Baby Daddy, part II

19 hours into a 24 hour shift, at about 2 AM I called a c-section on this girl whose first baby was just not tolerating labor. She had been lying in this labor room all alone for hours, but when I went in to discuss c-section with her she had company. My nurse had warned me that the "baby daddy" was an interesting character, so I was anticipating some antics. He was talking on his cell phone, but when he saw me he put it down and said, "DOCTOR, you's the one who delivered my other baby mama's baby on August 5th. Yeah, you did a good job on that c-section. You gon' do this one too, right?" Then he proceeded to tell whatever unfortunate person was on the phone how this same doctor delivered "Keisha's" baby, and wasn't that great?

What a busy guy. August 9th and December 27th? Baby mama just lay there and nodded her head. Apparently she knew what she was getting into.

Twins

I met a new patient yesterday who seemed to be quite normal and boring. She's pregnant with twin boys. I asked the usual questions, including whether she had picked out names yet.

Yes, indeed. "This (pointing to her right) is M.D.B. This (pointing to her left) is M.D.B."

Pardon? She then repeated her African American sounding identical names one more time. Apparently, despite ultrasound evidence that these are identical twins, she doesn't believe us. She thinks they won't look alike, and she is giving them the exact same name.

Pica, part II

Recall that urge for anemic people to eat strange things, such as ice, dirt, etc? My patient took it further and ate so much cornstarch that she got a complete intestinal obstruction and required surgical bowel resection. This is the same patient who required surgery on her finger where she accidentally broke her crack pipe and shoved the glass in down to the bone. Being in jail now, she seems like a perfectly normal, sober person.

I got my first gift from a patient. She brought me a coffee mug with snowmen on it for Christmas. I would have been thrilled with a card.

Last week, I had a car accident. Don't worry, everyone is fine, but the rear bumper of a gold Mercedes Benz did get some scrapes. The lady got out, wearing her red fur coat and Chanel earrings, and offered that I could just give her money to replace her bumper. Personally, I would not have fixed it, but I don't drive a Benz. She then started to rub her low back, and I decided that it would be more prudent to let my insurance company handle this one. She called the police (apparently several times because they were taking too long) and I called my insurer. In good faith, I gave her my business card and cell phone number, which she immediately called to make sure that it rang in my pocket. It did.

Looking at my card, she said, "Oh, you're an OB/GYN? You have to see this!" Crazy lady went to the front seat of her Benz and retrieved a polaroid photo of the fibroid tumors recently removed from her uterus. She then proceeded to consult me on whether her vaginal bleeding pattern was currently normal, and to tell me that at 44 with fibroids she still planned to get pregnant. Let me tell you, that really reinforced my decision to not handle this between the two of us! She's completely crazy. Nobody gets pregnant at 44 after two myomectomies.

Meanwhile, we hear a fire truck racing toward us. Apparently this nutty lady called the 911 operator so many times that they assumed she was seriously hurt, so they sent 3 paramedics, a fire truck, and an ambulance. As the physician on scene, I can vouch that this was ludicrous. When the police officer finally arrived and she berated him for taking too long, he agreed with me. She got a citation for "creating a dangerous environment" by calling 911 and claiming to be injured! Of course I got a citation for following too closely, but I just kept my mouth shut. Now the lady has told my insurance that she was indeed injured in the accident...

Express yourself

Yesterday I noticed a trend in fashion. Usually I'm oblivious, but I couldn't help but note the new high style of stretching various words over large butts. One patient who weighed about 220 lb had on tight sweatpants with the word "Bootylicious" spanning from her left hip to her right. Another wore a T-shirt with "Between boyfriends" stretched over massive breasts. Maybe I should take pride in my voluptiousness as well--do you think I could get scrubs with DDoctor on the front?

Modern King James

My scrub tech, while waiting for us to move the patient out of the operating room, sat down at the computer and logged on to Walmart.com. She proceeded to peruse the large selection of discount Bibles--just in case you're in the market.

brand spanking new med students

Okay, I've gotten enough ego-boosting fan appeals that I can't possibly stop the blog. It's taken on a life of its own. Enough already. I may not post as often, but I will keep posting.

