tag:blogger.com,1999:blog-335198952024-03-06T20:26:59.864-08:00NotesIn ancient Greece, the asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The Rod of Asclepius is a roughhewn branch entwined with a single serpent.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.comBlogger2207125tag:blogger.com,1999:blog-33519895.post-60545889301071006862016-12-28T18:49:00.001-08:002016-12-28T18:49:21.615-08:00Write"But in its aimlessness, in its desperate commitment to the word, in its primal order of birth and rebirth, a poem remains the most general guarantee that we can still do something, that we can still do something against emptiness, that we haven't given in but are giving ourselves TO something."<br />
-Miroslav Holub<br />
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"Poets have been known to be smug about their fine uselessness, but the Vietnam War led many poets of my generation to try to use poetry to make something stop happening. We will never know whether all that we wrote shortened that nightmare by one hour, saved a single life or the leaves on one tree, but it seemed unthinkable to many of us not to make the attempt and not to use whatever talent we had in order to do it. In the process we produced a great many bad poems, but our opposition to that horror and degradation was more than an intellectual formulation, and sometimes it tapped depths of bewilderment, grief, rage, admiration, that took us by surprise. Occasionally it called for writings that may be poems after all."<br />
-W.S. Merwin<br />
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In an age of 140-characters and texts and holiday photo cards adorned with pictures, we hardly write anymore. We rarely just sit with pen and paper (and tea and candle) and ramble. Letter-writing seems archaic. Poetry feels obsolete. We want instant gratification and videos on demand and news in snippets. Even reading seems to be going away.<br />
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I am incredibly guilty of this. I go through spurts and hesitations with my writing. I took a poetry class where I wrote a poem a week, and that habit has since faded. This blog will go away soon. But I really do believe that writing gives me such unique pleasure, that its work is like exercise, we loathe to start, but we need it. So coming upon this New Year, I resolve to write more. It will be in different forms and forums, different guises and jests, but it will be good for me. Soothing. Nurturing. Healing.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-76947300803867272952016-12-25T03:44:00.002-08:002016-12-25T03:49:39.242-08:00Merry Christmas<div>
<span style="white-space: pre-wrap;">"A human being is a part of the whole called by us 'the universe,' a part limited in time and space. He experiences himself, his thoughts and feelings, as something separate from the rest – a kind of optical delusion of consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening the circle of understanding and compassion to embrace all living creatures and the whole of nature in its beauty." – Albert Einstein</span></div>
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<span style="white-space: pre-wrap;">It's three in the morning on Christmas Day and I am just finishing up at the hospital. Of my last seven Christmases, I've probably spent about half of them at work. I will admit, it's never easy. There are mixed sentiments; on the one hand, there's a sense of pride in widening our own small lives to encompass those in need, a giving Christmas in a different sort of way. There a sense of duty, almost like filial piety; it is the right thing. But ultimately what I think about is that no matter what negative emotions I have about being here, patients must have so much more. I am here by choice to take care of those without that luxury.</span></div>
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<span style="white-space: pre-wrap;">That doesn't make it any easier. How hard it is to spend holidays alone in the hospital when friends and family gather and celebrate. How hard it is on our own spouses and families as they sacrifice with us, when we are not there. What a strain it places on our relationships. What it's like to see everyone else in anticipation of the holidays when instead, we dread the interminable call. How isolating it feels when no one else really understands what it's like to miss half your Christmases. Why scrolling down my Facebook feed of trees and presents and dinners and kids makes me feel a little resentment. And then, ironically, how we judge ourselves bad people for feeling that resentment.</span></div>
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<span style="white-space: pre-wrap;">There was recently a great JAMA article on "The Things We Have Lost" by Jennifer Best that describes those sacrifices we make as physicians, things like "absence from 'unique and unrepeatable events' - holidays, birthdays, weddings, and funerals." We feel like we can't talk about these losses because they are minuscule compared to the losses we witness in our work: the loss of independence or health or security or family. But tonight I break that silence. I hold vigil for what I've lost in caring for others holiday after holiday. It is quiet here. Peaceful.</span></div>
Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-39458004808068446752016-11-12T20:59:00.001-08:002016-11-12T20:59:12.664-08:00ElectionI purposely veer away from writing about politics in my blogs; politics is fascinating to me, but this is not the forum where I want to discuss it. I only write to say that this last election made me think of the classic American ballad "<a href="https://www.poets.org/poetsorg/poem/casey-bat">Casey at the Bat</a>" by Ernest Lawrence Thayer. The last stanza really echoes how I feel.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-9351497804641203692016-10-17T17:17:00.003-07:002016-10-17T18:52:40.323-07:00Writing"Writing is wonderful when you talk about it. It's fun to contemplate. But writing as a daily physical activity is not agreeable. You put on weight, you strain your gut, you get gout and chilblains. You're alone, and every day you have to face a blank piece of paper."<br />
-Norman Mailer, <i>The Spooky Art</i><br />
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I love this quote. There are so many things that fall in this category. Growing up, I loved the idea of classical music and mastering a difficult piece and performing. Oh, but I hated practicing daily. For so many years, blogging also had that same sheen. On occasion, I'd have that perfectly formed idea, pre-packaged and ready for delivery. But most of the time, it was sitting down to an empty screen and forcing myself to write. Now, I'm taking a class on poetry writing, and it's the same thing all over again. Sitting around a table with other hopeful writers drinking tea and reading blank verse is really fun. There's a lot to explore, wonder, learn, and imitate. But then you go home and you sit with idle pen and blank slate. It becomes a narrative of captivity (rather than a captivating narrative) (a quote from a long-time friend of mine, Revati). The daily exercise of writing is a lonesome and individual activity, intimidating, grueling, and challenging. But it is also necessary to get better, to capture those fleeting moments of illumination, and to become more than a dilettante. In part, this is why I am simplifying my life and obligations, to focus on passions I would like to cultivate, and I think I want to give writing a go.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-25883823738444316162016-10-11T23:02:00.001-07:002016-10-17T14:04:36.422-07:00Oxytocin"There are no events but thoughts and the heart's hard turning, the heart's slow learning where to love and whom. The rest is merely gossip and tales for other times." - Annie Dillard, <i>Holy the Firm</i>.<br />
