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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

Good Moon Rising

In the transition from an urban medical practice to a rural one, I have found that some of my personal habits mark me as a city slicker. Like an ocean fish that does not notice that it breathes salt water until it is taken out of it, I find that I am now conscious of some things that were invisible to me in the city. My sleeping patterns, for example.

I have always been a late riser, and don’t need to be reminded that medicine is a poor fit for a nocturnal personality. I wish I had thought of that going in. When a person weighs career choices, the time the alarm clock goes off in the morning seems a most trivial factor. Ah, but I was fooled! Rolling out of bed at 4 am for a patient in the ER is a punishing task for someone who considers an 8 o’clock waking a burden. For me, nothing that happens before 11 am is free of the fog of sleep. When I shower in the morning I have to pay attention when I wash my hair, or I may in my morning stupor forget what I have done and wash it again. I have reason to believe that I may have washed it as many as 3 times on especially hazy mornings.

Late rising always struck me as a personal weakness, but it was not until I ensconced in McComb that I recognized it as a city habit. The electric light. The 24-hour grocery. The crowded street at midnight. Cities are always going, going, going. The surrounding bustle  ensures that a doctor doesn’t feel so strange working at night.

In New Orleans I always did hospital rounds after clinic. This meant sometimes starting in the hospital as late as 7 at night, and rounding until 10 or beyond. My latest time home: 2:30 am. Some argue that morning rounds are advantageous – they allow doctors to check on patients after the long night, and to write orders and plan tests for the coming day. If a patient is admitted to the hospital late at night, the morning rounders catch them first thing in the morning. Any poor sucker assigned to me and admitted at midnight might not see my face until the next evening. (Although, in my defense, if a patient was really sick I would trot over during my lunch break to lend them an eyeball.)

On the other hand, an early rounder misses afternoon admits, which wait until the next morning.  My afternooners waited only hours. And I swept the ER before going home at night, meaning only the really late admissions were waiting long. But more importantly, there is simply no doubt that I am faster and better at night. My morning-to-night mistake ratio is probably 3 to 1. Believe me, if I am your doctor, you want to see me at night.

In New Orleans I was not the only late rounder. When I finished rounds and went to my car at 10 o’clock, there were usually several other cars left in the doctor’s parking lot. Not always the same ones, but other ones, nonetheless.

Not in rural Mississippi. Here I get finished at 7 pm and nurses are saying, “Working late, huh?” In my previous life if I got home before 8 my wife would ask me if I had been fired. When I leave the hospital these days, I see one lonely car in the parking lot.

Such is the rural life. We are pretty well modernized here, with plumbing and all I mean, but there is still a culture left over from the days when the milk in the breakfast cereal came from Bessie in the barn. In farm culture everything has to be done in the daylight. When the sun goes down, the thresher is in the barn and the cows have been milked. Even though most people around here are no longer farmers, they have inherited the ethic of the early riser. Almost everything in town is closed after dark, except for the grocery store, a pharmacy, and thank heaven, my exercise club. But I have been up and down my street at midnight and seen lights off at every single house except my own. I feel like an eccentric. Even my wife has taken to turning in at 10:30.

In the city, night and day are just two phases of a continuum, and this is especially true in our fluorescent medical world. I would check on my patients in the ICU at Methodist at 11 pm and the nurses would talk to me as if it were the 10 am coffee break. To them, it was. And this made me feel almost normal, as if I were supposed in a bright room checking the setting on a ventilator while a window few feet away sealed me from a lightless world where crack and money moved in opposite directions, occasionally interrupted by the peal of a 9 millimeter. That was my world. Maybe I shouldn't have been comfortable with it, but I was.

I know the error of my ways. Why should people insist on scurrying about in artificially lighted rooms when there is 12 hours of perfectly good daylight? All the beasts in nature respond to the rhythms of day and night. A doctor is supposed to know the limits of the human machine. What can be accomplished by night that cannot be accomplished as well or better by day?

Well, a lot. On the occasion when I rounded in the AM, I competed with other doctors for charts. Patients were up, going to therapy, going to surgery, going to Xray, going, going, gone – no, not gone THAT way – just hard to find. I would waste precious time wandering around the hospital looking for them. At night, everyone was in bed. Everyone had just completed a day of tests, of therapy, of surgery, and they had stories to tell. Or they were too tired to tell stories, which was just as good for me, since that meant I got home 10 minutes earlier. All peace and quiet, and I had the computers, the staff, the patients, everything to myself.

