Thursday, June 30, 2005

on call number 2

"Healing may not be so much about getting better, as about letting go of everything that isn't you - all of the expectations, all of the beliefs - and becoming who you are"- Rachel Naomi Remen

i realize that i am not naturally fearless. i am unsure of my skills as a doc. i care if the attending thinks im an idiot even though i dont want to. i think before i stop rounds and make sure the 70 year old spanish speaking only man understands that a cardiac catherization is dangerous sometimes and he shouldnt sign the consent unless he understands that fully. but i got a translator for my booty spanish that doesnt carry the intricacy of 50 words for scales of danger and vitality post surgery.

32 hours on and sitting down for a total of 45 minutes is draining. yesterday i got called for two chest pains that could be heart attacks, admitted 5 very sick cardiac patients, talked to three families about their loved ones chances and pulled the ventillator on a brain dead patient. a patient was crashing in the ER and i kept getting paged that the patient's family in the cardiac intensive care unit wanted to talk to me. i couldnt get up there in time. i am trying to get used to being pulled in so many directions and saying no. i am not that good at saying no. i dont know why. at the bottom of the stairs was a young mexican woman who was in tears and she asked me if i spoke spanish and i said yes and she asked if i could help her find her grandmother who she thinks might be dying and urgent care hasnt seen her yet and could i talk to urgent care. and i was so behind for the night and i had to see a patient that was crashing in the ER and i couldnt. i talked to her for a couple minutes.

finally i got up to the 4th floor and walked behind the curtains to see the family of my patient on the vent. there were 15 people in that little area around the bed. two boys at the head of the bed, their heads shaved, about 22 years old crying for their father. and when i walked into the room i apologized for taking so long. and i have realized in a week that patients are so hungry for some communication and the medical field in general and acute, highly skilled specialists in particular are so bad at sitting down and talking to patients for a couple of minutes. and there is so little time in LA county hospitals but it has to be done and it isnt being done. and patients are ridiculously grateful for honesty and a brief minute.

so i walked into that room and explained we would pull the vent and start a morphine drip if they agreed. and they wanted to. what is crazy is that the most intimate, crucial stuff the best stuff of being in medicine never shows up in rounds. like robert horry whose stats the next day are not that great but you know he won the game for his team with all the hustle and the little stuff.

so the stats the next morning are all that is important and they are mostly numbers.
and i am trying my damndest to keep doing stuff that will never show up in rounds and i think most of the other interns at harbor are too. but the fellows dont for the most part and the attendigs, rarely. i cant remember when i have been impressed by an attending bedside chat with a patient. long time, i think.

today i am off. i need to set up my place. we got it painted yellow and red. i went to home depot and got the colors mixed the way i wanted. it has a little spanish villa feel if you stretch your imagination:)

the roofs are low and it is this little one bedroom hideaway less than a five blocks from the beach.



sri

Sunday, June 26, 2005

internship day one.

internship day one: today is recovery day one.

i had the most awesome, difficult, hectic, frazzled, crazy day on the fist day on. i volunteered to be on call. i wanted today off for krishnas wedding. viral and gurm and hash will be in town. 32 hours. no sleep. none. my patients are sooooooooooo sick. i dont know much. overwhelmed is a good word. nervous is another. but it is such a sacred space to witness all of this stuff. in one night two patients coded. they were both my patients. 10 minutes of pumping on the chest and pulses coming and going, flat lines. they put me in the cardiac intensive care the first month. fifteen patients are super sick. breathing machines and tubes and swan ganz chaths. a 24 yr old drug adict with tubes and on ventilation and crashing. she had tatoos and was in septic shock and bluish. red hair, tatoos everywhere. she looked like the posterchild of death but maybe it was because so young or i could picture her struggling with drugs or being touch but i was emotional to see her about to die. and my name is first to call for the nurses if anything happens. and i am first to call to talk to the parents. it is really a trip to click on a patients name and have your name come up as the doc taking care of her.

there was once a poet(it has now been a full three years since she died) who said it is hard to keep a white shirt clean(and i was in india and a little tibetan kid squirted some blood from his nose onto my white kurta. and as i took off my white white shirt and washed it by hand in that bathroom bucket i was reminded of that phrase it is hard to keep a white shirt clean and i thought of that poet and something swept over me emotionally and i almost started to full on cry.)

but anyway it is very hard to keep a white shirt clean and before i left NY trevor told me to keeping a white shirt clean means that you have to put yourself in positions to get it dirty, really freaking dirty. you cant just chill at the laundry room and be happy that your white shirt is clean. so the point being, i am spent after last night and i feel like i am about to fall on my face and get my shirt bloody but at least i am in that place.