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"Life is not about writing great books, amassing great wealth, or achieving great power. It is about loving and being loved. It is about savoring the beauty of moments that don't last." - Sue Suter.<br />
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Love is perhaps life's greatest mystery. Where does it come from? Where does it go? What do we talk about when we talk about love? It seems so simple and yet so large both at once. It can be such an overwhelming life-force and at that same time curiously irrational. It feels so important, and somehow different from all the other things we think important.<br />
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Philosophers sometimes talk about "emergent" or "second-order" properties, things that characterize a system but cannot be found in the components of the system. A baseball player doesn't have "teamwork" per se, but when you group a bunch of them together, "teamwork" emerges. A single neuron may not think, but a network of them might have the novel and irreducible property of consciousness. I have not yet read a philosopher bold enough to tackle love as an emergent property, but that is what fascinates me most. We live in a physical, deterministic world. How does love fit in?<br />
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Poets and writers love to ponder the transience of love. The unrequited love, the love lost, the entreaty of love, the many masks of love - these inspire libraries of literature. We don't know what it is. We don't know why it exists. We vow to love endlessly. We decide to move on. "All things come to an end. / No, they go on forever." (Ruth Stone, "Train Ride"). We struggle with the feeling that love is so powerful, so irrefutable, and so out of our control. We try to reconcile the pure, perfect love from poetry, pop songs, and promises with the dingy sheen of practical love, love that fatigues and confuses and leaves us wanting.<br />
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I don't have a particular direction in this post. It comes from being at the most beautiful wedding this last weekend and also thinking about dear friends who may, someday, part. In seeing the many manifestations of love and thinking about its many faces in my life, I realize I know so little of it and want to know so much more. Love feels simultaneously mundane and magical, perfect and incomplete, ritual and personal story. We make ourselves vulnerable. We become gourds and vessels. We drink and thirst. We invite our friends to dance madly into the night. We invite our friends to hold vigil. There is no greater mystery.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-80742883693140134942016-10-04T12:04:00.000-07:002016-10-04T12:08:37.446-07:00Settle“Our worst fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous, talented and fabulous?’ Actually, who are you not to be? You are a child of God: your playing small doesn't serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We were born to make manifest the glory of God within us. It is not just in some of us, it is in everyone and as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.” – Nelson Mandela (1994)<br />
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Should you settle? Should you settle for a job that doesn't maximize your full potential, a relationship that leaves you wanting, a meal that is lukewarm? Should you settle for getting three wood for your two sheep when you really want wheat? (Should you settle for a half-hearted pun when you know you could write better?)<br />
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It's so easy for us all to say do not settle. You have this one life, this limited set of opportunities, all heart and ambition, so <i>carpe diem</i>. Who wasn't inspired by "Dead Poets Society"? We all remember being teenagers and thinking we could achieve anything, everything. Isn't that the American Dream? Work hard enough and life will be "better and richer and fuller" (James Adams, 1931).<br />
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Does it ever scare you that we will chase dream after dream and find them ephemeral, fleeting? That we will never be satisfied (still listening to "Hamilton"), that we will keep following the rainbow but emerge empty handed. I can always dream bigger dreams. I can always imagine something that just might make me happier. We live in a society where we always want more: the bigger house, the spiffier car, the latest phone. We want to show off our relationships, our kids, our jobs, our diplomas, our connections. We are always looking for the next big thing, trying to trade up, pursuing the unknowable, unattainable, and yet unspeakably coveted.<br />
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I worry about this. I worry that I want too much, that I have passed or will pass over something perfect in pursuit of a mirage. That settling isn't bad. That being content is more important than being fulfilled if by our very nature, we cannot be fulfilled. There are no bounds to human want, no bounds to human curiosity. "I burn, I pine, I perish" ("10 Things"). It is our obligation to ourselves not to succumb to the hubris of Greek tragedy. It's not to say we should want no more, but to say that in some facets of life, we accept the cards we are dealt with gratitude and find happiness in what we have.<br />
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I worry about the opposite as well. A life without purpose is like motion without moving. I should not settle to live in a world with injustice, suffering, immorality. I should not settle to live a personal life plagued by injustice, suffering, immorality. Idealism, even if I know it cannot be fulfilled, has a place. Humans were meant to dream.<br />
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"Harlem"<br />
Langston Hughes<br />
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What happens to a dream deferred?<br />
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Does it dry up<br />
like a raisin in the sun?<br />
Or fester like a sore--<br />
And then run?<br />
Does it stink like rotten meat?<br />
Or crust and sugar over--<br />
like a syrupy sweet?<br />
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Maybe it just sags<br />
like a heavy load.<br />
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<i>Or does it explode?</i><br />
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(FYI, being post-call tends to draw these types of posts out of me)Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-36638674187799351642016-09-27T20:43:00.002-07:002016-09-27T20:47:06.149-07:00Green“Never doubt that a small group of concerned citizens can change the world. Indeed, it's the only thing that ever has.” – Margaret Mead<br />