Yesterday I got two new medical students--BRAND NEW. They were so cute. It was their first day ever in the hospital and they followed me like puppies, but not nearly fast enough. When I was a med student I thought we should come with leashes, and I'm still all for that. They'll learn to walk fast after they lose me once or twice. They got sort of a bad intro to the operating room because we did a vaginal hysterectomy and no other cases yesterday. You can imagine that with me, two attendings, and a scrub tech working on that vagina the students couldn't see a thing. But they're still learning things like not to touch sterile stuff and how to help move the patient, so they got a lot out of it.

Anyway, I gave them an hour to relax in the library and get some lunch (I needed a break) before doing a post-op check on our patient. I went to find them when it had been a long time and they didn't call me. During their enthusiastic report it became clear to me that they had actually found a blood pressure cuff and taken the patient's vitals themselves. She had like ten sets of vitals on the chart, but I'll give them kudos for enthusiasm. It will probably never happen again! There are techs and machines for that sort of thing.

It doesn't seem like four years have passed since that was me. There was a day when I couldn't write a note and didn't know how to interpret vital signs. Tomorrow we let them scrub in for surgery for the first time. I'm stockpiling my patience!

Rocking feathers

J said that she didn't want to "ruffle the boat" at work, so she kept her mouth shut.

What an appetite

This story comes from one of my highly entertaining colleagues, Dr. B, who was evaluating a patient for vaginal discharge.

Upon placing speculum in her patient, Dr. B met resistance and saw an object in the vagina. She retrieved half of a green apple from her patient and held it up to show her. "What the hell is this?"

The patient replied enthusiastically, "There's my apple! I been lookin' for it."

Upon inquiry as to why she might have half an apple in her vagina, the patient stated, "My pussy was hungry, so I fed it! " Then, soberly, "I shouldn' have fed it, should I?"

After some scolding, Dr. B asked what the patient had learned today. She replied, "When the pussy is hungry, don't feed the pussy."

Sound advice for many situations, I say.

Adventures of a mortified intern

I know, I've been absent for awhile. I'm pondering retiring the blog. We'll give it another couple of entries and see how I feel.

Here's another women's urgent care encounter. I had a very sweet, sort of naive ER medicine intern working with me. She went to assess an 16 year old pregnant patient with vaginal bleeding, our bread and butter patient complaint. When she came out of the room 20 minutes later she looked absolutely awful--red-faced, befuddled, and angry all in one expression. She said, "That was the strangest encounter of my life. I feel violated." Well, that's quite a statement given where she'd been working for the past year.

The girl, who asked her baby daddy to step out, spent the entire speculum exam massaging her own clitoris. When my intern asked why she was doing that, the patient replied that it made her "feel better" and then the exam hurt less. The doctor explained that this was inappropriate and made her feel uncomfortable. The patient replied, "But it's more comfortable for me this way." She continued masturbating throughout the cervical exam, and then my intern fled the room. From the look of her, she may need therapy to deal with the trauma.

found her

Well, after thinking about my breast cancer patient last week, I decided to try the disconnected number one last time (of course I had put it in my palm pilot because I'm compulsive). Her cousin answered! The patient was home and I got her to come to my clinic that day. We signed her up for the cancer center, medicaid, etc. I hope this one will be a happy ending. Here's to persistence and compulsion. I have some real job satisfaction on this case.

AWOL patients

In addition to the many other frustrations of working in a public hospital, we have to contend with the fact that most of our patients can't give us a reliable phone number. When you go to your doctor and have a test done, he/she may promise to call tomorrow with the results, right? Generally, when tomorrow comes, your phone works and rings in a place where you can be found. I've learned to ask for multiple phone numbers, but still often get number that are disconnected (about 30% of the time) or that belong to the patient's sister's baby daddy. He never knows where my patient is.

I saw a patient with a breast lump. She was 40 years old and had no family history of breast cancer, but the lump seemed a little too irregular and firm for my liking. I debated whether to send her for a mammogram and then to surgery clinic for a biopsy or just to put a needle in it myself in the urgent care. The referral process takes at least a month, and I just didn't think she would necessarily show up for her mammogram, despite her desperate concern over this mass. I took the nurse practitioner in there and taught her how to do a fine needle aspiration biopsy so that we could save this lady time. She gave me her cell phone number, and I promised to call her when the results came back in a few days. Well, four days later the cytology came back as invasive poorly differentiated ductal carcinoma = really bad cancer. I've never diagnosed breast cancer before, and now I had to prepare to tell this lady over the telephone what her results were. I didn't think that out very well, as none of my patients has had it come back with cancer before. Before calling, I arranged appointments for her with the oncologist and the breast surgeon for the following Monday morning so that I woulod at least have a plan for her when she got the news.

