Archive for the 'Medical Musings' category

Friday thoughts

Jun 24 2011 Published by under Medical Musings, Medicine

I made a really good medical decision the other day. I can't go into details of course, although some day it may end up anonymized and folded into a story, but it felt good (for me and the patient).   It involved using several different layers of knowledge to come up with  a solution, a bit like solving the Friday NYT crossword puzzle: not impossible, but difficult enough to be fun (when I say "difficult" about the crossword, I speak for myself, not my genius brother-in-law who could solve it blindfolded, upside-down, and drunk).

Medicine is full of puzzles, most of which aren't particularly good for the patient.  It's much better to be a boring patient than an interesting one.  There are no truly "boring" patients of course.  When someone relatively healthy comes in, I get to learn about the work they do, often something I've never heard of.  I hear unique family tales, tragedies and triumphs; this is one of the joys of medicine, being allowed to hear other peoples stories.  I never consider the time wasted.

I recently spent twenty minutes with a patient discussing recipes.  Not only did I learn a few tips, but I also learned about how this particular hypertensive patient prepares and eats his meals.  And I made a friend.  Medicine involves a lot of salesmanship.  I have to talk people into doing some fairly unpleasant things, so being on friendly terms with them helps grease the, er, wheels.

In past posts, there have been debates as to whether medicine is "special":  is it a job like any other, or is it more of an identity?  I favor the latter in many situations.  Sure, being someone's  banker involves a level of trust and intimacy, a sharing of private knowledge, but medicine takes it a stop further.   Just a few moments ago (while I was typing paragraph three) a heard screaming form the other end of the cafe.  A barrista had just spilled a pitcher of boiling water on herself.  I invited myself into the back to tend to her.  This was possible only because our gives a special trusted status to physicians (warranted or not).  Once I announced I was a doctor and I was willing to help, there was no argument, no fear, just a look of relief.  I left the office before five today, but I never truly leave the job.

The puzzles, the identity, the stories, the relationships all make medicine unique and enjoyable.  Whatever the instability in the business of medicine, I can never leave the job, because I am the job, and the job is me.

11 responses so far

Another day...

Jun 02 2011 Published by under Medical Musings, Medicine

My poor, poor blog.  So neglected.  So much quackery left un-busted.  It turns out that real life can sometimes be more consuming than other interests.  After a significantly disruptive illness, life rarely snaps back to it's previous shape, but slowly takes on new forms and habits.  I no longer have to bathe MrsPal and pack her wounds daily, but I still have to give her IV fluids and help her with medications.  I no longer have to cancel patient time to pick up PalKid or get to the hospital to visit my wife, but she's still a needly little thing (the Kid, that is), clinging to me like one of those stuffed monkeys with the Velcro hands and feet.

And of course, the needs of my patients don't change at all.  An abnormal chest x-ray is just as important no matter what else is happening in my life.  Patients have a doctor, not a team, at least not usually, and that doctor is responsible for gathering and communicating data, facilitating testing and consultations, and all sorts of other time-sensitive work.  Many jobs are like that I suppose, but from my biased viewpoint, doctoring is different.

I'm currently  having an ethical discussion with myself (not aloud) about whether I can make up a bottle of Placebo for PalKid.  At night as attention starts to focus away from her, her throat hurts, or her lip, or some other boo-boo and she wants medicine.  It seems foolish to pump her full of ibuprofen, but she sees me giving Mommy medicine and helping her feel better.  I'll probably never make up that bottle, probably never give her as much attention as she wants, but she'll probably get as much as she needs.

20 responses so far


May 29 2011 Published by under Medical Musings

This is a re-post of a piece I just happen to like a lot. Seemed fitting for Memorial Day weekend somehow.  --PalMD

I met this beautiful woman the other day. She had a sad, glowing smile, was dressed impeccably, and had this wonderful accent. I imagined her voice would be at home in some small corner of Europe where the pastries are always fresh, the coffee fragrant. She was sitting in a chair next to man, or what used to be a man. He lay stiffly in a bed like a bundle of fallen sticks---one of the sticks was being held gently by the beautiful woman, his wife. The room was too big for them, the high ceiling and white walls almost deafeningly empty.

