Review: Juno

The movie Juno, released in 2007 and directed by Jason Reitman, enjoyed wide popular and critical acclaim despite a minuscule production budget. Like the Blair Witch Project, it became a sleeper (no pun intended) hit, eventually winning an Academy Award for best original screenplay. The show deals with teen sex and pregnancy, which obliquely involves family medicine, so I guess I have some reason to talk about it other than the fact that I did like the movie.

Juno is a 16 year old girl who gets pregnant after a tryst with her longtime best-friend and occasional boyfriend (depiction of the act is repeated, but tasteful and not gratuitously revealing). She initially chooses to have an abortion, but decides against it after a rather uncomfortable experience at the only local clinic that performs the procedure for free. Instead, she decides to put the baby up for adoption, and chooses a wealthy couple desperately seeking a child. The story dispenses with much of a dramatic climax - other than to require some very adult-like decision making by Juno. It turns out that the rich have their problems too, although their kind often crouch behind over-sized front doors, huddle in spacious breezeways or waltz softly in cellars devoted to past wishful glories. Juno’s parents weather the shock of her predicament well, with an admirable balance of reasonable judgmentalness and loving support. “I was hoping it was cocaine or shoplifting,” the step-mother confides to Juno’s Dad after they hear the news.

I can see why the screenplay beat out other brilliant scripts at the Awards. The writing credit goes to Diablo Cody - that’s a woman, not a an eternal being from the outer realms of darkness, or perhaps somewhere in Wyoming - who started her writing life as a stripper. Her imminently popular blog about the skin trade led to her contract to write Juno. Some wonderfully witty moments pepper the script, and deserve the attention they received. However, the actors rescue some lines that with lesser players would have devolved into jarring triteness. Credit the director for drumming up Ellen Page to play the title role, who herself borders on unbelievability, but is rescued in turn by moments of incisive honesty in her script. This symbiosis - script and actress relying the other - occurs regularly through the movie and probably saved the enterprise as a whole.

The depiction of the family planning clinic probably did not depart far from the reality. State-supported medical clinics tend to run heavy on the documentation and short on things like staff and, say, furniture. Given the number of teen-pregnancies my clinic deals with, I found the depiction of Juno fair and respectful. Not every teen is a bimbo with no grasp of consequences; there is nuance to many of their situations. That said, Juno exhibited a more sophisticated persona than most teenagers. Her sense of self and values was decidedly adult. In fact, we should be so lucky to have teens work through complicated issues like sex and pregnancy in such an honest and careful way. Many adults don’t rise to the level of emotional acumen we see in Juno. Frankly, much of America worships ardently at the altar of pleasure to the exclusion of anything or anyone else. Juno, like few of us at 16, and maybe even 35 or 65, spends most of her time focusing on her problems and solving them. Nary a misstep does she make after her single afternoon of what was, likely, something like 33 seconds of coital bliss in an over-stuffed red chair.

Fair or not, I enjoyed a cathartic moment when the step-mother - in the room with Juno and her best friend during her ultrasound - dresses down the tech for denigrating Juno’s situation. Chatty ultrasound techs have caused problems for more than one of my patients. In one case a tech hinted to my pregnant patient that something was wrong with the baby, “but I can’t tell you about it, you’ll have to talk to the doctor” (scan turned out to be fine but the woman had nightmares for the rest of her pregnancy). In other countries, OB ultrasounds are performed by the doctors themselves, and so can give an official read right there in the exam room. In the US, we have techs do it, who understandably become tempted after their 1000th scan to give the patient their own interpretation. Some techs are good enough that they’re usually going to be right, but legally they are required to keep their traps shut. Interpretation and commentary is NOT their job, acumen in that area be damned.

Humph! Anyway…

As a father, I watched the movie hoping I would know my daughters well enough to prevent them these kinds of dilemmas, knowing in all honesty that I won’t be the one doing any such thing. Hormones and pubic maturity arrive around 13 years of life, and from there I will be but a distant guide - one mild tenor in a chorus of influential voices. I also envisioned myself behaving quite like the father in the story - angry and protective but ultimately on-line and ready to help. God only knows if I could really manage such levelheadedness.

Politically, I knew that anti-abortion types would love the grim clinic scene and applaud the choice made by Juno to keep the baby. Many in the conservative right believe that pro-abortion forces are out to talk the rest of the planet into having the procedure - men too, if possible - and would DIE before they even discussed the alternatives to it such as adoption. My own experience with pro-abortion people suggests much more balance and pragmatism among them. Still, I did feel a sense of satisfaction on behalf of my pro-life friends in seeing a viable alternative to abortion played out step-by-step to a tenable - and preferable to all possible worlds, in this case - conclusion.

Juno glossed over the considerable emotional toll something like this must put on a young girl. The end scene is of Juno, back with her boyfriend (one assumes, also back in the sack, this time with a more proficient prophylactic). They sit idyllically in dappled sunlight on stairs leading into his front yard. Whimsically, they play guitars together and sing a melodic paean to teenage life. Consequences, perhaps lingering in soft shadows at the corners of the closing frame, hold no sway in this myth.

We should all be so lucky.

A REAL Doctor

Was seeing a patient for the first time the other day when, toward the end of my visit with her, she asked, “So…are you a real doctor?”

I wasn’t quite sure how to respond.

Missing a beat, I then replied, “Well, no, actually. I’m just a resident. Training. Dreaming big dreams of one day being the real thing.” I felt a bit like Pinocchio.

