A Tale of Two Residents

So yesterday, we returned to the hospital for our other child's tonsillectomy and adenoidectomy procedure. We were more worried about this one because he is younger. To read about the positive and negative aspects of our first experiences, please read the Tonsillectomy tales 4-part series. Everything pretty much went well except for a ridiculous situation that occurred shortly after the surgery. My son (who is only two and a half) did not wake up from the anesthesia in a pleasant state. He was crying, screaming, arching his back, and squirming. Of course, the nurse on the floor didn't have the orders for pain meds from the nurse who was with him in the recovery room. This is one of the most annoying and common things that happens upon a transfer to a new floor and can so easily be corrected by implementing an efficient system. How about this idea? Don't transfer a patient to a new floor UNTIL the floor has all the orders for the medications. Sheesh.

Anyway, in the midst of this chaos, a meek lady with a white lab coat walks in and just starts asking medical questions. If anyone has read this blog before, you know that I cannot stand this. Medical professionals need to introduce themselves when they walk in a room. So my answer to her first question was "Who are you?" She apologized and said she was the pediatrics resident and asked a bunch of questions that didn't seem to us to have much bearing on the situation at hand. We asked about why my son was making unusual gasping breaths ever since he woke up and she said it was because he was crying. We said that he was making these breaths before he started crying. She then said it was probably hiccups. My wife, who is a registered nurse, said there was no way it was hiccups because she felt him pressed against her body and could tell. The resident then said that it was probably due to the anethesia. I could tell she was just giving that answer to say something but really had no clue what was going on. So I challenged her on it and said "Have you ever seen this after aneshesia before?" She paused and said, "Maybe once." That's nice. Then how can that be thrown out so cavalierly as the explanation?! If you don' know, say you don't know, and get someone who may know such as a senior resident or attending physician.

After 15-minutes of needless screaming, the nurse finally comes in with two syringes. One had Tylenol. Another had codeine. Within 5 minutes, my son's face started to swell and get red, as did both of his arms. We told the pediatrics resident about this and she said that it was probably because he was crying. Oh no, I thought, here we go again. So I had to point out that these were new findings since the codeine and that it may be an allergic reaction. She said it may be from the anesthesia. Sighhhh. I again explained that the symptoms just started as soon as he took codeine and that he never took codeine before. I then suggested the possibility of an anti-allergy medication and she said she agreed and would order Benadryl. I sat there amazed that here I am as a non-MD having to lead an MD to figure out what is happening here. So then the nurse walks in and I asked if she had the Benadryl. She said she saw the resident in the hall who just said they are not going to use Benadryl. Ummmmm. Do you think the resident ever informed me of this? Nope. I was of course aggravated at this but then the ENT resident walked in.

What a difference. His first comment to my wife and I was "You two know your child better than anyone and you are the first line of defense." OK, so instantly he is acknowledging we have some insights that need to be listened to since after all, we are his parents. Good. Then he demonstrated he was taking our complaints seriously, examined my son, acknowledged this could be an allergy to codeine, explained the pros and cons of Benadryl at that stage, and assured us this would be appropriately and closely monitored. He also said that he was in charge here and not the pediatrics resident since this was an ENT patient. He also said he would have his senior resident come down to take a look just to be sure. Two different residents, the same exact situation, and both handled in polar opposite ways. What a relief it was to have the ENT resident and I felt very comfortable at that point. We decided not to use the Benadryl in favor of observation. In reality, this story has nothing to do with Benadryl, but has everything to do with communication and coming across professionally. Eventually, the symptoms went away and the breathing problems stopped. Today, my little buddy was having fun scooting around the house on his fire truck. :)

Stupid interviewing techniques

I had a case recently of a person who went to the hospital with a sudden onset of stroke symptoms. In addition to having expressive language impairment at the time she was also confused and understandably anxious. She was alone and the physicians tried to obtain information from her, which included the estimated time that symptoms began, personal medical history, and family medical history. This is all well and good, provided that it is written in the patient's records that the information was obtained from the patient in an acute confusional state. But it wasn't. The history was reported as if that was the actual true history.

The patient saw what was in the records for the first time when I reviewed them during my own detailed interview. At almost every turn, she said that information in the records was simply not true and emphasized she was interviewed alone in a confused state. This is why when I write reports, I use phrases such as "the patient reported" or "the patient stated." This way, it is clear where the information is coming from. If I have a patient that cannot provide a good history, there are no medical records, and no reliable informants to contact, then I will note that "the patient appears to be a poor historian and therefore the history provided cannot be relied upon as necessarily being accurate." Simple as that. It just amazes me that people cannot use common sense and realize that the information obtained from someone in an acute confusional condition may not be right, and to list in the medical records as if the information is factual is just plain silly.

Drug reps and the bribing of the modern U.S. physician

Yesterday, I was reading a fascinating inside story
about the life of a psychiatrist who became drug rep, or as some politically correct people would say -- a pharmaceutical salesperson. The psychiatrist wasn't literally selling the medications but he was providing the sales pitch that led to the sale in the end. The article raised many interesting ethical issues and brought to mind that this was a topic I had some strong opinions on yet never voiced on this blog before. So, here we go….

The bottom line to me is that the practice of giving doctors gifts in exchange for a chance to swindle them into selling a certain medication should be illegal. Told you I had a strong opinion on this. For me, it’s a matter of common sense. We are talking about people's health and treatment decisions such as medication selection should be based on the experience of the physician and objective research data. It should not be because I feel like I owe Joe the drug rep for the 10 pepperoni pizzas he just brought by to feed me and my residents.

I am a neuropsychologist and I do not prescribe medications. Despite this, in all of the medical settings I have trained in, I was always encouraged by the drug rep to attend the talk. Now why would that be? Because psychologists are prescribing medications in some states such as New Mexico and they know it is just a matter of time before this happens in more states than not. So why not build the relationships early, they figure. They do not know that I have no intent to prescribe medication one day, but there may also be another reason why they wanted me to attend. Believe it or not, physicians are always asking neuropsychologists what medication they recommend for certain conditions. Knowing this, the drug reps want to get the word out on their medication to as many people as possible. Or maybe they just want me to grab some of the promotional materials and distribute them so as many patients see these as possible and see it as a possible endorsement of the medication.

To those outside the medical community, here is the typical situation: A meticulously dressed young male or female, usually quite attractive, arrives to the hospital with a room set aside to do a talk on a specific medication. The drug rep spends time prepping the room, making sure the food is there and that promotional materials are spread out everywhere. So when you eat the food for the "Wonder-drug" you best believe you will be eating it on a Wonder-drug plate, wiping your face with a Wonder-drug napkin, and drinking from a Wonderdrug cup. You'll be taking notes with your very elegant and shiny looking Wonder-drug pen on some very fancy Wonder-drug paper. You may be slightly distracted by the Wonder-drug clock you received, or maybe you'll be busy reading the pamphlet of glossy Wonder-drug propaganda sheets you were handed about the medication. You'll hear some of the presentation, but you'll probably be distracted by going up for seconds in the lunch line since the selection of food and the quality of it is ten times better then anything the best chef can hope to serve up in the hospital cafeteria.

Physicians do not have a lot of time to read research independently, but they need to make the time. If they don't and they rely on their information from biased sources who have essentially bribed them, how are the patients supposed to benefit? If anyone thinks bribe is too strong a word, consider that there used to be (and maybe there still are) programs in which physicians can earn points for how many of a certain medication prescribed. Earn more points and you get a bigger gift, such as a trip to the Bahamas. How is that not corrupting? Is any physician doing this with bad intentions? I doubt it. But do many physicians have their eyes closed as to how they are being manipulated, however so subtly? Probably not, or if they do, the thoughts are likely minimized. Also, not all physicians attend these lunches and some are able to see through the fog. But too many are not and it those physicians that concern me. As a patient, how am I to know? The only answer is to make it illegal for drug reps to provide gift-based lunches when trying to sell a medication. Can't make it illegal. Then have the American Medical Association implement this into the ethical code. Oh, sorry, can't do that because they are making millions off providing the drug companies ways to identify physicians and their prescribing habits. Click the story in the first paragraph to read more.

