Sunday, August 23, 2009

Time Travel

I've left the island behind and am now land-locked, having started at a new clinical rotation site many, many miles from the sea. I miss it, and last night I dreamed of the ocean's clear, blue-green water lifting me gently, and offering to carry me as long as I wished. Now, I'm almost claustrophobic with the thought of thousands of miles of rock and dirt spreading out concentrically, with me trapped at the center. That feeling distracts me from the beauty of the landscape.

And it is pretty. There's a running and biking trail that runs out of town for over a hundred miles here (they can afford to make a trail that long, where nothing exists to get in the way), and I've run three or four times this week, each time a little further out, testing my endurance and exploring the winding path. The trail itself is happy to have me. I see no one else out here, ever, and wonder how many tax dollars were spent so that I can have these moments all to myself.

Where is everyone? I don't know and don't particularly care during these moments, but it seems they must be on another planet or maybe in another dimension, where this path doesn't exist for them.

And even the town itself is a little out of time. It plays up its wild west background, with numerous "saloons" and "gambling emporiums" and even a museum next door to my apartment (pretty much just an old house belonging to some rich guy who made his money poisoning the frontier with alcohol and cigarettes). One of the main attractions in town is a graveyard, containing some notable headstones. You have to pay to get in, or die I guess, and I'm not willing to do either.

This weekend the songbirds compete without hope with the sounds of a classic car show that has overtaken town. Were cars in the 1950s and 60s really that loud? How did anyone get any sleep? Can you imagine trying to sneak up on a farmhouse? You'd have to park 12 miles away. But the people love it, and some of the cars are undeniably cool. Like this one:

Look kids ... Mom and Dad brought home the Batmobile!

The best of show judging takes place in about half-an-hour, and I can hear the cars as they blast their mufflers though downtown, heading to the parade grounds. Prius, anyone? I think I might take a walk down and see which '57 Chevy takes the blue ribbon, as I scan the crowd for the ghost of Calamity Jane.

Tuesday, July 14, 2009

Free At Last?

Pretty much the whole of the time I was behind bars, I was looking forward to getting out (I'm sure I'm not the first guy to say that). But now that I'm out, there are some things I miss.

I miss the freedom. That might sound odd, but behind bars, I was allowed to practice medicine with great (and sometimes total) autonomy. I scheduled patients when I thought I needed to see them. I saw them. I examined them. I diagnosed them, and then I prescribed them medicines. I did whatever my meager medical knowledge could conjure up. If they got better I didn't see them again. If they didn't, they came back and I gave it another try.

Of course we were supervised, but it was mainly from afar, when the preceptor read through our notes on his computer screen after the patients had already been seen.

Now that I'm out, I realize the good and bad of that experience. The good was the chance to do it all, and do it myself, to sink or swim. The bad was I was probably sinking sometimes without even knowing it, without getting the feedback I needed to add some wisdom to the experience.

Now, at my new clinical rotation, I have to wait for permission to see a patient. Some of them are deemed beyond my abilities, and I never get in the same room with them. The ones I do see, I don't treat. I gather the chief complaint, do my exam, and then go find my preceptor, to "present" the patient in traditional medical student manner ...

"I have a 50-year-old white male with a history of blah-blah-blah, complaining of blah-blah-blah." ...

I make an assessment, and then offer my plan of treatment. Then the preceptor goes over my plan and its shortcomings, makes suggestions, and asks me a question or two. Then we go see the patient together to finish off the encounter. The preceptor may do some extra physical exam (or repeat the same one I did to double-check me) and ask a few more questions as I watch. Then he or she explains the plan to the patient and answers any patient questions. Then we're done. As we leave the room, I have a chance to ask my preceptor some more questions and talk about the case a bit.

It's much slower than behind bars, and I see fewer patients. But the encounters are built for learning, not for speed. I also feel a lot dumber, or more precisely, I experience my ignorance in real time.

When I present the patient, I usually realize I gleaned only a fraction of the info I needed to gather when I was in there interviewing. When I say my plan out loud, it doesn't sound nearly as solid as I thought it was. And when I get called on it, I feel just plain dumb. The preceptor doesn't intend to make me feel stupid. He's infinitely kind. I just feel ridiculous sometimes, as I should.

I gotta say, I'm learning a lot more, and the supervisory environment is way more appropriate and professional. But when I'm standing here twiddling my thumbs, waiting for someone to give me a patient (and sometimes begging someone to give me a patient), I miss the free-wheeling days behind bars, when it was just me. When I looked at that schedule that I'd made, and called in the next patient who was counting on me to make him better. I had little fear, few limits, and no chains binding me. I was doing it, and it felt great.

Saturday, July 11, 2009


After much tribulation, nearly ending in divorce, we’ve survived the stress of packing up all our belongings, hauling and storing them away for six weeks in various corners of the city, and finding a temporary home for our lunatic cat. We’ve now landed in an island paradise.

We’ve been here two weeks. I have internet access again, and we’re settled in for the next month, trying to enjoy ourselves while paying exorbitant tourist prices for life-saving sunscreen and other daily necessities.