“What I mean is,” She continued, unperturbed, “are you really just a nurse. You know, one of those nurses that acts like a doctor…or are you actually a doc?”

“OH!” I reply, thinking oh yes…THIS stupid conversation. (It’s endless, it goes on and on. It’s like the circumcision debate) “Yeah. I’m a real doc. Except for the ‘in training’ thing.”

“Great, because I normally see a nurse, but I’d much rather just see you.”

Obviously, this kind of thing makes me feel a bit pleased that I have impressed a patient enough to want to see me again. But it could be simply that this patient wants to see me instead of her nurse largely because of the interaction of their two personalities. My medical acumen may have very little to do with it.

ARNP’s, PA’s, NP’s and the rest all serve important roles. In all honesty, many of them know more than I do about medicine and sometimes I frankly can’t come up with any good reason why a patient should go to me rather than to them.

When I DO get my hackles up, however, is when I find that those professions not only disrespect mine, but see family doctors as superfluous. A recent circulating rumor I heard is that the latest national NP conference displayed a HUGE banner on their wall claiming that in time, they would put family medicine out of business. I’m the kind of guy who isn’t too competitive until you try to crush me under your boot…or, white nurse’s shoe, as it were. Then I get a little riled.

First, let me present a very basic sketch differentiating between the training demands of MD’s like me and some of the other midlevels:

Clinical training hours:
DNP: 1000* (this is the latest nursing degree you can get…a doctor of nursing. Sounds a bit oxymoronic to me, really).
PA: 2400
MD/DO: >12,000

*Can be done PT & online

Look at the difference. It’s unbelievable. MD’s and DO’s train more than 5 TIMES longer than the next highest mid-level. This doesn’t mean these people aren’t smart, or that they don’t know lots of medicine. At times, they might know more than an MD about a particular ailment. But on average, their training pales in comparison.

More concerning is that limited training can lead to limited humility. I once heard the a guy say that the definition of an expert is someone who is exquisitely familiar with what s/he does NOT know. The more training you have, the more likely you will know when you are beyond your knowledge or abilities, and avoid the dangers of the Dunning-Kruger effect (read ’bout it here). The D-K effect is the phenomenon where people who know little tend to think they know more than they do, while people who know a lot tend to think they know less than they do. Given the propensity for medicine to hurt you, or save you from something terrible, let me assure you the best doctor is in the latter category, not the former.

I don’t have any problem with mid-level medical providers, of all shapes and sizes. But I do think that - aside from my own bias as a result of all the training sacrifices I’ve made over the years - MD’s and DO’s should be understood to be the best-trained, and certainly not replaceable. Although my first inclination about why my patient wanted to drop her NP to stay with me had to do with their personalities, it is also true that poll after poll shows that patients would rather be taken care of by a doctor, not a PA or a ARNP or NP.

Finally, an analogy:

In college I went to this church called Calvary Chapel. These churches pride themselves on the fact that most of their pastors don’t have a seminary degree (they were “called by God”, just like the original mostly uneducated disciples). At the church I went to, one guy had been to seminary and all the other pastors hadn’t. Guess who I liked the most? The seminary guy. He just knew stuff. He taught better, and I learned more.

I think it’s the same way for many patients. Most would rather be seen by a person who has taken care of people in hospitals, been there when they were born, held their hands when they died. They would rather have a doc who has worked in ER’s and has actually done CPR on a real human not a doll named Annie.

So much of medicine is about experience. Every day, people come in with a cough and need me to tell them if it’s gonna kill them. Odds are good it won’t. But is it MRSA pneumonia? The sentinel case of pulmonary anthrax? PCP pneumonia? Not likely. Only God really knows. The rest of us have to rely on knowledge and experience. Doctors have simply see more bad stuff than mid-levels; there’s a better chance we’ll make the right call.

Fundamentally, when an MD says, “In my experience…” it’s a very different statement than when a mid-level says it. We pay a heavy price to see all that we have, but in the end, that experience may just be what saves your life.

No Money, No Care

One of my favorite families brought their 6 year old boy to see me for ADD the other day.  Dutifully, the parents had filled out the questionnaire about their son’s behavior, and they had successfully obtained a similar form from one of his teachers at school.  The scores were not good.  In fact, they had just come from the principle’s office, as the boy had been detained there for fighting that very day.

The parents of this boy do their level-best to take good care of him.  That said, there are many children in the house and they are mixed from previous marriages.  I admire both parents for overcoming numerous destructive behaviors earlier in their lives and focusing on building a healthy family.  The mother has chronic headaches, but refuses to take narcotic medications for them.  With kids scattered all over their small apartment - including a needy newborn - I very much respect her efforts to be a good mom, and she is one.

So, I trust that this boy is in good hands.  But he struggles in school.  He often explains his bad behavior by stating that “forces” tell him to punch kids, or tip over desks.  In reviewing his ADD assesment scores, his inattention was not the primary problem.  The bigger scores centered around behavior issues.  When evaluating children for ADD, we tend to give medication to kids who can’t pay attention, but not to the ones who have behavior issues.  Meds only seems to help the inattention kids.  What this very fun little boy needs, I think, is consistent and thorough counseling.  I am especially convinced of this because his problems are largely confined to school.  Even in his sometimes hectic and certainly cramped home, the boy behaves.

