Oh How I Love Erasing That Board

The easiest way to keep track of all the patients we are seeing who remain inpatient is to write them all on the resident room white board. It's very easy sometimes for this board to become completely filled with names, locations, and diagnoses.

But every once in a while there is opportunity to start erasing names. People who no longer need our expertise, people who have been discharged, or, more sadly, people who have died become little more than a black smudge at the extreme edges of the board.

I know this is short, but damn it's a good feeling.

Vacationing Sucks - When It's Not You

When I went on vacation, it was awesome. For me. And those with me. But it didn't take long for me to realize that it wasn't so awesome for some others.

The other first year resident with me at JEI spent the week by herself manning, or womaning, all the consults; not to mention there was overall one less resident to do all the work. It would have helped if certain people did a better job blocking the appropriate clinics when people are gone, but that seems to be too difficult a task to be done correctly.

At any rate, upon my return, she was gone the very next week and it was me manning all the consults. My first day back the board was full of inpatients who would need followup at some point in time - her week had obviously been very difficult. Even though I was able to eventually clear some of those off, more just kept getting added on. And when we're down a resident, you can't leave the afternoon clinic to go see floor consults; they just have to wait until the end of the day, thereby pushing the "end of the day" further back.

We will be back to full numbers this week. This should make everyone happy. Too bad tomorrow morning's clinic has more people in it than ever have been; at least more than I've ever seen.

A Little Background

This is a blog about me becoming a doctor, among other things. So it's only appropriate that there is something on here somewhere about why I chose to become an eye MD.

Some time ago, like at age eleven, I thought I wanted to be a geneticist (thank God that didn't work out). But then something happened. Two of my brothers, one older and one younger, were one day firing broken paper clips hooked over rubber bands at each other. I maintain to this day that I wasn't partaking in the games. In fact, I distinctly remember going into the kitchen to grab my sixth-grade English book off the counter when I turned to the doorway. In it was standing my younger brother, locked and loaded. Before I knew it, I was pulling a paper clip out of my eye. Who knows if that was really a good idea or not?

We immediately went to the emergency room and I recall waiting a good long time for the ophthalmologist on call to show up. I had gotten a chance to see what my eye looked like and found it with a teardrop shaped pupil. My vision was slowly improving (from just a yellowish light) but was still pretty crappy.

Dr. M. finally arrived and after only a brief look decided I had what we affectionately call an open globe, or more specifically a corneal laceration. I went to the operating room that night where he put five stitches on my cornea. I spent two nights in the hospital (odd, I will have to expand on this later) without much excitement and then went home. I just remember the awesomeness of having a Nintendo at my disposal at all hours.

I visited Dr. M several times over the next several months, finally getting the final stitch out about six months later. I was very fortunate. To this day, with glasses, my vision is 20/20 in that eye.

At that time, I had decided I wanted to be an ophthalmologist. Sure I was young, what did I know? But I stuck with it and knew when I started freaking high school (way, way, way, before medical school) what I wanted to do. Sure other things caught my eye, but for various reasons, they didn't lead me astray.

Healthcare and Social Assistance

Now this guy needs social assistance.

I am currently signed up with a survey service that sends me online surveys about various topics on at least a weekly basis. Each survey earns me points, and the cumulative points can be exchanged for some sort of cheaply made merchandise or gift card. Each point is worth about one-half cent, and at least 5000 points are needed to get any thing worth while. It takes a while to get there.

Any way, there are always classification questions asking about my age, my race, where I live, what kind of work I do, etc. Sadly, it's the same group of questions with every survey which becomes redundant. And when comes down to my line of work, social assistance and health care are lumped into the same category. Totally irrespective of the truth of it.

I did not go to four years of college, followed by four years of medical school, followed by four years of residency to be a social servant, or a social worker. I am a doctor. Please note the difference.

Writer's Block

This isn't the kind you get when you want to write about anything, but just aren't able to do so. This is a very specific kind - a research kind. Trust me, I have plenty of potential blog topics about which to write - all one would have to do is look at my dashboard to find many titled but unwritten entries.

I have spent a fair amount of time looking through many patient charts, copying several bits of information, and all in hopes of finding some sort of statistically significant information. The data was all analyzed by the bioinformatics people, but I don't think they came up with anything I couldn't have on my own. That is not to say they suck at their job - just that my pile of data sucks. It's not bad data, just data that doesn't really show anything.