Lastly, I am not opposed to drug reps speaking to physicians, but it needs to be done without any type of gifts. Just come by, let people bring their own lunches again (gasp!), do the talk, take some questions, and end any sense of impropriety.

Heart warming story

Sometimes, patients give you insights into things in life with just a few simple words. I figured I would share this story around the holidays. It's a short story but sometimes short stories provide powerful messages. So here goes. I was interviewing a female patient once and her family was trying to give me some insights into her kind demeanor and personality, which I was already able to detect from the interview. When she stepped out of the room, one of her family members mentioned how her son was born with a developmental disability. No one knew exactly what the diagnosis was but the child had been going through evaluations from numerous specialists. One of the family members asked her "What if it is autism?" Now, I am not sure what type of answer they were expecting but I don't think they anticipated the one she provided. She reportedly paused, turned her head towards the person who asked the question, and answered "Love him."

Who is the "crazy" one here?

I recently saw a case of a man who suffered a severe traumatic brain injury and spinal cord injury. He was rushed to a local hospital and placed on life support. The doctor told his wife that he had less than a 1% chance of living and suggested removal from life support. Amazingly, this suggestion came less than 12 hours after the injury. Anyway, the patient's wife held physicians in great regard and had the mindset that "the doctor must be right." She again asked if he was sure the chances of living were less than 1% and he reportedly said yes once again. At this point, the patient's wife elected to remove him from life support. But something happened -- he kept breathing. And a few hours later, something else happened -- he opened his eyes, gingerly removed the cold compress from his forehead, folded it again, and placed it back on his head. He then lapsed into unconsciousness again. Amazed, his wife ran into the hall and asked for another doctor's opinion. The second doctor reportedly stated that if the patient is still breathing by himself the next morning that they will transfer him to a level one trauma center.

The next morning came and the patient was still breathing. His wife decided to have him transferred immediately. It is at this point that the most distressing event occurred to the patient's wife. She stated he overheard one of the nurse's say that the wife was "crazy" for trying to keep him alive and transfer the patient. Well, seems to me that the wife was correct because now the patient has regained many of his cognitive faculties (although not at the level he was before the injury), can hold a perfectly normal conversation with people, and although still partly paralyzed, can enjoy watching and interacting with his children. This was an important story which highlighted that doctors are sometimes too quick to elect to pull patients off life support and that some patients can pull through and fight the odds. We owe these patients the chance to make that fight (at least give them more than 12 hours!). To not do so, well, that is what would be "crazy."

What To Do When You Cannot Afford Medications

Unfortunately, many Americans find themselves in situations where they cannot afford medications. There are many reasons for this such as: a) no insurance coverage, b) termination of coverage through workers compensation or no-fault insurance, c) excessively high co-pays combined with a limited ability to pay due to poverty. As a result, many patients assume that there is no way to get the medication they need when this is not necessarily the case. What follows is a list of resources that you, a loved one, or friend can use to obtain the medications you need when limited finances are an obstacle.

1. CONTACT THE PHARMACEUTICAL COMPANY THAT MAKES YOUR MEDICATION

Did you know that many pharmaceutical companies have special programs for those who cannot afford it? Generally, a three-month medication supply is provided. After this time period, a new request is needed just as a new prescription is needed when refills are exhausted. Medications are shipped directly to the patient or physician in about two weeks, but some programs request up to a six-week lead time. The following resources can help you find medication assistance programs:

Partnership for Prescription Assistance: The Partnership for Prescription Assistance brings together America’s pharmaceutical companies, doctors, other health care providers, patient advocacy organizations, and community groups to help qualifying patients who lack prescription coverage get the medications they need through the public or private program that is right for them. Many will get them free or nearly free. Its mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible. Through this site, the Partnership for Prescription Assistance offers a single point of access to more than 475 public and private patient assistance programs, including more than 180 programs offered by pharmaceutical companies. Patients can determine which programs they may be eligible for by answering questions and using the online application wizard. To access the Partnership for Prescription Assistance by phone, you can call toll-free at 1-888-4PPA-NOW (1-888-477-2669).

Needy Meds.com: A non-profit organization with the mission of helping people who cannot afford to pay for their medications. Click this link to find patient assistant programs through their website.

2. CHECK IF YOUR STATE HAS A PHARMACEUTICAL ASSISTANCE PROGRAM

Many states have pharmaceutical assistance programs for qualifying residents. Qualifications vary, and some programs are only for senior citizens. The American Association of Retired Persons Foundation (AARP) maintains a state by state list of these programs with contact information. If your state is not listed, try contacting your county health department (check your telephone book) to see if there are other programs in your particular state or county.

3. CONSIDER GENERIC INSTEAD OF BRAND NAME MEDICATIONS

After a certain period of time, pharmaceutical companies must allow other companies to produce their medication. Generic medications must have the same active ingredients as the name brand, but the inactive ingredients could be different. Inactive ingredients may include colors, preservatives, or other fillers. A pharmaceutical company that wishes to sell their generic medication must prove to the Food and Drug Administration (FDA) that it is equivalent (known as "bioequivalent") to the brand name medication. To be bioequivalent, the active ingredients in a generic medication must be absorbed at a similar rate and in a similar amount as the brand name medication. The generic does not have to act exactly the same as the brand name medication, but it does have to fall within certain guidelines set by the FDA. These guidelines may vary from medication to medication.

To be sure that the generic medication you are offered has been established as bioequivalent to the brand name, always check with your pharmacist. Your pharmacist has access to information about generic medications from the FDA's Orange Book. The Orange Book contains listings of medications and their bioequivalency status. The electronic version of the Orange Book is searchable by active ingredient and brand name.

If your doctor has written a prescription for a medication using the brand name for that medication, the pharmacist must fill it with that specific medication. The pharmacist can call your doctor and talk about substituting a generic form of the medication. Alternatively, you can talk with your doctor about generic vs. prescription medications when the prescription is written.

Generic versions are not available for all brand name medications, but it is worth asking your doctor about this since it can save you significant money. For more information on generic medication, see the website of the Office of Generic Medications from the FDA.

4. ASK FOR FREE SAMPLES

If there is no generic version of your medication available, ask if your health care provider has samples of the medication. Many doctors are given free samples of commonly used medications by drug company representatives. This is not a long-term solution, but a few samples might be able to hold you over until a real solution is found.

5. LOOK INTO PILL SPLITTING

You may be able to save money by purchasing your medication in a double dose and splitting the pills. Again, you will need to discuss this possibility with your health care provider. This approach cannot be used with all medications.

6. ASK FOR LONGER PRESCRIPTION INTERVALS

Instead of getting a prescription filled that will only last 30 days, you can request one that will last for 60 to 90 days if you anticipate future financial hardship or termination of insurance benefits. Your health care provider's willingness to do this will depend on the type of medication. For example, this request will be more likely to be granted for an anti-depressant medication than a narcotic pain reliever, due to the addicting qualities.