It turned out that I didn't need to worry, as the patient's phone was disconnected. I looked in her hospital records and there was no other number, so we ultimately sent her a registered letter at the listed address to inform her of her diagnosis and her urgent appointment with the breast surgeons. Who knows if she lives at that address. I don't think she's been back yet, and it's been over a month. She's probably going to show up in the ER in 6 months with tumor in her lungs. That's depressing, as her prognosis otherwise would have been okay. Only 40 years old.

I've learned my lesson--next time I'm suspicious of something bad I will just bite the bullet and give her my pager number so she can call me.

been done had it

I oveheard a clerk yesterday vehemently stating that "I been done did that yesterday...I ain't fi'in to do it again today."

Two years ago, I wouldn't have understood.

fornication

I came in last week at 7AM to be told that there was a lady in room 4 who was 5 months pregnant complaining of her water breaking. Well, that will get an OB excited in a hurry, because 5 months could actually be 24 weeks ,which is the threshold of fetal viability. I went quickly into the room with my ultrasound to assess her for possible preterm rupture of membranes. I found a lady with crack hands and crack brain lying on the table clutching her belly. She stated that her water done broke all over at 6 AM today, and she's 5 months along. I feel her belly and can't find a big uterus, but think maybe she just has a really small pregnancy with no fluid left. However, I then put on my ultrasound and see an empty uterus. Well, she could be very early in her pregnancy and just horribly mistaken about dates, so I do a pelvic exam and find nothing there either. When asked what she and her boyfriend had been smoking or otherwise ingesting last night, she giggles and denies crack. The guy laughs and states that he had some angel dust.

She kicked him out of the room to tell me that she had been going to the HIV clinic for a month or so, but he doesn't know. At least she told me.

While I was waiting for crack lady's pregnancy test to come back negative so that I can get her out of my urgent care, my shy latina clinic assistant found me and mumbled something in a very thick accent. I understood "husband" but not much else, and she seemed quite embarrassed about it. A few minutes later, the other nurse enlightened me that the assistant had walked into the room to retrieve linens and found the couple fornicating on the floor. At 8 AM, after she had called the ambulance for her broken water, she was passing on HIV and orgasms in exchange for crack, and doing it on the floor of my urgent care center.

We kicked him out into the waiting room and put her in a room with no door in direct view of the nurses' station, and she still eloped with her IV, IV pole, and gown before we got our drug screen. Given that she had tested positive for cocaine in February, I guess I didn't really need it. The pregnancy test was negative, so had she just peed on herself like crack ladies do. She'll be back next month, but I won't!! This was my last week on the worst duty ever.

Absentee blogger

Sorry, this may be my longest blog-free time. It's not for lack of stories, but for multiple other things drawing me away.

A few weeks ago, I got a call from a local psychiatric hospital saying that they had a patient on a legal hold for psychosis who was pregnant and bleeding. Being the hospital of last resort, we accept almost any transfer that nobody else wants, so I told them to bring her on up to my urgent care. She arrived about 30 minutes later, in leather and rubber restraints holding her hands to her waist. At 250 pounds, 6 feet tall,--with a beard-- this woman was quite a sight. She arrived screaming and crying because her "baby be fallin' out, doc." Her chaperone, a 5'2" 125 lb. woman, seemed initially to be in control of the situation. The patient (PT) was escorted, screamind and crying, to an exam room where she proceeded to somehow remove her restraints. My nurse had been patient up to that point, but said "oh no, I'm out of here..." and fled once PT's hands were flailing freely. I grabbed my medical student, who can't say no, and took him in with me to examine this huge crazy lady.

PT initially refused examination, but finally took off her pants to show me her maxi-pad, pointing to the spotless white surface. "My baby on there. You can't see her, but she on there...she fall out. You need a microscope...do you have a microscope??" Her eyes were wild.

I said, "Yes, we have a microscope, but why don't you put the baby on the table and I'll look for her after we know you're okay."

To my amazement, PT put the pad on the Mayo stand and finished taking off her pants. Showing her the long vaginal ultrasound probe, I said, "We need to look and make sure the baby isn't still inside." She insisted on putting the probe in her vagina herself, ramming it practically up to her diaphragm.

