Monday, March 30, 2009
In some respects, capitation makes sense; a general pediatrician sees many, many well children a year, and the reimbursement for seeing a well child should be straightforward to calculate: the physician's time, health education, vaccinations, vision and hearing exams, routine laboratory tests, overhead, a little more to cover expected sick visits, etc.
But capitation also has disadvantages. For example, teenagers rarely go to the doctor. Capitation favors practices that recruit teenagers; they'll get paid each year for each teenager, but can double book teenagers expecting that they won't show up. On the other end of the spectrum, very sick children such as those with genetic or chronic diseases will be costly for physicians to take. If reimbursements are the same for a healthy child and a sick child, this is a disincentive to caring for those who need it the most.
Sunday, March 29, 2009
Resisting gas-mask theriac
plunging this pool of honey
faces quivering like reflections in a pebble-battered
pond of honey
viscous struggle, filling ears and eyes and mouth and nose
dancing into my brain
A daffodil sees itself calm
among lakes of gold
idling away petals
a sick-saccharine breeze-
dreamlike, this painted town where
lovers try positions they can't handle
lanterns trickle through the streets
that radiant face
that scented glow
clouds can hardly conceal
Up down in out
paddling through amalgam river
quicksilver and longing
to wake up again.
Image is of Narcissus by Caravaggio, 1597-1599, oil on canvas, Galleria Nazionale d'Arte Antica, taken from Wikipedia, in the public domain.
Saturday, March 28, 2009
Friday, March 27, 2009
First, there is a paucity of research, data, and information on this sort of situation; we don't even have accurate numbers on how common "in-flight consults" are. Common "emergencies" include neurologic problems (fainting, strokes), exacerbation of cardiovascular or pulmonary disease, and gastrointestinal symptoms. About 10% of the calls are for kids (often having seizures). Unfortunately, medical kits aboard U.S. planes are often woefully incomplete. The stethoscope (and blood pressure cuff) are limited by the loud ambient noise (imagine listening for wheezes over the noise of the engines). Equipment for an IV line is available, but the only bag to hang is 500cc of normal saline, hardly enough to do a resuscitation. Needles are present, but due to safety fears, scalpels are not. For pulmonary problems, there are oral and nasal airways along with a generic bag-valve-mask and oxygen. All planes carry an AED (defibrillator to shock the heart in case of a life-threatening rhythm) which can be used as a monitor and rudimentary EKG. The drugs on board are frighteningly limited: epinephrine, nitroglycerin, 1 amp of D50, diphenhydramine, atropine, and perhaps one or two more medicines.
Physician volunteers act as a consultant to the pilot. They can have the pilot do several things: continue the course, drop to a lower altitude (useful to increase the partial pressure of oxygen and decrease expansion of gases in a closed space), or divert. Diversions, as you would expect, are extremely expensive and still take a substantial amount of time. They're also limited; a transatlantic flight doesn't have that option. Planes often consult with ground medical staff who are familiar with the resources on the plane.
Legally, responders on a plane are protected by Good Samaritan laws. I think it's important to respond in such emergencies. It's scary, and the resources are limited, but as physicians, we carry our knowledge, skills, and responsibilities into different and strange settings.
Image is in the public domain.
Wednesday, March 25, 2009
I was talking to one of my classmates who was less enchanted about primary care pediatrics. One question that was brought up was whether these visits were important or necessary. For the most part, these kids are healthy, thriving, and happy. Many of them are only here for vaccinations. Yet they take up a decent amount of health care resources; the clinic is always overflowing and physician time is precious. Do kids who get routine pediatric care do better than kids who do not? I'm not sure, and I actually think it's an interesting and worthwhile question. Certainly, we would like to think that people plugged into the health care system do better, but given a population which is so healthy in general, what is the cost-benefit analysis?
Tuesday, March 24, 2009
Monday, March 23, 2009
This rotation has less formal didactics than other rotations; we have one afternoon for laid-back case discussions. But we join the residents for morning report and noon conference, and most of the learning is on the job.
Sunday, March 22, 2009
Questions of Travel
The doctor surprised me,
young, no-nonsense, hair in a bun,
black steel and angled.
She did not blink.
Her questions carve
turkey for Thanksgiving dinner.
This woman could take call like Scheherazade,
live in a hospital and crave nothing else.
I needed vaccinations for Egypt,
a land of hieroglyphics, Nefertiti,
and pharaohs in sealed tombs, as if
the country produced nothing but history and historians.
Oh, how it surprised me when I saw
cars rather than camels traveled the roads
and hotels were not shaped like clay pyramids.