7. CONSIDER APPLYING FOR MEDICAID

Medicaid is a health insurance program funded at the federal (national) and state level for individuals and families with low incomes and resources. The application process, eligibility requirements, and coverage policies vary from state to state. In some states, people who qualify for Supplemental Security Income (SSI) automatically qualify for Medicaid. It is best to contact the Medicaid agency in your state for an application and any questions you may have, particularly about whether or not Medicaid covers prescriptions in your state. Your local Department of Social Service (check your telephone book) may be able to help you with the process. In New York state, the website for Medicaid is found here. In Syracuse (Onondaga County), the contact information for Department of Social Services is Onondaga County Civic Center, 421 Montgomery Street , Syracuse, New York 13202-2923 (phone: 315-435-2928).

The MedFriendly Common Sense Diet

Every where you look these days, someone has their new master plan for the BEST diet in the world. And once you believe you have found the best diet, it sometimes starts to take on religious overtones. You do your daily dieting ritual and spread the word to others about how your diet is the best and how the others diets are wrong. As an example, just think back to the war of words between the Atkins dieters and the non-Atkins dieters. Each side swore they were correct and each side had evidence to support their claim.

Has anyone ever stopped to think that if there really was one and only one diet that worked, wouldn't everyone be using it by now? What diets do is they provide people with a sense of structure to help them more carefully monitor (e.g., calorie counting) their gluttonous impulses or put them on a specific schedule so they no longer need to worry about making improper food choices. The diet also provides the person with a belief system (e.g., carbs are evil) that fuels the motivation to continue the dieting program.

The truth is that there actually is one and only one diet that works, but the truth is that no one can sell it since it requires you to take control of your decisions rather than having the dieting program make all the decisions for you. Since no one has given this diet a name, I am going to name it here today. It is called the MedFriendly Common Sense Diet. The basic common sense equation behind it is as follows: If you burn more calories than you consume you will lose weight. Simple as that. This means (and here is the hard part everyone), you have to exercise. That's right, you actually have to move and get your body going to burn calories.

When it comes to dietary selections, just use plain old common sense. Check the fat content of everything you buy and generally try to avoid servings that contain more than 3 grams of saturated fat and 600 mg of sodium. Remember that food items in the store contain multiple serving, so if you eat that microwaved meal with 3 grams of saturated fat per serving and there are 3 servings, well, you just ate 9 grams of saturated fat my friend.

Pace yourself to eat three meals of day and keep at least two of them relatively light. Get some fruits and veggies in you each day. If you hate veggies, try the new V8 fusion drink which tastes like a fruit drink but actually has a full serving of veggies in it. Work in a few salads throughout the week if you can, have some fresh fruit, eat some fiber, avoid large amounts of red meat, and drink plenty of water. Just monitor yourself informally. I am convinced that the reason diets fail is because ultimately people feel like they are a prisoner to the constraints of the diet, give it up engorge on all the food they were denied during the diet, gain all the weight back, and then later chose some other diet and the cycle repeats again.

With the MedFriendly Common Sense Diet, you don't have to feel like a prisoner. You are allowed to make your own judgment calls during the week. If you see some pizza or cake that you want and think you've eaten your fair share of healthy food that week and have exercised like you should have, then go for it. You need to use will-power and self-determination to do this. If anyone has questions or comments just let me know and I'll post responses here in subsequent entries. This is the approach I follow and have never had a problem. No more rituals, no more imprisonment, and no more food that tastes like cardboard. Take your life back, use common sense, and enjoy the food that life has to offer.

*Note: This posting does not constitute medical advice. As usual, you should check with your physician before making major lifestyle changes.

Hell week

This has been the week from hell. You've had them before. The type of week where EVERYTHING goes wrong. It was a nice intermixture of family and work-related stressors all of which were more extreme than normal. One was on Monday, another in the middle of the week, and yet another on Thursday and Friday. Hence the delay in blog entries. Each of the events that happened to me are now successfully resolved with the only lingering side effect being residual exhaustion since I did not have the chance to sleep, having had to bring my dog to a pre-planned vet appointment at 8:40. When you are in the midst of the week from hell, there are a few things you can do to help yourself navigate through it as best as possible.

The main thing to do is to moderate your reaction to the stressor. This gives you a way to take control over an event that may have initially been beyond your control. For example, it would be beyond your control that someone sent you and email with distressing content but you can control how to react to it. Monday's event was related to a stressful family member email I received at midnight. I reacted to the email and chose to take a route to end further discussion on the matter. This prevented my week from being even more hellish because it ended the conversation and eliminated the need for a constant back and forth flow of emails. Nevertheless, I went to bed later than I should have and paid the price the next day in terms of how I physically felt.

In the middle of the week, I had an overly complex case at work that took the entire day and was mentally draining. Since I was exhausted from earlier in the week, this just made things worse. And then, I had a work-related crisis towards the end of my day on Thursday which required me to kick into high gear and push my body past its limits (past 2am) to address it. Unlike Monday's event, this was a serious matter and one in which I had to invest the proper time into to make sure it was addressed properly.

Throughout the week, I purposely stayed calm and relaxed, well aware that if I became overly emotional that I will not be able to control these situations and deal with them as effectively as I needed to. Finally, it is all over and I am thankfully off one Monday. Tonight, I am going to turn into Rip van Winkle and get the sleep I need. Back to the regular blogging tomorrow. I would be interested in hearing on how some of my reader's deal with their hell weeks or some examples of your hell weeks.

The Chief Complaint

In the introduction to yesterday's blog entry on the popular Kevin MD blog it was noted that physicians are trained to write the chief complaint in quotations so it is phrased in the patient's own words. Coincidentally, this was exactly the topic I planned on blogging about today. Over the years, I have read thousands of medical reports from physicians from all sorts of specialties. For those who list a chief complaint section in the report, many use the quotation system noted by Dr. Kevin. Unfortunately, there have been many times where I have read these quotes and just shook my head because of what was written. Here are some examples of what I have seen, starting with my favorite.

Chief complaint: "Uh."

Chief complaint: "I don't know."

Chief compliant: "Hi, I'm John."

These three separate examples tell me absolutely NOTHING! Well, ok, it tells me tat when the physician walked in the room and said "So, Mr. Jones, what seems to be the problem today?" that the person responded "Uh." But so what?. The body of the report would obviously contain reasons about why the patient came in but that is beside the point. The chief complaint section is designed as a way to convey what is most distressing to the patient. If you are not going to put something in that section that conveys this, it is best to just leave the section blank. When I interview patients, I ask them "What are the three main symptoms that bother you the most at this time in your life. It could be a physical symptom such as a headache, an emotional symptom such as depression, or a cognitive symptom such as a memory problem." I ask them to rank these symptoms in terms of which causes the most distress, the second most distress, and the third most distress. Once you have obtained that information, you are conveying real information and helping you and your readers better understand the patient. Now that's something worth putting in quotes.

The Inappropriate Use of Quotes in Healthcare

On my Christmas wish list this year, I have just added another item…that health care professionals reduce their use of putting what patient's say in quotations without any explanation as to what the content of the quotes mean. This practice can be very misleading. For example, I recently reviewed records of patient who was collided into during a sports game. The records state that after she was hit, she did a "back flip." Now, what do you think of when you hear the word "back flip?" I think of someone who literally flipped over backwards, which would be quite a traumatic event and indicate that the person was hit with a significant amount of force. These are important things for me to know when I am trying the determine the nature of the injury. So when interviewing the patient and discussing this event she again used the term "back flip." So I asked her "Did you literally flip over backwards?" She said no, that was just her term for landing on her back. Big difference! But you would never know that if you just relied on the note that said "back flip" without an explanation.

Another recent case I reviewed said that after a head injury that the patient "saw Tweety birds flying above her head." Sounds funny and like something out of a cartoon but I was left wondering, was the patient just joking or was she hallucinating? Again, an important distinction and one with diagnostic implications, but it was not clarified in the note.

