshine. You don’t need an expensive roof today.

“Consider when it rains. Most of the time the rain is light. A few 10 mph gusts. Nuthin’ much. You don’t need an expensive roof then, neither.”

“Friend,” I said, “I appreciate your concern for my financial well being. But I would like to point out that within the last year we had a hurricane. Hurricanes bring one hundred and twenty-five mile-an-hour winds.” I was in no mood to talk in abbreviations. “I am not concerned about sweet winds jostling the daffodils. I am concerned about a storm sending my roof into the swamp.”

“Yes, but, hear out, hear me out. A storm like that comes every 100 yrs. A T-storm bad enough to knock this roof off will come once a year. That’s 4 hrs. in 1 day, or only 0.04% of the time. On the flip side, that means the roof is fine 99.96% of the time. I don’t know about you, but a roof that works 99.96% of the time sounds like a great deal to me.

“You’re a doctor, aren’t you, Mr. Hebert? How would you feel about a medical treatment that worked 99.96% of the time? 99.96 . . . .99.96 . . . . 99.96 . . . .”

I blinked. My house was gone, the roofer was gone. I was in my office, in an exam room, talking to one of my patients, Mrs. Plum.

“Ninety-nine dollars and ninety-six cents. That’s what my cousin pays for one prescription of blood pressure medications. I can’t afford that.”

Rising out of my daze, I said, “Mrs. Plum, you don’t need anything as expensive as all that. I can write you a generic. The point, though, is that your pressure has been a little high the past two visits. It is a problem we ought to address.”

“Doctor Hebert,” she said nicely. I stiffened in my seat. When a Southern lady suddenly turns honey sweet, that means she does not intend to be denied. “My pressure is only high when I come into your office. When I take it at home, it is fine. I think it is just the anxiety of coming to the doctor.”

“Yes, I understand that, but . . . “

“I only come here once every few months. The rest of the time I am at home, calm and relaxed, and my blood pressure is fine. Ninety-nine percent of the time, it is fine. Why do I need to take pressure pills when my pressure is only up one percent of the time?”

I opened my mouth to answer the question, but I thought I heard tremendous roar of a hurricane gust strike my office. I looked out the window, and the view was calm and peaceful. Stalks of pine bark crowded the slopes outside, and the honest sun shone beneficently down upon it all.

It went against reason that a single hour, one twenty-fourth of one three hundred-and-sixty-fifth of one seventy-seventh of a life could make all the difference. Experience said otherwise.

That kind sun was shining on thousands of little Hurricane Katrinas at that very moment, thousands of tiny little blockages in the coronary artery system that would only last a few hours but would produce enough damage to splinter an entire life.

“Mrs. Plum,” I finally said, “you don’t take heart medicine when your heart is sick. You take it to keep your heart from getting sick. Now is the time to start taking your medicine because you are well. If you wait until the damage is done, all you will be doing is picking up the debris.”

“Debris?” she said. “Debris? We’re not talking about a tornado here, doctor. We’re taking about my heart!”

I wrote her a prescription for an antihypertensive. She said something to me as she left, but I can’t remember if she told me she was going to take it or not. I was distracted by the view in the window, the silent spring day, ever so placid.

                    The winds that will be howling at all hoours
                    And are upgathered now like sleeping flowers.

-- W. Wordsworth.



Friday
Mar242006

Big Brother Strikes Again

It is one of the most disturbing developments I have seen in the medical blogosphere in quite some time. GeekNurse is gone! GeekNurse was a blog about the experiences of a pediatrics RN in Auckland, New Zealand. It was also one of my favorite medical blogs, though I was a latecomer. I often enjoy reading nurses' blogs, because they offer a perspective on the medical life that is different from the physician.

GeekNurse closed down with a very cryptic and Orwellian message:

Closed

Owing to concerns raised by staff and management, GN's archive has been removed from public display.

 

What confounds me the most is the very bureaucratic and political nature of the statement. It is written in the passive voice ("concerns raised by staff and management" and "archive has been removed"), a stylistic ploy authoritarians use to hide the identity of the perpetrator (as in the classic Washington standby, "mistakes have been made"). The phrase "staff and management" also has that Iron Curtain-ish feel to it. GeekNurse is a lively and often humorous writer, and I have a hard time believing he could have authored that statement, at least not without a gun to his head.

The commenters on the site seem to feel "staff and management" refers to the administrators at the hospital where he works. Though GeekNurse is a pseudonym, he apparently identified himself by name in the copyright statement of his blog, so he would have been an easy target for witch hunters. Having worked in many hospitals myself, I can see how a hospital administration might apply pressure to one of its employees to prevent him from embarrassing them, or (more legitimately) from compromising patient confidentiality.

It is worth noting that if the closing of GeekNurse was the act of a hospital administration and if it was done over the concern for patient confidentiality, this does not excuse an act of censorship. Often, especially in academic or public-minded institutions, there is the belief that censorship is acceptable if the intent is benign. Unfortunately, this attitude overlooks the value of the discordant voice in any society. In my mind, there is no distinction between benificent censorship and forced homogeneity.  