The night is a little lonely, but when your job involves talking to 50 people a day, this can be a blessing.

As we get older, we tend to get up earlier. Perhaps this is hormones, or our biological clock, or fear that we have forgotten to take out the garbage, or the realization that our time in this world is running out and we are afraid we will miss something. Though instead of looking for something important not to miss, most of us turn on the TV.

For all of my adult life, I have resisted getting up early, but the tug of the old farmer's life may be unmooring me at long last. There is a reason to get back in sync with the world as I know it. As my children get older, they develop regular day-night cycles. If I want to see them awake, I have to be home. In the morning they will be busy getting ready for school, by mid-evening already asleep dreaming of their next day of fun and lessons. If I get home late I only get to see them asleep.

I have a patient here in Mississippi who, every night for the week that I attended him in the hospital, would look at his watch as I came in and say kiddingly, “You have a wife? Not for long if you are still working at 7 o’clock.”

I want to tell him that 7 is nothing compared to my past days. I don’t. I just finish up and hurry home.

A small town is about friends and family. It has to be, because rural life lacks the endless options of the big city. There is nothing to do after dark but be with each other. This is why every small town I have ever been to describes itself as “family-oriented.” It had better be, because “boring-oriented” is the only alternative, and it just doesn’t have that same ring.

The options may be limited, but then again, whether you live in the city or the country, any alternative to friends and family isn’t much comfort anyway. Country folk aren’t fools; they get their work done early so they can go home and cultivate their most important crop -- family life. I can stand to do a little cultivating myself.


Furniture at Last!

Last Wednesday was a big night at our household. About 7 o'clock, there was a knock on our door, and behind it a very tired-looking delivery man who had come all the way from New Orleans. There it was. Furniture. It was a partial shipment, a sofa, a chair and ottoman, a TV stand, and a computer desk. More will come in a few weeks.

It was the first real furniture we have had since Hurricane Katrina. After the storm, we lived in a hotel for a week, my aunt's house in Baton Rouge for a month, and then my mother-in-law's home for two months before we bought our house in McComb, MS. Since then we have subsisted on a cheap futon that was our sofa by day and our children's bed by night, and on some surprisingly comfortable lawn chairs that we picked up at a department store in Metairie. My wife and I still sleep on the floor on an air mattress, as we have most days since August 29.

I am not looking for any sympathy -- this outcome is mostly our fault. After the hurricane, as we went around shopping for replacement furniture, my wife and I made two crucial decisions. First, we decided to buy all our new furniture in New Orleans. Second, we elected to get quality furniture. Since the storm washed everything away and we were starting from scratch, we decided to get the stuff we really wanted, and not to settle for whatever we could get. This complicated things, because by October every decent piece of furniture in southeastern Louisiana was sold out and on 10 weeks’ backorder. But we stuck to our guns. If we were going to replace everything we had, why buy cheap junk off the shelf and then have to replace it in a year or two? It seemed better to order exactly what we wanted, and then wait it out.

Furniture stores opened very early after Katrina. Within a month many homeowners were back in town, FEMA check in hand and ready to rebuild. Needless to say anyone who sold a product related to domestic life was doing great business. If it didn’t have mold it was good as gold. When we were shopping in October and November, it was a pleasure dealing with hardworking salespeople, many of whom had lost everything too, who had rushed back to the city to get their stores re-opened and to help returning evacuees get back on their feet.

At many of the places we went, construction crews were pulling up carpet and ripping out drywall in the showrooms while a few feet away salespeople closed the deals on bedroom sets for anxious people trying to restore order to their entropy-sodden lives.

And while this furious activity was going on, news outlets were telling America that New Orleans was an abandoned wasteland and that the people there were aimlessly wandering about waiting for government handouts.

Nothing changes a person’s appreciation for regular working people like a natural disaster. I remember checking out at a grocery store in early October, watching a man bag my groceries and thinking how glad I was that he came back to work. When no one is around to cut the grass, sweep the sidewalks, deliver the mail, or stock the dairy freezer, you begin to appreciate these things. Not just the heroes in the boats and helicopters that were on TV, but the regular people who do nothing more than show up for work every day and collectively make the world go round.

