Wow, I haven't blogged since OCTOBER?! Doubtful that anyone still reads this, but here is an a recollection written from the depths of the hospital at 4 am!
I rounded on a 76 yr old female this morning who showed up for her EGD and
colonoscopy yesterday a bit delirious so was admitted to us. The bowel
prep might have caused insomnia and dehydration; her head CT
was normal. With a little fluid and rest, she was back ot her effusive
self.
Here is an except of what I understood while she talked for 10-15
solid minutes, all the while holding my hand or wrist:
You are such a young doctor. It is wonderful that you speak two
languages, mi muchachita. My doctora also speaks Spanish but she left
to have her bebita. I brought her baby a present. She has
taken care of me and husband for so long. It's so great that you take
care of people. Do you have children? [No] Oh you are getting married?
That's good because the Biblia says it's not good to be alone and my
son in California had brain cancer. One day, I went to pick him up
from school and some kids were beating him over the head with a sports
trophy. He was confused and went to the hospital. Then years later
they found a cyst or a tumor and operated. He married a crazy lady who
wasn't very good. I told him he should move in with me, but he said
all of his doctors and medical records are in Califonia. It's not good
to be alone, hija. You has to have understanding of your partner. All
men have faults. You have faults too, but it's nice to be together.
You are just so young [kisses my hand]. Bring me a picture from your
wedding!
(I think I may have missed the message of her story, although I'm fairly
certain she was lucid and any misunderstanding was due to my lack of
geriatric Spanish comprehension. But I'm also fairly certain that
someone got beat up by an athletic trophy.)
Wednesday, March 7, 2012
Wednesday, October 26, 2011
Button up your lip no more
As my Granny once said before my family took a cruise to Alaska, "button up your lip, and buy a new hat." It's Granny's version of if you can't say anything nice, don't say anything at all. I've tried to keep my blog from becoming Negative Nancy's Pity Party @ blogspot.com since I started my job almost 5 months ago, but I'm done buttoning up my lip! (Not done buying new hats, however...)
My sunny, optimistic last blog makes me laugh. Every month at my job has presented new challenges, a steep learning curve, and bipolar-like swings on my job satisfaction scale. First I had to adjust to seeing more patients per day than ever before. This has given me time to reflect on my cushy schedule in residency and in prison (10 patients/day? Ha!) as well as a new skill set -- cutting people off. All too often, patients, with laundry list of ailments in tow, try to derail my 20 minute appointment. I'm improving my ability to interrupt and suggest they schedule a follow-up. I feel bad about this, but it's a reality in my 17.5 patient/day world.
Just when I thought I had a handle on clinic, I started taking inpatient call and doing OB at a community hospital with about 100 beds. My call schedule is quite variable in terms of calls/week. I also do some medicine only calls and some medicine/OB calls. Most of our inpatient service is moms and new babies, with about 1-3 medicine patients at a time (so far anyway...the winter is sure to increase our census, and winter arrived in Denver last night in case you've been watching the news.) While this may sound like a manageable feat, and occasionally it is, OB overrides everything. It's tough to take care of the medicine patients when I'm tied up assisting in multiple C-sections. I am missing my intern to help divide and conquer the work!
One of my biggest gripes is the fact that my clinic expects us to carry on with our clinic schedule post call, no matter if I have a normal "8" hr clinic day (read 10) or 12 hr clinic day (usually 13ish) afterward. I've been struggling to figure out how the other docs maintain this schedule or how they work around it. Sometimes I wonder what planet I'm on altogether. (Do these people really think it's reasonable to work 36 hrs without sleeping?! I'm a basketcase after 24 hrs on.) I have one day a week off, so apparently this is supposed to make up for working nights and weekends. However, my Monday fun day doesn't really soften the blow of a brutal post call Wednesday, unfortunately.
Which basically brings the blog up to speed with the present day. Yesterday I had a 24 hr med/ob call where I delivered 6 babies and was up all night. While I had high hopes of a quick 2 hr 4 am nap, the morning ended in the worst post partum hemorrhage I've ever managed. The patient had a large tear from her delivery, which I repaired, but she continued to have brisk bleeding. I called the obstetrician to come in and help, and we spent an hour or more in the operating room trying to stop persistent vaginal pulsing and oozing. She lost about half of her blood volume. I think she will recover well, but it was terrifying. Then I changed out of my bloody scrubs and put on some clinic clothes. My misery peaked when I had to rescue my Subaru, discovered in the parking lot with the help of automatic key clicker as Scarlet was entombed in 7 inches of ice and snow. Turns out wear clogs wasn't a great choice for the first day of winter. I didn't last through much of my clinic day, but I did hear some neat comments like "you look so tired" and "oh, your hair is different." Indeed the red rimmed eyes and post call frizzy ponytail were, at best, unbecoming.