While the above example may not seem a crucial matter, there are times when putting terms in quotes can lead to misdiagnosis. A common area where this occurs in the area of mild traumatic brain injury (i.e., concussion). To meet the criteria set forth by the American Congress of Rehabilitation Medicine for concussion diagnosis, one needs to have evidence of an alteration in mental status such as loss of consciousness, disorientation, memory loss surrounding the event, etc. A focal neurological symptom would also count but we won't go over that here. So I was reviewing the records of a person who suffered a head injury while the patient was in front of me. Turns out, he had been diagnosed with a mild traumatic brain injury because he told the provider that he was "dazed" after the accident. The provider took this as an indication of altered mental status. However, when I spoke with the patient he denied any loss of consciousness, any disorientation, or any memory loss surrounding the event. So I turned to him and said "Well, what did you mean when you said you were dazed?" He said he meant that he was surprised about what happened but had no alteration in his thinking abilities. In actuality, he never suffered a mild traumatic brain injury but was told that he had. That's a problem folks.

Lastly, there are times when use of quotes is appropriate. Examples include when the patient cannot clarify what he/she means beyond saying whatever was said in quotes. In this case, I would put what was said in quotes but also mention that it is unclear exactly what was meant. There are other times when patients say something truly bizarre that you can only capture in a quote but in that case it will be clear to the reader why you are using quotes. The key point to ask yourself when using quotes is "Am I leaving things unclear for whoever who may read this in the future?" If the answer is yes, ditch the quotes.

Guest Blog Entry: The Conflicted Patient

This week's guest blog entry is the longest that has ever been posted here, but I urege that not to dissuade you because as you will see from reading the first few sentences, the author draws you right in. The author in this case is known on the medical blogosphere as "SeaSpray." She is a prolific blogger and you can visit her blog site here.
SeaSpray worked in a local hospital for 20 years in Patient Access (primarily emergency registration) but also Out Patients and Admitting. In addition to working at the hospital, she also worked at the Hospital VNA as a Lifeline Rep in which the primary focus was working out in the field visiting clients for the purpose of installation, educating client and family about the program along with follow-up tech support with lots of TLC mixed in.With that beind said, here's SeaSpray...

Part I - Background for the latter part.

After working for 20 years in Emergency registration with the hospital staff & patients, I know exactly what happens on the crazy nights in the ED when the rigs roll in seemingly non stop, sometimes accompanied by the paramedics (which is never good), the patients lie in stretchers in the hall because there are no other beds left, and the walk ins keep coming in like the outdoor signage is advertising free samples. Most of these patients believe that their emergency is “the” emergency and they are rarely alone which adds to the ever crowding ED. The phones are ringing, the patients get impatient, and everyone on both sides wants everything done yesterday. Among the emergent patients are some truly critical patients who will have priority with the staff. In compliance with the universal law of the ED -things get backed up! And amidst all of that there will invariably be grumpy patients who aren’t emergent that want to know why they can’t get a bed and why can’t the doctor “just look” at them so they can go! They are oblivious to the fact and perhaps wouldn’t care that a patient just died in room 3 and that staff is valiantly performing CPR on a cardiac pt in room 4, nor do they seem concerned that they can hear a multi-trauma pt screaming in pain down the hall. I understand the frustration coupled with desperation of both the staff and family when things are going south. I have seen how in the midst of this chaos they still find the time to console a grieving spouse or encourage a young mother. And on these shifts they don’t have time to eat and can barely stop to use the restroom.

Whether at my desk, a patient’s bedside or somewhere in between, I was at a good vantage point to observe both staff and patients. I know the ED staff’s goal is to treat and move the patient out the doors or onto the floors ASAP. Yes, sometimes a patient does get lost in the mix and staff isn’t always perfect but most of the time they give 100% and then some. I know how the staff thinks…the conversations between doctors, nurses and any other hospital employee that joins in. I know.

I also know how the patients and families think and react. I tried to diffuse the potentially negative situations by explaining that the staff was concerned about them but that they were tied up with another emergency and would be with them as soon as they could. I have heard all the complaints and witnessed the tirades and walk outs. Sometimes they did have legitimate concerns and complaints but most of the time not at all. While never showing my true feelings to the patients, I often thought that I would NEVER act like “they” were acting. (Judgments come easily when you’re not walking in the same shoes.)

Part II – View From the Stretcher

Then I became a patient. I don’t mean the kind of patient getting routine tests and exams but the kind of patient who is dependent on the assistance and skills of the medical professionals because they are so ill or in so much pain and maybe even a little scared, whether it is for one night or a chronic illness requiring “frequent flier” visits.

It is a given that the patient’s perspective regarding treatment may differ from that of the staff. I have had ample opportunity over the last few years to look through a patient’s eyes…my eyes, but from the unique perspective that I had always been the one on the other side of the desk interacting with the patients. Now…I was the patient looking up from the stretcher. I suppose I could be labeled as the conflicted patient. Regardless of my reason for being in the ED or an inpatient, it was always difficult for me to be “just” the patient. I continually saw things from the “staff” perspective, even at my most dire moments. The only exceptions were being in need of intervention for the most excruciating physical moments and even then I felt guilty for “bothering” them. While writhing in pain with my first kidney stone and vomiting, I remember thanking the OR staff for helping me before they put me out because I know how hard they all work and I wanted to let them know I was grateful for their help. As a patient, I also try to give encouragement when something isn’t going right (like not getting the IV in) or whatever else might apply and they are always appreciative.

Aside from a few exceptions here and there, I have had mostly terrific experiences at the local hospital I have chosen for my health care. That being said, the last two visits were less than stellar. The first negative experience involved post-op nurses who did not listen to me when I knew I was right about needing a foley catheter. I politely asked twice but they told me to calm down, stating it was normal to feel that way. One nurse said to me. “You DON’T want a catheter!” This was my fifth ureteral stent placement and I could feel the difference from the previous times. AND I didn’t need too “calm down” as I was never agitated. But instead of being assertive, I suffered in quiet desperation with tears silently streaming down my face. Their view of me was obscured by the curtain but fortunately my doctor came back in, asked me what was going on and took care of me.

A more recent experience involved going to the ED this past August. I was feeling great after the urological procedure and my friend, her daughter and I were going out to a late lunch but about 10 minutes after leaving the urology office, I started feeling weird and I thought maybe my blood sugar was low because I hadn’t eaten since the night before and now it was going on 4 in the afternoon. Even after orange juice I was rapidly feeling worse, actually feeling like I might die (not exaggerating) but I didn’t tell them how bad, just that I needed to go to the ER. I was so weak that I had to have her daughter call the urology office from my cell and then I left a message telling them which hospital I was going to just in case it had something to do with the procedure. I got sick in their car just before getting there. Suffice it to know I was quite ill and needed assistance to get into the ED. I know how triage works and so very much understood the 2 hr wait in the waiting room. An ED nurse came out to apologize and I said, “Don’t worry…I’m o.k. and I know exactly what you are going through because I worked in ED registration for 20 years.” (Lie #1 but I could see how busy they were) Two hours later I was still too weak to walk and so a nurse pushed me in a wheel chair to my room.

