Graduated – No Crying

The last days of residency passed – perhaps with a bang, and certainly no whimpers – and I am now full into my first week as a real, live doctor.

Everything feels the same, but with more sleep.

My graduation ceremony occurred 4 days ago, on Saturday.  For as emotional as I felt that night, I managed to survive the entire ordeal without much blubbering.  This had largely to do with my particular approach to the ceremony itself, which involved a skateboard, a wacky helmet and some iffy poetry.

Since there are only 6 graduating residents from our program, each of us enjoys (or endures) a sizeable amount of limelight as we graduate.  It starts with a picture slide show of us from our earliest days up to the present.  Some of my shots were strange, if not embarrassing, as you might imagine.

We are then introduced – for an agonizingly long time – by a faculty member.  Here our history, foibles and dreams are put on display for all in attendance to see.  This part can also be rather painful too.

It was then my turn to speak.  We aren’t given time-limits on our speeches.  As mentioned, there’s only 6 of us, so I guess we have the berth and he right to ramble a bit if we want to.

I survived the process with almost zero public display of emotion.

I’m not sure why this was some sort of goal for me.  I’ve always been a lousy crier.  I’m good at complaining, whining, moaning and bellyaching, mind you.  Rather too good.  But my crying skills must have atrophied somewhere in my childhood.

If I were to guess, I suppose it happened when I was about 5 years old and my biological father had just punched his girlfriend in the face.  He then leered at me and asked, “You gonna cry about that like a little girl?” in a drunken haze.

“Nope.”  I said.  And I never have.  These days, I can only cry when Ariel gets her statue of Eric blown up by King Triton, or the Broncos trade their franchise quarterback to the Bears.

So, I have some issues.  Fine.  I’ll bet you do too.  Intellectually, I admire the Roger Federers of rhe world who can stand on the international stage with unabashed tears streaming down their cheeks when they lose (or even win, sometimes) their latest tennis match.  Emotionally, I want to smack them with their own tear-stained pink hankies, tell them to find their purse and go back to the parlour where life doesn’t hurt so much.

Anyway, I wasn’t going to cry.  Smash my thumb with a hammer…we’ll talk.  But for this?  No way.

So, my approach was to first ride my Sector 9 longboard skateboard up to the podium wearing a tin foil-wrapped, overly-festooned bike helmet.  Why such a rather dumb graduation display?  Why, especially, at a solemn ceremony for a new practitioner of the healing arts?

sector9Aside from the fact that medicine is frequently too pompous and full of itself, I figured that if I could keep it fun and light, I could keep my eyes dry.  Plus, I ride my longboard to work most days, and I religiously never wear a helmet of any kind, much to the dismay and consternation of virtually every person I meet on the hospital campus.  For 3 years I’ve put up with near-constant haranguing to wear a helmet.

Why don’t I wear a helmet?  Well, I just figure that anyone traveling less than a mile, at about a mile an hour, while less than 3 inches off the ground…should garner me the right to feel the wind in their hair.  Granted, there isn’t much wind at that speed…and I don’t have much hair.  But that’s my metaphorical argument, people, and I’m sticking to it.

I also think that Americans are too stupidly safe these days.  We think we have allergies to things that 6000 years of humanity had no problem with.  We pad every corner in our houses and put seatbelts on our T.V.’s just in case the wall trembles and pushes that deadly thing over on a kid.  We have warnings on things like plastic 5-gallon buckets and nylon shower curtains.  Frankly, the fact that my children will never ride barefoot in the back of a bouncing pick up truck, screaming like golden-haired eagles as the wind whips wildly into their eyes, brings me no end of sorrow.

I grew up burning leaves, shooting bottle-rockets out of my hand and hunting fish with a whittled stick.  I think life is risky, and living life is an exercise in managing that risk.  Knee-jerk safety measures without true analysis of risk leads to heard-mentality that rarely leads to anything but really really bad groupthink: racism, genocide, militant nationalism, day-glo, Milli Vanilli, toilet-seat-shaped pillows for airplane flights that everyone carries around airports but never actually use for more than 10 minutes, to name a few.

So, in truth, I don’t wear my helmet when longboarding because I’m determined to not become a Nazi.  Gotta admire a guy like that, right?