To avoid the aforementioned NNPP blog, I'll end on a positive note. The only patient on our hospital service right now is my own - a 40 ish yr old guy with moderate developmental delay and low potassium due to a month of diarrhea. One of the nurses must have told him I delivered a baby because when I checked on him later in the night he said with genuine awe, "You delivered a baby? Wow! That's AMAZING! I'm so proud of you! Wow! You do EVERYTHING!" I was touched and will try to keep in mind that my job is full of special, privileged moments, despite its demands.
Hopefully my next blog won't be so delayed!
My sunny, optimistic last blog makes me laugh. Every month at my job has presented new challenges, a steep learning curve, and bipolar-like swings on my job satisfaction scale. First I had to adjust to seeing more patients per day than ever before. This has given me time to reflect on my cushy schedule in residency and in prison (10 patients/day? Ha!) as well as a new skill set -- cutting people off. All too often, patients, with laundry list of ailments in tow, try to derail my 20 minute appointment. I'm improving my ability to interrupt and suggest they schedule a follow-up. I feel bad about this, but it's a reality in my 17.5 patient/day world.
Just when I thought I had a handle on clinic, I started taking inpatient call and doing OB at a community hospital with about 100 beds. My call schedule is quite variable in terms of calls/week. I also do some medicine only calls and some medicine/OB calls. Most of our inpatient service is moms and new babies, with about 1-3 medicine patients at a time (so far anyway...the winter is sure to increase our census, and winter arrived in Denver last night in case you've been watching the news.) While this may sound like a manageable feat, and occasionally it is, OB overrides everything. It's tough to take care of the medicine patients when I'm tied up assisting in multiple C-sections. I am missing my intern to help divide and conquer the work!
One of my biggest gripes is the fact that my clinic expects us to carry on with our clinic schedule post call, no matter if I have a normal "8" hr clinic day (read 10) or 12 hr clinic day (usually 13ish) afterward. I've been struggling to figure out how the other docs maintain this schedule or how they work around it. Sometimes I wonder what planet I'm on altogether. (Do these people really think it's reasonable to work 36 hrs without sleeping?! I'm a basketcase after 24 hrs on.) I have one day a week off, so apparently this is supposed to make up for working nights and weekends. However, my Monday fun day doesn't really soften the blow of a brutal post call Wednesday, unfortunately.
Which basically brings the blog up to speed with the present day. Yesterday I had a 24 hr med/ob call where I delivered 6 babies and was up all night. While I had high hopes of a quick 2 hr 4 am nap, the morning ended in the worst post partum hemorrhage I've ever managed. The patient had a large tear from her delivery, which I repaired, but she continued to have brisk bleeding. I called the obstetrician to come in and help, and we spent an hour or more in the operating room trying to stop persistent vaginal pulsing and oozing. She lost about half of her blood volume. I think she will recover well, but it was terrifying. Then I changed out of my bloody scrubs and put on some clinic clothes. My misery peaked when I had to rescue my Subaru, discovered in the parking lot with the help of automatic key clicker as Scarlet was entombed in 7 inches of ice and snow. Turns out wear clogs wasn't a great choice for the first day of winter. I didn't last through much of my clinic day, but I did hear some neat comments like "you look so tired" and "oh, your hair is different." Indeed the red rimmed eyes and post call frizzy ponytail were, at best, unbecoming.
To avoid the aforementioned NNPP blog, I'll end on a positive note. The only patient on our hospital service right now is my own - a 40 ish yr old guy with moderate developmental delay and low potassium due to a month of diarrhea. One of the nurses must have told him I delivered a baby because when I checked on him later in the night he said with genuine awe, "You delivered a baby? Wow! That's AMAZING! I'm so proud of you! Wow! You do EVERYTHING!" I was touched and will try to keep in mind that my job is full of special, privileged moments, despite its demands.
Hopefully my next blog won't be so delayed!