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We live in a world of stuff. We are consumers, buying things, using them up, discarding them, acquiring more. As I look at the next generation of cell phones and computers, contemplating upgrades, I start worrying about our preoccupation with having things. It's not that I find this hobby superficial or silly (though in a way, I do), but it's because I worry it's ruining our world. Like health care, our resources in this world are finite. Our consumer-driven culture will end up consuming those limited resources. Even if we recycle all that we buy, the cost of manufacturing the new goods and reclaiming the resources of the old worries me. I've been thinking about carbon footprints, <a href="http://xkcd.com/1732/">global warming</a>, and other environmental issues recently, and I worry that the legacy we are leaving to future generations is more problem than solution. While reducing waste, improving our commuting routines, eating less meat, and composting all make a difference, I think we need to overhaul our cultural disposition to consume. I also struggle with the itch to use stuff up and get more, but I'm trying to curb that. It is our responsibility to rein in waste, to protect our world.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-62925224962289043832016-09-19T23:59:00.000-07:002016-09-20T00:06:24.104-07:00Anesthesiology and Critical Care"Love. You can learn all the math in the 'verse, but you take a boat in the air that you don't love, she'll shake you off just as sure as the turning of the worlds. Love keeps her in the air when she oughta fall down, tells you she's hurtin' 'fore she keels. Makes her a home." - Serenity (2005).<br />
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This will be my last post about medicine. I might have some lingering thoughts about other facets of this strange life we live, but for now, I think I have accomplished what I wanted to with this blog, and it's time to step back. I started writing here on September 1, 2006, when I knew nothing of this ship I was boarding. It was the day before orientation for medical school. Ten years later, I have written over twenty two hundred posts, most of which are essays on becoming a physician, musings on the inner workings of medicine, reflections on the emotional and subjective experience of medicine, and stories of my life during medical school, residency, fellowship, and (hopefully) the beginning of a career. There is no way to summarize this, and while I want to make grand sweeping statements on what this means with flowery and literary-device-laden language, it's really not necessary. Someday, I might highlight those blogs that I am most proud of, but for now, I let this website speak for itself.<br />
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This is the path I chose, from the many I could traverse. It has been harrowing, lonely, exhausting, dangerous, frightful, upsetting, and profoundly sad. But it has also been enlightening, inspiring, heartening, beautiful, transformative, and dare I say it, fun. As a career, I am so happy to be an anesthesiologist and intensivist. My day-to-day and week-to-week work life is filled with moments of sheer wonder, great pride, meaningful connection, poignancy, and growth. I can think of no other vocation I would instead choose.<br />
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I thank all of you who have read this blog, and I apologize that it is coming to an end. I hope I have shared some glimmer of the magical and miraculous world I see every day. I hope to continue writing in the future and contributing to the literature of medicine in different forums and settings. Like every other incredibly difficult decision in my life, I have very mixed feelings about this, as evidenced by my lollygagging in saying good night. But here it is: please contact me (you can always post a comment) if you'd like to continue the conversation on medicine. I greatly appreciate your patronage, and I hope you have enjoyed reading. I have loved every facet of this. Good night.<br />
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In ancient Greece, the Asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The rod of Asclepius is a roughhewn branch entwined with a single serpent.<br />
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With respect, love, and passion,<br />
CraigCraighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com10tag:blogger.com,1999:blog-33519895.post-1145352644432197002016-09-18T23:04:00.004-07:002016-09-18T23:04:39.666-07:00Last WordsI make little notations to myself about blogs I want to write. I jot them down on scraps of paper, saved emails, and notepad documents titled "temp." Some of them make little sense to me when I find them again (kind of like trying to write down my dreams). Some feel so big and important that I want to set aside dedicated time to write conscientiously. Unfortunately, the window of opportunity is closing. For a lot of reasons out of my control, this blog is making its last rounds.<br />
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One note I wrote to myself was, "Anesthesia is not easy; discuss risk taking and dependence on surgeons." I don't specifically remember what stimulated that idea. There's a great deal that I could say (and have said in the past). Anesthesia is one of the few specialties that depends heavily on the skill of another professional. The doctor on the other side of the drapes affects almost everything I do. For the same surgery, two different surgeons may require very different anesthetic plans. Whether the surgeon is speedy or slow, loses a lot of blood or loses nothing, requires deep anesthesia and paralysis or manages with little - it all affects my decision-making. I have written before that anesthesiology is protecting the patient from the (necessary) surgery and surgeon, and I really believe that. It's no small thing to cut into someone, and my job is to safeguard the patient while that happens.<br />
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Of course, the skill of the anesthesiologist affects the surgeon. What I do can profoundly change the surgical conditions from whether there's excessive bleeding to how much the brain swells. I can think of very few other symbiotic medical specialties; perhaps obstetrics and neonatology, but not much else.<br />
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It's easy to underestimate how difficult anesthesia is. There is a metaphor of the Stanford undergraduate being a duck; on the surface of the pond, she appears serene and relaxed, but under the water, she is paddling furiously to stay afloat. Sometimes, that's how I feel with anesthesiology. Although we show a calm demeanor above the drapes, we may be working tirelessly to mitigate risk and optimize every single aspect of the perioperative period.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-88742931654638377972016-09-15T17:37:00.000-07:002016-09-15T17:39:14.603-07:00The Impact of AnesthesiologyI hadn't seen this when it came out almost four years ago, but the New England Journal of Medicine for their 200th anniversary (such an impressive milestone) asked the question, "What has been the most important article in NEJM history?" This <a href="http://blogs.nejm.org/now/index.php/the-most-important-article-in-nejm-history/2012/11/01/">blog</a> concluded that the first description of anesthesia in 1846 by Henry Bigelow was the most significant report, surpassing even articles on aspirin for heart attacks, tPA for stroke, and development of vaccination. Indeed, the field of anesthesiology allowed advancement of surgery and the surgical subspecialties. Before anesthesia, no one would even consider an elective procedure; it would be terrible to put someone through pain and agony for a disease process that was not life-threatening. But with inhaled ether, and later similar compounds, we made possible so many other advances in improving human health.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-64865915169633222412016-09-12T22:21:00.001-07:002016-09-12T22:21:46.302-07:002200<div class="separator" style="clear: both; text-align: center;">
