After the Marathon

The comparatively small medal from last year's relay race.

This is going to be one of those posts that has little to do with medicine. I think I am allowed to do that once in a while, despite the intention of this blog. Most life events are better commented on by my wife since we experience many of them together, so she often beats me to the punch with such things. Surprisingly, there are a few things more privy to just my experience.

To get the medicine aspect out of the way, I am currently on the OB/Gyn rotation. The first three weeks, of which I am about to enter the third, I am on the gynecology oncology service - essentially revisiting three weeks of the surgery rotation complete with early mornings and standing in the OR. The excellent thing about this rotation so far is there are five of us students on the service. On any given day, one of us has to attend the clinic, one student needs to be in each OR (of which there only one or two a day), and the rest, assuming they're not in private practice that day, go home after rounds. On Wednesdays, we have lecture and all that jazz after which we are free to go home on this service - which is usually by eleven ("This day goes to eleven"). Fridays entail a noon pre-op conference over catered (i.e. drug rep) lunch after which, again, we go home. Days are thus either long (5A to 5P), or laughingly short. Following will be three weeks of OB, one in the clinic and one on the L&D ward. I look forward to it, surprisingly.

On to other things. So today was the marathon. All 26.2 miles of it. I have been working up to this point since September or October, steadily increasing the length of my longer runs until I hit 20 miles, and then tapered down to rest the week or two before the race. It was all good and well - I was able to work up to and do 20 miles without much trouble. Most people could do it; it's just a matter of going through the motions of training. Granted, some have the misfortune of having joints that just don't agree with running that far/long, and that's a valid reason for some folks not doing it, but not for as as many folks who use it as an excuse. Sure, if you were going to run today after not having done it in a while, your knees will hurt. But there were plenty of people out there today far older than I running like champs.

Anyways, off my soapbox of sorts, today was the first day I ran over 20 miles. I started the race superbly. I was with or slightly ahead of the 3:30 pacer (which is an eight minute mile on the dot) until mile 13 or 14, during a long, two to three mile uphill stint. Suddenly, shortly after passing the 20 mile marker, my right calf muscle started spasming, hard. It was a bizarre feeling, powerful contractions that hurt like no other. I don't know if you've ever tried to run with a spasming calf muscle, but it can't be done. I had to walk for about half a mile. I passed the 21\2 mile marker and soon my left calf almost started doing the same thing, so again I walked a little bit. This time up to two miles. When I passed mile marker 24, I promised myself I would run the last 2.2 miles. I did, but they were a slow two miles. I finished in 3:58, which if I may say, ain't to shabby for my first race and considering I did over two miles worth of walking. I don't yet know where I placed amongst the thousands of runners involved in the event, but I know it was within the first two hundred marathoners, and I even finished before some of the half marathoners. An extremely large marathon medal (the world's largest marathon medal, seriously) and my always beautiful and wonderful wife awaited at the finish line to congratulate me on a job mediocrely done.

The environment of the race was wonderful. The comradery of the local Little Rock folk is awesome - people along almost the entire course cheering you on, calling you out by your first name (as it's on the race bib), and volunteering to hand out water and fruit along the way. (You can't run 26 miles and not eat and drink along the way!) The scenes and sights were great. We passed the Clinton Presidential Library, the river numerous times, Central High School (recall the Little Rock Nine), the capitol building, the governor's mansion, the beautiful Rebsamen golf course, and of course all around downtown LR.

Of note, one less fortunate individual passed away shortly after crossing the finish line today. He collapsed in the finishing area and EMS tried to resuscitate him, but were unable to do so. I don't yet know how old the gentleman was, but the details are less important. I am sure he had no intention of seeing this race as his life-ending event. Our thoughts and prayers go out to his family and friends for their loss.

I suppose that is all for now. I will go mend to my wounded feet and dehydration.

On Mental Illness

I have once again risen from the the ashes to create another post. Only read on if you wish to know about the crazies.