We recently had a new child psychologist open a practice in the area, and he gave a presentation to our clinic the other day.  He began his talk by noting that most children with psychological problems are in the low socio-economic groups.  Meaning, they don’t have any money.  He said nobody was able to explain the correlation sufficiently, but that’s just the way things are.  He went on to talk about many effective treatments and interventions he has for children with phobias, anxiety, depression and behavior issues.

He also provided some good information.  For example, the most common childhood psychopathology is not ADD or depression, as I would have guessed, but anxiety.  He said depression is often a comorbidity as a result of underlying anxiety.  He said anxiety afflicts 10-15% of children and is often unrecognized.  Of the anxiety disorders, he said that separation anxiety is the most common, and that the disorder manifests itself differently in different age groups.  Some kids fear something will happen to their loved ones once separated.  Some are afraid of the sheer distance - so the farther the parent will be from them, the more anxious they become.  Other kids become afraid of things like monsters, animals, insects (well, me too on that one) and the dark.

Maybe this is the problem with my patient.  I would love to have him evaluated by a specialist who does this every day.  Especially one with years of experience and a nice new office with lots of open time slots because the practice only just recently opened.  “Do you take insurance?”  I asked, hopefully.  His answer was and enthusiastic, “Oh yes, I take all kinds!”

“Good.  I’ve got a patient for you.  His parents have medicaid.”

The good doctor’s face winces, “OH!  Sorry, actually, I don’t take medicaid.”

So, we’re back to me, with little time and experience, to try to help this kid.  This is common in the medical world.  I don’t really blame the psychologist, either.  I sure hope I have a limited proportion of medicaid/care in my practice.  I’ll never get out of debt if I get paid as badly as they pay.  The frank truth is that until universities and banks become altruists, doctor’s should be either.  So, his refusal to take government insurance - in the process of lowering payouts to even worse that they are currently - is understandable.  But that still leaves me with a beautiful little boy that needs good psychological care.  In talking with him, he was kind, very sharp - at 6 years old he correctly used the words “opposite” and “thorough” in sentences - and actually rather sweet. 

But any kid that young getting suspended that much is not headed toward a successful life.  It’s hard to really believe you have something to offer the world when you’re constantly in trouble from the time you’re 6 years old.  Likely, he will end up making a living with a gun and knife, threatening the lives of doctors, bank execs and child psychologists as they walk to their fine cars outside their well-funded clinics.  This is medicine in America.

Gestational Diabetes - What We Did

A while ago I wrote a ‘You Be The Doc’ regarding a patient with borderline gestational diabetes. That patient had her baby recently, and it was something of a white-knuckle affair. Here’s what happened:

The initial test for GDM is a 1 hour glucose tolerance test, and the patient was VERY positive with a score in the 190’s. In the medical world, it’s considered bad form to designate someone as ‘very’ positive, or ‘borderline’ positive. These numbers are cut-offs. If you are past the cut-off, you’re positive. That’s it. No rounding, no data massage. The cut-off for GDM is 140. So the test is positive.

There are lots of reasons why the 1-hour GTT is lame. You can eat virtually anything on the McDonald’s menu, then come to the clinic and take the test and have a pumped up test result. So, because you can’t really trust a 1-hour GTT, we follow it with a similar test that is at least a bit more rigorous (still lame, though). The 3-hr takes 4 blood glucose tests - a fasting, then 1, 2 and 3 hours after drinking a sugar-rich solution. Our patient had normal values for all but the 4th test, and it was only off by about 3 points. 3 points! Everything else was normal. In my last post, I pondered whether or not to bestow the diagnosis of GDM on this patient with this glucose profile.

We did not. We told her she was fine. No intervention.

Hey, we’re family doctors. We’re mellow. A coupla out of range values. So what? No big deal right? Actually, you might ask, what is the big deal? Well, the whole point is to determine if your body can metabolize (that is, put away) glucose correctly. Glucose - sugar - in your blood stream is a BAD thing. It doesn’t belong there, it belongs in your body’s cells. Think of it as energy. Like little burning, flaming, sparking packets of sun-beam radiation (that, incidentally, also taste really, really good). As this stuff flies around your blood stream, it’s like an average 2 year old boy left alone in a glass-blower’s museum (well, at least my 2 year old boy). This is, metabolically speaking, why eating high-sugar foods isn’t healthy…or at least risky. At any point, your body may look at all that glucose tearing apart your capillaries in your eyes and kidneys and brain, start wringing its metaphorical hands and just curl up into an useless whimpering pancreatic fetal ball and give up. If, for some reason, your body can’t vanquish the insane levels of glucose the average American pours into their arteries in a given meal, you have diabetes. High blood glucose levels cause all kinds of problems. The most important of which, in pregnancy, is HUGE kids. We call ‘em “macrosomic”.

My patient - who we did not treat for GDM - went into labor around 8pm. Very little cervical change occurred through the first 10 hours. By noon the next day - we’re talking about 16 hours of labor here - she was finally ready to push. After pushing for 5 hours, the baby still wasn’t out, in fact, she hadn’t really moved at all. Imagine, after five hours of the hardest work you’ve ever done in your life…you get to hear your doctor say something oblique and vaguely encouraging like, “You’re doing GREAT! I’m sure things will progress if we keep working.” There’s a thing called the “labor curve” to mention here. Typically, if there isn’t continual cervical change, and steady descent of the baby once the patient starts pushing, the patient is said to be “falling off the labor curve.” When this happens, docs need to start looking for a problem. In general we look for one of 3 P’s: Power - mom just can’t push hard enough or uterine contractions not strong enough, Pelvis - is the “chute” too small?, and Passenger - is the kid too big? In this case, the patient was off the curve, and we couldn’t be sure that any of the P’s were adequate.