I started this research project in hopes of finding some sort of publishable information; something that could potentially get practitioners thinking about the way they do things and how they might change. I know that in order to be a competitive fellowship candidate, a few good publications related to oculoplastics under my belt would be super helpful.

I have none. And all the writing in the world can't save me.

That Tuft of Grey Hair



Who says grey can't be sexy?

I have mentioned in the past peoples' incessant commenting on my young looks. But as proof that I'm not as young as my boyish features suggest, there are more and more grey hairs popping up over time.

There are a number of possibilities for this. One is that I'm a dad of a two year old. Let's face it, Mia is a hand full. A lovable, non-stop handful.

Another possibility is residency. Again, let's face it, the work is not easy. When not at work, we're at home studying. (Or writing a blog.) The only reason it hasn't given me wrinkles is because I don't often smile, laugh, or even frown about it. It is what it is.

Or it could be that every time someone accuses me of being nineteen, another one pops up. Thankfully I have otherwise beautifully thick hair. Anyways, my twentieth birthday is coming up soon, so slow down, Life.

Isn't this a blog about being an eye doctor?

Gas Station Contacts

I recently found out something that was downright frightening to me.

There are places, gas stations for example, where a random Schmo-jo can walk in and just buy an over-the-counter contact lens. Of course these are usually wacky colored and patterned ones for what some odd ones call "style" or "making a statement." But the point remains, no prescription, no proof that one knows how the hell to take care of a contact, and no guidance on how to do so is required.

What's worse is someone can walk in, stick their grubby little fingers in the contact container to try one, not like it, and put it back. It's true!! Or so our contact specialist has told me, and I see no reason why she would fabricate this.

There a few idiots here:
1) The idiot who makes and distributes them: I have low suspicion that reputable contact manufacturers allow this. But who does, I do not know. This is a law suit waiting to happen.
2) The idiot who sells them: As if they have any idea what to tell buyers.
3) The idiot who buys them: Really? I mean, really? At least go buy real ones - even reputable makers of contacts have these special ones available, but at a higher cost. A cost you should be willing to pay.

Naturally we have seen these people show up in our clinic with problems related to improper contact use. Who knew?

I have no financial relationships or obligations to makers of contact lenses. Or any other ophthalmic devices or medications for that matter.

One Way to Get Burned

Rachel's former employer

As people who take home call, i.e. we don't sit overnight at the hospital waiting for people to page us, we have to develop good working relationships with the people who frequently consult us in the middle of the night. This is primarily limited to the ED physicians and trauma team - with whom, overall, I have developed good relationships. When one I really trust calls me and relays to me what is going on, I can pretty much take it as truth and make immediate clinical decisions. I will discuss in a later post those instances in which what I'm told can be taken as nothing more than pure fiction.

I give in specific the case of orbital fractures. In a given week, we see these more times than I have ever cared to count. And for the most part, barring any catastrophic globe injury, there is nothing emergent about the fractures for us to address. So when a trusted ED physician calls with a routine orbital fracture and tells me the vision and pressure and eye exam are essentially normal, I feel comfortable having the patient follow up in the clinic the next day without an immediate visitation by me. In the private world, this is how it routinely happens. Of course in academics, it's rare that one would try to do this, but I was going to give it a shot. It had been done successfully in the past by others.

The clinic visit comes and goes, and the patient doesn't show up. You may note if you're a frequent reader, I have talked about this before. My heart pounds up into my throat and I wonder if I have made a mistake by not seeing the patient in the emergency room when I had the chance. I call the patient, but of course the available phone numbers are not connected. Ass.

This is how you can get burned. Thankfully, he showed up two days later, thinking that was his scheduled appointment, and everything regarding his eyes truly was okay. But talk about a moment of clench. I am sure clench moments will be much more warranted as I become more experienced in my training, but the simple thought of a program director yelling at me if a patient was lost and had a complication is frightening.

That Dreaded First Page

There are a lot of trends noted on call. This one is a trend much discussed among colleagues.

You can never know how a night of call will turn out - at least not before it starts. But it doesn't take very long to figure it all out. Typically, within the first few pages of the night, the pattern is set.