They put me in one of the trauma rooms at the far end. It was cold with two air conditioning vents blowing directly down near me. There were 2 huge bright light panels shining down on me that never shut off and there was no call button and no pillow although there was a sheet. I wasn’t feeling pain at this point because of the Percocet I had taken earlier for the urology procedure. I did request a pillow. When the nurse returned she hooked me up to an IV pump but forgot the pillow. I could hear the rigs rolling in one after the other on the other side of the door that was in the room and so I didn’t want to bother her. I was also NPO (not allowed to eat food or drink by mouth). However because she hooked the pump into my right arm, I set the pump off every time I moved my arm. The pump alarm went off for long periods because obviously they were tied up in the ED. I was embarrassed that I did it AGAIN. (After a while I shut the alarm off my self anytime I activated it.) However, prior to that, when the nurse came to shut the alarm off I told her I needed to take my antibiotic because of the urology procedure and also medication for HTN but she said “No, your NPO.” My husband found someone and I eventually got a pillow. I had pain in my right upper quadrant and right flank…I would say a 5 out of 10. They never did bring the pain meds.

The ED doc came in to tell me I would be going for an ultra sound and then he apologized for my having to wait so long. I smiled and said, “That’s ok…your busy saving lives…I understand.” (Lie #2 but I didn’t want to bother him). To which he said “Thank you, but you are important too.” I thanked him. It was nice to hear him say that. It wasn’t ok and I was miserable. I also asked him for meds and he said he would have the nurse get them but then she never did. If it was a regular room it would’ve been o.k. but this was awful. After 6 hrs in that room with only a sheet I was freezing. I would have asked my husband but I didn’t want to wake him because he needed to go to work in the morning. By the time the ultra sound tech came to get me at approximately O1:00 she could see my teeth were chattering, she felt my arm and got me a warm blanket. BTW that warm gel never felt so good.

On the way back to my room there was a cheerful patient standing at her doorway that recognized me from when she first came in and said, “You’re STILL here?” I smiled and said “I’m still here.” *Mental note made, this pt who didn’t appear as sick as me who came in 2 hrs after I was waiting in the waiting room is in a good room, with low lights, a television (not that I would’ve watched-I needed to sleep if possible), a call bell and better controlled temperature. I hadn’t eaten since 10 pm
the night before and so now 27 ½ hours later I was feeling hungry, feeling pain and now feeling scared because I didn’t understand what was going on. And I was feeling forgotten and neglected by the ED staff and then feeling guilty for feeling that way because truthfully, the rigs were still coming in and I knew they must have been having a hellacious night. Still it was what it was and I felt what I felt.

The ED doc came in about 02:00 to tell me that I had pancreatitis that appeared to be caused from the gallbladder, maybe a little stone blocking. He recommended admission and stated that I would need a procedure and possibly surgery. My internal stressometer was off the scale but I didn’t let on to him. I was additionally stressed because I believed the serious urology concerns were behind me and now I was being told I would need another procedure and possibly surgery for something else. I told my husband to go home because he had to get up in a couple of hours. I couldn’t sleep because of the bright lights and I was feeling awful physically. I gave up and just sat up on the stretcher with legs dangling over the side because my back was beginning to bother me lying on the stretcher. But I had wrapped the blanket and sheet around me because I was getting cold all over again.

The nurse came in around 03:45 and this is when it happened. First though, remember my 20 years experience with understanding the dynamics of a busy ED? Remember my sensitivity to the plight of the busy ED staff trying to juggle everything and my reassuring the patients? Drum roll please……I crumbled like a little girl and with tears welling up in my eyes… I asked the nurse, “Why did you put me in THIS room? Why does the woman who came in after me and doesn’t seem as sick have a nice room? (There could have been 10 women like that) Did I do something wrong?” I can- not -believe that “I” uttered THOSE words to an ED nurse and was ashamed the second the words left my mouth. She said, “Oh n-o-o-o. We’re just busy.” She checked my BP which had now spiked up high (it wasn’t when I first came in) and had me lie back. She left but came back with the blood pressure medication I had requested earlier. She apologized for not bringing the pain meds but said I would get them when I got to my room. Without any mention from me, she apologized about the lights stating that they are unable to turn them off in that room and she apologized that it was a cold room. From that point on she was attentive toward me, being extra nice until I was transferred upstairs at 04:30.

BTW- it is a good thing they didn’t give me the pain medication because the floor nurse told me she was about to give me the Morphine. I stopped her from giving it to me because I get violently ill form that drug. She said it was in the admit orders and was hesitant to believe me. (sigh) This time I stood my ground. I explained that I told both the triage and ED nurses that they should never give me Morphine or Dilauded. She came back later, apologized and said I was right. At least I was assertive with this.

Part III – Final Thoughts

Please know that I am aware (and was at the time) that I was not having a life threatening emergency or even a 10 out of 10 pain experience and things could have been so much worse. I admit that I was also feeling angry. I was feeling banished and forgotten. Yet I knew that in the ED you get whatever bed is available although sometimes they will put certain patients in specific locations for a purpose. I also knew that as great as ED staff is…they do forget people. I have done that with patients on my end of things when it’s super busy…it happens. Did that happen to me? Maybe, but I also didn’t speak up for myself. I lied or omitted information almost every time I had an opportunity to be proactive about my care because I was trying to be supportive of them. Perhaps if I hadn’t done this, the doctor and nurses would have re-evaluated my location. And I would surely verbalize my concerns if an acute medical problem exacerbated because in the end there is no other choice. The shocker for me was that I became this whiney, self pitying patient –ugh!

Also please know that I am not writing this post to complain but rather to share my observations. I am perplexed with my inconsistency in being proactive with my health care when I am in a hospital setting, although I am totally open with my private physicians. One would think that because of my experience in the medical environment that I would naturally assert my concerns until I feel heard. Yes, I do ask for help, but there have been other times in the past where I have held back because I continually identify with the work environment and don’t want to bother anyone, hinder the process or make waves when I disagree. Regarding my crumbling like a little girl if I hadn’t been so worn down from hunger, exhaustion, pain and stress and I had stopped projecting myself on the other side of the stretcher, identifying with the staff -but instead was honest with “my” concerns; I don’t believe I ever would have said what I said. I had a weak moment and I just crumbled. I was in the ED for 11 hours. (I recently read on another ED blog where patients are in the ED for 24-48 hours!)

And if I, a person who has been in the business for 20 years could feel so distressed, how much more so would an individual who doesn’t have any understanding of what goes on in a hospital? Do other health professionals feel conflicted when they are patients? Do doctors and nurses feel compelled to tell the staff how to do their job? Or do they retreat as I sometimes do? I did read about a physician who as a patient in the hospital withheld his personal opinion because he didn’t want to be competing with his colleague who was treating him, but that somehow worked against him although I don’t recall why.

When is nice too nice? Who is it really serving? What is the gain? What is the loss? Honesty and open communication is key and is what best serves the common goal to facilitate healing. I have always thought of myself as being compassionate with patients, but my journey as a chronically ill patient these last couple of years has all the more enriched my perspectives regarding patient experiences and I know that when I return to work, I will have even more to give back…because I have really been in their shoes and I have walked the walk.

Just Leave Me Alone

One day, I had a patient who had been through the most unbelievable history of botched medical care and botched surgeries, basically leaving him without an intestine, with possible dementia, and with a possible seizure disorder, among many other things. His neurologist had stopped practicing and he was transferred to someone new who had some different opinions about some of his problems. For example, the new doctor thought he may not actually be having seizures and that some of his problems may be due to dysfunction of the autonomic nervous system. As a result, the doctor was considering changing his medication. The patient, however, had been through so much medical duress and years of finding a medication regimen that he was happy with that he was very upset about the prospect of ANY changes. The patient was also upset he was referred to me for a neuropsychological evaluation because he did not see the need for it. He also did not see why he needed to stop driving even though he had been driving through red lights and exhibiting poor judgment on the road. He did not see the need to have someone take away his access to guns even though he had suicidal thoughts at times. In his words "If you take away my guns, I'll just use some other method one day if I ever feel like killing myself."