We were able to see the baby’s head well enough to allow us to use a vacuum, which did help bring the baby into the base of the pelvis. At that point, we had an OB in the room to evaluate for C-section. She was particularly concerned with our decision to not treat for GDM based on this patient’s glucose profile. Almost certainly, she said, this baby was macrosomic because she, by definition, had GDM (remember, our 4th value was out of range by 3). She also said that she would have treated the patient for GDM based on her very high 1-hour test, forgoing the 3 hr. entirely, since it had been “very” positive.

You can imagine my handwringing concern at this point. I let this patient sit around for MONTHS, cooking up a huge baby that was not going to get stuck in her pelvis. Bad things happen when babies can’t fit through pelvises. To think I could have prevented it by just being more aggressive early gave me the opportunity to experience some new emotion - as yet unnamed - that combines stark fear with wistful, sharp regret and a sticky sort of guilt all mashed together with insecurity and self-castigation. We’ll call this feeling FRGIS. Mid way through this experience, I felt extremely “Frgis-y”. That is, quite terrible. I’d, perhaps singlehandedly, resigned this mother to surgery (best case), or perhaps something more terrible due to shoulders, head or neck getting stuck in the birth canal.

In the end, the vacuum (which only adds about 10% more power than the uterus and mother already provide) created just enough extra oomph to get the baby’s head through. The shoulders were a tight squeeze, but there was no distocia (shoulders caught on the pubic bone…can be REAL bad). The mother hemorrhaged and required 3 different medications to get it stopped, and she had a pretty good-sized laceration that took about a hour to repair. But the baby did fine. Actually, rather cute. I usually think they look like aliens.

The upshot was that the baby weighed around 8 lbs. This IS NOT MACROSOMIA! This is a big baby, but not medically large. In the end, we had nothing more than a difficult delivery, which probably had more to do with the mother being new at pushing and not really knowing how to do it than anything else. More stringent glucose management may have helped keep the baby a bit smaller, but she wasn’t especially large even without management. And the patient got no shots, no medications and no extra worry about having a metabolic disease while she worried about just getting through her pregnancy.

In the end, the patient ended up with a beautiful, normal-sized baby. Yes, there was a pretty big laceration, but these are relatively common irrespective of the size of the baby. But in general, our management was within the standard of care, although there is room to debate whether or not we should have been more aggressive. True, the doctors lost hair and years from their lives (or, my life, anyway), and experienced the wonderful emotion called FRGIS, but hey, this is medicine, right?

Reply to ‘Lawsuit’

My latest blog - ‘Certain Lawsuit’ - received a great and challenging reply from a reader (goes by ‘one who knows’ round these parts). I enjoyed the comment so much I’ve responded to parts of it with some of my thoughts:

“There has to be a tort - in other words, the plaintiff has to have suffered some form of actual damage.”

This is the growing problem - the focus on an actual damage. Whenever anything goes wrong, there’s damages. From here, the question is whether it can be proved in court that a doctor is at fault.  And this is the slippery-slope that drive the process.  In the same way that a parent is always at least distantly responsible for anything that happens to their kid, so a doctor is responsible for their patient.  Doctors want it this way.  This is the responsiblity of medicine that doctors see as sacred.  This concept of nearly-global responsibility has become a functional revenue-source for lawyers.  You can always find fault in something a doctor did, even if the letter of the law is followed.

“And there has to be a credible allegation that the standard of care wasn’t followed.”

Your point here is well-made. To some degree I agree with you, and often we console ourselves with this fact. The problem is that “standard of care” is a shifty thing and, worse, you can always find something that didn’t go exactly according to guidelines.  Add to this the ‘responsibility’ conundrum mentioned above and you have serious liability before doctor and patient even meet. There’s so much more gray in medicine that people realize. Dig into any chart and you will see deviances from standard of care, especially because that standard is variable and constantly changing. What if the doc followed the latest recommendations of the Academy of Neurology, but in so doing s/he defied the standard of care in that particular medical community? What if the patient was just 2 minutes past the point when TPA is recommended? Forget it? No treatment? What if nobody can verify when the symptoms occurred and the family is begging that the patient gets treatment, so the doc does and the patient ends up with a bleed? There’s so many nuances, a lawyer that makes a living on tort cases can always find something that can be presented as “deviance from standard of care”.

“Legal preparation and discovery cost time and money; attorneys are not going to waste their resources on cases that are weak or marginal.”

Strong point. Probably the only limiting factor in the entire system. But you can always find a lawyer willing to waste YOUR resources, which some people are willing to spend because they know that the payoff will offset their up-front costs. They can even work it out so that the settlement amount gives them a 20% or better return on their up-front investment. Additionally, I readily admit that this is my own bias - and probably a bit alarmist at that - but I think hungry trial lawyers don’t really look at case merits but simply whether or not there is payout potential. Hospitals prefer to settle cases, so if the case was based in a hospital and a large payout can be justified…well then, son, let’s open up that medical chart and find some mistakes!

“I personally think all medical schools should provide a required course on medicine and the law.”

