As seen on TV

I started working in the emergency department this week and it
definitely hasn't been as exciting as you would think an ED would be.
It's actually a lot of psychiatry, which I hated while in medical
school and which I still kinda hate out of medical school.

However, I did have a case which still has me thinking, "Could I have
done things differently?" It was a woman who was a few weeks after
delivering her baby and she came in complaining of bleeding. However,
when I saw her, she had minimal bleeding on exam and I discharged her.
Not 30 minutes later, while she was still in the room (thank goodness
discharges take awhile - at least in this case), she just started
hemorrhaging. Blood everywhere. Pale as a ghost. Blood pressure
dropped. Could I have done something differently? If I had, would it
have been any different? She ended up doing fine and the general
consensus was that it was such an odd presentation, but I still think
back on it.

In reflection, I guess it's good that I still think back on the case.
I hope never to be a doctor that doesn't care about the outcome of her
patients. I want to be able to follow up on my patients, realize how I
could have done things better (sometimes realizing that I may or may
not have done something wrong), and learn from the experience. I've
had several cases this year so far that have been me pause and think
back on what I did and if I could have done things differently.
Thankfully, all outcomes have been good.

In becoming a doctor, I am given the awesome privilege to help people,
but with that comes great responsibility.

Stating the obvious

Apparently, some people in Chicago asked people while they were in the hospital to name doctors that may be taking care of them and 75% of them failed to name a single person on the team taking care of them.  Is this a surprise?  Not to me.  I'm surprised if the patient even recognizes me as a doctor.  

Today, I was taking care of an 87 year old man (yeah, I'm not doing Ob/Gyn at this moment - I'm actually doing a rotation on inpatient adult medicine right now) and did my rounds, said, "Hello, my name is Dr. Truong and I will be the doctor taking care of you today."  I turn around, see another patient, and go back to see him and he looks at me, looks at his son (who appeared in those 5 minutes), and I introduce myself again.  He then says, "Wait, you're a doctor?"  Maybe it's because he was old, had hit his head, or because I seemed too young (he kept on asking me when I started medical school) - either way, he had no idea what my role was, let alone my name, even though I had told him no more than 5 minutes before.  

However, I guess the question to be asking is whether this matters.  Does it matter that this 87 year old man didn't know my name?  Or that I was a doctor?  It certainly doesn't matter in terms of his ability to get in contact with me - as his nurse is aware of who I am and they're the ones (incessantly) paging me anyways.  It would matter to his son, who seemed to be more in tune to what was happening to him and concerned about the quality of care he was getting (which he stated was much better than an unnamed private insurer/hospital system that he belonged to).  

Does it make me feel bad and hurt my feelings - thereby making me less likely to provide optimal care?  Certainly not.  Dear, I can't even remember half my patients' names sometimes, so I cannot blame them. Does that make me a bad doctor?  I don't think it does.  Does it make me a bad person?  Possibly so.

It's about time

I'm very happy and encouraged that one of President Obama's first acts as President was to rescind the Global Gag Policy. 

Dracula struck

I just took the bandaid off of my neck and it looks like Dracula bit me.  (Yeah, she had to go in twice for the FNA.)

Cried like a baby

I just got back from the doctor's and got my fine needle aspiration (FNA), to finally find an answer to this pain in my neck.  I have to admit that I screamed like a baby when she did it.  Dude, it hurt.  And it stung.  And it hurt.  And then it hurt more.  It still hurts.  And when I saw how little tissue she actually got out, I was kinda sad.  I mean, all that pain and no gain?  She did say that the "thing" didn't want to give up tissue easily.  Let's hope that's not a bad sign. 

The pathologist (yes, a pathologist who sees real, live people!) did look at it right away and just said her initial impression was normal, just lots of "polys" (which means lots of white blood cells, meaning it's likely infectious).  I won't have an answer til Friday at the earliest.  And the culture takes at least a week, so we'll see. 

Of course, she couldn't help but mention TB.  "Your case is so typical for TB."  I eye her suspiciously, "Yeah, and the public health department will have a field day if it is."  "Yeah, it wouldn't be pretty." 

So, let's keep our fingers crossed that it's neither TB nor the dreaded "C" word.  And let's hope that I get answers, come Friday.

Sick.

I'm sitting at my parents' house feeling sick.  Sick like I haven't felt in a long time. 

1. My lymph node is still huge and still hurts.  As the doctor I saw put it: "Yeah, that's a big lymph node.  Gosh, that's the size of a golf ball!  That can't be normal... [then scribble something down]... it could be scrofula! You know, where you have TB in your lymph node. That'd be cool."  Cool, yes, if it weren't happening to me and it weren't one of the most painful things I have ever felt. 
2. I've got a fever!  Yeah, how does one get a fever after being on big gun antibiotics for nearly two weeks?  Clearly, can't be good. Nonetheless, I'm on Tylenol around the clock.
   