It was clear that this man had poor insight but it was also clear that he was just plain fed up with everything. In describing his plight, I will never forget how he looked at me and said in the clearest and most deliberate manner, "I…just…want…to…be…left…alone." He did not want to be tested, did not want his medications changed, and just wanted to stay home and accept his fate. Although I did not think he was making all of the right choices (which I made this clear to his wife), I felt a profound feeling of sadness for this man's situation and could see myself thinking the exact same thing if I were in his situation: "Just leave me the alone." The interview took so long because of his complex medical history that he was scheduled to come back another day for testing. He never retuned.

When is a doctor a doctor?

Earlier this week, I wrote two blog entries that created quite a stir in the medical community which you can read at here and here. One of things you will notice is that one or two people wrote comments that poked fun of the word "doctor." This was done by referring to me with the word in quotes and by with another comments saying: "Great, a PhD posing as a doctor."

I know some are going to take this post as being defensive, but that actually is not the intent. The intent is to expose the logical fallacy behind this ridiculous argument. Trust me, I have full confidence in the fact that I am a doctor and I believe that people who use the term in a disparaging way towards others are really saying more about their low-self esteem than anything else because they appear to me to feel threatened by others use of the term.

So let's start with some facts, shall we? First, what is a doctor? The origins of the word come from the Latin word "docere," which means "to teach." According to Merriam-Webster's Online dictionary, here are the relevant definitions of doctor to this discussion, which you can see here if you want:

1: A person who has earned one of the highest academic degrees (as a PhD) conferred by a university

2. A person skilled or specializing in healing arts; especially : one (as a physician, dentist, or veterinarian) who holds an advanced degree and is licensed to practice

Now, isn't it interesting that the dictionary actually lists "PhD" as an example of a doctor? This really destroys the argument that if you have a PhD and call yourself a doctor that you are somehow "posing." Let's look at the second definition. I am a neuropsychologist and psychology is a field that does help people heal. It lists physicians, dentists, and veterinarians as examples; more on this later) but does not say these are the only people who can use the term. It also refers to having an advanced degree and a license to practice, both of which I possess.

So where does the problem lie? The problem lies in the fact that some physicians who have their bowties and penny loafers on a little too tight want to monopolize their use of this term to inflate their feelings of self-worth. I am sure you can find a definition of doctor somewhere that says "physician" as one of the lists but is not the only one by a long shot.

Now, here is where we turn the situation away from PhDs just to let you know how silly this situation gets. I cannot tell you how many times I have heard physicians (people with an MD) refer to other types of MDs as "fake doctors." The two most commonly cited groups I hear this about is psychiatrists and physiatrists. Psychiatry is put down because they see "mental health patients" and do not perform surgery. Physiatrists (who are rehabilitation medicine doctors) are often put down because some of the elitist physicians consider it too easy. Just so I am clear, I think that is absolute nonsense. I work closely with both psychiatrists and physiatrists and have great respect for them and they deserve to be called doctor if they earned the degree. I have heard physicians say many times that dentists and veterinarians are not real doctors. Gee, both prescribe medication and can do surgical procedures so I don't get that one. I guess teeth and dogs aren't difficult enough for the "good 'ol boys" perched in their ivory towers.

And lest anyone think this problem is isolated to doctors, it is not. I have also heard many bedside nurses say that nurses not providing bedside care (e.g., those who work in the OR) are not real nurses because they are not doing the "real nursing work." When will it end? When each person is capable of being comfortable in their own skin and do not need to demean others to feel better about themselves. To quote the eminent scholar, Rodney King, "Can't we all just get along?"

Wow!

Well, yesterday's blog entry has created quite a stir. I have spent so much time responding to it (and to another entry) that this is going to suffice as my posting for the day. If you haven't read the post, please feel free to get involved with the discussion. Thanks to all for making the MedFriendly Blog so popular.

Residents revisted

Seems like my posting the other day on the Resident versus the Physician has caused quite a stir, and rightfully so. It is a controversial issue that is rarely discussed and it seems like there are very strong opinions on both sides. I decided to expand on my thoughts on this topic after reading the responses to the prior posting.

Let me first start with what in my opinion is the most important factor here: the patient's right to know. Almost every hospital has a Patient Bill of Rights posted in the hallway. These rights were adopted by the US Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998. These rights include (and I am quoting here) "Participation in Treatment Decisions: You have the right to know your treatment options and to participate in decisions about your care" and "Choice of Providers and Plans: You have the right to a choice of health care providers that is sufficient to provide you with access to appropriate high-quality health care."

The patient must be told in advance if someone else is going to do the surgery. When I say in advance, I mean when the initial consultation is done, not 30 minutes before the surgery that the patient waited two months for. I also believe it is unethical for doctors to give patients 5-10-page long consent forms before the surgery while hovering over them and then later say "Well, you consented to a resident treating you on the form" if the patient complains. Informed consent forms are useless if the patient does not know what he/she is signing. In my hospital, I have an informed consent form that I go over with every patient to get permission for me to enter their data in a statistical database for research purposes. Even though it eats into my clinical time, I go over the form and the risks and benefits. Bottom line: people need to know what they are signing and getting into. Inconvenience is no excuse.

Several people have written in that "residents won't be able to be trained" if patients have a choice, but it is important to keep in mind that there is no "Resident Bill of Rights." Secondly, I do not even believe the prior statement is true. For example, in my case, my daughter had to get her tonsils out…period. I had a few choices in town. If each person told me he was using a resident for part of the procedure, I would have no choice to consent to this. If the lesser trained doctor told me he was doing the entire procedure, whereas the highly trained doctor said he would do most of the procedure and the resident would only do a small part, I would pick the doctor who uses the resident.

So the issue is not so black and white as is implied by statements such as "if you have a choice, residents won't get trained." I simply cannot envision a scenario in which every surgeon in town would say that only he/she would do the surgery and that there would be no assistance from residents. Residents will always be a part of the medical establishment and patients will consent to their use because there simply are not enough surgeons. When someone needs surgery for a medical problem, they are going to consent to a lesser trained person taking part in the procedure if the alternative is waiting an unreasonable amount of time for another physician who is not using residents.

The next point is that like it or not, the reality of our current medical system is that disadvantaged groups (e.g.,uninsured) are whom many residents train on. For example, in one city I worked in there was a dental clinic in the hospital for people who could not otherwise afford dental care. The patient's knew there was a supervising dentist present but that the people providing the care and doing the bulk of the dental work were dentists in training. These patients understood the situation and consented to having a lesser trained person provide medical care.

One last point. I was talking to a physician today who needed back surgery a year ago. When he went to the hospital, he demanded that no resident take part in the case because in his words "I didn't want to wind up paralyzed." Probably an extreme statement, but you get the point. So for every physician who writes in telling me that we need to keep the system the way it is because residents won't get trained, I would like to know if you would consent to a resident doing most of your cardiac bypass surgery or most of your brain tumor resection? No? Didn't think so.

Tonsillectomy tales, part 4 -- What went right

Fortunately, many more things went right with the visit to the hospital compared to what went wrong. I offer this information to people who work in hospitals across the country as models of what should happen when a child goes to the hospital. First, registration went as smooth as could be. No long wait. No big crowds. No hassle when we were called in. The receptionist gave my daughter and two-year-old son a pack of crayons, a hand puppet to color, and a small slinky. They were so excited and played with these things for about an hour combined during the wait for the surgery, which was about three hours.

