How many people does it take

A little while ago I helped deliver twins in an emergency C-section situation. The babies were way early, way small and unfortunately they had to be delivered right away... "Stat", on steroids.

This scene is absolutely chaotic. Or rather sort of an organized chaos. At one point I counted 16 people in the room with various roles and responsibilities. There is the scrub team which includes a surgeon, an assistant, and a surgical tech. There is a respiratory support team for each of the twins. There is an anesthesia team which includes a physician and a nurse anesthetist. Then there is the pediatric and neonatal resuscitation team from pediatrics and neonatal intensive care. Then there is a charge nurse for the operating room and patient care assistants to assist all of the team members.

It truly begins as a rather chaotic scene with all the members of the team scurrying around the room preparing for the delivery. But once the timeout is complete and the scalpel hits the skin it is truly poetry in motion. I don't believe there is any more skilled team in healthcare today then those that deal with high-risk births. It is truly a pleasure and a blessing to be a small part of the effort.

Gross Anatomy is not Gross

139 years ago, Thomas Eakins painted Dr. Samuel Gross, his colleagues and students performing surgery on a live patient with what I suspect is a cowering family member shielding her eyes from the carnage. Dressed in his daily attire, the depiction of his bloody hand wielding a scalpel and his colleagues retracting and cutting on this leg is sobering. Infectious disease experts shudder in horror at the scene.

I'd like to think that my course in "Gross Anatomy" was named for the man, the surgeon and the teacher who had the audacity to perform such an event absent gown, gloves, mask or other protective equipment. But many of my colleague argue that it's simply a reference to gross or macro anatomy on a large scale as opposed to micro (small) anatomy. Either way, I'm proud to be in the line somewhat of such men who dared to do cutting edge things, albeit without gloves.

We really have come a long way in surgery and the study of Anatomy in the past 140 years. And we don't let family watch surgery from a kneeling position in the corner of the room either. Although, perhaps we should.

Target --> Bladder Catherization

The target was the bladder. Run a catheter made of a rubber like material into the urethral opening, up the urethra into the bladder to allow a conduit for urine from the bladder to a bag hanging on the bed frame.

The procedure is done 1000's of times per day across the U.S. by nurses, medical assistants and other healthcare professionals. There is even a program for patients to "cath" themselves.

It's not rocket science but has some risks of complications including infection. If the procedures are followed correctly, complication are minimized and the procedure is effective and often necessary in the healthcare of the patient. Unless....

Unless of course you fail to understand the anatomy. In the female, the urethral opening is located anterior (toward the front) to the both the vagina opening and the anus.

Earlier this year, I heard a cry for assistance from a nurse in the OR. "I think there is poop coming out of her urethra. does she have a fistula?" I gloved up and made the attempt to assist her as she struggled with the procedure. But very quickly I recognized that she was attempting to place the urinary catheter into the rectum through the anus. A normal place for poop to be located.

It was everything I could to do to laugh out loud, but behind my mask, I had the biggest grin you can imagine.

She thanked me profusely for assisting and pointing out her problem with the very complicated female anatomy.

Nutrition

There has been so much cancer, infection of all kinds, diabetes and GI tract diseases. Seems we are being inundated with it all at the community hospital level. And over the years I've read good discussions about the connection between what we eat and all of these. Isn't it time we made a strong effort to return to a more natural way of eating to at least test the theory?

It would be unheard of to deliberately go to the medicine cabinet and ingest antibiotics and/or hormones for no reason. Yet we ingest foods with both and somehow that seem normal to society when we eat meats. We continue to be an obese people eating too much of the "white" stuff including flour, milk, salts and sugars. More amazing, how much of this stuff we feed to sick patients disguised as "nutrition" during hospital stays and convalescence.

Consider raw fruits and vegetables. They really are our natural diet. They contain all of the essential nutrition we need for life. They are complete foods including fats and proteins. They are composed mostly of water, necessary for good hydration and water balance in the body. They are low in salt, fats without any preservatives, additives, cholesterol, uric acid, adrenaline, hormones, antibiotics or pathologic bacteria in their natural state.

But, the dietician retorts, what about protein? Most plants can biosynthesize all 20 standard amino acids (the building blocks of proteins). Every vegetable and fruit has protein, some more than others. In a diet that contains fruits, vegetables, nuts, seeds, legumes and grains...we will get the protein we need without adding meats to the mix. Each food varies from 4-8% protein with all 8 essential amino acids that we cannot produce ourselves but need. Tomatoes, zucchini, cukes are particularly good sources as are leafy greens, carrots, celery, cashews, chia seed, sunflower seeds, flax seed, mushrooms, sprouted beans, lentils and spirulina. Protein is the essence of "green drinks" in that way. I suggest there is plenty of protein.