3. And a rash to boot.  Turns out I'm allergic to the big gun antibiotics that I've been getting, with proof in the pudding - the pudding being my skin mottled with a nice rash. 
   

Yeah, let's just say it's been fun.  And I was on call yesterday.  I made it in, did some rounding, then realized that maybe I shouldn't stay around, in pain, with a fever, delivering babies. So, that's when I decided to drive to my parents' house before taking my Tylenol #3, which was a questionable decision given I don't know which is worse - driving with a high fever (every time I get a fever, I get the same crazy thoughts, like weird puzzles that recycle over and over in my head - yeah, I may be crazy) versus driving under the influence of narcotics.  Oh well. 

Fortunately, I do have my spiked Tylenol and my dad has some Vicodin to help me sleep at night.  Thank god for pain medicine.

Oh, did I mention that the CREOGs are this week?  For those not medically-inclined (I can't blame you), CREOGs are the in-service exam for Ob/Gyn residents - basically like a yearly SAT to see how you compare to everyone else in the country.  Let's hope my fever stops by then.

Health reform - can it happen?

The New England Journal of Medicine (a favorite of mine, albeit biased because I did a rotation there in med school) just came out with an article putting it very succinctly and eloquently the reasons why health care reform has not been succesful and possible strategies to have it happen.  In summary, he points out the reasons why health care reform efforts have failed in the past - there are lots of parties who prefer the status quo, reform is difficult, bureaucracy always gets in the way, and reformers have yet to support a single approach. 

 

He quoted Machiavelli (whose political philosophy of realism differs from my own, but who has a lot to contribute to political thinking nonetheless) in summarizing, "There is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success . . . than to initiate a new order of things. The reformer has enemies in all those who profit from the old order and only lukewarm defenders in all those who would profit from the new order." 

 

I just found it a very nice article on why health care reform is so difficult, yet how it is not impossible.  

Paging Dr. CNN

So, the blogs are all abuzz about the rumor that Dr. Sanjay Gupta, of CNN medical correspondent fame, was approached to be the next Surgeon General.  What do I think about this?  I think that surely, we must have more qualified doctors than a talking head on tv.  Am I biased against doctors on TV?  Yeah because I don't think that you can ever be a good one (don't even get my started on the show, "The Doctors"... an Oprah spinoff which no one, including Ms. Winfrey herself, should ever watch). 

 

At one point, I wanted to be Surgeon General.  I think I might have even mentioned that on a medical school admission essay or two (or at least thought about putting that in).  I still think that it'd be pretty nice to be Surgeon General, but my sights are on other positions (HHS Secretary is a good start, then WHO director or UNAIDS director - hey, maybe even throw in a MacArthur genius grant somewhere in there).  However, I think that whoever holds that post should be someone more than a (non-)talking head.  They should be ready to elevate the position to something of stature, and elevate it beyond the public health ruins in which it currently finds itself - especially with a willing and ready president, as I hope Obama will be (my hope for his first act as President, as others before him - repeal the Mexico City Policy).

 

On the other hand, I find it encouraging that someone who is merely 39 may be Surgeon General.  That gives me a chance at doing before I'm 35.

 

Ouch

I think I have an infected pinkie. I'm being my hypochondriac self and thinking of the possibility of it turning into sepsis, all through a hang nail (worse things have happened, I suppose). It's been throbbing all day, kind has this funky discharge, is warm, swollen, and red. That meets all the qualifications for something that I should be worried about, no? I'll wait a day or two and then I'll forget about it, I'm sure. Or, I'll develop fevers and nausea and vomiting and curse the day I took off that hang nail.

Polypharmacy

I have a patient who is under the age of 40 and is on 16 medicines. Yes, 16. And some she takes more than once a day. Who really can keep track of 16 medicines? Of course, the reason why she takes so many medicines was completely preventable if she took the 2 or 3 she had to take years ago. And, of course, she doesn't take all of her medicines, which brings her under my care.

There has to be a better way of doing things.

What did you say?

Isn't there a saying that "A watched syringe won't melt"? Because that's what I'm doing - watching a frozen med syringe defrost in front of my eyes before I can give it to the patient. This is what I trained 4 years for, right?

A nonsensical policy

When did family planning become a bad word? When I was little, we used to drive past this building with the words, "Planned Parenthood" on it. I didn't know what it was nor did I know the controversy surrounding such clinics. However, the words struck me. "How great is that? People can plan on when they want to become parents!" This was when I was in elementary school. Now that I am older, I still think the same. How great is is that people can control their own reproductive choices?