Absolutely cannot agree with you more…we don’t know a damn thing about the legalities of medicine. But this is sad. It’s acquiescence to put classes about it in medical schools. Doctors should be left to learn their own profession. This is hard enough. I honestly thought I was going to drown sometimes during medical school. The information was totally overwhelming…and that was only the medical science. And keeping up on the changes in medicine challenges even the brightest of us.  But successful doctors today are required to be mini-lawyers, and mini-businesspeople, too. Ask any doctor you know, and >90% of them will tell you they just want to be left alone to do medicine. Most don’t care about the law and many hate business too. They just want to help patients, and spend the majority of their time with them. But this idyllic. It’s juvenile. Today’s doctors need to be out to help themselves. At least, that’s what a good defense attorney would tell them. Patients are risk, and every encounter should be judged in terms of risk exposure. Most of us find this new side of medicine revolting.

“There’s an astounding lack of knowledge among physicians about how the court system works, and as a result you’re all running scared on the fuel of misinformation, exaggeration and urban myth.”

I hope you’re right. I hope all the talking doctors do about lawsuits is more talk than reality. To parse out the real from the mythical, I’m trying to get a lawyer - an actual defense or, better yet, prosecuting attorney - to give a series of presentations to our residency on this issue. Like coding, like business analysis, like charting, I hate it and have no innate intellectual curiosity about it. But I have to learn it, like it or not. This is American medicine in the 21st century.

Certain Lawsuit

Here’s a sure way to get sued:

Use TPA on 100 patients. That’s all it takes. 100 times, statistically, and it’s off to the courts.

TPA is a pretty cool drug because it is the only one that actually breaks up blood clots. Effectively Drain-O for the body, TPA drills through plugs holding blood from crucial areas of the brain. Ostensibly, it could be used for clots in other areas like the heart and the legs, but it usually isn’t. In fact, there are EXTREMELY strict guidelines for exactly when to prescribe the drug. Roughly, those rules claim that you can only use it within about 3 hours after a person exhibits classic symptoms of a stroke. An ischemic stroke, by the way, not a hemorrhagic one.

Why so many rules? Wouldn’t a drug like that be the answer to the world’s medical problems? Think of how many people die every day because of clots forming in our vasculature that shouldn’t be there. This is why docs are so obsessed with cholesterol, for example. It contributes to clogging up coronary arteries. Arteries get blocked, heart muscle doesn’t get oxygen…heart attack. Pretty simple, really. So this drug should save the world. Maybe we should all take it on a regular basis, just to keep things thinned out.

The problem is that the drug works incompletely. It does, in fact, break up clots, but sorta like a photon torpedo from the Star Trek Enterprise would break it up (it must be quite cool to watch). You end up with bujillions of little clots in your blood stream. If they’re small enough, they will pass through even the smallest capillaries and not clog anything up. But usually, all those clots will lodge somewhere else and cause more problems…like mini-strokes, mini-heart attacks etc.

But the legal problem with the drug is that approximately 1 in 100 patients will end up with a brain bleed as a result of the drug. The reason is because after a clot forms, holes open up in the artery downstream from the clot as things dry up. The holes are basically caused by shrinkage like anything shrinks after it dries out. Then the TPA comes along and busts up the clot. Blood starts flowing again, and viola! it rushes across the newly-formed holes and pours into the brain.

“My doc gave me a hemorrhagic stroke.” Defend THAT mister docta man.

There is no incentive in our system to NOT bring litigation against doctors or anyone else. Sure, most lawyers don’t want to waste their time, but when there is a basic complaint as glaring as “my doctor caused my brain to bleed”, most will give it a whirl. Think about it: Plaintiff attorneys have a 50-50 chance of winning on the basic charge alone. Some poor patient gets on the witness stand, drooling and drooping and describing what their life was like before Dr. Flamethrower over there pasted him with that terrible medicine. But even if the case loses, most lawyers make money. Bringing charges…brings charges. Trial lawyers bring cases with big pay off potential (most stroke cases fit this bill), settlement potential, or when the patient can pay up-front.

I think there should be a litigation approval process where complaints can’t be filed unless approved by a board of medical professionals. The proper use of TPA should never lead to litigation - bleeding or otherwise, if the risks of using it are described to the patient, or the patient’s family if the patient is incapacitated.  In many situations, TPA is the patient’s only hope of salvaging some brain tissue.

But this isn’t how things work in this country. A person can sue for any reason - rational or not, understandable or not. Fortunately for me, family docs don’t often use TPA. Use of the drug is left to ER docs and neurologists. With this kind of involvement of the un-trained legal profession in the medical world however, more and more docs of all specialties are taking a hard look at that 100th patient who could use TPA. Statistically, the lawsuit is virtually assured.

Beware The Silence

Know what it sounds like when a kid drowns?

Silence….

That’s what I was taught in my lifeguarding class. Our teacher, a guard for 20+ years admonished us in a stern voice, “Beware the silent pool.” Rarely is there thrashing and splashing and gurgling out a diminuitive “hel..gh..lp!”. Typically, the affair is alarmingly un-dramatic. It happens this way with adults sometimes too, but especially with kids. They just slip quickly beneath the water’s surface and unless they’re seen within about 60-120 seconds, the result is terrible.

This little rule correlates well with much of medicine, too. Last night, for example, I saw two cases, one “loud” and one “quiet”.

The loud case was a boy who came in by ambulance - siren, lights, DRAMA - because the mother is certain there’s something wrong with him. She says he has unexplained fevers, and doesn’t eat sometimes. Once in awhile, it doesn’t seem like he urinates normally. She noticed that he gets short of breath, too. She wants a full work-up and if we aren’t willing to do it (or not capable), she wants transport to the Very Excellent Children’s Hospital up the road. For her, there is certainly some sort of major metabolic problem and serious intervention is needed.