They belonged to another time, this couple. The light poured through the window, stopped by a single IV pole which left a long, thin shadow on the wall, like a tree in winter. I pictured them in a different light, one a little richer, maybe browner, the colors subdued but present, not washed out like this day. They must have held hands then, too, but less delicately, with less fear. The young doctors stood by, also dwarfed by the room, but somehow less out of place. It's not just that they were doctors, and this a hospital---they were more a part of this life, this place, this time. They were near the beginning and middle of their journeys, not the end. It was palpable. They thought, "where might I be tomorrow? In bed yet? Answering a call? Drinking?" The questions hanging over the couple in the room were, "Will I be tomorrow? Are there any left? Why?"

It's strange---to be in the middle point of my own journey, surrounded by people nearly at the end, or perhaps past the end. Some live for the moment, never thinking it will end. Some mourn for the sepia-past that never was. But mostly I think they just cling to each other and to the moments, waiting, unsure, and watching as we middle-folk go about as if there will always be another day, another cup of coffee, another kiss.

20 responses so far


May 29 2011 Published by under Medical Musings

Last night PalKid really wanted to sleep with Mommy, so after getting the kiddo washed up and heparinizing MrsPal's IV, I tucked them in, turned out the light, and backed away slowly.

This gave me a little while to browse the Twitters, and I started eavesdropping on a conversation between authors Tom Levinson and Jennifer Ouellette.  These are both authors who take the geekiest of topics (obscure history, physics, Joss Whedon, zombies) and turn them into compelling narratives in which story and science blend seamlessly----no, they don't blend, they are the same thing.

Much of what occurs in science and medicine is fascinating in the hands of a good story teller.  The everyday dramas in science, the every day giggles and horrors, those that we on the inside share only with each other----these can be translated successfully into a good read, one which is a good read because it is scientifically and medically true.

(See Samuel Shem's House of God which helped immortalize truthful, dehumanizing conditions, simultaneously making us laugh and making us hate ourselves for laughing).

Any conversation based on typed 140 character statements can be easy to misinterpret, but from what I could gather, they were trying to parse out the difference between striving for accuracy in drama, and creating drama that teaches accurate science.  My take is that drama that happens to incorporate accurate science teaches without being didactic.

I love to tell stories.  I may not be up there with Tom and Jennifer, but the whole blog thing has given many of us who have stories to tell an outlet, and while I like to know that people read,  and I love the feedback, it is the writing that I really love.  My favorite category is the one I call "Medical Musings," a place I tend to put less scientific pieces, but stories that are still set in the world of medicine.  But I also like to share brief tales of medical discovery, stories that share with others my love for what I do.

My stories tend to be medically accurate, even though the patients are amalgams of various people I've seen, and they form the framework of what I'm trying to get across, but there is no reason a real writer, someone who writes professionally and is damned good at it, cannot learn about the real drama in real life, life that is based on science and affected every day by medicine.

While I stick to non-fiction, there is no need in fiction to make up medical facts,  no need to invent implausible neutrinos or new diseases.  Real life tosses us enough drama.  I work in a thousand-bed hospital.  There are at least that many stories here, real, engaging stories of real people with real diseases.  And these people go home, and have families, and friends, and the stories are right there, waiting to be told.

3 responses so far


May 14 2011 Published by under Medical education, Medical Musings, Medicine

One of my early lessons in medicine was "listen to the nurses".  This isn't to say that nurses know everything and doctors nothing.  But we have very different knowledge sets, and it would be easy for a young medical student to simply dismiss anything told them by a "mere nurse" (in this case, "mere nurse" meaning someone who they think---often erroneously---cannot affect their grade).  Not only do nurses spend more time with the patients, but the have skills that med students need to learn.  Some of the essential skills taught to young physicians by nurses include how to draw blood and place IVs, how to turn patients, how to lift people safely.  At many hospitals special teams take care of IVs and blood draws, but many of us trained at hospitals where we were often responsible for these tasks.  During emergencies, it helps to know how to do everything---if someone's heart has stopped, waiting for the IV team would be a pretty bad idea.

In addition to the nurses, at least a dozen pregnant women taught me to place IVs.  Pregnant women often have nice, plump veins, making it easy for the novice to slip in a needle.  Getting in the needle and catheter is only a small part of it though;  you have to learn the preparation and the dance.  You have to learn how to tear the tape you need ahead of time, how to secure the IV and flush it, and all the other bits of knowledge that surround getting the needle into the vein.  Most important, you have to remember that the vein is attached to a human being, one who may be frightened and in pain, and needs your confidence, your ear, and all of your empathy and compassion.