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On a trip to Prague last year, I saw this building and managed to snap a photo. Ten years ago, when I started this blog, I picked this URL, but I don't remember why. Nevertheless, I've grown to like it.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-29150865758317690572016-09-09T19:30:00.003-07:002016-09-09T19:30:58.793-07:00Personal IdentityWhen I studied philosophy as an undergrad, one topic that really fascinated me was personal identity. How do we know we are the same person we were yesterday? What defines us? Is it causality, physical identity, some kind of metaphysical "soul," or something else? The philosophical literature on this is quite dense and less interesting to me now. But sociological ideas about identity still captivate me.<br />
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Many health care workers, I think, identify very strongly with their profession. If you were to encounter them in the supermarket and ask them what they do, they might reply that they are a doctor or nurse or therapist. We are proud of what we've accomplished, and our jobs have taken up so much time in terms of years of education and our daily lives. Our professions also carry such emotional weight, give us such deep satisfaction, and involve such close interpersonal interactions. It is no wonder that our profession, role in society, and vocation are tied to our sense of personal identity.<br />
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Over time, I have found that my sense of identity is less and less tied to my profession. This surprises most people, even those close to me. At work, I am very much a physician, anesthesiologist, and intensivist. I enjoy my work, I take pride in doing it well, and it defines me for sixty hours of the week. I am really quite present.<br />
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But once I leave the hospital, that part of me fades. My identity is only loosely tied to being a physician. I spend most of my time, energy, and effort pondering other things - writing, books, music, dance, cooking, travel. So it always surprises me when friends (and family) tell me that I'm a good doctor. I'm glad for such affirmation, but it feels strange to me to hear that from the world outside the hospital.<br />
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Part of this dissipation of a medical identity, I think, is the reason why I'm winding down this blog. It has always been my firm intention to keep this blog medical in nature. I think focus is important in writing, and writing broadly about medicine has yielded me thousands of posts. I think it's also earned me a reputation of someone who thinks, reflects on, and writes about medicine all the time. Perhaps that was true in medical school and residency when medicine was the whole of my life. But as that part of my identity softens a bit, I am less wont to continue blogging.<br />
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In any case, this is a rambling post that stems from me pondering my own identity, who I am, and who I'd like to be. As a doctor, I am proud of what I have become and where I'm going, but I tire a little of all those who assume that is mostly who I am. My departure from writing regularly here is a personal stimulus to broaden my sense of personal identity. I am understanding how much people change, and how important it is to discard the detritus of identities past.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-85729620561309641542016-09-06T21:01:00.002-07:002016-09-06T21:01:33.354-07:00The Cost of MedicinesOne of the biggest challenges we face in the coming years with regard to health care is reining in costs. I recently read a great synopsis on why prescription drugs cost so much in the United States. This <a href="http://jama.jamanetwork.com/article.aspx?articleid=2545691">JAMA article</a> is definitely worth perusing. It explores concisely and clearly why normal supply-demand economics don't apply to prescription medications. By looking at protected monopolies created by patents, restrictions on government negotiation for Medicare drugs, tactics used by the pharmaceutical industry to delay generic drugs, and physician prescribing practices, it sheds a lot of light on why we are here now. The article also addresses a lot of counterarguments relating to the cost of medications in the U.S. such as research and development investments and cost-sharing with patients. It proposes several reasonable and well-supported measures to decrease the burden of prescription medications on health care cost in America. I don't often write a blog that points to a separate article, but I really believe this paper summarizes the problem in a more comprehensive, accessible, and thought-provoking manner than I could ever achieve.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-67834133084204217612016-09-03T19:00:00.003-07:002016-09-03T19:00:53.016-07:00Quality of Life III feel that relationships and passion are at the center of quality of life. When I meet with a family of a dying patient, I often ask them to tell me about the patient. They almost always tell me about the patient's personality, his relationships with others, or his passions in life. In our conversations, these characteristics seem intertwined in creating meaning and value for that person (or least, the family's interpretation of it). And indeed, when it becomes clearer that the patient is losing his personality, unable to maintain his relationships, and will never recover to pursue his passions, the conversation about the end of life follows.<div>
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For me, at least, many of the decisions I make stem from my relationships with those around me and the values, interests, and commitments I have. I am proudest of these things, most creative with them, and happiest when I delve into them. Whether it is holding a board game night or learning a new dance or reading "Harry Potter 8" or crafting a new poem, I am energized, sometimes exuberant. When I reflect on curtailed relationships, lost hobbies, disinterest, I find little substance and joy. My mood and indeed my quality of life follows the robustness of my relationships, the devotion I give to my passions.</div>
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Although medicine is not aimed at such lofty goals, I do think we can make small differences in helping patients achieve these goals. We center our patients in their universe of relationships; we ask about their spouse, kids, friends, family. We help them bridge estranged relationships. We encourage their support network to buoy them up. We ask them what they love doing. As they recover from illness or cope with disease, we orient them in their world of passions, helping them engage as best they can in the things that give their life meaning, quality.</div>
Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-8310725490669634972016-08-31T21:37:00.003-07:002016-08-31T21:37:49.250-07:00Quality of Life IAlthough quality of life feels incredibly fuzzy and subjective, I think it's important to contemplate. It is perhaps the truest and least-spoken goal of medicine. And along with passing on our genetic makeup, it may be our most fundamental want as people. We don't talk about it enough. In all the lectures of medical school, studies and articles in journals, and posts on this blog, it represents a tiny fraction of what we discuss in medicine. In the same way that death and the dying process is glossed over, the ephemeral phrase quality of life usually earns only hand-waving and idealism.<div>
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Although there are quality of life measures taken with psychometric tools and surveys, I like to think it is in the "I know it when I see it" category (originally attributed to Supreme Court Justice Potter Stewart). Yet I'm not sure it really is. Outsider (physician) impressions of the quality of a patient's life often differ greatly from the patient's assessment of his own life. We all have our own ideas of whether we would want to go to dialysis three times a week or be wheelchair-bound or not be able to eat or suffer constant pain. But if any of us were actually in any of those situations, we might change our mind.</div>
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Nevertheless, I will talk about quality of life as if we knew what it was. The reason we allow surgeons to cut into people, prescribe medications with side effects, and hospitalize patients is because we think it'll improve their quality of life or length of quality life. But we never think of it that way. It's almost a rote reaction; we diagnose a patient with hypertension and prescribe hydrochlorothiazide; we find appendicitis on CT scan and book the operating room; we witness a suicide attempt and place the patient on an involuntary hold. We do so hoping or imagining that as a result, the patient will live longer and/or have a "better" life.</div>
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Why is it that medicine's boundary stops there? Should we actively participate in enriching a patient's quality of life? Or is that out of our scope of practice, someone else's responsibility? Sometimes, I think our social workers who find shelters for our homeless patients, reunite families, and help patients cope with their illness have a more direct impact on quality of life. I think of our physical and occupational therapists who help patients get back to their sports or climb the stairs in their house or use a prosthetic limb. Why is it that doctors are concerned only with the disease and its treatment? Is medicine nearsighted this way? Or is it simply a division of labor; we cure disease and defer a patient's happiness to someone else? I'm really just rambling, but I figured this is an important topic of conversation, and I wanted to open the door.</div>
Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-32952397690528325582016-08-29T21:14:00.000-07:002016-08-29T21:14:11.122-07:00The Future of MedicineI was asked recently what I thought the next breakthroughs in medicine would be. I have no idea. Although I like to read about where science is going and although I used to participate in research, now my career has greatly diverged from that. Nevertheless, sometimes you get asked a question and you just have to hypothesize.<br />
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We've been talking about personalized medicine for (it seems like) forever, but I think it's going to happen. President Obama launched the Precision Medicine Initiative and that helps funnel NIH funding to those areas of research. We are definitely getting more knowledgeable about how all the "omics" (genomics, proteomics,, metabolomics, gut microbiomics) affect disease and health. Despite this, it hasn't translated to everyday clinical application. For example, though whole genome sequencing has become cheaper and more readily available, genetic testing is not widely used by physicians to make clinical decisions. Only a few tests are standard of care (such as testing for an HLA gene before starting someone on the HIV medication abacavir). I believe physicians are just late adapters of technology. Once genetic testing becomes a more commonplace clinical tool, I think personalized medicine will really hit its stride. This will almost certainly increase costs. We just await to see if that translates to better outcomes.<br />
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To me, personalized medicine comes in flavors beyond the interaction of genetics and diseases. One form of personalized medicine is the use of feedback loops and technology to achieve our health goals. For example, insulin pumps for type I diabetics can almost work on autopilot. They can test a person's sugar, adjust the dose of insulin, and check to see if it worked in an entirely automated algorithm. Will anesthesia move in that direction? Will we end up having machines that can detect the level of anesthesia for a patient and automatically adjust the medications to achieve a target? (This was attempted with a robotic sedation system which never caught on; it's now off the market). To me, these individualized therapies also represent a kind of personalized medicine.<br />
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With regard to areas of medicine that will blossom, I think immunotherapies and treatments for neurodegenerative diseases will become a big focus in the coming decades. We must focus our resources on diseases like Alzheimer's which currently doesn't have effective treatments but will become a growing burden on society and our health care system. These are, at least, my predictions; who knows where things will go in the next few decades.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-70589306367112965332016-08-27T07:49:00.000-07:002016-08-27T07:49:00.140-07:00Youth and ResilienceWe see two kinds of youth in medicine: the invulnerable and the sick. The classic young and invulnerable patient is the trauma patient. He is drunk and foolish and thought himself a superhero. He is recalcitrant and won't change his ways. He'll be back with new broken bones or head trauma or stab wounds. It's a terrible story but all too common in trauma centers everywhere.<br />
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Then there's the chronically ill person in her twenties or thirties. At that age we see diseases like inflammatory bowel conditions, schizophrenia, pregnancy-related problems, and even chronic pain. It's hard for me to fathom how it must feel to deal with pain, symptoms, or medications every day for the rest of one's life. How it must change one's dreams, for better or for worse. I've met patients whose experiences have motivated them to pursue incredible art, service, and academic achievements. But I've also met patients whose diseases have broken down their resilience; they struggle every day to survive.<br />
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What determines our resilience and reserve? Why do some people fly through adversity while others struggle? Is it one's fortitude, genetics, and upbringing? Or is it one's social support, medical care, and environment? Can we arm others to succeed through hardship? Can we arm ourselves to succeed through hardship?<br />