Anyway, I understand that most of you dear readers will find fault in my little tirade, and will probably want to admonish my opinion about helmets just like all of the faculty, nurses, staff and freaking maintenance workers I see.

But take heart!  You don’t need to worry!  I rode to the podium in a helmet for the first time.  Just to make everyone happy.  Just to acknowledge that I’ve finally heard the message.  I give up.  It’s time to be responsible and extra-duty safe.  I’m a doctor now.

‘Course, my helmet was covered in tin foil and had sticks extending from it in every direction with tinfoil balls on the end of the sticks…but it was a helmet.

Then I delivered a poem.  It was supposed to be a rap – with a thumping beat and maybe a couple of dancers and lights flashing/spinning with everyone on their feet, their hands in the air all hip-hoppin’ on the floor.

But I’m white.  I’m a doc.  I’m in a tie.

Forget it.  It’s a poem.  A really bad 1-2-3-2 rhyme sequence that rhythmically scans like ice cream might feel if you were dumb enough pick a pile of it out of a sandbox and eat it.  But, in honour of my creation and the initial inspiration for it, I allowed that I would not in fact be delivering a rap, OR a poem that night.  It would be an amalgam, a mixture…a PAP.

This is fitting, of course, since we were all gathered to celebrate my new status as a fully-trained family medicine doctor.

My Pap made my mom cry.  I think my Dad too.  Kinda my wife.  And most of the people I talked to afterward said it made them a bit misty.  My goofy, two-bit hyper-syllabic tossed salad?

Cool.  People cried.  I didn’t.  I was too busy looking goofy, or saying goofy things.

Dear old Dad would be proud.

Mistrial II

There is a surprising amount of information about the charges against the doctor from my program who recently survived his criminal trial end due to a hung jury. The accusations are galling, and although there were 3 women listed as accusers in the trial, there are numerous others in the initial filing. You can read about it here, if you’re interested.

And why would you – loyal and growing nation of secretwave101 readers – be interested? Who would want to read stuff like this? Well…think about the astounding number of really serious allegations that can be leveled at a doctor and yet still not be enough to lead to a conviction in criminal court. And just how valuable is it to file a report if it merely leads to this? I imagine it takes some courage for a woman who has been sexually assaulted to come forward and make a claim. They have to relive the experience, endure ridicule and skepticism. They may have to appear in court and be subjected to character-withering cross examination by the defense. All of these women (I think there were complaints from woman “A” through “I”) did what they should have done and yet it ended in a mistrial.

sarlacc.jpgAnother wrinkle is that his license is suspended for a catastrophically bone-headed medical error in addition to the sexual allegations. The guy dropped a lung doing a trigger-point injection…a type of injection that shouldn’t go in more than a few millimeters. His response to the error is even more bizarro. His license is suspended as much for the error as it is for the allegations of groping and frotteurism.

The failed trial was only for criminal charges and whether or not he should go to jail. But he isn’t anywhere near being off the hook. He now is open to civil trials and…lawsuits. The standard of proof in these trials is MUCH lower and I shudder to think what awaits him now. He’s headed toward the Sarlacc Pit of the legal system (*ahem* please pardon the Star Wars reference. People who fall into this pit are kept alive for 1000 years and are slowly digested over that time). Although he avoided jail time (unless the D.A. decides to re-file charges), his life is still a mess.

Medical Mistakes – Never Apologize

I learned early on that you don’t say “oops” in the OR during an operation. Even though the patient can’t hear you (supposedly), you still never give any indication that a mistake occurred. Ever. It’s like religion. Don’t mess with it.

What I’m still coming to terms with is that you really shouldn’t say “oops” anywhere in the medical field. A trial lawyer’s favorite word is “oops”. And there’s this unspoken pressure to withhold admission of mistakes from patients because – doctors worry – the patient will lose confidence in the competency of the doc if it is clear that a mistake was made.

brain1.jpgI once gave a patient what is generally regarded as a pretty small dose of dilaudid – a narcotic pain med commonly used on hospital floors. She was about my age and of normal weight and having excruciating headaches, we think caused by herpes virus infecting the meningeal layer of her brain.