It is possible to get protein, needed fats and carbohydrates, nutrients of all kinds and the nutrition the human body needs from this type of eating, so it would seem. What's important now is to test this inexpensive intervention and support individuals through the transition from the old to the new way of eating. It's not a diet, it's a lifestyle change. Including some movement exercise, this is a lifestyle with the potential to reverse the trend of disease in developed countries. It's certainly worth the effort. We have nothing to lose but ill health.

Bruno

I recently met a patient who, when describing her previous illnesses and treatments, mentioned being involved with a group supported by the teachings of Bruno Groening.

I'd never heard of him or his claims. Bruno claimed to be a healer and spoke widely on the subject of healing in the early 1900's in seems. He thought no illness incurable with his beliefs or techniques. Around the globe today, there are many "Friends of Bruno" who gather regularly to learn and practice healings.

Apparently the techniques could not heal the colon cancer my patient had or the goiter/thyroid enlargement Bruno had. He died in his early 50's. With any luck of the scalpel, this lady should last longer than Bruno. It's amazing to me what people believe or want to believe as they deal with their own health.

Abroad Tea

Any starts talking to me about magic potions from lands beyond the U.S. border, and I'm all ears. I've seen too many pharmaceutical poisonings over the years and anything that is natural and as effective as the drug company variety is fascinating to me. I smelled it as soon as I entered the doctor's lounge. It was something I'd never smelled before.

"What is that?" I asked my colleague. In broken English my FMG friend told me it was Mate' from his native Argentina made from the dried leaves of yerba mate, also known as llex paraguariensis (Paraguay?) to the science types. I have tasted many strange teas in my life, from many countries, but this one I missed. Before I could say anything more, he vanished to the locker room and brought back a bagged sample of the tea for me to try. I promised to savor it at home. Cute little donkey on the label.

He proceeded to describe the potential benefits of the tea. He said it's a strong stimulant when steeped for longer period of time and acts on the muscles to relax them. He warned of mental clarity without the buzz or addiction of caffeine. He beamed with talks of boosting the immune system and stimulating healing tissue.

I don't know about all that, but I've been buzzing on one cup all day. It was delicious, but I can feel it working on my brain, muscles and nerves. Wonder if I steeped it too long. Now I'm trying to figure out how to fall asleep without countering the effects with something chemical. Wonder how my immune system is doing. Probably to buzzed to notice the bacterial floating around my body. And I don't know how I missed this gem but the scientific community seems to have found it as well and is interested in it's medicinal properties - http://www.ncbi.nlm.nih.gov/m/pubmed/20599603/ .
Thanks for the sample! Now, just need to find a supplier.

Sobering

Emergency C-sections are one of the most sobering events in medicine/surgery. Life is fragile as well as tenacious.

27 weeker babies, fetuses really, are so small and discolored with labored breathing and frantic resuscitation teams doing their best and giving their all to encourage and save life. I forget how much effort they require, how much attention they need at this stage. They just aren't ready for prime time.

I heard one of the nurses say, "this one's not done yet. Put it back in". A bit amusing, but entirely sobering. Off to the NICU for several 100s of thousands of $ of attention and need.

Paraphernalia Stories

Once upon a time there was a baby and his father who lived full time on an ocean going freighter moving "Made in China" tools from Hong Kong harbor to the Port of Los Angeles. One night, the father was strolling with the toddler, just beginning to learn to walk, on the deck of the monstrous ship. All at once a rogue wave swept over the boat and washed the baby and his father off the deck into the cold Pacific....never to be seen again.

I'm not normal. Walking along the beach the other day after a storm that brought up huge waves, I found a pacifier in the seaweed and debris. I don't think about the litter and trash that is polluting our beaches from who knows where. I think about the story behind the pacifier.

I think about the male or female baby in far off lands who somehow lost his or her comforting rubber and plastic binky off some ocean going freighter that his Mom or Dad worked to keep him/her fed and sheltered. Or maybe Tsunami debris from Japan or an eroding dump in the Caribe islands, cascading into the sea.

There must be a story attached to this and other pieces of humanity that wash up on the shores of our beaches. I just try to fill in the blanks.

Healthy Lunch and Dinner

Lunch: Blend smooth and drink...

1/2 for lunch (250 calories), 

1/2 for dinner (250 calories)

Orange Carrot Green Machine

3 apples

1 orange

2 1/3 carrots

1/2 banana

1/3 kiwi

3/4 mango

1/3 cup pineapple juice

2 tbs lemon juice

1300 mg spirulina

400 mg chlorella

100 mg broccoli

100 mg spinach

50 mg blue green algae

50 mg garlic

75 mg wheat grass

50 mg ginger

50 mg parsley

16,000 u vitamin A

94 mg vitamin C

836 mg potassium

Or just go buy two bottles of Naked and mix together. 