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There's always something. Whether it is a job transition, an elective surgery, a parent with cancer, a newborn whose growth curves are worrisome, divorce, financial trouble, miscarriage, or any number of stressful life situations, there's always something. It may seem way smaller or way bigger than what others struggle with, but it's relative. For the one in it, whatever it is, it's a big deal.<br />
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We must all find resilience. We depend on our family and friends. We look to our communities, our faith, our values, and our principles to guide us. We go through anger and rage and moping and sadness and denial and escape and acceptance. Sometimes we are able to reconcile and repair the situation, and sometimes it is out of our hands. In the same way, we must help our family and friends through their own struggles. We must provide for them what measure of strength we can, the patient ear, the kind shoulder, the word of resolve. Together, we overcome the ebbs and tides of everyday life.<br />
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(The wonderful thing about writing blogs is that when I start, I have no idea where they are going to go.)Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-79758746965073465962016-08-26T22:55:00.000-07:002016-08-26T22:55:00.162-07:00Blogging"When power leads man toward arrogance, poetry reminds him of his limitations...when power narrows the areas of man's concerns, poetry reminds him of the richness and diversity of his existence." - JFK, 1963<br />
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Dear Reader,<br />
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One of the challenges I struggle with daily is the limited time and energy I have. So much of myself is devoted to the people I love, the projects I'm trying to cultivate, and my personal well-being. My work and personal life have been really stressful as of late, and trying to eke out more creativity, energy, and productivity has been really hard. I feel spent. As I ponder my priorities and restructure my life, I've become more and more certain that creative writing should and will take up more of my time. As JFK pointed out, I have certainly become more arrogant and more narrow; it is time to allow poetry to expand my perspectives. With writing, I hope to salvage balance in my life. </div>
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This blog, of course, has been a project and adventure that has taken me far beyond where I imagined I'd go. It's been a wonderful exercise in creative writing, commitment, responsibility, and exploration. I've really appreciated everyone who has come across this, commented to me about it (in person or online), and spent a little time on this website. As I think about my life and its transition points, though, I am becoming more certain that this blog will finally come to an end. I'm planning on winding this down over the next few weeks. </div>
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Commitment is such an important thing. It's a strange idea for me that I will part ways with this quasi-daily activity. I spend a lot of my time finding things to write about, refining ideas, and planning my entries. I've learned a lot of what works and what doesn't, and indeed, I have much more to learn. But I started this journey ten years ago, in September of 2006. It seems only fitting that I will say goodbye a decade later.<br />
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Commitment wears thin. In an era where young people change jobs every few years, where marriages are perhaps closer to "serial monogamy," where we move and travel and change our identities, I've learned the hard way that the values underlying commitment are mutable. I love this blog so much, and the opportunities it has given me have been tremendous. Through it, I helped a young man change careers, pursue medical school, and choose anesthesiology. Through it, I became involved in The American Resident Project, reaching far bigger audiences. Through it, I have talked to physicians in Canada and India and South America. I've met nurses who've read this blog, medical students who recognize my name through it, and real web presences that have interviewed me about it. It's a commitment that's really paid off. Despite all that, it's time for me to move on. I will miss it and want to linger, but I know new adventures await and new projects are beginning to bloom.<br />
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With great affection,<br />
Craig</div>
Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com4tag:blogger.com,1999:blog-33519895.post-80608901802709391852016-08-24T18:35:00.000-07:002016-08-24T18:35:53.774-07:00The BlockSamuel Shem's iconic <i>House of God</i> describes the block with hyperbole. When the emergency department calls for an admission, you try to block the patient and turf him to a different service. If you're an orthopedic surgeon and the patient has a hip fracture, maybe she also has chest pain so she would be safer on a medicine service with an orthopedic consultation. If you're an intensive care physician and the patient is dying of septic shock, perhaps you can dig up an advance directive and POLST saying the patient wouldn't want aggressive medical treatment in this situation.<br />
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This is not healthy behavior, but <i>House of God</i> describes why it proliferates; every service is trying to block patients, and if a physician accepts patients indiscriminately, her service will blow up in size. When we are residents and fellows, our clinical volume has no relationship to our salary so there's little incentive to take a lot of patients. Most specialty consultants master the art of the block, and as a result, patients get dumped onto the general medicine or intensive care services. We are the catch-all for any medical problem, so if no one else will admit them to the hospital, medicine will (or the medical intensive care unit if they are sick enough). In general, I was okay with that because the patients got better care, but the idea of blocking always bothered me.<br />
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Private practice is the exact opposite. For many of us (but not myself), clinical volume determines our revenue. I was surprised to learn consultants were eager to take on extra work and that there was no push-back when I asked other services to accept patients. A patient's disposition (the medical term of who takes care of them and where in the hospital they go) is determined entirely by medical factors. This is the way the system should be; physicians shouldn't block patients; we should care for them, treat them. Perhaps its not wrong to link this to financial incentives. The goal is to have a collegial and smooth-running system that focuses on the needs of the patient.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-44690099911421774852016-08-22T23:23:00.000-07:002016-08-22T23:23:04.339-07:00Statistics<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-3KweTmdz2IEbpHcJhI0ryUnESc2eGuZMfpWMaDiwZsKgdveJ0R0G2wAHfOvDzBHp8C6ah_jjzyiFqCXaH5It0CyDOwUEVg8y4Eu_DAQ46KU9Oxwxqrv6lmDg6wlAmzsFYNo5Nw/s1600/The_Normal_Distribution.svg.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-3KweTmdz2IEbpHcJhI0ryUnESc2eGuZMfpWMaDiwZsKgdveJ0R0G2wAHfOvDzBHp8C6ah_jjzyiFqCXaH5It0CyDOwUEVg8y4Eu_DAQ46KU9Oxwxqrv6lmDg6wlAmzsFYNo5Nw/s320/The_Normal_Distribution.svg.png" width="320" /></a></div>