Suppose the first pages are soft balls - easy consults or things that don't even require my presence at the hospital. Generally the rest of the night will be similar, quiet or at the very least with just a few simple things. On the other hand, suppose the first page is a complicated lid laceration or an open globe injury - the two things which commonly make us go to the operating room in the middle of the night. You can then expect the rest of the night to go poorly. Now it may just be because going to the operating room in the middle of the night requires a lot of leg work and eats up a ton of time. But it's no exaggeration that one bad case generally means another will follow too soon.

Though I have never literally gotten the "Your call will suck balls," page, that is certainly what I see sometimes.

The "I'm Not A Diabetic" Argument

Some people have a very difficult time admitting or understanding the fact that they have diabetes, and how it's not something to take lightly.

I would venture to say that no one sees more diabetics than ophthalmologists, except endocrinologists and primary care physicians. Mostly because every diagnosed diabetic needs at least an annual eye exam. And there are plenty of cases where a diabetic is seen in our clinic far more than their own primary care doctor, sometimes as often as every few weeks.

But then there's the population of people who don't recognize their own diabetes who present to an eye doctor first when things start going down hill. On more than one occasion, I have seen a patient come into the clinic with some acute vision change. I ask them about any history of diabetes and they claim they had it at one time, but oh it has been controlled with diet ever since their second year of disease, fifteen years ago. And then I ask them who manages their diabetes. Well, no one, they might say. In some cases this is because they have failed to present to any primary care doctor on a routine basis. But in others, there is a failure of the primary care physician to keep a check on things.

Plain scary. If I had diabetes that was "diet controlled," I would sure as hell still want to know on a fairly routine basis if anything had changed.

I Think It's Time to Go to the ER

What is it about the middle of the night that makes people think they should go to the emergency room for their problems?

Here is a not so uncommon patient. Mr. Schlofferboot presents to the ED complaining of "eye pain." On further questioning, he reports the pain to have been present for somewhere between 3 and 4 weeks, although he isn't quite certain. At this point there are two available paths, or follow up questions if you will. The first: "Why the hell did you come now, then?' The second: "So what changed about your condition which made you decide to come to the ED now?" The first question may get me in trouble, if nothing else make me mad at myself later when Mr. Schlofferboot details some sob story about how his mom was ill and he had to be out of town where there wasn't a nearby doctor. The second at least allows him to explain himself; whether or not I choose to believe him is another story.

Fact is, it is usually not the Schlofferboot family drama keeping people from seeking care during daylight. People go to the ED seeking free, or at least cheap, health care. Emergency doctors being just like most others (and no offense), the eyes present somewhat of a mystery. And then in academics, every patient is just expected to be seen at the drop of a hat. While this is largely inappropriate (again no disrespect to our ED physicians) it just happens to be the culture of academic medicine - no consult gets turned down. Mostly.

So, Mr. Schlofferboot, if something is bothering you for more than a couple days, but not so much you seek emergency care emergently, the emergency room is not your best choice. Call your doctor, or the nearest eye doctor. Because unlike many other specialties, you don't usually need a referral to see an eye doctor.

Mr. Schlofferboot is a made up person. Any (un)likeness of this person to a real person, named Mr. Schlofferboot or otherwise, is purely coincidental and should be ignored. Except for the decision to delay seeking care part.

Back Home

No, I can't pencil you in.

Let me just say it's good to be back home.

We had a lot of fun in San Antonio. Did some shopping, some site seeing, some theme parks (well, really just Sea World), etc. We got to spend some quality time together, and quality time apart - that's needed too you know, especially on vacation. Rachel and I even got a fair amount of time to ourselves with free babysitting, courtesy of doting grandmothers.

But now, after a nearly nine-hour drive back home today, it is time to get back to the real world. (Man, I hate that phrase.) I was able to get a fair amount of data entry for my research done while on vacation, but still have a long way to go, with the first of two practice talks scheduled for this week. In fact, the only reason I have this copy of a calender for myself is because it was the only to plan out and keep track of everything up and coming. Six calls and four presentations over the next two weeks.

Welcome home, Doctor.

San Antonio

Fresh duck, eating my fresh chips.

Greetings from our vacation spot in San Antonio, Texas. Well, technically, we are merely nearby - about 20 minutes from the town proper. We have rented a house in Converse, Texas. No matter; it's quiet here aside from the frequent taking off of aircraft from the nearby air force base.