Way easier! 

Even if it's a Pepsi product and they have been sued for false advertising of contents.

Creating Takes Time

I watched a turtle the other early morning. Such is the byproduct of being on call. Up in the middle of the night when only nocturnals are also out and about. But I was there for a reason. So I watched.

Slowly, deliberately and with extreme labor, I watched the several hundred pound beast pull itself out of the water and up the hard packed sand. Then into the soft sand, with less tractable footing. For over an hour she pulled and seemingly huffed and puffed to get ashore to her "spot". Then she dug for another hour and then laid her eggs in the bottom of a pit created by her own urine. And then, the march back to the sea for another hour. Truly an amazing thing to watch and experience.

Things worth doing, that create life and abundance, are worth doing slowly and deliberately. And perhaps, in the middle of the night.

Bright Side

In medicine, we have a habit of "eating our young." And this mentality seem to extend from clinical leadership for the most part; Searching extensively for the negative qualities, deficits in people instead of their value(s).

Leadership guru Balconi encourages wise leaders to look at what an employee can do rather than what he cannot do. This subtle perspective change is extremely valuable in this age of "team" medical care and not something trained in medical school.

The glass 1/2 full attitude in medical leadership would go a long way and I've been lucky to experience such leadership in my tenure. Talent of our colleagues in medicine should be about identify core skills a person can do, and helping each other in those areas that are holding us back from achieving individually or for the team, or patient.

As Balconi says, "Talent is not a commodity. It is the lifeblood of the enterprise and those leaders who look for it, nurture it, and seek to capitalize on it are ones who achieve their objectives." We can only hope for more enlightened leaders in medicine who can make such a reality.

Higher Selves

As long as we are in touch with our higher selves our egos are not a threat, rather a tool in service of the spirit.

It's a rare thing in medicine, but when I find true professional, willing to talk openly about approach to problems in patient care...it can be magical. But it supposes for even an instant that all parties open their minds beyond "what's done here" and their own prejudices. I've learned so much that way. There are MANY ways to do almost everything in medicine. I can watch 5 people sew up the same wound 5 different ways. The knee has at least 8 approaches (if not more) for arthrocentesis.

Having such discussion usually happen late at night, in corners of intensive care units with like minded providers. They are insightful glimpses into the genius that is in most of us when others truly listen and open their minds to the possibilities. It's also about deferring such discussions from the presence of the patient and others so we don't feel the need to prove ourselves.

I am so surrounded by ego, and it's "my way or the highway" mentality that we often miss the point, and allow the patient to suffer in the process. But even during long, long days engulfed in 90 hour work weeks, there is still some possibility of finding our higher selves in spite of the attack of ego of others. It's better for the practitioner, better for the practice of medicine and better for the patient.

Bullshit Rules

I know the rules. The rule in surgery, your hands should never slip below your waist. Everything below the table level is considered "unsterile". Once your hands enter that area, they should never be brought back into the sterile field.

So when I lowered my hands to adjust my lead apron, hands at belly button level, technically I was in violation. I was careful to keep my hands in front and not below table level or my waist. One of my esteemed anal retentive, subversive, passive-aggressive colleagues (an oxymoron) pointed out to the entire OR my faux pas.

But in our world, it's a moot point, filled with inaccuracies and frank bullshit. We sit and stand regularly in the OR bringing our entire torsos to nipple level below the table and pop back up again...regularly, with impunity.

Some things are just bullshit. In this case, not sure if it's the rule without evidence or the colleague without discretion or sense. It's likely a commentary on more broad issues in the world of medicine, pseudo teamwork, inexplainable rule without evidence and ego than contamination.

I changed my gown and gloves without saying a word.

Surrender

"No retreat, no surrender; that is Spartan law. And by Spartan law we will stand and fight... and die." - Leonidas

But I wasn't willing to die. And I wasn't willing to give up my passion, compassion, sensibility, ethics, morality, optimism or sanity.  So I surrendered and did an absolutely unheard of act. I left residency.

I think the breaking point for me was the election of our new chief residents for next year who have been widely quoted that "the only thing I want in my medical career is lots of money". Money as a motivation for this pathway was never present for me.

Medicine is no fun by definition and had become less so under the direction of individuals with the sensitivity of granite and no sense of what adult education is all about. I've met very few people in my education and training that represented what I wanted to become and they have largely left medicine or are at their waning moments of practice. And the few role models I found were outside of my program, just an arm's length away, sequestered by "the match".

Truth is I don't know many happy people working in medicine, or maybe I just identify those folks more readily. I've almost resigned myself to unhappiness in my career myself. But one thing I wasn't willing to do is sacrifice another chunk of years to an end result that was so disappointing as the specialty I defaulted into, with people I didn't respect, in a place I didn't want to live in. I've left a residency spot open for someone else to fill (and fill it they will, easily) with someone who appreciates it much more and has the mentation to do it well.