GeekNurse was never offensive that I know of. And erasing an entire blog is a radical response to a conflict of interest. If there was a problem, why couldn't GN remove the few entries in question and then issue a public statement explaining what was done?

I worry about this because I too am a hospital employee, having signed on with Southwest Mississippi Regional Medical Center in McComb, Mississippi. Though Southwest has never said a word to me about my website (in truth, I do not know if they know it exists), I occasionally worry that one day I will be approached about the content of my blog. Since I am a doctor, my employment options are many, so I doubt I would take any kind of censorship lying down. Of course, one never knows until the time comes.

What I would like from GeekNurse is an explanation. I would even more dearly like to hear from "staff and management." Freedom of speech is a very precious right, and we bloggers should not let something like this pass without comment. 

 

Thursday
Mar162006

The Internet "Recency Bias"

A friend writes:

Personally, I'm strongly against the extreme recency bias of the internet.

I like the choice of words, "recency bias." The internet, of course, being a means of rapid communication, lends itself easily to immediacy. But sound thinking and immediacy often (though not always) find themselves enemies.

There is an international movement among chefs, the slow food movement, to  return to the pleasures of prepared foods and "escape the homogenization of modern fast food and life." A great idea.

Maybe we need a Slow Thinking Movement. For those of us that take a week or two (or months, or years) to make up our minds about issues. The Gulf War? Not sure yet. The Sexual Revolution? Still thinking about subscribing to Ms. magazine to see what the fuss is about. The Renaissance? Waiting to see if it takes.

Every election, I get to have my brain insulted by political attacks on flip-floppers. Hey, a flip-flopper is someone who has made up his mind twice. That's a commitment to rapid commitment if I've ever heard of one. I can think of issues I have known about since childhood that I have not made up my mind about once. Jesus. Well, there's one right there.

Somebody needs to stand up for all the people who just don't know. The Slow Thinkers. The ones getting around to it. Do we really have to have an opinion today? Can't it wait? We could band together and force leaders worldwide to take things under advisement instead of blurting out first responses. Islamic extremists, for example, would benefit handsomely from a few more "Anti-American Reconsideration Committees." (Speaking of which, I love the word committee. Two ms, two ts, two es. A word that just doesn't want to end.)

We could encourage people to check off the "I don't know" option to every answer for every survey. Of course it would mean the end of the careers of many pundits, but luckily we haven't decided to eliminate welfare just yet. That plan is in the slow cooker.

I  could be the leader. Well, let me think about it . . . . 

Tuesday
Mar142006

Democracy in New Orleans?

Of all the stories coming out of New Orleans lately, this one irritates me the most: The NAACP is trying to block mayor and city council elections scheduled for April 22, arguing that too many displaced individuals will not be able to vote. Since the displaced people are mostly black, this means the election, if held, will discriminate against them.

There is some merit to this argument, but it is wrong on so many other levels that the NAACP is insane to pursue it. The NAACP is petitioning a federal court, arguing that the election is illegal because it will leave too many voters out. Now, I have lived in a democratic society my entire life, and I have never before heard anyone argue that it is against the law for a city to hold a general election, especially one mandated in the city charter. Since when is it illegal to hold an election in America? The election has already been postponed once!

Imagine two athletes are about to compete in a sprint. Then, suppose one of the referees in the race says the race is unfair because it is too short a distance and favors one runner over the other. The referee argues that the race should be lengthened to make it fairer. So far so good. But here’s the catch: the referee declines to say exactly how long the race should be. Instead, he intends to end the race when his favorite racer is in the lead, no matter when that happens.

This is exactly what the NAACP is doing. It wants to delay the elections, not to a specific date, but to some time in the future when there are enough black people back in New Orleans to make the electorate 50% African-American.

This strategy is very close to fixing an election. How else to describe a legal effort to block an election until the ethnic balance of the electorate suits your druthers? One of the glorious things about an American election is that, come election day, no one really knows who is going to show up. This and the many other unknowns keep elections out of the reach of schemers who try to manipulate the democratic process. In New Orleans, more than in any big city election in recent history, no one knows who will vote. That is the beauty of the thing, and the reason the elections should happen, rain or shine, as soon as possible.

What could be more fair than an election with an outcome totally up for grabs? The mayor’s race has 23 candidates. That is the most dramatic evidence of a fair election you will ever see in America. The fact that 22 people think they can beat an incumbent mayor tells me that there are a lot of people around who feel that this is the one time they have a fair chance to make their mark in what ordinarily is an insider’s game.

Clearly the evacuees need to be heard from in the election. This is not prohibitively difficult. The first time I ever voted in an election, I voted absentee from my college in Virginia. Absentee voting works in every other election. It works for all the troops in the military stationed throughout the world. It can work for New Orleans.