The “quiet” case is an older man who “just has a cough, man.” His friends made him come in because he keeps coughing and recently isn’t interested in eating…or drinking. Once in the ER, it is found that he has been smoking lots of cigarettes for lots of years; the patient says he’s had this smoker’s cough for a long time. “‘Course,” He adds in apparently sudden introspection, “…I guess the blood is new.” Over the past week or so, each cough is not just tinged with blood, but volumes of red, mucousy blood that is painful to produce. Labs show that his kidneys are virtually destroyed and after multiple liters of fluid he still can’t pee (one liter and you’d be running for the bathroom every 10 minutes…assuming you don’t have this guy’s kidneys). We also noticed that he has no platelets - the blood elements that cause clotting.

So, I’m sure you can see which case is medically alarming and which one isn’t. This is not to say that the kid really has a problem, he might. Odds are, however, that his mom is the one with the problem and will improve dramatically with some close doctor contact and lots of reassurance. It could also be that the old guy is also relatively ok. Maybe it’s just a pneumonia and severe dehydration or something simple like that. But there’s a good chance, he’s headed toward multiple organ failure and his time in this realm is short. Here’s a couple of the major flashing red lights in this case, if you haven’t seen them for yourself: Not eating for a short time really isn’t very interesting from a medical perspective. Lots of people have fluctuations in their eating habits, especially if they get basic, non-dangerous viral infections, etc. Not drinking is a BIG DEAL. In the brain, the drive to drink far superscedes eating. It trounces heat-seeking, comfort-seeking, sleep, procreation and even safety. Probably the only drive more dominant than drinking is breathing. Losing your drive to drink means something very basic in the base of your brain stem is awry. Also, some blood-tinged sputum after frequent coughing is nearly normal. It has to be looked at by a doc, but it can happen easily with even a common cold. Volumes of bright red blood is a problem. There’s a few things that cause it, all of which are life-threatening, most not treatable. Add to this the no platelet thing…and we have a serious problem in the guy who says he just has a little cough.

The contrast between these two patients - in terms of their severity - in interesting mostly because it reminds me that sometimes, the bigger problem lies quietly in the patient adamantly assuring everyone around them that things are fine, there’s nothing to worry about…and please, take care of that poor sick kid with the frightened mom.

Jesus Christ and Medical Data Cards

If you read this blog much, you’ve heard me wax eloquent (well…wax, anyway) about the merits of national health care. And while national health systems have their weaknesses…our system is even worse. Since we’ve never been able to agree on a national system, but still ethically know we can’t turn sick people away, we have a bastardized system that carries all the problems of both a market system and a social system. Aside from just relenting, admitting that we do have a social health system and fixing it, we could at least improve things dramatically by finally developing a medical data card.

In Israel where I went to school, everybody has a health care data card. Looking exactly like a credit card, effectively every pertinent medical fact about their lives is contained on it. Every medical facility has the same computer system, and when the patient goes to the doctor, the card gets swiped and everything pops up on the doc’s computer. Every Xray. Every doctor’s visit. Every allergy and surgery, every doctor’s note, every blood test, every medication. It’s all there. Aside from colluding all medical care so that safety and efficacy is dramatically improved, a nice little card like this would have certainly prevented a minor problem in our clinic today:

We’ve been seeing a patient for her 7th pregnancy. Obstetrical care for her is not simple. Aside from the fact that after a few pregnancies, care gets more complex, she has many medical conditions that complicate things even further. What we didn’t know was that this patient, along with being seen regularly by my clinic, she was also going to another clinic down the street for the same thing. When it came time to deliver, the other OB showed up and so did we. Nobody knew who would actually catch the baby. After some rather unprofessional-looking confusion, the other group performed the delivery. Now we’re all wondering who is getting paid for all the work we did. It was doubled up: High-risk ultrasounds, glucose tolerance tests, frequent visits. It was expensive for us. It was expensive for the other clinic. We all expected to be at least marginally paid for all that work.

The patient’s explanation was an honest and wide-eyed, “I didn’t think it would be a problem. My care was complex and I figured if you both wanted to care for me, two would be better than one.” She had absolutely no idea about the financial impact this kind of care takes on our clinic. And why would she? She doesn’t pay for it. Medical care, to her, is like a drinking fountain in a public park. Do you ever think about who pays for the water in a public drinking fountain? Who purifies it? Who bought the fountain itself? I just figure it’s there for me and I can use it, as much of it, as I want. And unless there’s a line, I can use it as often as I want. Never would I even consider it a problem to use one fountain and then again using another one a block away.

This patient clearly sees her health care the same way. Our clinic director was livid. Since the other clinic actually ended up doing the delivery, they’re likely to be the ones to get paid. We can then bill the patient, but she can’t pay for it. She never could. How many of us can come up with $4000 in an instant? In the end, our clinic will have to pay out of pocket for the care, and don’t be fooled by the nice building and sign out front…nobody’s getting rich off our clinic. There are months when we’re in the red and we all hope that there well be months in the black enough to cover the lean times. The wolf is always at the door.

If she had to give us her medical card to swipe, we would have seen her visit to the other OB two doors down that the patient saw yesterday. We could have told this patient to just see one doc and the expensive problem she caused would have been avoided. This is just one example of a problem that could be fixed by a national health data card.

