Four hundred twenty. That's the number you get if you multiply the age of one of my patients by the number of times I've seen her this week.
Mrs S is a 105-year-old who fractured her hip after a fall. I saw her Monday evening as part of my preoperative evaluation. Her blood on the day of surgery (Tuesday) was too thin, so she got some vitamin K intravenously, and a repeat lab showed her blood just barely met the threshhold for the surgeons to operate. (I still wasn't happy about it; the case wasn't emergent, and I didn't think we should risk excess intraoperative bleeding when she wasn't really optimized. I wasn't happy about the I.V. vitamin K either. Strangely, this can rarely cause a life-threatening anaphylactic reaction, whereas intramuscular vitamin K is pretty safe. I warned the orthopedic resident to give it I.M., but the attending internist wanted I.V. (!) And so, for a non-emergent surgery, they stood by her bed and pushed I.V. vitamin K, ready to resuscitate her if needed.)
Anyway, the case was the last one of my day, and after we'd gotten her to sleep and I placed the breathing tube, I started off by sending off some baseline labs and pumping in four units of donor plasma to help her blood clot. By the time the fourth unit was in, I noticed there had been significant blood loss, so I sent another set of labs and started transfusing. (Good thing I didn't wait for the labs to come back before transfusing; her blood count had dropped significantly.)
When it was all said and done, the orthopedic surgeons had lost nearly a liter of 105-year-old blood. However, we were able to get the patient breathing & extubate her before transferring her to the unit.
I saw her again yesterday for my post-op evaluation, and then again today since another patient of mine was in the same room. She is an adorable, if slightly demented, lady; and it's amazing to think that she was a teenager during World War I. She was in her 60's when JFK was shot. And Sept 11 happened in her 100th year of life.
The other thing that will stay with me about this case is how irritating I find some surgeons' mindset. I feel like half of what I do is protect my patients from their surgeons. Especially in situations like this, where some rather unwise decisions were made.
Thursday, November 30, 2006
Monday, November 13, 2006
Surgeons can sure be annyoying...
...like when they hurry me to get a patient into the room. One would think that it wouldn't be too hard to figure out that if some patients' surgeries take longer than others, then the preoperative assessment for some patients will take longer than others, especially those with congestive heart failure, coronary artery disease, cerebrovascular disease, hypertension, diabetes, multiple past surgeries, etc. And it should also be common sense that an add-on patient (a patient I find out about immediately before the surgery) will take longer to evaluate than one whom I've known about and have read about the night before.
Any good suggestions for responses to when surgeons complain about "turnover time" given the above? Maybe I should just point blank ask them, "Are you complaining that I took too long to evaluate this patient?"
Even worse is interruptions. This has got to stop. At least three times this last week, I was interrupted by surgery residents or attendings as I'm visiting with a patient. It seems the height of rudeness to break in and start speaking while a physician is evaluating a patient. I need to have a good line ready; maybe something as simple as, "Excuse me, you just interrupted me. Could you please wait for me to finish?"
The nurse in the recovery room, however, takes the cake. A patient for whom I was to provide monitored anesthesia care was tearful even as the I.V. was being put in by another nurse! As high-strung as she was, I tried to be reassuring. At the end of my preoperative assessment, she asked me, "Have you done this before?" I smiled and said, "Many, many times."
As she was waking up from the sedation after the procedure, this patient kept saying in a cute groggy manner, "Thank you all so much for taking care of me! Thank you!" Then she looked at me and said she hoped I hadn't been insulted. I asked her what for. She explained she felt bad for asking about my experience.
Before I could answer that if I were a patient I would certainly be interested in my anesthesiologist's credentials, the recovery room nurse broke in, "It doesn't matter. He just does anesthesia."
Any good suggestions for responses to when surgeons complain about "turnover time" given the above? Maybe I should just point blank ask them, "Are you complaining that I took too long to evaluate this patient?"