So I have started my psychiatry rotation. Once again, I am at the veteran's hospital, only now I am in North Little Rock, a nice half hour drive twice a day. Granted, I know some make much long commutes daily to and from their jobs, but I think they too fall in the crazy category. Starting on January 7th, I did three weeks of outpatient clinic where I saw patients who mainly suffered from depression and/or PTSD. I saw a patient who was at least manic, if not bipolar, who denied his condition despite a recent episode of wandering neighborhoods all night and hiding in peoples' bushes. I saw a schizophrenic in clinic who, while currently well controlled on antipsychotic medication, continued to report the voices of demons telling him he was the son of Perdition and the Antichrist. Those two together are a might heavy charge, if you ask me. Now, and for the next two and a half weeks, I will be working with the patients who are committed because they are super crazy, are super depressed, or have super PTSD symptoms. So I currently have a schizophrenic patient who is NOT well controlled on his medications. His retard Christian Evangelist born-again psychologist, likely from the hills of Deliverance, told him to stop taking the meds as they were causing his diabetes. While this may be true, it's better to have easily controlled diabetes than psychotic symptoms requiring hospitalization. He came in, self admitted, with grandiose delusions about how God worked through him in such a way that he was to communicate with high religious figures to spread information about the Antichrist. Again, a crazy claiming connection to the bringer of everything evil. Is there really a connection? He also thinks the police and millions of others are constantly surveilling him, just waiting for him to slip up and say the name and whereabouts of the Antichrist. It's him and "his people" versus the rest. I haven't yet asked what side I am on for fear of my life. He also sweats blood, much like Jesus and the apostle John, and doesn't want meat even though he knows animals are God's gift of meat to us. More medications, I say.

I would also like to bring up something educational. I saw to patients receive ECT, or electroconvulsive therapy, this morning. Let's dispel some Hollywood misconceptions, shall we? ECT does deserve its criticism, IF YOU LIVE IN THE PAST! It used to be a very barbaric procedure, and overused, such as we have seen as follows:

Jack Nicholson in One Flew Over the Cuckoo's Nest

Or, more recently, this one:

Ellen Burstyn in Requiem for a Dream



Notice, these people are awake and either strapped down or several people are holding them down. This is so far removed from the case of today, it's hard to imagine a time like this. Now, people are under full anesthesia, intubated so that they may breathe, and have been given a paralytic agent so that the induced seizure doesn't cause physical harm or kidney damage. The seizure lasts between thirty seconds and two minutes, ideally, and the only indication of its presence is an EEG (a machine which monitors electrical activity of the brain) and a seizing foot. The physician puts a blood pressure cuff around ankle to keep the paralytic agent out of the muscles of the foot to give the team a physical indicator of seizure activity. There may be some facial grimacing as preventing this would require far more paralytic agent. When the procedure is done, the paralytic agent is reversed with another drug, the patient is woken up and extubated. Simple (and boring) as that.

To be fair, here is a link to a pamphlet opposing ECT: http://www.antipsychiatry.org/ect.htm

There are MANY things wrong with this pamphlet. First, the website itself. I at first thought this was by a Cruise-lovin' scientologist based on that alone. Nope - it's a blood sucking lawyer, perhaps even worse. Second, he quotes books and articles dating as far back as the 30's up to the nineties, with a few updates at the bottom. Outdated information is a sign of poor research. Thirdly, amongst all his listed sources and recommended readings, ALL are opposing pieces. A well-written stance provides information from both sides. Now, there are some M.D.'s out there who also oppose ECT - psychiatrists in fact. Fair enough. But since when does any psychiatrist know an inkling about how their treatments really work? Fourthly, the "author" uses more quotation marks than Lisa Ramsey on a crack "binge" - simply "annoying." Sure there is some short term memory loss - as in they might forget the morning of the treatment, maybe the day before hand. Any more than that is exceedingly rare. Sure they may be in a trance for a bit after the procedure, but so are most seizure patients. It's called being in a post-ictal state, and it always passes without harm. There is no good evidence for permanent brain damage, especially since chronically depressed patients, the only patients in whom it is used, likely have brain damage anyway. It is NOT used as a scare tactic for patients - that's just crap. All the patients I have seen involved in it chose to do it on their own accord, and it's a rare enough procedure that the possibility of them being scared into it by others is highly unlikely, if not impossible. Here's what ECT IS:

1. More effective than taking a pill every day.

2. A VERY good option for those who have recurrent, severe depression unresponsive to other medications.

3. A last resort.

4. It can, and does very well, turn this:

In to this:

So there you have it, my standing on ECT. Just thought I would dispel some common myths about it. Soon, I will give my standing on the presidential candidates based on their standings on health care issues. Our good friend connection in Chicago, Carrie, hasn't yet reported on individual health care opinions, and I need to be informed. I fear for the future of medicine.