Tuesday, June 14, 2011
New Directions
Hello from week 2 of orientation! After some much enjoyed time off visiting friends and family in Cincinnati and Seattle, I have returned to the land of the working. My new clinic is part of federally qualified community health center organization that runs 4 clinics just outside of Denver. From humble beginnings with one provider in a small house with a curtain dividing the living room, our clinic has grown to provide over 170,000 patient visits yearly. About 40% of the patients are uninsured, 40% have medicaid, 15% have medicare, and a few have private insurance. I was surprised to learn that 98% of of our patients are below 200% of the federal poverty level. The clinic's mission is to be the medical provider of choice for low income people in our service area.
All new providers go through a 3 week orientation before being turned loose. This orientation includes 12 training sessions with my sworn electronic health record enemy, NextGen. I used this system for a year and a half in residency and made a little promise to myself that I wouldn't ever take a job that used NextGen. Alas, that promise has been broken, and I'll have to get over it. The real boon of NextGen is that you can use it for billing and data generation, despite its lack of user friendliness. (Click, click, click...Epic, I miss you...sniff, sniff.)
The first day of orientation, I had a skype meeting with our clinic scheduler who happens to work remotely...in Israel. I've also spend a lot of time shadowing the providers, medical assistants, front desk workers, and case managers at my clinic in addition to meeting with various people in the administrative office. Today I met with the finance department, HR, and the development director. Apparently, it takes 14 full time people in billing to collect our revenue!
Last week the CEO, who has worked in his position for over 20 years, took me to lunch at a local sandwich shop. (I don't think a CEO of anywhere else I've worked has ever said boo to me, much less bought me an artisan sandwich.) The clinic is all about teamwork, and they've done a good job to assure I have a good understanding of how the team functions.
I've been impressed by the many innovative problems that the clinic has been pursuing for the last 10+ years such as group visits, an integrated behavioral health program, and patient registries for diabetes, depression, hypertension, and pregnancy that generate quite a bit of data to support our quality outcomes.
And best of all, the clinic is about 20 minutes from my apartment!
To quote Annie, I think I'm gonna like it here!
All new providers go through a 3 week orientation before being turned loose. This orientation includes 12 training sessions with my sworn electronic health record enemy, NextGen. I used this system for a year and a half in residency and made a little promise to myself that I wouldn't ever take a job that used NextGen. Alas, that promise has been broken, and I'll have to get over it. The real boon of NextGen is that you can use it for billing and data generation, despite its lack of user friendliness. (Click, click, click...Epic, I miss you...sniff, sniff.)
The first day of orientation, I had a skype meeting with our clinic scheduler who happens to work remotely...in Israel. I've also spend a lot of time shadowing the providers, medical assistants, front desk workers, and case managers at my clinic in addition to meeting with various people in the administrative office. Today I met with the finance department, HR, and the development director. Apparently, it takes 14 full time people in billing to collect our revenue!
Last week the CEO, who has worked in his position for over 20 years, took me to lunch at a local sandwich shop. (I don't think a CEO of anywhere else I've worked has ever said boo to me, much less bought me an artisan sandwich.) The clinic is all about teamwork, and they've done a good job to assure I have a good understanding of how the team functions.
I've been impressed by the many innovative problems that the clinic has been pursuing for the last 10+ years such as group visits, an integrated behavioral health program, and patient registries for diabetes, depression, hypertension, and pregnancy that generate quite a bit of data to support our quality outcomes.
And best of all, the clinic is about 20 minutes from my apartment!
To quote Annie, I think I'm gonna like it here!
Tuesday, May 17, 2011
Getting Paroled
It's the eve of my last day in prison and my emotions are mixed. I am happy that I will be "free" of the long Monday morning commute and being away from home all week, but I am also sad to leave the friends I've made (nurses, not inmates) and leave the patients without a doctor. Someone will come to fill my worn out Dansko clogs before too long I hope. And sooner or later, I know I will run into an inmate on the street or in my next office.
Overall, I feel really grateful to have been employed for the last 7 months and to have had this experience in prison. The correctional population has definitely experienced the health effects of poverty and being uninsured and I have enjoyed getting to take care of people who have no one else looking out for their medical needs (and often haven't been getting any primary care on the streets for years before they came to prison). I am constantly surprised and saddened by the number of women who attribute their long term health problems to physical abuse and drugs. I saw a 27 yr old today who had all of her teeth pulled and didn't qualify to get dentures in prison. I started talking to her about nutrition and eating fruits and vegetables, and she told me the kitchen doesn't given her any because she can't chew them. She broke my heart. It also seems like 90% of the women in prison are mothers, which I also find to be very disheartening. What choices and circumstances led the middle school school English teacher I saw today to end up in prison?