Even worse is interruptions. This has got to stop. At least three times this last week, I was interrupted by surgery residents or attendings as I'm visiting with a patient. It seems the height of rudeness to break in and start speaking while a physician is evaluating a patient. I need to have a good line ready; maybe something as simple as, "Excuse me, you just interrupted me. Could you please wait for me to finish?"
The nurse in the recovery room, however, takes the cake. A patient for whom I was to provide monitored anesthesia care was tearful even as the I.V. was being put in by another nurse! As high-strung as she was, I tried to be reassuring. At the end of my preoperative assessment, she asked me, "Have you done this before?" I smiled and said, "Many, many times."
As she was waking up from the sedation after the procedure, this patient kept saying in a cute groggy manner, "Thank you all so much for taking care of me! Thank you!" Then she looked at me and said she hoped I hadn't been insulted. I asked her what for. She explained she felt bad for asking about my experience.
Before I could answer that if I were a patient I would certainly be interested in my anesthesiologist's credentials, the recovery room nurse broke in, "It doesn't matter. He just does anesthesia."
Sunday, November 05, 2006
Gems from The Economist, part 2
As I've said before, I love the writing in The Economist. Smart, witty, often quirky. Some examples follow.
From the Sept 30 issue in an article about Brazil's presidential incumbent Lula, the writer notes some issues which now face the country. "Brazil's dismal standard of public education suddenly seems intolerable, prompting the president to campaign on the clunky slogan 'development with income distibution and quality in education'."
And in same issue, the obituary for former Texas governor Ann Richards begins, "Not much about Texas is becoming or demure. The coast is muddy and malarial; the west, seen from the air, is an immense brown mat of desert; the centre is scrubland munched by cattle. The state's history is one long tale of men imposing their wills on the landscape; and, much more rarely, of big-haired weather-beaten women imposing their wills on the men."
From an Oct 7 article about the cool relationships between China, Japan, and the Koreas, "Most Chinese profess contempt for 'little Japan', and young people with no experience of the war often jeer more stridently than their parents. But few appear to let patriotism get in the way of shopping."
The Economist editors know when to use forcible and when to use forceful. And they make abundant use of the comma, as seen in this sentence: "On October 3rd, as the five permanent members of the UN Security Council steeled themselves to think about imposing sanctions on Iran for failing to suspend its uranium-enrichment programme, the Iranians proposed, out of the blue, that one of the five, France, lead a consortium to enrich uranium on Iranian soil."
And a final example of knowing eactly how to get a point across: "If the question is to secure the oil-rich Gulf against Iranian adventurism, insist America's Arab friends, a good first step would be to deny Iran and its rejectionist allies moral traction, by doing something about the festering Palestinian issue."
From the Sept 30 issue in an article about Brazil's presidential incumbent Lula, the writer notes some issues which now face the country. "Brazil's dismal standard of public education suddenly seems intolerable, prompting the president to campaign on the clunky slogan 'development with income distibution and quality in education'."
And in same issue, the obituary for former Texas governor Ann Richards begins, "Not much about Texas is becoming or demure. The coast is muddy and malarial; the west, seen from the air, is an immense brown mat of desert; the centre is scrubland munched by cattle. The state's history is one long tale of men imposing their wills on the landscape; and, much more rarely, of big-haired weather-beaten women imposing their wills on the men."
From an Oct 7 article about the cool relationships between China, Japan, and the Koreas, "Most Chinese profess contempt for 'little Japan', and young people with no experience of the war often jeer more stridently than their parents. But few appear to let patriotism get in the way of shopping."
The Economist editors know when to use forcible and when to use forceful. And they make abundant use of the comma, as seen in this sentence: "On October 3rd, as the five permanent members of the UN Security Council steeled themselves to think about imposing sanctions on Iran for failing to suspend its uranium-enrichment programme, the Iranians proposed, out of the blue, that one of the five, France, lead a consortium to enrich uranium on Iranian soil."