Belated

Fireworks from God only knows where, or to celebrate what year; but New Year's fireworks just the same.



So I'm about two months behind on blogging. I have little to blame except for myself, the surgery rotation, board exams, Christmas, New Years, family, the Wii, Rachel's need for attention, Cali's need for attention, etc., but nothing else. It really has been a busy time aside from the past week and a half. So, what's been going on?

Let's begin with surgery. It's over, long over in fact. I had fun, liked it a lot, didn't really mind the long hours, and met people in whom I instill trust to one day write for me a letter of recommendation used to land an awesome ophthalmology residency. Don't want to get ahead of myself, though. Plastic surgery taught me more about wound care than I cared to know - I saw some deep, nasty looking wounds. Vascular surgery was less than exciting, but this lies merely in the fact that the attending was gone for most of the first week, and the second week was in alignment with Thanksgiving. These all added up to not much to do for two weeks but sit around and wait for evening rounds. My four weeks of "general" surgery at Children's was fun, although I didn't want to do any clinic. I guess I just hoped to go for eight weeks without any clinic, it being surgery and all. I did see some impressive childhood tumors, ones that required two adult hands to hold and looked like big balls of pulsating goo. They had dedicated blood vessels larger than the ones that supplied their little arms. It's amazing to think that many of these childhood cancers have a better prognosis than many of the smaller adult cancers. I asked one of my surgery attendings there if he could write me a letter when the time came; he was glad to oblige.

The holidays came and went, much as they do every other year. Families were seen, gifts were exchanged, as were household common colds, and Cali was left home alone yet again for what seemed to her like years. We came back to critter who wanted us to believe she was a gray old hag. Hag maybe, lazy for sure, but not gray or old. I got a Wii for Christmas. I have played it ALOT, as has the Mrs. But she spends more time toying with the Sims and finding a new job than she does with the Wii. I, on the other hand, just wish to sit on the couch and try my hand at another (totally scientifically inaccurate) surgery. Good one, Mon. I've also been reading Life of Pi, another gift I got from Monica, even if it was given last year. Oh, and she also got us all tickets to the Trans-Siberian Orchestra. It was a show as much about lights, lasers, and fire as it was about music. What's in store for next year? Does she perhaps have something in store for the next holiday, MLKJ day? Only time will tell.

I am on call starting today for my job. That's right, the job I acquired back in AUGUST, I am finally going to make some money with. Oh, and help save some peoples' sight. Maybe I will get some sleep, maybe I won't. The great thing is, if I don't get much sleep, I am still off from school until Monday, and I'm not on call from 8AM to 4PM, so plenty of nap time.

Well, I really don't have much else to say. You've heard all about Rachel from her blog, I'm sure. Anything else I might have to say is not rated for this public blog.

Let the Surgery Begin

Our little campfire just outside our home last night. It's nice with cool weather, plenty of wood from living in the woods, and plenty of supplies to make s'mores.



I've decided to give folks an update once again. I apologize for not being more diligent in my blog, but I suppose I've had to be more diligent about other things as of late. I just finished my second week of the surgery rotation, so where to begin with the story telling? I started out on plastic surgery, and have been there for the last two weeks. Let me first dispel some possible misconceptions about what a plastic surgeon does. Plastics is derived from the Greek word "plastikos," meaning to mold or shape. In the mind of a surgeon, this of course translates to the molding and shaping of human tissues. Sure they are great at making incisions and then stitching them up beautifully, but it's not all about boob and nose jobs. Perhaps in a more private practice setting, this would be the bulk of the clientele. But in working with a plastic surgeon who works for the hospitals, things are a little different. Most of our adult patients were older men, with a woman here and there, who were in a bed or wheelchair chronically for whatever reason, and had subsequently developed stage IV bed sores, or ulcers. Stage IV is bad, very bad, sores that go all the way down to the bone bad. Surgeries often entailed cutting a bunch of unhealthy tissue out, which often included shaving or pounding away at questionable bone, usually the pelvic bones. The wound gets left open for several days and then we go back and close the gaping holes left behind and pray the patient doesn't do something to dehisce (split open) the wound.