Imagine that pain for a moment: If you’ve ever had a cold sore or fever blister…think of that happening inside your skull, but scattered all over your brain. I think I’d rather just crush my head in a trash compactor. Naturally, until we could actually do something to cure this woman (there actually isn’t much that CAN be done), I wanted to do what I could to help with the pain. Still, she was young and thin, so I ordered a fairly minimal dose range of 0.5 mg – 2 mg. The actual amount could then be determined by the nurse based on how much pain the patient was having.

The next day, I returned to the hospital to find that my patient had nearly quit breathing overnight, after just one dose of the narcotic at 1 mg. The nurses had called a “rapid response” team to her room, which is one step away from calling the “code” team, which is that group of heros in primary-color spandex who come in and bashes on your dead chest screaming, “C’mon, dammit, don’t you leave me!” So, basically, she almost died. My first thought was that I contributed to the problem because I gave the order for the narcotics. I figured I shouldn’t have given a dose range and should have just written for the 0.5 mg dose until I saw how she handled that amount. And I could have spent more time with her to determine how she reacted to narcotics. I could have avoided narcotics in general and just told her to, “Quit gripin’ you baby-faced American. It’s just a headache. They don’t have IV dilaudid in Darfur and everybody does just fine.”

So, I got up to her room quickly after morning report and found that her mom was also in the room. I should mention that I regarded both of these women as friends as well as patients. This woman’s headaches waxed and waned, so in the previous days I spent as much time talking about life and joking about all kinds of common interests with she and her mom as I did talking about her condition. We got along great and I related to them – in particular I related to my patient’s wry sense of humor and I admired her courage as she dealt with what really is a “short straw” dealt to her by life. So, naturally, when I heard she almost stopped breathing, I was concerned and dismayed. It was like being told your friend almost died but don’t worry, everything’s ok now.

Really? What happend? I need to talk to her and make sure for myself.  Like any friend would.  Like any doctor should.

Swooping into her room that morning, I already noted that her vital signs had stabilized over the previous few hours and that things were – from a “gonna die or not” perspective – resolved. “Jeez, what a tool of a doctor you have!” I exclaimed. “Wow, I’m really sorry about that. I never expected it at that dose.”

After checking her out and seeing that she was actually fine, I asked in all seriousness, “So, did we get rid of the headache?” The three of us laughed. “By God, if it kills me, I’m going to stop the pain!” She replied. We then seriously talked over the best plan for her…which didn’t involve the same level or type of narcotics.

The patient did well over the next couple of nights and eventually went home. It seemed to me that we were on good terms with each other and I felt like I had approached the interaction in total honesty throughout. Was her near-calamity my fault entirely? No. But I did contribute to it, and felt that admitting it was a good thing to do for the relationship between me and the pt. and her family.

So I apologized in the way that a friend might apologize to another friend. I was as much saying I was sorry for the way things turned out as I was saying that I did something wrong. It’s like I took a friend to dinner and they got food poisoning. I would apologize for that. But I would be expressing regret over the situation entirely, including whatever I may have done to facilitate my buddy sinking his head in the white throne of grace for 3 days straight. This thinking, however, met with some harsh responses among my superiors. “You APOLOGIZED? Don’t you know that’s effectively an admission of guilt? How do you know it was you? Maybe she took something else you didn’t authorize. Maybe the nurse dosed it wrong. Maybe she was dehydrated.” Blah, blah. My point was I was sorry for what happened…HOWEVER it happened.

court.jpgI can’t see where the legal system has helped medicine that much. I’m certainly dismayed to work in an environment where I can’t say I’m sorry without first considering the legal ramifications of doing so. Lawyers have succeeded in sucking the notion of friendship and genuine relationship between doctor and patient entirely out of the equation. In the vacuum, they have managed to inject calculation and risk-management. If I’d been told prior to going to med school that I would be required to appraise every patient for their potential aggressiveness; to size up their projected risk to me, I most certainly would have chosen another field.

But, hey, the system demanded 300k in loans from me, so I’m stuck. Therefore, I’m practicing a stable of post-error responses akin to: “Too bad that happened. Must suck to be you, but good thing you have an infallible doctor that didn’t contribute in any way to what happened. The nurses around here are pretty air-headed, by the way. Did I mention that before? Anyway, not to worry. I’ll find that nurse and rest assured I won’t sleep until I can be certain you get the correct dose next time.”