Month: July 2015

Another day, another shooting

Another day, and another senseless act of gun violence.

I sat down tonight to start writing about my experiences working as a locums primary care physician in the heartland of America and the Indian Health Services.

There’s a lot to write about, in terms of the myriad of chronic diseases facing this population and the stressed healthcare services that’s trying to care for them.

Cancer, heart disease, diabetes, tobacco abuse, alcohol abuse, obesity etc etc.

I forgot about one particular epidemic until I received a push notification on my phone about the shooting in Lafayette, Lousiana.

Another city, different from where I’m working but still uniquely American, trying to persevere through violence perpetrated by some who believe was just a person. Other’s who will attest he’s a person who culturually and perhaps legally was allowed to obtain an unneccssary appendage of violence.

In tragedy, the natural tendency is for people to come together.
When it comes to tragedy from gun violence, we seem to grow further apart as a nation, debating the merits of a vestigial amendment. This too, another uniquely American reality.

Another shooting and another night of mourning.

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"My dad says I’m disabled"

In my last post, I mentioned how I discovered a few things I had started writing before I had this blog. The following is something I started to write after my experience as a part-time disability examination provider for a national company. It wasn’t an opportunity that I particularly enjoyed, but with a mountain of debt to repay right out of residency, I decided to give it a try.
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“My dad says I’m disabled”
      Room number 2 was the one. It was worth coming in 15 minutes early just to grab that spot. With 12 hours of monotony from 22 patients getting disability evaluations, the view from that room (and the extra income) made this day worthwhile. In between patients, I would place my palms on the one way panoramic window to channel the warmth generated by the Arizona sun shining down on the black facade of this nondescript office building.  From the 10th floor, I took full advantage of my peripheral vision by taking in the seemingly endless hills, mountains and blue skies. Such mental escapes were fleeting and constantly interrupted by patients trying to make a case to qualify for government assistance.
      I always took the time to review the charts the night before. It allowed me to be more efficient and objective the day of the exam. Whatever skepticism I had about each patient’s claim, I would try not to bring it to the office. I constantly reminded myself that it was my job to make an honest assessment of their medical conditions.  It was up to the government to ultimately determine if they qualified for disability payments. Most of the patients had chronic debilitating illnesses and I knew no matter what I wrote in in my assessment, they would probably qualify.
        When I read Jaina’s file the night before, I felt disappointed but also grateful. I couldn’t believe a 20 year old with only depression and obesity would want to and try to qualify for disability. But I also realized this would be an easy visit that I could work through quickly and make up the time spent on more complicated patients. If the day became too long or frustrating, I would try to convince myself that I was performing a public service by helping determine if tax payer dollars should be used to support these patients.
      When I actually saw Jaina my skepticism was unfortunately confirmed. She walked in and sat next to me without any difficulty. My physical exam revealed nothing despite her assertion that knee and back pain limited her capability to work. My conversation with her had clues that her depression is what really limited her. She had a morose look to her face and struggled making eye contact. She was diagnosed by her primary care physician but had poor follow-up with him. She also hadn’t been referred to any mental health services which made me think if her depression was better managed, it wouldn’t be “disabling.” I asked a series of questions in terms of her abilities to do a variety of menial tasks and her answers indicated she could do everything. With each question she must have sensed my increasing skepticism towards her disability claim. At one point she looked away and welled up with tears. I asked her if she was okay when she muttered “I know I can do that stuff, but my dad says I’m disabled.” I paused, unsure what to say. I wanted to delve further but I was running out of time as the proverbial walls started coming up around her. Her answers after that confession was curt and she kept directing me back to her back and knee pain. I eventually had to complete the visit and send her on her way. I felt troubled by what she had just said. I felt even more unsettled thinking about all the things I would never see or understand about Jaina’s life that led to our meeting that day.
In retrospect, as I learned more about medicine and our health care system many things became clearer. I continue to believe she really was clinically depressed. In our perversely broken healthcare system, she probably had difficulty accessing primary care services.  She probably had limited access to mental health services especially ones that could be tailored to patients with specific cultural or language needs. Every day as I continue to see the critical role family plays in both good and bad health, I keep thinking about the injustice Jaina’s father had done to her. A 20 year old physically capable girl should be able to dream big and pursue happiness. Instead, it appeared that her father traded in her self-esteem and hope in exchange for an opportunity to get a few hundred dollars every month from the government. Conversely, I wondered what was going on with the father and his own struggles in our society that would make him take his own daughter down this path.

              It took me only a few minutes after reading her chart to figure out that the odds were against her to qualify for disability. It has taken me years of experience and a single moment to reflect to believe that the odds are against her for a chance at anything at all in this life. 