The surgeon with whom I worked managed patients at UAMS, the VA, and ACH, which meant a lot of traveling for me. At the children's hospital, we saw kids with one too many fingers, malformed ear lobes, and various other malformities. He also did a fellowship in hand surgery, so he sees orthopaedic hand cases - broken hands and the sort. I have been at Children's far more than any other place. It's been an overall excellent experience, sans clinic days when all I did was follow him around without any autonomy for myself. He said I was a big help in surgeries, at one point complemented me on my eye-hand coordination (thank you Half-Life and TR), and claimed he would give me a good grade. Next, I start vascular surgery at the VA tomorrow.

Now for a word on ATV's. Part of the problem may be that I grew up in the suburbs and didn't really have any friends or family with land where an ATV was a reasonable thing to own. But at the end of the day, regardless of my past, I have decided ATV's are a horrible idea, especially for kids under 16 or so, and ESPECIALLY for riders without a helmet. Let me explain myself. Right from the start of surgery, I met a young girl who suffered a terrible ATV accident. She was crossing the road when a truck collided with her. Had it not been for an EMS individual smart enough to put a tourniquet on her destroyed leg, she would have died right there on the side of the road from hypovolemic shock (blood loss). When she came to the OR (at least the second time around by the first time I saw her), she had no skin on the front and sides of her leg from just above her knee all the way down to her foot. There at the foot she had intact (although burned) skin continuous with skin that ran up her calf. Her bones already had rods placed in them and were broken so badly they didn't touch. The muscles in the front of her leg, the ones that allow you to pull your foot and toes up, were all gone - exposing much of the bone to all of God's creation if not in a cast. After two or three two-hour surgeries to clean the massive wound and cut away dead tissue, another eight to nine hour surgery underwent to place a muscle flap harvested from her back to cover her exposed leg bones and destroyed muscles. This was done so a skin graft could be started a few days later with synthetic skin since skin wont grow over exposed bone. Eventually, she will have real skin grafts placed over the artificial skin one piece at a time. I met a few other girls on clinic days who were further along their course of hours of work. Just this morning, with my eye enucleation job, there was a kid who died flipping head over handlebars from his ATV - no helmet = one very dead kid about to donate the one of his eyes that was salvageable. I unfortunately was unable to attend the case, but I heard all about it from the coworker who did. If you ride an ATV, fine, just don't be a retard. Don't put your kids on it (or a riding lawnmower for that matter), and for God's sake, wear a helmet.

I don't recall if I have given you a formal decision yet, but I have decided to train for the full marathon this year. If it doesn't quite work out, then I should have no problem being trained enough to do the half marathon. I ran nine miles today, and for the first time since I started training, I truly feel pooped out. Lord, beer me strength.

See you soon!

The Ending of Peds

Readers - If you're reading this blog, I congratulate you on your everlasting determination in checking this blog for the rare updates I give.

So the pediatric rotation is closing its final chapter this week. I had my last day of clinic today, I get tomorrow "off" to study all day, and then take the board exam on Friday. It has been a wonderful experience. I have reaffirmed that I do, in fact, love working with kids. Despite this passion, I would never want to be a pediatrician. Aside from a period when the child is 7-9 months old through the age of three or so (it's at this age that kids realize strangers truly are strange and there is no comfort like being in the arms of someone familiar), kids will do what you ask of them since they look up to you. It's always the mean nurse who gives the shot, not the doctor with the toys in his pocket. The parents - now there's a different story. Disclaimer: Working at state funded hospitals such as UAMS and ACH provides us a skewed population. These are people who are often uneducated, uninsured, and many are just downright trashy. In private practice and for-profit hospitals, it's a completely different story. The parent's can't always tell their left foot from right, one father of their children from another, or much less Tylenol from Motrin. OK, so the last is an exaggeration, but you would be surprised how many folks I see don't seem to know how many people fathered their three to eight kids. They don't seem to understand viruses can cause fever, even when you attempt to instruct them using influenza as a perfect example: viral infection = fever. They often look at me, question my age and place and life, and then don't believe anything I say, followed by an attending physician who repeats everything I said. If I had a dime for every time someone questioned my age. . .