As I get farther out from school, I start thinking of disciplines I wished I studied more. Some, like English literature or computer science, I think one day I might pick up again. But there's one discipline that I should have studied yet never will, and that is statistics. In the last few years, I've been learning from perusing medical journals (rather than textbooks and lectures which comprise most learning for medical students and early residents). The more I read, the more I realize that statistics matter so much. A study's design is its foundation, and without a solvent knowledge of statistics, I feel like I'm often evaluating the facade of a study rather than its real integrity. Nevertheless, for whatever reason, statistics classes just never engaged me. The one I took in college just passed me by. For me, it is like music theory; growing up, I enjoyed playing an instrument, but never cared for music theory. I guess there will always be a few things where we recognize the importance but just can't make ourselves endure. That being said, I think if we were to rethink the premedical curriculum, statistics is far more relevant than subjects like physics.<br />
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Image is in the public domain, from Wikipedia.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-42958384844141296442016-08-20T22:37:00.000-07:002016-08-20T22:37:26.100-07:00Technology and the Cardiac Exam<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrQGtRSTlH9mDKHRT__uG25OEM728wT0vmaCxFPGVf4-XpYCzNUn7Ofuu8sUKUPd-qGT3f2f-7XpP374BPvldns02basUtxDdf_Z8upUs9wij9xIiIqwQv9Y4pQwip3q9iHypoVw/s1600/Stethoscope-2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrQGtRSTlH9mDKHRT__uG25OEM728wT0vmaCxFPGVf4-XpYCzNUn7Ofuu8sUKUPd-qGT3f2f-7XpP374BPvldns02basUtxDdf_Z8upUs9wij9xIiIqwQv9Y4pQwip3q9iHypoVw/s320/Stethoscope-2.png" width="320" /></a></div>
The stethoscope is the iconic symbol of medicine. There so much I love about it: how it was conceived, the panoply of obscure sounds that indicate specific pathologies, the synecdoche of listening to a patient's heart for the patient-doctor relationship. But I also imagine a time where the stethoscope is relegated to history. Why do we still use an instrument invented in the early 19th century? Physicians are notoriously slow to adopt new technologies, but I can think of two inventions that should replace the stethoscope.<br />
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If listening to heart sounds is crucial to medicine, why don't we develop a microphone that we can place on a patient's chest that will record the patient's heart and lung sounds? We have the electronic ability to filter extraneous noises and amplify relevant sounds. Computers can analyze the sounds to dissect out what fledgling medical students struggle to discern. In the same way that the computer reads EKGs, programs can be developed to detect an extra S3 or S4, the type of murmur, or the presence of a rub. Recordings can be saved and compared to prior captures; wouldn't it be fantastic if we could compare today's lung crackles to yesterday's?<br />
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And this may be anathema, but I'm not sure listening to the heart offers that much diagnostic value. I definitely think it's important for the patient-doctor relationship and has interpersonal, even therapeutic, value. But it's pretty rare that what I hear on heart or lung exam changes my decision making. This is definitely because of my clinical specialty; in the intensive care unit, I'll often order chest X-rays and echocardiograms, and in the operating room, few heart sounds will cause me to cancel a case. But still, there's less medical utility in the stethoscope than we might wish.<br />
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This leads me to wonder when bedside echocardiograms will replace the stethoscope. Handheld echo probes are starting to drop into the affordable range. There's certainly a learning curve, but once bedside echo is mastered, it gives a lot more information than listening to the heart. One day, I think this will become the cardiac exam.<br />
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Image is in the public domain, from Wikipedia.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-6765672712716269352016-08-15T10:35:00.000-07:002016-08-15T10:35:01.798-07:00One More ICU StoryIt is Saturday midnight, and I'm called by the emergency department to admit a patient who was intoxicated at a party with unknown substances. I ask the nurse if we know anything more about the patient - his identity, other medical problems, etc. She replies, "We don't know too much but we searched his pockets and found a little plastic bag with what looked like crystal meth. But when we gave it to the police, the police replied, 'That's not crystal meth.' I asked, 'What is it?' And he replied, 'That's just crystals. Like decorative crystals.'" That made my night.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-28846428210710316542016-08-13T10:34:00.000-07:002016-08-13T10:34:05.485-07:00Five Days in ICUMonday<br />
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A young man is picked up by emergency medical services unresponsive and hypotensive. He is intubated but despite liters of fluid, his blood pressure remains barely measurable. On exam, his belly is rock hard; I think it's filled with blood. After we start a massive transfusion, we're able to get him to the CT scan, and we find a massive retroperitoneal bleed. He is whisked off to the operating room. On return, his drains pour out liters and liters of blood. The color of the blood coming from the drains is the same as blood drawn from the arterial line. Of course, he returns the operating room and then to interventional radiology for an emergency TIPSS because he has severe cirrhosis. All in all, over a 12 hour period, he gets 25 units of blood, 25 units of plasma, 4 six-packs of platelets, and 2 units of cryoglobulin. Over the week, he goes into acute respiratory distress syndrome with impressive oxygenation requirements (FiO2 100%, PEEP 18), cardiovascular collapse needing pressors, renal failure requiring continuous renal replacement therapy, alcohol withdrawal, continued transfusions, and a return trip to the operating room.<br />
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Tuesday<br />
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I sign out to the night-time intensivist at 6PM. I finish my notes over the next two hours, clean up pending items, and get ready to go home. On my way out, the nurses flag me down because a surgical patient who was doing fine and planning to leave the ICU had an acute aspiration. After intubating and stabilizing the patient, I sit down to finish those notes as well. I get home well past 9.<br />
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Wednesday<br />
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I am called by the emergency department to help with an intubation for a cardiac arrest. When I rush down, I see the nurses doing compressions on a child. A three year old previously healthy girl presented with ventricular fibrillation and seizure. Other than accidental overdose of medications, I'm not even sure what causes cardiac arrest in a child. I intubate her, but an hour later when I am admitting a separate patient from the ER, I see that they call time of death. The family is in hysterics. I go home to wrestle with family crises of my own.<br />
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Thursday<br />