This post is about family planning. I had a friend call me the other day and we discussed family planning. She is pro-life, I think, and asked me, somewhat rhetorically, "Why wouldn't any pro-lifer support family planning?" She went on to argue (and I'm paraphrasing here) that anyone who is pro-life should be for any prevention in unwanted pregnancies, including comprehensive sex education and teaching and enabling people to use birth control. So, this in light of a recent op-ed in the New York Times highlighting President Bush's "pro-life" choice to cut off birth control funding to many international organizations, got me raging. Seriously, doesn't he get it? Not giving people condoms doesn't stop them from having sex. Giving them condoms simply gives them a way to protect themself from infection and unwanted pregnancy when they do have sex. I mean, if the President decided not to fund any programs that provided sex education or birth control in the United States, people would be outraged - wait, he already did and people are outraged. I guess we can give President Bush brownie points for being consistent.

Meanwhile, a "young woman lies in a hut, bleeding to death or swollen by infection, as untrained midwives offer her water or herbs. Her husband and children wait anxiously outside the hut, their faces frozen and perspiring as her groans weaken." [Quoted from Kristof, "Can This Be Pro-Life?"]

One of those days

It's just one of those days where I want to curl up into a ball and hide in a corner of the hospital - after I throw my pager into a brick wall. 

 

The other side

Warning to those who may be "shy" - the following post contains references to male and female body parts.  Gasp!

So, I have been doing internal medicine for the last 6 weeks or so - it's an ob/gyn's way of getting primary care training and being able to manage things such as hypertension, pneumonias, and diabetes.  I actually really like the program that I am at because it does offer this training as I think being a primary care physician is integral to the way that I want to practice in the future.  However, there have been a few times when I wished that I was delivering babies again - and this is mostly when I have to do a male-specific exam or manage a male-specific problem.  For instance, I did my second prostate exam - ever - the other day.  Yeah, how did I manage to get through medical schol without being required to do more of these?  Maybe I was just in the right place at the right time, meaning not in the vicinity of any person in need of a prostate exam.  Granted, it's not that bad, and admittedly, easier than a pelvic exam - but still unpleasant nonetheless (and yes, I will acknowledge that it was definitely less pleasant for the poor soul who needed it).

Reflecting on my service, I have had 4 men with urinary tract infections (UTIs).  I do get a lot of experience managing UTIs, but in men, it's a somewhat different ballgame.  So, I find myself trying to figure out how to ask about their prostate.  And I find myself asking patients about "penile trauma" and then patiently wait for the awkward answer. 

That's not to say I am not getting a lot out of this rotation.  I set a goal for myself to learn more about antibiotic use and that definitely is coming to fruition (out of 4 admissions last night, all 4 were on antibiotics).  And I am definitely getting the hang of managing high blood pressure, diabetes, pneumonias, etc. 

In short, I miss delivering babies.  I miss not having to worry about my patients and their hallucinations (such as the one I had last night).  I miss the generally healthy ob/gyn population.  I miss doing more than mountains of paperwork and orders for my patients.  Ah, only a few more weeks, then I'm back to the OR. 

Healthcare reform

The New England Journal of Medicine, for which I have a lot of respect after seeing how it works (I spent a month at their offices in medical school - one of the best months of medical school, ever), just published two "articles" written by Senator Obama and Senator McCain on how healthcare reform will look like under their administrations.  It's interesting to see the perspective in both.  For those of you interested in healthcare, as everyone should be, it's a good read. 

I will save my opinions for another day.  And, I can't seem to focus enough right now to really read the articles in-depth to be able to converse intelligently about them - just thought that I'd put the articles out there. 

So cool it's hot

When I first told my parents that I wanted to get a degree in public health, they kind of just smiled and nodded. I don't think that they knew what it really was. Now, after many explanations, my dad proudly explains to other people that it deals with getting safe water and vaccinations to populations. My mom, however, is still a little confused. Er.

However, apparently college students get what it is. An article in the Washington Post focuses on how hot the public health classes and majors are on college campuses. I wish that they went into the graduate degree level as well, as those are the people likely to work in public health.

There's a lot to be speculated about why public health is so cool nowadays. In the article, Dr. Thomas Coates pointed his finger directly at HIV/AIDS, saying that it raised the public awareness. I don't know if that's entirely true (and I think he's biased - look at his bio!). Even after the HIV epidemic became large and publicly well-known, public health was still not totally cool. I think a lot of factors have helped public health become a hot commodity - the terrorist attacks of September 11th (and the subsequent nationwide discussion of chemical and biological warfare), the prominence of the Bill and Melinda Gates Foundation and other global foundations and their focus on global health, and the culmination of numerous articles on public health issues domestically (i.e. food contaimination scares, drug contamination scares, the growing number of obese Americans, etc). Regardless of the reason, I think it's great that there is more interest in public health.