How it surprised me when I asked
the doctor Questions of Travel
instead of the sterile and rehearsed,
she recited Elizabeth Bishop's poem,
eyes closed, lips deliberate in rapture, anticipation.
Friday, March 20, 2009
Thursday, March 19, 2009
I've always been somewhat interested in anesthesia given my past experiences. As an undergraduate, I serendipitously stumbled upon a seminar taught by anesthesiologist Dr. Rosenthal, an emeritus professor at Stanford. Since then, I have worked with anesthesiologists in clinical and research settings. I like the combination of procedures and medicine, the focus on one patient at a time, the defined length of care. My personality fits anesthesia well; I like being organized, planning, anticipating problems, and instant gratification. I enjoy the OR setting. If I went into anesthesia, I would further train in critical care or cardiac anesthesia because I like complexity and difficulty. I think after this rotation, anesthesia remains high on my list of possible specialties, but I know there are things I'd miss about medicine if I only did anesthesia.
Wednesday, March 18, 2009
Tuesday, March 17, 2009
Monday, March 16, 2009
But I've been convinced that the lay public, and even most doctors have no idea what anesthesia involves. We spend our time behind the blue curtain, projecting a confident smile, but behind the scenes, anesthesiologists do an amazing amount. Surgeons sometimes complain that "all the patient sees after the four hour operation is the dressing." Anesthesia is the same. The best you can do is what is expected, for the patient to wake up with her original baseline function. None of the stuff that anesthesiologists do is ever seen by patients or other doctors.
Anesthesia is the practice of vigilance. Most surgeries go as planned, without complications. But the anesthesiologist must be prepared to deal with anything. One attending compared it to driving a car. There are so many things to attend to that it's surprisingly difficult at first. I have my eye on the heart rate and blood pressure, and all of a sudden the attending points out the IV bag is empty or the patient might be moving or the surgeons are having more blood loss. As I'm putting in the IV, I have trouble listening to the beep of the heart rate or keeping an eye on the monitors. My attending reassured me that like driving a car, things are overwhelming when you start. But after a while, you can pay attention to the road, know the cars around you, gauge your speed, watch your gas, adjust the temperature, listen to the radio, navigate, and (with a hands-free device) talk on the phone. I can see how anesthesia is similar.
Sunday, March 15, 2009
Unaccustomed to the civilities of high tea
we picked at our three tiered sandwiches
and let our conversation wander to the named days:
Pi Day, preceding the Ides of March.
Gone are the days of cryptic soothsayers;
now we have scientific hypotheses, cause and effect,
domino by domino, clacking down train tracks.
Nevermore will Oedipus and Jocasta sin,
no longer will we call on Odin's fury.
No - life now consists of Earl Grey
and double Devonshire clotted cream,
organic and sustainable, scientifically justifiable.
The Ides of March have come and gone.
Saturday, March 14, 2009
However, the most amazing surgeries I saw were the heart surgeries. I saw two bypass surgeries (CABG) and one aortic root repair for an aortic aneurysm. At the beginning of the surgery, the resident begins harvesting the bypass vein (saphenous for both of the surgeries I saw) while the attending does a median sternotomy. This vertical midline incision involves sawing through the sternum or breastbone. We adjust our ventilation settings to allow the surgeon to work in the chest cavity and dissect out the pericardium to examine the heart.
Seeing the heart is beautiful. I love seeing the dynamic pumping, the anatomy, and the pathology. All the surgeries I saw were done on cardiopulmonary bypass where they stop the heart, remove blood from the body to oxygenate it and remove waste products, and return the blood to the body. In order to do so, they have to cannulate the aorta and superior vena cava. We bring down the blood pressures to allow the surgeon to cut into the aorta, put in a tube, and suture it down. We then heparanize the patient to thin the blood for bypass.
Finally, the perfusionist starts the cardiopulmonary bypass, and the surgeon cross-clamps the aorta. The heart is stopped with ice and medications. I always feel apprehensive watching the heart bathed in ice and watching the EKG show hypothermia, then arrhythmias, then asystole. After the heart is still and empty of blood, the surgeon can begin the procedure, sewing the graft onto the heart in the CABGs or sewing an artificial mesh into the aortic root repair. After the repair, we take the patient off bypass, reverse the heparin with protamine, and watch tensely to see if the heart regains function. In some surgeries, I've seen the heart go into ventricular tachycardia and then fibrillation, a life threatening condition. While the surgeons shock the heart directly, we gave resuscitation medications. I unfortunately also saw an intraoperative myocardial infarction ("heart attack"), all risks with such large procedures. The surgeons finally insert chest tubes to prevent cardiac tamponade and wire the sternum together.