I made it my business to learn as many of these lessons as I could.  I volunteered to start IVs and get blood from the most difficult "sticks".  I wanted to be the one people would call if they couldn't get the job done themselves.  While I rarely use these skills anymore (an excuse often tossed out by young docs who don't want to bother to learn them) I still value them, and especially now I need to send out a "thank you" to all of the doctors, nurses, techs, and patients who taught me.

This morning I hung a bag of IV fluids for my wife.  It seemed familiar.  It took me a second, but the understanding, the comfort with the process came back to me quickly.  Because of this, we can sit together at home instead of at the hospital.  This is worth every night I spent on call alone and tired, surrounded by other people's loved ones.

14 responses so far

Thunder and lightning

I'd be asleep right now if a loud clap of thunder hadn't sent me bolt upright.  Fortunately, my daughter's only reaction was to mutter senselessly, turn over, and snore peacefully. She's slept with me nearly every night since her mother has been in the hospital.   She's done remarkably well with unexpected changes, even sleeping at a friend's house.  At night she mentions missing mommy, but generally she's her usual charming self.  Last night she realized she'd left her favorite pillow at her friend's house, and that broke her.  She sobbed uncontrollably for her pillow until finally, at nearly midnight, my friend came by in her PJs and dropped it off.

We stopped by another friend's house last night.  It turns out that when there's a crisis, friends are a good thing to have.  She played with the other kids and I ate sushi with the adults, two of whom she refused to believe were married because "girls don't marry girls"---except of course when they do.  She'll figure that one out eventually.

Despite her sticking to me like glue, she's getting pretty tired of a boring old adult, so I just dropped her at another friend's house to play and paint Easter eggs, so for a while at least I get a break from single parenthood.  At least it's a temporary single parenthood.  I was chatting with a colleague yesterday who recently lost his wife.  I am also even more amazed that MrsPal gets done everything she needs to in a day.  I've bent my work schedule nearly to the breaking point and it still takes all the help I can get just to get PalKid where she needs to be from moment to moment.

I don't really know yet how PalKid is processing this whole thing, except that I have a little bedfellow every night, one that despite her diminutive stature can turn a king sized bed into a small palate.

Hopefully she'll enjoy the whole Easter egg thing and come home nice and tired.  Daddy needs some sack time.

16 responses so far

"This bodes some strange eruption..."

Apr 06 2011 Published by under Medical Musings, Medicine

So that rash isn't anything horrid apparently.  My dermatologist, who is wonderful, described it as a mixture of eczema and very dry skin (sort of a mix of eczema craquelé, atopic dermatitis, and xerosis).  She advised less frequent lukewarm showers, good moisturizer, and a high-potency steroid cream.  Hopefully, the change in weather will allow us to get some humidity into the house, but the shower thing is a problem.  I work in small rooms with sick people, so I shower once in the morning to avoid offense in the exam room, and once in the evening to avoid contagion at home.  The doctor recommended a week in Florida, but that's not on the agenda.  The steroids should do it though, eczema being one of those diseases where the immune system is a bit irrationally exuberant.

Antibody molecule

Speaking of immunologic illnesses, I was confronted last weekend by an annoying case of common variable immune deficiency (CVID).  The primary problem in CVID is a failure to make sufficient quantities of antibodies, the chemicals that mark biologic invaders for destruction.  Antibodies are part of the adaptive arm of the immune system that recognizes specific invaders.  The immune system also has a passive arm that can respond to molecules that look generally like invaders.  Antibodies though are very specific.  One may recognize a particular surface molecule on a staph bacterium, another an influenza virus.

The arms of the "Y" on the immunoglobulin molecule are the end that bind to antigens (molecules that form parts of various bacteria, viruses, and other invaders) and can bind very specifically, like a lock and key.  Given the millions of foreign molecules we are exposed to, many of which are harmless, how can we possibly maintain a library of antibodies against invaders?