i was in on the decision whether to stop treatment on this patient. i signed the DNR. i talked to the family. this whole figuring out how to be real and still a doctor. both the codes were still alive when i left the hospital.

the hospital is chaotic and awesome and my patients speak mostly spanish. there was five women- age 16 to 55 praying loudly around 2 am. standing up and crying in a circle, raised hands and praying in spanish. it was beautiful and sad. tears rolling down their cheeks. and i am running to replace magnesium on my patinets and try to make sure everybody lives through the night. so many lives are being played out it is crazy. and i am responsible in some part for some of these lives. lucky the residents and the fellows hold your hand a bit.

i got off and drove home to my parents house and slept. woke up and ate. and slept through the night. this is going to be a hard year. exciting, i think but so hard. every intern looked liked they were drowning and frazzled. first day, two of my patients coded. tomorrow. day two.

today, a wedding.

sri

Thursday, June 23, 2005

orientation

into third day of orientation for my new residency. people are super cool and bright. start friday in Coronary critical care unit.

found a place to live... redondo beach, few blocks from the beach. it is this little bungalow behind a single mom and her two kids. a hideaway. want to try and paint it tomorrow before friday starts. there has been a lurking feeling that this country and medicine are misguided, drastically. in so many ways. we just got told yesterday that if a patient vistor comes to the hospital and collapses it might be better not to touch the patient for liability reasons. in a plane it might be better to say you arent a doc... pretty misguided.

been reading krishnamurti a bit... always challenges the kind of cookie cutter approaches to life that i can fall into. puts into question what is worth living for and priorities and what is the measure of success that everybody is striving for without really pressing the underlying reason for that seeking... why do we get more conservative as we get older and joy seems to leak out and slip away from the older and older folks.

my uncle had a heart attack on monday night... been back and forth to orientation and the hospital... last week so much partying for b's wedding. this week life turned on a dime.

s

Monday, June 06, 2005

WHO india

more wedding stuff every day. this is good exposure on how to plan what you want in a wedding. what to leave out. what to include. a house full of women. b dressed up in her wedding stuff yesterday. grooms fam comes in tomorrow. pick ups and drop offs and drama and kids running all over. this is a topsy-turvy household if there ever was one:)

here is something that steph actually read and though it might bore you faithful one or two readers i thought id post it. To the WHO rep in INDIA.


Dear Sir or Madam,

My name is __ I am a United States based physician who had the opportunity to travel to South India and work at the the Tibetan refugee colony in Bylakupee, Karnataka. During nearly four weeks in April/May, 2005 I lived and worked on site at Tsepal Tobkyed Hospital in Bylakupee, fourth camp. The hospital aims to serve over 3000 monks and 600 nuns of camp four and lay persons in the surrounding community. While I was there, however, there was no doctor on site and no doctor had been present for quite some time.

During my stay at the Tibetan colony, I was able to meet with Dr. Gopinath, the government doctor located at first camp, in charge of overseeing India’s Revised National Tuberculosis Control Programme (RNTCP) in that area. I was deeply impressed that high quality, first line medications were being distributed for no cost. While the treatment and objectives of the program were strong, there were no health workers present to diagnose tuberculosis and no oversight and regulation of TB drug administration. No one in that area was trained in recognizing harbingers of tuberculosis and recommending sputum Acid fast bacilli tests.

During my short month at the colony, one monk was in St Johns hospital for spinal TB and two others were undergoing treatment. A preliminary assessment of the community, especially the adolescent monks, revealed numerous previously undiagnosed and untreated cases of tuberculosis. The ones who were being treated did not have adequate oversight and follow up to ensure that a complete course of medications was administered.

As you are aware, Multi Drug Resistant Tuberculosis in the Tibetan community is documented in the medical literature. The very high quality of the drugs being used mandate that treatment be more regulated than currently standards in order to not cause an even greater increase in the number of MDRTB cases.

Many cases remain altogether, undiagnosed. In a population where many of the monks in the colony I worked in were sleeping 14 to a room, and often 75-100 per classroom tuberculosis is present in epidemic proportions. In my opinion it is necessary to:

To place a government health worker at Camp 4 to stay on permanently. Isolation of sputum positive patients must be stressed.

Formal train a few Tibetan monks and nuns to recognize the symptoms of TB in order to increase the amount of sputum AFB's being done. The need is present and the trained monks and nuns will be on sight, long term in continuous direct contact with the patient population.

An experienced government lab scientist deployed to train Camp 4 Lab technicians would help ensure accurate diagnosis of contagious sputum positive TB patients.

A periodic evaluation is necessary to determine There is currently no way of evaluating the incidence of patients with TB or the success of the RNTCP with such little oversight of Camp 4.