Wailing, she kept repeating, "We gotta push it back up. My baby fallin' out ---you gotta push it back up..."

I convinced her that we first needed to look at the baby and then she could push it back in as long as it looked okay. She agreed to this plan, so we looked at her normal 8 week pregnancy and saw the heartbeat. Thank goodness for me, because had it been anything other than a normal pregnancy, I may have found myself attempting some awful procedure. She pushed the baby back up quite forcibly with the ultrasound probe, and we rapidly left the room to do some paperwork and get her transferred back to the psych hospital.

Shortly, I heard a commotion in the hallway and looked up to see several security guards running around. As we know from prior experiences, it takes quite an event to get them moving in a timely fashion. PT had run--she escaped from our semi-secure area and was nowhere to be found. Six security guards could not locate a 250 lb, 6 ft tall bearded woman with wrist restraints and no pants!

Turns out they needed my expertise. PT had been crying about calling her friend in the pharmacy for the entire hour she was with us, but he didn' show up to save her. I sent security to the oupatient pharmacy--four floors away--and they easily recognized the fugitive amongst the customers. She came back to the fourth floor in shackles, wailing, with five security guards and, sadly, a viable intrauterine pregnancy. It's going to be a long 32 weeks until she delivers.

Cool sexually transmitted infections

This week trumped my prior triumph of diagnosing primary syphilis.--I saw an extremely rare social disease (<600 cases/year), known as LGV. It's a phenomenal diagnosis, really. The poor 54 year old married woman certainly didn't think so, but the MD consensus is in: cool as hell. Yep, I've been bragging. She even let me take photos for my teaching files.

The second weird one wasn't as cool, but still unusual. This woman in the body mass index category of "extreme obesity" came in with bumps under her pannus (in the belly fold--see prior posts). They had been present for months but were now oozing discharge and smelling bad. Well the discharge and smelling bad was just some yeast, but the bumps themselves were genital warts. Clear as could be--genital warts under the pannus. My intern called me in to see this because she just wasn't sure. Yes, indeed, there's nothing else it could have been.

To cap off my week, I had my third encounter this year with the sex-for-crack trade gone wrong. The special "victims" unit of Atlanta PD brought in a lovely rock star too drunk to tell her story, but quite certain that she had been raped. When she sobered up a bit, she told the familiar tale of offering sex for drugs and then finding out after the act that he didn't have any crack. In street justice, this apparently qualifies as rape. She called the police, so we had to then do an evidence kit and pelvic exam on said rock star. She then delightfully occupied my urgent care center for the greater part of Friday. What great use of healthcare resources. Should I have put her in rehab? Maybe.... It just seems futile given the number of toothless crack addicts marching through there every day. I intervene when there are children at stake.

Feline familiarities

I got some new slang in my clinic yesterday. A woman came in about 16 weeks pregnant. Her chief complaint: "I got this pressure in my cooty-cat." Or maybe it's Kooty-cat or Cooty-kat, I'm not certain of the spelling. Please enlighten if you are familiar. The less formal version, "cat" apparently also works, as in "I told my Mama my cat be hurtin and she told me to come in an tell you". I dutifully checked out her cat and found everything to be in order.

I also met a new 16 year old at her first prenatal visit. She had gotten Chlamydia, Gonorrhea, Syphilis, and Trichomonas from one of her four recent sex partners. Or maybe one disease from each, now that I think about it. So good of her to spread it around. She's not had sex in a whole month, though, so I think we're out of the woods. Her HIV test, however, is still pending. Of all that, she seems most upset about the pregnancy. I'm most upset about the swollen lymph nodes in her neck when I don't yet have a negative HIV test.

Finally, one of my patients was going through my briefcase while I was out of the room looking at her nasty vaginal discharge under the microscope. I came back to find my bag moved, the buckles undone, and my patient very fidgety. She didn't get to my iPod before I got back, and I didn't catch her red-handed, so I just curtly escorted her to discharge. What nerve.