I start surgery on Monday. I don't yet know where I will be working, what kind of surgery I will be going to, etc. I hope we find out something soon.

I walked into the hospital the other day and the scent of french toast filled the air. I suddenly realized how long it has been since I ate such a thing.

I started training for the marathon last week. I have been running at least once or twice a week ever since the race last year, but never more than four miles a day. I up and ran six miles last Saturday without any problems. I wasn't ever sore afterwards, and I didn't even stretch before or afterwards. I hope this is a good sign. This weekend I will go seven miles - further than I've ever gone.

That is all I have to say for now. I thought I would have more, but I guess I don't.

Out in the Clinic

I, for the first time ever, and getting a real amount of clinic work under my belt. For the first twelve weeks of my third year, I worked only on wards - seeing the same patients, day after day, and writing about their progress in a chart which tended to grow exponentially the longer they were admitted. See, you would expect a linear growth, or perhaps a decreased rate of growth over time. This isn't the case - but I won't dwell on this for too much time for those not inclined to care for one second about mathematical relationships.

Clinic is. . .different. In clinic, I see different patients throughout the day, each one with a different history I have to learn in a few short minutes. I do a focused history and physical in the specialty clinics, taking much less time than a new hospital admit. I am now at the end of two weeks of subspecialty clinics - a different clinic each day, sometimes a different clinic between AM and PM. This means a new attending each day, and each one gives me a Pass, Fail, or Honors rating. Thus far, I have received all honors sans the one clinic I have yet to do. But this really isn't a true honor as most attendings hand out such ratings like they do stickers. I just don't feel as special as the five year old with a new Scooby Doo sticker. My first clinic was the immunolgy/allergy clinic. What a way to start - a bunch of little ones with runny noses and autism. That's another thing - every mom thinks her child has autism, which isn't the case. Perhaps more on this later, perhaps not. I have also worked in the adolescent clinic (which, mind you, I escaped without having to do a single teen STD/pelvic exam!), cardiovascular clinic, hypertension and nephrology clinics, genetics clinic, hematology/oncology clinic, the ER, and tomorrow is my last day on subspecialties, spent in the neurology clinic. They've all been pretty fun - some more than others. Working in the ER almost had me switched to emergency medicine, or pediatrics in the very least. Then I remembered that as long as our country's healthcare reimbursement/insurance system is set up as it is, common civilians will continue to be forced to misuse the ER. Oh well, ophthalmology it is. You may ask which clinic I enjoyed the most - but I don't have an answer. It varies too much say, depending on your attending, patient loads/types, nursing staff, etc. Most had their advantages and disadvantages all in the same experience. For instance, Dr. Kahler in the genetics clinic is a great teacher and a very interesting person to talk to, but he often talks TOO LONG.

Next week is when I start the nursery. I will be there for one week, and hopefully "catch" some babies. I won't be delivering them - that's reserved for the L&D rotation later on. Catching them simply means I take them after they've been born, clean them up, get them stimulated and crying, and make sure they're OK. We only do this with babies that don't appear as though anything will be wrong - if any problems are likely to happen, they are usually delivered in a much more closed and controlled environment without amateur medical students around to muck things up. But the nursery, much like the ER, is a hit or miss experience. Some people catch a lot of babies within the first few days. Some, like the students there now, are around very few deliveries and between the three of them, have caught maybe five babies since Monday. I hope a full moon pops up next week and draws the pregnant ladies out of the woodwork. The good Lord doesn't need to know that all I want to do is rub some babies clean.

I have a grill. It kicks arse. I got a good deal on it. I like to grill. Beef is good.

I don't have much else to report for now. I sold my truck, by the way. I keep saying I need to call Kyle to make sure he has a backup groom's man just in case I won't be able to make it. I have an exam tomorrow and my mind is therefore not in the mood to recount experiences over the past several weeks or rant over some aspect of medicine about which none of my readers will really care. And oh yeah, lastly but not leastly, Rachel is the best!