New Orleans is suffering from a terrible absence of leadership, and the last thing it needs is a lame duck mayor and city council wandering aimlessly, awaiting an election. New Orleans needs an election immediately, if for no other reason than to shake things up and get some people in place with a voter mandate for change. Without change, this city could stumble and fall.

Looked at that way, the NAACP is the worst enemy the African-Americans of New Orleans have.

Sunday
Mar122006

Off the Cuff Remarks

I was just covering for the weekend. "Just covering" means doing a lot of dancing on thin ice. I round on dozens of patients, none of whom I have ever seen before or will ever see again. All I know about them is what I read in the chart in the previous 5 minutes before I go into the hospital room. Though I know the medicine concerning every patient -- pneumonia, pulmonary embolism, or squamous cell carcinoma of the lung -- what I lack is knowledge of the specifics of the case. I know the science, but I don't know the patient. When I go into the hospital room and start talking, I immediately start my ice dancing routine, telling them everything I know about the science of their illness, and nothing about their personal situation. It may not be fair, but it gets me through most of the time.

Room 441 looked easy. DNR was written loudly on the chart, telling me that the patient and family recognized that the end was near and were requesting that no resuscitation measures be taken. The most recent progress note from the primary care physician was even more assuring. The patient, who had had advanced lung cancer, suffered cardiopulmonary arrest at home when a blood clot from her leg flaked off and lodged in her lung. The heart stopped for 15 minutes, and she now had severe brain injury. The last remark on the note was a nice, clean skating line: "Comfort care measures only." A simple, straightforward case of a patient waiting for death. All I had to do was play the babysitter, as easy a gliding path as I could hope for.

I went in, and found myself surrounded by anxious family members. My stomach told me this would not be as easy as I had hoped. Yes, the family had consented to abandon all medical intervention except comfort measures, but they were not entirely comfortable with their decision.

The patient's middle-aged daughter was at the bedside, and I could tell that the eye of this storm of anxiety quietly spun around her. She had many questions.

She was probing me. Every doctor has this experience from time to time. A patient or family member is not entirely satisfied with another doctor's opinion, so she probes another doctor to see if he agrees. Each question and statement she made seemed a test to see if I would answer the same way my partner did. Did I agree with the diagnosis? The prognosis?

I strapped on my skates. Carefully I spiraled around every question, throwing in triple loops and double axels of knowledge to keep my answers sounding credible. This lady was very sick, and she would not last long. I tried to assure the daughter that the decision to limit treatment to comfort care was indeed the right one, even though ten minutes ago I did not even know this patient existed.

Everything kept coming back to a single concern. In the intensive care unit, her mother continually ran a low blood pressure. As soon as she got to the floor, her pressure jumped up fifty points higher and has remained there ever since. How could it be that her pressure suddenly rose?

I tried the typical dance moves. Maybe the equipment was different. Maybe a medication had been changed that raised the pressure. Patients often have variations in blood pressure from day to day. Anyway, I said, it was nothing to worry about. High pressure or low pressure, I assured the nervous family, her prognosis was the same.

Still the daughter pursued the issue. I couldn't figure out the concern, but it was obvious that the blood pressure discrepancy was important to her. During her queries, my eyes wandered, and I spotted a blood pressure cuff (technically, a sphygmomanometer) mounted on the wall. I sighed impatiently. I was busy. I was running way behind. It had been a long day, and I didn't want to do it. But she was not going to stop, so I did something I haven't done in a long time.

I took a blood pressure measurement myself. With my own, pristine, doctor's hands. As every eye in the room focussed on me, I velcroed the cuff around the woman's flaccid arm and adjusted and readjusted its position. I pumped up the bladder, and slowly bled the air. Then I did it again, just to be sure.

"Ninety over fifty-eight," I said. It was the same measurement the ICU nurses had been getting. I had just proved the floor nursing aides wrong.

Trouble. That was my first thought. The daughter would use this information to argue that the floor aides were incompetent.  Now I would hear it: the floor nurses don't know what they are doing, they have given up on my mother because she is dying. I braced myself.

The daughter surprised me. Her face relaxed as if a great hand had passed over it, delivering the blessing of peace. I had made her happy.

Then I realized what had happened. The daughter had been fearful that the higher pressure meant her mother's heart was getting stronger. She was having doubts about her decision. When I demonstrated that the low pressure was real, she relaxed in the knowledge that indeed her mother's heart was as weak as ever. It reassured her she was right in continuing with comfort care.

She was wrong to doubt herself. Her mother's brain was gone, no matter what the blood pressure was. Strong heart, weak heart, no matter. She was still a vegetable. The daughter logically knew this, but she needed proof.

When the daughter expressed her relief I was able to excuse myself at last and left the room. I closed the door and walked down the hall thinking, I just did nothing. Absolutely nothing. Yet the nothing I did mattered very much to that patient's daughter.

The patient died that night.

It was a typical day's work for me. I am often at my best when doing the least,

Author's Note: Some of the identifying facts in this story were changed after the first posting to keep the identity of the patient in confidence.