For me, it was surrender and live.

P.S. Congratulations to my colleagues from medical school who matched in 2013. It's very exciting to see some bright young minds entering the field to hopefully make a difference.

Greatness Prescription

We all with for mentors in life that embody all of the characteristics of greatness to observe and emulate. Sure greatness is a perception of one's self, but it is a composite of learned skills and discipline that provides the pathway to, even private, greatness. I see those characteristics in the many medical professionals around me: colleagues, administrators, attending docs, nurses, physician assistants, pharmacists and other health care professionals. I've even seen it in the non clinical staff...campus security, maintenance, housekeeping folks. Some of those characteristics I've noticed:

1. Relaxed confidence - It's both in skill and emotional maturity that relaxed confidence exudes. More than a look or feel, it allows one to think logically, respond appropriately and overtly remained balanced in this unbalanced life.

2. Knowing what's really important - Se never learn this skill in school but some learn it on the street or at home. It's the ability to honestly follow one's heart, mesh it with education and experience, and figure out what's really important. More than anything, this allows releasing anger or frustration for those thing that aren't really important.

3. Focused activity - I've heard it indirectly referred to as "doing what's important" but it's really doing those things that feed what's important once you've identified that (see #2). When we become in "other" things we are distracted from the path to that success we seek.

4. Play - You've heard work hard, play harder? Well more than having the capacity and finding the time to play, it's also about seeing the fun in the everyday. It's easy to focus in the negative and what's wrong, but when we consciously understand that bad stuff happens, and deliberated search for the "present(s)", the good, the playful, the fun... our whole outlook improves and we become better at playing in the off time.

5. Positive expectations - A program director MD has never complained about what's not. But he constantly searches for ways to positively identify what's possible in the future. His expectations are verbalized in his statement of every problem that arises, offering solutions and positive outcomes as a probability.

6. No excuses - "I couldn't because..." is not helpful. Identifying what needs to be done and understanding our limitations, expressing them to others, is conquering over ego and stubborn pride. Excuses are mental obstacles that keep us in the past.

7. Balance - Life at home, work, play, gym, eating etc...all in balance. If it's not "peaceful" than you are out of touch with what's the right reality for you (from a nurse who smiles all the time).

And so it is, I've got lots of work to do.

Viral something

Yep, you got the flu or that flu like thing or could be flu lite or viral this or that.

Yes, could be plague or burbonic or consumption, or rheumatiz. Sure could be the blight too. What? You saw the river "part" on your way to the hospital? Ya, amazing.

Nope. No antibiotics. Just lots of fluids, a hot water bottle, chicken soup, ibuprofen or tylenol for aches and fever, sleep and time in bed...time.

And throw away your toothbrush when you start feeling better.

I know. I got the vaccination too.
Bless you! Oh, that was a cough? I take back the blessing then.
Don't want to waste those.

Flu-like what?

Sick Kids

Pediatrics is a funny place. Mostly I have found we just humor the parents until the kid gets better. Expectant hand holding, saline mist, bulb suction, and lots of talk about poop, wet diapers, vomiting and breast feeding. Any people get paid for this?

But every once in awhile, a really sick kid comes in and the real art comes in. I'm blessed to have seen some really keen artists practice this craft, separating the patient from the ranting parent, and actually make a cool diagnosis and heal sick kids. I gain greater respect for pediatricians every single day.

God bless YOU!

A room full of doctors. One sneezes. Several say "God bless you". The sneezer says "thank you". All totally without thought, automatically. For those who claim to practice evidence based medicine, there is little evidence that saying "God bless you" provides any healthful benefits that we know of.

History says we have been saying "God bless You" since about AD 77. There are lots of theories where this came from and no real consensus on the origin. Could be from the lavish blessings Pope Gregory 1 in AD 590 ordered to fight the bubonic plague when sneezing was thought be an early sign.

Or it could be to bless a person to prevent the soul from being thrown from the body during a sneeze....a shield against evil. Another theory says that saying "God bless you" restarts the heart, thought to stop during a sneeze. Or maybe, it's just a reaction to feeling like you have to do something when you don't know what to do or say.

So next time I hear "God bless you", I'll know the plague is prevented, the soul is retained and the heart will continue to beat.

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**Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service, and stop saying it around other clinicians.

Slavery, today?

It is hard to believe that it still exists. Millions of working "slaves" in farming, domestics, manufacturing, sex trade and other industries around the world today. All forced to work without basic rights, compensation, freedoms or care. All ages, all continents. Struggling to find a way out but feeling there is no help. But there is help.

January is National Slavery and Human Trafficking Prevention Month. It is our duty to identify and stop human trafficking in the world.