Drivin' in Style

So, readers, I finally bought a new car the other day, a used one actually. It's a 2004 Honda Accord with just over 80K miles on it for just under $17,000. It has a sun roof, leather interior, and factory tinted windows. I wasn't looking for these things, knowing they were luxurious amenities and I didn't have the money to be picky about such things, but alas this one was amongst the used car selection and one of the lowest prices. For your viewing pleasure:

On another note, if you know anyone who would like to buy the beautiful, wonderful truck pictured below for $4,000, send them my way. I would LOVE to hear from them. I hate parting with my truck, but now I have to.

Moving On

Arkansas Children's Hospital, the place where I will spend seven of the next eight weeks, shown before the campus wide infiltration of construction processes with bulldozers and dump trucks.

Some would argue I have been neglecting my readers, few as they may be, by not having posted a blog in quite some time now. This may or may not be the case. I've been pretty busy - moving, finishing my first rotation, contemplating things, the usual. I have nothing phenomenal here to report, just an update on life.

So we moved into our house. Of course, everyone who reads this has probably already read it in a blog by Rachel first, so I don't really know what else to say. Now, we both promise, there WILL be pictures, perhaps a virtual tour, of the house up eventually. Give us time. Some say it takes a full year to get truly settled in and things the way you want them, but not with us. Three weeks (tops!) more is all we need. The twelve mile drive to and from the hospital every day has made me question, yet again, the utility of keeping my truck. A great vehicle, it really is, but at twelve miles a gallon, and two gallons a day, it will require a fill up at least twice a month, three times if it all falls on the right days. Let's see, seventy dollars a fill up, that's up to $210 a month for gas on a bad month. I know a car payment is a little more than this - but it may be worth it. That is, unless, I wanted to lease a car - but no thanks. I've been looking online a little bit and have decided I want to go with a either a Honda Accord or Civic, probably circa 2005 or so. We shall see.

In medicine, internal medicine is over. The board final was last Friday, followed by a three (and a half) day weekend - not a bad way to end it. It was all fine, I learned a lot, helped on a couple procedures, but I had long grown tired of it. Internists are obssessive compulsive; I am not. Patients would get daily CBS's (complete blood counts) and BMP's (basic metabolic panels) whether they needed them or not. We would end up finding petty little things wrong with the numbers and end up keeping patients a day longer than needed when they could have gone home and the numbers would have naturally corrected themselves. A patient could be receiving treatment for a community acquired pneumonia, improving substantially, and they would still want a follow up chest X-ray. In an acute enough time line, a chest X-ray will only show worsening, not improvement. As a general rule, the clinical picture of pneumonia improves vastly more quickly than the corresponding chest X-ray - the film may take several weeks to completely clear up, long after symptoms are gone. Now that I am at Children's, I can only speculate on how pediatricians will be. Many of them basically practice internal medicine for kids. And no, kids aren't just little adults, at least not medically, and must be treated totally different. But the logic, the process behind it all, can't be all that different. I guess we'll see soon enough. Today was just orientation - no introduction to the team or anything. It's probably just as well since we move around a lot more in peds. I start with four weeks of wards, two on the hematology/oncology ward and two on the general wards. This is followed by fall break, and then four weeks of clinics consisting of one week of nursery back at UAMS, one week of general pediatric clinic, and then two weeks of rotating through various pediatric subspecialty clinics which change daily. These clinics are even sometimes different before and after lunch - do allergy clinic before lunch and asthma clinic after lunch. Lot's of moving around. I'm anxious to work with kids, it will be a good change.

So I am officially an eye ball harvester now. To be more specific, a cornea harvester. Since I don't yet have my pager, I spent the weekend with my phone on just in case a case came through and I would be able to tag along and learn some procedural stuff. Basically, we go to these patients who have just passed away, have elected to donate their corneas, and have no disqualifying medical history, and take the eyes out. If the patient is outside the Little Rock area, God willing, the eyes are taken out and transported to us. Either way, once the eyes are in our hands, we take them to the lab and cut off the corneas and save them in a bio-supportive medium until they are needed. It's a daunting task dealing with something so little and delicate as just one part of the human eye, much less the whole thing. But then, I want to be an eye surgeon - better get used to it.

On Healthcare

A view of the construction of the new hospital during the wee hours of the morning - taken with my phone on the long walk to the VA.

