Monday, January 26, 2009

It wasn't a time when I new the difference between sick and well. For God sakes I was only nineteen. But the feel of Alex holding onto my arm for dear life made me age quickly. And feel frightened. But unfortunately no more wise

I had gotten the phone call thirty minutes earlier. His fraternity brother saying it was an emergency. To come quick. When I arrived I found Alex. Panicked. Holding his chest. His face was flushed. And he kept on saying over and over again....I'm going to die...I'm going to die.

His roommate sauntered over to me casually with a stupid grin on his face and handed me his car keys. We're all too fucked up! Can you take him to the ER. He then disappeared with the rest of his fraternity brothers into their rooms. And I, towering over Alex, gently tried to coax him off the ground and towards the car parked in the driveway.

His eyes were blood shot. His gait unsteady. His breath smelled of alcohol.

None of this was missed by the nurse checking him in at the front desk. So what did he take...heroine, shrooms, LSD? The truth is I didn't know. And Alex wasn't going to confess. The nurse absentmindedly took his vitals and gestured for us to sit in the waiting room.

Alex began to panic. He grabbed his chest and moaned. He told me his heart was racing. The holding area was empty but a few remaining stragglers visibly distanced themselves from our seats. And so we waited...and waited...and waited until someone came to get Alex and told me to stay behind.

A few minutes later a Doctor beckoned me to come to Alex's bedside. He was agitated and the doctor felt that a familiar face would calm him down. I held his hand as an EKG and blood tests all came back normal.

Eventually Alex calmed down enough to return home. The Doctor gave me instructions and wished us well. As I was leaving he looked over his shoulder...So what are you guys studying anyway? My head slumped forward as my answer came out almost a whisper: Premed.

And now years later I often wonder what happened to Alex. Did he ever become a doctor? And what drug had he taken that day anyway? With the experience of years I realize that Alex wasn't that sick at all. Just scared, inebriated.

And I try to be a little easier on people......

especially in their moments of frailty.

Thursday, January 22, 2009

Primary Care

In the winter
Of my discontent
The welfare line forms
Outside the office

And I
The phony banker
Dispense phony treatment
Like monopoly

In exchange
For the incoherent mass
Of unsatisfying

Light headedness
Numbness and tingling
And then

Abdominal pain
Without vagaries
The belly jumps
With my slightest

A keeper

Ultimately eludes me
On the eaves
Of the Scalpel's
Sharp Tongue

From the chapbook Primary Care, The Lives You Touch Publications

Monday, January 19, 2009

Does A Good EMR Erase Some Of The Benfits Of Hospitalists?

Although I don't personally use hospitalists I am a supporter. To internists who don't want to leave the office they are indispensable. In today's fast paced ever changing health care scene hospitalists are a bastion of stability and bring excellent care to almost any system.

To put it simply....hospitalists give efficient, timely care, in a cost effective manner. In fact it has been this cost efficiency (as well as the benefits to PCP's) that has been trumpeted as the battle cry to advance hospitalist programs.

But as time goes by the data are starting to illustrate that maybe the cost savings aren't as great as we once thought. That doesn't negate the force of the movement. After all there are other efficiencies besides economic. But it does make you wonder. Can a good EMR level the playing field a little bit.

For instance. In my current hospital system we use a highly effective EMR called EPIC. Using this system I round early in the morning. When I arrive at my office I open up the EMR from the Internet. As I am doing my morning paperwork I also scan vitals and labs right as they come back from the laboratory. As the day progresses the regular commotion begins. Between seeing outpatients I review xrays, consultant notes, and even discharge patients right from the comfort of my office.

It is safe to say I am more in touch with what is going on with my patients throughout the day then I ever was previously...even as a hospitalist. Even though I may be deluged with outpatients, I only have a few people in house at a time so it is easy to keep on top of them.

I don't know for sure but I suspect my length of stay and cost of care data is right on par with our hospitalists.

As an outpatient primary care doctor I feel more connected to my inpatients then ever. And I wouldn't have it any other way!

Sunday, January 11, 2009

Sitting In a Trendy Bar in LA

Sitting in a trendy bar in LA I find myself out of my element. My eyes wander to the tables adjacent. The room sways with the music as the beautiful people inhabit their space. And then out of the corner of my eye I catch a glimpse of two men embracing. Young. One then reaches his arm around the other putting him in a mock headlock. And instantaneously the image transports me back to a week earlier...

I'm rushing to the emergency room from my office. I have a thirty minute break between patients. The buildings are connected. I try to sort out what I am gong to say to the family I'm running to meet. Their mother has just died unexpectedly in the nursing home. She was deathly ill but that won't make it any easier. I feel a twinge of guilt as if I could have done anything differently.

I enter the hospital from a side door and start down the long passage that eventually leads to the main entrance and the ER. My eyes forward I almost crash right into the women in the white coat. She is standing at the intersection between hallways. Holding a hand up towards me she is speaking in harsh loud sentences. Her head is turned towards the bisecting hallway. "Okay...okay...they have a bed for us move him forward..." a bead of sweat falls from her forehead.

Next five large security guards stumble forward into view. They are struggling to carry a thrashing figure. They each have a limb wrapped squarely between large arms. The fifth has the patient's head in his hands and is holding it for dear life in a headlock. They are all obviously fatigued already. The man in front responds, "okay...we have to hurry...we can't take it much longer".

And just as quickly as it has come the commotion disappears. Later as I walk through ER I see the attending and nurses scurrying to the exam room with syringes. Ready to sedate on command. The security guards are loitering at the nursing station. Each grasping a cup of water. And I, distracted by the scene, still am not sure what I am going to say to the family as I pass through the main area and head towards the crisis room.

The men in the bar are now sitting. They toast eachother with their newly delivered drinks. And I let go of that day in the ER. It all seems so far away now....

sitting in a trendy bar in LA.

Friday, January 9, 2009

Another Holiday

As the snow gently drops onto my windshield it is quickly whisked away by the wipers. It's another holiday. 5:30 AM. And I'm in the car on the way to the hospital. I've worked them all. Holidays, birthdays, anniversaries. I've missed countless family events. I generally leave the house before the children awake. Occasionally I return after they are sleeping. And when I'm not working...I'm constantly thinking. Mulling over a patient....a disease. Agonizingly trying to grasp the ephemeral. The missed diagnosis..the hidden clue. My wife rolls her eyes when she asks a question and I fail to respond. My head in a cloud I'm lost in the ether, desperately clinging to fleeting thoughts. So why do I do it. Why be a physician?

I am not a religious man. I have never read the bible. When times get tough I do not pray. But I have a sense of what must make it so gratifying. The husbands gentleness as he helps his wife onto the examining table. The ward secretary who sneaks into the hospital room to hold the patient's hand because there is no one to sit with him while he dies. The countless acts of beauty and kindness that occur behind closed doors when we are all at our worst. This....this is as close as I get to feeling God's presence.

This is the mistress that whispers in my ear early in the morning and forces me to get up. To leave my family on a holiday. To drive a half an hour in the snow to the hospital. To practice the craft that I have been taught. A craft which invites me into the most intimate moments of others lives. And gives me the unique possibility to help.

No matter how bad it gets there will always be doctors.....

There will always be doctors!