Rock Star

Yesterday morning around 7 AM, I was minding my own business and drinking my coffee when my favorite battle-axe nurse came looking for me. She pointed her crooked finger at me and said, "Doctor....I have a problem in room 1." I dutifully listened to her situation. A crack addict had run out of money and become startlingly sober. Upon awakening, this lovely lady remembered that sometime in the past few weeks she thought she had put two tampons in her vagina; she did not recall removing them. Thus, she presented to my emergency room seeking expert assistance. I put down my coffee and cookie and followed Miss B to room 1, where a nasty odor greeted us. As rapidly as possible, I placed a speculum and removed only one malodorous brown tampon from near her cervix. Miss B, being very experienced in such matters, stated that the key was to get it wrapped in plastic as quickly as possible to keep the smell down. This she did, and my search for a second device was fruitless and we got out of that vagina ASAP.

The crackhead stated that she had barely found money for cocaine over the past week, so she had not eaten lately. We rapidly exited the room and sent a naive tech in with some bad breakfast.

Miss B had a difficult time finding the patient's chart. Ultimately it turned up....in the box indicating that she was a patient of the other MD's service. The woman wasn't even my responsibility.

I forgave Miss B, but she owes me a couple of cups of coffee.

P.S I found out this week that the pervasive generation X compliment "Rock Star" can no longer be used at my workplace. Apparently, if I were to say "Miss B, you're a rock star for getting that morphine so fast," she could mistake it for a horrible insult. "Rock star" on the street now also means "crack whore". Fascinating.

Nurse-doctor relations

It's been a herpes kind of week. Three cases in four days. Yesterday I saw the worst genital herpes I've ever seen. This poor girl said she was raped last week and went to the hospital but couldn't afford the medicine they gave her to prophylax against chlamydia, gonorrhea, etc. Of course, we don't give prophylaxis for herpes anyway, so that wouldn't have helped her. She got a raging case of pelvic inflammatory disease and couldn't afford the medications for that, either, so I had to admit her to the hospital for antibiotics. That's probably best for her, given that a bit of IV morphine will do her good with the ulcers on her bottom. What a horribly depressing job this can be. We won't know her HIV status for six weeks.

I could blog really depressing stories from the urgent care on a daily basis, now that I'm finally back to taking care of sick poor people again. However, you read this for funny stuff and sarcasm, right?

The world is on end for the past couple of days. Everyone who should be nice has been nasty as hell, and people who are expected to be nasty have been nice. There is conflict everywhere. Have you noticed this? I had another fight with a nurse on Sunday because she found a way not to carry out my pain medication order for a patient. I ordered a morphine infusion for a poor lady having her third dead baby at 5 months. The nurse decided, after verbal clarification, that she didn't think that was the appropriate pain control and went over my head to my chief resident to get the order changed. I went back to deliver the lady's fetus and found her without pain control. I was livid. Being a control freak like most MDs are, I absolutely lost my temper on this horrible passive-aggressive nurse. She proceeded to tell me that when the orders are "not appropriate" she "climbs the ladder" until she gets what she feels is proper treatment for the patient. She does this all the time, but Sunday was not the right day to pull it on me.

It went something like "You have no right to change my order without talking to me. I verbally clarified it with you. You are scolding me like I'm three years old. I'm 31 and have two doctorates, and my mother doesn't even talk to me that way. If you wanted to write orders, you should have gone to medical school...this is not your call. It was appropriate, compassionate care, and I won't change my orders to make them a little more convenient for you at the cost of worse pain for my patients. This was rude, disrespectful behavior, and if you ever go over my head again, I will go over yours."
Something like that. We'll see how she treats me from now on. Her colleagues made no eye contact and didn't say a word. I'm sure she bosses them around all day, too. I really don't believe in yelling at anyone, but I saw red.

Discretionary Dispensing

Pharmacists, as you can see in the article below, are taking it upon themselves to decide which legally prescribed medications are morally appropriate for their customers. This is not a fluke--it happens to us all the time. I, the doctor, discuss options for contraception with my patient, and she leaves my office with a valid prescription from a licensed physician who has counseled her about the medications given. She presents the prescription to a pharmacist, often with much embarrassment and reluctance, and then goes through the public humiliation of being told that this pharmacist does not dispense such medications because of his/her belief that it is immoral. Often, this is a 15 year old girl who was responsible enough to seek emergency contraception after an unplanned or undesired sexual encounter.