Ladies and gents, it is hot! It's up to 104 degrees the next two days, 107 after that, and then tapered down to 96 over the next week or so. Hot! Hot! Hot! And to top it all off, we start moving this week in it! Bummer. Everything here is off the walls, everything except the curtains in our bedroom. The holes are patched and ready for the poor fool who has to paint behind us. We also start painting this week. The master bedroom will be colored something like this, with an accent wall like this. The master bath will be like this. The office will be somewhere around here, and the spare bedroom here. This is the hall bath, and I can't mimic the living room with the available text colors - it will be a khaki type color. We'll refinish the already white trim with a fresh coat, and I will replace all the power receptacles and light switches with new white ones instead of those old yellowed ones. It's gonna rock.

Life at work has been interesting. My new team is OK, but I like the old one better - aside from the attending,; I like my current attending better. I have also learned that the VA hospital presents with its difficulties. While their computer system for managing patient information is one of the best, the government-run hospital is otherwise a pain in the ass. It may take days to get simple things done. A simple at home dialysis catheter placement may have to wait a week; the patient, in the meantime, sits in the hospital to receive inpatient dialysis. Even the cafeteria is completely shut down over the weekend. It's not the end of the world, but UAMS is faster, and more accessible.

It makes me think of what health care would be like if coverage/insurance became universal. It wouldn't be all that bad - I would argue we could maintain a better system than what is found overseas. People rave about such foreign systems because everyone is covered and mortality rates are lower - and they're right, to some degree. Can we, here in America, do it better? 50 million uninsured people is unacceptable - especially when a VERY significant portion of these folks are working. Which reminds me - we have to get away from this associating insurance coverage with our place of employment - we're the only country to do this and it is causing the system to fail. We could have more money for coverage (if HMO and insurance CEO's were shot and buried) than other places, maybe. We have the money now; it's just in the wrong hands. In other countries, every woman gets prenatal and postnatal care covered, and every child is covered - here, our president makes the retarded statement that we can just send our uninsured children to the ER for medical care (he too should be shot and buried). This means money going to the wrong type of care for kids, wasted money. In other places, pharmaceutical companies aren't allowed to advertise to the general public - here, the companies spend a fortune doing it, confuse the public with their crappy, nondescript ads, and ultimately piss doctors off because people are convinced they need this new blood pressure medication instead of losing a little weight and laying off the salt. Maybe all that advertisement cost can go to help paying for drugs that some can't easily afford because they're overly priced. Suppose a man has been at a company for twenty years and has always had company insurance. He has a desk job, doesn't exercise, is fat, lazy, develops hypertension, diabetes, and eventually suffers a heart attack - all because he is a moron. But, he had insurance beforehand, so he's covered and he doesn't suffer too much financially. Suppose there's a young woman who is healthy, has insurance, and develops an autoimmune disease by fate. She's covered until she has to move and find a new job at a small company. She only goes without insurance for a little over a month before reapplying for the new insurance. She's denied because of a preexisting condition and not being covered continuously. See a problem? I think about this all the time, probably even more so than the young woman in the above scenario since I see patients from both sides of the story (unhealthy idiots and the unhealthy by fate) every single day.

There's a flip side to the problem, though. Should everyone receive the best of care, no matter how little money they have? I don't think so. Basic, but sufficient and appropriate, health care may be a right in a country as wealthy as ours. However, if you're one of the ones actually helping to pay for it, and since the poor and homeless can't pay for any of it, shouldn't there be a stepped level of care? Of course there should be - and there is. It's the difference between UAMS and Baptist, between Medicaid and private insurance. Both are great medical centers with great technologies, but patients at Baptist are more likely to get one-on-one care with a broader choice in caretakers and medications. Patients at Baptist can expect to see their doc whenever they want. Patients at UAMS can't. Universal care can only exist if everyone takes their part - pay what you can afford (which ought be determined by income/household size/etc.), and use preventative medicine instead of tertiary treatment medicine. In other words, don't get fat and hypertensive in the first place. Genes only predispose you to becoming obese; you still have to fuel the pounds with food and laziness since fat doesn't develop out of thin air. Granted, there are some cases where weight is truly uncontrollable, the hypertension uncontrollable, the high cholesteral unavoidable (this is actually more common), and the lung cancer that develops in a never smoker - but these are all pretty darn rare. I have never seen a skinny, physically active 45 year old person with hypertensive heart disease and late-onset diabetes. People in other countries don't necessarily have lower mortality just because of health care. While this plays a smaller part (and a significant enough one to justify universal care), the bigger part is the fact that they are healthier - yes, it's that simple. As these Eastern countries become more Westernized, we will see how their universal health coverage no longer lives up to its "glory" - and you remember that, fat ol' retarded Mr. Moore.

