" /> Toads-in-the-Hole: October 2007 Archives

« September 2007 | Main | January 2008 »

October 31, 2007

Trick-or-Treat

Meeeeaow!

Tonight Adelaide learned all about Halloween.

Mama, Adelaide, and The Pumpkins

Or, at least, Adelaide learned about dressing up like a cat,

Inbetween Candy Attack

driving from house to house,

Fellow Tricksters

hanging out with friends,

The Plunder

and scoring some serious Halloween loot (Thanks for the sweet candy bag, Marmee!)

Happy Halloween!

October 11, 2007

Therapy Kills

A perfectly healthy woman came in for an elective hysterectomy. She was in her 40s and had been suffering from heavy periods. Hormone therapy hadn’t helped, and she didn’t like the sound of a thermal ablation of the uterine lining. A careful review of her lab tests and vitals showed nothing out of the ordinary other than mild anemia. As she went under anesthesia and we began surgery, I braced myself for calamity. And, sure enough, alarms began to sound, nurses started bellowing alerts, and everything started to swirl sickeningly around the drain as I searched desperately for the best action to take. I wasn’t the least surprised, it’s what I’ve come to expect from standardized tests.

The above example that I made up could have sprung from any of the six standardized medical exams I’ve taken (or “written” as my masters say) this year. The test question consists of a “stem” detailing the patient’s initial condition, the inevitable terrible thing that happens to them, and is concluded by 5 to 20 multiple-choice options, usually asking what I should do next. And, after I finish the first nightmarish scenario in which all of nature’s and medicine’s best intentions plummet off the edge, I have another 367 to go.

I try to take each question on its own, without letting one bleed into another. This is important, for when I inevitably encounter a question that is especially difficult, confusing, or upsetting, I tend to worry about it afterward, letting my own unanswered questions distract me from the next disaster. It’s also necessary to try and isolate each question, answer it, and then forget about it, because experienced as a group, the litany of disease, despair, and dribbling fluids makes me yearn for a brisk walk and a shower, neither of which are allowed under the strict security rules of the testing situation. I remember a long stretch of questions all of which revolved around the setting of trauma. Perhaps because it’s a common scenario or perhaps because of a personal fixation on the part of the question writer, many featured obese men involved in car crashes. There were also a few gunshot wounds and a man who had incurred an accident while cleaning his chainsaw. At the end of that twenty-minute segment, my hands felt sticky and my cubicle was redolent with the tang of blood.

The majority of the questions, however, concern “complications” of treatment. In other words, medication side effects, surgeries with unfortunate outcomes, and the nosocomial (secondary problems associated with being treated at a hospital). I think my masters focus on this side of health care because it is presumed I know the first two steps of doctoring, (diagnosis and treatment) and that I should be focusing on the third step, which is known by a variety of names (e.g. “covering your ass”), but I think of it as “clean up.”

Presuming you have the right diagnosis, a doctor can usually pick from a short list of treatment options, including doing nothing. All of these choices can have negative consequences, and, my masters seem to be emphasizing to me, I should just go ahead and assume that the patient with the seemingly routine gall bladder surgery is going to turn septic overnight.

This bleak viewpoint is not realistic, but it does reflect a time-honored unease that can be summed up as “therapy kills.” Most patients undergoing “routine” treatment (as opposed to “emergency” or “experimental” treatment) do pretty well, and some are even (for lack of a more cautious term) cured, but for many patients and doctors, once the body has been fiddled with- dosed with a drug, cut with a knife, or simply poked and prodded- it’s never quite the same sacred machine. Hence our stern and intimidating mandate: First Do No Harm, which looms invisibly over every prescription pad and operating room.