So how could we go to another city to buy furniture, when these salespeople, in ordinary times beneath anyone’s notice, were working so hard to bring our lives and their own back to normal? We ordered our furniture, and went home to wait the customary 8-12 weeks for it to arrive.

The sofa is great. The kids will be sleeping on it until their beds arrive. As for me, I’ll just keep pumping up that air mattress for a little while longer.


Perhaps a Reason to Study Medicine?

I was reading St. Augustine's Confessions recently, and I came across this passage:

If I ask which would cause the greater inconvenience to someone's life, to forget how to read and write or to forget these fabulous poems [Virgil's Aeneid], who does not see what answer he would give, unless he has totally lost his senses? So it was a sin in me as a boy when I gave pride of place in my affection to these empty fables rather than to more useful studies . . . . (Chapter I xiii (22))

Augustine takes the ascetic attitude that study of fiction or art for pleasure's sake is sinful. We should spend our time learning more basic knowledge, knowledge that will take us closer to God. He believes that the more practical and simpler disciplines are the purer.

It is a flawed argument, to be sure, but it is also one of the reasons I abandoned my career in the arts and letters for medicine. I was looking for a knowledge of practical truth; I wanted to read and write more than to indulge in

Such madness [that] is considered a higher and more fruitful literary education than being taught to read and write.

Read and write is what I do, and I shall not be ashamed of it.


Abortion at 33

This past week marked the 33rd anniversary of Roe v. Wade. Thirty-three is not a landmark year in the typical way we mark anniversaries (10th, 25th, 50th, etc.), but it does have an oddball resonance. In the Christian tradition, 33 was Christ’s age when he was crucified.

Though I consider myself an anti-abortionist, I do not hold that abortion is murder. Murder is the intentional, unjustified, malicious killing of a human being. Even law recognizes that a person can justifiably kill another person in certain circumstances. Substitute a 6 week old fetus for “person,” and “certain circumstances” becomes a murky question.

But not too murky. Many people justify their tolerance for abortion by arguing that it is not knowable when life begins. This is foolish talk. A fetus may not be a full person, but it is not dead. Not by any biological definition of life I have heard of. A rock is not alive; a single cell is. A fertilized egg is a cell. Not fully human as we understand it, but a living, functioning cell.

One of the interesting features of anti-abortion arguments is that they tend to be very biological. They focus on things like when the heart starts beating, when the organs form, and when the fetus starts to suck its thumb. Anti-abortion arguments are very factual, perfused with statistics and blood and gore. Pro-abortionists tend to argue about rights and the imposition of morality upon others. It is an irony of the abortion debate that the side most concerned about morality (anti-abortion) argues biological facts, and the side most concerned about health issues and the mental health of mothers argues the legal ethics. Shouldn’t it be the other way around?

Many people have wondered aloud if the issue of abortion will ever be settled in public life. I don’t think so. Abortion is about pregnancy, which is about sex. As long as humans have lived in societies there have been fundamental disagreements over who should be having sex with whom and when. One side says sex is about pleasure, and that people should do it whenever and wherever they want. The other argues that sex carries the attendant responsibility of reproduction and emotional attachment and that people should do it only with the confines of committed relationships. Or to simplify it, one side considers pleasure the goal of sex, and the other places primacy on reproduction and social structure.

I do not think pleasure should be excluded from discussion about sex by any means. But neither should the potential of reproduction. One of the things that riles moralists most about pro-abortionists is that they seem willing to make sexual intercourse a free lunch. If one drives drunk and kills someone, it is not possible to pay a cash sum for a replacement person and go back to work on Monday. In almost all ethical situations, when a person behaves recklessly, that person must take responsibility for a bad outcome. With sex, a person can behave recklessly ( not use birth control or use it improperly) and still get away from taking responsibility for an undesirable outcome via abortion.

As I see it, this pleasure/reproduction conflict is at the center of the abortion debate, and explains why the battle is likely to go on and on. The pleasure side is willing to jettison the consequences of sexual decisions; the reproductive side is not. Since this difference in views is as old as human civilization, it is hard to see why it should be resolved any time soon.

We all know that the main use for abortion in this country is birth control. There are 1.3 million abortions a year in the U.S., and there is no way the condom broke all those times, or that all those pregnancies are from rape or incest. The vast majority result from women (and men) who simply did not use adequate birth control, and now want a “do over.”