One of the reasons we don’t have such a system in America is because Christian conservatives oppose the idea as a result of their literal reading of the Biblical book of Revelation. They believe the anti-Christ will be a great ruler that will rise to global power, force all to denounce Christ - Mohommed also, I presume - and then herald the end of the world in the battle of Armageddon. This battle is to occur in the Valley of Meggido (see pic), which is actually a rather tight fit if the armies of the entire world are to battle there. But never mind this practical problem with prophecy…I digress. Part of the prophecy is that this ruler will use national numbering and collective data to control the world. A nationalized medical information system, especially with cards or UPN strips embedded in our skin, is thought to have been prophesied as part of the ruler’s master plan for global domination.

Aside from my previously-mentioned annoyance at seeing Christians reason from a foundation of fear - rather than elation at the knowledge that they will be victorious even in death - I will add these points: First, the government has total access to nearly all personal information through our social security numbers anyway. If they want you, they have you. They’ve had all the tools necessary to tag and number every single American since the Red Scare in the ’50’s when Christians were fretting about the marching scourge of Communism. I also suggest that NOWHERE in the Bible are believers told to politically or physically oppose the anti-Christ or his/her rise to power. I don’t believe Revelation is literal - all the beauty of that book is contained in the metaphor of it - but assuming for a moment that it is literal, I can’t see any admonition to fight the anti-Christ in any manner except to resist any force that subverts Christ as the One True God.

The rise of the anti-Christ is foretold. Christians are not commanded - anywhere - to oppose this. And anyway, why should Christians oppose prophecy from their own Holy Scriptures? They ARE told to oppose religious conversion forced upon them by this powerful leader. So, I really can’t see a rational opposition to a national medical data card. Even one embedded in my arm. Given my penchant for losing things, I’d be the first to sign up for an implant. And doing so doesn’t violate even my most literal reading of Revelation or any other book of the bible. Even if the anti-Christ proposed it.

The life purpose of a Christian is not survival, especially not political survival. Christians are called to glorify God. Helping more people become healthy in this world - you could call it healing if you’re being dramatic - is most certainly more glorifying and reflective of God’s spirit than fighting the rise of potential anti-Christs.

Football Vs. Karate

I’m currently seeing patients in rooms 6, 8 and 10 on one hospital floor. Rooms 6 and 10 are interesting because both patients have similar problems, but totally different ways of approaching them. Actually, the two cases are very different medically. But the projected course and endpoints are very similar: suffering for an unpredictable length of time - anywhere from a few days to a few weeks - and then death. Both patients are elderly, having lived good, full, rich lives…but the end is now near.

In moving between rooms multiple times through the night, I’ve designated room 6 the “football” room, and 10 is the “karate” room. Here’s why:

Patient #6 wants to fight her disease every step of the way. EVERY step. She wants full CPR if she stops breathing, even though the likelihood of success is around 1% while the probability of a poor outcome - like a broken sternum and/or brain damage - is around 60-80%. She is getting tube feedings and IV feedings too. She does not want to be comfortable…she wants to fight. The sounds of the football field of medicine ring from this room: oxygen hydrators, infusion pumps, nebulizers and the chattering T.V….the sounds of life and conflict. One team has a huge lead in the 4th quarter - we all know who is going to win - but the losing team doggedly lines up play after play, hoping for the best. The football room is boisterous, clamorous and (medically, at least) some version of violent. The room is a clenched fist of rebellion and will.

Four doors down is Patient #10. This is the karate room. You will find serenity and focus here. No bubbling, no beeping, no chattering. Her husband maintains a constant vigil to make sure she is not in pain. At the slightest quiver of her brow, he jumps up and presses the PCA (patient-controlled analgesic) machine to give her narcotics. He last did this at 4am, since he was wide awake and monitoring any sign of pain she might exhibit. She is on a constant narcotic medications to keep her in a state of semi-consciousness, which protects her from the worst of what would be literally inhuman levels of pain. By day, other members of her family surround her, softly whispering their salutations and goodbyes. An aura of sadness and stoicism flows from this room. Unlike the fist of battle rage in room 6, the karate room is an open hand of acceptance, and the peace that surely follows it. In room #10, I constantly know the dignity of this human life as it ends before my eyes.

I grew up watching football. Still love my Denver Broncos (C’mon, donkeys, get an O-line!). I love the clashing and bashing…the sheer conflict of it. So, there is a part of the approach in room 6 that inspires me. Sometimes, I think, I want to go out like that; fighting tooth and nail ’till the very end. When I get there, I’ll be muddy, sopping wet and beat to hell. But so too (hopefully) will my opponent to some degree.

By contrast, I don’t know anything about karate…except some stuff I learned from watching “Karate Kid” in Jr. High about how if you get it right, you can chop beer bottles in half with your bare hand. So, I suppose I should be more inclined to agree with the approach in room 6. But I’m surprised to realize that in fact I hope to go out like the lady in room 10. I’d rather die dignified and comfortable than covered with mud and blood. There’s something about accepting fate in this approach that I find appealing…and right.

While living in Israel, I found that western-trained doctors (as Israeli doctors are) were frequently annoyed when they cared for Arab patients with terminal diseases, especially the more traditional ones. Many Muslims are quick to assent to fate; they believe they are in the hands of Allah and take peace in this. They often are lackadaisical about fighting their disease with allopathic medicine. As a Christian, I think this is a lesson we need to learn better from our Arab half-brothers. If we REALLY believe we are going to a better place, why fight so hard against death? Christians are supposed to be free from death. Why do we fear it so much?