Thus far we have done more relaxing than anything. We got in late afternoon on Sunday after a nine-hour trip. Mia actually did quite well on the way - just a few short bouts of fussiness and constant asking of questions. On Monday we visited the historic Alamo and took a quick overview gander at the Riverwalk. We shall revisit later this week. Yesterday we visited the zoo and to our surprise, Mia was not as thrilled as we hoped. Oh well. Today we have done essentially nothing. I have worked on some research and reading a novel. Perhaps we will visit the movie theatre later this evening.

Up next, Sea World and a more thorough look at the Riverwalk. TTFN.

Vacation

Starting tomorrow, and for the next week, we will be on vacation. We will make the nine hour drive to San Antonio to get away for some fun. No, San Antonio is not particularly well known for any beaches, but you get the point.

In the meantime, for all those who read regularly, I don't anticipate much in the way of blogging during the next week. I may have a few posts, but these will likely be more related to our trip, not the usual droning on about the fallacies and wonders of what I do.

So go enjoy yourself. I know I will, I hope.

The Difference Between DNR and Comfort Care

Recently while on call a nurse called me from ACH. She stated that a Dr. So-and-so called in a particular dilating drop for a certain baby. She was only questioning the order because the baby had been made DNR (do not resuscitate) earlier that day. Firstly I told her that Dr. So-and-so was an outside eye doctor, so if he was calling in orders for a particular patient, they needed to call him, not me. Secondly I asked her what difference it made if the baby is DNR.

I don't think she really understood what DNR means and how it is VERY different from comfort care or hospice care. DNR is what is done when it isn't felt a person is well enough to survive resuscitative efforts, should they become required. DNR means simply this: if a patient enters cardiac or respiratory arrest, efforts are not to be made to restore those functions. Outside of one of these two occurrences, all possible care is to be provided. This includes any antibiotics, any minor procedures (major ones requiring intubation in the operating room require a temporary lift of the DNR order but are otherwise allowable), and basically any other medical treatment necessary for the patient's well being, even pressor support if need be. So if Dr. So-and-so wanted her to have dilating drops so that he may perform a good dilated exam the next day, this is perfectly acceptable.

Comfort care is very different. Comfort care should occur when there is absolutely no hope that a patient will get better, and will with 99% certainty die, typically very soon. I would say 100%, but you never can be 100% sure. At any rate, all medical treatment is stopped. The only treatments provided are those meant to keep the patient comfortable until the time of death, as implied by the name. Patients going into hospice care are generally in this category, though I once took care of a patient in the ICU who came from a hospice care facility with the family thinking she was there in substitute for a nursing home. Very different, but there was no convincing the family of that.

Oh, and don't ever tattoo "Do Not Resuscitate" on your body. If you have a witnessed cardiac arrest, and are otherwise kinda healthy, not even necessarily totally healthy, your chances of survival are high, and you've instead just bought yourself a death wish. Very, very stupid.

Why I Will Never Do Research at the VA

All of the residents have three sources from which to gather data for their research projects - UAMS, ACH, and the VA. Most of us choose to limit our data pool to patients/charts from UAMS and the VA. But one of my bolder colleagues has decided to also gather data from the VA. She is working on the type of project the VA population can provide a large number of data points, so it's reasonable for her to involve them. Question is, is it worth it?

Not uncommonly she presents with yet another frustration related to her project. And pretty much every time it goes back to her involving the VA patients. I have seen the list of forms she has had to fill out just to look at the same charts she looks at every day at work. The amount of redundancy between them is amazing. Taken out, there would really only be a couple forms remaining. She has made more phone calls for a simple retrospective review than one would ever think necessary. To top it off, she has literally had to gain special security clearance to go talk with certain people  (who work in the very same building our clinic is in) behind locked doors about doing this. There is more red tape than I thought 3M capable of making.

What makes the veterans any more privy to privacy protection than the next person? Nothing.

The Undecided Third Year

As we are nearing the end of yet another academic year, the third year medical students are beginning (or already have) to submit schedules for their fourth and final year of medical school. Most of them by this time have a pretty good idea what their primary interest is. This is not the case for everyone.