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I see twenty two patients today. We only have 21 beds, but we started with 17 patients and despite sending a bunch to the floor, I get 5 new admits. I'm not even sure if clinic physicians see 21 patients in a day. I make myself a spreadsheet to keep track of notes, orders, and to-do items. The most interesting patient is a person who comes in with torasdes de pointes (shown below). We all learn about torsades in medical school, but this may be the first time I've actually seen a case. It is caused by medications she takes. That first afternoon, she kept having scary episodes of polymorphic ventricular tachycardia, but they finally subside as the medications metabolize off her system.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigT9C8r_AdS0jaYbsE8TIk0mRlui2fO-xRWKwuI_c0sbYNIhLoZBHXyaLgql0GKB0PqURmqhgkAKw0vmKqi9voPI_IzVlQcWfmvaTqZn88CxpTxQMKLFoDza1JV49PEbpPVotYQw/s1600/Torsades_de_Pointes_TdP.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigT9C8r_AdS0jaYbsE8TIk0mRlui2fO-xRWKwuI_c0sbYNIhLoZBHXyaLgql0GKB0PqURmqhgkAKw0vmKqi9voPI_IzVlQcWfmvaTqZn88CxpTxQMKLFoDza1JV49PEbpPVotYQw/s320/Torsades_de_Pointes_TdP.png" width="320" /></a></div>
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Friday<br />
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I get my most interesting patient on my last day on service. A young woman is intubated in the emergency department because of "bizarre behavior." When I get the call, I wonder how bizarre her behavior was to necessitate intubation and sedation. Apparently, she hasn't been herself for two months. She works at a cafe in the daytime, but according to her boyfriend, she started going out every night to four or five in the morning. She'd sleep for three hours, then go back to work. He wasn't sure what she did at night, but wonders if she was smoking, drinking, and doing drugs. The day before admission, she parked her car on the shoulder of a freeway and ran across the highway. Fortunately, she was picked up before getting hurt and brought to our emergency department. Initially she was admitted to psychiatry, but over the course of the day, she became more combative, even hitting a nurse and harassing another patient. She got 25mg of haldol, an impressive amount, as well as atypical antipsychotics and benzodiazpines. Finally, the ER decided she simply needed to be sedated so they intubated her to get a lumbar puncture and head imaging. She was negative for meningitis, encephalitis, or structural abnormalities. Her toxicology showed benzos and marijuana. I really don't know what was happening with her, but I suspect either intoxication or withdrawal of drugs or a new psychiatric diagnosis with a manic or psychotic episode.<br />
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I haven't worked this many hours since fellowship. Along with these cases, I also had the usual old person presenting with sepsis from a nursing home, cirrhotics with low blood pressure, slow ventilator weans, chronically ill patients who had been hospitalized for over a month, gastrointestinal bleeds, and postoperative patients. What a week.<br />
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Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-67724024379663298512016-08-10T05:18:00.000-07:002016-08-10T05:18:00.710-07:00The Originally Celebrated Curiously Strong<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhd_JAOAEW_CJbJoM0qNGYiHdAjxNRXMOwurr09UCgsjNf13HnfZLXkK3t8G-5oxLQFog-217plUBCJRgSEAzqrDmO3UaHvciMnzZZYFE_cqI3plTk246d33HeG5W-sRfEVUUYlng/s1600/800px-Altoid_and_tin.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhd_JAOAEW_CJbJoM0qNGYiHdAjxNRXMOwurr09UCgsjNf13HnfZLXkK3t8G-5oxLQFog-217plUBCJRgSEAzqrDmO3UaHvciMnzZZYFE_cqI3plTk246d33HeG5W-sRfEVUUYlng/s320/800px-Altoid_and_tin.JPG" width="320" /></a></div>
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In an attempt to understand how acetaminophen might help some musculoskeletal pain I have, I tried to conduct a blinded placebo-controlled trial on myself. It wasn't very successful, which might have been for several reasons. First, I'm pretty sure I could tell when I got an altoid rather than the trial medication. Second, the acetaminophen I was using is expired. I'm pretty sure nonsteroidal anti-inflammatories would have been a better intervention. Oh well, this is why I never made it as a research scientist.<br />
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Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0tag:blogger.com,1999:blog-33519895.post-38570327660853622612016-08-07T21:00:00.000-07:002016-08-07T21:00:03.563-07:00Expectations and Medical Decision MakingA pregnant woman at term comes in with active labor. However, she is adamant she does not want her vital signs to be checked, an IV to be placed, or labs to be drawn. She insists on having none of it despite understanding the risks. There's no compelling reason; it's simply her birth plan and preference. It's not clear why she decided to deliver in a hospital rather than at home or a birth center. Nevertheless, she is declining hospital standards of care by refusing an IV and vital signs.<br />
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For generations, decision-making was entirely up to the physician. Medicine was paternal; a doctor would tell a patient the plan. In the last few decades, we've recognized the ethics of patient autonomy and shared decision-making. We do our best to inform and educate a patient about the nature of their condition and the risks, benefits, and alternatives of diagnostic or therapeutic interventions. We may give our recommendation but we would never force a patient to undergo something he or she did not want.<br />
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I wonder sometimes whether we've reached the other extreme, allowing a patient to dictate everything. One reason to deliver at a hospital over home or a birthing center is the insurance against an emergency. The vast majority of patients do fine, but a few need interventions like an urgent C-section. By declining vital signs, IV access, ultrasound examination, and other tests, that benefit is negated. This patient did not receive prenatal care so we had no idea whether the placenta was normally implanted, whether she had pre-eclampsia, even whether the baby was breech (other than by physical exam). The patient was of "advanced maternal age" and there was a real possibility of needing a Cesarean (fortunately, she did not).<br />
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While one could argue that with adequate counseling, a patient can understand that risk and decline those interventions, I think that is ultimately unfair to the providers. In a case like this, unacceptable risk is transferred to me. I am not comfortable in a situation where someone may need emergent surgery but does not have an IV. Even if that's what a patient demands, do I have to acquiesce? (Ultimately I did, but these issues are real conundrums).<br />
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Like every relationship, the one between patient and provider cannot be controlled entirely by one party. Biomedical ethics is much more than simply reciting "autonomy, beneficience, nonmaleficence, and justice" (what they teach in medical school). We have to learn and approach real-life ethical dilemmas with care, nuance, and compassion.Craighttp://www.blogger.com/profile/17072102331564743101noreply@blogger.com0