The immune system, specifically a type of white blood cell called a "B-cell", creates antibodies whose structures are random.  Not every one of these will bind pathogens.  During development of immune cells, this part of the immune system is very closely regulated, so that immune cells that recognize "self" molecules are turned off.  This culls out cells that would attack us, and (normally) leaves the ones we need to patrol for invaders.  If an antibody happens to find an antigen that fits, it will bind, setting off a cascade of changes which will ultimately lead to production of more of that antibody.  This way, a large repertoire of potentially useful antibodies are created, but only the ones that are needed are produced.

As a wise physician once told me, "antibiotics never cured anyone," meaning that antibiotics generally help our own immune system gain control of an infection.  In CVID, antibody production is impaired, so when the patient becomes ill, antibiotics may not be sufficient to save them.  While penicillin may inhibit bacterial cell wall synthesis, antibodies can not only mark bacteria for destruction, but send out a chemical signal to call in more immune cells, evening the odds.

Patients with CVID often become much more ill from common infections that patients with normal immune systems.  Since these patients cannot make enough of their own antibodies, one possible treatment is to give them antibodies from someone else.   Since the antibodies are floating around in the plasma, perhaps we could simply give the patient a plasma transfusion.  The problem here is that any single donor may not happen to have the specific antibodies needed.  If, for example, my CVID patient had an infection with Streptococcus pneumoniae serotype 7F, but the donor had never been exposed to that and therefore did not have antibodies, the plasma would not be helpful.  The solution is to take plasma from thousands of donors, pool it, and divide it up so that each unit will have a wide variety of antibodies.  This is remarkably effective.

So as I spend my precious minutes under the lukewarm shower, I'll contemplate the wonder that is the immune system, and the hard work that has gone into giving us the ability to manipulate it, allowing me to scratch less, and preventing another patient from dying of a normally curable disease.


14 responses so far

Yet more medical ramblings

Mar 23 2011 Published by under Medical Musings, Medicine

The Midwest is home to some pretty crazy weather.  Thirty-five years ago this month a tornado tore apart the new, rapidly-growing Detroit suburb of West Bloomfield.  MrsPal was looking through pictures of the aftermath saying, "That was so-and-so's house.  And that one was across from..." etc.  Everyone knew someone whose body or property was damaged.  I knew a kid who had scars all over his body from a house collapsing around him.  He had the same name as another local kid, so we always would say things like, "No, not that Steve, tornado Steve."

Tonight, it's not stormy, but something is falling from the sky that isn't hail, isn't sleet, isn't snow, isn't rain.  Whatever it is, it hurts, and I have to chip away at my car door to get in.  We just got back from dinner.  A local Lebanese place has great fish during Lent (the rest of the year, feh).  It's a whole Great Lakes whitefish, fried, and covered in lemon juice, garlic, and other yummy things.  Before that we were at a shiva, the reason for braving the weather in the first place.  The decedent had been a patient of mine, but I also knew him socially.  I met him many years ago when he and his wife, neither of them terribly young, were sitting in my office holding hands and making eyes at each other like drunken teenagers.

He was concerned about his memory.  He was a brilliant medical professional, and he and his wife visited all the local experts and had been unable to avoid the conclusion that he was becoming demented.  Oh, but they were so in love, and while they were frightened and sad, they had each other.

That was ten years ago, and his life went on as these things often do, with those around him trying to lead normal lives while a man they deeply loved slowly but surely disappeared.   It is one of the privileges and one of the sorrows of medicine to develop uniquely intimate relationships with strangers only to preside over their decline.

I've been in practice about ten years now.  The recent move to a new practice, which has kept me away from the keyboard, took a bit of work.  One of the most unsettling tasks was going through a list of thousands of patients to contact and weeding out the dead---it's bad form to send letters to dead people.  Each time I would come upon a name, I would halt and see an image of them, remembering their voice, the way they lived, the way they died.  Sometimes, I wasn't sure if they were dead---maybe they just hadn't been by in a while, but they sure were old.  I would cross-check various databases and then delete their name from the mailing list, wondering how they had left.

While I may see a lot more of my older, sicker patients, I know that the younger ones will eventually spend more time with me, around the same time I start seeing my own doctor more than once a year.  It reminds me that every night that my daughter pesters her mother at bedtime whining for Daddy, I should be there.  Every second with my family, even the "bad" seconds, are precious.  It seems that it would be easy to accumulate regrets in life, many of which are seen best in retrospect.  Perhaps I can learn this sooner rather than later, that despite being carded at a restaurant last week, time isn't infinite, childhood cannot be taken for granted, and no one has ever said at the end of their life, "I wish I'd spent more time at work and less with my family."