I had to laugh to myself yesterday when I walked through the prison yard and a diabetic inmate said to me "Bye, Doc!" and then, to her friends, "That's my doctor!" (Like there is any other doctor in our prison...) There have definitely been some satisfying moments, heart breaking stories, a few good laughs, and many patient tears, plus a few of my own. I leave with gratitude for my time in the slammer and excitement for my next adventure.
Hasta la vista, La Quinta!
Overall, I feel really grateful to have been employed for the last 7 months and to have had this experience in prison. The correctional population has definitely experienced the health effects of poverty and being uninsured and I have enjoyed getting to take care of people who have no one else looking out for their medical needs (and often haven't been getting any primary care on the streets for years before they came to prison). I am constantly surprised and saddened by the number of women who attribute their long term health problems to physical abuse and drugs. I saw a 27 yr old today who had all of her teeth pulled and didn't qualify to get dentures in prison. I started talking to her about nutrition and eating fruits and vegetables, and she told me the kitchen doesn't given her any because she can't chew them. She broke my heart. It also seems like 90% of the women in prison are mothers, which I also find to be very disheartening. What choices and circumstances led the middle school school English teacher I saw today to end up in prison?
I had to laugh to myself yesterday when I walked through the prison yard and a diabetic inmate said to me "Bye, Doc!" and then, to her friends, "That's my doctor!" (Like there is any other doctor in our prison...) There have definitely been some satisfying moments, heart breaking stories, a few good laughs, and many patient tears, plus a few of my own. I leave with gratitude for my time in the slammer and excitement for my next adventure.
Hasta la vista, La Quinta!
Tuesday, May 10, 2011
The Mother Load
If you are unsatisfied with the medical attention you have received in prison, should you:
A) send excessive kites, each with more capital letters spelling URGENT and exclamation points that the last
B) write a "grievance" stating your complaint, which must be answered in a meeting with the nurse supervisor
C) have your mother call the warden and threaten that if the warden doesn't call back in 30 minutes, your mother will go to the media
All of the above have happened, and choice C (+/- media or lawyer contact) occurs to a surprising degree. I mean what business does the mother of a 38 year old former methamphetamine user with chronic leg pain have calling the prison medical clinic? I am totally appalled by the number of parent phone calls my boss fields for FULL GROWN INCARCERATED ADULTS. (It's not like the teenagers' parents are calling.) I mean, I know my mom has my back, but if I went to prison, I think I'd have to make my prison bed and lie in it.
A) send excessive kites, each with more capital letters spelling URGENT and exclamation points that the last
B) write a "grievance" stating your complaint, which must be answered in a meeting with the nurse supervisor
C) have your mother call the warden and threaten that if the warden doesn't call back in 30 minutes, your mother will go to the media
All of the above have happened, and choice C (+/- media or lawyer contact) occurs to a surprising degree. I mean what business does the mother of a 38 year old former methamphetamine user with chronic leg pain have calling the prison medical clinic? I am totally appalled by the number of parent phone calls my boss fields for FULL GROWN INCARCERATED ADULTS. (It's not like the teenagers' parents are calling.) I mean, I know my mom has my back, but if I went to prison, I think I'd have to make my prison bed and lie in it.
Monday, May 9, 2011
Welcome to Prison!
Recently I attended a provider training meeting at a department of corrections facility called the Denver Reception Diagnostic Center. While it may sound like a place where pepperidge farm cookies and lemonade greet you while you wait for a mammogram, the DRDC is actually the prison where all of the inmates get a physical exam before being sent to other prisons around the state. It is surrounded by a double fence with many, many rows of razor wire. Not so friendly. Initially, I was hoping to be placed at that prison since it's a short commute from my apartment, but it wasn't in the cards.
The provider meetings are a nice opportunity to chat with the other prison docs, NPs, and PAs and to compare experiences. The prisoners seem to get very good healthcare in prison, even for all the bureaucracy required for specialist visits and non-formulary medications. I do feel like I've won when a patient I've referred to a specialist has surgery (and I receive a legible consult note!), even though that's not supposed to be the most gratifying part of primary care. Seeing improvements in hemoglobin A1cs has also made me feel like I'm "doing something," which is also satisfying.
The guest speaker at the meeting was a retired infectious disease specialist who now works for a drug company. One might think that a drug company doesn't stand to benefit much from having a relationship with the department of corrections and its limited drug formulary. However, with oral Hepatitis C drugs on the market, there is a lot of money to be made, especially if a large organization like DOC starts incorporating oral anti-virals into its Hep C protocol.