More worrisome, however, is the denial by some pharmacists to fill prescriptions for medically indicated therapeutic medications. I prescribed cytotec to be taken in a large dose administered vaginally, and the pharmacist refused to fill the prescription. It can be used to augment medical abortions. Okay, fine. My patient, however, was having profuse vaginal bleeding from an incomplete miscarriage and wished for medical management as a less invasive (and much less costly) method to stop her hemorrhage. She had no insurance and could not afford the bill for a D&C, and this was an acceptable, cheap, and safe alternative. Despite my explanation of the circumstance, the pharmacist refused to dispense the medication because she "was not comfortable with that off-label use of the product". The patient, bleeding and cramping, was forced to shop around for pharmacies and explain her private medical concern to other pharmacists. Ultimately, somebody filled her prescription.

Our new solution to this problem, common in GA, is to stock and dispense our own medical abortion pills, emergency contraception, and contraception in the clinics. In this state, I am licensed to "prescribe, administer, and dispense controlled medications". In many states in the union, a doctor can only prescribe. I don't know how they will provide for their patients.

infuriating "pro-life" practices

http://www.latimes.com/news/nationworld/nation/la-na-pill2apr02,0,2122785.story?coll=la-home-nation

Illinois Drugstores Required to Fill Birth Control Prescriptions


By Stephanie Simon, Times Staff Writer
ST. LOUIS — Responding to complaints about a Chicago pharmacist who refused to dispense birth control pills, Illinois Gov. Rod Blagojevich on Friday issued an executive order requiring drugstores to fill prescriptions for contraceptives.The policy, the first of its kind in the U.S., requires pharmacies that carry contraceptives to fill prescriptions without delay.


"No hassles, no lecture, just fill the prescription," Blagojevich said.If an individual pharmacist will not provide birth control pills because of moral or religious beliefs, the drugstore must have a plan to ensure that the patient receives the pills promptly. In most cases, that means having another pharmacist on hand to dispense the drug.The policy does not require that all drugstores carry contraceptives; many don't, especially in Catholic hospitals. But if the pharmacy has them, it must dispense them to anyone with a valid prescription — or risk suspension of its license, said Susan Hofer of the Illinois Department of Financial and Professional Regulation, which oversees pharmacies.Because Blagojevich issued the policy as an emergency rule, it would remain in place for 150 days. During that time, Hofer said, the state will hold public hearings on a proposal to make the policy permanent."When you or I walk into a pharmacy with a prescription," she said, "we have to have a strong level of confidence that we're going to walk out carrying the drugs we need. If the drug is in stock, it must be dispensed. End of discussion."But that's not the end of the discussion for a growing number of pharmacists who consider it immoral to dispense birth control pills and morning-after emergency contraceptives.Some consider the morning-after pill a form of abortion because the hormones can block a fertilized egg from implanting in the uterus. Because they view that as tantamount to murder, they may not only refuse to provide the hormones, but also to transfer the prescription to another pharmacist."To transfer the prescription would make me part of a bucket brigade … a party to selling something that demeans or endangers life," pharmacist Neil Noesen told the National Catholic Register this year.Noesen was recently reprimanded by an administrative law judge in Wisconsin for refusing to fill a college student's birth control prescription in 2002. That state's Pharmacy Examining Board will meet this month to decide whether his license should be restricted.Similar cases have cropped up in Georgia, New York, Ohio, Texas, Missouri and other states in recent years."We're hearing about it happening more and more frequently," said Karen Pearl, interim president of the Planned Parenthood Federation of America.In response, abortion rights groups are promoting legislation that would require pharmacists to fill prescriptions or promptly transfer them to someone who will. A California Assembly committee is scheduled to consider such a bill next week.On the other side of the debate, abortion opponents have proposed bills to protect pharmacists from lawsuits and disciplinary action if they refuse to provide contraceptives. In the mid-1970s, after abortion was legalized, most states passed laws that let doctors and nurses refuse to participate in procedures that violated their religious beliefs. But only Arkansas, Florida, Mississippi and South Dakota explicitly extend that right to pharmacists.Legislation to give pharmacists the right to act based on their beliefs is pending in several states, including Wisconsin."People should not feel excluded from entering the pharmacy field because they hold a certain view on when life begins," said Francis Manion, a lawyer with the American Center for Law and Justice, a group that presses religious rights cases.Manion acknowledged that letting pharmacists turn away prescriptions could be "horribly inconvenient" for some patients, especially those in rural areas who might not have ready access to another drugstore."I know if I went into a drugstore and was told the pharmacist wouldn't give me my medicine, I'd be really mad," Manion said. "But that's the price we pay for being a society that values religious freedom."