The best way to do no harm, of course, is to continuously and strenuously do nothing, but that’s pretty much impossible these days; Americans want their drugs and surgery. But there is an important grey area about treating something that’s not immediately life-threatening. A woman undergoing a hysterectomy for excessive uterine bleeding, for instance, is having an elective surgery. I can think of a few ways her condition could kill her; she could develop severe anemia, which can cause high-output heart failure or simply make her dizzy enough to fall down some stairs, and of course her uterus could become cancerous, but generally speaking she would make it without the surgery. The surgery, however, could definitely kill her, but it probably won’t, as it has a mortality rate of one death per thousand surgeries (Which, I know, seems pretty high. I’ve never heard a surgeon/gynecologist quote this number to a patient, but it’s been reproduced in several studies.) It’s hard to balance out the benefits vs. the risks of a non-life-saving procedure when one of the risks is death.

(An opposite example is hypertension. Hypertension is called the “silent killer”, because even though it is the major risk factor for heart disease and stroke [contributing to an incredible 35% of deaths in America] it doesn’t cause any symptoms. The main therapy for hypertension is a “water pill”, a diuretic that lowers blood pressure by making you pee. This pill is essentially risk-free, cheap, and after a few weeks most people don’t even notice that they’re peeing more, but they’re reluctant to take it, often because they don’t really believe that they’re sick, but also because they have learned that therapy kills.)

Americans have a dysfunctional relationship with health care. As a culture, we demand and receive an ever-increasing amount of intervention. Simultaneously, our awareness of the mistakes, criminal negligence, and randomly bad outcomes of medical therapy is growing, along with personal and public distress about medical expense. But something happens when we get sick: all that ambiguity drains away leaving a raw hunger for healing, whatever the cost.

October 5, 2007

Omaha, Nebraska

Earlier this week, Joel had his very first [in a line of six (and counting ...)] residency interview at the University of Nebraska Medical Center in Omaha, Nebraska. While Joel interviewed for 10+ hours with the attendings and residents of UNMC's pathology program, Adelaide and I played around in Omaha.

The night before the interview, Joel had a supper date with a couple of UNMC's residents, so Adelaide and I walked from our very, very comfortable hotel room to Omaha's Old Market, a quaint section of downtown with cool little shops and restaurants. Although I drooled at the sight of an Indian cafe, Adelaide chose Spaghetti Works, where she dined on peas and popcorn chicken and we fought over the last mozzerella stick. After supper, we strolled around in the fading light and happened on a toy shop. Of course, we couldn't leave empty handed, so Adelaide is the proud owner of a wooden snake (in commemoration of her both saying and signing "snake" last weekend when confronted with a poor Garter snake that unwisely crossed Nine's path ... But, I digress ... Back to Omaha ...)

Splish Splash!

On Thursday morning, after a quick breakfast of bagels and coffee, Adelaide and I found a technicolor, interactive welcome to the city at Omaha's Children's Museum. Along with many other stay-at-home parents and tots, we played for nearly two-and-half hours at the museum. The exhibits were great, especially the not-too-spooky haunted house called Cobweb Castle.

Behind the wheel

We ate an improvised picnic of breakfast leftovers, blueberries, and applesauce at the museum, and then it was naptime ... Remember that time we visited France? Remember that we didn't really have an escape plan? Remember that Joel and I arrived in Paris from the South of France on the TGV and spent twelve weary overnight hours at Charles de Gaulle? In a similar way, Adelaide and I didn't really have a place to adequately rest post-lunch, so we kind of aimlessly drove around the downtown neighborhoods. At one point while Adelaide was snoring in the backseat, I got totally confused and lost and frustrated ... Somewhere between one and two o' clock, Adelaide and I ended up strolling around this weird, almost-abandoned Target. I ended up buying a single feather pillow, mostly because I think I needed a nap and it reminded me of sleep. I also bought an iced tea, which must have perked me up a bit, because after leaving the strange, empty Target, I drove us to Omaha's WWII Memorial Park and we passed an hour or so walking around the gardens, remembering fallen veterans, and smelling the flowers.

Adelaide and Colonnade

Memorial Park had this great, brand-new playground and we spent a happy time sliding, climbing, throwing sand (boo), and swinging before it was time to pick up Joel at the hospital.

Playground!

Omaha gave Adelaide and I a positive impression (in spite of that yucky post-lunch time); it seems like a really family-friendly town with small neighborhoods and navigable streets. If you're interested in Joel's impressions, email him privately.

Thanks, Omaha!