The island has at least three distinct cultures: The Locals (subdivided into indigenous people, Caucasian, and Philippine), the Tourists, and the Japanese. Why separate the Japanese? Because they operate apart from the rest of us. They have their own chartered buses, their own sections in the grocery, and there are clubs and businesses which cater directly to them (namely the gun club, which offers Japanese men and women a chance to shoot a wide array of handguns and assault rifles at an indoor shooting range; something they can’t easily do in gun-restricted Japan. In fact, the barkers handing out business flyers for the range don’t even give the flyers to whites. They know who their customers are). So the Japanese create and occupy a space that belongs to them alone. There’s something industrious about that, without being inherently aggressive or obnoxious.

For the most part, the clients at the clinic belong to none of these dominant cultures. They are what Michael Harrington, in 1962, called “The Other America.” The other America is still here in 2009, sicker and crazier than ever.

There’s the guy I saw yesterday, whose life took a nosedive when his lover died of AIDS and then he subsequently tested positive. He smokes “a little meth each morning, just to wake up.” My preceptor asked him if he’s tried coffee.

There’s the woman who seems pretty unremarkable, until she tells you she prefers living in a storage unit to a real house.

There are broken hands from gay lovers beating each other hard enough to displace bone.

There are coughing fits violent enough to cause emesis, from a man who says incredulously, “But I haven’t smoked in a week!” This, after a lifetime of lighting up.

There’s the sad sack loser who expects you to believe his puppy took his bottle of pain meds out in the yard where they got rained on, and now he needs another 90 vicodin.

And there are the voices--Heard inside the minds of some of the sickest individuals.

Schizophrenia lives at this clinic. I’ve seen someone nearly every other day who hears them. After the description one man gave me, I just shook my head. He blames a baptism gone wrong, when as a baby his soul was connected to his also-disturbed Auntie instead of his god. Doing a ton of drugs didn’t help either, he said. He hears them outside his window at night. They cough at him. They slyly suggest he hurt himself, by asking what would happen if he just happened to step out into traffic at a certain moment. Sometimes they’re inside his head, and sometimes farther away, but always working on him.

There’s not much I can do about all that. It’s for the psychiatrist he sees to sort out. The problem for me is that his understanding of cause and effect is so distorted, that it’s tough to get him to work on his hypertension, high cholesterol, and diabetes. Pharmacology means nothing to him. The pills are imperfect amulets, and he wants to know which single medicine is the best protector. I try to explain that this one is for your pressure, this one is for your cholesterol, and … forget it. He’s already asking, again, if mixing them can make his neck hot, and whether eating rice can increase pressure in his brain. I ask when his next psychiatric appointment is and excuse myself. I head out the room looking for my preceptor, the voice in my head is asking me what I’ve gotten myself into.

Saturday, June 27, 2009

Final Tally: Top 10 Complaints/Illnesses through Week 6 Behind Bars


Wednesday, June 24, 2009

Oh Come ON ...

I hope this doesn't mean I'm getting cynical...

... but if you claim you need a wheelchair because of "excruciating" sciatica, and you have an appointment to evaluate whether you still need that wheelchair assigned to you, you should probably show up to your appointment IN that wheelchair, instead of walking over from your unit as if out for a Sunday stroll.

Tuesday, June 23, 2009

Interesting Case of the Day

Today's candidates for Interesting Case of the Day are:

1. Pus-draining armpit.
2. HIV+ patient not getting better, not getting worse.
3. Bad-smelling urine after eating the turkey in the cafeteria.
4. Drug-seeker.
5. Hepatitis C patient seeing "flashes of light."
6. I know my blood sugars are high, but I'm working on it.
7. Imperforate Anus.

And the winner is ...

Drug seeker!

No, just kidding. The winner is of course the young man with a history of imperforate anus. He's a new arrival to the prison here. He's in for "getting real angry" and "shooting up a house while some people were in it." No one got hurt, and he got 48 months. Anyway, he was actually born without an asshole, as he says. Thus he disproves the oft-quoted maxim that "opinions are like assholes; everybody's got one."

After living with a colostomy bag for a while, surgeons created an artificial anus for him. Unfortunately, it doesn't work as well as yours and mine. For one, it has no anal tone (I know because I had my finger in it a couple of hours ago) and it looks a little different from the standard anus. It's basically just an opening in the anal cleft ('butt crack' to you non-medical types).

Having no sphincter means he can't really control what comes out, and he's in clinic today requesting medical approval for a private cell because he soils himself daily. Unfortunately this often happens while he sleeps. He wants a private cell so he can use the toilet right away, when he needs it, without worrying about his cellie needing it or being in his way. And also so he can clean himself and his clothes without being embarrassed and having to deal with a roommate. And he has "really, really bad gas," too, he told me. Yep. I found that out during the interview.

Will he get a private cell?

Highly doubtful, regardless of what we recommend. And we are willing.

UPDATE 6/24/2009:
There is a private cell currently available, and other inmates have been complaining about this patient, so the hope is that staff will accommodate him with a cell of his own.

I just hope it's not in solitary.

Sunday, June 21, 2009

Top 10 Complaints/Illnesses through Week 5 Behind Bars

1. ALLERGIC RHINITIS, takes a commanding lead.
2. VIRAL HEPATITIS, just won't go away