I suppose this is somewhat of a foreign concept to me. I knew what I wanted to do before I even hit the doors of my high school years. After being cared for when I had my eye injury, I was forever inspired and chose ophthalmology as a career path. Which is a damn good thing since at the time my aspiration was to become a geneticist, and thank God I didn't. At any rate, I tried my best to maintain an open mind during medical school should some other practice grab a stronger hold of my attention, but none did so. Those that came close offered a relatively shittier resident life with higher divorce and suicide rates. No thanks.

But still, it would seem at this point that the decision ought to be near made. I am full aware that one of my close colleagues didn't decide until June of her third year to enter ophthalmology.  She is very fortunate it worked out for her - it's an overall pretty competitive field which meant she already had good credentials. She is probably the exception - especially for blooming ophthalmologists since their match is earlier than others.

Well, I wish you well, third years. Give yourself time to decide, because you'll want to test the waters some more before you commit.

The Patient's Responsibility

There is only so much we can do to ensure a patient gets the proper care.

Suppose a patient comes to you in your clinic with a problem that is going to require regular and frequent follow up. They came to you in the first place because no one else could or would take care of it. It's obviously a bad enough problem for them to seek help, so expecting them to maintain good follow up should be natural, right? I think so - it's certainly not an outrageous expectation.  So you tell the patient, "Mrs. Flaggerbatham, I will need to see you again in two days."  "All right," she says. You make the appointment, you give her a specified time, and even a phone number to call if she can't make the appointment.

Two days go by. You are nearing the end of clinic and you have realized, perhaps an hour or two before, that Mrs. Flaggerbatham didn't arrive. You call the phone number she gave reception at her initial check in. This may or may not be a real phone number. You call it anyway, but no one answers. You leave a polite, though blunt and grounded message. "Mrs. Flaggerbatham, I noticed you didn't keep your appointment today. It is very important we see you again. Your condition is very serious and without proper care you could loose your vision or your eye. I expect to see you in clinic tomorrow, and if not, please call us." This message is also documented in chart, for you lawyers.

Another day goes by. No Mrs. Flaggerbatham. Another phone call, another no answer, another message. You do this two or three days in a row, and then send a certified letter, to what is possibly a rogue address. Ultimately, Mrs. Flaggerbatham doesn't show and is never heard from again.

Sadly, this happens. As doctors, we kind of feel that this circus should end after the first phone call, perhaps even at the end of that first visit. If a patient is given all the proper warning, all the proper information, the ball is in their court from the time they leave the clinic, the hospital, or the emergency room. It should be, and quite frankly is, their responsibility to get proper medical care.

Unfortunately, malpractice attorneys don't see it this way. Bastards.

All characters above are fictional, except for me. Anyone found to be named Mrs. Flaggerbatham, on Google or otherwise, is purely coincidental and has no bearing on my saying so.

A Trip Down Memory Lane

Throughout most of my college years, I worked as a pharmacy technician. It helped pay the bills, gave me experience working in the hospital and ultimately likely helped pave the way for my entry into medical school. I met a lot of very cool people, and made some great friends, some of whom I still talk to on occasion.

One of these was a quite goofy guy, but a good one. For whatever reason his brain decided to do so, he coined the name "Dr. Bear" relatively early on. Most of the people there knew I had plans to go to medical school, and I wasn't shy about saying so. Not cocky, just clear on my goals. At any rate, the name stuck and many people referred to me as such. Some still do.

Sometime later, in my infinite wisdom, I mentioned this name to another good friend of mine, who we now call "Dr. G." He got quite a kick out of this and picked up its use instantly. He wasn't content keeping it to himself though. He felt the need to tell mutual friends/acquaintances. One of these was also mutual through a few people at my college, Drury University. Even though, he somehow didn't get the memo that Bear wasn't actually my surname. We will call him "Guy."

On a return to campus one day, this guy stopped in on one of my former professors. I had sent a very simple message with him.

Guy: "Oh, hey Dr. X. So I was supposed to tell you Brad Bear said 'Hi.'"
Dr. X: "Who?"
Guy: "Brad Bear, you know."
Dr. X: "No, I don't. I have no idea who the hell that is."
Guy: "Well he said 'Hi' anyway."

When Guy later found out what he had done, he went straight into ROTFLOL. I hope Dr. X still hasn't figured it out.