Pica

Regarding the starch eating phenomenon: Pica is a symptom associated with iron deficiency anemia. Patients get cravings for dirt, ice, starch, clay, etc. It most commonly occurs during pregnancy. One colleague had pica that made her crave soap lather on a daily basis. Many of my pregnant women, following the advice of their gradmas, will eat "white dirt" that they can buy in southern gas stations and markets. This is some sort of powdered clay that contains no iron but otherwise seems not to be harmful.

Thus, my old lady eating corn starch with a spoon concerned me, as she had risk factors for severe iron deficiency anemia. It's easy to see anemia in white people; if my blood count dropped at all you would be telling me how pale I look. However, in people with dark skin you cannot tell as easily when their hematocrit drops dangerously low. We learn to look at the whites of the eyes and the skin under the fingernails where there is no pigment. I can count on two hands the number of white people I've taken care of in residency, so I've gotten better at this.

Anyway, my lady's pathology came back as a benign polyp of the endometrium. She'll need outpatient surgery for removal, but it's not likely to have any cancerous areas.
She's lucky.

The other moral argument

As a physician serving primary impoverished
communities, I would like for any
politician--conservative or liberal--to address the
other moral question in this case. In my mind, the
primary question involves our society's misallocation
of severely limited healthcare resources.

How many vaccines and prenatal visits could I have
provide for the amount of money spent keeping Ms.
Schiavo "alive" for 15 years on feeding tubes? How
many cases of neonatal HIV could I have prevented?
Finally, how can we justify leaving millions of
Americans without basic preventive care while we keep
others on expensive life support without hope of
recovery? This is the real moral dilemma.


P.S. March 30 is Doctor's Day. If you have a good one, send him/her a note.

nurse

Yesterday in my clinic I met a very nice 62 year old woman who had not been to the doctor since her last baby was born. She wouldn't tell me exactly how long that was, but I'm guessing 35 years or so. Yep, no pap smear in 35 years.

I asked if she was afraid of the doctor, and she sheepishly nodded. She wasn't afraid of me, however, as she repeatedly called me "nurse" after I introduced myself as Dr. T. Finally I said, "Maam, there's nothing wrong with being a nurse, but I went to school way to long for you to call me that." She was a little embarrassed, as proceeded to call me doctor every chance she had from then on.

She said that she never went through menopause, but that she had stopped bleeding for about 2 years in 2000-2001. Then her bleeding came back and now it's just all the time. Concerned, I called in my assistant with all sorts of biopsy tools. Upon inserting the speculum, I found about a 3-inch tumor popping through her cervix and oozing blood. The last time this happened, the lady had a terrible uterine cancer. I took a little biopsy of it and ordered an ultrasound. We had a long chat about what the uterus and cervix are, and why her bleeding is not normal. She then admitted to sitting up late at night eating corn starch with a spoon--a sign of severe anemia.

Her biopsy and labs are pending, and I'm hoping for a benign endometrial polyp, but it doesn't look good. I'll let you know. I think she'll come back for the results, but we'll find out in three weeks.

money

Yep, I'm going to say it. I think those who do REI (infertility) often do it for the good money and great hours. There are few emergencies, good hours, and they make tons of cash. Of course there are exceptions, but this is my observation.

I just have a personal issue with going into a field (aneshesia, radiology, dermatology being most common) that pays great and has pleasant hours but doesn't hold your interest. If you ask med students these days, many are comparing specialties not based on their passionate drive to know more or help patients, but based on how many nights they will spend awake and how early they can retire. People have taken to the idea that medicine is a job that should have sane hours but still pay tons of money, but it's never been that way. It's a lifestyle that one adopts, and it involves personal sacrifice. I just can't imagine being fulfilled by my beach house and Benz at age 40 if my job bored me to tears. Maybe I'm an idealist, but I chose a specialty with crappy hours, mediocre pay, and lots of excitement and unanswered questions. I chose it because it was the only thing that got my brain mulling things over after hours and my adrenaline pumping all day.