Pro-abortionists argue that a woman’s right to emotional well-being supersedes the rights of a clump of cells to continue to live. In other words, a woman’s right to happiness gives her the right to kill. Note I did not say murder, I said kill. It may be debatable whether abortion is murder, but I do not think it is debatable that abortion is killing. Some have argued that a life form must exist independently from its parent to be considered alive, but I know of no biological concept that supports this. Parasites are dependent on their hosts, completely, to exist, but no one argues that they are not alive. You have to kill a tapeworm to get rid of it.

At the very least, pro-abortionists should have the honesty to admit that abortion is not an absolute, but rather a relative right. It is dishonest to argue that abortion is not killing; instead, the more honest argument is utilitarian: abortion is the greater good trumping the lesser. I versus a cockroach. Both have some right to live, but one clearly is more valuable than the other, and there is no way both can live together. (I will not live with a cockroach. So it goes.)

Of course, abortionists shrink from this argument because they know as soon as they admit the fetus is alive they have opened themselves up to being tagged as killers. In the interest of fair play, anti-abortionists can ease the pain of this admission by making the counter-concession that abortion is not murder. If both sides could at least come that far, there might be a way for us to tolerate each other.

If we could just come to agree that abortion is killing, and that it is undesirable, we could start to make progress. It bothers me a little that abortion is considered a civic right, but what really bothers me is that it happens 1.3 million times a year. If pro and anti people could agree that abortion is killing but not murder, we could get to the important part – getting that 1.3 million number down.

Would I like to see Roe v. Wade overturned by the Supreme Court? Actually, I am indifferent to that. Many people think that if Roe v. Wade were overturned abortion would be illegal in the U.S. Not so. Roe v. Wade made it illegal for states to write laws banning abortion. But if Roe is overturned, all that means is that states can ban abortion if they want to. Many, including California, New York, and Massachusetts are almost certain make abortion explicitly legal if Roe is undone. Others, like Utah and Louisiana, are just as certain to restrict or ban it. Conservatives, who think they are winning a great battle by packing the Supreme Court with conservative judges, will find the abortion question thrown to each state legislature. There will be a state-by-state battle for abortion, and pro-abortionists will win some and lose some, creating a patchwork quilt of abortion laws nationwide. Then abortion will become like gambling is in this country – banned in most places but available within a 2 hour drive from almost anywhere. Only Alaska and Hawaii are remote enough to have a realistic chance of eliminating abortion access for their citizens should they choose to do so.

If this sounds like further politicization of an already over-politicized issue, it is. No matter what the law says about abortion, one side or another will always be rallying to defeat the other. If the Supreme Court recuses itself by abandoning Roe, the national battle will balkanize into 50 state battles. This will never forward the cause of morality.

In the case of murder, every state has laws against it. For the average citizen, this means the problem of legalities is settled, leaving individuals to get down to the more substantial work of creating a society in which no one wants to commit murder. Good schools, good jobs, a fair legal system, and so on. We ban murder, but it still happens. The hardest work is not banning it, it is getting the numbers down.

Perhaps we could all agree to set aside the legal issue and concentrate on the numbers. If anti-abortionists and pro-abortionists would just agree that abortion is killing but not murder, and that it is not a desirable form of birth control, we could skip over the legal wrestling match and start teaching people to behave responsibly.

As a doctor, I have never turned down a request for birth control unless it was medically contraindicated, which is a very rare situation. I feel every birth control prescription I write potentially saves an abortion, and with that mentality I would write for it all day every day until my fingers bled, if necessary.

Abortionists say that women must be allowed the right to choose it because they have the right to their own bodies. I am not willing to concede that women have the freedom to kill under for any reason whatsoever, whether it be because the pregnancy is life-threatening or because the woman is going to the Bahamas in 3 months and doesn’t want her stomach to pooch out in a bikini. Certainly anyone can see that those two situations are completely different and that completely different ethical standards apply.

If there were only 10,000 abortions a year in this country, the question of legality would be important. In that case, abortion would be rare and only carried out for serious reasons. The battleground would be over hard cases, like 14 year olds who had been raped by their fathers, or women with cancer who need chemotherapy immediately. The more cases there are, the more safely we can assume that abortions are being performed for convenience rather than necessity.