Then we arrived in the pre-surgical area where we had our own room to prepare for the procedure. This involved a change of clothes and it was nice that the gown had some little tigers on it to make the child feel comfortable. All the nurses wore clothes with kid-friendly themes such as various cartoons that my daughter instantly recognized. The floor was clean, with bright colors on the walls and child-appropriate themes in each room such as animals, smiling children, and doctor cartoons. Different ethnicities were incorporated into the cartoons so no child felt left out. In the hallway, there were pictures of Sesame Street characters, which my children loved. The best part was that the hospital provided individual kiddie cars that my children could ride in up and down the hallway. They had an absolute blast doing this and it was a terrific idea. Anyone who has children knows they usually don't want to be cramped up in a small room and the chance to have them move around in a kid-friendly hallway was terrific.

All of the nurses and doctors were very nice and made an effort to speak on my daughter's level so as not to scare her. They tried their best to make everything seem calming and relaxing and to incorporate fun themes into everything that was happening. For example, instead of giving the child a scary-looking anesthesia gas mask to wear, she was told that it was something that would let her smell a scent she chose from a special bag. The scent is used to disguise the smell of the anesthetic gas. My daughter chose cotton candy, which is apparently the top pick among kids.

After the surgery, a hospital staffer took me on a tour of the unit and told me that the hospital philosophy was to treat the child as if it was your own. That's nice to say but I could tell this guy really believed it. The person who transported my daughter to her room was very nice and caring, which made her feel very comfortable after awakening from the procedure. The floor had security cameras all over the place to dissuade anyone from even thinking about stealing a child. They had slurpee machines, lots of food for family members, and almost immediately wheeled in a TV with a DVD player and gave my daughter a selection of age appropriate and contemporary titles to choose from, which held her attention until she fell asleep. As you can tell, the hospital really did a good job so thumbs up overall. I go back in a few weeks for my son's tonsillectomy and so we may have another exciting "tonsillectomy tales" series yet again.

Tonsillectomy tales, part 3: What went wrong

While at the hospital, there were many things the staff did right but a few things they did wrong. Today will focus on what went wrong. The first problem was when we were waiting in the room before the surgery. At some point, one of the nurse's came in to get some information for the chart and take some vital signs. She just came in and started asking questions without introducing herself. I absolutely cannot stand that. What makes it worse is when the person has an ID badge that is turned around because it is not attached to anything stable. What good is it to wear an ID badge if I cannot identify you when you walk in the room? This practice should not be allowed. I always identified myself to patients when I did inpatient consults and I always wear my ID badge on my collar so it cannot twist around. So after giving her a few minutes, I said, "Excuse me but ummm, who are you?" It was at this point when she identified herself. This same person also spelled my daughter's name wrong on her ID bracelet, which is another problem we caught.

Third problem. My daughter has latex sensitivity so she cannot get regular band-aids because her skin gets red and swollen. This was labeled on her chart AND on a big yellow bracelet on one of her arms. Despite all of this, one of the nurse's tried to give her a latex band-aid. Thank goodness my wife was there to intervene. People like to think that medical professionals do not make mistakes but they do. This is why is takes an extra set of eyes to make sure things do correctly, even if they get offended. For example, I just saw a patient who had meningitis and the nurse accidentally gave him Prograf (a medication uses to SUPPRESS the auto-immune system) in transplant patients. The medication was actually intended for his roommate. Nothing like fighting that infection by giving patients medications that reduce their ability to fight it!

And this brings me to my last point -- roommates. Why on earth would you put another child in the room who has a severe life-long developmental disability who just had major back surgery and is moaning and whaling all night. My wife got one hour of sleep as a result. I know everyone can't get a private room, but they really should place patients who have more serious surgeries in rooms with each other and patients who had more minor surgeries which each other. This way, you allow patients (and family members) with minor surgeries to maximize the chance that they will get some sleep. Those with more significant surgeries probably won't get much sleep anyway, so why not put another patient in that room since he/she will likely be up all night anyway. Ideally, the goal should be for each patient to have a private room since we all know that sleep and rest promotes the healing process. Stay tuned tomorrow for what the hospital did right.

Tonsillectomy tales, part 2: The Resident vs the Attending

Today I am going to reveal an inside scoop about hospitals that many in the public have no idea about. Specially, you may think you are getting operated on by a specialist with extensive experience when someone else actually does the surgery. Most hospitals have different levels of physicians who care for patients. At the top of the tier is a doctor known as the "attending physician." At the bottom of the tier is the "resident physician" or "fellow." The residents and fellows are there to learn from the attending physician. They all have medical degrees but the attending physician has far more experience. When you consult with a doctor who will be doing surgery on you or a loved one, you need to ask whether the attending physician will do the surgery or whether the resident will do the surgery. And trust me, there is a difference because the experienced surgeon should definitely be able to do a better job (e.g., less complications, quicker surgery time).

My feeling is that you should have a say on who operates on you or a loved one and should not be allowed to go into a surgical procedure thinking the specialist with 30 years experience will be doing it when it will actually be a resident with one year of experience. Knowing full well that this happens in hospitals, I asked the attending physician who was supposed to be operating on my daughter if he does the surgeries himself or if he is just there to supervise a resident. He paused and said, "Well, that depends." He did not say what it depends on but stated that sometimes the residents do all of the surgery, sometimes they do some, and sometimes they watch him do it. He knew I worked in a hospital and that my wife was a nurse, so when we asked if he could do the entire surgery he said he would. He added that there tends to be less bleeding when he does the surgeries and less pain for the child. So, ummm, yeah, can you do the surgery please?

Turns out, the surgery was a smashing success and my daughter has not been in any pain whatsoever. I cannot stop thinking about how different it would have been if I did not request that he do the surgery and a resident operated on my daughter instead -- because that is what was going to happen. So take this knowledge, pass it on, and make an informed decision the next time you go for a surgical procedure.

Tonsillectomy tales: part 1, Preparing a child

This week, my three-year-old daughter had her tonsils and 75% of her adenoids removed. This is a standard surgical procedure and is often listed dismissively by patients when they provide their medical history, as if it was no big deal. But as a parent -- no surgery is too small. The next few blog entries are going to describe my experiences as a parent, psychologist, and someone who knows the inner workings of hospitals -- as does my wife, who is a registered nurse. Today's entry will focus on the psychology of the preparation phase for a three-year-old child.

To begin with, you really have to put yourself in the mindset of the child and remember that he/she does not have your life experiences and that a hospital is likely going to be a strange and scary place. But my wife and I decided we had to tell her the truth because if anything we say to her is going to have any impact in the future, she needs to know she can trust us. So for a few weeks, we told her that she was going to go to the hospital, where she will see the doctor to get her tonsils out. We told her where her tonsils were located and why they had to come out. We repeatedly conveyed the message that "everything is going to be ok" and that "daddy and mommy will be there." This is important because the child needs to feel emotionally and physically safe and maintaining that parent-child bond is crucial. We also told her that we had our tonsils out when we were children too, which also makes it feel more safe for the child.

We tried to always emphasize the positive, such that she will get to eat lots of ice pops, ice cream, and pudding afterwards and this made it sound fun to her. We also made a little joke with her that she would ask the doctor for ice cream as soon as she saw him. She found that funny. So after weeks of preparation the day finally arrived and I am certain that it helped get her out the door without a hitch. We brought one of her stuffed animals for additional psychological security purposes. Whenever you are taking a child from the safety of their home, it is a good idea to bring something that represents the home environment with them because it maintains that connection.

When we arrived to the hospital, the goal for us was to make every part as fun as possible. For example, when her name was called by the registration clerk we made her feel special by saying someone was calling just for her. When given an ID bracelet and allergy bracelet, we made this out to be like she was receiving a gift, rather than a mandatory hospital policy. Sometimes, you just can't think of everything though and she just did not want to slip into the hospital gown. Therefore, we just continuously focused on the tigers on the gown and how the doctor said she had to wear it in order to get her ice cream. Eventually, she listened. Going hours without food was not easy either, but the continued promises of ice cream did wonders to appease her.