And a final example of knowing eactly how to get a point across: "If the question is to secure the oil-rich Gulf against Iranian adventurism, insist America's Arab friends, a good first step would be to deny Iran and its rejectionist allies moral traction, by doing something about the festering Palestinian issue."
Saturday, November 04, 2006
Gems from The Economist, part 1
I have a stack of 8 copies of The Economist beside my desk with dog-eared pages and circled quotations, saved, of course, for the blog. Without further ado...
From the Sept 9 issue, a leader entitled, "Welcome aboard." This mock speech by a flight attendant reveals how airlines are often less than forthcoming with their fliers regarding airline safety.
It opens, "Good morning, ladies and gentlemen. We are delighted to welcome you aboard Veritas Airways, the airline that tells it like it is. Please ensure that your seat belt is fastened, your seat back is upright and your tray-table is stowed. At Veritas Airways, your safety is our first priority. Actually, that is not quite true: if it were, our seats would be rear-facing, like those in military aircraft, since they are safer in the event of an emergency landing."
It continues in witty fashion, including, "Your life-jacket can be found under your seat, but please do not remove it now. In fact, do not bother to look for it at all. In the event of a landing on water, an unprecedented miracle will have occurred, because in the history of aviation the number of wide-bodied aircraft that have made successful landings on water is zero."
The article concludes, "We appreciate that you have a choice of airlines and we thank you for choosing Veritas... Cabin crew, please make sure we have remembered to close the doors. Sorry, I mean: 'Doors to automatic and cross-check.' Thank you for flying Veritas."
From the Sept 23 issue, a brief article about the hTAS2R38 gene in humans. What this means to you and me is that different people have different types of taste buds. The research seems to suggest that broccoli really does taste bad to some people, okay to others, and good to still others--including me.
The same issue continues the food theme with a snippet about meat grown in vats rather than on animals. This meat could avoid bacterial contamination and could also be modified to include healthy omega-3 fatty acids. Eating cultured meat "would allow vegetarians to have their meatloaf and eat it too."
From the Sept 9 issue, a leader entitled, "Welcome aboard." This mock speech by a flight attendant reveals how airlines are often less than forthcoming with their fliers regarding airline safety.
It opens, "Good morning, ladies and gentlemen. We are delighted to welcome you aboard Veritas Airways, the airline that tells it like it is. Please ensure that your seat belt is fastened, your seat back is upright and your tray-table is stowed. At Veritas Airways, your safety is our first priority. Actually, that is not quite true: if it were, our seats would be rear-facing, like those in military aircraft, since they are safer in the event of an emergency landing."
It continues in witty fashion, including, "Your life-jacket can be found under your seat, but please do not remove it now. In fact, do not bother to look for it at all. In the event of a landing on water, an unprecedented miracle will have occurred, because in the history of aviation the number of wide-bodied aircraft that have made successful landings on water is zero."
The article concludes, "We appreciate that you have a choice of airlines and we thank you for choosing Veritas... Cabin crew, please make sure we have remembered to close the doors. Sorry, I mean: 'Doors to automatic and cross-check.' Thank you for flying Veritas."
From the Sept 23 issue, a brief article about the hTAS2R38 gene in humans. What this means to you and me is that different people have different types of taste buds. The research seems to suggest that broccoli really does taste bad to some people, okay to others, and good to still others--including me.
The same issue continues the food theme with a snippet about meat grown in vats rather than on animals. This meat could avoid bacterial contamination and could also be modified to include healthy omega-3 fatty acids. Eating cultured meat "would allow vegetarians to have their meatloaf and eat it too."
Friday, November 03, 2006
Stuyvesant Town
It was big news around town recently when Met Life sold Stuyvesant Town and Peter Cooper Village in the biggest residential real estate deal to date in this country (something on the order of a few billion dollars). These two apartment complexes sit on Manhattan's East Side, and they were developed on land aquired through eminent domain and given to Met Life for the purpose of providing housing to soldiers returning from World War II.