STICU

Recently, I found a collection of things I had written as a medical student. I didn’t have a blog in those days and saved them as Gmail drafts hoping to finish one day. It feels great to discover an old memory, as grim as this one may seem. It’s one of my few distinct memories from my surgery rotation.
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STICU
The alarms forced my body to wake up at 5 AM. By 5:30 AM as day break approached, my body resorted to muscle memory to push the accelerator pedal and turn the steering wheel in order to guide my ugly early 90’s era sedan through the quiet streets of inner city Brooklyn. There was only enough cognition at that hour to determine what color the traffic lights were. Decision making was limited to stop or go. By 5:57 AM, my brain would arrive at 2 rational thoughts. First, I had 3 minutes to make the walk from the parking lot to the STICU. The second completely rational thought was that 3rd year of medical school was making me regret my career choice.
By 6:05 AM, the team collected behind the central counter of the STICU (surgical trauma ICU) and descended upon the resident on-call the preceding night. On this particular night, it was a middle aged, overweight, Turkish anesthesia resident who appeared especially sweaty. From his bloodshot eyes you could tell he was feeling too old to be doing residency all over again here in the United States. Marty, a precocious and social urology resident appearing clean and freshly shaved looked at the exhausted resident and said what the rest of us were all thinking.
“Rough night buddy?”
The on-call resident gave us all a brief look and regretful smile. It was 6:06 AM and although I had been up for over an hour my brain did not register enough of the world to make a reasonable and appropriate response. I wanted to somehow support this resident who had a difficult night but simply couldn’t muster the energy to do anything. In fact, this was as far as I would let my mind explore the emotional realities of being a member of this dungeon. The next 12 hours was not about feeling or learning. It was simply about reacting and doing whatever needed to be done for the 8 occupants of the STICU.
Bed 1: Gastrointestinal bleeding. Draw a blood as soon as the meeting breaks and every 6 hours after that. (I hated drawing blood)
Bed 2: Motorcycle accident: Find out from the pulmonary doctors if he can extubated. (I hoped the pulmonary fellow wouldn’t bark at me for bothering him)
Bed 3: Nasal Bleeder: Ask the ENT doctors if he really needs to be here (More scut work)
Bed 4: Aortic Dissection: Call his pharmacy or family and find out which blood pressure medications he should’ve been on (Even more scut work)
Be 5: Empty. (Mr. Marcellus apparently coded for 45 minutes the night before. The bed looked really comfortable. I didn’t care someone had died on it)
Bed 6: Smoke inhalation, Acute Respiratory Distress Syndrome, Sepsis and a deeply pious Orthodox Jewish family. Go to radiology, get a report of today’s xray and bring it upstairs. (Apparently, family was in and out of the STICU all night praying at his bedside.) Talk to the family and let them know they can only come inside during visiting hours or if there’s any acute change in his status. (I’m sure a grieving family loved having a 3rd year student restricting access to their loved one)
Bed 7: MICU boarder. Medical ICU patient. Go talk to the medical ICU residents and see if they have a bed available to take her back. (I was sure the answer would be no.)
Bed 8: Liver failure in DIC. Check his labs every 6 hours. (He was a goner, but I knew he’d keep us all busy.)
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Later in the day we coded bed number 8 several times until he died. I remember the final horrific experience of doing chest compressions on his bloated dying body. My arms were tired from several rounds of CPR and my neck became sore from trying to keep my head turned away from his face. After a while, I couldn’t stand to see that lifeless zombie stare where instead of words coming from his mouth there was only regurgitated stomach contents. And instead of tears there were only drops of crimson blood oozing from the corners of his eyes, 
Through the entire process, I did what I was told by our code leader. Rather than thinking about what was happening to this poor unfortunate soul, I remember counting the chest compressions in my head wondering how events in my life could’ve culminated with me bearing witness to this horror.
By 2:30 pm after taking care of some odds and ends, I had the opportunity to go eat lunch. I had to hurry because although Bed #8 was empty now, a replacement for Bed #5 was on the way.

The Half-Full Glass

     Its cliché, but I frequently reference the saying “The glass is always half-full.” There are always unexpected twists and turns in life, and that saying definitely helps me keep a positive outlook on things. I look back at sentinel moments in my life that didn’t go as expected and inevitably most of it turned out extremely positive. For example, although I didn’t get accepted to a US medical school, my experience at an off-shore Caribbean school (SGU) was life altering. Besides a great education I came away with numerous lifelong friends, few of whom became like brothers. After residency, I found limited job opportunities around NewYork City and settled on a position in academics. This was despite swearing during residency never to work in academics! But unexpectedly while surrounded by great mentors, residents and students I developed a passion for medical education that changed my career aspirations. After almost 6 years, I moved to Texas to continue my work in medicine and academics. Although I wanted to hit the ground running, I hit a major roadblock in the form of an unexpected 6 month hiatus from my career.
     While in a bureaucratically imposed exile, disappointment naturally set in as the weeks and months went by. But I resorted to my favorite cliché and two incredible things happened. First, I got to nurture another passion; fatherhood. 
     I remember flipping through my phone on my HuffPost app, coming across an article about the state of parental leave in America. It’s sad and disappointing. The following infographic shows how we (the USA) lags behind the rest of the world in taking care of our new parents and the children they’ve brought into the world.

    My unexpected time off has given me the opportunity to watch my youngest daughter grow through her formative infant months. This has been a precious and memorable “paternity leave” that otherwise would be difficult to attain in our workforce. Furthermore, the medical school debt that physicians carry (a whole other topic!) makes extended parental leave for mothers and fathers a rare luxury. Nevertheless, though it wasn’t planned, the time off spent with my darling has been wonderful.
     But at some point, I did have to start working again (bills bills bills!)and fortunately the world of Locum Tenens  (temporary contract work) offered plenty of great opportunities. Although it wouldn’t be in academics, this New Yorker suddenly found himself in the middle of rural southern Oklahoma, a new resident of the Chickasaw Indian Nation and a physician for the Indian Health Services.
     Once again, my favorite clichè did not let me down. What started out as simply a need to work is rapidly becoming a unique experience that is giving me new perspectives and insight on medicine, the state of our healthcare system, culture, history and my own abilities as a physician. In the coming weeks and months, as I delve further in this experience, I hope to blog all about it!
T.S. Eliot
“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”
― T.S. EliotFour Quartets