Aside from spiritual issues, it does not escape me that patient 6 is forcing the rest of us to pay for the extremely expensive care that will negligibly prolong her life. Neither the patient nor the family can in any way afford the extraordinary care that is currently demanded. Suddenly, the battle in that room seems craven and virulent. The strategy went from a romantic frontier ideal of manifest destiny to wanton coercion of the group collective forced to uselessly give care.

So, when my day arrives to hear the doctor say, “Hmmmm, this doesn’t look good,” (assuming some high-speed, fate-tempting endeavor doesn’t do me in first), I hope I have the presence of mind to tell my family, “Please, just give me the karate room.”

Missed Diagnosis

So, I finally did it. I correctly diagnosed a previously-missed diagnosis. I’ve found that most of the time when a doc talks about catching something all the other super-smart docs missed, they have some sort of ax to grind. Most commonly - and not to start a war about the merits of chiropractic - I’ve heard it from chiropractors. I even heard one talk about how he correctly diagnosed herpes zoster after the patient had seen two other specialists.

Sometimes, like with the chiro guy, I don’t believe the stories. Mostly, though, I don’t believe in myself enough to think that I could catch something these other incredibly smart docs miss. I remember my med school class. Those people were SHARP. I watched them evaluate and diagnose patients every day. It never seemed like they missed a THING while I was always bumbling around trying to untangle myself from the IV tubing. Now, in residency, I’m a little less in touch with my colleagues, but they all seem so infallibly competent as well. I trust most of them implicitly. This is doubly true of the docs who are working and practicing in the community. These are full-fledged doctors. How could I ever do it better than them?

But I did. It wasn’t because I was smarter or better. The diagnosis was simple. If anything, I picked up what others missed just by listening to the story. Maybe everyone else was rushed when they saw this patient. They all got into highly competitive residencies and ostensibly know more medicine than me. But somehow, four doctors mis-diagnosed this patient. I knew his problem within 10 minutes.

The patient is a middle-aged male who came in saying he had an appointment with a specialist (a urologist) because he’s been having severe pelvic pain for the past 2 weeks. Come to think of it, it’s actually been much longer than that, but the past 2 weeks it’s been really bad. He was seen by two doctors in an urgent care clinic, who first gave him antibiotics and told him he had an infected prostate (in spite of a perfectly normal UA), and then gave him pain meds and told him to go to the ER if things got worse. Then he went to our vaunted ER, and was also told he had prostatitis and maybe prostate cancer and that he needed to see a specialist.

Sitting my office, he says he “hates doctors” (greaat, nice to meet you too) and hasn’t seen one since he was 12. He’s one of those tougher-than wood kinda guys that has worked in construction since the trade was invented. And I notice that he’s near tears. It’s the cancer bit, I figure. Works every time. I don’t know why docs throw that out there when they have no evidence. So now this guy is sitting on the exam table, visibly shaking, taking deep breaths and scared to death. I’m thinking that it would be easier to make a slab of drywall cry than to make a guy like this emotional, so I know he’s about a low at he gets.

None of his symptoms sound like prostatitis. Or a UTI, which is pretty rare in males anyway. The pain argues against cancer. Few people this upset are mere drug-seekers, and he isn’t asking for drugs anyway (although seekers use this tack frequently too). “Let me see this famed abdomen,” I say. I already have an idea that he simply has hernias. Sure enough, one quick check and it’s abundantly clear he has bilateral, indirect inguinal hernias. A med student coulda made that diagnosis. I think HE thought it was hernias. But both he and I figured we must be wrong because all these brilliant, well-trained docs said it was something else.

“Nobody’s actually done that exam thing on me,” He said as I took off my glove. “They always just jammed a finger up my butt. Don’t you need to do that too? I HATE the finger thing.”

“I hate that test too” I said (just read my blog about it, I think sardonically) “But I’d do it if I thought you needed it…and you don’t. You have hernias and if you go see that urologist, whatever doc referred you there is going to be pretty embarrassed. Cancel the appointment. Today. You don’t have cancer, either. It’s a simple surgical problem; you’ll be out of the hospital the same day.”

He couldn’t believe it. “REALLY?” He says. We look at each other in perfect understanding. I’m not offended by his suspicion. I’m this punk family medicine resident, not even out of training yet. I ride a skateboard to work, my hair’s never combed and I’m rarely on time. I went to school in Israel as a ploy to make global traveling look legitimate. Who am I to contradict wiser heads than mine?

“Man, I’m telling you. I’m dead-on. It’s hernias.” It felt good, strong, to say that. Even if it was only hernias.

Yesterday, I saw the guy again. Surgery is done. He’s all wide-eyed and looking at me like I’m brilliant. Says he told everyone in the ER (went back there while waiting for surgery because the pain got so bad, and got the surgery emergently that night) that I was the only doc in town who got the diagnosis right. I’m sure the ER doc loved hearing THAT. In truth, I made an elementary diagnosis partly because other stuff had been ruled out and partly because I had the time and wherewithal to really listen to the guy’s story. I think that’s why there’s more than one doc on this planet, and why there’s such a thing as second opinions. None of us gets it right every time, which is why I hate medical litigation. We’re all just human. I don’t even want to THINK about how many times my colleagues have picked up the fragmented pieces of my near-misses and forged them into a good outcome for my patients. But, for once, it was gratifying to be the guy who picked up the pieces. To make things right. This patient thinks I’m a hero. I figure it was just my turn…and it sure was fun.