Who are you to decide what constitutes convenience or necessity, some will ask. Well, I guess I am nobody. It has never been my desire to tell people how to live their lives – I have my hands full living mine. But if we can agree that abortion is killing in some form, then we can agree that there is some moral value in preventing it. Certainly if two people go to bed together thinking, “Well, if she gets pregnant we’ll just go for the abortion,” something is amiss. There can’t be that many people around who consider abortion a form of birth control ethically on-par with condoms, or even abstinence.

It is also reasonable to argue that if abortions are moral in all cases then we should also legalize euthanasia for people who are depressed. After all, the justification of abortion is that the suffering the mother would endure in having the child is greater than the harm done in killing a fetus. This implies that killing may be justified to relieve emotional pain. Hence, a deeply depressed person should be put down if that is his choice.

Laws, if enforced properly, might prevent almost all abortions. Or they might engender distrust and hatred and put society in the uncomfortable position of having to imprison doctors and formerly pregnant teenagers. (Those arguing that only abortion doctors need be prosecuted are fooling themselves. How do you ban something and then let the person who makes the choice to violate the law go free?) As for me, I would be satisfied with preventing as many abortions as I can and leaving the most painful decisions to the people making them.

Before I close, I want to tie up two loose ends. First, the problem of exceptions. A friend of mine once criticized my anti-abortionism by saying that my readiness to consider exceptions for rape and incest is a flaw. I don’t think so. Society recognizes exceptions to killing in other contexts, such as the person who shoots an intruder in his home or the soldier who kills an enemy. I am not above saying that killing is sometimes necessary. My way out with abortion is that I do not consider it murder, but rather killing. Killing can be justified. Although I am dubious about rape and incest as a justification for killing, I am willing to admit that not everyone sees things my way and that many consider the emotional pain of bearing the product of a rape of greater importance than the life of a fetus. Again, I want to reduce abortions, and if an agreement to exceptions brings both sides together and lays the groundwork for a concerted effort to prevent abortions, then is a concession I am willing to make. Better that than having the pro-abortionists banging the table and demanding full moral amnesty for all abortions no matter what, as they are doing now.

The second loose end: the reader may have noticed that I do not use the words “pro-life” and “pro-choice.” These are silly phrases that obscure the real issue at hand. I support life and I support choice. I want more women to choose not to have abortions, or even better, to choose the medical means we have to keep from ever getting pregnant in the first place. I am not against choosing. I am against abortions.


Katrina #8: Severe ER Shortages in New Orleans

Of all the national media outlets, National Public Radio has done the best job of covering the post-Katrina story. Today it has an excellent story about the crippled ERs of New Orleans. To wit: Katrina shut down so many facilities in the city that there is now a critical shortage of ER beds. The 4 existing hospital ERs are running at way over capacity, and any sudden spike in ER need (a flu epidemic, or Mardi Gras, for example) could mean disaster.

In a previous post I noted that 10 hospitals in the New Orleans area were destroyed in Hurricane Katrina. That includes 3 that I used to work at. Those 3 facilities are all owned by one company, Universal Health Services of King of Prussia, PA. Unfortunately, UHS has no intentions of refitting two of the facilities it owns at this time. The third it may open again in 5 years.A quick visit to the UHS website supports my impression that UHS intends to do nothing -- the page discussing the status of the facilities has not been updated since September.

Only 4 years ago, the three hospitals in New Orleans East were owned by three different organizations, but since then UHS came in and bought up all three, later closing one of the three as an acute care facility.

While it is understandable that UHS, as a for-profit company, would want to wait until it is assured of a steady income before re-investing millions in a ruined hospital, I think the patient load in the surviving ERs in the city strongly suggests that any reopened ER would be extremely busy. Hospitals are more than just profit centers, though. Anyone who owns a hospital license (and UHS has three) has a responsibility to its community to try to operate, especially after a major natural disaster, even if only on a limited basis.

But UHS is doing nothing, holding its cards, perhaps looking to sell out later when the value of its holdings go up, perhaps waiting until its truly profitable investments, like outpatient surgery and cath lab, can come back. Meanwhile New Orleanians suffer.

I think UHS has a responsibility to the city to either sell to anyone who will develop the hospitals now or to try to get some kind of temporary services going. But all it does is sit and sit. It has already laid off all of its staff, meaning any recovery effort is months away from even getting underway.

What a shame.

On a brighter note, I would like to wish Wolfgang Amadeus Mozart a happy 250th birthday. In celebration, I will be listening to Wolfie all day in my office.