6 responses so far

Medgadget nominees announced

Feb 01 2011 Published by under Medical Musings, Medicine

The White Coat Underground has been around in one incarnation or another since May 2007, and in that time I've experimented with my writing style and content. Over time, I've moved from angry quackbuster to angry quackbuster who prefers to write more eclectically. This year, Medgadget's annual medical blog award nominees include WCU.   Of course I'm excited for myself, but I'm more excited that over the years I've been able to engage a diverse group of readers in serious discussions about medicine, my passion and my avocation.

As my readers may know, I recently moved to a new practice, one that is extremely busy.  It sits at the confluence of several major avenues and highways, making it easily accessible from the city and a variety of suburbs.  It has a good reputation, earned the hard way by my new partners.  One of the physicians recently moved out of Michigan, and the staff and his patients have been warm and welcoming.

Building a relationship between a doctor and a patient is not simple.  Your abdominal pain may be run-of-the-mill to me, but for you, it is unique, painful, and frightening, and somehow I must win your trust in a few simple minutes.  I have to get you to tell me your most intimate secrets, and you must allow me to examine you in ways that seem somewhat less than natural.  In that short time, while meeting your eye and listening, I'm watching---watching how you sit, how your brow furrows in subtle discomfort when you move a certain way, the color of your skin, what you do with your hands.

Sometimes, when I listen to the heart, I close my eyes.  I need to see the chest rise and fall and watch the effects of the heartbeat on the chest wall, but after that, I close my eyes, try to shut out everything else, and listen to the heart sounds, for the character of the first and second sound, for any extra sounds, for murmurs.  I lose myself in the beauty of the physiology of the heart, of how much can be gleaned from just listening.

If I spend a couple of minutes listening patients usually ask, "everything OK with the heart, Doc?"

"It's been beating for 70-odd years, and it's never stopped.  How amazing is that?  I don't see any reason it should stop now."

The science of medicine, the mystery of the doctor-patient relationship, none of it is ever boring, and though I may write less frequently, I hope we can continue this conversation for a long time.

4 responses so far

Weekend musings

Jan 15 2011 Published by under Fatherhood, Medical Musings, Medicine

It's another cold, windy, winter day here in the Great Lakes state.  From my kitchen table I can see the snow drifts pile up against an old oak tree.  There's a baby swing still hanging from the lowest branch.  PalKid hasn't been able to sit in it for years, but for some reason, I've never bothered to take it down.

Yesterday around five a.m., a small voice woke me up.

"Daddy, I can't sleep."

"Come on in bed next to me and you can stay here, just be quiet, honey."

A few minutes later: "Daddy, I don't feel good.  I have a headache. Can I have a cold cloth?"

Mrs. Pal called me at work later to tell me PalKid had a fever of about 102 and was feeling miserable.  I ran into a colleague today at the hospital and he told me, "You're only as happy as your least happy kid," and that seems about right.  Last night was rough, and that cute little voice got me up at four this morning.  She was feeling miserable, and after getting some tylenol in her, she asked for a cool bath.  A few hours later, I was on my way to the hospital, not for her thankfully, but to see patients.

My new practice uses a hospitalist service, so I'm not the one taking care of my patients in the  hospital anymore, but I still like to check on them once in a while when time permits.  The new practice is very, very busy, which is great, but there really isn't time to round regularly.  I did manage to visit a couple of folks today (and missed a few also...sorry).  I got a big hug from one patient, and nearly cried.  I was happy to see he was recovering nicely after a big scare.

Someone asked me this week how I deal with giving bad news, with maintaining a clinical distance.  I have no idea.  Much has been written about this, but there is no right way to deal with these boundaries.  Being a physician is a privilege, and a strange one.  It's a bit like being a writer, inhabiting lives that aren't yours, being privy to the private dialog of others, to their happiness and tragedy.  Sometimes it hurts.  Sometimes it is ecstasy.  Rarely is it simple.

But for today, at least, I'm mostly a daddy taking care of a sick kid, bringing her ginger ale in bed, enjoying a smile meant just for me.

8 responses so far

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