On the one hand, it seems they've served their purpose, and the real estate eventually should feel the tug of market forces. (Why should retired people pay 1/2 market rent in Stuyvesant and own a second home in Florida, while young people struggling to make it in the city pay much more for a smaller apartment?) On the other hand, I see some legitimacy to the protection of poor folks and those on fixed incomes, which is provided by rent stabilization. It's a complex social and economic issue.
My favorite part of the issue, however, is this photograph which appeared in "AM New York: Manhattan's Largest Circulation". The paper is popular only because they hand it out free at subway stations, not because of the thoughtfulness or scope of its writing, and certainly not because of its journalistic integrity.
Need I explain the humor in this picture? Clearly they wanted a shot of a Stuy resident, but why only half his face? And this is no passerby. He is Samuel Lichtenberg, 80, a long-time resident. Thanks for the smile, AM New York!
On the one hand, it seems they've served their purpose, and the real estate eventually should feel the tug of market forces. (Why should retired people pay 1/2 market rent in Stuyvesant and own a second home in Florida, while young people struggling to make it in the city pay much more for a smaller apartment?) On the other hand, I see some legitimacy to the protection of poor folks and those on fixed incomes, which is provided by rent stabilization. It's a complex social and economic issue.
My favorite part of the issue, however, is this photograph which appeared in "AM New York: Manhattan's Largest Circulation". The paper is popular only because they hand it out free at subway stations, not because of the thoughtfulness or scope of its writing, and certainly not because of its journalistic integrity.
Need I explain the humor in this picture? Clearly they wanted a shot of a Stuy resident, but why only half his face? And this is no passerby. He is Samuel Lichtenberg, 80, a long-time resident. Thanks for the smile, AM New York!
Wednesday, November 01, 2006
Friends in town
Nearly two weeks ago, three of my good friends from medical school clame to visit. Dave & Louisa live in Cleveland where they are in surgery, and Alison does OB/GYN with the military in Washington D.C. New York City, therefore, was a practical and fun place to meet in the middle. (The true geographical mean would have been somewhere in the countryside west of Harrisburg, Pennsylvania. I found this spot by finding the midpoint between D.C. and NYC, and then going 1/3 of the way from that point to Cleveland. As satisfying as a true "meet in the middle" weekend would have been, NYC worked quite well.)
Fort Tryon Park overlooking the Hudson River
I met Alison at the train station, and then we had some tea at my apartment while we waited for Dave & Louisa to arrive, which they did around midnight. Thankfully, 1:00 AM is not too late to get a bowl of noodles for a late dinner near Columbia. (We were, however, warned at 1:15 AM that the restauarant closes at 2:00, and then at 1:45 we were hurried to slurp up the last of the noodles since the restaurant was officially closed. I could comment on the quality of service at Asian restaurants, but will wait for another post...)
The South Street Seaport. Very Navy Pier-esque (Chicago)
On Saturday we hung out at the South Street Seaport, bought discounted tickets for a show, ate cupcakes from the Magnolia Bakery, toured and had coffee at the Time Warner Center at Columbus Circle, stopped by Rockefeller Center, and then saw The Producers. At another late dinner at the Chelsea Grill on Ninth Avenue, I had one of the best burgers I've ever had.
The big window at the Time Warner Center overlooking Columbus Circle
I ushered for the first time at church on Sunday. Fairly unremarkable, only more bulletin-folding than I expected. That, and people would look timidly at me when it was their time to go forward for communion. All I had to do was give a subtle nod and a smile, and people knew to go up! I bet one raised finger and a direct stare would slow down those attempting to go forward while the line was too long!
The cupcakes were worth the 30-minute wait at the Magnolia Bakery!
We finished the weekend with Dim Sum and then relaxed at my apartment while waiting for the appropriate time to leave for the airport. As fun as the weekend is, it was this last lazy hour or two of doing nothing at home that reminded me most of spending time with these friends in med school! It was great!
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