Image is in the public domain, from Wikipedia.
Thursday, March 12, 2009
I've also gotten to do a few other cool things. I got to insert a spinal needle, do some regional blocks (femoral nerve and sciatic nerve), and thread a Swan-Ganz catheter from the superior vena cava into the pulmonary artery. For shorter cases, I get to put in a laryngeal mask airway or nasal airway; to empty the stomach, I put in orogastric or nasogastric tubes. All these hands on things are pretty fun, but make me realize that preparation is the key to success.
Image is in the public domain, from Wikipedia.
Wednesday, March 11, 2009
Tuesday, March 10, 2009
On this rotation, our primary objectives are to learn the role of the anesthesiologist, the prepartion of a patient for a surgery, and basics of airway management, sedation, and pain control. We are encouraged to do as much hands-on stuff as we can, especially putting in IVs and intubating (putting a tube in the trachea or windpipe so that a ventilator can help someone breathe). We learn a bit about making an anesthetic plan, interpreting data, and anticipating problems. It's just a two week rotation, but there's a good mix of didactics and clinical operating room experience; as a result, I'm having little time to blog.
Sunday, March 08, 2009
Dostoevsky, to his Brother
Russia's never warm any time of year
but my other option was hell
I was blindfolded, back against the wall
ready for the tolling of the bell
Someday I might write a book
one of the pastimes of exile
a writer emerging from imprisonment?
will never go out of style.
Saturday, March 07, 2009
I love stories. I love reading fiction, listening to people's lives, writing. In medicine, I enjoy patient narratives, learning about who they are, even thinking about the evolution of their diseases. I like drunk speeches, bedtime stories, historical accounts, philosophical arguments. I can't converse about sports figures or movie stars, but I like talking about authors. Instead of collecting souvenirs from worldly travels or fine wines, I have a folder with my favorite short fiction and a collection of my favorite poems. I rarely talk about food; instead, I talk about the conversation held over dinner. Everyone has their thing; stories are mine.
Friday, March 06, 2009
Thursday, March 05, 2009
Tuesday, March 03, 2009
"There is still some talk in medical deans' offices about the need for general culture, but nobody really means it, and certainly the premedical students don't believe it. They concentrate on science.
They concentrate on science with a fury, and they live for grades. [...] The atmosphere of the liberal-arts college is being poisoned by premedical students. It is not the fault of the students, who do not start out as a necessarily bad lot. They behave as they do in the firm belief that if they behave any otherwise they won't get into medical school.
[There ought to be] some central, core discipline, universal within the curricula of all the colleges, which could be used for evaluating the free range of a student's mind, his tenacity and resolve, his innate capacity for the understanding of human beings, and his affection for the human condition. For this purpose, I propose that classical Greek be restored as the centerpiece of undergraduate education. The loss of Homeric and Attic Greek from American college life was one of this century's disasters. Putting it back where it once was would quickly make up for the dispiriting impact which generations of spotty Greek in translation have inflicted on modern thought. The capacity to read Homer's language closely enough to sense the terrifying poetry in some of the lines could serve as a shrewd test for the qualities of mind and character needed in a physician."
Monday, March 02, 2009
One of the things we are supposed to do as an undergraduate is get clinical experience, most likely through volunteering. I volunteered my time at a VA, providing social support to long-term patients in the psychiatric facility there. Now that I am actually in medical school, I realize that experience gave me no clue what most of clinical medicine was about. Yet so many of us premeds diligently put in our time, and it was questionable whether the driving force was a resume or true compassion. There seem to be so many things in life that we shoot for, not knowing really what it is we're getting ourselves into. We're asked to jump through hoops, and most of those hoops aren't even oriented in the right direction.
Sunday, March 01, 2009
Clearly, Robert Frost had not been schooled
in the mechanics of quantum mechanics
when he wrote "The Road Not Taken."
If he had, he might have instead written
"The Electron Takes Both Roads" or
"The Road that Vanishes if We Watch" or
"Poetic License Allows Me to Characterize
The Road Not Taken, though Such Phenomena
Only Occur at a Macroscopic Level."
Thank God Schrodinger did not stroll past
Frost's New Hampshire farm; Thank God
Frost did not down a few pints with Planck.
Imagine, we might not have this ridiculous
American poem - we might not have anything to say
at graduation speeches or best man toasts
if Frost had attempted a marriage
between poetry and physics, the cutest couple
I may or may not have ever known.