Maybe I'm just bitter that it's been a 32 hour week and it's only Wednesday AM. However, we saved a woman's life at 2 AM Monday night. She had 2 liters of blood in her belly from a ruptured ectopic pregnancy. Nope, a radiologist didn't have to get out of bed for that. And no, we didn't make any money either.

offensive

I don't mean to offend. I have lots of young women in my ghetto clinic with infertility issues and I enjoy taking care of them. I also have wonderful patients at this REI clinic who really benefit from our help. Many have diseases that are extremely complicated to treat and that do require the expertise of infertility specialists. These docs are excellent surgeons and endocrinologists.

I'm just tired and there are terrible office politics in this REI clinic--nothing to do with the patients-- so it was an unpleasant week. It taints my perception of the specialty. Anyone should be able to have a baby when she wants to---I just wish we were better at preventing the unwanted ones.

old lady

I'm an old lady. Surgery hurts. Me--not the patient. I strained my back moving a 300 pound patient two weeks ago, and it's not better yet. This job is horribly demanding on the body. My colleague was right, I have taken off the intern weight and then some because this year is just so difficult. My biceps are toned from lifting all those bellies...We operated all day today on bad ovaries, fibroids, etc. I'm just exhausted--my feet are used to it, but my arms and back haven't yet caught up. However, I did get to do cool laparoscopic surgeries this morning, and I do love to operate.

This month we are completely changing gears and taking care of older patients with fertility issues. We are a far cry from my 16 year olds with two babies and uncertain but fertile baby daddies. These are the professional types with some money who waited to have babies and are unable for any number of reasons. For large sums of money we do our best to help them out.

Much like abortion, I'm glad these services are available but I'm not up for dedicating my life to offering them. I've delivered too many BUFA (baby up for adoption) kids and seen too many people trying not to get pregnant but failing. I guess it's just not an interest of mine, but good knowledge to have.

No great ghetto stories this month, I'm afraid.

Babygirl

This week I had a patient named Babygirl--the mother was named that. She was a rather pathetic and apathetic creature of twenty-something years having her first baby. She barely said a word to me during her labor, with the exception of "It hurts." She delivered a baby girl, whom she neither held nor looked at during the first hour after delivery. I didn't see her after that, so I don't know whether they eventually bonded.

When a baby is born, depending on the hospital, it gets a medical record number and labels, wristbands, etc., that say "Smith, babygirl (babyboy)" or "Smith, female (male)". We think that Babygirl's mother either thought the hospital already named her, since her wristband said "XXXXX, Babygirl", or just didn't care enough to give her a name at all and she remained Babygirl by default.

When Babygirl delivered her babygirl, I asked, "What's her name?" She replied, "Don't have one."

Vagina Spanglish

I've been getting my butt kicked on labor and delivery the past two weeks. Sorry for not posting.

Our patient population is almost 50% Hispanic--mostly Mexican, but also from miscellaneous Central American countries. I do not speak Spanish, but I have picked up enough of what we call "vagina spanglish" to get along in a basic obstetric emergency. I can say the following:

Contractions?
Baby is moving?
Do you have pain? Where?
Blood from vagina?
Liquid from vagina?
I need to examine your vagina.
1,2,3,4,5,6,7,8,9, 10 centimeters
Relax your legs.
Lift your butt.
The head is here.
PUSH!
DON'T PUSH!
Relax.
The baby is fat/perfect/pretty.
Congratulations, papa.
To the house tomorrow. Mui Bien.


Things generally occur in that order, give or take some misunderstandings and the occasional c-section. one of my colleagues who prides herself on her Spanglish accidentally told her clinic patient to come for her c-section on Wednesday...it was scheduled for Thursday.

Galliant= gallant + valiant

Veteran nurse fired for using racial slur

Yes, the headline is true. In February of 2005, a nurse at a large public hospital has been terminated for using racist terminology in the workplace.

It's not what you might be thinking...a black nurse of Caribbean origin unwisely referred to one of the anethesiologists, saying, "I ain't gonna take no more from that Cracker today-- I'm not in the mood." Sadly for the RN in question, she did not used good judgment in choosing her audience. The aforementioned "Cracker" physician remained in earshot. Worse yet, their mutual (black) patient also witnessed the colorful commentary.

Cracker doctor (CD) reported the incident to the nursing manager, who placed the nurse on suspension pending investigation. She denied having used any disrespectful language in front of the patient. However, much to the crazy nurse's dismay, the patient confirmed CD's accusations. The nurse wisely accepted an offer of early retirement over being fired. Sad, but true.