Another interesting stat I learned at the meeting:
1/4 of HIV positive patients interact with the justice system in a given year. This represents an exceedingly high burden of disease for the corrections population. All prisoners get testing for HIV, syphilis, Hep C, and Hep B on arrival to the reception diagnostic center. I did get to tell a very relieved patient last week that her HIV test was a false positive (after an indeterminate Western Blot and an undetectable viral load x 2 over 6 agonizing months of not knowing for sure). My HIV patients are actually super stable and will be more like to die with HIV than from HIV. It's amazing how well HIV can be managed, especially when detected early. Hard to believe 20% of people in the U.S who are living with HIV don't know it. (Shout out to Aurelie and our grand rounds!)
The provider meetings are a nice opportunity to chat with the other prison docs, NPs, and PAs and to compare experiences. The prisoners seem to get very good healthcare in prison, even for all the bureaucracy required for specialist visits and non-formulary medications. I do feel like I've won when a patient I've referred to a specialist has surgery (and I receive a legible consult note!), even though that's not supposed to be the most gratifying part of primary care. Seeing improvements in hemoglobin A1cs has also made me feel like I'm "doing something," which is also satisfying.
The guest speaker at the meeting was a retired infectious disease specialist who now works for a drug company. One might think that a drug company doesn't stand to benefit much from having a relationship with the department of corrections and its limited drug formulary. However, with oral Hepatitis C drugs on the market, there is a lot of money to be made, especially if a large organization like DOC starts incorporating oral anti-virals into its Hep C protocol.
Another interesting stat I learned at the meeting:
1/4 of HIV positive patients interact with the justice system in a given year. This represents an exceedingly high burden of disease for the corrections population. All prisoners get testing for HIV, syphilis, Hep C, and Hep B on arrival to the reception diagnostic center. I did get to tell a very relieved patient last week that her HIV test was a false positive (after an indeterminate Western Blot and an undetectable viral load x 2 over 6 agonizing months of not knowing for sure). My HIV patients are actually super stable and will be more like to die with HIV than from HIV. It's amazing how well HIV can be managed, especially when detected early. Hard to believe 20% of people in the U.S who are living with HIV don't know it. (Shout out to Aurelie and our grand rounds!)
Wednesday, May 4, 2011
Know the Code
Hello from National Correctional Employee Appreciation Week!
This week, to thank us for our hard work, the prison is providing daily treats. Today was rootbeer float day...tomorrow nachos....Friday BBQ. Some of the other prison workers will be enjoying a steak dinner...others, a shoeshine. I think I would prefer the shoeshine to yesterday's "pop and popcorn," but the breakfast burritos on Monday were tasty!
And now, a fashion lesson from a recent prison email:
"With the warmer weather upon us it is a good time to revisit 4469-01, Appearance and Dress Code, particularly with respect to non-uniformed staff. The regulation does allow for wearing of "dress gauchos or capris" and provides the following definitions:
Capris/Crop Pants: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with slightly flared legs.
Gauchos: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with legs that are flared to resemble a skirt.
With both definitions, the key points to remember the fit (LOOSE), the length (MID-CALF) and that they are to be "dress" versions of these garments. To be allowed, the article of clothing must meet these definitions, regardless of how they are marketed."
For my remaining two weeks, I'm sticking to slacks.
This week, to thank us for our hard work, the prison is providing daily treats. Today was rootbeer float day...tomorrow nachos....Friday BBQ. Some of the other prison workers will be enjoying a steak dinner...others, a shoeshine. I think I would prefer the shoeshine to yesterday's "pop and popcorn," but the breakfast burritos on Monday were tasty!
And now, a fashion lesson from a recent prison email:
"With the warmer weather upon us it is a good time to revisit 4469-01, Appearance and Dress Code, particularly with respect to non-uniformed staff. The regulation does allow for wearing of "dress gauchos or capris" and provides the following definitions:
Capris/Crop Pants: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with slightly flared legs.
Gauchos: A style of pants that is loose fitting and designed to end mid-calf or just below the calf with legs that are flared to resemble a skirt.
With both definitions, the key points to remember the fit (LOOSE), the length (MID-CALF) and that they are to be "dress" versions of these garments. To be allowed, the article of clothing must meet these definitions, regardless of how they are marketed."
For my remaining two weeks, I'm sticking to slacks.
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