Giving her as much warning about any transitional changes was very important in preventing her from becoming too scared. We explained to her that the doctors wear silly hats and white coats and that the doctor needs lots of helpers like Santa Clause does. When the medical team came for her, despite all the preparation, she was still scared and did not want to be taken away. Thankfully, the doctor let my wife take her to the operating room, where my wife and the nurse sang her a song and the anesthesia quickly took effect. The surgery was a success and five minutes after waking up she looked at me, smiled, opened her mouth wide and with a big blue ice pop in her hand said "Look daddy! I just got my tonsils out."

Guest blog entry: Dermatology consults

This week's guest blog is a first. It is the first time that a guest blog entry has been written by one of you -- a reader. That reader is Bruce Kalin, PA-C, a Dermatology Physician Assistant with Kuflik Dermatology, in Ocean County New Jersey. He is a graduate of the Medical College of Pennsylvania & Hahnemann University Physician Assistant Program, and has been in practice dermatology practice for 11 years. Prior to that he was in Family Practice. He is the current President of
the New Jersey Dermatology Physician Assistants, a past Vice President of the New Jersey State Society of Physician Assistants, a frequent presenter and consultant on "The Proper Utilization of Physician Assistants in a Dermatology Practice," and, lectures on the topic of skin cancer. Bruce Kalin is married for 30 years, has raised three adult sons, two of whom are employed by a Derm-Path Lab, and the third
planning to enter a Physician Assistant Program.

Here is the entry, written exlusively for MedFriendly.com. Please keep in mind that the comments of guest bloggers do not constitute medical advice by MedFriendly.com and you should always check with your health care provider for medical advice for your speciic situation.

A Free Dermatology Consult

Everyone knows there is really nothing in this life that is free, especially a visit to a medical specialist. But, this advise is truly free, as it cost you nothing but the time it takes you to read this from beginning to end, to benefit from what I am about to tell you.

It is now the beginning of the fall and, soon to be winter season in the Mid Atlantic Region of the US. This means, "the itchy season" is here. The percentage of patients coming in for a consult because of itching all over, or on their scalp, arms, legs, etc. will go up significantly for every dermatologist in the area. Primarily, the patients that will be seen in the office fit into a few distinct categories, but at this time I am only going to discuss the itchy patients who are of the self inflicted variety. What I mean by self inflicted itching is, that they are using products, and/or living in an environment that promotes dry, itchy skin. Some of the most common things that people do to create drying of their skin is, bathing with very drying products, using very drying shampoo, bathing in very hot water, keeping the temperature in their house excessively warm, and wearing too much warm clothing for extended periods.

Years ago, it was common for a physician to tell a patient to bath infrequently in the winter to avoid drying out the skin, which would cause itching. With the advent of newer bathing products, and the knowledge that water alone does not help remove the dead skin layer, most dermatologists will recommend bathing and moisturizing the skin on a fairly regular basis, using the correct products. When bathing or showering, it is best to use a gentle cleanser, such as Dove Soap or Cetaphil Cleanser. There are other products on the market that will perform as well, you just need to search for the product that works best for your skin. It should be noted that most anti-bacterial cleansers are very drying. Because of the prevalence of MRSA in our communities, anti-bacterial cleansers are no longer recommended for general cleansing, due to their promotion of resistant bacteria, so avoid them if at all possible. Rubbing and scrubbing with a wash cloth is also not recommended, as it promotes irritation, rather than a cleaner skin layer. Simply using your hands to apply the cleanser is more than adequate to clean your skin.

An application of a moisturizing lotion after every bath/shower is also strongly recommended. A lotion is easy to apply, and goes on more quickly than a cream. A moisturizing cream, on the other hand is better than a lotion if you begin to develop dry areas of skin, but you can go back to using your preferred lotion once the dry area resolves. Also keep in mind that thicker applications of cream or lotion on your skin are NOT better. The products will not soak into your skin hours later because you put on a thick layer. In fact, most of the cream that was not massaged into the skin will have already rubbed off on your clothing, your bed linens or, someone else long before it had a chance to soak in. You just wasted most of the product. A thin film, applied more frequently is always better. If you have a tendency toward dry skin, apply the lotion two times a day, or more if needed. Shampoos fall into the same category as soaps. A medicated shampoo obtained over the counter without a prescription, applied several times weekly, according to the manufactures recommendations is your best first line of treatment for an itchy scalp.

Using hot water in the shower or bath has an anesthetic effect on the skin, so most people that tend to itch like to take very hot showers. The problem is that the hot water is actually causing a low grade burning of the skin, which in itself is creating more of an itch. If you want to test this, just go into your hot shower, enjoy it for the moment, and then come out. Your itch will return with a vengeance. While I'm on the subject of showers, let me recommend that you towel dry while still in the shower, with the curtain or shower door closed. This will help to prevent the cooler air of the room to cause excessive evaporation of the water from the surface of your skin. Evaporation is a drying process, so if you step out of the shower while still soaking wet, you will be right back to where you started from before your shower - maybe even worse. So, as far as showers go, you want to take a warm shower, use a gentle cleanser, dry off in the shower with the curtain closed, and apply moisturizing lotion before you exit the shower. Enough for showers, so let's move out side of the bathroom.

As we age, we lose much of the fat layer under our skin. The fat is our natural insulator, and without this insulation we tend to have less ability to retain our own body heat. So, in cold weather we try to compensate for heat loss by turning up the thermostat in the house, or try to save on the heating bill by wearing warmer clothing indoors, or both. Since the clothing has no natural thermostat, which could release the heat at the proper temperature if it did have one, we overheat, the body compensates with sweat (a cooling and drying process), in an effort to cool off. Unfortunately, that sweat will evaporate, and the dry, itchy skin process will be well under way. People that work outdoors in the winter, and those who participate in exercise and outdoor sports in the winter, and who don't wear special clothing to help wick the sweat away from their bodies, will also tend to develop itchy skin. A good example of this are Police Officers that wear armored vests, but don't wear the recommended moisture wicking underwear. They tend to develop irritant, itchy rashes on their upper body. Another example are construction workers who wear the same pair of heavy socks inside their work boots all day, also will sweat and develop an itch on their feet. Most of the red itchy feet that dermatologists see in the winter are due to sweating and dryness, not fungus. The same goes for heavy underwear, which accounts for most of the rashes in the groin and in the arm pits, also known as intertrigo.

It is best to try to avoid dry skin, but if it develops, treat the condition as quickly as possible so that it doesn't get out of hand. Remember, when you itch you scratch, and scratching makes you itch more so, you scratch more, which makes you itch more .................. and on, and on and on. Dry skin, plain and simple is itchy skin, and once you begin to scratch, it is very difficult to stop. Left untreated for extended periods of time, chronic scratching can create lichenification, which is a thickening of the skin. More severe scratching can open the skin to infection, as well as leaving life long scarring. As a last ditch effort, prior to seeking medical help you can try this remedy. Take the thickest moisturizing cream that you can find without a prescription (usually Aquaphor)and an over the counter cortisone cream. Mix the both of them together in equal parts in a jar. Use this mixture in the morning, in the evening, and every time you itch. DO NOT SCRATCH - apply the mixture instead. As soon as the itch resolves, go back to your normal moisturizing routine. DO NOT continue the steroid mixture for any time greater than a week. DO NOT use it on your face, arm pits or groin for more than a few days.

When all else fails, and if the itch has not resolved by one week, you'll need to follow up with your medical professional. You should not expect that to be a free consult.

Bruce Kalin, PA-C
NJDPA President
http://www.njdpa.org
AAPA, SDPA, NJSSPA, NJDPA