As an MD/MPH, I think it's also very important for physicians to be interested in public health. My medical school class was pretty split between those who understood and were interested in public health and those who couldn't have cared less. The student quoted at the end of the article was so optimistic about public health and so pessimistic about medicine (she was planning on getting an MD). That's a sad prospect. Do public health people really think medicine is still its old, stody self? Perhaps it still is, but there is still a lot to be had for public health-minded people who want to go into medicine. I have only gotten the greatest response to my public health degree among my classmates and my attendings. It's a hot commodity in medical schools, just like in undersgrad. I think that the medical profession is slowly changing towards a more global perspective - global in the sense of geography as well as disciplines - and that, in the end, it will be better for doctors and patients.

The article just got me thinking about public health and how it relates to my career plans. I feel as though my public health mind has been put on hold while I'm in residency, as it's hard to do both. Then, I'm reminded of my public health training every time I work with patients to provide more comprehensive care.

Dear Dr. Papanicolau

How much better it is to give than receive an annual. Ouchies!

Now every woman out there, get up, call your doctor and line up to get one (I'm serious here... cervical cancer is much harder to handle).

Staying the straight and narrow

I'm currently on outpatient medicine, which means much much better hours (more like "normal people" hours) and a much easier workload. I see about 10 patients a day, which is unbelievably light considering I would see at least that many, including deliveries, on Labor and Delivery (otherwise known as L&D). However, the work can be a little less than stimulating. Actually, a lot of it is for diabetes or high blood pressure management. I have enough Spanish in me to deal with uncomplicated diabetes and repeatedly say, in my psuedo-Spanish, "Es muy importante para usted chequa sus sucres cada manana porque los doctores cambian sus medicinas por los sucres. Tambien, es muy importante para tener ejercisio una media hora cada dia." Ahh, my wonderful Spanglish. Basically, I just tell them that it's important for them to check their sugars daily and to exercise half an hour a day (boy, only if I listened to my own advice!).

So, yeah, just a demonstration of my wonderful Spanglish skills. It's funny because half of the people completely understand what I'm saying and then the other half look at my like I'm speaking Chinese to them. The ones who do understand then nod their heads and say yes, I promise I will do that, doctor. And then they turn, leave the room, and laugh at the ignorant Asian doctor (or at least that's what I imagine happens). But then, I had one yesterday who said "God bless" as she walked out - which is infinitely better than laughing at me.

Yo hablo Espanol

"Hola. Como esta? Soy Doctora Truong."

I say that one line nearly every hour of everyday that I work. More than half of my patients are Spanish speaking only, so it's a nice way to be thrown into speaking Spanish. Now, that's not to say that I know how to speak Spanish well. The last time that I spoke Spanish, prior to two months ago, was more than ten years ago, in high school. And that's not to say that my Spanish then was good, or even mediocre. So, now, I speak a good amount of Spanish, or at least "vaginal Spanish" (I'm much more comfortable asking, "Tiene sangre por vagina?" than I am about much more ho-hum things). The other day, I realized that a good half of the day, I'm speaking and listening to Spanish. I like it because I think that it's nice to be able to communicate with my patients without using an interpreter (yeah, you can go through the whole argument of "why don't they learn English?" but unless you figure out a way for a laboring woman to learn English when she walks onto Labor and Delivery, I am going to continue speaking Spanish").

One weird side effect of my Spanish speaking is that I have been tempted to write my histories and physicals (H&P's) in Spanish. Many times have I written, "No sangre, dolor, o flujo" and then realized that most people reading the H&P (e.g. medical professionals) are not Spanish speaking. Another weird side effect is that I assume that everyone is Spanish speaking. I even walked into a Bosnian patient's room and was tempted to speak Spanish... I guess my mind just assumed that since they don't speak English, they must speak Spanish.

On a related note, I realized that my medical Spanish is much, much better than my medical Vietnamese. I had a Vietnamese patient yesterday who spoke only Vietnamese and I ended up using the Vietnamese nurse as an interpreter half the time. I mean, when you learn to speak Vietnamese at home, you don't learn phrases like, "How long have you been having contractions?"

All this said, most patients are very appreciative when you speak to them in their native language, especially considering that they are particularly vulnerable when I see them and they just want to feel comfortable (which is hard when you have your legs open for the world to see for hours on end, sorry for the imagery). So, my goal will be to be able to speak Spanish and Vietnamese well enough to not need an interpreter, ever. Then, maybe learn Chinese (yeah, I know it's ambitious).

Ouch!

I had my first needlestick today and it sucks. First, getting stuck by a needle hurts. Being stuck by a needle that went through a patient with known Hepatitis C hurts even more. And then sitting in the ED waiting for nothing feels like salt on the wound.