Don't get me wrong, I love what I do.

Half time

This is where we spent the last two nights of our honeymoon. And although it has been some time ago now, I will never forget our experience there.

The first half of the internal medicine rotation is nearing, and I can't begin to tell you how much I have learned. Not only that, but what I'm learning is far different from anything learned by reading a book. They say we learn best by doing; well, they is correct. There's nothing like admitting a patient with some rare disease and then reading all about it at home and how I will spend the next few days treating the person.

The residents/interns/attendings switch rotations at the end of the month. Yes, even attendings get assigned a month of ward or clinic duty here and there, just like on House. I suppose what I'm getting at is, yesterday was my last day with Andreoli and that team; today was a whole new bunch (sans one intern) of interns, a resident, and an attending. The students, however, don't change locations until the beginning of next week. This gives us some continuity between groups - those patients covered by the students can easily be made familiar to the new interns and resident during the students' last few days on the ward. Almost everyone is moving either between wards and clinic, or perhaps from one ward to another. I, however, not only am on wards again, but I am on the same team. In other words, our new team today is the team stuck with me through the end of August. The other three students with whom I work will change on Monday and be replaced by two others. It will almost be an all male team, except the attending and that one intern who also didn't change locations. The two of us will stick out seven out of our eight weeks together (they started in July a week before we did).

I've seen a lot in these last few weeks. I've seen large, draining chest tubes go in guy and stay there for a week draining nasty fluid, a few different venous lines go in or come out of folks, I assisted on a lumbar puncture (spinal tap) (which I probably shouldn't have since the guy was HIV positive); I've seen some patients wither away to death and others come back from looking like death was near; and I've seen diseases at the VA that one is much less likely to come across while working at University. This is because our patients, the veterans, come to us, and only us. Other people can to to University, Baptist, St. Vincent, their little clinic in PoDunk BluffVille, AR, or wherever they want, thus spreading out the locations of rare conditions. The vets, on the other hand, come to us a total train wreck - sick as hell and unable to go anywhere else.

Another thing, even more gratifying than anything else, is that most of my patients really seem to enjoy my company. I even had one of them tell me today that I was the light of his day - he was referring to the otherwise bleak overview of his care by the nurses and others at the VA (more on this later). Others have just flat out said, "I like you Dr. Bradley." Yes, I have been called Dr. Bradley - no new Dr. Bears yet, though. It's not that I'm a better people person than the interns and docs on the team - it's just that I only have three or four patients at a time to take care of, meaning I can spend more time with each one of them answering questions.

But I have learned other types of things, and have had some not so good experiences as well. I have come to realize the unbelievable unreliability of some of the nursing and assisting staff. Our team has a wonderful social worker, a greatly knowledgeable pharmacist, etc - I am not referring to any of them. It's the nurses and their aids. We want to monitor a patient's urine output, but we can't rely on what has been recorded except on rare occasion when we know there is a trustworthy nurse on our side. I want my patients to get their pain meds on time so we can get a potentially painful procedure done on time and pain free, but I often have to hound them until it gets done. Now there are many of them, particularly on our floor, who are just wonderful and will bend over backwards to get anything you want done, done. But when we have patients on another floor, the simplest of things can be a huge fiasco. It most aggravates me when I see a note written by a nurse, perhaps even an APN or PA (advanced nurse practitioner or physician's assistant) from an outside clinic, that claims no abnormal physical findings on a certain part of the exam when it is clear as daylight - it may even be behind their chief complaint. The inaccuracy of some of the charted notes about these patients makes life difficult sometimes.

In other news, still anxious to get to the new (used) house. We've got colors for the walls picked out and painting supplies purchased. Just two weeks until we begin painting and moving. Come over for dinner sometime.